Despite uncertainty about ACA most states moving forward with Medicaid expansion

Although the future of Medicaid funding is unclear with the ongoing efforts to repeal and replace the Affordable Care Act (ACA) (P.L. 111-148), many states were still working to expand Medicaid services and benefits, according to a joint Kaiser Family Foundation (KFF) and Health Management Associates (HMA) report. In an annual survey collecting data about Medicaid policies in place or implemented in fiscal year 2017 and policy changes that will be implemented or are being discussed for fiscal year 2018 in each state and the District of Columbia, KFF and HMA noted that some of the biggest changes are occurring in eligibility policies, managed care reforms, and the expansion of benefits.

Eligibility and Premiums

In 2017, seven states made changes to expand Medicaid eligibility and in 2018 another seven are planning to implement eligibility expansions. These changes include eliminating the 5-year bar on Medicaid eligibility for lawfully-residing immigrant children or providing coverage for a new eligibility group of individuals who are chronically homeless, justice-involved, or in need of substance abuse or mental health treatment with an income below 5 percent of the federal poverty level. A few states are looking to make changes to restrict Medicaid eligibility by imposing work requirements and asset tests.

In recent years, many states have made changes to the way Medicaid coverage is handled when beneficiaries are in the criminal justice system. Some states have opted to suspend coverage when someone is incarcerated rather than terminate coverage, as they have done previously, so it is easier to reinstate coverage when the beneficiary is released. Additionally, some states have developed initiatives to work with and train criminal justice employees to assist with Medicaid applications after a person is released.

Managed Care

Twenty-nine of 39 states with risk-based managed care organizations (MCOs) reported that 75 percent or more of their Medicaid beneficiaries were in enrolled in MCOs as of July 1, 2017. Most states carve-out certain services, such as behavioral health services, from their MCO contracts. In 2017 at least six states took steps to carve in behavioral health services into their MCO contracts and ten states reported plans to work toward carving in behavior health services in 2018. Twenty-six of the 39 MCO states reported that they would use the funds available for inpatient psychiatric treatment or substance use treatment under the 2016 Medicaid Managed Care Final Rule; however, many states commented that the 15-day limit was too restrictive for the type of treatment that it was meant to cover. Sixteen states in 2017 and 17 states plan in 2018 to include specific initiatives to encourage MCOs that cover LTSS to expand access to home and immunity-based services (HCBS).

Benefits

Twenty-six states reported new or enhanced benefits in 2017 and 17 states plan to add or enhance benefits in 2018. These added benefits include mental health and substance use disorder services, alternative plain therapies, family planning and cancer screenings. Nineteen states reported new or expanded initiatives to expand dental access or improve oral health outcomes in 2017 or 2018. Additionally, 19 states reported initiatives to expand the use of telehealth in 2018 or 2019. For 2018, 22 states reported plants to adopt or expand initiatives such as patient-centered medical homes or accountable care organizations in an effort to encourage integrated care. Fourteen states in 2017 and 13 states plan in 2018 to report expansions and additions to the HCBS programs, including personal supports, supported employment, home delivered and medically tailored meals among others.

Although most states are continuing to look ahead to expand Medicaid benefits and eligibility, almost all states are still concerned about the negative fiscal consequences that they would face in the proposed limits on federal Medicaid spending. Medicaid directors from the 32 ACA Medicaid expansion states reported the states would not be able to continue providing coverage for expansion population, or the coverage would be at a substantial risk, if the ACA federal match was terminated.