Medicaid Expansion Report: Snapshot of Progress, One Year Later

One year after the implementation of the “key Medicaid provisions” of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), the Kaiser Family Foundation (KFF) found that the expansion of Medicaid has contributed to a broadening basis of coverage for the low-income population and has “accelerat[ed] state efforts to move from antiquated, paper-driven enrollment processes to a new modernized enrollment experience.” In its 13th annual 50-state survey of Medicaid and Children’s Health Insurance Program (CHIP) eligibility, KFF highlights the data supporting these findings and emphasizes the status of coverage and enrollment experience for those in states that have chosen to expand Medicaid under the ACA and those in states that have rejected the expansion.

Expansion and Enrollment Numbers

As of the end of 2014, KFF reports, 28 states—including New Hampshire and Pennsylvania, both of which made the decision to expand Medicaid in 2014—had expanded Medicaid coverage to individuals with incomes of up to 138 percent of the federal poverty level (FPL). This led to an increase of median income eligibility levels in those states compared with the time before the implementation of the ACA, particularly among childless adults who were, for the most part, previously excluded from Medicaid coverage. On the other hand, in the 23 states that have chosen not to add a broadened base of Medicaid eligibility under the ACA, KFF states that levels of eligibility are very limited and “in all but one of these states (Wisconsin), childless adults remain ineligible for Medicaid regardless of their incomes.”

The KFF reports also notes, however, that Medicaid and CHIP coverage for pregnant women and children “remains strong,” as “all but two states cover children at or above 200 percent of the FPL through Medicaid and CHIP with 19 states covering children at or above 300 percent of the FPL.” Meanwhile 33 states provide coverage eligibility to pregnant women who have incomes at or above 200 percent of the FPL.

Streamlined Processes

The report also revealed positive trends in regard to the streamlining and increased ease of enrollment as states are expanding Medicaid coverage under the guise of health care reform. Specifically, KFF found that, in all but one state, individuals are able to apply for Medicaid benefits at the state level online and “the majority of states are accepting Medicaid applications by phone.” In Tennessee, the only state where online enrollment applications are not available, individuals are instead directed to the federally-facilitated Marketplace (FFM) to enroll. Additionally, 36 states provide enrolled individuals an opportunity to set up an online account to aid in the management of their Medicaid coverage and 40 states have put processes into place that use electronic data sources to verify income prior to enrollment.

The KFF report also identified several new processes that have been created in states in an attempt to make further improvements in the enrollment process including the implementation of: (1) presumptive eligibility determinations for children and pregnant women; and (2) the Express Lane Eligibility (ELE) program, which uses other “means-tested programs such as the Supplemental Nutrition Assistance Program (SNAP)” to identify cases of eligibility for Medicaid and CHIP. Finally, the report found that 12 states operate a single, integrated system that makes eligibility determinations under the state’s Medicaid guidelines and Marketplace coverage options. The failure to implement this type of coordination in other states, KFF notes, contributed to delays in Medicaid eligibility determinations in 2014.

What’s Next

In more than one place in its discussion, KFF highlights the fact that there is no deadline for states to expand Medicaid under the ACA, as well as the fact that, in some states, the debate over Medicaid expansion will continue into 2015. On another note, the report’s authors caution that without Congressional action, CHIP funding is set to expire in September 2015. If this funding is withdrawn at that time, KFF warns that this will have budgetary implications on the state level.

Kusserow on Compliance: 2014 OIG Year in Review

The HHS Office of Inspector General (OIG) posted  more than 35 podcasts to their website in 2014.  The latest podcast is a summary of their 2014 Year in Review that looked back at highlights of their activities.

  1. The OIG reported nearly $5 billion dollars in expected recoveries in fiscal year 2014. The recoveries resulted from program audits and investigations.
  2. The OIG reported 971 actions against individuals or entities that engaged in crimes against HHS programs as well as 533 civil actions during the fiscal year.
  3. Medicare Strike Force efforts by the OIG and its partners at the Department of Justice resulted in the filing of charges in 232 criminal actions.
  4. Six OIG Most Wanted fugitives were captured during the year.
  5. The OIG excluded more than 4,000 individuals and entities from participation in federal health care programs during 2014. Among them was pediatric dental management chain CSHM, for “repeated and flagrant violations” that put kids at risk.
  6. The OIG negotiated more than 40 corporate integrity agreements (CIAs), among them one with the Extendicare nursing home chain that alleged “effectively worthless care.” Extendicare agreed to pay $38 million dollars.
  7. The OIG found that, after Health Insurance Marketplaces first opened, they faced major challenges with inconsistencies in applicant data.
  8. In its report, Access to Care: Provider Availability in Medicaid Managed Care, the OIG found that slightly more than half of Medicaid managed care providers could not offer appointments to enrollees.
  9. The OIG testified at 10 hearings on Capitol Hill in 2014. You can read that testimony on the OIG website.

Other reports summarizing OIG activities in 2014 include its Semi-Annual Reports to Congress, OIG Work Plan, and OIG Budget Proposal.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2015 Strategic Management Services, LLC. Published with permission.

Burwell Extends Olive Branch to Congress on Everything but the ACA

Several potential areas of common ground between HHS and the new Republican-led Congress were discussed by HHS Secretary Sylvia Burwell at the New America Foundation. Although Burwell expressed an expectation that Congress and HHS could work together successfully on several issues—including Medicare, Medicaid, opioid abuse, Ebola, and drug development—Burwell made clear that she had no intention of backing away from her support of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148).


Burwell’s comments seemingly took discussions about the ACA off the table. Burwell said, “I also hope that we can move beyond the back and forth of the Affordable Care Act and focus on the substance of access, affordability and quality.” She expressed her opinion that “the law is working” and that she would continue to “be vigorous in making the case.” Burwell also encouraged states that have not yet expanded Medicaid under the ACA to join those that have.


The HHS Secretary made several comments about the importance of addressing the growing problem of opioid abuse. Burwell’s remarks were premised on the understanding that opioid use and abuse is rising at record-breaking rates. She indicated that in 2012, 259 million opioid prescriptions were written—enough for every American adult to have a bottle. Similarly, in 2009 drug overdoses outnumbered car crash fatalities for the first time. To address the rising figures, Burwell called on Congress to address opioid prescription practices and to incentivize the production of abuse deterrent medications.


Burwell thanked Congress for making efforts to stop the global Ebola crisis at its source. Specifically, Burwell commended Congress by responding to the Ebola crisis by investing $597 million towards global health security. She also lauded the efforts of the U.S. and other countries for working together to stop outbreaks like Ebola before they become pandemics.


Another area that Burwell encouraged Congress to facilitate is innovation and science in medicine. She acknowledged that Congress itself was aware of the bipartisan need to accelerate and further innovations for vaccines, cures, therapies, and rapid diagnostics. Burwell placed particular emphasis on working with Congress to achieve more in the area of precision medicine, or diagnostic and treatment methods that are tailored to the individual and genetic characteristics of a patient.


According to a story from Kaiser Health News, despite Burwell’s comments regarding a strong stance on the ACA, HHS can expect to work successfully with senators and representatives from both sides of the aisle. For example, Sen. Lamar Alexander (R-Tenn) said that “we have plenty we disagree on, but we also have plenty of issues that are important to millions of Americans upon which we should be able to get results, including, for example, getting life-saving drugs, treatments and devices through the FDA to patients faster; remodeling the health care delivery system; and improving global health security.”

Kansas Reveals Home and Community Based Services Program Proposals

The final proposed changes to the Kansas Home and Community Based Services (HCBS) programs have been made available by the Kansas Department for Aging and Disability Services (KDADS) alongside the state’s applications to CMS for renewal of those programs. KDADS published the proposed changes on its website with an explanation as to why the agency elected to undertake the program changes. Proposed changes include updates to program definitions and language, background checks for providers and other updates to enhance the individual HCBS programs.


KDADS proposed changes and applied to CMS for renewal of its HCBS programs related to autism, intellectual/developmental disability, physical disability, serious emotional disturbance, technology assistance, traumatic brain injury, and the frail and elderly. The HCBS application for each of the programs is available on the KDADS website. The proposed changes to the programs were open for public comment in November and December of 2014. The published proposal and applications include changes that KDADS adopted following the review of those public comments.


In addition to the proposed changes affecting all the programs, like the language updates and the proposal to require that providers undergo background checks, KDADS made several proposals related to specific HCBS programs. For the physical disability program, among other proposals, KDADS is seeking approval from CMS to establish a maximum age limit of 65 so that, after the age of 65, beneficiaries will move out of the physical disability program and into the HCBS frail-elderly program. KDADS also proposed an alternative meal preparation services for beneficiaries of the frail-elderly program. Other proposals include a rehabilitative progress eligibility requirement for beneficiaries and a mandatory training curriculum for providers in the traumatic brain injury program.