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Medicaid Expansion

What is Medicaid Expansion?

Medicaid expansion is the extension of Medicaid eligibility to non-elderly individuals with annual incomes below 133 percent of the federal poverty level ($15,521 for an individual or $31,720 for a family of 4 in 2014) who are under 65 years of age.1,2 In June 2012 the Supreme Court ruled to make Medicaid expansion voluntary for states. Many, but not all, states have expanded their Medicaid program. However, it is estimated by the Congressional Budget Office that in 2014, Medicaid and Children’s Health Insurance Program (CHIP) coverage will be expanded to approximately eight million low-income, non-elderly people, a population with increased rates of HIV/AIDS, viral hepatitis, STD, and TB infections.3


What is new?

In 2014: 	Two doctors looking at the camera and smiling

Millions of low-income individuals are newly eligible for Medicaid coverage

Individuals and families can use the Health Insurance Marketplace (also known as the ‘Marketplace’ or ‘Exchange’) throughout the year to apply for and determine their eligibility for coverage through Medicaid or CHIP in one simple process. If the eligibility criteria are met, they will be seamlessly directed to the Medicaid and/or CHIP enrollment process.4 It is important to note that while Marketplace open enrollment for 2014 ended March 31, 2014 (with the next open enrollment beginning November 15, 2014 and lasting until February 15, 2015), the Marketplace remains open for Medicaid enrollment.

Newly eligible Medicaid enrollees will receive a package that includes the "essential health benefits," a minimum set of services and items that includes preventive and wellness services, and the preventive services covered without cost-sharing.5,6

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What are the implications?

More individuals at risk for HIV, viral hepatitis, STDs, and TB may be eligible for Medicaid or private insurance.

Populations at risk for HIV, viral hepatitis, STDs, and TB are disproportionately low-income and, therefore, likely to be newly eligible for Medicaid or Marketplace coverage.7 This is particularly true for low-income males since single, childless males are less likely to meet the traditional Medicaid eligibility criteria.8

Enrollment through the Marketplace will simplify and streamline Medicaid enrollment for eligible individuals. The Affordable Care Act ensures newly eligible Medicaid and Marketplace enrollees have coverage for many HIV/AIDS, viral hepatitis, STD, and TB clinical preventive services.

New coverage may increase uptake of clinical preventive services by reducing or eliminating financial barriers.

Health department engagement with private primary care providers will be increasingly important.

Private primary care providers may have more opportunities to deliver preventive services to newly eligible Medicaid and Marketplace enrollees. However, providers may have limited experience serving individuals at risk for or with HIV/AIDS, viral hepatitis, STDs, and TB; providers may also be unaware of community or public health services that are available.

Medicaid data may become more useful to health departments.

With Medicaid coverage being extended to more people with HIV/AIDS, viral hepatitis, STDs, and TB and with the increase in use of electronic medical records by providers, Medicaid service data may prove to be increasingly useful for public health activities. (See Examples of states using Medicaid data to improve health outcomes)

Health departments may have additional opportunities for being reimbursed by Medicaid for direct services they provide to enrollees.

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How might health departments respond?

1. Become familiar with the Medicaid program in your state.

Determine if your state has opted to extend Medicaid eligibility to low-income adults.

Be aware of your Medicaid agency’s regulations, processes, and requirements with regard to the eligibility, enrollment, and care of persons at risk for or with HIV/AIDS, viral hepatitis, STDs, and/or TB.

Identify the critical services for HIV/AIDS, viral hepatitis, STD, and TB prevention that Medicaid covers in your state. Identify service delivery requirements, cost-sharing, and provider reimbursement rates.

Note: Programs in states that are implementing “alternative” means to expand Medicaid (i.e. expanding Medicaid through “premium assistance”) should be mindful of state decisions regarding coverage and cost-sharing of relevant preventive services for newly eligible Medicaid enrollees.

2. Explore opportunities to work with Medicaid to establish and achieve population health objectives.

Engage state Medicaid agencies in discussions concerning mutual goals and objectives with regard to enrollment, education, and health outcomes relevant to your programs.

Work with the appropriate agencies or organizations to facilitate Medicaid enrollment for eligible at-risk populations.

Establish relationships with private primary care providers and relevant organizations and associations to assure delivery of quality and comprehensive care to newly eligible Medicaid enrollees.

Use Medicaid data to monitor trends in service utilization and identify gaps in service delivery.

3. Develop capacity to bill Medicaid (and other payers) for services provided to Medicaid enrollees, if appropriate.

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1 Centers for Medicare & Medicaid Services. What if my state is not expanding Medicaid? Accessed 2013 September 24. Available at: www.healthcare.gov/what-if-my-state-is-not-expanding-medicaid/#state=georgia

2 Patient Protection and Affordable Care Act, Pub. L. No. 111-148, §2001, 124 Stat. 171 (2010), amending Section 1902(a)(10)(A)(i)(IX) of the Social Security Act, 42 U.S.C. 1396a. Available at: www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf

3 Congressional Budget Office. Table 2: February 2014 Effects of the Affordable Care Act on Health Insurance Coverage. Accessed 2014 March 17. Available at: www.cbo.gov/sites/default/files/cbofiles/attachments/43900-2014-02-ACAtables.pdf

4 Centers for Medicare & Medicaid Services. Coordination with Affordable Insurance Exchanges. Accessed 2013 November 14. Available at: www.medicaid.gov/AffordableCareAct/Provisions/Coordination-with-Affordable-Insurance-Exchanges.html

5 Patient Protection and Affordable Care Act, Pub. L. No. 111-148, §2001(c), 124 Stat. 276 (2010), 42 U.S.C. 1396u-7(b)(5). Available at: www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf

6 Patient Protection and Affordable Care Act, Pub. L. No. 111-148, §4106(a), 124 Stat. 559 (2010), amending Section 1905(a)(13) of the Social Security Act, 42 U.S.C. 1396d(a)(13). Available at: www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf

7 Centers for Disease Control and Prevention. Establishing a Holistic Framework to Reduce Inequities in HIV, Viral Hepatitis, STDs, and Tuberculosis in the United States. Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; October 2010. Available at: www.cdc.gov/socialdeterminants/docs/SDH-White-Paper-2010.pdf

8 Kaiser Family Foundation. Medicaid’s Role for Women. Issue Brief: An Update on Women’s Health Policy. Washington, DC: Henry J. Kaiser Family Foundation, 2004. Accessed 2012 December 20. Available at: http://files.kff.org/attachment/medicaid-role-for-women-across-the-lifespan-issue-brief

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