Medicaid: An Overview
Alison Mitchell, Coordinator
Analyst in Health Care Financing
Evelyne P. Baumrucker
Analyst in Health Care Financing
Elicia J. Herz
Specialist in Health Care Financing
January 10, 2014
Congressional Research Service
7-5700
www.crs.gov
R43357
Medicaid: An Overview
Summary
Medicaid is a means-tested entitlement program that in FY2012 financed the delivery of primary
and acute medical services as well as long-term services and supports to an estimated 57 million
people, and cost states and the federal government $431 billion. In comparison, the Medicare
program provided health care benefits to nearly 50 million seniors and certain individuals with
disabilities in FY2012 at a cost of roughly $557 billion. Because Medicaid represents a large
component of federal mandatory spending, Congress is likely to continue its oversight of
Medicaid's eligibility, benefits, and costs.
Participation in Medicaid is voluntary for states, though all states, the District of Columbia, and
U.S. territories choose to participate. In order to participate in Medicaid, the federal government
requires states to cover certain mandatory populations and benefits, but the federal government
also allows states to cover other optional populations and services. Due to this flexibility, there is
substantial variation among the states in terms of factors such as Medicaid eligibility, covered
benefits, and provider payment rates. In addition, there are several waiver and demonstration
authorities that allow states to operate their Medicaid program outside of federal rules.
Historically, Medicaid eligibility has generally been limited to low-income children, pregnant
women, parents of dependent children, the elderly, and individuals with disabilities; however, the
Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) included the ACA
Medicaid expansion, which expands Medicaid eligibility to individuals under the age of 65 with
income up to 133% of the federal poverty level (FPL) (effectively 138% FPL) at state option.
The ACA makes a number of other changes, which together represent the most significant reform
to the Medicaid program since its establishment in 1965. In addition to the ACA Medicaid
expansion, the ACA also expands Medicaid eligibility for children ages 6 to 18 and former foster
care children; transitions to the modified adjusted gross income (MAGI) counting methodology
for most nonelderly Medicaid enrollees; requires alternative benefit plan (ABP) coverage for
certain Medicaid enrollees; provides enhanced federal matching funds for the ACA Medicaid
expansion; increases uniformity among Medicare, Medicaid, and the State Children’s Health
Insurance Program (CHIP) program integrity activities; and provides the Centers for Medicare &
Medicaid Services (CMS) with the ability to test methods to improve coordination of care for
dual-eligible beneficiaries, among a number of other changes.
This report describes the basic elements of Medicaid, focusing on who is eligible, what services
are covered, how enrollees share in the cost of care, how the program is financed, and how
providers are paid. The report also explains waivers, program integrity activities, and the dual-
eligible population. In addition, the report describes the following selected issues: the ACA
Medicaid expansion, the impact of the ACA health insurance annual fee on Medicaid, and the
ACA maintenance of effort (MOE) with respect to Medicaid eligibility.
Congressional Research Service
Medicaid: An Overview
Contents
Introduction ...................................................................................................................................... 1
Eligibility ......................................................................................................................................... 3
Modified Adjusted Gross Income (MAGI) ............................................................................... 4
Medicaid Enrollment Trends ..................................................................................................... 5
Share of Enrollment Versus Expenditures, by Population ......................................................... 6
Benefits ............................................................................................................................................ 7
Traditional Medicaid Benefits ................................................................................................... 8
Alternative Benefit Plans (ABPs) .............................................................................................. 9
Medicaid Benefits by Eligibility Classification ....................................................................... 10
Service Delivery Models ......................................................................................................... 11
Medicaid Service Spending ..................................................................................................... 12
Beneficiary Cost-Sharing ........................................................................................................ 13
Financing ....................................................................................................................................... 14
Federal Share ........................................................................................................................... 14
State Share ............................................................................................................................... 16
Expenditures ............................................................................................................................ 17
Provider Payments ......................................................................................................................... 18
Medicaid Program Waivers ............................................................................................................ 19
Program Integrity ........................................................................................................................... 22
Selected Issues ............................................................................................................................... 23
ACA Medicaid Expansion ....................................................................................................... 23
State Decisions .................................................................................................................. 24
Premium Assistance Model ............................................................................................... 25
States Not Expanding ........................................................................................................ 26
Dual-Eligible Beneficiaries ..................................................................................................... 28
Impact of ACA Health Insurance Annual Fee on Medicaid .................................................... 29
Maintenance of Effort (MOE) ................................................................................................. 30
Medicaid Resources ....................................................................................................................... 31
Figures
Figure 1. Past and Projected Medicaid Enrollment, by Population ................................................. 6
Figure 2. Estimated Medicaid Enrollment and Expenditures for Benefits, by Enrollment
Group as a Share of Total ............................................................................................................. 7
Figure 3. Medicaid Medical Assistance Payments, by Category ................................................... 13
Figure 4. Federal and State Actual and Projected Medicaid Expenditures .................................... 18
Figure 5. State Decisions Whether to Implement the ACA Medicaid Expansion.......................... 25
Congressional Research Service
Medicaid: An Overview
Tables
Table 1. Examples of Medicaid Benefits, by Eligibility Classification ......................................... 10
Table 2. FMAP Rates for ACA Medicaid Expansion .................................................................... 15
Table 3. Key Characteristics of the Primary Medicaid Waiver Authorities Compared to
State Plan Requirements ............................................................................................................. 21
Table A-1. Selected State Medicaid MAGI Income Eligibility Standards Expressed as a
Percentage of the Federal Poverty Level .................................................................................... 32
Table B-1. State-by-State Medicaid Enrollment, Expenditures, and FMAP Rates ........................ 35
Appendixes
Appendix A. State Medicaid and CHIP Income Eligibility Standards........................................... 32
Appendix B. State-by-State Medicaid Data ................................................................................... 35
Contacts
Author Contact Information........................................................................................................... 37
Key Policy Staff ............................................................................................................................. 37
Congressional Research Service
Medicaid: An Overview
Introduction
Medicaid is a joint federal-state program that finances the delivery of primary and acute medical
services, as well as LTSS, for a diverse low-income population, including children, pregnant
women, adults, individuals with chronic disabling conditions, and people age 65 and older. In
FY2012, Medicaid is estimated to have provided health care services to 56.7 million individuals1
at a total cost of $431 billion, with the federal government paying $249 billion (about 58%) of
that total.2
Medicaid is an important health care safety net3 for low-income populations with
approximately 18% of the U.S. population enrolled in Medicaid in CY2011.4 For some types of
services, Medicaid is a significant payer. For instance, in CY2011, Medicaid accounted for 42%
of national spending on long-term services and supports (LTSS) and 25% of all mental health and
substance abuse treatment spending.5 Also, along with the State Children’s Health Insurance
Program (CHIP), Medicaid paid for almost half of all births in the United States (about 1.8
million hospital births) in 2010.6
Medicaid is one of the largest payers in the U.S. health care system, representing 15.1% of
national health care spending in calendar year (CY) 2011; in that year, private health insurance
and Medicare accounted for 33.2% and 20.5%, respectively.7
Medicaid was enacted in 1965 as part of the same law that created the Medicare program (the
Social Security Amendments of 1965; P.L. 89-97). State participation in Medicaid is voluntary,
though all states, the District of Columbia, and the territories8 choose to participate. States are
responsible for administering their Medicaid programs. Medicaid is jointly financed by the
federal government and the states. Federal Medicaid spending is an entitlement,9 with total
expenditures dependent on state policy decisions and use of services by enrollees.
1 This enrollment figure is measured according to “person-year equivalents,” which represents the average program
enrollment over the course of a year, and differs from “ever enrolled” counts which measure the number of people
covered by Medicaid for any period of time during the year. (Office of the Actuary [OACT], Centers for Medicare and
Medicaid Services, U.S. Department of Health and Human Services, National Health Expenditure Projections 2012-
2022: Forecast Summary, 2013.)
2 Centers for Medicare & Medicaid Services, CMS-64 data.
3 The health care safety net is defined as those organizations and programs, in both the public and private sectors, with
a legal obligation or a commitment to provide direct health care services to uninsured and underinsured populations.
4 Calculation based on data from Medicaid and CHIP Payment and Access Commission (MACPAC), Overview of
Medicaid and CHIP, January 2013.
5 CRS analysis of National Health Expenditure Account (NHEA) data obtained from the Centers for Medicare and
Medicaid Services (CMS), Office of the Actuary, December 16, 2012; MACPAC, Overview of Medicaid and CHIP,
January 2013.
6 MACPAC, Report to the Congress on Medicaid and CHIP, June 2013.
7 Micah Hartman, Anne B. Martin, and Joseph Benson, et al., “National Health Spending in 2011: Overall Growth
Remains Low, But Some Payers and Services Show Signs of Acceleration,” Health Affairs, vol. 32, no. 1 (2013), pp.
87-99.
8 The five territories are American Samoa, Guam, the Commonwealth of the Northern Mariana Islands, Puerto Rico,
and the Virgin Islands.
9 Medicaid is an entitlement for both states and individuals. The Medicaid entitlement to states ensures that, so long as
(continued...)
Congressional Research Service
1
Medicaid: An Overview
States must follow broad federal rules in order to receive federal matching funds, but have
flexibility to design their own version of Medicaid within the federal statute’s basic framework.
This flexibility results in variability across state Medicaid programs. Each state has a Medicaid
state plan that describes how the state will administer its Medicaid program. States submit these
Medicaid state plans to the federal Centers for Medicare and Medicaid Services (CMS) for
approval.10
Medicaid was designed to provide coverage to groups with a wide range of health care needs who
were historically excluded from the private health insurance market (e.g., individuals with
chronic disabling conditions who require LTSS or indigent populations in geographic locations
where access to providers is limited). Because of the diversity of the populations that Medicaid
serves, Medicaid offers some benefits that are not typically covered by major insurance plans
offered in the private market (e.g., nursing facility care or early and periodic screening, diagnosis,
and treatment [EPSDT] services).11 Medicaid also pays for Medicare premiums and/or cost
sharing for low-income seniors and individuals with disabilities, who are eligible for both
programs, referred to as dual-eligible beneficiaries. For other Medicaid enrollees, out-of-pocket
costs are generally nominal, which may not be the case with most employer-sponsored or
exchange health insurance coverage.12 The Medicaid program pays for special classes of
providers, such as federally qualified health centers (FQHCs), rural health clinics (RHCs), and
Indian Health Service (IHS) facilities, that provide health care services to populations in areas
where access to traditional physician care has been limited.
Since its inception, the Medicaid program has expanded in a number of different directions.
Federal laws have changed virtually every aspect of the program, affecting eligibility, benefits,
beneficiary cost-sharing, and fraud and abuse protections, among others. The Patient Protection
and Affordable Care Act (ACA; P.L. 111-148 as amended) is the most recent federal law to make
fundamental revisions to the Medicaid program, including a substantial expansion of Medicaid
eligibility, beginning in 2014. The ACA will likely broaden Medicaid’s role in providing health
care coverage to the U.S. population, and increase the likelihood that, going forward, Congress’s
attention to health policy issues will involve Medicaid.
The ACA was designed to reduce the number of U.S. citizens without health insurance by
preserving the existing system of employer-based health insurance, making changes to the
individual insurance market, and expanding coverage to the uninsured through Medicaid and
health insurance exchanges (also referred to as marketplaces).13 Under the ACA, Medicaid and
(...continued)
states operate their programs within the federal requirements, states are entitled to federal Medicaid matching funds.
Medicaid is also an individual entitlement, which means that anyone eligible and enrolled in Medicaid under his or her
state’s eligibility standards is guaranteed Medicaid coverage.
10 The state plan outlines Medicaid eligibility standards, provider requirements, payment methods, and health benefit
packages among other program design criteria. Although this report describes federal Medicaid requirements, a number
of these requirements can be waived, with approval from the Secretary of Health and Human Services (HHS), as
discussed in the subsection on waivers.
11 See “Benefits” section for a discussion of these benefits.
12 For more information see CRS Report R42978, Comparing Medicaid and Exchanges: Benefits and Costs for
Individuals and Families.
13 Exchanges were established under the ACA as market places where certain individuals and businesses can purchase
private health insurance. For more information about the exchanges, see CRS Report R42663, Health Insurance
Exchanges Under the Patient Protection and Affordable Care Act (ACA), by Bernadette Fernandez and Annie L. Mach.
Congressional Research Service
2
Medicaid: An Overview
the exchanges are envisioned to work in tandem to provide a continuous source of subsidized
coverage for lower-income individuals and families.14 Medicaid agencies are required to
coordinate with the exchanges to educate people about new health insurance options and assist
them in navigating the enrollment process.
This report describes the basic elements of Medicaid, focusing on who is eligible, what services
are covered, how enrollees share in the cost of care, how the program is financed, and how
providers are paid. The report also explains waivers, program integrity activities, and the dual-
eligible population. In addition, the report describes the following selected issues: the ACA
Medicaid expansion, the impact of the ACA health insurance annual fee on Medicaid, and the
ACA maintenance of effort (MOE) with respect to Medicaid eligibility.
Eligibility
Eligibility for Medicaid is determined by both federal and state law, whereby states set individual
eligibility criteria within federal minimum standards. Individuals must meet both categorical
(e.g., elderly, individuals with disabilities, children, pregnant women, parents, certain nonelderly
childless adults) and financial (i.e., income and sometimes assets limits) criteria.15 In addition,
individuals need to meet federal and state requirements regarding residency, immigration status,
and documentation of U.S. citizenship. Some eligibility groups are mandatory, meaning that all
states with a Medicaid program must cover them; others are optional. States are permitted to
apply to CMS for a waiver of federal law to expand health coverage beyond the mandatory and
optional groups listed in federal statute (see the “Medicaid Program Waivers” section for more
information about waivers).
If a state participates in Medicaid, the following are examples of groups that must be provided
Medicaid coverage:
• poor families that meet the financial requirements (based on family size) of the
former Aid to Families with Dependent Children (AFDC) cash assistance
program;
• pregnant women and children through age 18 with family income at or below
133% of the federal poverty level (FPL);16
• low-income individuals who are age 65 and older, or blind, or who are under age
65 and disabled who qualify for cash assistance under the Supplemental Security
Income (SSI) program;
• recipients of adoption assistance and foster care (who are under age 18) under
Title IV–E of the Social Security Act;
14 For more information, see CRS Report R42978, Comparing Medicaid and Exchanges: Benefits and Costs for
Individuals and Families.
15 Some groups, such as young people under the age of 26 who have aged out of foster care, are eligible for Medicaid
coverage without regard to the youths’ income and assets.
16 The poverty guidelines (also referred to as the federal poverty level) are a version of the federal poverty measure.
They are issued each year in the Federal Register by the Department of Health and Human Services (HHS). The
guidelines are a simplification of the poverty thresholds for use for administrative purposes—for instance, determining
financial eligibility for certain federal programs.
Congressional Research Service
3
Medicaid: An Overview
• certain individuals who age out of foster care, up to age 26, and do not qualify
under other mandatory groups noted above; and
• certain groups of legal permanent resident immigrants (e.g., refugees for the first
seven years after entry into the United States; asylees for the first seven years
after asylum is granted; lawful permanent aliens with 40 quarters of creditable
coverage under Social Security; immigrants who are honorably discharged U.S.
military veterans) who meet all other financial and categorical Medicaid
eligibility requirements.
Examples of groups that states may provide Medicaid to include
• pregnant women and infants with family income between 133% and 185% of the
FPL;
• certain individuals who qualify for nursing facility or other institutional care and
have incomes up to 300% of SSI benefit level, referred to as “the 300 percent
rule”;
• “medically needy” individuals who are members of one of the broad categories
of Medicaid covered groups (i.e., are aged, have a disability, or are in families
with children), but do not meet the applicable income requirements and, in some
instances, assets requirements for those eligibility pathways;17 and
• working people with disabilities.
Beginning in 2014, states have the option to expand Medicaid eligibility beyond the historical
categorical eligibility groups to all citizens under age 65, who otherwise are not eligible for
Medicaid with income at or below 133% of FPL (i.e., the ACA Medicaid expansion). The income
limit is effectively 138% of FPL (after adjusting for a 5% income disregard applicable if
individuals are at the highest income limits for coverage).18 (For more information about the ACA
Medicaid expansion, see “ACA Medicaid Expansion.”)
Modified Adjusted Gross Income (MAGI)
As of January 1, 2014, the modified adjusted gross income (MAGI) rules are used in determining
eligibility for most of Medicaid’s nonelderly populations, including the ACA Medicaid
expansion.19 This change could mean some individuals currently eligible for Medicaid would no
17 For these groups, states are required to allow individuals to spend down to the medically needy income standard by
incurring and paying medical expenses.
18 42 CFR §435.603(d)(4).
19 Under ACA, certain groups are exempt from income eligibility determinations for Medicaid based on MAGI. Prior
law's income determination rules under Medicaid will continue to be used for determining eligibility for the following
groups: (1) individuals who are eligible for Medicaid through another federal or state assistance program (e.g., foster
care children and individuals receiving SSI), (2) the elderly, (3) certain disabled individuals who qualify for Medicaid
on the basis of being blind or disabled without regard to whether the individual is eligible for SSI, (4) the medically
needy, and (5) enrollees in a Medicare Savings Program (e.g., Qualified Medicare Beneficiaries for whom Medicaid
pays the Medicare premiums or coinsurance and deductibles). In addition, MAGI does not affect eligibility
determinations through Express Lane enrollment (to determine whether a child has met Medicaid or CHIP eligibility
requirements), for Medicare prescription drug low-income subsidies, or for determinations of eligibility for Medicaid
long-term services and supports.
Congressional Research Service
4
Medicaid: An Overview
longer be found eligible (and vice versa) due to the change in the way income is counted for
Medicaid eligibility. For example, the conversion to MAGI might make some children that are
currently eligible for Medicaid ineligible because stepparent income is often excluded from
current income counting rules but included for MAGI. On the other hand, children currently not
eligible might become eligible because MAGI excludes child support income, which is generally
included for current income counting rules.20
MAGI is defined as the Internal Revenue Code’s adjusted gross income (AGI, which reflects a
number of deductions, including trade and business deductions, losses from sale of property, and
alimony payments) increased (if applicable) by tax-exempt interest and income earned by U.S.
citizens or residents living abroad.21 While the Internal Revenue Service’s definition of MAGI
excludes non-taxable social security benefits, P.L. 112-56, enacted on November 21, 2011,
changed the definition of income for Medicaid eligibility to include such non-taxable social
security benefits.
Under the MAGI counting rules, the state will look at the individual’s MAGI, deduct 5%, which
the law provides as a standard disregard, and compare that income to the new income standards
set by each state in coordination with CMS. See Table A-1 for the new MAGI-based eligibility
levels adjusted for the 5% disregard effective January 1, 2014.
The transition to the MAGI income rules has significant implications for the Medicaid eligibility
determination process. It represents a major change in terms of the types of information collected
(such as what counts as income) and the definition of household (such as the inclusion of the
income of a step parent) compared to former Medicaid eligibility rules. These changes necessitate
a redesign of the existing Medicaid eligibility and enrollment systems for each state. The system
must be integrated with the exchanges as well as with other social programs that serve low-
income populations (e.g., the Temporary Assistance for Needy Families [TANF] and the
Supplemental Nutrition Assistance Program [SNAP]).
Medicaid Enrollment Trends
Figure 1 shows historical and projected Medicaid enrollment for FY2000 through FY2021 (see
Table B-1 for state-by-state Medicaid enrollment for FY2010). The figure shows steady
enrollment growth, especially among non-disabled children and adults, punctuated by years of
faster enrollment growth in periods immediately after recessions.22 During periods of economic
downturn, state Medicaid programs face program enrollment increases at a faster rate because job
and income losses make more people eligible. One study estimated that for every 1% increase in
the national unemployment rate, Medicaid enrollment increases by 1 million individuals.23
20 John L. Czajka, Translating Modified Adjusted Gross Income (MAGI) to Current Monthly Income, State Health
Access Reform Evaluation, May 2013.
21 For more information, see CRS Report R41997, Definition of Income for Certain Medicaid Provisions and Premium
Credits in ACA.
22 According to the National Bureau of Economic Analysis, the United States was in recession from March 2001
through November 2001 and December 2007 through June of 2009.
23 John Holahan and A. Bowen Garrett, Rising Unemployment, Medicaid and the Uninsured, Kaiser Commission on
Medicaid and the Uninsured, Publication #7850, January 2009.
Congressional Research Service
5
Medicaid: An Overview
The ACA changes to Medicaid eligibility (including, but not limited to, the ACA Medicaid
expansion) are projected to add 8.6 million people to Medicaid in FY2014 and 18.3 million
people by FY2021. About 83% of new adult enrollees are projected to be “newly eligible” (i.e.,
eligible for Medicaid through the ACA Medicaid expansion), while 17% are projected to be
individuals who would have been eligible for Medicaid prior to the ACA changes, but were not
enrolled.24
Figure 1. Past and Projected Medicaid Enrollment, by Population
FY2000–FY2021
Source: Christopher J. Truffer, John D. Klemm, and Christian J. Wolfe, et al., 2012 Actuarial Report on the
Financial Outlook for Medicaid, Centers for Medicare & Medicaid Services’ Office of the Actuary, 2013.
Notes: Enrol ment is measured by “person-year equivalents,” which is the average enrol ment over the course
of the year.
For purposes of this figure, “Newly Eligible Adults” are adult enrollees who are newly eligible in 2014 and later
as a result of the expanded eligibility criteria in the ACA. “Children of Newly Eligible Adults” are defined here as
the dependent children of newly eligible adult enrollees, even if these children were eligible under current
criteria. Currently eligible adults who become enrolled as a result of the publicity and outreach efforts associated
with the ACA are included with “Adults,” and their dependent children are included with “Children” in this
figure.
Share of Enrollment Versus Expenditures, by Population
Different Medicaid enrollment groups have very different service utilization patterns. Larger
enrollment groups account for a smaller proportion of the Medicaid expenditures and some
24 Office of the Actuary (OACT), Centers for Medicare & Medicaid Services, U.S. Department of Health & Human
Services, 2012 Actuarial Report on the Financial Outlook for Medicaid, 2013.
Congressional Research Service
6
Medicaid: An Overview
smaller enrollment groups are responsible for a larger proportion of Medicaid expenditures. As
shown in Figure 2, for FY2011, roughly half of Medicaid enrollees were children without
disabilities, who accounted for only about 20% of Medicaid’s total benefit spending. The next-
largest enrollee group—adults—accounted for about 24% of all enrollees, but only about 15% of
benefit expenditures. In contrast, individuals with disabilities represented about 17% of Medicaid
enrollees, but accounted for the largest share of Medicaid benefit spending (about 44%). Finally,
the elderly represented about 9% of Medicaid enrollees, but about 20% of all benefit spending.
While these statistics vary somewhat from year to year and state to state, the patterns described
above generally hold true across years.25
Figure 2. Estimated Medicaid Enrollment and Expenditures for Benefits, by
Enrollment Group as a Share of Total
FY2011
Source: Christopher J. Truffer, John D. Klemm, and Christian J. Wolfe, et al., 2012 Actuarial Report on the
Financial Outlook for Medicaid, Centers for Medicare & Medicaid Services’ Office of the Actuary, 2013.
Notes: Totals and components exclude DSH expenditures (i.e., payments to hospitals treating large numbers of
low-income patients), territory enrollees and expenditures, and other adjustments.
Benefits
Federal law provides two primary benefit packages for state Medicaid programs: (1) traditional
benefits and (2) alternative benefit plans (ABPs). Each of these packages is summarized below. In
addition, states can use waiver authority (e.g., Section 1115 of the Social Security Act) to tailor
25 Office of the Actuary (OACT), Centers for Medicare & Medicaid Services, U.S. Department of Health & Human
Services, 2012 Actuarial Report on the Financial Outlook for Medicaid, 2013.
Congressional Research Service
7
Medicaid: An Overview
benefit packages to specified Medicaid subgroups (see “Medicaid Program Waivers” for more
information about Section 1115 waivers).
Traditional Medicaid Benefits
The traditional Medicaid program requires states to cover a wide array of mandatory services
(e.g., inpatient hospital care, lab/x-ray services, physician care, nursing facility services for
individuals aged 21 and over). In addition, states may provide optional services, some of which
are commonly covered (e.g., personal care services for the frail elderly and individuals with
disabilities who need long-term services and supports, prescribed drugs, physician-directed
clinical services, physical therapy, and prosthetic devices).
States define the specific features of each covered benefit within four broad federal guidelines:
• Each service must be sufficient in “amount, duration, and scope” to reasonably
achieve its purpose. States may place appropriate limits on a service based on
such criteria as medical necessity.
• Within a state, services available to the various categorically needy groups26 must
be equal in amount, duration, and scope. These requirements are the
“comparability” rule.
• With certain exceptions, the amount, duration, and scope of benefits must be the
same statewide, referred to as the “statewideness” rule.
• With certain exceptions, enrollees must have “freedom of choice” among health
care providers or managed care entities participating in Medicaid.
The breadth of coverage for a given benefit can, and does, vary from state to state, even for
mandatory services. For example, states may place different limits on the amount of inpatient
hospital services a beneficiary can receive in a year (e.g., up to 15 inpatient days per year in one
state versus unlimited inpatient days in another state)—as long as applicable requirements are met
regarding comparability; statewideness; and sufficiency of amount, duration, and scope.
Exceptions to state limits may be permitted under circumstances defined by the state.
The federal Medicaid statute also delineates special benefits or special rules regarding certain
benefits for targeted populations. For example:
• Most Medicaid children under age 21 are entitled to Early and Periodic
Screening, Diagnostic and Treatment (EPSDT) services. Under EPSDT, children
receive well-child visits, immunizations, laboratory tests, and other screening
services at regular intervals. In addition, medical care that is necessary to correct
or ameliorate identified defects, physical and mental illness, and other conditions
must be provided, including some services that states may not otherwise cover in
their Medicaid programs.
26 Categorically needy groups include families with children, the elderly, persons with disabilities, and certain other
pregnant women and children who meet former AFDC- and SSI-related financial standards, or have income below
specified percentages of the FPL. Beginning in 2014, or earlier at state option, this classification will also include non-
elderly, non-pregnant adults.
Congressional Research Service
8
Medicaid: An Overview
• Unauthorized aliens (i.e., illegal aliens, foreign nationals who are not lawfully
present in the United States) are ineligible for Medicaid. Individuals who meet
the eligibility requirements for Medicaid but are ineligible due to immigration
status may receive Medicaid coverage for emergency conditions (i.e., emergency
Medicaid) only, which includes costs associated with emergency labor and
delivery for pregnant women and excludes costs for organ transplants.
• Special benefit rules apply to optional medically needy populations (for more
information about the medically needy see “Eligibility”). States may offer a more
restrictive benefit package than is provided to categorically needy populations,
but at a minimum, must offer (1) prenatal, delivery, and postpartum services for
pregnant women, (2) ambulatory services as defined in the state Medicaid plan
for individuals under 18 and those entitled to institutional services, and (3) home
health services for individuals entitled to nursing facility care.27
• Medicaid law gives states the option to extend home- and community-based
services (HCBS) to Medicaid enrollees under the HCBS state plan option
(Section 1915[i] of the Social Security Act) without requiring a Secretary-
approved waiver for this purpose (under Sections 1915[c] or 1115 of the Social
Security Act).
Alternative Benefit Plans (ABPs)
Alternative benefit plans (ABPs) are a Medicaid benefit structure that has different requirements
than the traditional Medicaid benefits.28 For example, under ABPs states may waive the
“statewideness” and “comparability” requirements that apply under traditional Medicaid. This
flexibility permits the state to define populations that will be served and the specific benefit
packages that will apply. In general, ABPs may cover fewer benefits than traditional Medicaid,
but there are some requirements, such as coverage of EPSDT services, family planning services
and supplies, and both emergency and non-emergency transportation to and from providers that
might make them more generous than private insurance.
States that choose to implement the ACA Medicaid expansion are required to provide the
individuals newly eligible for Medicaid through the expansion Medicaid services through ABPs
27 Broader requirements apply if a state has chosen to provide coverage for medically needy persons in institutions for
mental disease and intermediate care facilities for the mentally retarded. In these cases, states are required to cover the
same services as those which are mandatory for the categorically needy, or alternatively, the care and services
described in 7 of the first 24 paragraphs in the federal Medicaid statute defining covered mandatory and optional
services.
28 Prior to the ACA, ABPs were referred to as benchmark and benchmark-equivalent benefit packages (as per the
Deficit Reduction Act of 2005, P.L. 109-171). Pre-ACA Benchmark coverage included one of the four benchmark
options: (1) the standard Blue Cross/Blue Shield preferred provider option offered through the Federal Employees
Health Benefit program; (2) State employee coverage that is offered and generally available to state employees; (3)
commercial HMO with the largest insured commercial non-Medicaid enrollment in the state; and/or (4) Secretary-
approved coverage, a benefit package the Secretary has determined to provide coverage appropriate to meet the needs
of the population. Pre-ACA Benchmark-equivalent coverage was required to have the same aggregate actuarial value as
one of the benchmark plans and was also required to include (1) inpatient and outpatient hospital services; (2) physician
services; (3) lab and x-ray services; (4) emergency care; (5) well-child care, including immunizations; (6) prescribed
drugs; (7) mental health services; and (8) other appropriate preventive care (designated by the Secretary). Such
coverage was also required include at least 75% of the actuarial value of coverage under the applicable ABP for vision
care and hearing services (if any).
Congressional Research Service
9
Medicaid: An Overview
(with exceptions for selected special-needs subgroups). In addition, states have the option to
provide ABP coverage to other subgroups.
ABPs must cover at least the 10 essential health benefits (EHBs) that also apply to the qualified
health plans offered in the exchanges.29 In addition, ABP coverage must comply with the federal
requirements for mental health parity,30 and special rules also apply with regard to prescription
drugs, rehabilitative and habilitative services and devices, and preventive care.
Rules regarding how states must design their Medicaid ABPs to meet the ACA requirements have
been established through regulation.31 As a part of the benefit design process, CMS established a
policy whereby states can use benefit substitution as a tool to fill in coverage gaps to ensure that
all EHBs are represented and/or to align their benefit plans with traditional Medicaid state plan
coverage and/or with exchange coverage.32 This substitution policy has the potential to make
Medicaid ABP benefit coverage look very different than the benchmark and benchmark-
equivalent benefit coverage that existed prior to ABPs.
Medicaid Benefits by Eligibility Classification
Table 1 provides examples of Medicaid benefits available by selected eligibility classifications.
As illustrated, different Medicaid subpopulations may have access to quite varied benefit
packages.
Table 1. Examples of Medicaid Benefits, by Eligibility Classification
Eligibility
Classification
Traditional
Medicaid
Section 1115
Non-Elderly, Non-
Type of Benefit
Populationsa
Medically Needy
Waivers
Pregnant Adults
Mandatory -Inpatient
hospital
-Prenatal and
-Negotiated between -ABPs
delivery services
the states and the
-Nursing facility care
Secretary of HHS
(age 21+)
-Ambulatory services
(< age 18; individuals
-EPSDT (< age 21)
entitled to
institutional care)
29 The 10 essential health benefits required under the ACA include (1) ambulatory patient services, (2) emergency
services, (3) hospitalization, (4) maternity and newborn care, (5) mental health and substance use disorder services
(including behavioral health treatment), (6) prescribed drugs, (7) rehabilitative and habilitative services and devices, (8)
laboratory services, (9) preventive and wellness services and chronic disease management, and (10) pediatric services,
including oral and vision care.
30 Health insurance coverage for mental illness had historically been less generous than that for other physical illnesses.
Mental health parity is a response to this disparity in insurance coverage, and generally refers to the concept that health
insurance coverage for mental health services should be offered on par with covered medical and surgical benefits. For
more information about mental health parity, see CRS Report R41249, Mental Health Parity and the Patient Protection
and Affordable Care Act of 2010, by Amanda K. Sarata.
31 Centers for Medicare and Medicaid Services (CMS), “Medicaid and Health Insurance Programs: Essential Health
Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes, and Premiums and Cost
Sharing; Exchanges: Eligibility and Enrollment,” Final Rule, 78 Federal Register, July 15, 2013.
32 For a discussion of the substitution process, see CRS Report R43328, Medicaid Coverage of Long-Term Services and
Supports, by Kirsten J. Colello.
Congressional Research Service
10
Medicaid: An Overview
Eligibility
Classification
-Physicians
-Home health for
those entitled to
-Federally qualified
nursing facility care
health centers
-Family planning
-Pregnancy-related
services
Optional -Clinic
services
-Nursing facility care
-Negotiated between -For special needs
the states and
subgroups, option to
-Prescribed drugs
-Clinic services
Secretary of HHS
have same benefits
-Physical,
-Physical,
as categorically
occupational, and
occupational, and
needy or enrol in an
speech therapy
speech therapy
ABP
-Other practitioners
-Other practitioners
-Dental
-Dental
Traditional Benefits
Traditional Benefits
Traditional Benefits
Not applicable
ABPs with
Versus ABPs
exceptions
Sources: Title XIX of the Social Security Act and related federal guidance.
Note: With respect to medically needy groups, broader requirements apply if a state has chosen to provide
coverage for medically needy individuals in intermediate care facilities for the mentally retarded or in institutions
for mental diseases. In these cases, states are required to cover the same services as those which are mandatory
for the categorically needy, or alternatively, the care and services described in 7 of the first 24 paragraphs in the
federal Medicaid statute defining covered mandatory and optional services.
ABP—Alternative Benefit Plans
EPSDT—Early and Periodic Screening, Diagnostic and Treatment services
HHS—Health & Human Services
a. Traditional Medicaid populations include the elderly, individuals with disabilities, children, and pregnant
women.
Service Delivery Models
Benefits are made available to Medicaid enrollees via two alternative service delivery systems:
fee-for-service or managed care. Under the “fee for service” (FFS) delivery system, health care
providers are paid by the state Medicaid program for each service provided to a Medicaid
enrollee. Under the “managed care” delivery system, Medicaid enrollees get most or all of their
services from an organization under contract with the state. States have traditionally used the fee-
for-service service delivery model for Medicaid, but since the 1990s, the share of Medicaid
enrollees covered by the managed care model has increased dramatically. As of July 2011, more
than 74% of Medicaid enrollees were covered by some form of managed care.33
There are three types of Medicaid managed care:
• Managed care organizations (MCOs)—states contract with MCOs to provide a
comprehensive package of benefits to certain Medicaid enrollees. States usually
33 Centers for Medicare & Medicaid Services, Medicaid Managed Care Enrollment Report, November 2012.
Congressional Research Service
11
Medicaid: An Overview
pay the MCOs on a capitated basis, which means the states prospectively pay the
MCOs a fixed monthly rate per enrollee to provide or arrange for most health
care services.
• Primary care case management (PCCM)—states contract with primary care
providers to provide case management services to Medicaid enrollees. Typically,
under PCCM, the primary care provider receives a monthly case management fee
per enrollee for coordination of care, but the provider continues to receive FFS
payments for the medical care services utilized by Medicaid enrollees.
• Limited benefit plans—these plans look like MCOs in that states usually
contract with a plan and pay them on a capitated basis. The difference is that
limited benefit plans provide only one or two Medicaid benefits (i.e., behavioral
health or dental services).
While managed care has largely been used for Medicaid subgroups that do not have chronic
health care needs, some states are turning to this type of service delivery system for the elderly
and individuals with disabilities.
Medicaid Service Spending
Figure 3 below shows the nationwide distribution of Medicaid expenditures across broad
categories of service for FY2012. These data illustrate that roughly one-third of benefit spending
is for acute care services, while capitated payments under managed care arrangements account for
another third, and LTSS represent slightly more than one-fourth of Medicaid benefit payments. In
general, when other sources of insurance/payment are available (including Medicare), Medicaid
wraps around that coverage.34
34 For related details, see Federal regulations at 42 CFR 433.135, 433.138, and 433.152.
Congressional Research Service
12
Medicaid: An Overview
Figure 3. Medicaid Medical Assistance Payments, by Category
FY2012
Source: Centers for Medicare & Medicaid Services, CMS-64 Data (base expenditures), FY2012.
Notes: Medical assistance expenditures exclude Medicaid expenditures for administrative activities. DSH stands
for “disproportionate share hospital” payments, which are provided in addition to Medicaid payments otherwise
received by certain qualifying hospitals.
Beneficiary Cost-Sharing
Federal statutes and regulations address the circumstances under which enrollees may share in the
costs of Medicaid, both in terms of participation-related cost-sharing (e.g., monthly premiums)
and point-of-service cost-sharing (e.g., copayments to providers). States can require certain
beneficiaries to share in the cost of Medicaid services, but there are limits on (1) the amounts that
states can impose, (2) the beneficiary groups that can be required to pay, and (3) the services for
which cost-sharing can be charged.
In general, premiums and enrollment fees are often prohibited. However, premiums may be
imposed on enrollees with incomes above 150% of FPL. In state fiscal year (SFY) 2013, 39 states
had at least one group able to participate in Medicaid by paying a premium, with a total of 59
different premium programs.35
States can impose cost sharing, such as copayments, coinsurance, deductibles, and other similar
charges, on most Medicaid-covered benefits, both inpatient and outpatient services, but cost
35 Vernon K. Smith, Robin Rudowitz, and Laura Snyder, Medicaid in a Historic Time of Transformation: Results from
a 50-State Medicaid Budget Survey for State Fiscal Years 2013 and 2014, Kaiser Commission on Medicaid and the
Uninsured, October 2013
Congressional Research Service
13
Medicaid: An Overview
sharing cannot be imposed for emergency services and family planning services and supplies.
Some subgroups of beneficiaries are exempt from cost sharing (e.g., children under 18 years of
age and pregnant women). The cost-sharing amounts that can be charged vary with income. In
SFY2013, 46 states (including the District of Columbia) reported having copayment
requirements.36
Higher beneficiary cost-sharing is allowed in certain circumstances, and recent ACA regulations
modified some of these provisions.37 For example, for non-emergency care in a hospital
emergency department, a maximum $8 payment can be charged to individuals with family
income at or below 150% of FPL,38 and there is no specified limit for individuals with income
above 150% of FPL when alternative providers are available.
The aggregate cap on all out-of-pocket cost-sharing is generally up to 5% of monthly or quarterly
income.39
Financing40
The federal government and the states jointly finance Medicaid. The federal government
reimburses states for a portion (i.e., the federal share) of each state’s Medicaid program costs.
Because federal Medicaid funding is an open-ended entitlement to states, there is no upper limit
or cap on the amount of federal Medicaid funds a state may receive. In FY2012, Medicaid
expenditures totaled $431 billion. The federal share totaled $249 billion and the state share was
$182 billion.41
Federal Share
The federal government’s share of most Medicaid expenditures is established by the federal
medical assistance percentage (FMAP) rate, which is generally determined annually and varies by
state according to each state’s per capita income relative to the U.S. per capita income.42 The
formula provides higher FMAP rates, or federal reimbursement rates, to states with lower per
capita incomes and lower FMAP rates to states with higher per capita incomes.
36 Vernon K. Smith, Robin Rudowitz, and Laura Snyder, Medicaid in a Historic Time of Transformation: Results from
a 50-State Medicaid Budget Survey for State Fiscal Years 2013 and 2014, Kaiser Commission on Medicaid and the
Uninsured, October 2013
37 Department of Health and Human Services, Centers for Medicare and Medicaid Services, Essential Health Benefits
in Alternative Benefit Packages, Eligibility Notices, Fair Hearing and Appeal Processes, and Premiums and Cost
Sharing; Exchanges; Eligibility and Enrollment; Final rule, Federal Register, Vol. 78, No. 135, July 15, 2013.
38 Beginning October 1, 2015, such cost-sharing must be increased by the percentage increase in the medical care
component of the CPI-U for the period of September to September of the preceding calendar year, rounded to the next
higher 5-cent increment.
39 Section 1916A of the Social Security Act.
40 For more information about Medicaid financing and expenditures, see CRS Report R42640, Medicaid Financing and
Expenditures, by Alison Mitchell.
41 Centers for Medicare & Medicaid Services, CMS-64 data.
42 For more detail about the FMAP rate, see CRS Report R42941, Medicaid’s Federal Medical Assistance Percentage
(FMAP), FY2014, by Alison Mitchell and Evelyne P. Baumrucker.
Congressional Research Service
14
Medicaid: An Overview
FMAP rates have a statutory minimum of 50.00% and a statutory maximum of 83.00%.43 In
FY2014, 15 states have the statutory minimum FMAP rate of 50.00% (Rhode Island is slightly
above at 50.11%), and Mississippi has the highest FMAP rate of 73.05% (see Table B-1 for each
state’s FY2014 FMAP rate).
The FMAP rate is used to reimburse states for the federal share of most Medicaid expenditures,
but exceptions to the regular FMAP rate have been made for certain states (e.g., the District of
Columbia and the territories), situations (e.g., during economic downturns), populations (e.g.,
certain women with breast or cervical cancer and individuals in the Qualifying Individuals44
program), providers (e.g., primary care physicians and Indian Health Service facilities), and
services (e.g., family planning and home health services). In addition, the federal share for most
Medicaid administrative costs does not vary by state and is generally 50%.
The ACA includes new FMAP exemptions, including the “newly eligible” FMAP rates and the
“expansion state” FMAP rates. Under the “newly eligible” FMAP rate, from 2014 through 2016,
states receive a 100% FMAP rate for the cost of individuals who are “newly eligible” for
Medicaid due to the ACA expansion. This “newly eligible” FMAP rate phases down to 95% in
2017, 94% in 2018, 93% in 2019, and 90% thereafter.45 The “expansion state” FMAP rate is
available for individuals in “expansion states
” who were eligible for Medicaid on March 23,
2010, and are in the new eligibility group for nonelderly, nonpregnant adults at or below 133%
FPL. The formula46 used to calculate the “expansion state” FMAP rates is based on a state's
regular FMAP rate, so the “expansion state” FMAP rates will vary from state to state until 2019,
at which point the “newly eligible” FMAP and the “expansion state” FMAP rates will converge to
93%.
Table 2. FMAP Rates for ACA Medicaid Expansion
2014 2015 2016 2017 2018 2019 2020+
“Newly eligible”
100% 100% 100% 95% 94% 93% 90%
Adults in all States
Certain Individuals
75%-
80%-
85%-
86%-
90%-
93% 90%
in “Expansion
92%
93%
95%
93%
93%
states”
Source: Prepared by CRS.
Notes: For the calculation of the “expansion state” FMAP rates, the lower bound is a state with a regular FMAP
rate of 50% (which is the statutory minimum), and the upper bound is a state with a regular FMAP rate of 83%
(which is the statutory maximum).
43 Section 1905(b) of the Social Security Act.
44 States are required to pay Medicare Part B premiums for Medicare beneficiaries with income between 120% and
135% FPL and limited assets (referred to as “qualifying individuals”), up to a specified dollar allotment.
45 The “newly eligible” FMAP rates are available for these specific years, regardless of whether a state implements the
ACA Medicaid expansion in 2014 or a later year.
46 Expansion state FMAP formula = [regular FMAP + (newly eligible FMAP – regular FMAP) * transition percentage
equal to 50% in CY2014, 60% in CY2015, 70% in CY2016, 80% in CY2017, 90% in CY2018, and 100% in
CY2019+].
Congressional Research Service
15
Medicaid: An Overview
While most federal Medicaid funding is provided on an open-ended basis, certain types of federal
Medicaid funding are capped. For instance, federal disproportionate share hospital (DSH)47
funding to states cannot exceed a state-specific annual allotment. Also, Medicaid programs in the
territories (i.e., American Samoa, Guam, Northern Mariana Islands, Puerto Rico, and the Virgin
Islands) are subject to annual spending caps.
State Share
The federal government provides broad guidelines to states regarding allowable funding sources
for the state share (also referred to as the non-federal share) of Medicaid expenditures. However,
to a large extent, states are free to determine how to fund their share of Medicaid expenditures. As
a result, there is significant variation from state to state in funding sources.
States can use state general funds (i.e., personal income, sales, and corporate income taxes) and
“other state funds” (i.e., provider taxes,48 local government funds, tobacco settlement funds, etc.)
to finance the state share of Medicaid.49 Federal statute50 allows as much as 60% of the state share
to come from local government funding.51 Federal regulations also stipulate that the state share
not be funded with federal funds (Medicaid or otherwise).52 In SFY2011, on average, 72% of the
state share of Medicaid expenditures was financed by state general funds, and the remaining 28%
was financed by “other state funds.”53
A few funding sources have received a great deal of attention over the past couple of decades
because states have used these funds in some financing mechanisms designed to maximize the
amount of federal Medicaid funds coming to the state. This is referred to as “Medicaid
maximization.”54 In general, some states have used “Medicaid maximization” strategies that
47 For more information about Medicaid DSH payments, see CRS Report R42865, Medicaid Disproportionate Share
Hospital Payments, by Alison Mitchell.
48 States are able to use revenues from health care provider taxes to help finance their share of Medicaid expenditures
as long as the provider tax is broad-based and uniform. Also, states are not allowed to hold the providers harmless for
the cost of the provider tax (i.e., they cannot guarantee that providers receive their money back). In addition, provider
tax revenue is prohibited from exceeding 25% of the state share of Medicaid expenditures. For more information about
provider taxes, see CRS Report RS22843, Medicaid Provider Taxes, by Alison Mitchell.
49 National Association of State Budget Officers, State Expenditure Report: Examining Fiscal 2011-2013 State
Spending, 2013.
50 Section 1902(a)(2) of the Social Security Act.
51 The federal statute allows for the significant use of local funds in financing Medicaid because local governments
financed a significant amount of the health care services provided to low-income individuals prior to the enactment of
Medicaid. (Medicaid and CHIP Payment and Access Commission, Report to the Congress on Medicaid and CHIP,
March 2012.)
52 42 C.F.R. 433.51(c).
53 National Association of State Budget Officers, State Expenditure Report: Examining Fiscal 2011-2013 State
Spending, 2013.
54 National Health Policy Forum at The George Washington University, The Basics: Medicaid Financing, February 4,
2011; U.S. Government Accountability Office, Medicaid Financing: Long-Standing Concerns about Inappropriate
State Arrangements Support Need for Improved Federal Oversight, testimony of Marjorie Kanof before U.S. Congress,
House of Representatives, Committee on Oversight and Government Reform, GAO-08-255T, November 1, 2007;
Andy Schneider and David Rousseau, The Medicaid Resource Book, The Kaiser Commission on Medicaid and the
Uninsured, Publication Number 2236, January 17, 2003; Teresa A. Coughlin and Stephen Zuckerman, States’ Use of
Medicaid Maximization Strategies to Tap Federal Revenues: Program Implications and Consequences, The Urban
Institute, June 2002.
Congressional Research Service
16
Medicaid: An Overview
involve the coordination of fund sources, such as provider taxes and intergovernmental transfers
(IGTs),55 and payment policies, such as DSH and other supplemental payments56 to draw down
federal Medicaid funds without expending many, if any, state general funds.
Expenditures
The cost of Medicaid, like most health expenditures, has generally increased at a rate significantly
faster than the overall rate of U.S. economic growth, as measured by Gross Domestic Product
(GDP).57 In the past, much of Medicaid’s expenditure growth has been due to federal or state
expansions of Medicaid eligibility criteria,58 but per-enrollee costs for Medicaid have also
increased faster than the economy. However, when compared to other forms of health insurance,
Medicaid per-enrollee expenditures are relatively low.
One of the major factors impacting Medicaid spending is the economy.59 Also, state-specific
factors, such as policy decisions and demographics, impact Medicaid expenditures and cause
Medicaid spending to vary widely from state to state. In 2011 and 2012, Medicaid experienced
unusually slow rates of growth, which is the result of improved economic conditions and state
efforts to limit the growth of Medicaid expenditures due to the expiration of the temporary
increase of the FMAP rate.60,61
Figure 4 shows actual Medicaid expenditures from FY1997 to FY2011 and projected Medicaid
expenditures from FY2012 through FY2021 (see Table B-1 for state-by-state expenditures for
FY2012). These expenditures are broken down by state and federal expenditures. In FY2012,
Medicaid spending on services and administrative activities in the 50 states, the District of
Columbia, and the territories totaled $431 billion. Medicaid expenditures are estimated to grow to
$795 billion in FY2021.62
55 IGTs are transfers of public funds between government entities, such as from counties to states or between state
agencies. This financing mechanism is commonly used to enable states and local governments to carry out shared
functions.
56 Supplemental payments are Medicaid payments made to providers that are separate from and in addition to the
standard payment rates for services rendered to Medicaid enrollees. Often, providers receive supplemental payments in
a lump sum.
57 Christopher J. Truffer, John D. Klemm, and Christian J. Wolfe, et al., 2012 Actuarial Report on the Financial
Outlook for Medicaid, Centers for Medicare & Medicaid Services’ Office of the Actuary, 2013.
58 Rachel Garfield, Lisa Clemans-Cope, and Emily Lawton, et al., Enrollment-Driven Expenditure Growth: Medicaid
Spending during the Economic Downturn, FFY2007-2010, Kaiser Commission on Medicaid and the Uninsured,
Publication #8309, May 2012.
59 Christopher J. Truffer, John D. Klemm, and Christian J. Wolfe, et al., 2012 Actuarial Report on the Financial
Outlook for Medicaid, Centers for Medicare & Medicaid Services’ Office of the Actuary, 2013.
60 For FY2009 through FY2011, the federal share of Medicaid expenditures was higher than usual due to the temporary
FMAP increase provided to states from October 1, 2008, through June 30, 2011. The temporary FMAP increase was
originally provided through the American Recovery and Reinvestment Act of 2009 (P.L. 111-5) and extended through
P.L. 111-226.
61 Christopher J. Truffer, John D. Klemm, and Christian J. Wolfe, et al., 2012 Actuarial Report on the Financial
Outlook for Medicaid, Centers for Medicare & Medicaid Services’ Office of the Actuary, 2013; Anne B. Martin, Micah
Hartman, and Lekha Whittle, “National Health Spending in 2012: Rate of Health Spending Growth Remained Low for
the Fourth Consecutive Year,” Health Affairs, vol. 33, no. 1 (January 2014).
62 U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, Form CMS-64 data,
April 16, 2012; Christopher J. Truffer, John D. Klemm, and Christian J. Wolfe, et al., 2012 Actuarial Report on the
Financial Outlook for Medicaid, Centers for Medicare & Medicaid Services’ Office of the Actuary, 2013.
Congressional Research Service
17
Medicaid: An Overview
Figure 4. Federal and State Actual and Projected Medicaid Expenditures
(FY1997 to FY2021; dollars in billions)
Source: Actual expenditures are from Form CMS-64 Data, and the projected expenditures are from the CMS
Office of the Actuary’s 2012 Actuary Report on the Financial Outlook for Medicaid.
Notes: The expenditures shown in this figure include al Medicaid expenditures, which include both
administrative and benefit spending.
Historically, in a typical year, the average federal share of Medicaid expenditures has been about
57%, which means the average state share is about 43%. However, the federal government’s share
of Medicaid expenditures is expected to increase with the implementation of the ACA Medicaid
expansion because the federal government is funding a vast majority of the cost of the expansion
through the “newly eligible” and the “expansion state” FMAP rates. By FY2020, the average
federal share of Medicaid is estimated to be 60%.63
Provider Payments
For the most part, states establish their own payment rates for Medicaid providers. Federal statute
requires that these rates be sufficient to enlist enough providers so that covered benefits will be
available to Medicaid enrollees at least to the same extent they are available to the general
population in the same geographic area.64
63 Congressional Budget Office, An Overview of the Medicaid Program, September 18, 2013; Christopher J. Truffer,
John D. Klemm, and Christian J. Wolfe, et al., 2012 Actuarial Report on the Financial Outlook for Medicaid, Centers
for Medicare & Medicaid Services’ Office of the Actuary, 2013.
64 Section 1902(a)(30)(A) of the Social Security Act.
Congressional Research Service
18
Medicaid: An Overview
Low Medicaid physician payment rates in many states and their impact on provider participation
have been perennial concerns for policy makers. Still, in recent years, under recessionary budget
pressures, many states have reduced Medicaid provider payment rates. Improvements to state
finances for SFY2013 resulted in more states enhancing rather than restricting provider rates for
the first time since SFY2009.65
The ACA requires that Medicaid payment rates for certain primary care services be raised to what
Medicare pays for these services for CY2013 and CY2014. The federal government is picking up
the entire cost of that increase in primary care rates (i.e., the difference between Medicare
payment rates and the existing Medicaid payment rates as of July 1, 2009) for those two years.
In some cases, states make supplemental payments to Medicaid providers that are separate from
and in addition to, the standard payment rates for services rendered to Medicaid enrollees. Often,
providers receive supplemental payments in a lump sum. States are permitted to make
supplemental payments to providers, but federal regulations specify upper payment limit (UPLs),
which prohibit using federal matching funds for Medicaid fee-for-service payments in excess of
what would have been paid under Medicare payment principles.66 The institutions subject to the
UPL requirement are hospitals (separated into inpatient services and outpatient services), nursing
facilities, intermediate care facilities for the intellectually disabled, and freestanding non-hospital
clinics.
Medicaid DSH payments are one type of supplemental payment, and federal statute requires that
states make Medicaid DSH payments to hospitals treating large numbers of low-income patients.
In FY2012, federal DSH allotments totaled $11.4 billion.67 The ACA makes aggregate reductions
in Medicaid DSH allotments for FY2014 through FY2020. The Middle Class Tax Relief and Job
Creation Act of 2012 (P.L. 112-96) and the American Taxpayer Relief Act of 2012 (P.L. 112-240)
extended these DSH reductions to FY2021 and FY2022. In FY2023, DSH allotments are
scheduled to rebound to the pre-ACA reduced levels.
Medicaid Program Waivers
The Social Security Act authorizes several waiver and demonstration authorities to provide states
with the flexibility to operate their Medicaid programs. Each waiver authority has a distinct
65 Vernon K. Smith, Robin Rudowitz, and Laura Snyder, Medicaid in a Historic Time of Transformation: Results from
a 50-State Medicaid Budget Survey for State Fiscal Years 2013 and 2014, Kaiser Commission on Medicaid and the
Uninsured, October 2013; Vernon K. Smith, Robin Rudowitz, and Laura Snyder, Medicaid Today; Preparing for
Tomorrow A Look at Medicaid Spending, Enrollment and Policy Trends: Results from a 50-State Medicaid Budget
Survey for State Fiscal Years 2012 and 2013, Kaiser Commission on Medicaid and the Uninsured, October 2012; and
Vernon K. Smith, Robin Rudowitz, and Laura Snyder, Moving Ahead Amid Fiscal Challenges: A Look at Medicaid
Spending, Coverage and Policy Trends, Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2011
and 2012, Kaiser Commission on Medicaid and the Uninsured, October 2011.
66 In practice, the UPL rules simply ensure that Medicaid does not pay a class of providers in the aggregate more than
Medicare would have paid for the same or comparable services delivered by those same institutions. (Medicaid and
CHIP Payment and Access Commission, Medicaid UPL Supplemental Payments, November 2012.)
67 DSH allotments are different from DSH payments. Allotments reflect the maximum amount of federal DSH funding
available to states, and DSH payments are the amounts paid to hospitals. Each state receives an annual DSH allotment,
which is the maximum amount of federal matching funds that each state is permitted to claim for Medicaid DSH
payments. For more information about Medicaid DSH payments, see CRS Report R42865, Medicaid Disproportionate
Share Hospital Payments, by Alison Mitchell.
Congressional Research Service
19
Medicaid: An Overview
purpose and specific requirements. Under the various waiver authorities, states may try new or
different approaches to the delivery of health care services or adapt their programs to the special
needs of particular geographic areas or groups of Medicaid enrollees. The primary Medicaid
waiver authorities include:
• Section 1115 Research and Demonstration Projects—Under Section 1115 of
the Social Security Act, the Secretary of HHS may waive Medicaid requirements
contained in Section 1902 (including, but not limited to, what is known as
“freedom of choice” of provider, “comparability” of services, and
“statewideness”). States use this waiver authority to change eligibility criteria in
order to offer coverage to new groups of people, to provide services that are not
otherwise covered, to offer different service packages or a combination of
services in different parts of the state, to cap program enrollment, and to
implement innovative service delivery systems, among other purposes.
• Section 1915(b) Managed Care/Freedom of Choice Waivers—Section
1915(b) of the Social Security Act permits states to establish mandatory managed
care programs or otherwise limit enrollees’ choice of providers.68
• Section 1915(c) Home- and Community-Based Services Waivers (HCBS)—
Section 1915(c) authorizes the Secretary of HHS to waive certain requirements
of Medicaid law allowing states to cover a broad range of HCBS (including
services not available under the Medicaid state plan) for certain persons with
long-term care needs. Specifically, under Section 1915(c) states can waive rules
regarding “statewideness” and “comparability” of services. States may also apply
certain income counting rules to persons in HCBS waivers that allow an
individual to be eligible for Medicaid who might not otherwise qualify.
• Section 1915(b) and (c) Waivers—Section 1915(b) and (c) waivers allow states
to provide HCBS to disabled and elderly populations in a managed care setting or
within a limited pool of providers. States must apply for each waiver authority
concurrently and comply with the individual requirements of each waiver.
States often operate multiple waiver programs with their state plan. Key characteristics of these
primary Medicaid waiver authorities compared to state plan requirements are summarized in
Table 2. The statutory requirements that may be waived under each type of waiver are different,
but all types of waivers are time limited and approvals are subject to reporting and evaluation
requirements. In addition, all types of waivers must comply with various financing requirements
(i.e., budget neutrality,69 cost-effectiveness,70 or cost-neutrality).71
68 There are four types of authorities under Section 1915(b) that states may request: (b)(1) allows states to require
Medicaid beneficiaries to enroll in managed care; (b)(2) allows states to designate a “central broker” to assist Medicaid
beneficiaries in choosing among competing health care plans; (b)(3) allows states to use cost savings made possible
through the recipients’ use of more cost-effective medical care to provide additional services; and (b)(4) allows states
to limit the beneficiaries’ choice of providers (except in emergency situations, for recipients residing in a long term
care facility, and with respect to family planning services).
69 Budget neutrality means that the estimated spending under the waiver cannot exceed the estimated cost of the state’s
Medicaid program without the waiver.
70 Cost effectiveness means the cost of payments under managed care cannot exceed the cost of fee-for-service absent
the waiver.
71 Under the cost-neutrality test, expenditures under the waiver may not exceed the cost of institutional care that would
have been provided to waiver recipients absent the waiver.
Congressional Research Service
20
Medicaid: An Overview
Table 3. Key Characteristics of the Primary Medicaid Waiver Authorities Compared
to State Plan Requirements
Sec. 1915(c)
Home and
Sec. 1915(b)
Community
Sec. 1115
Managed
Based
Sec.
Research and
Care/Freedom
Services
1915(b)/(c)
Demonstration
of Choice
(HCBS)
Concurrent
Medicaid
Key Characteristic
Waiversa
Waivers
Waivers
Waivers
State Plan
Number of
73 waivers (in 41
22 waivers (in
321 waivers (in
2 waivers (in
N/A
Waiversb
states and DC)
18 states)
47 states and the
2 states)
District of
Columbia)
Statutory requirements that may be waived
“Statewideness”c X
X
X
X N/A
“Comparability”
X X X
X
N/A
of Servicesd
“Freedom
of
X X X
N/A
Choice” of
Providere
Income
and
X
X
N/A
Resource Rulesf
Federal
Matching
X X X
X
N/A
Funds for Costs
Not Otherwise
Matchable
Evaluations
X X X
X
N/A
Duration
5 year initial,
2 year initial,
3 year initial,
Must prepare
Once
renewed for up to
renewed for up
renewed for up
separate
approved
3-year intervals
to 2-year
to 5-year
renewal
duration
intervals
intervals
requests
indefinite
Financing
Budget neutral
Must meet cost-
Must meet cost-
Must meet
Open-ended
over the life of the effectiveness
neutrality test
cost-
mandatory
program
test
effectiveness
entitlement
neutrality and
cost-
effectiveness
tests
Enrollment caps
X X
X
Individual
and waiting lists
entitlement
Source: Prepared by CRS based in program rules and regulations.
a. The number of Section 1115 waivers includes only those under the oversight of CMS’s Children and Adults
Health Programs Group. This count includes standalone family planning waivers.
b. Data for number of waivers from lists of operational waivers posted on the CMS website as of 12/4/13.
c. Waiving the “statewideness” requirement (as permitted under Section 1902[a][1] of the Social Security Act)
allows states to target waivers to particular areas of the state where the need is greatest, or where certain
types of providers are available, for example.
Congressional Research Service
21
Medicaid: An Overview
d. Waiving “comparability” of services (Section 1902[a][10][B] of the Social Security Act) allows states to
target waiver services to particular groups of individuals or to target services on the basis of disease or
condition.
e. Waiving the “freedom of choice” requirement (Section 1902[a][23] of the Social Security Act) allows states
to implement managed care delivery systems or otherwise limit choice of provider.
f.
Institutional deeming rules (Section 1902[a][10][C][i][II]) of the Social Security Act) means that income and
resources are not deemed to the recipient from a spouse or parent. This allows states to cover medically
needy individuals under home and community-based service waivers who would not be eligible for waiver
services under the community rules, but would be eligible under institutional rules.
Program Integrity
Program integrity initiatives are designed to combat fraud, waste, and abuse in the Medicaid
program. Some oversight efforts focus on preventing fraud and abuse through effective program
management, while others focus on addressing problems after they occur through investigations,
recoveries, and enforcement activities. Areas such as eligibility determination have multiple
program integrity initiatives, while other areas, such as managed care, receive comparatively little
attention.72
Multiple agencies at the federal and state levels are involved in program integrity. The federal
agencies are CMS, the Office of the Inspector General for the Department of HHS, the
Department of Justice, and the Government Accountability Office. The state agencies involved
with program integrity activities include the state Medicaid agencies and the federally required
Medicaid Fraud Control Units (MFCUs). Coordination of Medicaid program integrity activities
can be a problem because there are so many agencies working on program integrity initiatives
and each state develops its own approach to program integrity.
The federal government and states contribute equally to fund most Medicaid activities to combat
waste, fraud, and abuse, although for some activities, the federal government provides additional
funds through enhanced FMAP rates. As mentioned earlier, all states receive the same FMAP rate
for administrative expenditures, including most program integrity activities, which is generally
50%. States receive higher FMAP rates for selected administrative activities such as 90% for the
startup of MFCUs and 75% for ongoing MFCU operation.
The ACA included some provisions to increase uniformity among Medicare, Medicaid, and CHIP
program integrity activities. For instance, the ACA introduced additional provider screening
requirements that are applicable to Medicare, Medicaid, and CHIP. The ACA also created an
integrated Medicare and Medicaid data repository to enhance program integrity data sharing to be
available to federal and state agencies and law enforcement officials. Moreover, the ACA
established a recovery audit contractor (RAC) requirement for Medicaid, under which state
Medicaid agencies contract with a RAC to identify and recover overpayments and identify
underpayments.
Beyond the ACA requirements, states report implementing a number of new and enhanced
Medicaid program integrity activities in SFY2013. For example, 26 states reported implementing
or enhancing analytical technologies used to prevent improper payments, 11 states implemented
or expanded an enhanced provider screening initiatives, 14 states reported new or enhanced
72 Medicaid and CHIP Payment and Access Commission, Report to Congress on Medicaid and CHIP, June 2013.
Congressional Research Service
22
Medicaid: An Overview
public/private data sharing initiatives, and 18 states reported a wide range of other program
integrity efforts or initiatives.73
Selected Issues
Currently, the Medicaid program is dealing with several major issues, which mostly stem from
the implementation of the ACA. First, the ACA Medicaid expansion began on January 1, 2014.
Since the expansion is optional for states, some are implementing the expansion, some states are
still deciding, and other states have chosen not to implement the expansion. Second, the
coordination of care for dual-eligible beneficiaries is a focus of federal and state policy makers.
Also, a new ACA health insurance annual fee may increase Medicaid expenditures through higher
Medicaid MCO rates. Finally, the ACA included a Medicaid MOE provision, which expired on
January 1, 2014, for adults but continues until 2019 for children.
ACA Medicaid Expansion
The primary goal of the ACA is to increase access to affordable health insurance for the uninsured
and to make health insurance more affordable for individuals who already have such coverage.
The ACA Medicaid expansion is one of the major insurance coverage provisions included in the
law.
As enacted, beginning in 2014, the ACA Medicaid expansion created a new mandatory Medicaid
eligibility group: all adults under age 65 with income up to 133% of FPL (effectively 138% FPL)
(see “Eligibility” for more information). The ACA requires most of the individuals covered under
the ACA Medicaid expansion to receive ABP coverage (see “Benefits” for more information), and
the law provides enhanced federal matching rates for coverage of this new eligibility group (see
“Federal Share” for more information).
The ACA provided states with the option to implement the ACA Medicaid expansion earlier than
2014. Between April 1, 2010, and January 1, 2014, states had the option to expand Medicaid to
individuals up to 133% of FPL, so long as the state did not extend coverage to (1) individuals
with higher income before those with lower incomes or (2) parents unless their children are
enrolled in the state plan, a waiver, or in other health coverage. Eight states74 and the District of
Columbia elected to implement the ACA Medicaid expansion early.
Originally, it was assumed that all states would implement the ACA Medicaid expansion in 2014
as required by statute because implementation was required in order for states to receive any
federal Medicaid funding. However, on June 28, 2012, the United States Supreme Court issued its
decision in National Federation of Independent Business (NFIB) v. Sebelius75 finding that the
73 Vernon K. Smith, Robin Rudowitz, and Laura Snyder, Medicaid in a Historic Time of Transformation: Results from
a 50-State Medicaid Budget Survey for State Fiscal Years 2013 and 2014, Kaiser Commission on Medicaid and the
Uninsured, October 2013.
74 The eight states that implemented the ACA Medicaid expansion early were California, Colorado, Connecticut,
Illinois, Minnesota, New Jersey, Ohio, and Washington.
75 132 S. Ct. 2566 (2012).
Congressional Research Service
23
Medicaid: An Overview
federal government cannot terminate the federal Medicaid funding a state receives for its current
Medicaid program if a state refuses to implement the ACA Medicaid expansion.76
State Decisions
Since the federal government cannot terminate current Medicaid federal matching funds if a state
refuses to implement the Medicaid expansion required by the ACA, the Supreme Court’s ruling in
NFIB effectively made state participation in the ACA Medicaid expansion voluntary. However, if
a state accepts the ACA Medicaid expansion funds, it must abide by the new expansion coverage
rules.
CMS informed states that they face no deadline for deciding whether to implement the ACA
Medicaid expansion, and according to CMS, states can also discontinue the expansion at any
time.77 If states want to take full advantage of the 100% federal financing for the “newly eligible”
enrollees, however, they need to implement the expansion on January 1, 2014. The statute
explicitly provides the 100% federal funding for the “newly eligible” enrollees for 2014, 2015,
and 2016, rather than for the first three years a state implements the expansion.
As of December 19, 2013, 24 states and the District of Columbia were planning to implement the
ACA Medicaid expansion on January 1, 2014, and Michigan is planning to implement the
expansion on April 1, 2014.78 Among the remaining states, 5 are still considering the expansion,
and 21 states are not implementing the expansion at this time.79 Figure 5 shows state decisions
about implementing the ACA Medicaid expansion.
76 For a discussion of the Supreme Court's decision on the Medicaid expansion, see CRS Report R42367, Medicaid and
Federal Grant Conditions After NFIB v. Sebelius: Constitutional Issues and Analysis, by Kenneth R. Thomas.
77 Centers for Medicare & Medicaid Services, Frequently Asked Questions on the Exchanges, Market Reforms and
Medicaid, December 10, 2012.
78 The Medicaid expansion for Iowa and Michigan is subject to CMS approval of those states’ 1115 Waiver
applications. (CMS, State Medicaid and CHIP Income Eligibility Standards Effective January 1, 2014, October 24,
2013.)
79 States’ decisions are based on CRS’s monitoring of state activity through media outlets and state tracking of
decisions done by CMS, State Refor(u)m, the Kaiser Family Foundation, the Advisory Board Company, and Avalere.
Congressional Research Service
24
Medicaid: An Overview
Figure 5. State Decisions Whether to Implement the ACA Medicaid Expansion
As of December 19, 2013
Source: States’ decisions are based on CRS’s monitoring of state activity through media outlets and state
tracking of decisions done by CMS, State Refor(u)m, the Kaiser Family Foundation, the Advisory Board
Company, and Avalere.
Notes: Al states (except Michigan) are supposed to implement the ACA Medicaid expansion on January 1,
2014. Michigan is planning to implement the expansion on April 1, 2014.
While there are some exceptions, most of the states implementing the ACA Medicaid expansion
tend to have low rates of uninsured individuals (relative to the national average) and traditionally
have provided Medicaid coverage to more nondisabled adults through relatively higher Medicaid
income eligibility levels. Also, in general, the states not implementing the ACA Medicaid
expansion have relatively higher rates of uninsured and traditionally have covered fewer
nondisabled adults under Medicaid.80
Premium Assistance Model
Most states implementing the ACA Medicaid expansion are doing so through an expansion of
their current Medicaid program. However, some states are using a premium assistance model for
their ACA Medicaid expansion, which means Medicaid funding is used to purchase health
80 U.S. Census Bureau, American Community Survey, 2012; Medicaid and CHIP Payment and Access Commission,
Report to the Congress on Medicaid and CHIP, March 2013.
Congressional Research Service
25
Medicaid: An Overview
insurance coverage for the ACA Medicaid expansion population through qualified health plans81
in the exchanges.
HHS approved Arkansas’s waiver to use a premium assistance model for its ACA Medicaid
expansion on September 27, 2013, and Iowa’s waiver was approved December 10, 2013. Other
states (including Florida, Ohio, Pennsylvania, and Tennessee) have expressed interest in the
premium assistance model for the ACA Medicaid expansion.82
States Not Expanding
States have chosen not to implement the ACA Medicaid expansion for various reasons, including
not wanting to expand Medicaid because they view the expansion as unaffordable to the state and
the Medicaid program as “broken.”83 State decisions not to implement the ACA Medicaid
expansion could have implications for low-income individuals, large employers with low wage
workers, and hospitals.
Low-Income Individuals
Even if a state does not implement the ACA Medicaid expansion, some of the individuals that
would have been covered by the Medicaid expansion may still gain health insurance coverage
under the ACA health insurance coverage provisions. The ACA provides premium tax credits and
cost-sharing subsidies to individuals with household income between 100% and 400% of FPL
who do not have access to minimum essential coverage.84 As a result, most uninsured individuals
with incomes between 100% and 133% of FPL living in states that decide not to implement the
ACA Medicaid expansion may become eligible for premium tax credits and cost-sharing
subsidies to purchase insurance through the health insurance exchanges. However, most
uninsured individuals with incomes under 100% of FPL living in states that decide not to
implement the ACA Medicaid expansion will likely remain uninsured because these individuals
are not eligible for premium tax credits or the cost sharing subsidies to purchase health insurance
through the exchanges.
Regardless of whether a state decides to implement the ACA Medicaid expansion or not, all states
are expected to experience an increase in Medicaid enrollment, due to the “woodwork” effect.
This is the term for uninsured individuals who without the expansion are eligible for Medicaid
deciding to enroll in Medicaid due to increased media attention and outreach efforts associated
81 In general, exchanges offer comprehensive coverage that meets the standards to be certified as “qualified health
plans” (QHPs), provided it meets requirements related to marketing, choice of providers, plan networks, and other
features, or is recognized by each exchange through which such plan is offered. In addition, all QHPs are required to
comply with benefit, cost-sharing, and generosity components of the essential health benefits package (described
above). In addition to qualified health plans, exchanges also offer multi-state QHPs, child-only QHPs, and CO-OP
QHPs.
82 “Health Policy Brief: Premium Assistance in Medicaid,” Health Affairs, June 6, 2013.
83 State Refor(u)m, Governors Address Medicaid Expansion in “State of the State” Speeches, March 2013.
84 The definition of minimum essential coverage is broad. It includes Medicare Part A, Medicaid, the State Children’s
Health Insurance Program (CHIP), Tricare, the TRICARE for Life program, the veteran’s health care program, the
Peace Corps program, a government plan (local, state, federal) including the Federal Employees Health Benefits
Program (FEHBP) and any plan established by an Indian tribal government, any plan offered in the individual, small
group or large group market, a grandfathered health plan, and any other health benefits coverage, such as a state health
benefits risk pool, as recognized by the Secretary of HHS in coordination with the Treasury Secretary.
Congressional Research Service
26
Medicaid: An Overview
with the ACA. The impact of the woodwork effect depends on the percentage of a state’s
population that is eligible but not enrolled in Medicaid. Nationally, an estimated 7.3 million to 9.0
million uninsured children and adults were eligible but not enrolled in Medicaid prior to the
implementation of the expansion.85
Large Employers with Low-Wage Workers
Large employers with low-wage workers in states that do not implement the ACA Medicaid
expansion might have greater exposure to employer penalties included in the ACA when the
penalty goes into effect in 2015.86 The ACA imposes penalties on “large” employers87 if at least
one of their full-time employees obtains a premium credit through the exchange. Individuals who
are not offered employer-sponsored coverage and who are not eligible for Medicaid or other
programs may be eligible for premium tax credits for coverage through an exchange. As
mentioned above, to receive premium tax credits, individuals must have income of at least 100%
and up to 400% of FPL.
In states that do not implement the ACA Medicaid expansion, large employers with low income
workers could be at greater risk of paying the ACA employer penalty. That is because more low-
income workers could qualify for premium tax credits.88
Hospitals
Hospitals in states that are not expanding Medicaid are concerned because DSH allotments will
be reduced by the same across the nation whether or not states implement the expansion. If a state
implements the expansion, uncompensated care for hospitals should decline along with the DSH
allotments (though not proportionally). However, if a state chooses not to implement the
expansion, the demand for uncompensated hospital care is expected to persist but the amount of
Medicaid DSH payments hospitals receive to subsidize such care may be reduced.89 As a result,
hospitals have been encouraging states to implement the ACA Medicaid expansion in order to
reduce uncompensated care for hospitals. Even though Medicaid provider rates are generally
85 Genevieve M. Kenney, Lisa Dubay, Stephen Zuckerman, and Michael Huntress, Opting Out of the Medicaid
Expansion under the ACA: How Many Uninsured Adults Would not Be Eligible for Medicaid?, The Urban Institute
Health Policy Center, July 5, 2012; Benjamin D. Sommers and Arnold M. Epstein, “Perspective: Why States Are So
Miffed about Medicaid - Economics, Politics, and the “Woodwork Effect”,” The New England Journal of Medicine,
vol. 365, no. 2, pp. 100-102 (July 14, 2011).
86 The employer penalty was supposed to go into effect in 2014, but on July 2, 2013, the Obama Administration
announced that it is delaying, until 2015, the enforcement and associated reporting requirements related to the employer
penalty. For more information about the delay to the employer penalty, see CRS Report R43150, Delay in
Implementation of Potential Employer Penalties Under ACA, by Bernadette Fernandez and Annie L. Mach.
87 A “large employer” is defined in the ACA (as related to the employer penalty) as an employer who employed an
average of at least 50 full-time equivalent employees (FTEs) on business days during the preceding calendar year.
88 For more information about the employer penalty, see CRS Report R41159, Potential Employer Penalties Under the
Patient Protection and Affordable Care Act (ACA), by Julie M. Whittaker.
89 Toluse Olorunnipa, “Obamacare Cutbacks Shut Hospitals Where Medicaid Went Unexpanded,” Bloomberg
Government, November 25, 2013. Letter from the Republican Governors Public Policy Committee to President Barack
Obama dated July 10, 2012, available at http://www.scribd.com/doc/99730375/Medicaid-and-Exchange-Letter-Final.
Sarah Kliff, “The super wonky reason states may join the Medicaid expansion,” The Washington Post, July 8, 2012.
Bob Neal, The Fiscal and Economic Impacts of Medicaid Expansion in Mississippi, 2014-2025, Mississippi Public
Universities University Research Center, October 2012.
Congressional Research Service
27
Medicaid: An Overview
lower than the rates paid by private insurance or Medicare, hospitals are likely better off with
payment for a Medicaid patient than no payment for an uninsured patient.
Dual-Eligible Beneficiaries
In FY2010, there were 9.8 million dual-eligible beneficiaries, who are individuals enrolled in
both Medicare and Medicaid,90 which is almost 15% of Medicaid enrollment. Individuals qualify
for Medicare because they are either age 65 or older, or under age 65 and have a disability and
have been receiving Social Security Disability Insurance for two years.91 As mentioned
previously, individuals qualify for Medicaid because they meet both the categorical (i.e., are a
member of a covered group, such as children, pregnant women, families with dependent children,
the elderly, or the disabled) and financial eligibility requirements, which vary by state.
Although commonly addressed as a single population, dual-eligible individuals are a diverse
population. While dual-eligible beneficiaries tend to be sicker and poorer than the Medicaid
population as a whole, not all dual-eligible beneficiaries are in poor health. Individuals receive
different types of Medicaid coverage (i.e., full benefits or financial assistance with Medicare
premiums and cost sharing).
There are numerous Medicaid eligibility pathways for dual-eligible beneficiaries,92 but the two
main categories of dual-eligible individuals are full dual-eligible beneficiaries and partial dual-
eligible beneficiaries. Full dual-eligible beneficiaries receive full benefits from Medicare, and
Medicaid provides them with full benefits in addition to financial assistance with their Medicare
premiums and cost sharing. Partial dual-eligible beneficiaries receive full benefits from Medicare
and financial assistance from Medicaid for Medicare premiums and cost sharing. In FY2010,
there were 7.4 million full duals with Medicaid spending totaling $135.4 billion, while the 2.4
million partial duals had $5.2 billion in Medicaid spending.93
Because Medicare and Medicaid are different programs, coordinating care and services for dual-
eligible beneficiaries presents challenges. Medicare is a national program administered by CMS,
while Medicaid is a federal-state partnership under which each state designs and administers its
own version of Medicaid under broad federal rules. Coordination of benefits between these
distinct programs is administratively complex. Dual-eligible beneficiaries and their service
providers must comply with Medicare and Medicaid program rules and processes, which are not
always aligned. In addition, delivery of uncoordinated or poorly coordinated health care and
related services can be costly and inefficient, affecting dual-eligible beneficiaries’ quality of care
and increasing Medicare and Medicaid spending. To reduce spending on dual-eligible
90 This enrollment figure is measured by individuals who were “ever enrolled” in the Medicaid program throughout the
year. (Medicaid and CHIP Payment and Access Commission, Report to Congress on Medicaid and CHIP, June 2013.)
91 Also qualifying for Medicare are persons who have End-Stage Renal Disease (ESRD). For more information about
the Medicare program, see CRS Report R40425, Medicare Primer.
92 The common Medicaid eligibility pathways for Medicare beneficiaries are Supplemental Security Income (SSI) cash
assistance, poverty, medically needy, special income rules for nursing home residents, home and community based
services waivers, Qualified Medicare Beneficiaries, Specified Low-Income Medicare Beneficiaries, Qualified Disabled
Work Individuals, and Qualifying Individuals.
93 This expenditure figure includes both federal and state Medicaid expenditures. (Medicaid and CHIP Payment and
Access Commission, Report to Congress on Medicaid and CHIP, June 2013.)
Congressional Research Service
28
Medicaid: An Overview
beneficiaries and improve the quality of their care, federal and state policy makers are focusing
on coordinating care for dual-eligible beneficiaries.94
The ACA established the Medicare-Medicaid Coordination Office within CMS in order to
improve care coordination for dual-eligible beneficiaries. In addition, the ACA provided CMS the
ability to test innovative payment and service delivery models to improve coordination of care
and reduce the cost of dual-eligible beneficiaries. With this new authority, CMS is funding
demonstration projects to develop approaches to coordinate care for full duals and also to
integrate Medicare and Medicaid financing for these individuals.
Impact of ACA Health Insurance Annual Fee on Medicaid
The ACA imposes an annual fee on certain for-profit health insurers, starting in 2014.95 The ACA
health insurance annual fee applies to Medicaid MCOs with the exception of non-profit insurers
incorporated under state law that receive more than 80% of their gross revenues from government
programs that target low-income, elderly, or disabled populations (such as CHIP, Medicare, and
Medicaid).96 According to one estimate, approximately 80% of Medicaid enrollees covered by
managed care receive coverage from a plan impacted by the ACA fee.97
Some insurance plans have informed shareholders and state insurance regulators that they intend
to pass on the cost of the fee to businesses and enrollees in the form of higher premiums.98
Medicaid MCOs do not have the ability to pass the cost of the fee on to enrollees through higher
premiums because few Medicaid enrollees pay premiums and when premiums are charged the
federal government requires the premiums to be nominal.
A number of state governors caution that the ACA health insurance annual fee will result in
higher costs to Medicaid. Federal regulations require that the capitated amounts paid to Medicaid
MCOs be “actuarially sound,” which means the state must consider MCOs’ costs, including
health benefits, marketing and administrative expenses, and taxes.99 For this reason, some states
have indicated they are willing to include the cost of the ACA fee in the capitation rates,100 which
will likely increase Medicaid expenditures.
94 Congressional Budget Office, Dual-Eligible Beneficiaries of Medicare and Medicaid: Characteristics, Health Care
Spending, and Evolving Policies, June 2013.
95 The aggregate amount of the ACA fee, to be collected across all covered insurers, will be $8.0 billion in 2014, $11.3
billion in 2015 and 2016, $13.9 billion in 2017, and $14.3 billion in 2018. After 2018, the aggregate fee will be indexed
to the overall rate of annual premium growth, as calculated by the Internal Revenue Service. (For more information
about the annual fee on health insurers, see CRS Report R43225, Patient Protection and Affordable Care Act: Annual
Fee on Health Insurers, by Suzanne M. Kirchhoff.)
96 The following are other types of health insurers or insurance arrangements not subject to the fee: entities that fully
self-insure, government-run insurance programs, voluntary employees’ beneficiary associations, and student health
insurance coverage that educational institutions purchase through a separate, unrelated insurer.
97 Marwood Group, Impact of the Annual Health Insurance Tax on State Medicaid Programs, Prepared for Molina and
Amerigroup, October 2011.
98 Ralph Giacobbe, Chris Carter, and Allison Ryne, et al., Managed Care: Health Insurance Tax - The $8B Question,
Credit Suisse, November 8, 2013.
99 American Academy of Actuaries, Practice Note, “Actuarial Certification of Rates for Medicaid Managed Care
Programs,” 2005, http://www.actuary.org/pdf/practnotes/health_medicaid_05.pdf.
100 Ralph Giacobbe, Chris Carter, and Allison Ryne, et al., Managed Care: Health Insurance Tax - The $8B Question,
Credit Suisse, November 8, 2013.
Congressional Research Service
29
Medicaid: An Overview
Maintenance of Effort (MOE)
In response to the economic recession (December 2007 through June 2009),101 Congress enacted
the American Recovery and Reinvestment Act of 2009 (ARRA, P.L. 111-5; extended in P.L. 111-
226). ARRA included a temporary increase in FMAP rates. In order to receive federal Medicaid
matching funds under ARRA, states were required to maintain the same Medicaid eligibility
standards, methodologies, and procedures in effect on July 1, 2008, through June 30, 2011. This
provision is referred to as the ARRA MOE requirement.
The ARRA MOE provisions were extended and expanded under the ACA. The ACA MOE
provisions were designed to ensure that individuals eligible for Medicaid or CHIP did not lose
coverage between the date of enactment of ACA (March 23, 2010) and the implementation of the
exchanges. Under the ACA MOE provisions, states were required to maintain their Medicaid
programs with the same eligibility standards, methodologies, and procedures until the exchanges
were operational. Additionally, the ACA MOE continues for Medicaid-eligible children up to age
19 until September 30, 2019. Failure to comply with the ACA MOE requirements means a state
loses all of its federal Medicaid matching funds.
The MOE provision did not prohibit states from cutting Medicaid in other ways, such as by
reducing provider rates or by eliminating optional benefits. In addition, states were not prohibited
from expanding Medicaid coverage during the MOE period.
The ACA provided an exemption to the MOE requirement for states that had a budget deficit, but
only with respect to adults who are non-pregnant and non-disabled adults who are eligible for
Medicaid under a state plan or waiver and whose income exceeded 133% of FPL. CMS reports
that four states (Hawaii, Illinois, Maine, and Wisconsin) reduced coverage for adults under the
ACA MOE exemption authority. Other states, such as Minnesota and Arizona, permitted certain
adult populations covered under their Section 1115 waiver programs to end (as permitted through
guidance and final regulation) without constituting violation of the ACA MOE requirements.
Under both the ARRA and ACA MOEs, states have not been able to restrict the income eligibility
for their Medicaid programs generally speaking from July 1, 2008, through January 1, 2014. With
the exception of eligibility standards for children, states now have the ability to reduce the cost of
Medicaid through reductions to Medicaid eligibility standards. While state finances are
improving, state budgets have not quite recovered from the effects of the recession, and some
states welcome an additional budget tool (i.e., reducing Medicaid eligibility thresholds) to reduce
the cost of Medicaid.
Eleven states (Illinois, Indiana, Louisiana, Maine, Minnesota, New Mexico, New York,
Oklahoma, Rhode Island, Vermont, and Wisconsin) reported plans to tighten eligibility for their
adult population groups in 2014.102 Most of the adults who will lose Medicaid eligibility in these
states will be eligible for subsidized coverage through the exchanges.103 States may be financially
101 As measured by the National Bureau of Economic Analysis.
102 Vernon K. Smith, Robin Rudowitz, and Laura Snyder, Medicaid in a Historic Time of Transformation: Results form
a 50-State Medicaid Budget Survey for State Fiscal Years 2013 and 2014, Kaiser Commission on Medicaid and the
Uninsured, October 2013.
103 For more information on the potential implications for these individuals, see CRS Report R42978, Comparing
Medicaid and Exchanges: Benefits and Costs for Individuals and Families.
Congressional Research Service
30
Medicaid: An Overview
better off shifting Medicaid enrollees to the exchanges because the federal government fully
funds the cost of premium tax credits and cost-sharing subsidies in the exchanges, whereas states
and the federal government share the cost of Medicaid coverage. For the federal government, it is
more expensive to cover these individuals through exchanges rather than Medicaid.104
Medicaid Resources
For more information on Medicaid, below is a selection of CRS reports that may be of interest.
• CRS Report R41210, Medicaid and the State Children’s Health Insurance
Program (CHIP) Provisions in ACA: Summary and Timeline
• CRS Report R42640, Medicaid Financing and Expenditures
• CRS Report R43328, Medicaid Coverage of Long-Term Services and Supports
• CRS Report R42978, Comparing Medicaid and Exchanges: Benefits and Costs
for Individuals and Families
• CRS Report R42893, Proposals to Reduce Federal Medicaid Expenditures
104 In July 2012, the Congressional Budget Office estimated that for the average person who does not enroll in
Medicaid as a result of their state not implementing the ACA Medicaid expansion and enrolls in an exchange instead,
estimated federal spending will rise by roughly $3,000 in 2022—the difference between estimated additional exchange
subsidies of about $9,000 and estimated Medicaid savings of roughly $6,000. (Congressional Budget Office, Estimates
for the Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision,
July 2012).
Congressional Research Service
31
Medicaid: An Overview
Appendix A. State Medicaid and CHIP Income
Eligibility Standards
Table A-1 depicts the new MAGI-based eligibility levels for Medicaid beginning on January 1,
2014. The table expresses these standards as a percentage of the federal poverty level (FPL).105
CMS worked with states to “convert” their Medicaid income eligibility levels to be based on
MAGI as required by the ACA. This table provides the Medicaid MAGI income eligibility levels
by FPL for the key groups—children, pregnant women, parents/caretaker relatives and other
adults—whose eligibility will be MAGI-based beginning in 2014.
Table A-1. Selected State Medicaid MAGI Income Eligibility Standards Expressed as
a Percentage of the Federal Poverty Level
Effective January 1, 2014
Children
Adults
Pregnant
Ages 0-1a Ages
1-5a Ages
6-18a Parentsb
Other
State
Women
Adults
Alabama 141%
141%
141%
141%
13%
0
Alaskac
203% 203% 203% 200% 129% 0%d
Arizona 147%
141%
133%
156%
133%
133%
Arkansas 211%
211%
211%
209%
133%
133%
California 261%
261%
261%
208%
133%
133%
Colorado 142%
142%
142%
195%
133%
133%
Connecticut 196%
196%
196%
258%
196%
133%
Delaware 209%
142%
133%
209%
133%
133%
District of
Columbia
319% 319% 319% 319% 216% 210%
Florida
206% 140% 133% 191% 31% 0%d
Georgia 205%
149%
133%
220%
36%
0%
Hawaiic
308% 308% 308% 191% 133% 133%
Idaho
141% 141% 133% 133% 24%e
f
Illinois 142%
142%
142%
208%
133%
133%
Indiana
208% 158% 158% 208% 20%e
f
Iowa
375% 167% 167% 375% 133% 133%
Kansas 166%
149%
133%
166%
33%
0%
105 The poverty guidelines (also referred to as the federal poverty level) are a version of the federal poverty measure.
They are issued each year in the Federal Register by the Department of Health and Human Services (HHS). The
guidelines are a simplification of the poverty thresholds for use for administrative purposes—for instance, determining
financial eligibility for certain federal programs.
Congressional Research Service
32
Medicaid: An Overview
Children
Adults
Pregnant
Other
Ages 0-1a Ages
1-5a Ages
6-18a Parentsb
State
Women
Adults
Kentucky 195%
159%
159%
195%
133%
133%
Louisiana
212% 212% 212% 209% 19%e
f
Maine
191% 157% 157% 209% 100% d,f
Maryland 317%
317%
317%
259%
133%
133%
Massachusetts
200% 150% 150% 200% 133% 133%d
Michigan
195% 160% 160% 195% 133% 133%
Minnesota 283%
275%
275%
278%
200%
200%
Mississippi 194%
143%
133%
194%
24%
0%
Missouri
205% 150% 150% 205% 20%e
f
Montana
159% 143% 143% 159% 48%
f
Nebraska 213%
213%
213%
194%
63%
0%
Nevada 159%
159%
133%
159%
133%
133%
New Hampshire
318%
318%
318%
196%
70%
0%
New Jersey
194%
142%
142%
194%
133%
133%
New Mexico
300%
300%
240%
250%
133%
133%
New York
218% 149% 149% 218% 133% 133%d
North Carolina
210% 210% 133% 196% 46% 0%d
North Dakota
147%
147%
133%
147%
133%
133%
Ohio 206%
206%
206%
200%
133%
133%
Oklahoma
205% 205% 205% 133% 43%e
f
Oregon 185%
133%
133%
185%
133%
133%
Pennsylvania
215% 157% 133% 215% 33% 0%d
Rhode Island
261%
261%
261%
190%
133%
133%
South Carolina
208%
208%
208%
194%
62%
0%
South
Dakota 182%
182%
182%
133% 54% 0%
Tennessee 195%
142%
133%
195%
106%
0%
Texas 198%
144%
133%
198%
15%
0%
Utah
139% 139% 133% 139% 46%e
f
Vermont 313%
313%
313%
208%
133%
133%
Virginia 143%
143%
143%
143%
49%
0%
Washington 207%
207%
207%
193%
133%
133%
West Virginia
158%
141%
133%
158%
133%
133%
Wisconsin
301% 186% 151% 301% 95%e 95%
Wyoming 154%
154%
133%
154%
57%
0%
Congressional Research Service
33
Medicaid: An Overview
Source: Centers for Medicare and Medicaid Services. Eligibility levels in effect based on information current as
of September 30, 2013, provided to CMS by states either for purposes of FFM programming of state-specific
Medicaid/CHIP rules, through state plan amendments, or by direct request from CMS. These levels are subject
to change.
Notes: For these eligibility groups, an individual’s income, computed based on the new modified adjusted gross
income (MAGI)-based income rules and adjusted by a 5% disregard, is compared to the income standards
identified in this table to determine if they are income eligible for Medicaid or CHIP. Other eligibility criteria also
apply, for example, with respect to citizenship, immigration status and residency. Note that this table reflects the
principal but not al MAGI coverage groups.
a. These eligibility standards include CHIP-funded Medicaid expansions.
b. In states that use dollar amounts rather than percentages of the federal poverty level (FPL) for 2013 to
determine eligibility for parents, CMS has converted those amounts to a percent of the FPL and selected
the highest percentage to reflect the eligibility level for the group. In addition, for states that are adopting
the Medicaid expansion, CMS has indicated the upper income limit for parents will also be 133% of the FPL,
since parents can be eligible for coverage under the new ACA Medicaid expansion group. The actual dollar
standards that states will use to determine eligibility are quoted in the monthly income tables available at
http://www.medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/Medicaid-and-CHIP-Eligibility-
Levels/medicaid-chip-eligibility-levels.html.
c. The dol ar values that represent the FPLs in Alaska and Hawaii are higher than for the contiguous 48 states.
For example, as of 2013, 100% of the FPL for a family of four is equal to $29,440 in Alaska and $27,090 in
Hawaii, compared to $23,550 in the other 48 states.
d. The state covers some 19 and 20 year olds—AK (129%), FL (31%), ME (156%), MA (150%), NY (150%), NC
(46%), and PA (33%).
e. Reflects parent coverage under the Medicaid state plan. The state has some additional coverage above state
plan eligibility standards through a section 1115 demonstration or a pending demonstration proposal. The
demonstration includes limitations on eligibility and/or benefits, is not offered to all residents of the state,
and/or includes an enrollment cap.
f.
The state has a Section 1115 demonstration or a pending demonstration proposal that provides Medicaid
coverage to some low-income adults. The demonstration includes limitations on eligibility and/or benefits, is
not offered to all residents of the states, and/or includes an enrollment cap.
Congressional Research Service
34
Medicaid: An Overview
Appendix B. State-by-State Medicaid Data
Table B-1 provides the most recent available data for state-by-state Medicaid enrollment,
expenditures (including both the federal and state shares), and FMAP rates.
Table B-1. State-by-State Medicaid Enrollment, Expenditures, and FMAP Rates
FY2012 Medicaid Expendituresa
($ in millions)
FY2010
Enrollmentb
FY2014
State
(in thousands)
State
Federal
Total
FMAP Rates
Alabama
1,016 $1,613 $3,589 $5,202 68.12
Alaska
126 $587 $854 $1,441 50.00
Arizona
1,531 $2,528 $5,639 $8,167 67.23
Arkansas
699 $1,288 $3,074 $4,362 70.10
California
11,335 $25,749 $27,522 $53,271 50.00
Coloradoc
632 $2,428 $2,488 $4,916 50.00
Connecticut
712 $3,331 $3,366 $6,696 50.00
Delaware
225 $707 $866 $1,573 55.31
District
of
Columbia
213 $681 $1,544 $2,224 70.00
Florida
3,703 $8,112 $10,535 $18,647 58.79
Georgia
1,870 $2,976 $5,819 $8,795 65.93
Hawaii
261 $749 $763 $1,512 51.85
Idahoc
223 $466 $1,050 $1,516 71.64
Illinois
2,780 $6,891 $7,105 $13,995 50.00
Indiana
1,174 $2,627 $5,264 $7,891 66.92
Iowa
555 $1,384 $2,190 $3,574 57.93
Kansas
394 $1,204 $1,631 $2,834 56.91
Kentucky
907 $1,665 $4,094 $5,759 69.83
Louisiana
1,177 $2,277 $5,077 $7,354 60.98
Mainec
352 $913 $1,652 $2,565 61.55
Maryland
952 $3,907 $3,998 $7,904 50.00
Massachusetts
1,654 $6,595 $6,731 $13,326 50.00
Michigan
2,257 $4,381 $8,560 $12,941 66.32
Minnesota
936 $4,460 $4,544 $9,004 50.00
Mississippi
772 $1,181 $3,438 $4,618 73.05
Missouric
1,033 $3,261 $5,743 $9,004 62.03
Montana
133 $336 $695 $1,031 66.33
Nebraska
250 $768 $1,024 $1,792 54.74
Congressional Research Service
35
Medicaid: An Overview
FY2012 Medicaid Expendituresa
State
($ in millions)
Nevada
340 $787 $1,045 $1,832 63.10
New
Hampshire
167 $614 $637 $1,251 50.00
New
Jersey
1,026 $5,404 $5,567 $10,971 50.00
New
Mexico
576 $1,063 $2,541 $3,604 69.20
New
York
5,570 $26,305 $26,769 $53,074 50.00
North
Carolina
1,876 $4,458 $8,418 $12,876 65.78
North
Dakota
82 $342 $446 $788
50.00
Ohio
2,246 $6,058 $10,768 $16,826 63.02
Oklahoma
829 $1,639 $3,005 $4,644 64.02
Oregon
644 $1,819 $3,103 $4,922 63.14
Pennsylvania
2,417 $9,466 $11,684 $21,150 53.52
Rhode
Island
205 $912 $1,032 $1,944 50.11
South
Carolina
909 $1,434 $3,381 $4,815 70.57
South
Dakota
131 $293 $492 $786
53.54
Tennessee
1,502 $3,115 $6,135 $9,250 65.29
Texas
4,844 $11,998 $16,936 $28,934 58.69
Utah
352 $593 $1,410 $2,003 70.34
Vermont
196 $570 $792 $1,362 55.11
Virginia
1,007 $3,511 $3,579 $7,089 50.00
Washington
1,353 $3,949 $4,171 $8,120 50.00
West
Virginia
430 $810 $2,121 $2,931 71.09
Wisconsinc
1,139 $2,898 $4,566 $7,464 59.06
Wyoming
87 $270 $296 $566
50.00
National Total
65,804 $181,370 $247,748 $429,118
Source: Medicaid and CHIP Payment and Access Commission, Report to Congress on Medicaid and CHIP, March
2013; Centers for Medicare & Medicaid Services, CMS-64 data; Department of Health and Human Services,
“Federal Financial Participation in State Assistance Expenditures; Federal Matching Shares for Medicaid, the
Children's Health Insurance Program, and Aid to Needy Aged, Blind, or Disabled Persons for October 1, 2013
Through September 30, 2014,” 77 Federal Register 71420, November 30, 2012.
Notes: May not sum to totals due to rounding.
a. Medicaid expenditures include benefit and administrative expenditures but exclude expenditures in the
territories and spending for State Medicaid Fraud Control Units, Medicaid survey and certification of nursing
and intermediate care facilities, and the Vaccines for Children program.
b. Enrollment numbers generally include individuals ever enrolled in Medicaid-financed coverage during the
year, even if for a single month. Numbers exclude enrol ees in the territories.
c. Enrollment data for FY2010 was not available for Colorado, Idaho, Maine, Missouri, and Wisconsin, and this
table show FY2009 for these states.
Congressional Research Service
36
Medicaid: An Overview
Author Contact Information
Alison Mitchell, Coordinator
Elicia J. Herz
Analyst in Health Care Financing
Specialist in Health Care Financing
amitchell@crs.loc.gov, 7-0152
eherz@crs.loc.gov, 7-1377
Evelyne P. Baumrucker
Analyst in Health Care Financing
ebaumrucker@crs.loc.gov, 7-8913
Key Policy Staff
Area of Expertise
Name
Phone
E-mail
Eligibility, waiver authorities, premium
Evelyne Baumrucker
7-8913
ebaumrucker@crs.loc.gov
assistance models, and interaction with
state exchanges
Dual-eligible beneficiaries, prescription
Cliff Binder
7-7965
cbinder@crs.loc.gov
drugs, administration and program
integrity
Long-term services and supports
Kirsten Colel o
7-7839
kcolello@crs.loc.gov
(LTSS)
Benefits and cost-sharing
Elicia Herz
7-1377
eherz@crs.loc.gov
Financing, ACA Medicaid expansion,
Alison Mitchell
7-0152
amitchell@crs.loc.gov
FMAP, DSH, provider taxes, and
territories
Congressional Research Service
37