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1 1 (June 9, 2021)

handle is hein.crs/govedpy0001 and id is 1 raw text is: Overview of the ACA Medicaid Expansion Updated June 9, 2021 The primary goals of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) are to increase acces s to affordable health insurance for the uninsured and to make health insurance more affordable for those already covered. The ACA Medicaid expansion is one ofthe major insurance coverage provisions included in the law. Supreme Court Decision As enacted, the ACA Medicaid expansionwas a mandatory expansion of Medicaid eligibility to non-elderly adults with incomes up to 133% of the federalpoverty level (FPL). However, on June 28, 2012, in NationalFedera tion of IndependentBusinessv. Sebelius, the U.S. Supreme Court found that the federal governmentcould not withhold payment for a state's entire Medicaid programfor failure to implement the ACA Medicaid expansion. Instead, the federal government could withhold only funding for the ACA Medicaid expansion if a state did notimplement the expansion, which effectively made the expansion optional. After the Supreme Court ruling, the Centers for Medicate & Medicaid Services (CMS) issuedguidancespecifyingthat states have no deadline for deciding when to implement the ACA Medicaid expansion. The guidance also stated that states opting to implement the ACA Medicaid expansion may end the expansion at any time. In addition, CMS issued guidance specifying that states were not able to receive the enhanced federal matching rates for the expansion with a partial Medicaid expansion (i.e., covering expansion adults up to an income level lower than 133% of FPL). Figure I.States Implementingthe ACA Medicaid Expansion, May 202 I ND SD Not Implemented 12 States SImplemented UPending Implementation 2 States Source: Congressional Research Service. Note: ACA = Patient Protection and Affordable Care Act. States' Decisions Since January 1,2014, states havehadthe optionto extend Medicaid coverage to most non-elderly adults with income up to 133% ofFPL. Twenty -five states (including the District of Columbia) implemented the ACA Medicaid expansion at that time. Since then, the following 12 states have implemented the expansion: Michigan (April 1, 2014), New Hampshire (July 1,2014), Pennsylvania (January 1, 2015), Indiana (February 1,2015), Alaska (September 1, 2015), Montana (January 1, 2016), Louisiana (July 1, 2016), Virginia (January 1,2019), Maine (January 10, 2019), Idaho (January 1,2020), Utah (January 1,2020), and Nebraska (October 1, 2020). (See Figure 1.) Oklahoma and Missouri approved ballot initiatives in June 2020 and August 2020, respectively, to implement the expansion. Bothstates are supposedto begin coverageof the ACA Medicaid expansion on July 1, 2021. However, the Missouri implementation of the exp ansion is uncertain, because the General Assembly adopted an operating budget that does not include funding for the Medicaid exp ansion and the governor has withdrawn a state plan amendment to implement the Medicaid expansion. Litigation about the Medicaid expansion in Missouriis pending. ACA Medicaid Expansion Coverage Most states implementing the ACA Medicaid expansion have done so through an expansion of their existing Medicaid programs. However, individuals covered under the ACA Medicaid expansion are required to receive alternative benefit plan (ABP) coverage, which is a Medicaid benefit structure that has different requirements than the traditional Medicaid benefits. (See CRS Report R45412, MedicaidAlternative BenefitPlan Coverage: Frequently Asked Questions.) Some states operate their expansions through Section 1115 waivers, under which the Secretary of Health and Human Services may authorize a stateto conduct experimental, pilot, or demons trationprojects that are likely to as sist in promoting the objectives of Medicaid. The waivers for these states vary significantly. There are currently a few common provisions in severalstates, such as (1) premiums and/or monthly contributions on enrollees with income above 100% of FPL; (2) healthy behavior incentives; (3) waivers of the requirementto provide coverage of nonemergency medical transportation; and (4) dis enrollment or lock-out provisions. Arkansas has a waiver providing premiumas sistance for Medicaid enrollees to purchase priv atehealth insurance through thehealth insurance exchanges. Financing of the Expansion The federal government's share of most Medicaid expenditures is determined according to the federal medical assistance percentage (FMAP) rate; exceptions to the regular FMAP rate have been made for certain states, situations, populations, providers, and services. There are two FMAP exceptions for the ACA Medicaid expansion: https://crs reports.congress.gov

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