Public Sector Coverage: Medicaid

Prior to the ACA, state Medicaid programs offered coverage to citizen and legal immigrant children under age 6 with family incomes at or below 133 percent of the federal poverty level (FPL), and children from age 6 to 19 with family incomes at or below 100 percent FPL—though some states had chosen to expand beyond these minimum levels. The ACA established a new minimum level of coverage for children, as described below. Children in Medicaid will continue to receive comprehensive benefits through Early and Periodic Screening, Diagnostic and Treatment (EPSDT), and total premium and cost-sharing will continue to be limited to five percent of a family’s income. However, the ACA implements major changes that will affect how children and youth obtain Medicaid, including:

  • New Medicaid Minimum Level of Coverage for Children: As of January 1, 2014, Medicaid eligibility for all children and youth expanded to a national floor of 133 percent FPL1, regardless of whether a state decides to expand Medicaid for adults. In states where Medicaid eligibility for children 6 to 19 was below 133 percent FPL, states had to transition these children from CHIP into Medicaid, and will continue to receive the enhanced Federal Medical Assistance Percentages (FMAP).
    • If a state chooses to expand Medicaid for adults, it will receive a 100 percent federal matching rate for this newly-eligible population in 2014 through 2016. The matching rate is gradually reduced to 90 percent in 2020 and beyond. It is important to note that children are not considered part of a state’s newly-eligible population.
    • In addition, the final rule (Federal Register Vol. 77 No. 57) from the Department of Health and Human Services states that parents eligible to receive Medicaid coverage must first enroll their children in minimal essential coverage before the parent can enroll themselves in Medicaid.
  • Former Foster Care Children: Foster care youth will remain eligible for Medicaid benefits through age 26.
  • Payments for Primary Care Doctors: States must pay primary care physicians, including pediatricians, who serve Medicaid patients no less than 100 percent of Medicare payment rates in 2013 and 2014 for primary care services.

NASHP Resources

Beyond the Expansion: Tackling the Other Medicaid Changes in the ACA: This StateRefor(u)m webinar discusses changes in Medicaid eligibility and enrollment, financing, benefit-design, and consumer assistance requirements as result of the ACA.

Tracking Medicaid Expansion Decisions Chart: StateRefor(u)m compiles the latest Medicaid expansion decisions and activities from governors and legislatures.

Other Resources

Affordable Care Act Coverage for Youth Aging Out of Foster Care: This First Focus analysis outlines the implications of the ACA on former foster care youth.

The American Academy of Pediatrics’ State Medicaid Fact Sheets outline the impact of Medicaid in each state.

The Centers for Medicare and Medicaid Services houses Medicaid State Plans and Amendments.

Increasing Medicaid Payments for Primary Care Physicians in 2013 and 2014: This Kaiser Family Foundation brief discusses the increase in Medicaid primary care physician payment rates.

Kaiser Family Foundation’s StateHealthFacts on Children’s Medicaid includes current Medicaid income eligibility limits for children and other program information.

States’ Medicaid ACA Checklist for 2014: This State Health Reform Assistance Network issue brief highlights requirements in the ACA pertaining to state Medicaid programs, regardless of whether a state chooses to expand Medicaid eligibility for adults.

Your Questions About the Medicaid Expansion Provision of the Affordable Care Act Answered:This Catalyst Center Q&A discusses the impact of the Medicaid expansion on children, families, and children and youth with special health care needs.

1The new Medicaid eligibility floor is 133 percent FPL plus a standard five percent disregard, effectively making the new Medicaid eligibility level 138 percent FPL.