Advocacy in Practice
[Link] The Nurse Practitioner December 2012 7
A primer on Medicaid and its expansion in 2014
By Louise Kaplan, PhD, ARNP, FNP-BC,
FAANP
One component of the June 2012
Supreme Court ruling on the Patient
Protection and Affordable Care Act
(PPACA) was that Congress may
not penalize States that choose not
to participate in an expansion of
Medicaid to cover adults with
incomes up to 133% of the federal
poverty level (FPL).
1
Many nurse
practitioners (NPs) provide care to
Medicaid patients; however, there
are specics of the program with
which some NPs are unfamiliar. This
article provides an overview of the
Medicaid program and how the
Medicaid expansion may affect NP
practice.
What is Medicaid?
Medicaid was enacted in 1965 by the
federal government to provide health
coverage to the poor and disabled. It
is administered by the states under
federal guidelines and jointly funded
by the states and federal government.
An estimated 67.7 million people
were covered by Medicaid for at least
1 month in 2010 with $404 billion in
Medicaid spending during the 2010
scal year.
2
Since 1982, all states have
participated in Medicaid.
3
Who is eligible for Medicaid?
Title XIX of the Social Security Act
species who may be covered by
Medicaid. These groups include
pregnant women and children under
6 with family incomes at or below the
FPL; children ages 6 through 18 with
family incomes at or below 100% of
the FPL; patients and caregiver
relatives who meet certain eligibility
requirements; and older adults or
those who have disabilities and
qualify for Supplemental Security
Income benets.
4
The 2012 FPL for a
family of four in the 48 contiguous
states and the District of Columbia is
$23,050; adjustments are made for
Alaska and Hawaii.
5
States have the
option to cover other populations
not mandated by law, and eligibility
requirements vary by state. Medicaid
has a website that allows individuals
to determine if they are eligible for
Medicaid or a different type of health
insurance, which can be accessed at
[Link]
How is Medicaid nanced?
At a minimum, the federal government
pays 50% of a states Medicaid cost. In
Fiscal Year 2012 (October 1, 2011 to
September 30, 2012), the maximum
the federal government contributed
was 74%, with an average of 57%. The
federal share of Medicaid is known as
the Federal Medical Assistance Percent-
age (FMAP). It is calculated using a
formula dened in Medicaid law. The
lower the average personal income in
a state, the higher the FMAP,
3
and the
highest FMAP is in Mississippi. A list
of the FMAPs by state is available at
[Link]
What does Medicaid cover?
Federal law mandates that all states
cover certain benets. Note that the
law does not mandate that all types
of NP services are covered. Examples
of mandated benets include the
following:
inpatient hospital services
outpatient hospital services
Early and periodic screening,
diagnostic, and treatment
(EPSDT) services
nursing facility services
home health services
lab and X-ray services
physician services
nurse midwife services
certied pediatric and family NP
services.
States have the option to cover
other benets. Although prescription
drug benets are optional, all states
offer this benet. Examples of other
optional benets include the following:
physical therapy
occupational therapy
podiatry services
speech, hearing, and language
disorder services
dental care for adults
chiropractic services
other practitioner services
prosthetics
hospice.
A complete list of mandated and
optional benets can be found at
[Link]
CHIP-Program-Information/By-
Topics/Benets/Medicaid- [Link].
The Medicaid expansion
The Supreme Court ruling in June
only voided the section of the PPACA
that would have penalized states that
did not participate in the Medicaid
programs expansion. In a July 10,
2012, letter to the states governors,
Secretary of the Department of Health
and Human Services Kathleen
Sebelius afrmed that the expansion
Copyright 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
8 The Nurse Practitioner Vol. 37, No. 12 [Link]
Advocacy in Practice
will go forward. Eligibility for Medicaid can be extended to
adults under the age of 65 with incomes up to 133% of the
FPL. States will receive 100% of the cost of the expansion
from the federal government from 2014 through 2016.
Federal funding will then reduce incrementally to 90% by
2020, still a much higher rate than any state currently
receives. States also have the exibility to design a benet
package for these new beneciaries.
6
In addition, states
will be allowed to decide whether and when to expand
Medicaid as well as whether to opt-out of the expansion.
7
However, if a state does not implement the Medicaid
expansion between 2014 and 2016, it will not receive 100%
of federal funding, which ends in 2016.
3
How will the Medicaid expansion affect NP practice?
NPs who work in states that implement the Medicaid
expansion may experience an increased demand to accept
new Medicaid patients. This demand will coincide with
the implementation of the State Health Exchanges, which
will provide millions of individuals the option to purchase
health insurance and also enter the healthcare system. It is
estimated that at least eight statesOklahoma, Georgia,
Texas, Louisiana, Arkansas, Nevada, North Carolina, and
Kentuckywill be unable to meet primary care needs
from the expansion of Medicaid alone. Even if primary
care capacity exists, providers may not accept new
Medicaid patients.
8
In states that do not expand Medicaid, individuals
may continue to be uninsured. The PPACA provides
premium tax credits and cost-sharing reductions to
purchase a qualied health plan through the insurance
exchanges only for people with income between 100%
and 400% of FPL. Individuals who are not eligible for
Medicaid and have an income lower than the FPL will
not qualify for this assistance. NPs who serve the
uninsured may continue to have uninsured patients in
their practice. This may be an unintended consequence
of the Supreme Court ruling.
NPs will need to decide if they will accept new
Medicaid patients to provide healthcare access on a
consistent basis including preventive services and care
for acute and chronic problems. NPs have always been
a solution to the access problem; without NPs, millions
of people would go without primary or specialty care.
Implementation of the Medicaid expansion will provide
another opportunity to participate in solving access to
care barriers. Within each individual state, every NP is
urged to advocate for the expansion of Medicaid to
assist the PPACAs goal to provide universal health
insurance coverage.
REFERENCES
1. Supreme Court of the United States. National Federation of Independent
Business et al. v. Sebelius, Secretary of Health and Human Services, et al. p. 55.
[Link]
2. Truffer CJ, Klemm JD, Wolfe CJ, Rennie KE. 2011 Actuarial Report on the
Financial Outlook for Medicaid. Ofce of the Actuary. Centers for Medicare &
Medicaid Services, United States Department of Health and Human Services;
2011. [Link]
ActuarialStudies/downloads/[Link].
3. Kaiser Family Foundation. Medicaid nancing: An overview of the Federal
Medicaid Matching Rate (FMAP). 2012. [Link]
load/[Link].
4. Kaiser Family Foundation. A guide to the Supreme Courts decision on the
ACAs Medicaid expansion. 2012. [Link]
load/[Link].
5. 2012 HHS Poverty Guidelines. [Link]
shtml#thresholds.
6. Sebelius K. Letter to the Governors. [Link]
Secretary-Sebelius-Letter-to-the-Governors-071012.
7. Presentation of Cindy Mann, CMS Deputy Administrator to National Con-
ference of State Legislatures, Medicaid and CHIP: Today and Moving Forward.
2012. [Link]
8. Ku L, Jones K, Shin P, Bruen B, Hayes K. The states next challengesecuring
primary care for expanded Medicaid populations. N Engl J Med.
2011;364(6):493-495.
Louise Kaplan is director of the Nursing Program and an associate professor of
Nursing at Saint Martins University, Lacey, Wash.
DOI-10.1097/[Link].0000422210.15422.49
Copyright 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.