What Are Medicaid Expansion and Medicaid Work Requirements?

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  • Medicaid expansion is a provision of the ACA that extends health coverage to low-income individuals, but Medicaid work requirements could impact eligibility.
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What Is Medicaid Expansion?

Historically, Medicaid provided health coverage to certain groups of low-income individuals, such as children and their parents, pregnant women, people with disabilities and older adults.

In 2010, the Affordable Care Act gave states the option to expand Medicaid to other low-income individuals. In states that have expanded Medicaid, all individuals with incomes up to 138% of the federal poverty level qualify for Medicaid. 

Medicaid expansion has led to large reductions in uninsured rates. States that have expanded Medicaid have lower uninsured rates than states that have opted out of Medicaid expansion. The decline in the number of uninsured individuals among the low-income population corresponds with gains in Medicaid coverage. 

How Many States Have Expanded Medicaid?

Most states have adopted Medicaid expansion. In total, 39 states, plus the District of Columbia, have expanded Medicaid. The states that have not expanded Medicaid include Alabama, Florida, Tennessee, Kansas, Georgia, North Carolina, South Carolina, South Dakota, Mississippi, Texas, Wisconsin and Wyoming. States that have not yet expanded Medicaid may choose to do so at any time.

What Are Medicaid Work Requirements? 

Commonly known as work requirements, these policies require Medicaid beneficiaries to participate in certain activities, such as work, job training or volunteering, in order to receive Medicaid benefits. Policies vary by state, but most require beneficiaries to verify that they engage in such activities for at least 80 hours per month. Generally, older adults, pregnant women and people deemed medically frail are exempt from Medicaid work requirements. 

What Is the History of Medicaid Work Requirements? 

Until recently, federal and state governments did not consider employment status when determining Medicaid eligibility. In 2018, however, the federal government gave states permission to require certain individuals to work in order to keep Medicaid benefits. 

Before a state can impose Medicaid work requirements, however, it must apply and receive approval for a waiver from the Centers for Medicare and Medicaid Services. A waiver is a tool that allows states to modify certain Medicaid program requirements to allow the exploration of new approaches in service delivery. 

Generally, states proposing Medicaid work requirements are seeking to apply those requirements to individuals who have gained Medicaid coverage under expansion. However, some states that have not expanded Medicaid are also seeking to add work requirements to their Medicaid programs.

How Many States Have Medicaid Work Requirements?

The Centers for Medicare and Medicaid Services has approved Medicaid waivers with work requirements in eight states:

  • Arizona
  • Georgia
  • Indiana
  • Nebraska
  • Ohio
  • South Carolina
  • Utah
  • Wisconsin

However, no states are currently imposing work requirements on Medicaid beneficiaries. In addition, seven states have such waiver requests pending approval by the Centers for Medicare and Medicaid Services. These states include:

  • Alabama
  • Idaho
  • Mississippi
  • Montana
  • Oklahoma
  • South Dakota
  • Tennessee

Four states have secured work requirement waivers from the Centers for Medicare and Medicaid Services but have had these waivers set aside by the courts:

  • Arkansas
  • Kentucky
  • Michigan
  • New Hampshire

In these states, the federal government is blocking the implementation of the work requirements. However, work requirements may be reinstated on appeal. 

Who Is Eligible for Medicaid? 

Medicaid eligibility rules vary by state. Generally, applicants must be:

  • A resident of the state in which they are applying for Medicaid
  • Characterized as low-income  
  • A citizen or a lawful permanent resident of the United States

In all states, federal law requires states to provide Medicaid coverage to certain groups of individuals. These groups include low-income families, poor pregnant women, certain low-income older adults and certain individuals with disabilities, among others. 

In some states, the Medicaid program covers all low-income adults under a certain income threshold, based on income alone. Individuals earning incomes up to 138% of the federal poverty level are eligible for Medicaid if they live in states that have expanded Medicaid. 

What Is the Income Level To Qualify For Medicaid?

Federal poverty levels are used to determine eligibility for Medicaid. For 2020, the federal poverty levels were:

  • $12,760 for individuals
  • $17,240 for a family of 2
  • $21,720 for a family of 3
  • $26,200 for a family of 4
  • $30,680 for a family of 5
  • $35,160 for a family of 6
  • $39,640 for a family of 7
  • $44,120 for a family of 8