To date, 39 states (including DC) have adopted the Medicaid expansion and 12 states have not adopted the expansion. The current status for each state is based on KFF tracking and analysis of state expansion activity.
Idaho voters approved a ballot measure in November 2018 that requires the state to submit a state plan amendment (SPA) to the Centers for Medicare and Medicaid Services (CMS) to implement the Medicaid expansion within 90 days of approval of the measure. Idaho submitted a SPA for the Medicaid expansion in February 2019. On April 9, 2019, Idaho Governor Little signed a bill passed by the legislature that makes changes to the Medicaid expansion program approved by voters. The legislation directs the Idaho Department of Health and Welfare to seek waivers for multiple changes, including adding a work requirement as a condition of eligibility for coverage. The legislation specifies that if the waivers are not approved by January 1, 2020, then all individuals up to 138% FPL will be enrolled in Medicaid.
Enrollment in Medicaid coverage under expansion began on November 1, 2019, and coverage for these enrollees began on January 1, 2020. The state is still working with CMS to secure approvals of four waivers that it submitted at the direction of the April legislation.
On March 27, 2019, the court set aside the reapproved Kentucky HEALTH waiver. In its previous decision, the court had set aside the original waiver approval, and on November 20, 2018, CMS reapproved the Kentucky HEALTH waiver with minor technical changes. Unless and until HHS issues another approval that passes legal muster or prevails on appeal, the work requirement, monthly premiums up to 4% of income, coverage lockouts for failure to timely renew eligibility or timely report a change in circumstances, heightened cost-sharing for non-emergency ER use, and elimination of retroactive eligibility and non-emergency medical transportation will not be implemented. The separate “institution for mental disease” substance use disorder payment waiver was not set aside and was allowed to go into effect. Kentucky’s expansion program was originally implemented and continues to operate under SPA authority. On November 5, 2019, Democratic Attorney General Andy Beshear defeated incumbent Republican Matt Bevin in Kentucky’s gubernatorial race. On December 16, 2019, Beshear signed an executive order rescinding the Kentucky HEALTH waiver. CMS subsequently removed the terminated provisions from the demonstration approval.
Maine implemented expansion on January 10, 2019. Maine adopted the Medicaid expansion through a ballot initiative in November 2017. After former Governor LePage delayed implementation of the expansion for months, new Governor Mills signed an executive order on her first day in office (January 3, 2019) directing the Maine Department of Health and Human Services to begin expansion implementation and provide coverage to those eligible retroactive to July 2018. CMS approved the state’s plan retroactive to July 2, 2018, on April 3, 2019.
On April 18, 2019, the Montana Legislature passed a bill (which was signed by Governor Bullock on May 9, 2019) to continue the state’s expansion program with significant changes until 2025. This action came after Montana voters voted down a measure on the November 2018 ballot that would have extended the Medicaid expansion beyond the June 30, 2019 sunset date and raised taxes on tobacco products to finance the expansion. The approved bill directs the state to seek federal waiver authority to make several changes to the existing expansion program, including adding a work requirement as a condition of eligibility and increasing the premiums required of many beneficiaries. Per the legislation, the state submitted a Section 1115 waiver proposal with these changes to CMS on August 30, 2019, and the request is pending.
Enrollment in Medicaid coverage under expansion in Nebraska began on August 1, 2020, and coverage for these enrollees began on October 1, 2020. Nebraska voters had approved a Medicaid expansion ballot measure in November 2018 and the state submitted a state plan amendment (SPA) for the expansion on April 1, 2019. The SPA delayed Medicaid expansion implementation until October 1, 2020, to allow time for the state to seek a Section 1115 waiver to implement expansion with program elements that differ from what is allowed under federal law, including a tiered benefit structure that requires beneficiaries to meet work and healthy behavior requirements to access certain benefits. CMS approved this waiver on October 20, 2020, with the implementation of some waiver elements to begin on April 1, 2021, and others (including the work requirement) to follow one year later.
Since Utah voters approved a November 2018 ballot measure to adopt the ACA Medicaid expansion up to 138% of the FPL, the state legislature has taken steps to roll back the full expansion. The state enacted a law in February 2019 that amended the voter-approved ballot measure, requiring the state to submit a series of Section 1115 waiver requests limiting the expansion to 100% FPL, first at its regular matching rate and then requesting the enhanced federal matching rate of 90%. The first waiver, the “Bridge Plan,” was approved in March 2019, and allowed the state to implement a coverage expansion to 100% FPL beginning April 1, 2019, at the state’s regular matching rate. In accordance with the legislation, the state also submitted to CMS its “Per Capita Cap” waiver on July 31, 2019, and subsequently its “Fallback Plan” waiver on November 4, 2019. On December 23, 2019, CMS approved the Fallback Plan waiver’s request to expand Medicaid eligibility to 138% FPL, effective January 1, 2020. CMS also approved several other requests from this waiver, including work requirements for the newly-expanded adult Medicaid population, but did not approve the request to cap enrollment. CMS is continuing to review numerous other provisions in the Fallback Plan waiver.
The Virginia General Assembly approved Medicaid expansion as part of its FY 2019-2020 budget on May 30, 2018; Governor Northam signed the budget into law on June 7, 2018. Expansion coverage became effective under state plan amendment (SPA) authority on January 1, 2019, after enrollment began on November 1, 2018.
Missouri voters approved a ballot measure on August 4, 2020, which adds Medicaid expansion to the state’s constitution. The amendment requires the state to submit all SPAs necessary to implement expansion to CMS no later than March 1, 2021, and for expanding coverage to begin July 1, 2021. Language in the amendment prohibits the imposition of any additional burdens or restrictions on eligibility or enrollment for the expansion population.
Oklahoma voters approved a ballot measure on June 30, 2020, which adds Medicaid expansion to the state’s Constitution. The amendment requires the Oklahoma Health Care Authority to submit a SPA and other necessary documents to CMS within 90 days of the ballot measure’s approval, and for expanding coverage to begin no later than July 1, 2021. Language in the approved measure prohibits the imposition of any additional burdens or restrictions on eligibility or enrollment for the expansion population.
Separately, the Oklahoma Health Care Authority had submitted and then on May 28, 2020, withdrawn a SPA to expand Medicaid. The Authority had also submitted to CMS on April 20, 2020, its Healthy Adult Opportunity Waiver to change the financing structure of the program and impose premiums and work requirements on expansion enrollees; however, on August 11, 2020, the state withdrew this request.
A recent Medicaid expansion ballot initiative effort was delayed by its organizing committee to the 2022 ballot. On January 14, 2020, Democratic legislators introduced bills in both the state House and Senate to put a constitutional amendment expanding Medicaid to a statewide vote, but these are likely to fail in the Republican-controlled legislature.
On October 15, 2020, CMS approved an 1115 waiver called Georgia Pathways to Coverage which expands Medicaid coverage to 100% FPL, with initial and continued enrollment conditioned on compliance with work and premium requirements. Coverage will begin on July 1, 2021. Georgia requested the enhanced ACA funding match for this new coverage group, but CMS denied this request (as it has done in other states). Georgia Pathways includes other eligibility and benefit restrictions. On November 1, 2020, CMS also approved the state’s Section 1332 waiver request to implement a reinsurance program and make other changes to marketplace coverage.
Medicaid expansion passed in the Kansas legislature in 2017 but was vetoed by Republican Sam Brownback, the Governor at the time. In 2018, Democratic Governor Laura Kelly ran for office on the issue of expansion, but Republican leaders in the 2019 session blocked her expansion bill from a vote in the Senate despite its passage in the House on March 20, 2019. On October 23, 2019, Republican Senate Majority Leader Jim Denning proposed his own version of Medicaid expansion, which the Senate Select Committee on Healthcare Access recommended to get further study in the 2020 legislative session. On January 9, 2020, Kelly and Denning announced a bipartisan Medicaid expansion bill that compromises between the 2017 bill vetoed by Brownback, the 2019 bill adopted by the House, and Denning’s October plan. The bill would expand Medicaid by January 1, 2021, and would fund the state’s share of the cost with a capped surcharge on hospitals. In addition to provisions such as premiums and a work referral program, the bill also directs the state to apply for waivers that would transition those between 100-138% of the FPL from Medicaid expansion coverage to Marketplace coverage, although the expansion is not contingent on approval of these waivers. The Senate bill is co-sponsored by 11 Republicans and 11 Democrats, and House members from both parties have expressed their support as well. Republican President Susan Wagle stalled the bill’s progress, however, by pledging not to allow a vote on expansion until an anti-abortion bill passed the House. The 2020 legislative session ended with no further progress on the bill after Democrats tried to force a vote on Medicaid expansion and failed on May 21, 2020.
Medicaid expansion was a key issue in the 2019 Mississippi gubernatorial election, dividing candidates in both the August 27 Republican primary and in the November 5 general election. Republican Lieutenant Governor Tate Reeves, who adamantly opposes expansion, ultimately won both races, making it unlikely that the state will take up expansion in the next four years.
On June 28, 2019, Democratic Governor Roy Cooper vetoed the state budget proposed by the Republican-controlled legislature largely over the issue of Medicaid expansion. On September 11, 2019, Republican House Speaker Tim Moore held a successful veto override vote with 64 of the House’s 120 members present. The budget was then referred to the Senate, where Republicans were unable to secure the votes necessary to override the veto before the legislature adjourned its session on October 31, 2019, without a new budget. On September 18, 2019, the House Health Committee passed House Bill 655, a Medicaid expansion bill with work requirements and premiums; however, the House did not schedule any votes on this bill before the October 31 session adjournment. Neither House Bill 655 nor the budget veto override vote have moved forward since the fall. In April 2020, Senate Republicans announced they would no longer attempt to veto the budget due to the coronavirus pandemic. Although Governor Cooper included Medicaid expansion in his FY 2021 budget proposal and Democratic legislators proposed including expansion in a COVID-19 relief bill, the legislature has not voted on expansion in the 2020 legislative session.
On July 17, 2020, the South Dakota attorney general filed explanations for two 2022 Medicaid expansion ballot initiatives. Both measures are sponsored by former Democratic U.S. Senate candidate Rick Weiland. One is an initiated constitutional amendment (which requires 33,921 signatures to get on the 2022 ballot) and the other is an initiated state statute (which requires 16,061 signatures). Advocates have until November 2021 to gather the signatures
On April 17, 2020, the South Dakota Democratic Party released a statement urging Republican Governor Kristi Noem to consider expanding Medicaid via Executive Order to address the COVID-19 pandemic by increasing access to health care.
Wisconsin covers adults up to 100% FPL in Medicaid but did not adopt the ACA expansion.
On November 12, 2019, the Wyoming legislature’s Joint Revenue Committee voted to move forward a Medicaid expansion bill to the full legislature. If passed, the bill would allow the Governor to direct state agencies to consider options for Medicaid expansion and then, if expansion is recommended, to direct the Health Department to submit an expansion plan to CMS with the Legislature’s approval. At the beginning of the legislature’s 2020 session on February 10, 2020, however, the House voted against including the bill on its consent agenda. A bill filed on February 13, 2020, by Republican Representative Pat Sweeney to put a constitutional amendment to expand Medicaid on the November 2020 ballot also failed in the House on February 14, 2020. The Legislature may revisit the topic, however: at a meeting focused on addressing the COVID-19 crisis on May 8, 2020 lawmakers voted to make Medicaid expansion a priority discussion topic for the Joint Revenue Committee in upcoming months.