Medicaid expansion in Kansas
- Bipartisan Medicaid expansion under consideration in Kansas; coverage would expand as of 2021 if it’s successful.
- Medicaid expansion bill passed in the House in 2019, but died in the Senate
- Lawmakers passed expansion bill in 2017, but Governor Brownback vetoed it
- KanCare 2.0 waiver extension (effective in 2019) initially called for a work requirement (without Medicaid expansion) and a 36-month cap on Medicaid eligibility. But CMS denied the 36-month cap, and Kansas asked CMS to postpone consideration of the work requirement.
Bipartisan Medicaid expansion legislation under consideration in 2020
of Federal Poverty Level
If the state were to accept federal funding to expand Medicaid, an estimated 150,000 people would gain access to Medicaid (KanCare) in the state, including 50,000 residents who are currently uninsured. As described below, legislation to expand Medicaid passed in 2017, but Gov. Brownback vetoed it. And Medicaid expansion legislation passed again in the Kansas House in 2019, but died in the Senate. But it appears that Medicaid expansion may finally be enacted in Kansas in 2020 and take effect in 2021.
Two bills have been pre-filed for consideration during this session. S.B.246 was pre-filed in early December 2019. It includes monthly fees that could be as high as $25 per enrollee, and would refer unemployed Medicaid expansion recipients to a job training program. And S.B.252, which was pre-filed in January, just before the start of the legislative session, was announced as a bipartisan compromise by Democratic Gov. Laura Kelly (who has long supported Medicaid expansion) and Republican Senate Majority Leader Jim Denning, and makes it likely that Kansas will be the next state to expand Medicaid.
A summary of the Medicaid expansion bills introduced for 2020, as well as measures that were considered in 2019, is available here.
The legislation has support from Kansas Democrats, but although it’s a bipartisan bill, some of the state’s GOP lawmakers have publicly opposed it, especially because it does not not have a work requirement. Gov. Kelly’s press release about the legislation notes that it includes a “work referral program that promotes self-reliance for non-working Medicaid beneficiaries, while limiting costly administrative red tape that drives up overall costs to taxpayers.” That’s a nod to the fact that Medicaid work requirements are expensive and complicated for states to administer — and almost certain to be challenged in court. By not including a work requirement, the Kansas legislation will cover more low-income residents and be less complicated for the state to administer.
Senator Barbara Bollier, M.D. who is among the sponsors for both Medicaid expansion bills, wrote an article on our site in 2017 about the importance of Medicaid expansion and her tireless efforts to convince other Kansas lawmakers to expand coverage. Bollier was a Republican at that point, but became a Democrat in 2018 and is running for election to the US Senate in the 2020 election.
Details of the bipartisan Medicaid expansion proposal being considered in 2020
A summary of the bipartisan Medicaid expansion legislation (S.B.252) is available here. In a nutshell, here is what’s being proposed:
- Full Medicaid expansion, as outlined in the ACA, as of January 2021.
- Kansas will conduct an actuarial study related to reinsurance and the possibility of switching people with income between 100 and 138 percent of the poverty level back to the exchange (this group is already eligible for coverage in the exchange — it’s only people under the poverty level who are in the Medicaid coverage gap — but they would transition to Medicaid as of 2021 under the terms of S.B.252).
- By 2021, Kansas would submit a 1332 waiver to CMS, seeking to implement a reinsurance program (this is likely to be approved, as has been the case for numerous other states). Reinsurance programs lower premiums across the board in the individual market, although the lower premiums are really only felt by people who pay full price for their coverage. For those who get subsidies (which includes 90 percent of Kansas exchange enrollees), the subsidy amounts decline along with premiums — in some cases, people who get subsidies end up paying more with a reinsurance program in place.
- At the same time, Kansas would submit an 1115 waiver to CMS, seeking approval to switch people earning 100-138 percent of the poverty level back to the exchange. If approved, this waiver would essentially mean that this population goes from private, subsidized plans in the exchange in 2020, to Medicaid in 2021, and back to private subsidized plans in the exchange in 2022.
- The plan to seek approval to transition people above the poverty level back to private insurance is a nod to conservative Medicaid expansion proposals, and is part of the bipartisan appeal of S.B.252. But this proposal is much less likely to be approved, as CMS has not yet approved it anywhere, despite some states efforts. [Most recently, Utah tried to receive Medicaid expansion funding while only expanding coverage to 100 percent of the poverty level, and CMS said no. Utah ultimately agreed to fully expand coverage, to 138 percent of the poverty level, in order to get full Medicaid expansion funding from the federal government.]
- And the legislation clarifies that if CMS doesn’t approve the 1115 waiver (or the 1332 waiver, although that’s much less likely to be an issue), full Medicaid expansion will continue in Kansas.
- Unemployed Medicaid expansion enrollees would be referred to the Kansas Works Program (this is a work referral program, as opposed to a work requirement; people would receive assistance with job training and securing work, but would not lose their health insurance as a result of not having a job).
- Premiums of up to $25/month could be charged for people with income above the poverty level. But people would not be locked out of Medicaid expansion for failure to pay the premiums (instead, they’d be subject to collection under the rules for debts owed to the state of Kansas). The $25/person fee would be allowed to amount to as much as $100 per month per family, but children under the age of 19 are eligible for Medicaid or CHIP in Kansas with family incomes as high as 230 percent of the poverty level, so they would not be subject to the fee, as they would not be newly-eligible for Medicaid under the expansion rules.
- As explained here by Charles Gaba and Dave Anderson (when Kansas considered similar legislation in 2019), a fee of $25/month would put some low-income Kansans in a worse financial spot than they currently have with subsidized coverage in the exchange. But non-disabled, non-pregnant adults without minor children are not currently eligible for Medicaid at all in Kansas if their income is below the poverty level. So even with a fee, Medicaid expansion would be better for them than the status quo. It’s also worth noting that the legislation includes a stipulation that monthly premiums for Medicaid expansion enrollees could not exceed 2 percent of income (it’s not clear, however, if the $25/month “fee” would is considered a premium). For a single person, that would amount to a premium cap of less than $25/month as long as their income didn’t exceed $15,000/year (under Medicaid expansion, eligibility would extend a little over $17,200 at the current poverty level amounts, although that indexes upward from one year to the next).
Medicaid expansion passed the house in 2019 but died in the Senate
H.B.2066, which called for Medicaid expansion, passed in the Kansas House in March 2019 by a vote of 69-54 (note that the bill was revised; it initially dealt with nursing regulations, but that text was replaced with the Medicaid expansion text in the final version). But it never reached a floor vote in the Senate, as explained here by Kansas Representative Brett Parker.
Like the legislation that’s been introduced in 2020, H.B.2066 included a job training referral program and a monthly fee of up to $25 for Medicaid expansion enrollees.
2017: House and Senate passed expansion but Governor Brownback vetoed it
In September 2016, Sandy Praeger, a Republican and former Kansas Insurance Commissioner, called on Governor Brownback and Kansas lawmakers to expand Medicaid, saying that there was “no logical explanation” for the state’s continued rejection of federal funding for Medicaid expansion, and noting that the decision has been based on politics rather than cost analysis.
And the state’s primary election in August 2016 resulted in several moderate Republicans getting onto the ballot for November, energizing Medicaid expansion advocates. Supporters became more confident than ever that they could get a bill passed in 2017 to expand coverage, particularly given that several of the primary winners had been outspoken about their support for Medicaid expansion.
On February 23, 2017, H.B.2044 passed the Kansas House of Representatives, 81-44. A month later, the bill passed the Senate, 25-13. But then-Governor Sam Brownback remained steadfast in his opposition to Medicaid expansion, and vetoed the bill. Although the Medicaid expansion legislation passed by a wide margin in both chambers, it was a few votes shy of a veto-proof majority.
On April 3, the House voted to uphold Brownback’s veto. The final margin was 81-44, three votes shy of the 84 votes that would have been necessary to override the Governor’s veto. Two representatives who had voted for expansion ended up voting to uphold the veto, while two others who had opposed the expansion vote shifted sides and voted to override the veto. In the end, the numbers ended up the same as they had been the prior week, and the governor’s veto remained in effect.
Brownback listed several reasons for vetoing H.B.2044:
- He wanted Medicaid reform to eliminate the existing waiting lists for disabled Kansans (a population that was already eligible for Medicaid pre-ACA)
- He wanted Medicaid reform to be budget neutral for the state (expanded Medicaid is funded almost entirely by the federal government, but states began paying 5 percent of the cost in 2017, and that has grown to 10 percent in 2020 and future years).
- He wanted a work requirement for able-bodied adults (as opposed to the work referral program in H.B.2044)
- He wanted Medicaid reform to cut funding for Planned Parenthood, and H.B.2044 did not do that.
- He believed it would be “unwise” to expand Medicaid given the uncertainty of the ACA on the federal level (ultimately, the ACA has remained in place, despite the efforts of GOP lawmakers and the Trump Administration).
In 2014, Brownback signed legislation (H.B.2552) that requires legislative approval in order to expand Medicaid (as opposed to allowing it via executive action, which is the path that governors in some states have used to expand Medicaid without having to obtain approval from lawmakers). H.B.2552 was popular with Brownback and 2014’s more-conservative legislature, particularly given the strong-than-anticipated gubernatorial campaign of then-House Minority Leader, Paul Davis — a Democrat who supported Medicaid expansion.
The American Cancer Society, which supports Medicaid expansion, reported that 82 percent of Kansas survey respondents wanted the state to accept federal funding to expand Medicaid. Hospital leaders in Kansas also pushed hard for Medicaid expansion, noting that without expansion, some rural hospitals would be forced to close. Although the measure passed by a wide margin in both chambers, it simply wasn’t enough to overcome the governor’s veto.
Lawmakers again considered Medicaid expansion during the 2018 legislative session, although the bill did not pass. Jeff Colyer, who assumed the Governor’s office in January 2018 when Brownback left the join the Trump Administration, was also opposed to Medicaid expansion in the state, and would have been likely to veto an expansion bill, just as Brownback did.
The Senate Public Health and Welfare Committee passed the 2018 Medicaid expansion bill (S.B.38) in February, but it did not advance after that. House Democrats also tried amending other 2018 bills, including a budget bill, to include Medicaid expansion, but were unsuccessful.
KanCare 2.0 waiver proposal initially called for a work requirement and 36-month cap on Medicaid benefits. CMS rejected the 36-month cap and Kansas withdrew the work requirement
The KanCare Medicaid program operates with a waiver from CMS that must be periodically extended. The state was given a temporary extension, through the end of 2018, but was in need of a longer-term renewal by the end of 2018. The state’s initially proposed KanCare renewal, dubbed KanCare 2.0, called for a work requirement for able-bodied, non-exempt adults, and would also have imposed a 36-month limit on Medicaid eligibility for adults who were subject to, and in compliance with, the work requirement (those who do not comply with the work requirement would lose access to KanCare after just three months).
In May 2018, CMS notified Kansas that the 36-month cap on Medicaid eligibility would not be allowed. The federal government was still considering the rest of the state’s proposal at that point, but the letter indicated that CMS was likely to approve the state’s proposed work requirements, and reiterated the fact that CMS has been willing to approve lock-out periods for people who don’t comply with work requirements, which was part of Kansas’ proposal.
But the KanCare extension approval, granted in late 2018 by CMS, noted that the state had asked CMS to defer consideration of the work requirement. The Colyer administration clarified that the state legislature had determined that a work requirement would need to go through the budget process, and would thus not be implemented as part of the KanCare extension that took effect in 2019.
The Trump administration has approved work requirements in several states, but a judge has overturned them in Arkansas, Kentucky, and New Hampshire. Indiana and Arizona have both paused implementation of their work requirements over the legal uncertainties. As of early 2020, Medicaid work requirements are in effect in just two states (Utah and Michigan).
Hospital closure puts a spotlight on Medicaid expansion
In October 2015, Mercy Hospital in Independence, Kansas announced that it would close, becoming the first Kansas hospital to shut down in nine years. The hospital’s closure has been linked to the state’s rejection of Medicaid expansion. In states that don’t expand Medicaid, the uninsured rate remains higher and hospitals continue to struggle with higher levels of uncompensated (charity) care – particularly since federal funds to offset uncompensated care costs are being phased out now that states have the option to expand Medicaid.
Mercy Hospital’s announcement triggered renewed calls for Medicaid expansion in Kansas, but the Brownback Administration and the Colyer Administration remained steadfast in their refusal to expand Medicaid to all adults with household income up to 138 percent of the poverty level. In response to editorials calling for Medicaid expansion in the state, an email from Brownback’s deputy communications director Melika Willoughby described Medicaid expansion as “morally reprehensible” and an “Obamacare ruse [that] funnels money to big city hospitals.” The email also said that Medicaid expansion would create a new entitlement “for able-bodied adults without dependents, prioritizing those who choose not to work before intellectually, developmentally, and physically disabled, the frail and elderly, and those struggling with mental health issues.” [This is disingenuous, though, as 60 percent of adults in the coverage gap are in an employed household; the problem is that their jobs are low-paying and don’t provide health insurance.]
Current Medicaid eligibility in Kansas
Medicaid programs and eligibility vary widely across the country. The federal government sets minimum eligibility levels for specific populations, but states can choose to set their eligibility levels higher than the federal minimums. All states are required to provide Medicaid to certain populations — like low-income children — to qualify for federal Medicaid funding. States that opt to cover additional populations are eligible for additional funding.
Unfortunately for low-income adults in Kansas, the existing KanCare Medicaid program is quite limited.
Kansas is one of 14 states that has not yet accepted federal funding to expand Medicaid to adults with income up to 138 percent of the federal poverty level. As a result, childless, non-disabled, non-elderly adults are not eligible for coverage regardless of how low their income is, and parents with dependent children can only qualify if they live in extreme poverty.
Individuals who meet the following income limits qualify for Medicaid in Kansas:
- Children up to age 1 are covered with family income up to 166 percent of the federal poverty level (FPL)
- Children ages 1 to 5 are covered with family income up to 149 percent of FPL
- Children ages 6 to 18 are covered with family income up to 133 percent of FPL
- Parents with dependent children are eligible with household income up to 38 percent of FPL. For a family of three, that’s $8,105/year in 2019.
- Children with family income too high to qualify for Medicaid are eligible for the Children’s Health Insurance Program (CHIP); the income limit is 242 percent of FPL
- Individuals who are elderly or disabled may also qualify for KanCare; see the eligibility guidelines
If and when Medicaid is expanded in Kansas (potentially as of 2021, if the 2020 legislation is successful), adults between the ages of 19 and 64 will be eligible for Medicaid with income up to 138 percent of the poverty level. For a single individual, that’s currently $17,236 in annual income.
See the income limits use the online screening tool to see if you may qualify.
As of July 2013, enrollment in Kansas Medicaid/CHIP was 378,160. By September 2019, it stood at 373,564, which was a 1 percent decrease since 2013 (total enrollment had increased by about 10 percent from 2013 through late 2016, but has since declined to lower than it was in 2013).
How to enroll in KanCare
For children and families:
- Apply online (or through Healthcare.gov).
- Complete an application. English and Spanish versions are available, or call 1-800-792-4884 to have an application mailed to you.
- You may return the application by fax: 1-800-498-1255.
- You may also submit the application in person or by mail. Use the office locator tool to find the address or phone number for a nearby Department for Children and Families (DCF) office.
- If you need help with the application process, contact DCF toll free at 1-888-369-4777.
For elderly or disabled individuals:
- Apply online.
- Complete an application. English and Spanish versions are available, or call 1-888-369-4777 to have an application mailed to you.
- Return the application by fax: 785-296-4813.
- Alternately, you may submit your completed the application in person or by mail. Use the office locator tool to find the address or phone number for a nearby Department for Children and Families (DCF) office.
- If you need help with the application process, contact DCF toll free at 1-888-369-4777.
Controversy around KanCare
In 2010, Kansas began researching options to reform its Medicaid program to improve health outcomes and control costs. In November 2011, the Brownback administration announced its plans to move all Medicaid beneficiaries, including fragile populations like disabled individuals and nursing home residents, into managed care programs. The reformed program was given the name KanCare.
In September 2014, Democrats on the KanCare Oversight Committee requested an investigation of the contracting process with the three managed care companies that participate in KanCare. Those requesting the investigation cited reports that the FBI interviewed numerous people involved in the contracting process. In October 2015, Amerigroup, one of KanCare’s three managed care organizations, hosted a fund raiser for Republican members of the Senate Health and Welfare Committee, which oversees KanCare’s performance. The fundraising continued a trend of financial contributions to lawmakers from the private companies that contract with KanCare, and called into question lawmakers’ willingness to provide meaningful oversight for KanCare’s performance.
Another area of concern was raised by a study conducted by the University of Kansas. Researchers found that nearly half of disabled individuals interviewed had problems accessing services through KanCare.
Finally, a former employee of one of the managed care companies that participates in KanCare has filed a lawsuit alleging fraud. Jacqueline Leary filed suit against Sunflower State Health Plan, and its parent company, Centene. Leary alleged she was wrongfully terminated after reporting potential fraud with her former employer’s network contracting practices for KanCare business. The lawsuit was dropped in July 2015.
As of 2017, nearly all (96 percent) of Kansas Medicaid enrollees were covered under the state’s Medicaid managed care program.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.