Kansas and the ACA’s Medicaid expansion

Medicaid expansion proponent Laura Kelly is the next governor, and will sign expansion legislation if lawmakers pass it

kansas Medicaid guide

Medicaid expansion proponent Laura Kelly wins governor’s race

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Kansas has not accepted federal funding to expand Medicaid. If the state were to do so, an estimated 150,000 people would gain access to Medicaid (KanCare) in the state. But Democrat Laura Kelly won the gubernatorial election in Kansas in 2018. Kelly supports Medicaid expansion, and has vowed “to advocate for and sign legislation to expand Medicaid in her first year.”

Kansas lawmakers passed Medicaid expansion legislation in 2017, but then-Governor Sam Brownback vetoed it and the legislature didn’t have enough votes to override the 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, is 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.

S.B.38 called for expansion of Medicaid for adults earning up to 138 percent of the poverty level. It also called for a mandatory work referral program for Medicaid expansion enrollees who aren’t working at least 20 hours per week, but stopped short of requiring enrollees to work as a condition of eligibility for Medicaid.

With Kelly in the Governor’s office, the issue of Medicaid expansion is sure to be brought up again in the 2019 session, and Kansas could become one of the next states to accept federal funding to expand Medicaid.

KanCare 2.0 waiver proposal calls for a work requirement and 36-month cap on Medicaid benefits, but CMS has rejected the 36-month cap

In addition to not expanding Medicaid, Kansas — under Governors Brownback and Colyer — has bee is seeking to make it harder for low-income parents to maintain their eligibility for KanCare. The state’s Medicaid program, which operates with a waiver from CMS, was given a temporary extension, through the end of 2018, but is in need of a longer-term renewal by the end of 2018. The state’s proposed KanCare renewal, dubbed KanCare 2.0, calls for a work requirement for able-bodied, non-exempt adults, and would also impose a 36-month limit on Medicaid eligibility for adults who are 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 is still considering the rest of the state’s proposal, but the letter indicated that CMS is likely to approve the state’s proposed work requirements, and reiterates the fact that CMS has been willing to approve lock-out periods for people who don’t comply with work requirements, which is part of Kansas’ proposal.

So it’s reasonable to assume that Kansas will have a Medicaid work requirement in the future, but the amount of time that a person can be enrolled in Medicaid will not be capped at 36 months.

Since Kansas has not expanded Medicaid, adults without minor children are not eligible for Medicaid at all, unless they’re elderly, pregnant, or disabled. Parents with minor children are eligible, but only if their income doesn’t exceed 38 percent of the poverty level. For a family of three, that amounts to less than $8,000 in total income in 2018.

There are several categories of exemptions detailed in the work requirement proposal, including pregnant women and adults who are caring for a child under the age of six or a disabled person. But non-disabled KanCare members who aren’t exempt from the work requirement would have to work 20-30 hours per week, depending on their circumstances.

Work requirements have been approved by the Trump Administration for three states (Arkansas, Indiana, and Kentucky), but all of those states have expanded Medicaid.

Arizona, Maine, Utah, and Wisconsin have also proposed implementing lifetime limits in terms of how long a person can be covered by Medicaid, but thus far, no states have received approval for lifetime Medicaid caps. Under the Obama Administration, a previous proposal from Arizona to impose a lifetime time limit on Medicaid coverage was rejected in 2016. And now the Trump Administration has also made it clear that lifetime caps on Medicaid eligibility will probably continue to be prohibited.

2017: House and Senate pass expansion, Governor vetoes 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 on March 30, he vetoed it. 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 current 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 will grow to 10 percent by 2020).
  • 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.

The details of the state’s vetoed expansion plan

H.B.2044, as amended prior to its passage in the Kansas House, called for Medicaid expansion in Kansas as of January 1, 2018. There are 150,000 people in Kansas who were expected to be newly eligible for coverage if Medicaid eligibility were expanded to 138 percent of the federal poverty level, as called for in the Affordable Care Act (ACA). The bill included a provision to refer unemployed or underemployed (fewer than 20 hours per week) enrollees to a work training and job search program, although there was an exemption for stay-at-home parents of minor children, and for full-time students.

H.B.2044 was originally introduced in order to include community-based rehabilitation services as a covered benefit under Kansas Medicaid. But Democrats and moderate Republicans in the Kansas House of Representatives amended the bill to include Medicaid expansion, and passed it through the House Committee of the Whole by a wide margin (83-40; it needed 70 votes to pass), after more than 160 people — representing stakeholders all over Kansas — testified in support of Medicaid expansion, while just five testified in opposition.

The move to amend H.B.2044 and pass it through the Committee of the Whole came the day after the House Health and Human Services Committee had voted 9-8 to table a Medicaid expansion bill (H.B.2064) until at least April 3. That had effectively killed H.B.2064, since February 23 was the deadline for bills to move out of the chamber where they originated (however, the committee vote on H.B.2064 marked the first time a Kansas legislative committee voted on a Medicaid expansion bill; others had been introduced over the last few years, but have died in committee without a vote).

H.B.2044 passed the House by a wide margin (81-44), but the vote was three short of what would be needed to override a veto. The Senate’s 25-13 vote was two short of the number needed to override a veto.

The Kansas Hospital Association noted that by not expanding Medicaid, the state had already missed out on $1.7 billion in federal funding that would otherwise have flowed into the Kansas economy and helped struggling hospitals stay afloat.

Advocates continued focus on expansion

Although the uninsured rate in Kansas had reached an all-time low of 8.7 percent by 2016 (and remained at that level in 2017, despite a slight increase in the nationwide uninsured rate in 2017) advocates note that there are 50,000 uninsured Kansas residents who would be eligible for Medicaid if the state were to expand coverage, and a total of 150,000 who would be newly eligible for Medicaid under expansion.

Kansas has thus-far decided against expanding its Medicaid program, despite a December 2013 poll that found 72 percent of registered Kansans voters favored expansion. The Kaiser Family Foundation estimates that 48,000 Kansans are in the coverage gap, given the state’s rejection of Medicaid expansion. Individuals in the coverage gap earn too much to qualify for Medicaid, but not enough to qualify for premium tax credits that would help them purchase private health insurance through the marketplace.

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 have 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.]

But then-State Senator Jeff King, a Republican, who was vice president of the Kansas Senate until 2017 (King did not seek re-election in 2016), represented the district where Mercy Hospital is located, and was swift in his condemnation of Willoughby’s email. King supported Medicaid expansion, albeit with a waiver that would allow Kansas to use private health insurance to cover the newly-eligible population (this is an approach that several other states have used to implement Medicaid expansion). The Kansas Hospital Association also disagreed with Willoughby’s position, and has repeatedly called for Medicaid expansion in the state. H.R.2064, being considered in the 2017 legislative session, was introduced by Rep. Sue Concannon (R, Beloit) on behalf of the Kansas Hospital Association.

A Medicaid expansion bill, HB 2319, was introduced in the 2015 session and got a hearing before the House Health and Human Services Committee. The acting secretary for the Kansas Department of Health and Environment testified that expansion would cost the state $2.4 billion between 2016 and 2025, and the committee didn’t act on the bill.

The federal government will always pay at least 90 percent of the cost of Medicaid expansion, but states will be responsible for ten percent of the cost by 2020. However, Kansas hospitals are projected to lose $2.6 billion between 2013 and 2022 if the state continues to reject Medicaid expansion. The state is also missing out on $5.3 billion in federal funding over that same time period by not expanding Medicaid. And a new Kaiser Family Foundation study found that states that have rejected Medicaid expansion actually saw their share of Medicaid spending increase twice as much in fiscal year 2015 as state Medicaid spending in states that have expanded coverage.

Brownback’s position remained unchanged throughout his term as governor. He maintained that the state could not afford to expand Medicaid, and that he would only consider expansion if it were budget neutral. Brownback said that the state should not move forward with expansion of Medicaid while they have currently-eligible residents who are on waiting lists for Medicaid services (part of that problem can be attributed to issues with KanCare, discussed below).

The Alliance for a Healthy Kansas renewed their call for Medicaid expansion in 2016, and launched a state-wide campaign to educate voters about the lawmakers who were on the ballot in November, and how voters can influence the state’s course on Medicaid expansion.

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 individuals in Kansas, the existing Medicaid program — which is called KanCare — is quite limited.

Kansas is one of 19 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 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 33 percent of FPL. For a family of three, that’s $6,738/year in 2017.
  • 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

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 November 2016, it stood at 416,379, which was a 10 percent increase since 2013 (although the total decreased slightly from July 2016 to November 2016).

From 2013 through at least 2015, Medicaid enrollment in Kansas among children age 1 to 5 had been declining, although state Medicaid officials haven’t pinpointed a specific reason and note that some of the children may be covered under CHIP instead (CHIP enrollment has grown slightly since 2013).

Kansas Action for Children, a state advocacy group, believes that the decline in Medicaid enrollment among young children is correlated with the fact that Kansas decoupled applications for Medicaid and TANF a few years ago. The plan was for the new Kansas Eligibility Enforcement System (KEES) to begin coordinating enrollment in various public programs in 2013, but it’s been delayed repeatedly and the system was not yet fully operational as of fall 2015.

How to enroll in KanCare

Kansas Medicaid has been experiencing an enrollment backlog since late 2015, due to a combination of a new computer system, all enrollments going through a single state agency, and an influx of new enrollees during the ACA’s enrollment period (Medicaid enrollment is year-round, but tends to peak during the individual market’s open enrollment period due to outreach and advertising; despite the fact that Kansas hasn’t expanded Medicaid, the “woodworker” effect means that people who were already eligible have been enrolling in larger numbers since 2014.

The state is working to get the backlog down to its historical levels before the 2017 individual market open enrollment period begins in November 2016.

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 fund raising continued a trend of financial contributions to lawmakers from the private companies that contract with KanCare, and calls 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.

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.

How to apply in KS

Children and families can apply online or complete an application in English and Spanish. Elderly or disabled individuals can apply online or complete an application in English and Spanish. Anyone needing assistance with the application process can call 1-888-369-4777 for help.

Eligibility: Children up to age 1 with family income up to 166% of FPL. Children ages 1-5 with family income up to 149% of FPL. Children ages 6-18 with family income up to 133% of FPL; children with family income up to 242% of FPL are eligible for CHIP. See the eligibility guidelines for those who are elderly or disabled.

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