Kentucky and the ACA’s Medicaid expansion

Enrollment up 105%; Kentucky HEALTH waiver would make changes as of 2018

Where in your state to call or visit for Medicaid.How to apply

Enroll online at Kynect. Apply by telephone by calling 1-855-459-6328 or TTY 1-855-326-4654. Fill out a paper application. Apply in person at a local office of the Department for Community Based Services.

Who is eligible in your state to get Medicaid?Who is eligible

Children up to age 1 with family income up to 195% of FPL. Children ages 1-18 with family income up to 159% of FPL; children with family income up to 213% of FPL are eligible for the Kentucky Children’s Health Insurance Program. Pregnant women with family income up to 195% of FPL. Adults with income up to 133% of FPL. See the Programs and Services page for guidelines for elderly, disabled, and others who may qualify.

Kentucky has been one of the most successful states in reducing its uninsured rate through the Affordable Care Act (ACA) — both by expanding Medicaid and adopting a state-run health insurance marketplace (Kentucky still technically has a state-run marketplace, but they began using HealthCare.gov’s enrollment platform in 2017). The Centers for Medicare and Medicaid report that Kentucky’s Medicaid/CHIP enrollment increased by 105 percent from 2013 to February 2017—by far the largest percentage increase of any state. And according to US Census data, Kentucky’s uninsured rate dropped 8.3 percentage points from 2013 to 2015, reaching a low of 6 percent.

As of the third quarter of 2016, there were 650,867 adults enrolled in Kentucky’s Medicaid program, and three-quarters of them were eligible due to the ACA’s expansion of Medicaid.

Bevin’s 1115 waiver proposal seeks to change Kentucky’s Medicaid

Kentucky residents elected Matt Bevin in November 2015 (incumbent Steve Beshear was term-limited and could not run). Bevin, a Tea Party Republican, has expressed his desire to pull back from the current Medicaid expansion in Kentucky. Early in 2015, Bevin said he would eliminate Medicaid expansion entirely, but his position softened towards the end of the campaign. By 2016, Bevin no longer planned to eliminate coverage for the 488,000 people who have obtained Medicaid under Kentucky’s expansion. Instead, he proposed that the state seek a Section 1115 waiver from the federal government to allow Kentucky to design its own version of Medicaid expansion.

In August 2016, Bevin did just that, submitting his Kentucky HEALTH Section 1115 demonstration waiver proposal to HHS for review. Bevin’s administration anticipates federal approval by summer 2017, and enactment of the waiver provisions as of January, 2018.

Kentucky HEALTH would implement a variety of changes, most of which constitute benefit cuts in an effort to control costs:

  • Dental and vision services (which are currently covered by Kentucky Medicaid), over the counter medications, and partial reimbursement for gym memberships would be available via a new system called My Rewards Account. To earn credit in a My Rewards Account (which can then be used for the aforementioned services), Medicaid enrollees will need to complete various actions such as smoking cessation programs, job training, taking the GED, or completing a course on managing chronic health conditions. Although the stated intent is to list people out of poverty and reduce spending on Medicaid, the proposal has been widely panned by public health experts, and dentists question the wisdom of reducing dental benefits in an area where dental disease is widespread.
  • Able-bodied, non-pregnant adults enrolled in Kentucky Medicaid would have a $1,000 “deductible” but it wouldn’t work like regular health insurance deductibles (some media outlets have reported this as if members will have to pay for their first $1,000 in medical costs, but that is not the case). Essentially, non-preventive services used will be tracked against a $1,000 balance in each member’s “administrative deductible account.” At the end of the year, up to 50 percent of the remaining balance of the “deductible” will be transferred to the member’s My Rewards Account. It’s an incentive intended to get enrollees to avoid unnecessary care, in order to keep the credit in the deductible account and then transfer some of it over to the My Rewards Account.
  • Some enrollees will have to pay copays and/or premiums.

Bevin’s underlying point all along has been that the state can’t afford to have half a million new enrollees in its Medicaid program under the ACA. Although Medicaid expansion waivers are certainly better than rejecting expansion altogether, they tend to limit enrollment more than straight expansion. That’s because waivers typically include some way for enrollees to have “skin in the game,” including premiums for some enrollees. But numerous studies have shown that imposing premiums on very low-income people tends to result in fewer people obtaining coverage.

Bevin’s opponents in 2015 — Democrat Jack Conway and Independent Drew Curtis — both supported keeping the current Medicaid expansion system intact in Kentucky. They and Beshear pointed out that Bevin’s plan — which has evolved with time — would result in a loss of coverage for at least some of the half million people in Kentucky who are newly-insured under Medicaid expansion.

See if you qualify for Medicaid

Use this chart to see if you may qualify for Medicaid. Kentucky’s eligibility levels are as follows:

  • Children up to age 1 with family income up to 195 percent of the federal poverty level (FPL)
  • Children ages 1 to 18 with family income up to 159 percent of FPL
  • Children with family income too high to qualify for Medicaid are eligible for the Kentucky Children’s Health Insurance Program (KCHIP); KCHIP is available to kids with family income up to 213 percent of FPL
  • Pregnant women with family income up to 195 percent of FPL
  • Parents and other adults are covered with incomes up to 133 percent of FPL

Kentucky Medicaid is available to a number of other populations, such as individuals who are elderly or disabled. See the Programs and Services page for more information.

Apply for Medicaid

You can do any of the following to apply for Medicaid.

  • Enroll online using HealthCare.gov or Benefind.ky.gov.
  • Apply by telephone (HealthCare.gov) by calling 1-800-318-2596 or TTY 1-855-889-4325, or Benefind at 1-855-306-8959.
  • Download a paper application. Mail your application to the DCBS Family Support P.O. Box 2104 Frankfort KY 40602. You may also fax your application to: 1-502-573-2007.
  • Apply in person at a local office of the Department for Community Based Services (DCBS).

Big benefits through Medicaid expansion

Despite the political unpopularity of the Affordable Care Act, Former Gov. Steve Beshear strongly advocated for Medicaid expansion and a state-run marketplace (Kynect). Beshear’s administration touted both the public health and economic benefits of Medicaid expansion, including improved health outcomes through access to health insurance, the creation of nearly new 17,000 jobs, and a $15.6 billion impact on the state economy over seven years.

A study by Deloitte concluded that through 2020, Kentucky’s Medicaid expansion will be a net financial positive for the state, although supporters of Medicaid expansion note that the improvements in the economy under Medicaid expansion will likely result in the program remaining financially sustainable long-term.

Medicaid expansion was effective as of Jan. 1, 2014. In the fall of 2013 — before the first open enrollment period under the Affordable Care Act — 606,805 people were enrolled in Kentucky’s Medicaid program. As of February 2017, total enrollment had increased by 105 percent, to 1,244,711.

According to Families USA, 55 percent of the newly-eligible Medicaid population in Kentucky is working adults – people who work in industries that are vital to the economy of the state, but who survive on household incomes under 138 percent of the poverty level.

Data collected by the Kentucky Cabinet for Health and Family Services shows that the new Medicaid beneficiaries are taking advantage of preventive screenings, with the following increases from 2013 to 2014:

  • 30 percent increase in breast cancer screenings
  • 3 percent increase in cervical cancer screenings
  • 16 percent increase in colorectal cancer screening
  • 37 percent increase in adult dental visits

The lead up to Medicaid expansion

Despite Gov. Beshear’s conviction about the benefits of expanding Medicaid, Kentucky did not announce the decision until May of 2013. Beshear cited concerns about the cost in explaining why the state’s decision came slower than in other states that adopted expansion.

The Kentucky legislature did not authorize Medicaid expansion, which was a concern for Senate President Robert Stivers. However, Kentucky’s Medicaid eligibility rules are defined in state regulations, which can be changed by executive order. Accordingly, legislative approval was not needed.

While Medicaid expansion was secure during its first couple years, analysis by the Rockefeller Institute indicated that the lack of legislative approval could leave the program in jeopardy after Beshear leaves office. That is exactly the scenario facing the state under Governor Bevin’s administration.

Bevin would be able to roll back Medicaid expansion without legislative action, although he backed off from that tactic very early on, favoring an 1115 waiver to make changes to the existing program instead. If HHS approves Kentucky HEALTH, Kentucky would be the first state to eliminate straight Medicaid expansion (as called for in the ACA, with no state-based variations) and replace it with a state-specific waiver.

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