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Massachusetts and the ACA’s Medicaid expansion

Enrollment up 29% since 2013; Gov. Baker wants to move 140,000 people from MassHealth to ConnectorCare

massachusetts Medicaid guide

It’s no surprise that Massachusetts has a robust Medicaid program, giving the commonwealth’s leadership in expanding health care coverage. Massachusetts has relatively high income limits for the groups it covered prior to the Affordable Care Act (ACA) rollout, and it adopted ACA Medicaid expansion to cover low-income adults in 2014.

There were questions about the future of Massachusetts’ Medicaid program when Republican Charlie Baker took office as governor in January 2015. Baker had said he would consider applying for federal waivers to enable to the commonwealth to “advocate for its own interests” relative to MassHealth, the state’s Medicaid program.

But in 2015, Baker’s primary focus with MassHealth was verifying eligibility of currently-enrolled residents and making sure that people who were automatically enrolled in MassHealth in 2014 (due to the glitches with the state’s health insurance exchange) were removed from the Medicaid rolls once their eligibility for other coverage is determined.

By 2017, Baker was advocating for cost-containment measures for MassHealth, including a proposal to move 140,000 people with income between 100 percent and 138 percent of the poverty level from MassHealth to ConnectorCare, and a proposed rule that would make people ineligible for MassHealth if they have access to affordable employer-sponsored health insurance (defined as having premiums equal to less than 5 percent of income). That provision was projected to make roughly 42,000 people ineligible for MassHealth.

Under ConnectorCare, people with income under 150 percent of the poverty level have access to plans with $0 premiums, $1,250 maximum out-of-pocket costs, and copays that range from $10 to $50, depending on the service. But ConnectorCare does not include dental coverage — enrollees would have to purchase it for $29/month — whereas MassHealth does provide dental coverage. So there were concerns that while the state might save money with the changes, the costs would simply be shifted to the low-income population currently served by MassHealth (the state has noted that while these individuals could purchase dental coverage, they would also have access to dental services through the Health Safety Net program, which reimburses providers who treat eligible low-income patients).

Ultimately, lawmakers passed legislation to temporarily (for 2018 and 2019) increase assessments on employers in Massassachusets in order to generate about $200 million in revenue for the MassHealth program, but did not implement Baker’s proposal to prevent people with access to affordable employer-sponsored insurance from enrolling in MassHealth. Starting in 2018, employers are paying a higher Employer Medical Assistance Contribution (the maximum contribution has increased from $55 to $71 per employee per year), and the state is also charging employers an additional assessment, of up to $750 per employee per year, if employees receive benefits via MassHealth or ConnectorCare.

But the Massachusetts Department of Health and Human Services also submitted an 1115 waiver proposal in September 2017, seeking permission to cap Medicaid eligibility for non-disabled adults at 100 percent of the poverty level. The state projects that 40,000 Medicaid expansion enrollees, and 100,000 parents and caretakers (who were already eligible for MassHealth before the ACA’s expansion of Medicaid) would be shifted from MassHealth to ConnectorCare if the waiver were to be approved. The state is primarily seeking savings and sustainability for the Medicaid program, but consumer advocates have noted that the proposed change would not further the goals of the Medicaid program, and could result in coverage becoming less affordable for the population that gets moved to ConnectorCare.

In early 2018, Baker renewed his push to move people earning more than the poverty level from MassHealth to ConnectorCare, amid ongoing budget concerns. The state’s 1115 waiver was still pending approval by CMS as of April 2018.

MassHealth eligibility guidelines

MassHealth is more generous than many other Medicaid programs. Individuals qualify with incomes up to the following levels.

  • Children up to age 1: 200 percent of the federal poverty level (FPL)
  • Children ages 1 to 18: 150 percent of FPL
  • Pregnant women are covered with family income up to 200 percent of FPL
  • Children with family income too high to qualify for Medicaid and pregnant women who aren’t eligible for Medicaid due to immigration status are eligible for the Children’s Health Insurance Program (CHIP); CHIP is available to kids with family income up to 300 percent of FPL and to non-resident pregnant women with income up to 200 percent of FPL
  • Parents and other adults are covered with incomes up to 138 percent of FPL

See FPL stated as dollar amounts at Medicaid.gov.

How you can sign up

  • Submit an application online at MAhealthconnector.org.
  • Fill out a paper application. Return your completed form:
    • By mail: Health Insurance Processing Center; P.O. Box 4405; Taunton, MA 02780.
    • By fax to 617-887-8770. Use this cover sheet when faxing your application.
  • Apply by phone by calling 1-800-841-2900 or TTY: 1-80te0-497-4648 for people who are deaf, hard of hearing, or speech disabled.
  • Apply in person at a MassHealth Enrollment Center. See the left side of this webpage for a list of centers or call 1-888-665-9993 (or TTY: 1-888-665-9997 for people who are deaf, hard of hearing, or speech disabled).

Medicaid expansion

Former Gov. Deval Patrick signed the legislation authorizing Medicaid expansion in July 2013.

Under the expanded Medicaid eligibility guidelines, 32 percent of uninsured residents of Massachusetts were eligible for either Medicaid or CHIP as of 2015.

While Gov. Charlie Baker has mentioned seeking a federal waiver to modify the commonwealth’s Medicaid program, he has not called for rolling back Medicaid expansion, and was one of the Republican governors who pushed back against his party’s efforts to repeal the ACA in 2017. Baker’s initial focus with regards to Medicaid was to ensure that the eligibility verification process was in place, so that the state wouldn’t have to provide MassHealth coverage to people who weren’t actually eligible. Baker has also called for transferring people earning more than the poverty level from MassHealth to ConnectorCare, although lawmakers have thus-far rejected the proposal.

Temporary MassHealth enrollment in 2014

The Massachusetts Health Connector is a state-run exchange that pre-dates the ACA. But the process of making it compliant with the ACA proved to be technologically challenging; the system was supposed to screen applicants to determine whether they were eligible for MassHealth or premium subsidies, but wasn’t functional in its first year. As a result, about 325,000 applicants were temporarily enrolled in MassHealth in 2014. This allowed those residents to have health insurance despite the exchange glitches, but it also cost the state about $140 million in 2014.

By the end of January 2015, about 130,000 people who had been temporarily placed on MassHealth in 2014 had been able to verify their eligibility for coverage through Massachusetts Health Connector. Roughly half of them were actually eligible for MassHealth and remained covered under the program (the rest were able to transition to private plans instead, with subsidies if eligible based on household income).

Eligibility verifications in 2015

When Governor Baker unveiled his budget in March 2015, one of the primary focuses was on reducing Medicaid spending. That included verifying eligibility for 1.2 million of MassHealth’s 1.9 million enrollees (the other 700,000 had enrolled recently enough that their eligibility was current). Federal Medicaid rules require that enrollees’ eligibility be verified annually, but the technology problems with the Massachusetts Health Connector in 2013 – 2014 resulted in MassHealth coverage being automatically renewed for 1.2 million people without verifying eligibility.

Enrollees had to update their information in order to renew their benefits, and by May 2015, the program had disenrolled 158,000 people – out of 500,000 – who hadn’t responded to the state’s information requests.  The state began combing through the next round of 500,000 enrollees in July, making sure that they’re still eligible to remain on MassHealth. By September, the eligibility verification process had reduced total MassHealth enrollment by about 205,000 people.

Medicaid growth

Between September 2013 (just prior to the first ACA open enrollment period) and August 2015, MassHealth and CHIP enrollment grew by 27 percent. By the end of 2017, more than two years later, total enrollment was up by 29 percent, so it had largely plateaued after the first two years of Medicaid expansion. As of December 2017, total enrollment stood at 1,668,763.

Increased costs associated with the MassHealth enrollment spike is cited as the biggest factor in the commonwealth’s budget deficit. About $230 million of a total gap of $765 million in the fiscal budget is attributable to MassHealth, according to the Baker administration. And MassHealth costs were the primary factor that contributed to Massachusetts spending $632 million more on health care in 2014 than their pre-determined spending target. But again, some of that had to do with people being temporarily enrolled in MassHealth due to Connector problems, and the automatic re-enrollment of 1.2 million people also contributed to the increased spending, but has been addressed in 2015.

Governor Baker’s FY 2016 budget included $15.3 billion in MassHealth spending, which was a 5.6 percent increase over FY 2015 spending. But without changes to the program (like the eligibility redeterminations), MassHealth spending was projected to increase by 16 percent, to $16.9 billion.

Massachusetts Medicaid

How to apply

Apply online. Fill out a paper application. Apply by phone: 1-800-841-2900 or TTY 1-800-497-4648. Apply in person at a MassHealth Enrollment Center.

Who is eligible

Children up to 1 year with household income up to 200% of FPL. Children ages 1-18 with household income up to 150% of FPL. Pregnant women with household income up to 200% of FPL. Adults with household income up to 138% of FPL.

More Massachusetts coverage

Insurance Guide

A guide to health insurance in your state.

Exchange

News, history, and enrollment info for your state marketplace

Medicare

Insurance for those over 64 (off-site)