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Massachusetts and the ACA’s Medicaid expansion

Enrollment up 37% since 2013

ACA’s Medicaid eligibility expansion in Massachusetts

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.

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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 was determined.

By 2017, Baker was advocating for cost-containment measures for MassHealth, including a proposal to move 140,000 people with income between 100% and 138% 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% of income). That provision was projected to make roughly 42,000 people ineligible for MassHealth.

Under ConnectorCare, people with income under 150% of the poverty level have access to plans with $0 premiums, $750 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 have been 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 Massachusetts 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. In 2018 and 2019, employers paid a higher Employer Medical Assistance Contribution (the maximum contribution increased from $55 to $71 per employee per year) if employees received benefits via MassHealth or ConnectorCare, and were also subject to an additional assessment of up to $750 per employee per year.

The Massachusetts Department of Health and Human Services also submitted a 1115 waiver proposal in September 2017, seeking permission to cap Medicaid eligibility for non-disabled adults at 100% of the poverty level. The state projected 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 have been shifted from MassHealth to ConnectorCare if the waiver had been approved, but CMS rejected that proposal in 2018 (consumer advocates had noted that the proposed change would not have furthered the goals of the Medicaid program, and could have resulted in coverage becoming less affordable for the population that would have been moved to ConnectorCare).

Massachusetts has accepted federal Medicaid expansion

  • 1,779,418 – Number of people covered by Medicaid/CHIP as of May 2021
  • 483,059 – Increase in the number of Bay Staters covered by Medicaid/CHIP fall 2013 to May 2021
  • 32% – Reduction in the uninsured rate from 2010 to 2019
  • 37% – Increase in total Medicaid/CHIP enrollment in Massachusetts since Medicaid expansion took effect

Who is eligible for Medicaid in Massachusetts?

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

  • Children up to age 1: 200% of the federal poverty level (FPL)
  • Children ages 1 to 18: 150% of FPL
  • Pregnant women are covered with family income up to 200% 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% of FPL and to non-resident pregnant women with income up to 200% of FPL
  • Parents and other adults are covered with incomes up to 138% of FPL

How does Medicaid provide assistance to Medicare beneficiaries in Massachusetts?

Many people with Medicare receive help through Medicaid with Medicare premium costs, prescription drug expenses, and expenses that Medicare doesn’t cover — such as long-term care.

Medicare Resources’ guide to financial resources for Medicare enrollees in Massachusetts provides an overview of those programs, including Medicare Savings Programs, nursing home benefits, and income guidelines for assistance.

How do I enroll in Medicaid in Massachusetts?

Residents have several options to apply for Medicaid in Massachusetts if they are under 65:

  • 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: 1-800-497-4648 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).

Seniors and people with Medicare can apply for Medicaid using this website or by contacting MassHealth at (800) 841-2900.

Massachusetts Medicaid enrollment numbers

There are 1,779,418 Massachusetts residents covered by Medicaid/CHIP as of May 2021. This includes 483,000 people enrolled under Medicaid expansion.

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

Historically, increased costs associated with the MassHealth enrollment spike was cited as the biggest factor in the commonwealth’s budget deficit. About $230 million of a total gap of $765 million in the 2015 fiscal budget was 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% increase over FY 2015 spending. But without changes to the program (like the eligibility redeterminations), MassHealth spending was projected to increase by 16%, to $16.9 billion.

Massachusetts Medicaid history

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

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

While Gov. Charlie Baker has called for modifications to the commonwealth’s Medicaid program (including capping Medicaid expansion at 100% of the poverty level, which the Trump administration rejected), he 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.

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.

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Apply for Medicaid in Massachusetts

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.

Eligibility: 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.

Massachusetts section

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