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Minnesota and the ACA’s Medicaid expansion

Medicaid expansion plus MinnesotaCare = coverage up to 200% FPL

Medicaid expansion in Minnesota

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In February 2013, then-Governor Mark Dayton signed HF9, a bill that expanded access to Medicaid Assistance (Minnesota’s Medicaid program) under the ACA.

HF9 eliminated the asset test for Medicaid eligibility (required under the ACA) and increased the upper income threshold for Medicaid eligibility for adults to 138 percent of the poverty level (133 percent plus a 5 percent income disregard, which is standard under the ACA).

Prior to 2014, Medical Assistance in Minnesota was available to parents with dependent children if their household income was up to 100 percent of poverty, and to adults without dependent children if their household income was up to 75 percent of poverty. Minnesota was already very progressive in providing Medicaid access for most of the state’s low-income population – in many states there was no coverage at all for childless non-disabled adults prior to 2014, and in states that haven’t expanded Medicaid under the ACA, there still isn’t.

The federal government paid the full cost of covering the newly-eligible Medicaid population through 2016. Starting in 2017, the state began paying a portion of the cost, but the state’s share will never exceed 10 percent. A few weeks prior to passage, an amendment had been added to HF9 that would allow Medicaid expansion to expire if the federal government ever defaults on its promise to always pay at least 90 percent of the cost of covering the newly-eligible population. But that amendment was removed from the bill prior to passage.

Medicaid estate recovery is now limited to cases in which long-term care was provided

Minnesota’s Medicaid program has utilized estate recovery (required under state and federal law) since 1967 as a means of recouping Medicaid costs after an enrollee dies. The estate recovery program applies to people who were 55 or older at the time they incurred Medicaid claims, and the program allowed the state to place liens against the enrollees’ estates, so that some or all of the money would be paid back to the state.

Prior to the ACA, the vast majority of adults 55 or older who were covered by Medicaid were elderly, low-income residents who needed long-term care (Medicare does not cover long-term care, but Medicaid does if the person’s income and assets are low enough). But starting in 2014, large numbers of residents — many of whom were 55 or older — became eligible for Medicaid, and many were caught off-guard when they found out that liens were being filed against their estates.

Lawmakers addressed the issue in 2016, amending the state’s existing protocol for Medicaid estate recovery. The state announced that pending federal approval, Medicaid estate recovery in Minnesota would be limited to cases in which long-term care was covered. The state intended to make that change retroactive to January 2014, but CMS did not grant approval for that. Instead, the new rules, which limit estate recovery to long-term care costs, apply to estate claims that were pending as of July 1, 2016, and to the estates of people who die after July 1, 2016.

Minnesota Care available up to 200% of poverty

In addition to Minnesota Medicaid, the state supports Minnesota Care (MNCare) for residents with incomes above 138 percent of poverty, up to 200 percent of poverty. MNCare has existed in Minnesota since 1992, but it became a much more robust program in 2014. As of January 2015, MinnesotaCare transitioned to a Basic Health Program under the ACA. BHPs are a provision of the ACA that any state can implement, but Minnesota was the only state to do so for 2015. New York established a BHP, effective January 2016.

Numerous improvements were made to MNCare effective January 1, 2014. The program no longer has a $1,000 copay for hospitalization, or a $10,000 cap on inpatient benefits.  The asset test has been eliminated just as it was for Medicaid, and premiums have been significantly reduced. It used to be available only to applicants who had been uninsured for at least four months, but that provision was eliminated in 2014.

Unlike Minnesota’s Medicaid program, MNCare has a small monthly premium that ranges as high as $80, but calculated on a sliding scale and not applicable to some enrollees. The preferred enrollment method is through MNsure. Enrollment in Minnesota Medicaid and MinnesotaCare is open year-round. By September 2016, average monthly enrollment in MinnesotaCare was a little over 100,000. Some were new enrollees, but many had already been enrolled in MinnesotaCare in 2014.

Federal funding for MinnesotaCare (and New York’s BHP, The Essential Plan) was reduced when the Trump administration cut off funding for cost-sharing reductions. The two states sued, and in August 2018 the federal government agreed to restore most of the federal funding for 2018.

Who is eligible for Medicaid in Minnesota?

In addition to the aged, blind, and disabled populations, residents who meet the below requirements are eligible for Medicaid in Minnesota:

  • Adults with household incomes up to 138 percent of poverty (adults with incomes above 138 percent of poverty but not more than 200 percent of poverty are eligible for coverage under MNCare).
  • Pregnant women with household incomes up to 278 percent of poverty.
  • Children 0-2 in households with income up to 283 percent of poverty.
  • Children from 2-18 in households with income up to 275 percent of poverty.

How does Medicaid provide assistance to Medicare beneficiaries in Minnesota?

Many Medicare beneficiaries receive assistance through Medicaid with the cost of Medicare premiums, co-pays, deductibles, and services not covered by Medicare — such as long-term care.

Our guide to financial assistance for Medicare beneficiaries in Minnesota explains these benefits, including Medicare Savings Programs, Extra Help, long-term care coverage, and income guidelines for assistance.

How do I enroll for Medicaid in Minnesota?

If you’re under 65 and not on Medicare:

  • You can enroll in Medicaid online at MNsure, the state-run health insurance exchange.
  • You can call 855-366-7873 for help enrolling or to locate a navigator in your area who can assist you with the enrollment process in person.
  • You can enroll in person at your County Human Services office (includes Tribal Health Care offices).

If you are 65 or older or have Medicare, visit one of these websites (seniors and people with disabilities) for help applying for Medicaid.

Minnesota Medicaid enrollment

In the fall of 2013, prior to the launch of the ACA’s exchanges, Minnesota’s total Medicaid/CHIP enrollment stood at 873,040.

There were 144,481 new Medicaid enrollments through MNsure, the state-run exchange, from October 2013 through April 2014, and total enrollment in Minnesota’s Medicaid program grew to 1,066,787 by August 2014, an increase of more than 22 percent over the enrollment total prior to October 2013. Many of these enrollees were already eligible prior to 2014, but were not aware of their eligibility.

MNsure Navigator organizations made a concerted effort to reach out to populations that have historically been underserved by the health insurance market, helping them to enroll through MNsure. Many of the enrollees helped by the navigator organizations are eligible for Medicaid and were uninsured prior to 2014.

By August 2015, however, total Medicaid/CHIP enrollment had declined slightly, to 1,019,309 (still 17 percent higher than it had been in 2013). According to U.S. Census data, the uninsured rate in Minnesota fell from 8.2 percent in 2013 to 4.5 percent in 2015.

The state publishes monthly enrollment data for Medicaid and MinnesotaCare. As of October 202, there were 979,534 people enrolled in Minnesota Medicaid and 91,132 people enrolled in MinnesotaCare. Eight managed care plans support Minnesota’s Medicaid program: Blue Plus, Health Partners, Hennepin Health, Itasca Medical Care, Medica, PrimeWest Health, South Country Health Alliance, and UCare. All but Medica also support MinnesotaCare. The majority of the enrollees in both programs are covered by Blue Plus and UCare.

In part due to the coranovirus/Covid-19 pandemic and associated losses of employer-sponsored health insurance, Minnesota’s uninsured rate was 8 percent as of May 2020.

Minnesota Medicaid history

Minnesota was one of the six states that enacted Medicaid as soon as the program became available, in January 1966.

In the 1980s, in an effort to control costs, Minnesota began implementing PMAP, or pre-paid medical assistance programs.  PMAPs provide blocks of Medicaid funding to non-profit HMOs and a variety of rural health programs across the state. The program was instituted as a demonstration project in 1983 and continued to be the mechanism by which Medicaid funds are dispersed to providers in Minnesota for decades.

The Minnesota Department of Human Services was tasked with setting rates for the payments that HMOs receive in the Medicaid PMAP.  Over the years, there have been improvements made to ensure that the various participating HMOs are using uniform reporting methods for their administrative expenses.

Minnesota had some of the country’s most generous eligibility guidelines for Medicaid prior to expansion under the ACA (up to 100 percent of poverty for adults with dependent children, and up to 75 percent of poverty for those without dependent children). And the state also became the first in the nation to establish a Basic Health Program under the ACA.

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 Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

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Apply for Medicaid in Minnesota

Enroll online at MNsure. Call 1-855-366-7873 for help enrolling. Enroll in person at your County Human Services office.

Eligibility: Children up to 1 year with household income up to 283% of FPL. Children ages 1-18 with household income up to 275% of FPL. Pregnant women with household income up to 278% of FPL. Adults with household income up to 138% of FPL; adults with income between 138% and 200% of FPL qualify for MNCare.

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