Key takeaways
- Mississippi has not expanded Medicaid under the ACA
- How will Mississippi handle Medicaid renewals after the pandemic?
- Mississippi lawmakers approve extending postpartum Medicaid coverage to 12 months after birth (instead of 60 days)
- Why did Mississippi’s 2022 ballot not have a Medicaid expansion initiative?
- Mississippi is seeking federal approval for a Medicaid work requirement, but is unlikely to receive approval under the Biden administration
- Of the 320 comments submitted to CMS on Mississippi’s proposed work requirement waiver, 319 were in opposition
How will Mississippi handle Medicaid renewals after the pandemic?
Medicaid disenrollments have been paused nationwide since March 2020, due to federal legislation that addressed the COVID pandemic. Even if a person’s circumstances have changed and they are no longer Medicaid-eligible, their coverage has continued throughout the pandemic. That will end, however, starting in April 2023. At that point, states will resume regular full eligibility redeterminations, and disenroll people who are no longer eligible for Medicaid.
Under federal rules, eligibility redeterminations for all Medicaid enrollees will have to be initiated during a 12-month “unwinding” period (states can take up to 14 months to complete all of the eligibility redeterminations). Mississippi is starting the eligibility redeterminations in April 2023, and will initiate renewals for all enrollees by March 2024, with the number of renewals spread fairly evenly throughout that window.
Mississippi Medicaid is asking all enrollees to ensure that their contact information is up-to-date, so that the Medicaid agency can send them renewal details and obtain the information that will be needed in order to determine whether a person is still eligible for Medicaid (if the Medicaid office can’t reach an enrollee to verify their ongoing eligibility, the person will lose their Medicaid coverage). But enrollees should wait to take other eligibility determination action until they receive a renewal notice, which might not come until late 2023 or early 2024, depending on their renewal date.
Mississippi has continued to request eligibility verification from enrollees throughout the pandemic, as have many other states. But people who didn’t respond or who were no longer eligible could not be disenrolled unless they requested that. Instead, Mississippi has been moving these people from managed care plans to fee-for-service Medicaid. This saved the state some money, but potentially reduced some enrollees’ access to the supplemental services that the Medicaid managed care plans provide.
If a person is no longer eligible for Medicaid and also not eligible for Medicare or an employer’s health plan, they will need to obtain their own replacement coverage. In most cases, the exchange/marketplace is the best way to do this, and Mississippi uses HealthCare.gov as its marketplace. To make it as easy as possible for people to make this transition. HealthCare.gov is offering an extended enrollment opportunity, from March 31, 2023 through July 31, 2024, for anyone who loses Medicaid at any time during that window. This means people will not have to enroll within 60 days of losing their Medicaid, as would normally be the case. However, the best course of action is still to enroll as soon as possible, in order to minimize gaps in coverage.
Because Mississippi has not expanded Medicaid under the ACA, the state does still have a coverage gap for adults with income below the poverty level. So when Medicaid disenrollments resume, it will be important for low-income residents to be aware of how to avoid this coverage gap.
Has Mississippi expanded Medicaid eligibility?
Mississippi Medicaid has not been expanded as allowed under the Affordable Care Act (ACA), despite the state medical association’s support of expansion going back to August 2016. Mississippi is one of just 12 states that have not yet expanded Medicaid as of 2023 (South Dakota will expand Medicaid in mid-2023, leaving 11 remaining states, including Mississippi). New legislation to expand Medicaid was introduced in Mississippi in 2023 (SB2070, HB458, and HB447), but the bills died in committee at the end of January 2023.
Non-disabled adults without children are not eligible for Medicaid in Mississippi regardless of how low their income is, and parents with dependent children are only eligible with incomes that don’t exceed 27% of the poverty level. This is one of the lowest eligibility caps in the country — only three states have lower limits.
[fpl_calculator]If Mississippi did expand eligibility for Medicaid as called for in the ACA, an estimated 220,000 would be newly eligible for coverage. Unfortunately, in the poorest, sickest state in the U.S., the majority of lawmakers and two governors have opted to reject federal funds that would provide health insurance for the state’s poorest residents.
Because subsidies are only available in the exchange for people whose household incomes are at least 100% of poverty, there are 102,000 people in Mississippi who are in the coverage gap and have no realistic access to health insurance (some analyses indicate that there are more like 130,000 people in the coverage gap in Mississippi). They aren’t eligible for Medicaid, and they also aren’t eligible for subsidies. According to the Kaiser Family Foundation, the share of the uninsured adult population in the coverage gap is highest in Mississippi (37%, versus an average of 27% across all states that had not expanded Medicaid as of 2014).
What is postpartum Medicaid extension, and has Mississippi implemented it?
Under federal rules, states are required to provide Medicaid coverage to pregnant women with incomes up to 138% of the federal poverty level, and nearly every state has set the income limit higher than that (in Mississippi, it’s 199% of the poverty level, and almost two-thirds of all births in Mississippi are covered by Medicaid). States must also allow the mother to keep Medicaid coverage for at least 60 days after the baby is born.
But starting in 2021, states began extending Medicaid coverage for new mothers so that it would last for 12 months after the birth, instead of terminating after just 60 days. This was due to a provision in the American Rescue Plan that provides federal funding to support this (the funding was initially just for five years, but the Consolidated Appropriations Act that was enacted in late 2022 made it permanent).
Most of the states have either already implemented an extension of postpartum Medicaid to 12 months, or have plans to do so in the near future. Mississippi has not yet done so, but the legislature passed a bill (SB2212) in 2023 that calls for the extension of postpartum coverage to 12 months, starting in July 2023. Mississippi Governor Tate Reeves has said that he will sign it into law.
Governor Reeves was previously opposed to the extension of postpartum Medicaid, but announced his support for it a few weeks after the measure passed the Senate in 2023. And House Speaker Philip Gunn, who was instrumental in previously killing measures to extend postpartum Medicaid coverage, had confirmed that he would not block the latest bill. (A similar bill was introduced in the Mississippi House in January 2023, but died in committee. The measure was also considered in 2022, when it passed the Senate and then died in the House.)
It’s worth noting that the extension of postpartum Medicaid coverage to 12 months (instead of 60 days) is not the same thing as Medicaid expansion under the ACA. As described above, Mississippi’s legislature has long opposed Medicaid expansion, and legislation to expand Medicaid failed once again in 2023. But the extension of postpartum Medicaid coverage would not make people newly eligible for Medicaid. The same eligibility guidelines would continue to be used for pregnant women, but instead of losing their coverage 60 days after their baby is born, they would continue to be covered for a year. Medical professionals have been strongly in support of this change, as having health coverage helps to reduce maternal mortality rates (which are high in Mississippi) in the months after a baby is born.
Why did Mississippi's ballot not have a Medicaid expansion initiative?
In 2021, Medicaid expansion advocates in Mississippi began gathering signatures to get Initiative 76 on the 2022 ballot. This measure would have let the state’s voters decide whether Medicaid should be expanded, and it’s worth noting that this approach has resulted in Medicaid expansion in several other states and voters have never failed to pass a Medicaid expansion measure in any state when it has been on the ballot. However, Initiative 76 was suspended in mid-2021, after it was determined that a state Supreme Court ruling in 2020 had invalidated the Mississippi ballot initiative process. So voters in Mississippi did not get a chance to weigh in on Medicaid expansion in the 2022 election.
Mississippi has not accepted federal Medicaid expansion
- 751,607 – Number of Mississippians covered by Medicaid/CHIP as of September 2022 (source)
- 217,000 – Number of additional Mississippi residents who would be covered if the state accepted expansion
- 99,000 – Number of Mississippians who have NO realistic access to health insurance without Medicaid expansion
- Over $2 billion – Federal money Mississippi left on the table in 2022 by not expanding Medicaid
Pending Mississippi Medicaid work requirement could end coverage for thousands, but is unlikely to be approved by the federal government
Despite the fact that Mississippi hasn’t expanded Medicaid and has some of the most stringent eligibility guidelines in the country, the state has sought federal approval to make it even harder for people to get Medicaid coverage in Mississippi.
In October 2017, Mississippi submitted a proposed 1115 waiver to CMS, detailing the work requirement that the state wants to implement. The waiver was still pending approval as of 2023, and the Biden administration has informed states that Medicaid work requirements are not compatible with the mission of Medicaid. The Trump administration had approved several states’ proposed Medicaid work requirements, but the Biden administration has revoked all of those approvals. Proposals like Mississippi’s, which were still pending when the Biden administration took office, have been left pending and are unlikely to be approved.
Mississippi’s proposal would allow the state to require some Medicaid enrollees to work, volunteer, attend school, participate in substance abuse treatment, or otherwise fulfill the work requirement for at least 20 hours per week.
People would be exempt if they are disabled, physically or mentally unable to work, a primary caregiver for someone in need of care, elderly, under the age of 19, pregnant, Native American, or included in various other exempt populations. Since Mississippi has not expanded Medicaid under the ACA, the vast majority of the state’s Medicaid enrollees would already be exempt from the work requirement. The work requirement would really only apply to certain low-income parents and people receiving transitional medical assistance (a program that extends Medicaid coverage for up to 12 months for people who start earning too much money to continue to qualify for Medicaid).
Mississippi Medicaid covers about 750,000 people, but only about 56,000 of them are in the low-income parent Medicaid eligibility category. And of those, most would have exemptions. About 15,000 to 20,000 people would end up having to work as a result of the work requirement, and many are already working.
Ultimately, about 5,000 people would be expected to lose coverage in Mississippi each year if the work requirement were to be approved and implemented (as noted above, that is not likely to happen under the Biden administration). And according to the Clarion-Ledger, 91% of the people who would lose access to Medicaid under the proposed work requirement in Mississippi are low-income mothers. And more than two-thirds are African American.
These low-income parents are in a catch-22 situation: If they earn more than 27% of the poverty level (that works out to about $518/month for a household of three), they’d no longer be eligible for Medicaid. And if they don’t work, they’ll also lose access to Medicaid as a result of the work requirement. So in order to have health insurance, they would either have to maintain a job that provides health insurance coverage, or earn at least 100% of the poverty level so that they could obtain premium subsidies in the exchange and purchase an affordable individual health plan. One hundred percent of the poverty level is about $1,919/month for a household of three, so it’s a big jump from the Medicaid eligibility cutoff to the start of eligibility for premium subsidies.
To address these concerns, the state proposed an additional 12 months of transitional Medicaid coverage for people who remain in compliance with the work requirement for the full 24 months. Georgetown University’s Joan Alker describes this as a “wholly inadequate solution.” It’s temporary, doesn’t provide any sort of solution after the 24 months of transitional Medicaid coverage ends, and hinges on the unrealistic expectation that low-income, working parents will not experience even one month of unemployment during their 24 months of transitional Medicaid.
CMS had initially opened a comment period in January-February 2018 for Mississippi’s waiver proposal. But after the state revised the proposal to add an additional 12 months of transitional Medicaid coverage, the comment period was re-opened. During the re-opened comment period, 320 comments were submitted, and 319 of them were in opposition to the state’s proposed Medicaid work requirement. The revised proposal is still under review by CMS as of 2023, but is unlikely to ever be approved.
Who is eligible for Medicaid in Mississippi?
As published by CMS, these are the income limits for key coverage groups under Mississippi’s Medicaid program (note that these numbers include a built-in 5% income disregard that’s used for income-based Medicaid eligibility determinations):
- Adults with dependent children are eligible if their household income doesn’t exceed 25% of poverty level. This is about $5,757 a year for a family of three, one of the lowest thresholds in the country.
- Infants under one are eligible for Medicaid if their household income is up to 199% of poverty.
- Children 1 – 5 are eligible if their household income is up to 148% of poverty.
- Children 6 – 18 are eligible if their household income is up to 138% of poverty.
- Children with household incomes above the Medicaid thresholds are eligible for CHIP if their household incomes are up to 214% of poverty
- Pregnant women are eligible for Medicaid if their household income does not exceed 199% of poverty. (Postpartum coverage for the mother continues for 60 days after the birth. Most states have extended this to 12 months or will do so soon. Legislation is under consideration in Mississippi to extend postpartum coverage to 12 months; it passed in the Senate in February 2023 and was sent to the House.)
How does Medicaid provide assistance to Medicare beneficiaries in Mississippi?
Many Medicare beneficiaries receive assistance through Medicaid with the cost of Medicare premiums, cost sharing, and services Medicare doesn’t cover — such as long-term care.
Our guide to financial assistance for Medicare beneficiaries in Mississippi explains these benefits, including Medicare Savings Programs, Extra Help, long-term care benefits, and income guidelines for assistance.
How do I enroll in Medicaid in Mississippi?
If you are under 65 and don’t have Medicare:
- You can enroll through HealthCare.gov, either online or by phone at 1-800-318-2596.
- You can fill out the PDF version of the Mississippi Medicaid Application Form and either click the application submit button, or save the completed PDF and email it to [email protected]
- You can also print out the PDF application, complete it by hand, and fax, mail, or deliver it in person. You can fax it to 601-576-4164. You can mail it to 550 High Street, Suite 1000, Jackson, MS 39201. Or you can take it to your nearest Mississippi Division of Medicaid regional office.
If you are 65 or older or have Medicare, use this website to apply for Medicaid.
Mississippi Medicaid enrollment numbers
Total Mississippi Medicaid enrollment was 678,035 as of September 2022, and 73,572 children had health insurance coverage under CHIP.
Looking back to when the ACA and Medicaid expansion were initially rolling out, nearly 14,000 Mississippi residents enrolled in Medicaid or CHIP between October 2013 and April 2014. During the second open enrollment period (for 2015), 10,699 Mississippi residents enrolled in Medicaid or CHIP. All of these enrollees were already eligible for Medicaid under the existing guidelines, but had not enrolled prior to the opening of the ACA exchanges.
Medicaid enrollment is year-round though, and people can also apply directly through the Mississippi Division of Medicaid (enrollment tends to increase during the ACA’s general open enrollment period due to outreach and education activities on the part of enrollment assisters). As of July 2016, total Medicaid/CHIP enrollment in Mississippi was 8% higher than it had been prior to October 2013. Net enrollment increased by 49,990 people during that time period. But by the end of 2017, net enrollment in Mississippi Medicaid/CHIP was only 4% higher than it had been in 2013.
By September 2022, however, total Medicaid/CHIP enrollment in Mississippi was 22% higher than it had been in 2013. The growth was largely due to the COVID pandemic. Under the Families First Coronavirus Response Act, states are receiving additional federal Medicaid funding, but on the condition that they cannot disenroll anyone from Medicaid, unless the person moves out of state or requests that their coverage be terminated. This has been the case since March 2020, and it continues through the end of March 2023. So Medicaid enrollment, nationwide, has generally trended upward since early 2020.
Prior to 2014, more than a fifth of Mississippi’s residents (22.4%) were uninsured. According to a Gallup poll, that number had only fallen to 20.6% by mid-2014, but was down to 14.2% by mid-2015. However, by the end of 2015, the Gallup data indicated that Mississippi’s uninsured rate had crept up slightly, to 14.7%. US Census data puts the state at a lower overall uninsured rate in both 2013 and 2014. The census found that the uninsured rate in 2013 was 17.1%, and that it had fallen to 11.8% by 2016. But even with the lower uninsured rate in the census data, only eight states had a higher uninsured rate than Mississippi in 2016.
Given that 30% of Mississippi’s remaining uninsured population is in the coverage gap, there is no doubt that Medicaid expansion would significantly reduce the uninsured rate in the state. Instead, Mississippi officials have sought federal permission to implement a Medicaid work requirement that would likely have reduced Medicaid enrollment by about 5,000 people per year (as discussed above, the work requirement is unlikely to be approved by the Biden administration).
Missing out on billions in federal funding
As the ACA was written, it called for Medicaid expansion in every state for residents with incomes up to 133% of poverty (plus a 5% income disregard, bringing the effective eligibility threshold to 138% of the poverty level). But in 2012, the Supreme Court ruled that states could not be penalized for opting out of expansion, and Mississippi is one of a dwindling number of states that have not yet expanded Medicaid.
In states that expand Medicaid, the federal government paid the full cost of expansion through 2016. After that, states gradually began to pay a share of the expansion cost, but the federal government will always pay at least 90%. As a result, states that reject Medicaid expansion are leaving billions of dollars on the table.
From 2013 through 2022, Mississippi gave up $14.5 billion in federal funding that would otherwise have been available to the state to help provide medical care for low-income residents. And states that newly expand Medicaid after April 2021 are eligible for two years of additional federal Medicaid funding under the American Rescue Plan, but Mississippi has not yet taken advantage of that.
Since residents in states not expanding Medicaid still have to pay federal taxes, Mississippi residents have been subsidizing Medicaid expansion in other states. Over a decade, people in Mississippi are paying $1.7 billion in federal taxes that are used to pay for Medicaid expansion in other states.
Will Mississippi expand coverage?
Governor Tate Reeves, who assumed office in 2020, campaigned on opposition to Medicaid expansion. His viewpoint is consistent with former Governor Phil Bryant. Bryant claimed that the state wouldn’t be able to bear the cost if the federal government were ever unable to uphold its promise to pay at least 90% of the cost. He’s referred to accepting Medicaid expansion as a “fool’s errand.”
Mississippi’s share of traditional Medicaid costs climbed from fiscal year 2012 to fiscal year 2017. Lawmakers have highlighted this as a reason for not expanding coverage, but they’re missing the point (whether purposely or not) that Medicaid expansion is funded under different rules from traditional Medicaid. Under Medicaid expansion, the cost to cover newly eligible residents was fully funded by the federal government through the end of 2016. In 2020 and forward, states pay 10% of costs associated with the Medicaid expansion population.
And of particular importance, states that have expanded Medicaid have seen substantially smaller growth in state Medicaid spending than states that haven’t expanded Medicaid.
In June 2013, Republicans in both chambers of the Mississippi legislature voted against Medicaid expansion. They did vote to continue the state’s existing Medicaid program, which came within days of expiring and had to be dealt with in a special legislative session called by Bryant. The issue of Medicaid expansion might not have even made it to a vote except that Democrats threatened to withhold their votes for renewing the existing Medicaid program unless Republicans would agree to take the issue of Medicaid expansion to a vote. No Republicans voted for Medicaid expansion, although one, Senator Billy Hudson of Hattiesburg, said that he would eventually vote for Medicaid expansion, “but not today.”
The Mississippi State Medical Association put forth a resolution in August 2016 calling for “expanded coverage” but didn’t use the words “Medicaid expansion” in their draft, knowing that the issue is too politically charged.
It’s possible that Mississippi might eventually pursue Medicaid expansion, possibly relying on a modified expansion waiver proposal similar to those used in a handful of other conservative states. And legislation has once again been introduced in 2023 that calls for Medicaid expansion (SB2070). But for now, in the nation’s poorest state, the poorest residents have no access to health coverage at all.
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.