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Mississippi and the ACA’s Medicaid expansion

Mississippi has not expanded Medicaid; Medicaid work requirement is pending CMS approval, but unlikely to be approved

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 2021.  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.

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If Mississippi did expand, 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).

Rhonda White is among them. Her job pays just $8.25/hour, and she can only get about 15 hours a week. She lives with her disabled husband and mother, along with her daughter and three grandchildren — all in a two-bedroom house in rural Mississippi. And while several of them have health conditions, they can’t access medical care because Mississippi hasn’t accepted federal funding to expand Medicaid.

The Build Back Better Act, which passed the House in November 2021 and is under consideration in the Senate, would temporarily close the coverage gap by providing full premium subsidies and cost-sharing reductions for people like Rhonda who are in the coverage gap in states that have not expanded Medicaid. Experts note, however, that Mississippi would still be better off if it accepted federal funding to expand Medicaid.

Mississippi has not accepted federal Medicaid expansion

  • 701,409 – Number of Mississippians covered by Medicaid/CHIP as of May 2021
  • 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 is leaving 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 is seeking 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 2021, 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 755,000 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 $467/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. 100% of the poverty level is about $1,731/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 late 2021, but is unlikely to ever be approved.

Who is eligible for Medicaid in Mississippi?

As published by CMS as of October 2020, these are the income limits for key coverage groups under Mississippi’s Medicaid program:

  • Adults with dependent children are eligible if their household income doesn’t exceed 21% of poverty level.  This is about $4,612 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 194% of poverty.
  • Children 1 – 5 are eligible if their household income is up to 143% of poverty.
  • Children 6 – 18 are eligible if their household income is up to 133% of poverty.
  • Children with household incomes above the Medicaid thresholds are eligible for CHIP if their household incomes are up to 209% of poverty
  • Pregnant women are eligible for Medicaid if their household income does not exceed 194% of poverty.

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, 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 618,767 as of May 2021, and 82,642 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 mid-2021, however, total Medicaid/CHIP enrollment in Mississippi was 14% 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 the COVID public health emergency period, which is currently slated to end in January 2022, but could be extended again instead (it gets extended in 3-month intervals). 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 are seeking federal permission to implement a Medicaid work requirement that’s expected to reduce Medicaid enrollment by about 5,000 people per year.

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 12 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% (this would temporarily increase to 93% under the Build Back Better Act). As a result, states that reject Medicaid expansion are leaving billions of dollars on the table.

From 2013 through 2022, Mississippi has given 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 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 (that would temporarily increase to 93% if the version of the Build Back Better Act that passed the House is enacted).

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. But for now, although the state has gone through the process of drafting a work requirement waiver proposal, it does not include any sort of proposed expansion of coverage. 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 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 Mississippi

You can enroll through or you can fill out a PDF of the Mississippi Medicaid Application Form.  You can also enroll by phone at 800-318-2596.

Eligibility: Parents with dependent children are eligible with household incomes up to 22% of FPL. Children are eligible for Medicaid or CHIP with household incomes up to 209% of FPL, and pregnant women are eligible with household incomes up to 194% of FPL.

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