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Missouri and the ACA’s Medicaid expansion

Medicaid expansion coverage is in effect in Missouri. But enrollment is lagging as applications are taking more than two months to process. And GOP lawmakers are still trying to unwind Medicaid expansion

Key takeaways

Missouri began processing Medicaid expansion applications as of October 2021

As described below, Missouri had a long and somewhat complicated road to Medicaid expansion. But the state’s voters approved a Medicaid expansion ballot measure in 2020, and as of October 2021, Medicaid expansion in the state was fully in effect. More than 17,000 people had already applied for coverage by the time the applications began processing.

Medicaid expansion extends coverage to adults under age 65 with household incomes up to 138% of the poverty level. In 2022, that amounts to about $18,754 for a single individual, and $38,295 for a household of four (children were already eligible for Medicaid at higher income levels).

This is eventually expected to result in 275,000 Missouri residents becoming eligible for MO HealthNet, but enrollment is lagging well behind expectations as of early 2022.

The federal government is paying 90% of the cost of Medicaid expansion in Missouri, just as they do in other states that have expanded Medicaid. But since Missouri’s expanded eligibility rules took effect after the American Rescue Plan was enacted, the state is also receiving an increase of 5 percentage points added to its regular federal matching rate for the traditional (non-expansion) Medicaid population, for the next two years (here’s a detailed overview of how this works).

In Missouri, that’s amounting to $968 million in additional federal funding over the next two years. Missouri had estimated that the state’s share of the cost of Medicaid expansion would be $156 million in fiscal year 2022, so the additional federal funding stemming from the American Rescue Plan will more than offset the state’s costs in the short term (the traditional Medicaid population is larger and more costly to cover than the Medicaid expansion population, which makes the temporary 5 percentage point increase in the federal matching rate particularly valuable to states that newly expand Medicaid).

58,000 people enrolled in Missouri’s expanded Medicaid by early 2022, which was well behind expectations

Although Missouri did eventually begin processing Medicaid expansion applications in October 2021 (three months after they were initially slated to begin, due to GOP lawmakers’ attempts to derail the program), enrollment has lagged well behind expectations. As of early 2022, only 58,000 people were enrolled in the program — well short of the 190,000 that the state had projected by that point.

But another 70,000 had applied and were waiting for eligibility determinations. CMS rules allow states up to 45 days to process MAGI-based Medicaid applications (Medicaid expansion uses MAGI for eligibility determination, as does Medicaid for children and pregnant people). But as of December 2021, it was taking Missouri an average of 70 days — up from just eight a year earlier. Monthly application volume for MAGI-based Medicaid enrollment had grown from 15,000 to 41,000 in that time. But the processing time had increased dramatically (to 49 days) by October 2021, when there were fewer than 19,000 applications.

GOP lawmakers work to unravel Medicaid expansion via funding and a constitutional amendment

Although Medicaid expansion took effect in Missouri in 2021 and tens of thousands of eligible residents are already enrolled, GOP lawmakers in the state are continuing their efforts to undo the program. This would subvert the will of the state’s voters, who approved Medicaid expansion on the 2020 ballot.

As described below, Missouri’s GOP lawmakers spent much of 2021 trying to thwart the impending implementation of Medicaid expansion by withholding funding. The Missouri Supreme Court eventually ruled that Medicaid expansion had to be implemented, but GOP lawmakers in Missouri are again trying in 2022 to undo Medicaid expansion via funding.

In February 2022, the Missouri House of Representatives was considering a measure that would ask voters to weigh in on a constitutional amendment that would make Medicaid expansion subject to annual budget allocations by the state’s legislature. If the measure ends up on the state’s ballot and voters approve it, GOP lawmakers in Missouri could essentially unwind Medicaid expansion by continuing to refuse to fund it.

The ballot measure would ask voters if the state could appropriate funding for each Medicaid eligibility category separately, rather than allocating funding for the whole Medicaid program. If voters approved it, lawmakers could then choose, for example, to allocate funding for the traditional Medicaid eligibility categories (low income people who are children, elderly, disabled, or pregnant) but not the childless adult population that’s newly eligible under Medicaid expansion.

A Missouri House of Representatives committee passed the measure in February 2022 on a party line vote. It’s unclear whether it has enough support to pass in the full house, or whether the Senate would approve it. And then voters would have to approve it too. So for the time being, it’s still a long shot and Medicaid expansion is still the law of the land in Missouri.

Sheldon Weisgrau, Vice President of Health Policy at Missouri Foundation for Health, explained that the House’s version of the ballot measure would first state that Missouri Medicaid is only available to Missouri residents. This is already the case (and is the case in every state; each state’s Medicaid program is only available to its own residents, and generally cannot even be used outside the state). But if a voter only reads that section, it would make sense that they would vote “yes,” as that’s a reasonable expectation. Unfortunately, that would allow the rest of the ballot measure to pass as well. But again, the state legislature would have to agree to the ballot measure before it could even appear on the ballot, and that is very uncertain as of early 2022.

Missouri Supreme Court rules that Medicaid expansion must be implemented

Although the federal government began providing funding to expand Medicaid in 2014, Missouri was one of 13 states that had continued to reject Medicaid expansion. But that changed as a result of a unanimous Missouri Supreme Court ruling that was issued in July 2021, and a subsequent order by the circuit court instructing the state to proceed with Medicaid expansion.

Voters in Missouri approved a Medicaid expansion ballot measure in August 2020 by a margin of about 53 to 47 (the history of the ballot measure is described in detail below). It called for the state to submit a Medicaid expansion state plan amendment to the federal government by March 2021, and for Medicaid expansion to take effect by July 1, 2021.

In keeping with the timeline called for in the ballot measure, the Missouri Department of Social Services (DSS) submitted a proposed Medicaid expansion plan to HHS in February 2021, calling for Medicaid expansion to take effect July 1.

But when state lawmakers passed the 2022 fiscal year budget, they refused to include funding for the state’s portion of the cost of Medicaid expansion. Lawmakers did allocate normal funding for Medicaid (MO HealthNet), but the DSS indicated that it would not change the eligibility criteria for Medicaid coverage, since lawmakers had not expressly allocated funding for that purpose. And the state withdrew the Medicaid expansion state plan amendment that it had submitted to HHS earlier in the year.

A lawsuit ensued, with plaintiffs who would be eligible for Medicaid expansion suing DSS. DSS argued that the ballot initiative itself was unconstitutional, since the state constitution clarifies that ballot measures cannot be used to appropriate state funds. In late June 2021, a circuit court judge ruled that Missouri’s Medicaid expansion ballot measure was unconstitutional because it didn’t include a funding mechanism (it had left that up to lawmakers, as has been the case in other states where Medicaid has been expanded via ballot measure). So Medicaid expansion did not take effect in Missouri on July 1.

The case was appealed, and the Missouri Supreme Court heard oral arguments on July 13, 2021. The following week, the Supreme Court vacated the lower court’s ruling, and noted that the Medicaid expansion eligibility criteria outlined in Missouri Article IV, Section 36(c) are “now in effect.” That’s the section of the Missouri code that contains the Medicaid expansion language stipulated in the voter-approved ballot measure, including the fact that the new eligibility rules are effective July 1, 2021.

The Supreme Court sent the case back to the Cole County Circuit Court, instructing the court to rule in favor of the plaintiffs and direct the state to expand Medicaid eligibility. That order was issued in August 2021, and the state proceeded with Medicaid expansion as a result. The MO HealthNet website indicated that people eligible for adult Medicaid expansion could submit an application at that point, but that it wouldn’t be processed until at least October 1. The state noted at that point that the administrative process of expanding Medicaid was expected to take up to 60 days, “due to current staffing capacity and funding restraints,” but clarified that medical costs incurred between the time a person applies and the time their enrollment is processed “may be reimbursed at a later date.” A later FAQ clarified that applications submitted by November 1, 2021 could have coverage backdated to July 1, 2021.

(There is some precedent for this, with the way Medicaid expansion was implemented in Maine in 2019. It was supposed to take effect in July 2018, but was delayed several months due to the governor’s opposition; once it was implemented, coverage was backdated to when people had applied, with retroactive effective dates as far back as July 2018.)

There were extensive administrative details that still needed to be sorted out. The state plan amendment had been withdrawn and had to be resubmitted to HHS. Lawmakers will also have to sort out any remaining funding issues, since the amount currently allocated for MO HealthNet may be insufficient with the newly eligible population added to the state’s Medicaid rolls (although as noted above, the additional federal funding under the American Rescue Plan will provide the state with some breathing room in terms of Medicaid funding in the short-term).

Before MO HealthNet started accepting applications for the newly eligible Medicaid expansion population, the state had very limited Medicaid eligibility for adults. Non-disabled adults without children were not eligible for Medicaid in Missouri regardless of how low their income was, and parents with dependent children were only eligible with incomes that didn’t exceed 22% of the poverty level. Only Texas and Alabama have lower Medicaid eligibility caps, at 18%. There were 127,000 people in the coverage gap in Missouri before Medicaid expansion took effect. They were unable to qualify for Medicaid because the state still had not expanded eligibility for Medicaid coverage, and unable to qualify for premium subsidies in the exchange/marketplace because they earned less than the poverty level. Fortunately, these individuals can now apply for MO HealthNet coverage.

Missouri was the sixth state to expand Medicaid via ballot measure

In the last few years, voters in Maine, Idaho, Nebraska, Utah, and Oklahoma have approved similar ballot measures to expand Medicaid. Missouri was the sixth state to expand Medicaid in this manner. South Dakota voters will have a similar opportunity on the 2022 ballot.

It’s also worth noting that while voters in Utah, Idaho, and Nebraska all approved Medicaid expansion ballot initiatives in 2018, all three states subsequently sought federal approval for Medicaid work requirements (Utah’s took effect in January 2020, but was suspended in April 2020 amid the COVID-19 pandemic), and have imposed various other restrictions and requirements, as opposed to simply expanding Medicaid as called for in their voter-approved ballot initiatives.

But the amendment that voters passed in Missouri prohibits the state from imposing additional eligibility requirements (other than the ACA’s income and immigration requirements) on the expansion population that aren’t imposed on the rest of the state’s Medicaid-eligible population. The Biden administration has also notified states that work requirements will no longer be approved, so that would be a non-starter at this point.

Missouri missed out on billions in federal funding by delaying Medicaid expansion until 2021

In states that expand Medicaid, the federal government paid the full cost of expansion through 2016. Starting in 2017, the states gradually started to pay a share of the expansion cost, and states now pay 10% of the cost (the 90/10 split will remain in place going forward). Because of the generous federal funding for Medicaid expansion, states that reject it are missing out on billions of federal dollars that would otherwise be available to provide healthcare in the state.

Federal poverty level calculator

From 2013 through 2022, Missouri was projected to give up $17.8 billion in federal funding by not expanding Medicaid.

Hospitals in Missouri that treat uninsured patients were especially hard-hit, as their federal disproportionate share hospital funding has started to be phased out (it was supposed to be replaced by Medicaid funding) and the uninsured rate has remained higher than it would have been with Medicaid expansion in place. As a result of Missouri’s decision to opt out of Medicaid expansion, hospitals in the state were projected to lose $6.8 billion between 2013 and 2022.

Fortunately, Medicaid expansion did eventually take effect in Missouri in late 2021. And as described above, Missouri is also receiving additional federal Medicaid funding as a result of the American Rescue Plan and the timing of when the state’s Medicaid expansion took effect.

The ballot measure that expanded Medicaid in Missouri

SB371, introduced in Missouri’s legislature in 2018, called for putting Medicaid expansion on the November 2018 ballot and letting voters decide, but the bill did not advance. A citizen-led effort to get Medicaid expansion on the ballot in Missouri was considered a non-starter in 2018, as it didn’t have the backing of any major groups at that point.

But in 2019, things were different. Healthcare for Missouri picked up the push for a ballot initiative, and received support and funding from The Fairness Project, which helped with the expansion ballot initiatives in other states in recent years.

The ballot initiative was submitted to the state in June 2019, and was approved for the signature-gathering process to begin. Advocates spent the summer determining the feasibility of Medicaid expansion by ballot initiative in Missouri, and announced in September 2019 that they would commit to gathering the 172,000 signatures necessary for the measure to appear on the ballot.

Dozens of petition-signing events took place in communities around the state in the fall of 2019 and early 2020. Although the COVID-19 pandemic put a halt to in-person signature gathering as of March 2020, Healthcare for Missouri announced at that point that they would still be able to submit the necessary number of signatures by the early May deadline, “thanks to a strong and early start to voter signature collections” in 2019.

The signatures had to be submitted by May 3, and Healthcare for Missouri announced on May 1 that nearly 350,000 signatures — almost twice as many as necessary — had been submitted to the Missouri Secretary of State’s office. The Secretary of State certified the signatures a few weeks later, and Governor Mike Parson soon announced that the measure would be on the August 4, 2020 primary ballot, instead of the general election ballot in November.

Parson, who is opposed to Medicaid expansion and the ballot initiative, said that he was placing the measure on the primary ballot in order to give the state more time to implement Medicaid expansion if voters approve it. But supporters of Medicaid expansion, including Parson’s Democratic gubernatorial challenger Nicole Galloway, felt that Parson chose to put the measure on a ballot for a lower turnout election, in hopes that it wouldn’t pass. Oklahoma Medicaid expansion advocates also gathered enough signatures to get an expansion initiative on the ballot in 2020, and Oklahoma’s governor — who is also opposed to Medicaid expansion — also opted to put the ballot initiative on the primary ballot. But voters in both states approved Medicaid expansion, despite the fact that the measures appeared on primary ballots instead of the general election ballots (Oklahoma’s Medicaid expansion took effect July 1, 2021, as scheduled).

Parson made his opposition to Medicaid expansion clear, but he stated that he would “uphold the will of the people” if the Medicaid expansion ballot measure was passed by voters. The Kansas City Star Editorial Board noted in late 2019 that GOP lawmakers in the state could still opt to craft their own version of Medicaid expansion during the 2020 legislative session, incorporating various limitations that could be achieved with an 1115 waiver. But the only Medicaid expansion bills that were introduced in the 2020 session (SB564 and SB603) were introduced by Democrats and did not advance during the session.

Missouri has accepted federal Medicaid expansion

  • 1,081,802 – Number of Missourians covered by Medicaid/CHIP as of July 2021
  • 235,718 – Increase in the number of Missourians covered by Medicaid/CHIP fall 2013 to May 2021
  • 24% – Reduction in the uninsured rate from 2010 to 2019
  • 28% – Increase in total Medicaid/CHIP enrollment in Missouri since late 2013

Who is eligible for Medicaid in Missouri?

MO HealthNet coverage is available to low-income children and pregnant women. And as a result of Medicaid expansion, it’s also available to adults under the age of 65 whose household income doesn’t exceed 138% of the poverty level.

In addition, low-income residents who are aged, blind, or disabled are also eligible for Medicaid, but they’re also subject to fairly strict asset limits in order to qualify for coverage.

How much money can you make to qualify for Medicaid in Missouri?

All Medicaid-eligible populations are subject to income limits (as we’ll discuss in a moment, some populations are also subject to asset limits). In Missouri, Medicaid members must have a household income that doesn’t exceed the following limits:

  • Adults under age 65: are eligible for Medicaid with household income up to 138% of the poverty level.
  • Infants under one are eligible for Medicaid if their household income is up to 196% of poverty. That amounts to about $43,000 in annual income for a household of three in 2021.
  • Children 1 – 18 are eligible if their household income is up to 150% of poverty. For a household of three in 2021, that amounts to just under $33,000 in annual income.
  • Children above the Medicaid income thresholds are eligible for CHIP if their household incomes are up to 300% of poverty.  This is among the more generous limits in the country.
  • Pregnant women are eligible for Medicaid if their household income does not exceed 196% of poverty (and a pregnant woman with one fetus counts as two people for the purpose of counting household size relative to the poverty level).

What is the asset limit for Medicaid in Missouri?

For the groups described above, only an income limit applies. But for Missouri Medicaid applicants whose eligibility is based on their status as aged (65+), blind, or disabled, there are both income and asset limits. This page is a Missouri-specific overview of how this works.

How does Medicaid provide assistance to Medicare beneficiaries in Missouri?

Many Medicare beneficiaries receive help through Medicaid with the cost of Medicare premiums, co-pays, deductibles, and services Medicare doesn’t cover — such as long-term care.

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

How do I enroll in Medicaid in Missouri?

If you are under 65 and don’t have Medicare:

The Missouri Department of Social Services also has information about the managed care plans that are available for MO HealthNet members, and how you can go about selecting one.

If you’re 65 or older or have Medicare, you can use this website to apply for Medicaid.

Missouri Medicaid enrollment numbers

From late 2013 through July 2021, total enrollment in Missouri Medicaid and CHIP grew by about 28%, to 1,081,802 people. The COVID pandemic played a significant role in driving enrollment higher, in Missouri as well as nationwide. Enrollment has grown since the fall of 2021, due to the state’s implementation of Medicaid expansion. But as noted above, enrollment has been slower than expected, due to a substantial backlog of applications.

Efforts to expand coverage in Missouri: 2012 – 2016

A University of Missouri School of Medicine study in 2012 concluded that “Medicaid expansion would be highly beneficial to the Missouri economy and its citizens.” And in June 2014, the Missouri Economic Research and Information Center announced that healthcare job growth in Missouri had slowed considerably since 2012, and was falling behind compared with states that had expanded Medicaid.  Healthcare is the state’s largest employment sector.

Former Governor Jay Nixon was a longtime proponent of Medicaid expansion, although the Republican supermajority in the state’s legislature blocked his efforts in 2012 and 2013.

But Senator Ryan Silvey, a Republican from Kansas City, was on board with Medicaid expansion, noting that “it’s going to be damaging to our hospitals if we don’t do something.” Silvey’s Democratic colleagues were also supportive of expansion. The legislature came close to approving a modified version of Medicaid expansion in the spring of 2014, and Silvey noted that some of the lawmakers who opposed it had since retired, meaning there might be a better chance for successful legislation in 2015.

In December 2014, Senator-elect Jill Schupp introduced SB 125, which called for expansion of Medicaid up to 138% of the poverty level, but it did not advance out of committee.

Several other similar bills were introduced during the 2015 session as well, including HB 153, HB 1351, and HB 474.  But Republican leadership in the Missouri legislature vowed to block any attempts to expand Medicaid during the 2015 session, and none of the bills advanced to a full vote. Bob Onder, a new state senator from St. Charles, made fighting Obamacare — including Medicaid expansion — his primary focus during the 2015 session. When the Supreme Court upheld the legality of subsidies in states like Missouri that use, Onder stated that the Court’s ruling was essentially liberal justices taking the opportunity to “rewrite” the ACA in order to “save” it.  There was hope — nationwide — that the Court’s ruling on King v. Burwell to uphold subsidies would galvanize the Medicaid expansion movement, since it indicated — at that time — that the ACA was here to stay. But opposition to Medicaid expansion among Missouri’s legislative leadership remained strong.

Unfortunately, the legislature’s refusal to expand Medicaid meant that hospitals had to cut costs, and in June 2015, Mercy Hospital announced 127 job cuts in Springfield.

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 Missouri

You can enroll through or through MO HealthNet.  You can also enroll by phone at 800-318-2596.

Eligibility: Parents with dependent children are eligible with household incomes up to 18% of FPL. Children are eligible for Medicaid or CHIP with household incomes up to 300% of FPL, and pregnant women are eligible with household incomes up to 196% of FPL.

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