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Ohio and the ACA’s Medicaid expansion

Medicaid enrollment up 48% since Medicaid expansion in Ohio

Medicaid expansion in Ohio

Ohio Governor John Kasich (in office 2011-2019) announced in early 2013 that the state would expand Medicaid using federal money to pay for the vast majority of the cost (the federal government paid the full cost through 2016, and the federal government will always pay at least 90% of the cost of covering the newly eligible population).

Ohio lawmakers who were opposed to Medicaid expansion brought a lawsuit against the Kasich administration in an effort to block expansion, because the full legislature was not involved in the decision to expand Medicaid — it was done through the Controlling Board (six legislators who handle budget adjustments in the state — most states do not have something like this) after the Ohio House and Senate both voted to block Medicaid expansion and Kasich vetoed their measure.

Ultimately, in late 2013, the Ohio Supreme Court ruled in favor of Governor Kasich, and Medicaid expansion took effect as scheduled in 2014. During the 2015 legislative session, lawmakers agreed to allow Medicaid expansion to continue, although the issue was just part of the budget agreement – there was no separate legislation on Medicaid expansion.

Ohio Medicaid enrollment up 48% since 2013, due in large part to Medicaid expansion and COVID pandemic

As of early 2022, total Medicaid/CHIP enrollment in Ohio stood at nearly 3.2 million people, which was up 48% from 2013, before the ACA’s expansion of Medicaid took effect. And roughly a quarter of those enrollees have coverage as a result of the ACA’s expansion of Medicaid: For the 2022 fiscal year, which began in July 2021, the state estimated that 831,425 people were enrolled under Medicaid expansion (this population is referred to as Group VIII, or the expansion group).

Medicaid expansion enrollment has fluctuated quite a bit over the last few years. As of June 2019, there were 526,100 Ohio residents enrolled in expanded Medicaid. This number was down from an estimated 700,000 enrollees as of early 2018.

Medicaid enrollment, including Group VIII and other eligibility categories, has grown significantly during the COVID pandemic. This is partially due to the widespread job and income losses, particularly in the early days of the pandemic. But it’s also been driven in large part by the Families First Coronavirus Response Act, which provides states with additional federal Medicaid funding on the condition that Medicaid enrollees not be disenrolled until after the COVID public health emergency ends. The public health emergency has been repeatedly extended in 90-day increments since the start of the pandemic, and is expected to continue at least until the fall of 2022. The result is that Medicaid enrollment has been steadily growing since the spring of 2020, without the normal eligibility redetermination and disenrollment process.

Ohio’s Medicaid enrollment growth is similar to the nationwide average, which is up 50% since 2013 (including the 12 states that have not expanded Medicaid under the ACA).

Ohio Medicaid work requirement never took effect

Federal poverty level calculator

In its 2018-2019 fiscal year budget, the Ohio legislature required the state to seek federal approval for a work requirement that would apply to the Medicaid expansion population. Although then-Gov. Kasich vetoed several items in the budget that applied to Medicaid, he did not veto the work requirement provision.

In February 2018, the Ohio Department of Medicaid posted the state’s proposed work requirement for a one-month public comment period. The official work requirement proposal was submitted to CMS in April 2018. While the Centers for Medicare and Medicaid (CMS) approved the waiver in May 2019, it was never implemented. Ohio had planned to implement the work requirement at the start of 2021, but it was delayed as a result of the COVID pandemic. In August 2021, CMS officially withdrew the waiver approval. And although the state appealed that decision, Medicaid work requirement waivers have been universally rejected or withdrawn by the Biden administration and none are in effect as of 2022.

It’s noteworthy that a few months after the state’s proposal was submitted to CMS, the Ohio Department of Medicaid published an extensive report on Medicaid expansion, which included the fact that 98.3% of people continuously enrolled in Ohio’s expanded Medicaid “were either employed, in school, taking care of family members, participating in an alcohol and drug treatment program, or dealing with intensive physical health or mental health illness (many had comorbid conditions).” In other words, this confirms the idea that the vast majority of the state’s expanded Medicaid population is either already in compliance with what the work requirement would entail, or would be exempt from it. (The state’s estimate was that about 36,000 expansion enrollees would have had to start working or enroll in job training, education, or certain volunteer activities, for a combined total of at least 20 hours per week, in order to avoid being disenrolled from Medicaid.)

Critics contend that Ohio’s work requirement for SNAP benefits (on which the proposed Medicaid work requirement is closely modeled) has resulted in significantly fewer Ohio residents receiving food assistance, but has not improved their employment situation. Instead, reliance on food banks and soup kitchens has increased sharply, and food instability is more of a problem than it was before the work requirement was implemented for SNAP. Advocates worried that the same thing would happen with Medicaid — a work requirement doesn’t give people better employment prospects, but it puts their health coverage in jeopardy, potentially making it that much harder for them to hold down a job.

The state’s detailed analysis of Medicaid expansion indicates that the majority of enrollees (nearly 84%) say that expansion has made it easier for them to maintain a job, and 60% of unemployed enrollees say that access to Medicaid has made it easier for them to seek work. Taking health coverage away from people is unlikely to make it easier for them to find or keep a job. But in Arkansas, which was the first state to implement a Medicaid work requirement, 12,000 people lost their Medicaid coverage within the first six months after the work requirement was implemented. There is no doubt that Medicaid work requirements lead to people losing coverage. In its 2018 waiver application, Ohio estimated that about 18,000 people would lose their Medicaid coverage due to lack of compliance with the state’s proposed work requirement.

While the Obama administration never approved work requirements for Medicaid, the Trump administration did approve work requirements in multiple states. But most of those had been overturned by courts or paused by state officials as of early 2020, and then the COVID pandemic (and the Families First Coronavirus Response Act’s additional federal funding in trade for not disenrolling anyone from Medicaid) made it essentially impossible to implement Medicaid work requirements. In 2021, the Biden administration officially withdrew the work requirement approvals that had been granted by the prior administration.

Consistent support for Ohio Medicaid expansion from governors

Ohio’s former Gov. John Kasich was not a fan of the Affordable Care Act (ACA), but he was one of the few Republican governors who supported the ACA’s Medicaid expansion component early in the process, and Ohio’s Medicaid expansion took effect as called for in the ACA, in January 2014. Kasich remained steadfastly supportive of Medicaid expansion, including during his presidential campaign in 2015.

In early January 2017, Republican lawmakers began taking steps to repeal the ACA. Kasich warned his fellow Republicans that repealing the ACA — without an equally robust replacement — could be disastrous. He pointed to the 700,000 Ohio residents who had gained coverage as a result of Medicaid expansion (a number that had grown to 725,000 by July 2017, dropped down to under 640,000 by mid-2018, and subsequently increased to more than 831,000 during the COVID pandemic), and asked Republican lawmakers to explain exactly how those folks would continue to access coverage and healthcare without Medicaid expansion.

Kasich also noted that Medicaid expansion in Ohio played a key role the state’s fight against opioid abuse, as people — who would otherwise have been uninsured — have been able to receive rehabilitation services covered by Medicaid.

Kasich was term-limited and could not run for reelection in 2018. His lieutenant governor, Mary Taylor, was one of the candidates running for governor in 2018. Taylor served as both lieutenant governor and director of the Ohio Department of Insurance in the Kasich administration, but she stepped down from the insurance director position in 2017. Taylor was outspoken about her opposition to the ACA. Although she defended Kasich’s expansion of Medicaid when serving as insurance director, she said that as governor she would end Medicaid expansion. Taylor’s proposal, instead, was to limit Medicaid coverage to people who are unable to work, as opposed to simply basing eligibility on income, as the ACA’s Medicaid expansion does.

Ultimately, Mike DeWine was the GOP candidate for governor in 2018, and won the election, narrowly defeating Democrat Richard Cordrey. Although DeWine has been critical of Medicaid expansion in the past, he had embraced it by mid-2018, vowing to keep the expanded eligibility guidelines in place as governor.

Lawmakers voted to freeze Medicaid expansion in 2017; Kasich vetoed

Lawmakers in Ohio came to a compromise on their budget bill in June 2017 and sent it to Governor Kasich, who had just two days to review it before the June 30 deadline for the state to enact the budget for the 2018 fiscal year, which began July 1, 2017. The Senate’s version of the bill had included a freeze on new Medicaid expansion enrollments after July 1, 2018, and that provision remained in the bill after it went through the conference committee process to reconcile the differences between the House and Senate versions of the budget.

Kasich had noted that the Medicaid expansion freeze would result in 500,000 people losing coverage in the first 18 months, since people would lose coverage if their income increased and would then be unable to get back on Medicaid if their income subsequently decreased (income volatility is particularly common among low-income populations).

Kasich used his line-item veto power to eliminate the Medicaid expansion freeze, and he also vetoed a provision that would have required Medicaid expansion enrollees to pay monthly premiums (in the form of health savings account contributions) for their coverage. Monthly premiums for Medicaid expansion populations require approval from CMS; the Obama Administration only approved limited premium requirements, and had rejected a more far-reaching premium requirement that Ohio had proposed in 2016 (details below). But the Trump Administration has made it easier for states to impose these types of requirements on Medicaid expansion enrollees.

On July 6, 2017, lawmakers in the House overrode Kasich’s veto of the provision that would have required Medicaid expansion enrollees to make health savings account contributions, but they did not vote to override his veto of the Medicaid expansion freeze (the Senate would also have to agree on the veto override for it to be successful, but could not vote until the House did so). In all, the House overrode 11 vetoes (most of which pertained directly to Medicaid) although the Senate only agreed to override six of those items — including a provision that allows the state legislature to determine whether additional optional populations will have access to Medicaid in Ohio, instead of allowing the Ohio Department of Medicaid to make decisions about populations whose eligibility is optional under federal Medicaid rules.

The proposed Medicaid premiums (health savings account contributions) in the House’s veto override would have been part of a “Healthy Ohio” program that was initially proposed in 2016 but did not receive approval from the Obama administration (in 2016, Ohio was requesting permission to charge premiums even for enrollees with income below the poverty level, which is not part of their 2018 budget proposal; see below for details about the 2016 proposal). But the Trump administration has made it clear that they are more likely to grant Medicaid waiver flexibility to states, even when the outcome is likely to be fewer people covered.

If it had been approved by state lawmakers and the federal government, the “Healthy Ohio” program would have required non-pregnant, childless adults with income above the poverty level (i.e., between 100-138% of the poverty level) to pay premiums, averaging about $20 per month (but not more than 2% of household income), for their coverage. This type of premium arrangement had already been allowed in some other states under the Obama administration. However, the Senate did not vote to override Kasich’s veto of the proposed Healthy Ohio premiums, so the provision did not advance.

The Ohio House still had the option to vote to override Kasich’s veto of the Medicaid expansion freeze later in the year, and they considered that possibility in September 2017, but ultimately did not move forward with a vote in 2017.

Obama Administration CMS denied request to make expansion more conservative

In September 2016, CMS denied the Healthy Ohio waiver proposal that would have required all enrollees (including those with income below the poverty line) to pay 2% of their income (but no more than $99 per year) into a health savings account. The problem for CMS was that the new guidelines would have resulted in people losing their Medicaid coverage if they got more than 60 days behind on their health savings account payments, and they would have had to get caught up on the payments in order to be able to re-enroll in the coverage.

The state noted that their estimate was that 125,000 people would lose coverage under the new guidelines, which was a non-starter for CMS — particularly because the state wanted to bar people from re-enrolling until they paid their overdue contributions.

The budget that lawmakers in Ohio passed in June 2017 called for the state to submit a waiver to CMS asking for permission to charge premiums for Medicaid, but only for enrollees with income above the poverty level. Governor Kasich vetoed this provision, but lawmakers in the House overrode his veto. However, the Senate did not vote to override the veto, so Ohio did not move forward with submitting a new waiver proposal to CMS.

Ohio has accepted federal Medicaid expansion

  • 3,188,776 – Number of Ohioans covered by Medicaid/CHIP as of January 2022
  • 831,425 – Number of Ohioans covered by Medicaid expansion as of fiscal year 2022
  • 46% – Reduction in the uninsured rate from 2010 to 2019
  • 48% – Increase in total Medicaid/CHIP enrollment in Ohio since Medicaid expansion took effect

Who is eligible for Ohio Medicaid?

Because Ohio has expanded Medicaid under the ACA, low-income adults without dependent children became eligible for the first time in 2014. The following residents can enroll in Medicaid in Ohio (immigration rules apply):

  • Adults with household income up to 138% of federal poverty level.
  • Children with household income up to 206% of poverty.
  • Pregnant women with household income up to 200% of poverty.

How does Medicaid provide financial assistance to Medicare beneficiaries in Ohio?

Many Medicare beneficiaries receive Medicaid’s help with paying for Medicare premiums, affording prescription drug costs, and covering expenses not reimbursed by Medicare – such as long-term care.

Our guide to financial assistance for Medicare enrollees in Ohio includes overviews of these benefits, including Medicare Savings Programs, long-term care coverage, and eligibility guidelines for assistance.

How do I enroll for Medicaid in Ohio?

Enrollment in Medicaid is year-round; you do not need to wait for an open enrollment period if you’re eligible for Medicaid

  • Ohio uses the federally-run insurance marketplace, so you can enroll through or use their call center at 1-800-318-2596 (use this option if you are under 65 and don’t have Medicare)
  • You can use the Ohio Medicaid (Ohio Benefits) website to enroll.  You click on “check your eligibility” first, and if you’re eligible it will take you to the enrollment page.
  • You can call or visit your county Department of Job and Family Services office (click on your county to see contact information).

Once you enroll in Ohio Medicaid, you’ll get a basic Medicaid (fee-for-service) ID card in the mail. Shortly after that, most new enrollees will receive a letter from Ohio Medicaid, asking them to select a Medicaid Managed Care program. There are five available:  Buckeye Health Plan, CareSource, Molina Health Plan, Paramount Advantage, and UnitedHealthcare. Ohio Medicaid puts out a report card each year, giving the managed care plans star ratings for various aspects of the coverage.

Ohio Medicaid history

Ohio enacted Medicaid in July 1966, just six months after the earliest states to do so. The state implemented CHIP (Children’s Health Insurance Program) in 1998, initially covering children up to age 19 with household income up to 150% of poverty (that upper threshold was later increased to 200% of poverty).

The federal government pays 67% of the cost of Ohio’s traditional Medicaid program, and the state pays the remainder. But the state gets a far better deal when it comes to Medicaid expansion: For 2014 – 2016, the federal government paid 100% of the cost of covering the population that’s newly-eligible population under the ACA’s Medicaid expansion guidelines. That percentage eventually declined to 90% as of 2020, but it remains at that level going forward, with the state never paying more than 10% of the cost of covering the newly-eligible population.

In 2011, Governor Kasich created the Ohio Governor’s Office of Health Transformation to “modernize Medicaid, streamline health and human services programs, and pay for value.”

And although the ACA’s Medicaid expansion took effect in January 2014 in Ohio (as it did in all states that were early adopters of Medicaid expansion), the state also used a Section 1115 waiver to expand Medicaid in 2013 to cover 30,000 non-elderly adults in Cuyahoga County. The eligibility threshold extended to 138% of the poverty level (the same as the ACA guidelines), so unless they had a change in income during the year, those early enrollees were able to transition to regular Medicaid expansion starting in 2014.

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 Ohio

You can enroll online at or at the Ohio Benefits website.  You can also enroll by phone at 1-800-318-2596 or 800-324-8680.

Eligibility: Adults are eligible with incomes up to 138% of poverty.  Children are eligible with incomes up to 206% of poverty, and pregnant women are eligible with incomes up to 200% of poverty.

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