Ohio and the ACA’s Medicaid expansion

639,000 people are covered under Medicaid expansion, but Ohio is seeking federal approval for a work requirement that would ultimately take coverage away from 18,000 of them

ohio Medicaid guide

Medicaid expansion status in Ohio

Ohio is awaiting federal approval for a work requirement for Medicaid expansion population

In the 2018-2019 fiscal year budget, enacted by legislation in 2017 (amid some disagreement between Republican Governor John Kasich and the Republican-led legislature; details below), Ohio implemented a requirement that the state should seek federal approval for a work requirement that would apply to the Medicaid expansion population. Although Governor 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, which ended on March 18. The official work requirement proposal was submitted to CMS in April; it was still pending federal approval as of November.

As of June 2018, there were 639,000 Ohio residents enrolled in expanded Medicaid (referred to as Group VIII). This was down from an estimated 700,000 enrollees as of early 2018 (and from the 689,000 enrollees covered under expanded Medicaid as of January 2017). The state’s estimate is that about 36,000 expansion enrollees will need 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. The rest of the Medicaid expansion population is either already working or would be exempt from the work requirement. Of those 36,000 people, the state estimates that about half will ultimately lose their Medicaid coverage due to noncompliance with the work requirement.

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 percent 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 work requirement would not apply to enrollees age 50 or older (that’s according to the official proposal; the state’s summary page and the state’s legislation both say 55 or older), children, pregnant women, caretakers caring for minor children or a disabled person, people receiving unemployment or Supplemental Security Income, people in drug or alcohol treatment programs, or anyone deemed physically or mentally unable to work.

Critics contend that Ohio’s work requirement for SNAP benefits (on which the proposed Medicaid work requirement is closely modeled) has resulted in 350,000 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 worry that the same thing will happen with Medicaid — people won’t necessarily have better employment prospects, but their health coverage will be 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 percent) say that expansion has made it easier for them to maintain a job, and 60 percent 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 requirment, 12,000 people had 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. Ohio estimates that about 18,000 people will lose their Medicaid coverage due to lack of compliance with the state’s proposed work requirement.

The Obama Administration never approved work requirements for Medicaid, but the Trump Administration approved Medicaid work requirements in Arkansas, Indiana, New Hampshire, Kentucky, and Wisconsin in 2018, and several other states are awaiting similar waiver approvals.

Governor Kasich defends Medicaid expansion, and Gov-elect Mike DeWine intends to keep expansion intact in Ohio

Ohio accepted federal funding to expand Medicaid, and about 639,000 residents had coverage under the new eligibility rules as of mid-2018. Ohio’s outgoing Governor John Kasich is not a fan of the Affordable Care Act (ACA), but he was one of the few Republican Governors who supported Medicaid expansion early in the process. Kasich has remained steadfastly supportive of Medicaid expansion, including during his presidential campaign in 2015/2016.

In early January 2017, Republican lawmakers began taking steps to repeal the ACA. The next day, Governor 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, but had dropped down to under 640,000 by mid-2018), 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 has 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 has been outspoken about her opposition to the ACA, and although she defended Kasich’s expansion of Medicaid when serving as insurance director, she has said that as governor, she would end Medicaid expansion. Taylor’s proposal, instead, is 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 on 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 vetos (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.

The “Healthy Ohio” program would, if approved by state lawmakers and the federal government, require non-pregnant, childless adults with income above the poverty level (ie, between 100-138 percent of the poverty level) to pay premiums, averaging about $20 per month (but not more than 2 percent 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 has not advanced.

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. Lawmakers in Ohio could still override the veto in 2018, but for the time being, there’s no freeze on Medicaid expansion in Ohio.

Medicaid expansion in Ohio

Kasich 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 under the current rules the federal government will always pay at least 90 percent 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 Kaisch 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.

Obama Administration CMS denied request to make expansion more conservative

In September 2016, CMS denied a new waiver proposal from Ohio that would have required all enrollees (including those with income below the poverty line) to pay 2 percent 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 has not yet moved forward with submitting a new waiver proposal to CMS.

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 percent of poverty.
  • Children with household income up to 206 percent of poverty.
  • Pregnant women with household income up to 200 percent of poverty.

How do I enroll?

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 HealthCare.gov or use their call center at 1-800-318-2596.
  • 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. The 2015 report is available here.

Enrollment numbers

During the first open enrollment period (October 2013 through April 2014) 156,899 Ohio residents were enrolled in Medicaid or CHIP (those who were newly-eligible under the expanded Medicaid guidelines were able to begin enrolling on December 9, 2013).

But people can enroll directly through Ohio Medicaid as well, and enrollment in Medicaid and CHIP continue year-round; it’s not a limited enrollment window like rivate plans. From the fall of 2013 to August 2018, total Medicaid and CHIP enrollment in Ohio grew by 28 percent. Net enrollment grew by 587,039 during that time frame (this was a drop from late 2017, when net enrollment was up 684,000 over where it had been in 2013).

Enrollment in expanded Medicaid has also fluctuated with time. A total of 1.26 million people have been enrolled in Ohio’s expanded Medicaid at some point, but only about half that many were currently enrolled as of late 2017, and only about a third have been continuously enrolled since 2014. As of June 2018, there were 639,000 people enrolled in expanded Medicaid in Ohio. But that was down from the 701,707 enrollees that the state reported as of early 2018, and even more of a reduction from 725,000 people who had been enrolled in expanded Medicaid as of 2017.

Expanded Medicaid enrollment in Ohio has higher enrollment than the net increase in total Medicaid/CHIP enrollment since 2013, but that’s because there are several eligibility categories, and enrollment fluctuates across all of them. So some of the gain in enrollment as a result of Medicaid expansion is offset by reductions in enrollment in other eligibility categories.

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 percent of poverty (that upper threshold was later increased to 200 percent of poverty).

The federal government pays 67 percent 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 has paid 100 percent of the cost of covering the population that’s newly-eligible population under the ACA’s Medicaid expansion guidelines. That percentage will decline to 95 percent in 2017, and by 2020 the state will be paying 10 percent 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 percent 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 healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

How to apply in OH

You can enroll online at HealthCare.gov 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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