West Virginia and the ACA’s Medicaid expansion

Enrollment up 53%, but West Virginia officials are considering a work requirement for expansion population

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West Virginia’s leaders opted to expand Medicaid under the Affordable Care Act (ACA) starting on January 1, 2014, providing coverage to low-income adults, most of whom have jobs but no option for employer-sponsored health insurance. The federal government paid the full cost for the first three years, but has gradually reduced the funding split until it reaches 90/10 in 2020, with the federal government continuing to pay 90 percent of the cost going forward.

Under the expanded eligibility guidelines, adults age 19-64 are eligible for Medicaid with a household income up to 138 percent of the poverty level. 156,775 people are enrolled under Medicaid expansion in West Virginia as of November 2019. Total enrollment in the state’s Medicaid/CHIP coverage is up about 49 percent since 2013.

Medicaid expansion has significantly exceeded the 93,000 people that West Virginia had initially projected to enroll by 2020 under the expanded eligibility guidelines, but enrollment has declined after peaking in 2016. The total number of people enrolled under expanded Medicaid declined slightly by January 2017, to 174,026, and declined further, to 165,917, by March 2018. By late 2019, it stood at nearly 157,000 people, roughly similar to the 154,000 people who had been enrolled a year earlier.

CHIP coverage for pregnant women as of 2019

SB564 was signed into law in West Virginia in 2019. The legislation called for CHIP coverage in West Virginia to be expanded to include pregnant women. CHIP eligibility for kids in West Virginia already extended to households with income up to 300 percent of the poverty level, and that’s the same level that now applies to pregnant women as well. The new CHIP coverage for pregnant women took effect on July 1, 2019 in West Virginia.

Only five other states (Colorado, Missouri, New Jersey, Rhode Island, and Virginia) provide CHIP coverage to pregnant women, but there are numerous states with fairly high income limits for pregnant women to qualify for Medicaid (for example, Medicaid coverage is available to pregnant women in Iowa with household income as high as 375 percent of the poverty level; in DC, it’s 318 percent)

West Virginia has considered a Medicaid work requirement but has not yet created one

As of late 2017, West Virginia’s Department of Health and Human Resources was considering the possibility of seeking a waiver from the federal government in order to implement a work requirement for the state’s Medicaid expansion population. But nothing has happened yet on that front. Legislation (HB3136) to create a work requirement was considered in the 2019 legislative session, but it did not advance to a vote.

Although work requirements were a non-starter with the Obama Administration, the Trump Administration has approved them in several states. But a judge has blocked the work requirements in Kentucky, New Hampshire, and Arkansas. Officials in Indiana have suspended their Medicaid work requirement pending the outcome of a similar lawsuit, and Arizona has also suspended implementation of a new work requirement.

Consumer advocates in West Virginia have criticized the possibility of a work requirement, noting that such programs tend to just make it harder for people to maintain their health coverage, due to documentation requirements, despite the fact that the majority of Medicaid expansion enrollees are already in a household where at least one person is working.

The state has already entered into a $300 million contract with Optum to verify eligibility for various need-based programs, including SNAP and Medicaid. If a work requirement were to be added to Medicaid, it would increase the reporting and verification measures necessary in order to confirm ongoing eligibility for Medicaid.

Medicaid expansion helping to combat opioid crisis

The opioid crisis has hit West Virginia particularly hard, and the state has the nation’s highest drug overdose death rate. But 22,000 people covered under expanded Medicaid had received treatment for mental health and substance abuse disorders by early 2017. Without Medicaid expansion, most of those people would have been uninsured and unable to access treatment.

Governor supports continued Medicaid expansion

West Virginia’s former Governor, Earl Ray Tomblin, was instrumental in West Virginia’s acceptance of Medicaid expansion but was term-limited and could not seek re-election in 2016.

Governor Jim Justice took office in January 2017. He campaigned and was elected as a Democrat, but in the summer of 2017, during his first year in office, he switched to the Republican party. However, Justice had reiterated his support for Medicaid expansion in the weeks leading up to his party switch, stating in late June 2017 that it would be “beyond catastrophic” if the people who had gained coverage under Medicaid expansion were to lose it. But Justice also vetoed a supplemental appropriation for the state’s Medicaid program in 2019, saying that the Medicaid program already had enough funding.

Substantial impact on uninsured rate

West Virginia had the sixth highest drop in uninsured rate during the first half of 2014, due primarily to Medicaid expansion (as of July 2014, 132,556 people in WV had enrolled in Medicaid, while 25,856 had enrolled in subsidized private coverage through the exchange).

According to US Census data, the state’s uninsured rate was 14 percent in 2013, and had fallen to 5.3 percent by 2016. It had increased to 6.4 percent by 2018, however, mirroring the nationwide trend of increasing uninsured rates under the Trump administration.

West Virginia’s uninsured rate had been similar to the US average (14.5 percent) in 2013, but the state’s uninsured rate in 2018 was well below that national average at that point, which was 8.9 percent.

Expansion of Medicaid has played a primary role in West Virginia’s sharp reduction in the uninsured rate.

Who is eligible?

As of 2014, West Virginia Medicaid is available for these legally-present residents, in addition to the aged, blind, and disabled.

  • Adults with incomes up to 138 percent of poverty
  • Pregnant women with income up to 158 percent of poverty
  • Children in households with income up to 158 percent of poverty (or lower, depending on age)
  • Children and pregnant women with household incomes above the Medicaid eligibility threshold but not above 300 percent of poverty are eligible CHIP (Children’s Health Insurance Program)

This booklet from the West Virginia Bureau for Medical Services shows eligibility levels based on total income.

How do I apply?

You can apply for West Virginia Medicaid through the federally-run exchange by visiting HealthCare.gov or calling 1-800-318-2596 24 hours a day.

Or you can apply through the state at www.wvinroads.org and that site can also provide SNAP and cash assistance programs for eligible residents.

Medicaid enrollment is year-round — there is no specific time frame during which applications must be completed.

How many people have enrolled?

As of mid-July 2014, there were 132,556 new Medicaid enrollees who were all newly-eligible under the expanded guidelines. Although most of the newly-eligible population enrolled during the first year, the number of newly-eligible enrollees had grown to 164,400 by June 2015, and to 178,394 by August 2016. But enrollment in expanded Medicaid declined slightly by the beginning of 2017, to 174,026, and declined further, to 153,874 by December 2018. It has since stabilized, and stands at 156,775 as of November 2019.

In 2013, the Kaiser Family Foundation estimated that about 143,000 people in West Virginia would be newly-eligible for Medicaid as of 2014. But the state’s estimate had been much lower, with a projected expansion enrollment of 93,000 by 2020.

Opponents of Medicaid expansion predicted that states with a surge in Medicaid enrollment would find that Medicaid patients were unable to get appointments for primary care, but West Virginia doctors weren’t indicating that was a problem when enrollment initially spiked. Instead, some of their challenges include a significant population of newly-insured people who are requesting pain medication at office visits, and patients who have previously been on free drug samples and need to be switched to another drug that’s covered by Medicaid.

And despite the unexpectedly large enrollment in Medicaid expansion — combined with the fact that the state began paying a portion of the Medicaid expansion costs starting in 2017 — West Virginia’s Medicaid budget had a surplus as of early 2019.

Uncompensated care costs decline sharply

According to data compiled by West Virginians for Affordable Health Care, hospitals in West Virginia saw a 40 percent decline in uncompensated care costs from 2013 to 2014, thanks in large part to Medicaid expansion that resulted in far fewer uninsured residents in the state.

But although the hospitals acknowledge that their uncompensated care and charity care costs have declined significantly, some also note that Medicaid reimbursements are less than the cost of providing care, and that their losses on Medicaid volume are offsetting the improvements they’ve seen in uncompensated care.

The decision to expand Medicaid

West Virginia had initially considered setting up a state-run exchange, but later opted for a partnership exchange, citing cost as one of the reasons for avoiding a fully state-run exchange.

State leaders have said that given the choice between a state-run exchange and Medicaid expansion, the latter seemed like it would provide more bang for the buck (and judging by the state’s extremely successful Medicaid enrollment in 2014, it would appear they were correct).

In May 2013, then-Governor Earl Ray Tomblin announced that West Virginia would proceed with Medicaid expansion. Enrollment for newly-eligible residents began on October 1, 2013, with coverage effective January 1, 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.

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How to apply in WV

Apply through HealthCare.gov or by calling 1-800-318-2596 (24 hours a day).

Eligibility: The aged, blind, and disabled.  Also, adults with incomes up to 138% of FPL; children with household incomes up to 300% of FPL are eligible CHIP; pregnant women with incomes up to 158% of FPL.

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