Health Reform Action Center



 Medicaid Provisions

The ACA requires States to expand their Medicaid programs by January 1, 2014 to cover all non-elderly, non-pregnant Americans with incomes at or below 133% of the federal poverty level (FPL). The Supreme Court in June 2012, however ruled that the federal government cannot penalize States for not implementing the expansion by withholding federal matching funds for other parts of the Medicaid program. Mediciaid is critically important to womens health.  Nationwide, Medicaid is the largest payer of pregnancy services financing nearly half – 41 percent – of all births in the US. In some States, Medicaid covers more than half of total births. Medicaid is also the largest payer of family planning services (71%).

The ACA also expands coverage of free-standing birth centers, midwifery services, smoking cessation counseling and institutes several delivery system reform changes, such as quality measure reporting and enhanced support of primary care. Learn more about how health reform implementation impacts the various aspects of Medicaid:

Medicaid Expansion

Medicaid Physician Payment

Family Planning

Quality Measures

Health Homes

Freestanding Birth Centers/Midwives

Primary Care Payment Bump 

 

Medicaid Expansion 

The ACA requires States to expand their Medicaid programs by January 1, 2014 to cover all non-elderly, non-pregnant Americans with incomes at or below 133% of the federal poverty level (FPL). The formula used to calculate income eligibility, includes a 5% income disregard, meaning that the upper threshold for the newly eligible populations will actually equal to 138% FPL. Full implementation is projected to extend health coverage to about 16 million uninsured individuals by 2019, including about 10 million women.

The Supreme Court ruled in June, 2012 that the federal government cannot penalize states financially for not implementing the expansion by withholding federal matching funds for other parts of the Medicaid program. CMS subsequently stated that there is no deadline for States to decide if they wish to participate in the expansion, and states that participate may drop coverage levels in the future without penalty.

For states that do expand Medicaid, from 2014 to 2016, the federal government will cover 100% of the Medicaid costs of newly eligible individuals. In 2017, the federal share will be 95%, in 2018 94%, in 2019 93%, and in 2020 and beyond, the federal share for this population will be 90%.

If a state chooses not to expand Medicaid, residents at 100% to 133% FPL will be able to receive federal subsidies to purchase insurance through the newly created health insurance exchanges. It is anticipated however that coverage and cost-sharing protections will be less generous in these plans. Residents below 100% FPL in a state that does not expand Medicaid would not be eligible for subsidies yet could be subject to the individual health insurance mandate. Because insurance premium costs at this income level are expected to be too difficult to meet, these individuals could be granted an exemption from the penalty requiring individuals to purchase insurance. Policies barring legal immigrants from accessing Medicaid for the first 5 years will still be in effect, as well as permanently barring undocumented immigrants from Medicaid coverage.

ACOG POSITION 

ACOG calls on federal and state governments to transform Medicaid into a quality public coverage option available to anyone without access to employer-sponsored coverage. ACOG’s roadmap to universal coverage supports building on the existing system of public and private coverage to make health coverage accessible and affordable to everyone. ACOG supports policies that ensure appropriate provider reimbursement in order to ensure access to care for Medicaid beneficiaries.

Timeline:

During the transitional period between April 1, 2010 and January 1, 2014, states have the option to expand Medicaid to “newly eligible” individuals as long as the state does not cover:

  • individuals with higher income before those with lower income, or
  • parents, unless their children are enrolled in the state plan, a waiver, or in other health coverage.

During this optional phase-in period, the enhanced federal match will not be available for covering such individuals.

The mandatory expansion will begin in 2014, although per the Supreme Court Decision the federal government cannot financially penalize states for not doing so.

Resources:

Considerations in Assessing State-Specific Fiscal Effects of the ACA’s Medicaid Expansion The Urban Institute (Aug. 2012)

The ACA’s Medicaid Expansion: Fiscal Bane or Boon to States Presentation The Urban Institute (Aug. 2012)

Q&A: The Supreme Court’s Decision on the ACA’s Medicaid Expansion (#1/2) NHelP (Jul. 2012)

Q&A: Disproportionate Share Hospital Payments and the Medicaid Expansion NHelP (Jul. 2012)

Mortality and Access to Care among Adults after State Medicaid Expansions New England Journal of Medicine (Jul. 2012)

How Health Reform’s Medicaid Expansion Will Impact State Budgets Center on Budget and Policy Priorities (Jul. 2012)

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Medicaid Physician Payment

In May 2011, CMS issued a proposed rule to ensure access to care for Medicaid beneficiaries. It is the first-ever federal guidance to states on how to comply with a prior Medicaid access standard. Specifically, the federal Medicaid statute requires that payments for covered services “are consistent with efficiency, economy and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area.”

ACOG joined other providers in calling on CMS to strengthen the proposed access rule. The National Association of Medicaid Directors has urged CMS to clarify that States do not need to conduct cost studies before adjusting rates, nor must their provider payment rates be cost-related.

CMS issued the rule partly in response to recent litigation by physicians, hospitals, other providers and beneficiaries challenging State cuts in Medicaid reimbursement. Inconsistent court rulings have created uncertainty for States about how to comply with the access requirement. In its proposed rule, CMS acknowledges the linkage between Medicaid provider payments and access to care.

The proposed rule would apply only to fee-for-service Medicaid and not Medicaid managed care plans including MCOs and other risk-based plans and primary care case management (PCCM) programs which cover over 70% of Medicaid beneficiaries nationally.

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Family Planning Coverage Expansion

The Affordable Care Act provided States the option to cover family planning services for non-pregnant women with incomes up to the same level at which Medicaid in your state covers pregnant women currently. States can only count your income, not the income of your parents, partner, or spouse with whom you’re living when determining if you are eligible for this benefit. Allows presumptive eligibility and States can count only the individual’s income, and disregard the income of others in the household, including a spouse or parent.

ACOG POSITION

Resources:

Birth Control Improves Maternal-Child Health Outcomes – Fact Sheet ACOG (Feb. 2012)

Medicaid Family Planning Eligibility Expansions – State Policies in Brief The Guttmacher Institute (Aug. 2012)

Estimating the Impact of Expanding Medicaid Eligibility For Family Planning Services: 2011 Update The Guttmacher Institute (Jan. 2011)

Facts On Publicly Funded Contraceptive Services In The United States – In Brief The Guttmacher Institute (May 2012)

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Quality Measures

The Department of Health and Human Services (HHS) on Dec. 30, 2011, released the initial core set of 26 quality measures for adults enrolled in the Medicaid program. This initiative was established by the Affordable Care Act and complements the CHIP Quality Measures Program which also includes maternity care measures. The initial core set of measures, as well as future additions are to be used on a voluntary basis by state Medicaid agencies. States may institute reporting requirements on physicians treating Medicaid beneficiaries. To date ACOG Fellow Kim Gregory, MD serves on the Agency for Healthcare Research and Quality panel tasked with identifying measures. Women's health specific measures in the initial core set are:

  • Breast Cancer Screening,
  • Cervical Cancer Screening,
  • Chlamydia Screening in Women Ages 21 - 24,
  • Elective Delivery before 39 Weeks Gestation,
  • Antenatal Steroids,
  • Prenatal and Postpartum Care: Postpartum Care Rate

For a complete list of all initial core set measures, view the chart on pages 4 and 5 of the HHS release.

ACOG POSITION

NM INPUT

Resources:

HHS: List of Initial Core Measures - See page 4 and 5

Medicaid.gov – Background Info: Initial Core Set of Adult Health Care Quality Measures for Medicaid-Eligible Adults

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Health Homes

The Affordable Care Act established Health Homes, which consist of a provider or a team of health care professionals that provide integrated health care. This means that if a person is participating in a health home, that person’s health care, from primary care doctor to dentist to behavioral health professional, all share the same information and coordinate treatment based on that information. Health homes operate under a “whole-person” philosophy – caring not just for an individual’s physical condition, but providing linkages to long-term community care services and supports, social services and family services. The integration of primary care and behavioral health services is critical to achievement of enhanced outcomes. Grants and contracts for local interdisciplinary teams to support services and provide capitated payments to primary care providers includes ob-gyns. The team links the medical home to community support services for those patients. Providers in the Health Home must report on applicable quality measures and the Secretary of HHS determines eligibility criteria for providers as well as payment methodology.

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Freestanding Birth Centers/Midwives

ACA ensures that State Medicaid Programs cover maternity care provided in freestanding birth centers and allows individual States to determine specific types of providers at these birth centers.

Learn more by visiting our page devoted to the topic.

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Primary Care Payment Bump

In an effort to bolster the diminishing primary care workforce the Affordable Care Act mandated a 10% pay bump over the next two years two primary care - leveling reimbursement rates with Medicare. In a letter to Acting CMS Administrator Marilyn Tavenner, ACOG expressed disappointment in the continued omission of ob-gyns in primary care reimbursement policies.  Ob-Gyns are not included in the group designated as primary care providers and therefore will not receive the 10% bump.

ACOG POSITION

While ob-gyns were not listed as primary care providers in the final bill, ACOG argues that ob-gyns routinely deliver primary care services to women and should be eligible for the bonus payments. CMS must be reminded that many state Medicaid programs already recognize ob-gyns as primary care providers. The failure for federal Medicaid policies to follow suit could result in continuity of care problems, particularly as the Medicaid expansion from the ACA gets set to take effect in 2014, adding millions of women to the program. ACOG expressed its concers in a letter to CMS Acting Adminstrator Marilyn Tavenner.

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Contact:

Government Affairs Staff 
Mailing Address:
PO Box 96920
Washington, DC 20090-6920
Phone (202) 863-2509
Fax (202) 488-3985
govtrel@acog.org