EXPANDED INCOME ELIGIBILITY FOR HEALTH INSURANCE

In addition to greater access to health insurance in expansion states, some nonexpansion states significantly altered eligibility criteria.

• Provided they meet a work requirement, more childless adults and parents in Georgia are eligible for Medicaid in 2024 than in 2020. Income eligibility for those meeting the work requirement is 100% of the FPL in 2024. In 2020, childless adults were not eligible for Medicaid coverage and only parents whose incomes were up to 35% of the FPL were eligible.
• Tennessee also increased its parent eligibility threshold from 82% of the FPL in 2023 to 105% of the FPL in 2024.

Medicaid Expansion Is Gaining Momentum After Years of Stagnation Among Nonexpansion States

In the year following North Carolina’s successful Medicaid expansion legislation, nonexpansion states with majority Republican legislatures have had notable bipartisan progress towards Medicaid expansion. For example, in 2024:

• Mississippi’s first ever bipartisan Medicaid expansion bill fell just short of the finish line when both chambers of the legislature could not agree on a final proposal.
• Legislation in Alabama to allow gambling revenue to be used for health care coverage for low-income adults (similar to the Medicaid expansion under the ACA) received bipartisan support, although the expanded coverage was eventually removed from the legislation.
• In Kansas, legislators held the first hearing on Medicaid expansion in 4 years.

States Considered Medicaid Work Requirements, Which May Limit Access to Care

Both expansion and nonexpansion states are increasingly considering imposing work reporting requirements as a condition for Medicaid eligibility, although implementation is dependent on the approval of the federal government. Georgia is the only state currently implementing a work reporting requirement for Medicaid. In 2023, Georgia implemented its partial Medicaid expansion program, Pathways to Coverage, which only covers individual up to 100% of the FPL and requires enrollees to work 80 hours each month to maintain their Medicaid coverage.

The impact of work requirements on the effectiveness of Medicaid is not fully clear. However, because of these requirements, far fewer individuals in Georgia than are eligible based on income alone enrolled during the first year of the program. As both expansion (e.g., South Dakota and North Carolina) and nonexpansion (e.g., Kansas and Mississippi) states consider work requirements, more needs to be understood about how this policy impacts those eligible for and enrolled in Medicaid.

1 State Increased the Pregnancy Medicaid Income Eligibility Threshold

Income eligibility during pregnancy is higher than income eligibility for childless adults or for parents who are not pregnant. Since 2020, Oklahoma was the only state to increase its Medicaid income eligibility threshold during pregnancy, from 138% of the FPL in 2022 to 210% of the FPL in 2023.

States Invested Funding to Expand Medicaid Coverage to Additional Populations

Since October 2020, four expansion states have implemented policies to extend coverage beyond the ACA guidelines, including to most adults with low incomes who were previously ineligible due to immigration status (California, the District of Columbia, Oregon, and Washington). In 2025, Colorado will expand coverage to children and pregnant individuals who were previously ineligible due to immigration status.

States Rapidly Adopted Extended Medicaid Postpartum Coverage

Before passage of the American Rescue Plan Act (ARPA) of 2021, Medicaid coverage for pregnant individuals typically only lasted through 60 days postpartum. When eligibility for pregnancy Medicaid coverage ends, then the person must switch to traditional parent Medicaid or use a subsidy to purchase health coverage on the Marketplace. Parent income eligibility for Medicaid is typically lower than eligibility thresholds during pregnancy.

In nonexpansion states, many of these new parents lose health insurance coverage after the postpartum period because their incomes are too high for traditional parent Medicaid eligibility, but not high enough (100% of the FPL) to receive subsidies to purchase insurance on the Marketplace.

Prior to the passage of ARPA, a small number of states sought to extend postpartum Medicaid coverage through Section 1115 demonstration waivers. ARPA expanded the pathways for states to extend pregnancy Medicaid coverage during the postpartum period, by including a temporary state option to use state plan amendments. The option for states to extend coverage via state plan amendments through ARPA went into effect on April 1, 2022, and the 2023 Consolidated Appropriations Act (CAA) made this temporary option permanently available to states.

Since October 2020, 47 states have implemented extended pregnancy Medicaid coverage to 12 months postpartum. As of December 1, 2024, two additional states (Iowa and Idaho) are in the process of extending coverage, leaving just Arkansas and Wisconsin with 60-day postpartum Medicaid coverage.

As states have extended Medicaid coverage through the first year postpartum, states need to identify how systems of care can work together to provide support during this longer coverage period – including identifying which providers are responsible for ongoing support of new parents in the first year postpartum.