Kansas State University


Issues in Health Reform

Category: Medicaid

Health insurance enrollment 2016, numbers and issues

Though somewhat specific to Kansas, this press release written by a KSRE colleague Katie Allen detailing an interview with me might be informative and useful in other contexts.

Released: Feb. 24, 2016

Health insurance enrollment numbers higher overall in Kansas

More consumers are enrolled in the Health Insurance Marketplace for 2016 compared to previous years.

 MANHATTAN, Kan. – According to the Health Insurance Marketplace, more than 12.7 million Americans signed up for a health insurance plan for 2016 during the marketplace’s open enrollment period that ended Jan. 31. This number includes more than 4 million new enrollees.

More than 100,500 Kansans were among those who enrolled in the marketplace, up from about 96,000 enrolled at this time last year.

Roberta Riportella, Kansas Health Foundation professor of community health at Kansas State University, said as the year goes on, the enrollment numbers are expected decrease slightly, because enrollees must pay the monthly premiums and some must also submit additional paperwork to be considered insurance policy holders.

“We expect to lose some, but these initial numbers for people who went to the marketplace are encouraging,” said Riportella, a health insurance specialist for K-State Research and Extension. “At least 80 percent of those people qualified for assistance in paying for their premiums, which makes the plans much more affordable.”

Since 2014, nearly all Americans are required to have health insurance. The Affordable Care Act, which made having health insurance mandatory, outlines a few exemptions (https://www.healthcare.gov/exemptions/). These could include certain hardships, financial status, life events and membership to some groups.

Enrollment numbers in the marketplace have continued to generally go up nationwide and in Kansas, Riportella said, for a variety of reasons.

“There is a greater awareness that there is an insurance marketplace where I can go ‘shopping’ for insurance that my neighbors and family members are using. It didn’t blow up. It didn’t go away. It wasn’t repealed, and it seems to be a fairly stable way for me to get insurance for myself and my family members,” she said. “Another reality is the fines for not being insured that people experienced for the first time when they filed their 2014 tax returns.”

In the current income tax season, taxpayers now have to show proof of health insurance enrollment – for at least nine months of the year in 2015 – on their tax documentation. For those without the required amount of coverage in tax year 2015, the penalty is 2 percent of household income, or $325 per adult and $162.50 per child under 18 up to a maximum fine of $975 – whichever is the greater amount. For those without coverage in 2016, the penalty will be the higher amount between 2.5 percent of household income, or $695 per adult and $347.50 per child to a maximum fee of $2,085. The fines will continue to increase, Riportella said, which discourages people from remaining uninsured.

Options outside the marketplace

Consumers who did not enroll in the marketplace before the Jan. 31 deadline may have other options to meet the nine-month requirement for health insurance coverage in 2016. Options available now typically have certain requirements for consumers to meet to enroll in coverage, but Riportella said some people still might have more than one option.

  • The marketplace (https://www.healthcare.gov/) is still available for those who experience a qualifying life event (http://www.hr.mnscu.edu/insurance/documents/Qualifying_Life_Even.pdf) this year. Qualifying events include losing job-based or other insurance, moving out of state, or changing family composition such as getting married or divorced, losing a spouse, or adding a child. Enrollees with a qualifying life event have 60 days after the event to sign up for insurance through the marketplace. This is considered a special enrollment period.
  • Job-based health insurance is an option if the employer provides coverage.
  • KanCare (http://www.kancare.ks.gov/), Kansas’ Medicaid program, is available to low-income U.S. citizens and lawfully present immigrants who are over 65, under 18, or disabled. Children and pregnant women might be eligible for KanCare if their household incomes are less than 245 percent of the federal poverty level.
  • For adults age 65 and older, Medicare (https://www.medicare.gov/) remains the health insurance option. Certain younger people with disabilities and people with end-stage renal disease and amyotrophic lateral sclerosis, commonly called ALS or Lou Gehrig’s disease, will continue to get their health insurance through this federal program.
  • Other public programs include TRICARE, Veterans Affairs (VA) or the Indian Health Service (IHS) for eligible enrollees.
  • Enrolling in private health insurance is another option available at any time, though many private plans mirror the same open enrollment period offered by the marketplace.

Because having health insurance is required for nine months of the year, consumers could still be within the legal requirements if their plans begin by April 1, Riportella said.

In addition to avoiding a tax penalty, having health insurance encourages appropriate and timely use of medical care while it protects against extraordinary financial risk, she said.

Medical expenses are a leading cause of personal bankruptcy, she said, so having health insurance protects families against that risk. Plus, families are better able to plan for medical expenses, and can budget for the premiums and out-of-pocket expenses of their plans.

More information

To learn more about how to enroll in the marketplace or KanCare, call the marketplace, available 24/7, at 800-318-2596. People who think they meet special enrollment criteria should contact the marketplace. The Kansas Health Institute also has numerous resources on its website (http://www.khi.org/).

Read more about issues in health reform on Riportella’s blog (http://blogs.k-state.edu/issuesinhealthreform/).

Sidebar: Addressing the health insurance gap in Kansas

The Affordable Care Act made it possible for consumers to purchase health insurance without being denied due to one or more pre-existing conditions, said Roberta Riportella, Kansas Health Foundation professor of community health at Kansas State University and K-State Research and Extension.

Also, in many cases, people are eligible to receive financial assistance in paying for premiums through advance premium tax credits, which lower consumers’ monthly insurance bills, and out-of-pocket health care costs through cost-sharing reduction plans, which lower items such as emergency room fees and prescription costs, Riportella said.

Financial assistance in the form of premium tax credits makes the policies in the marketplace more affordable for those who fall between 100 and 400 percent of the federal poverty level, or FPL (https://aspe.hhs.gov/poverty-guidelines). Eligibility for cost-sharing subsidies on Silver plans, or middle-tier plans, bought on the marketplace is available to those whose annual income lies between 100 and 250 percent of the FPL.

Another health insurance option for low-income individuals and families is Medicaid, called KanCare (http://www.kancare.ks.gov/) in Kansas, but eligibility is limited. Currently in Kansas, KanCare is available to low-income U.S. citizens and lawfully present immigrants who are over 65, under 18, or disabled. Children and pregnant women might be eligible for KanCare if their household incomes are less than 245 percent of the federal poverty level.

In 32 states, Medicaid expanded to include individuals under 138 percent of the FPL, so more people could be insured in that program, Riportella said, but in the 18 states that have not expanded, including Kansas, there is a lack of affordable options for health insurance. These people fall into a “gap,” as they cannot afford insurance on their own, are not eligible for assistance in paying for marketplace plans and are not eligible for Medicaid (KanCare) enrollment.

“We are enrolling lots of people who are eligible (for health insurance) in the marketplace, but we have about 100,000 low-income people in our state who would otherwise be eligible for Medicaid,” Riportella said. “Almost half of those, 49,000, are under 100 percent of the federal poverty level and aren’t eligible for financial assistance to pay for premiums and out-of-pocket costs if they were to purchase a plan in the marketplace. These folks are in what we call the ‘gap.’”

“This is because the law strongly encouraged states to expand their Medicaid programs to cover those with incomes less than the federal poverty level,” she continued. “So unless we expand Medicaid to include these folks, or have some type of program to insure or deliver care to those in the ‘gap,’ Kansas will be stuck where we are right now at about 14 percent of our population being uninsured.”

The gap affects not only individuals and their families, but also affects the communities in which they live, Riportella said. People without insurance seek care under more dire circumstances, and uninsured consumers who seek late care for perhaps greater health care needs raises the cost of care for all.

The uninsured gap is not shared equally by race in Kansas either, according to the Kansas Health Institute, which recently reported that Kansas has the most racial disparity in those not covered by health insurance of all states. In 2014, 17.4 percent of black Kansans were uninsured compared to 7.6 percent of white Kansans. Nationwide, 13.6 percent of black Americans were uninsured in 2014, significantly lower than the rate in Kansas (http://www.khi.org/news/article/despite-obamacare-insurance-disparities-persist-in-kansas).

For more information about eligibility to receive assistance through premium tax credits or out-of-pocket cost-sharing reduction plans, visit HealthCare.gov (https://www.healthcare.gov/lower-costs/qualifying-for-lower-costs/).


K-State Research and Extension is a short name for the Kansas State University Agricultural Experiment Station and Cooperative Extension Service, a program designed to generate and distribute useful knowledge for the well-being of Kansans. Supported by county, state, federal and private funds, the program has county Extension offices, experiment fields, area Extension offices and regional research centers statewide. Its headquarters is on the K-State campus, Manhattan.

Story by:
Katie Allen
K-State Research and Extension

For more information:
Roberta Riportella – rriporte@ksu.edu or 785-532-1942



Persisting disparities in who is insured

While overall the US is experience decreasing rates of people uninsured, these gains are not shared among the races equally.  Racial disparities that are related to more people of color working in part time and/or lower paying jobs, and in general, increase the rates of poverty among blacks and other nonwhites, are also having an impact on who gets health insurance.

Most of those part time and lower paying jobs do not come with health insurance.  Fortunately, there are now options in the state and federally run Marketplaces where many can purchase health insurance without worrying about pre-existing conditions excluding them.  Also, in many cases, people are eligible to receive substantial financial assistance in paying for premiums (Advance Premium Tax Credits) and the cost-sharing portions of insurance (Cost Sharing Subsidies).

However, in order to qualify for that financial assistance the family income must be above the federal poverty line ($11,880 for an individual; $24,300 for a family of 4).  In the 18 states where Medicaid has expanded to include individuals under 138% of that level, there are options for those who are ineligible to receive financial assistance.  Those individuals are insured through their states’ Medicaid systems.

In the 32 states that have not expanded however, there are no affordable options for insurance.   This is where we observe being poor and without a job that offers health insurance to impact racial minorities the hardest.   (The one exception is Wisconsin that has its own Medicaid coverage outside of the federal Expansion.)  And, as all uninsured people, those without coverage do often use health care, but they access care at inappropriate times (less preventive, more acute and severe care needs), and in inappropriate places (emergency rooms for routine care).  Finding a way to insure this population or provide them with more consistent health care would improve their health outcomes and community outcomes that thrive with a healthy workforce.

This issue is covered in detail in a news article and in a Kansas Health Institute issue brief.

The differences of opinion over Medicaid Expansion in Kansas

The reality of a southeastern Kansas hospital closure has pushed to the forefront the role that a Medicaid Expansion would or would not have played in keeping the doors to that hospital open.  A recent news release by the Kansas Health Institute summarizes well the differences of opinion over expanding Medicaid in Kansas, and whether doing so may have avoided the closing of the hospital.

Let’s first remember that Medicaid has been a state/federal partnership since 1966 that allows states to pay for medical services for low-income individuals and families using a mix of federal and state dollars.  In order to participate and receive federal dollars, the feds set certain minimum core standards that states must meet in their own programs.  (For more information on Medicaid see this website. For information on the core requirements see KFF issues brief, and particularly Appendix A.) Any divergence from those standards has to be approved by the feds through a waiver process.  Kansas has a waiver to allow for private managed care organizations to provide Medicaid services (using those federal dollars).  That program is called KanCare.  Those eligible for KanCare in Kansas include those who meet income requirements in the following categories:

  • Children up to age 19, including those who are in foster care or who get adoption support payments
  • Pregnant Women
  • Persons who are blind or disabled by Social Security rules
  • Persons age 65 or older
  • Persons receiving inpatient treatment for tuberculosis
  • Low income families with children
  • Persons screened and diagnosed with breast or cervical cancer through the Early Detection Works program

(The FPL income level varies by program but it’s worth noting that the federal standard minimum income level for parents to qualify is 28% FPL. The Kansas Medicaid program qualifies these parents close to that minimum, at just under 33% of FPL, $7870 for a four person household). Kansas does not include childless adults in its Medicaid program unless they are over 65 and meet income criteria for that category.)

The Affordable Care Act allowed for states to expand eligibility for states’ Medicaid programs to include all (children and adults regardless of whether or not they are parents) who have incomes under 138% of the federal poverty level ($16,243, single person household; $33,465, 4 person household, 2015).  The intent of the ACA was to encourage states to adopt this arrangement.  The Supreme Court ruling in June 2012 determined that the encouragement mechanism (expand or withdraw from all Medicaid federal supports) was too forceful and therefore allowed states to choose if they want to participate or not in the expansion.

Kansas is one of 19 states that have yet to expand Medicaid. There is no end date as to when states can expand.  Alaska and Utah are in the process of expanding and the other 28 states and the District of Columbia have already expanded; Wisconsin has a unique arrangement to cover all adults under 100% FPL not funded through these Medicaid Expansion federal dollars. For a discussion of why states (and Kansas in particular) are not expanding see this blog.

Regarding how hospital closures play into a Medicaid Expansion: Kansas Governor Brownback and the Lt Governor Colye have been arguing that expanding Medicaid would not fix the economic situation of failing hospitals.  They assert that the financial hardship for hospitals is caused by decreasing Medicare payments to hospitals as part of ACA. However, as importantly, they raise a moral issue about who is deserving of receiving state-supported care as an argument against an expansion.

“Those who say Medicaid  Expansion would save the Independence Hospital are lying.  It wouldn’t.  Instead, this Obamacare ruse funnels money to big city hospitals, creates a new entitlement class, and fails to rightly prioritize service for disabled citizens.  Governor Brownback will maintain his commitment to provide care to vulnerable Kansans before able bodied adults. (for full statement see Governor’s office statement on hospital closure and Medicaid Expansion.)

A point by point response from the Kansas Hospital Association can be found here. The response clarifies the reasons for Kansas hospital financial hardship, notes how these are more complicated than Medicare payment structure changes, and uses evidence on the impact on hospitals from other states that have expanded their Medicaid programs to suggest that Medicaid paying patients do help a hospital’s fiscal bottom line.

At its simplest, hospitals depend on a cash flow from paying patients. Medicare, Medicaid and private insurers are all part of the mix. Patients who are uninsured are still hospitalized, often times for illnesses that would have been better treated in community settings before they got severe enough to warrant hospitalizations. Those uncompensated hospitalizations impact smaller hospitals more since there is a higher rate of uninsurance in rural and smaller communities. That means those smaller hospitals are more reliant on public payers such as Medicare and Medicaid. The argument is that with more patients eligible to have their hospitalizations paid for by Medicaid there would be an additional payer in the mix and more income flowing to meet the hospitals’ expenses. And on a related and very important matter, Medicaid paying for community care for these uninsured community residents would help to decrease unnecessary hospitalizations at the outset.

Who would be eligible for Medicaid in Kansas? A report released in 2014 from the Kansas Center for Economic growth contradicts the notion that those who would be Medicaid eligible in the expansion are able-bodied adults who should be working.  In fact, most of those who would be newly eligible for an expanded Medicaid program have at least one family member who is working.  However, their jobs are often part time, and pay less than 100% of the FPL, the criteria for being eligible for premium tax credits in the Health Insurance Marketplace to help pay for insurance.  That is, these folks are too poor to qualify for assistance in paying for premiums.  This may seem odd but the ACA had a plan for those folks.  It’s called the Medicaid Expansion.  The ACA intended for those too poor to qualify for premiums assistance to be insured through state Medicaid programs.

The report goes on to detail the types of occupations, and the wages in those occupations, where working class people are most likely to be uninsured and eligible for Medicaid if the state chose to expand within new federal guidelines.  The report makes additional economic arguments for the wisdom of the expansion.  “Medicaid expansion would go a long way toward increasing economic security for uninsured workers.  It also would be an asset for small businesses—which will benefit from healthier and more productive employees—and the economy as a whole—which will benefit from the flow of federal dollars into the state.” The Kansas Center for Economic Growth report makes the case the expanding Medicaid would be good for Kansas local economies, especially rural communities, and the state as a whole.

Previous blogs on Medicaid that might also be of interest are on: March 13, 2015; April 23, 2014, July 13, 2013; May 23, 2013; May 8, 2013


How is the ACA faring according to enrollment criteria or what do the enrollment numbers mean?

If one uses as a standard the Forbes article analyzing recently released Census Bureau data ACA is performing at 71% of expected enrollment and is therefore a failure. True that the Census data used in that article in all new reports are likely more accurate than earlier reports based on smaller samples that had shown more hopeful progress. Still, I find it odd, to say the least, to call a drop in the rates of uninsured of about 8% overall to be a failure. The ASPE DHHS national data report now shows 17.6 million uninsured gaining health insurance coverage through the Health Insurance Marketplaces, Medicaid, and also including individual private market coverage.

The ASPE report also notes that the decreases in the uninsured has differentially affected racial and ethnic groups. The largest decline was among African Americans where the uninsurance rate was halved from 22.4% to 12.1%, 2.6 million people gaining insurance.  Hispanics had farther to go. They started at 41.8% uninsured and are now at 30.3%. That is still a high rate of uninsured that is complicated by matters of documentation but a significant drop nonetheless and affecting 4 million real lives. Whites had, and continue to have, the lowest rates of uninsurance among those three groups. They started at 14.3% and have declined to 8.3%, impacting 7.4 million lives.

Those are significant numbers of Americans now being insured and having much more balanced access to health insurance. No one can be denied a policy because they are sick. No one’s policy can be cancelled because they are sick. There are no longer annual nor lifetime maximums on the amount paid out for covered services. In a nutshell, not only are all of the new folks insured and protected, but most who are insured through employer plans also now share those same protections (there are exceptions for self-funded plans and for the small percentage still grandfathered in under old regulations). Further, this ability to access insurance through a place other than a place of employment has opened up opportunities for those who want to leave their current places of employment. In the past many were stuck in jobs solely for the purpose of keeping health insurance because they would have been denied coverage elsewhere because of pre-existing conditions.

So why is there less enrollment than anticipated? There are two barriers to fuller enrollment that the Forbes article does not acknowledge. The first barrier more critical to less than anticipated enrollment is the reality that 19 states have still not expanded Medicaid, the public insurance program through which it was anticipated many of the newly insured were to become insured. The ASPE Data Point Report shows that expansion states have dropped to lower rates of uninsurance (from 18.2% to 10.1%) compared to non-expansion states (from 23.4% to 16.1%), though it is telling that the non-expansion states had farther to go, indicating perhaps a less friendly environment for employment based opportunities for insurance and a host of other contextual issues that drive health disparities in those states at the start.

The second reason is that most of the states that are relying on the federal government to run their insurance exchanges had less enthusiasm for the law and perhaps created less supportive environments to ensure that all eligible individuals knew of their new insurance options. One cannot blatantly ignore the political realities that have created fear around the law and discouraged eligible families to consider their options. It is therefore understandable that initial anticipated goals have not yet been reached and it remains an uphill battle in many states to get to expected enrollment numbers.

Agreed that it would have been best not to have overestimated the potential of the ACA to decrease the number of uninsured, especially in such a hostile political environment. Still, you can decide if a drop from over 20% to under 13% uninsured makes the ACA a success or a failure. And then we can determine what needs to be done to make sure that more Americans can gain insurance.

What does it mean when politicians say health care is a right?

Of late President Obama and others have been touting the recent Supreme Court (SCOTUS) decision in King v Burwell that upholds tax subsidies for every state as proving health care is a right. Hmmm. That’s still a stretch. Let’s look at who is likely to either have health care paid for with the assistance of insurance, or have health care directly provided to them and who is still left out.

We have the public plans that do make health care a right for those who fit the eligibility criteria. There is:

  • Medicare for those over 65, the disabled, and selected other special disease interest groups (End Stage Renal Disease, Lou Gehrig’s disease).
  • Medicaid for those poor enough who are over 65, or under 19 (those who are in the state Children’s Health Insurance Programs (CHIP)), and now adults under 138% FPL ($27597 for family of four) in the 31 states that have expanded their Medicaid programs (as of July 2015)
  • The Veteran’s Administration system that provides care directly to veterans.
  • The Tricare system for active military that also provides care directly; and
  • The Indian Health Service for members of tribal nations that also provides care directly. Members also have access to all of the insurance options available for others (Medicare, Medicaid, CHIP, employer sponsored insurance, marketplace plans and plans in the private market)

We have a complicated private insurance system that now does offer health care as a right to all who qualify or can afford it. The “right” parts are the consumer protections where no one can be turned down because of a pre-existing condition, have a policy cancelled or maxed out, and because certain large employers are mandated to provide insurance. People covered under this “right” are:

  • Those who work for employers with over 100 employees, since January 2015 mandate
  • Those who work for employers with over 50 employees, mandate begins (if still in effect) January 2016
  • Those not covered through work who can afford private insurance without assistance if they are over 400% FPL ($97000, family of four), or between 100-400% if they can afford insurance with subsidies

That leaves out the 126000 in Kansas (Families USA data) who are like the 6.4 million others in states that also have chosen to not yet participate in the ACA supported Medicaid Expansion. Those folks fall between a state’s standing maximum eligibility to qualify for Medicaid (33% in Kansas for parents, 0% for childless adults) and 138% FPL. These folks are too poor to qualify for financial assistance paying for a marketplace insurance plan and too “rich” to qualify for Medicaid in states with very stringent criteria for eligibility.

Therefore, while it is true that things would have been even more difficult for the 80-90% of people in the marketplaces who depend on those tax subsidies to afford those insurance plans had the Supreme Court ruled otherwise in King v Burwell, to say that the SCOTUS decision means that health care is a right is more than a stretch of the implications of that ruling.

Medicaid Expansion for Kansas?

Next week Kansans and the Kansas legislature finally get to voice opinions about expanding or not Kansas’ Medicaid program, in line with the original intent of the ACA.  This will be watched closely nationally as Kansas is one of several states that have yet to have a hearing on this.  While the Kansas legislature told the Governor two years ago that no Medicaid Expansion could pass without their approval, there really has not been any hearing or public airing of this. The bill would override that previous legislation and allow the Governor to negotiate more freely an expansion option that might further allow public hearings on the matter.

As noted in this KHI news briefing observers expect both proponents and opponents to have much to say.

The proponents include:

  •  provider groups (the Kansas Hospital Association and such) who will benefit from having to provide less uncompensated care
  • consumer advocacy groups who believe that the ACA intended to make insurance more affordable to all, including those too poor to qualify for tax subsidies in the Marketplaces
  • community organizations who argue that all in community are affected by uncompensated care in terms of costs of health care in that community, and a healthier workforce when more are insured


The opponents include:

  • those who in general are against the ACA and believe its costs are not sustainable such as Americans for Prosperity
  • those who believe Medicaid is a failed an unsustainable program so expanding it is not the way to go

Over half of the states have already expanded their Medicaid programs, taking advantage of federal funding assistance as offered through the ACA. Some have done this as a direct expansion of their current programs. Others have tried more private pay models, requiring copayments or even premium payments on the part of participants. Families USA explains the impacts of these Medicaid Expansion decisions in a series of useful graphics. The Kaiser Family Foundation has a detailed list of what each state has chosen to do to date. Note that states can choose to request federal assistance with expanding at any time.

Medicaid cost recovery through payback from the estates of the deceased

Recovering costs from the estates of the deceased for Medicaid funds spent on long term (institutional) care has been a federal requirement for many years.  This has allowed the public to recoup usually extraordinary costs (average $80,000 annually) and have money to pay for future Medicaid recipients.


Because of those extraordinary costs of nursing home care, it is not surprising that Medicaid becomes the major payer even in circumstances when one was middle class and may have owned property.  To be eligible for Medicaid one must have less than some small amount of assets, usually about $2000 cash (or spend down to that amount).  A spouse can continue to live in the family home but when that surviving spouse also dies, then that property can be sold and cashed out to repay Medicaid. For some this comes as a surprise. Some financially savvy older adults (often at the urging of their adult children) learn how to divest their estates over time so that there is no estate property left in the older adults’ name for the state to come back and claim.  Whether or not we think that is an ethical practice, it is a legal one if done over time, years before a person may actually need nursing home care.


So, what is all the new news about?  In most states, Medicaid only paid for children, adults over 65 or the disabled in institutional settings.  With the expansion of Medicaid as part of the Affordable Care Act, states that have expanded their Medicaid eligibility are now paying for more than nursing home medical costs for large numbers of adults.  Ten of those states have their own laws that require the reimbursement of the Medicaid program from the estates of the deceased for adults over 55 who were receiving Medicaid even for regular medical care service costs.  The large expansion of the Medicaid population to cover children and adults under 65 in states with those laws put the estates of those over 55 in jeopardy.  This makes the Medicaid program that pays for medical expenses now a defacto short term loan program, with the family house being held as collateral.


Medicaid seems to be pretty alone as a publicly sponsored program that recoups costs from a former recipient’s estate.  The unfortunate consequence of what might be fiscally sound policy is that is discourages those who need medical care from receiving it, countering the major intent of extending insurance.  That intent was to remove the financial barrier to seeking care especially for those of lowest income who were likely delaying much needed medical attention.  As adults over 55 in those states find out about this caveat they are avoiding using Medicaid as a payer of their medical care so that they can at least bequest their houses to their intended beneficiaries.  Complicating this is that those on Medicaid rarely receive any bills so they have no way of knowing how much the program has paid on their behalf, nor how much their estate may owe upon their deaths.


Now that the cadre of those qualifying for Medicaid and needing medical services rather than institutional home care grows, it will be interesting to see how states with those repayment laws address this.  Also interesting will be the public discussion about what exactly an assistance program is and when is it appropriate to require payback, as if the assistance were only a loan.

How do I get health insurance before the next open enrollment period starting Nov 15, 2014?




Everyone with few exceptions (see https://www.healthcare.gov/exemptions) must have health insurance or may have to pay a penalty. Medicare Tri-Care, VA and Indian Health Service all remain the main insurance for those eligible for those programs. Because these programs qualify as insurance beneficiaries are not subject to penalties for being uninsured.

 Here are health insurance options for you to consider.

Your Job

 •   Your insurance stays the same unless your employer decides to make changes. If this work-based insurance is not affordable (costs more than 9.5% of your household income for a single policy) you may be eligible for financial help if purchasing a policy in the Marketplace.

 The Marketplace at healthcare.gov

 •   The Marketplace refers to a place for specific kinds of insurance policies that have been approved by the federal government to offer policies in Kansas.  Most think of it as the website where those policies can be found but it exists regardless of the website.  People can enroll via phone, mail, in person, or yes at the website.  The website offers an easy way to view and compare plans for providers, services and price. Anyone can shop in the Marketplace however, open enrollment is closed for 2014.

  •   Open enrollment for 2014 ended March 31. Only people with special circumstances can purchase in the Marketplace now   marketplace.cms.gov/help-us/enroll-limited-circumstances.pdf

  On November 15, 2014 the Marketplace will reopen for everyone else. KHN has a good story about those circumstances http://www.kaiserhealthnews.org/Stories/2014/May/09/Andrew-reader-question-on-insurance-between-open-enrollments .aspx?utm_campaign=KHN%3A+Daily+Health+Policy+Report&utm_source=hs_email &utm_medium=email&utm_contnt=12736814&hsenc+p2ANqtz-8xGUxlk04t5iCJ8D7Y8Jwxuv9SS7HSFMuLR4B3eRiCwWSwqRzCZzABM9aYnlvSyRfYLombN4pnWb0OtxE6FVYARW2m7A&_hsmi=12736814

  •   U.S. citizens, nationals and lawfully present immigrants living in the United States and not in prison can enroll in health insurance in the Marketplace.

  •   If you purchase in the Marketplace AND your household income is less than 400% of the federal poverty level (FPL), you may get tax credits to reduce the cost of the premium.  If it is less than 250% of FPL, you may also get help paying for out-of-pocket costs. This is not true for those who have work-based insurance that is considered adequate and affordable. Adequate means that the plan pays on average 60% of all your medical costs in a given year. Affordable is considered less than 9.5% of your annual household income. If work based insurance meets those criteria than you are not eligible for tax credits.

 KanCare at http://www.kancare.ks.gov/

 •   KanCare is the Kansas Medicaid program for U.S. citizens and lawfully present immigrants of low income who are over 65, under 18, or disabled.

 •   Children and pregnant women may be eligible with household incomes less than 225% FPL.

  •      Those over 65 have both income and asset limits, depending on the specific program.

  •   Check eligibility at http://www.kancare.ks.gov/ or the Marketplace healthcare.gov

  Additional options for young adults

  •   Stay on parents’ policies until age 26.

  •   Buy a catastrophic plan (for those under age 30 or with special financial circumstances).

  •   For higher education students, ask about student health insurance.

  Buy a private plan from an agent or broker.

  To get help or learn more to enroll in the Marketplace or KanCare

 •   Call the National Help Center at 1-800-318-2596 available 24/7.


Marketplace Eligibility Monthly Income

Marketplace Eligibility Monthly Income

Group Size

Up to 250% FPL Help with out-of-pocket costs

Up to 400% FPL Income limit for Tax Credits










For each additional person add

For each additional person add




Report argues for Medicaid expansion in Kansas

A recent report from the Kansas Center for Economic growth makes the case the expanding Medicaid would be good for Kansas local economies, especially rural communities, and the state as a whole. “Medicaid expansion would go a long way toward increasing economic security for uninsured workers.  It also would be an asset for small businesses—which will benefit from healthier and more productive employees—and the economy as a whole—which will benefit from the flow of federal dollars into the state.” The report details the types of occupations, and the wages in those occupations, where working class people are most likely to be uninsured and eligible for Medicaid if the state chose to expand within new federal guidelines.

The Affordable Care Act was crafted in a way that relied on states expanded their Medicaid programs to cover individuals who made less than 133% of the federal poverty line (138% in actuality when tax deductions were considered).  The federal government is set to pick up 100% of the expenses for 3 years and then 90% thereafter.  The Supreme Court decision of June 2012 made Medicaid expansions voluntary.  Kansas is one of 25 states that has not chosen to expand.



Even without expansion Medicaid enrollment changes coming to Kansas

Kansas is one of 7 states that has not yet made a formal decision about participation in ACA’s allowed expansion of the Medicaid program. (This is a good site for seeing the status of Kansas and other states re expansion.)  Regardless of whether or not Kansas expands Medicaid coverage, there are still changes that need to happen to make the process of applying comply with ACA, including new types of enrollment processes, basically linking Medicaid application with the Marketplace ones.

A recent and worthwhile publication out of the Kansas Health Institute details those changes.  As noted in the publications’ key points:

“1.  ACA adjusts how the state will enroll people in Medicaid and the Children’s Health Insurance Program, and adds requirements for coordination with the newly created health insurance exchange.
2.  Kansas will shift to a single streamlined application for individuals to access Medicaid, CHIP and federal tax credits through the exchange.
3.  Kansas must provide a “no wrong door” application and enrollment process for Medicaid, CHIP and federal tax credits through the exchange so that individuals can apply online, by phone, by mail or in person and be referred automatically to the correct program.
4.  The ACA also requires the state to convert income-counting rules for Medicaid and CHIP applicants to a new federal standard that aligns closely with the rules used for federal tax credits through the exchange.”