Not Out of the Woods Yet: State Waivers Threaten Medicaid Expansion

This blog is written in collaboration with Families USA.

One of the most important provisions of the Affordable Care Act (ACA) is the expansion of health coverage to low-income individuals and families through Medicaid. The ACA extends Medicaid eligibility to childless adults with incomes at or below 138% of the federal poverty level. This helps people who are homeless connect to a broad range of needed services, particularly for specialty care, substance abuse treatment, and life-saving surgeries often out of reach for the uninsured.

Over the past eight months, Congress has tried unsuccessfully to repeal the law – a move which could have resulted in millions of people losing their coverage.  While many advocates breathed a cautious sigh of relief, opponents of the ACA remain strategically active on the ground.

As a “plan B,” efforts are underway to weaken Medicaid at the state level through the use of Section 1115 Medicaid waivers – a process that does not require legislation from Congress, but can be done completely at the administrative level.

In March 2017, then US Health and Human Services Secretary Tom Price and Centers for Medicare & Medicaid Services Administrator Seema Verma sent a letter to governors explaining that states would have unprecedented discretion in running their Medicaid programs. Specifically, the letter reported that the federal government would view certain requirements, such as work activities, favorably.  Encouraged by that letter, more states have begun to chip away at Medicaid expansion through restrictive waiver requests that include work requirements, drug testing, cost-sharing, and premiums.

If approved, these waivers would create barriers to coverage and care for low-income people. It would particularly impact homeless populations that are more likely to be unbanked and have multiple barriers to workforce participation, including limited resources to pay premiums.

Although the political hype about the repeal of the ACA at the national level has somewhat diminished, advocates must remain vigilant to protect the gains made for millions of uninsured people under the law.

How You Can Take Action

Your state representatives and the Centers for Medicare and Medicaid Services need to hear from you!

  • Track the waiver’s impact. Gather stories from individuals you work with who are being impacted by harmful waiver policies. Contact Families USA’s story bank to ensure your voice is heard by lawmakers, and that any future lawsuits challenging these policies represent the people who are impacted.
  • Build a coalition. Start bringing together a diverse coalition of state and local partners, like social service organizations, providers, chambers of commerce, faith communities, and others that can speak out in unison on behalf of those in need.
  • Stay alert. As new states propose harmful waivers, seek opportunities to participate in hearings, and comment at the state and federal level.

Sign up for Families USA’s action alerts to receive information about new waiver proposals that would adversely impact access to care for vulnerable populations.

States Reporting Eligibility and Premium Changes in FY 2017 and 2018

Below is a snapshot of some 1115 Medicaid waivers that have been approved already and of some of the waivers that are pending approval.  For a more comprehensive listing and updates, please visit and explore the interactive map of state activity.

State Year Eligibility Requirements
AR 2018

Eliminate the conditions CMS placed on the state’s waiver of retroactive eligibility for expansion enrollees, including the medically frail – pending for expansion adults

Eliminate coverage for expansion population with income 100-133% FPL – pending

Work requirement for “remaining” expansion adults (0-100% FPL) – pending

IN 2018

Three month lock out of coverage following a 90 day period of disenrollment for failure to comply with redetermination requirements – pending for expansion adults

Require Transitional Medical Assistance parents up to 138% FPL to pay premiums like expansion adults – pending

Add a 1% premium surcharge for tobacco users beginning in the second year of enrollment – pending

IA 2018 Eliminate retroactive eligibility for all Medicaid enrollees – pending
KY 2018

Add premiums on a sliding scale based on family income for first two years of enrollment for those 100-138% FPL, with increases in third year – pending

Require payment of first premium before coverage is effective for those 100-138% FPL – pending

Dis-enroll those above 100 FPL who fail to pay premium after a 60 day grace period and bar re-enrollment for 6 months unless past premiums are paid or beneficiary completes a health or financial literacy course –pending

Require weekly hours of employment activities – pending

Prohibit beneficiaries who do not timely renew Medicaid eligibility from re-enrolling in coverage for 6 months unless beneficiary completes a financial or health literacy course – pending

ME 2018

Add a work requirement for many groups of adults ages 19-64: parents, former foster care youth, individuals receiving transitional medical assistance, medically needy parents/caretakers, individuals eligible for family planning services only and individuals with HIV – pending

Eliminate retroactive eligibility – pending

Apply a $5,000 asset test to all coverage groups that do not currently have an asset test – pending

Eliminate hospital presumptive eligibility – pending

MA 2018 Eliminate 90 day period of provisional eligibility for adults under the age 65 without verified income who are not either pregnant or HIV positive – pending
MO 2017 Family planning waiver ended and replaced with a state-only (non-Medicaid) program
NH 2017 Retroactive eligibility ended
NM 2018 Home equity exclusion changed from the federal maximum of $840,000 to the federal minimum of $560,000
UT 2018

Add a work requirement for Primary Care Network (PCN) group – pending

Eliminate retroactive eligibility for PCN adults – pending

Add 60 month limit on eligibility for PCN adults – pending

Eliminate hospital presumptive eligibility – pending

WI 2018

Add $8 premium per household per month for those 50-100% of FPL, beneficiaries face a 6 month lock out period if premiums are not paid – pending

Require weekly hours of employment activities or will have 48 month time limit; after time limit a lock out will be imposed for 6 months – pending

Require drug screening – pending

WY 2018

Income level for Breast and Cervical Cancer program reduced to 100% FPL

Income level for Employed Persons with Disabilities program reduced to 100% FPL

Chan Crawford is a Policy and Program Analyst at the National Alliance to End Homelessness. She can be reached at