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Medicaid and Medicaid Expansion. Where and How to Get it.

medicaid cartoon

By Bob Aronson

I will start this post by saying that you are about to get more information about Medicaid than you wanted or likely have seen in one place before.  I am doing that so that you have to do as little homework as possible.

In order to eliminate confusion the reader should know that as of this writing every U.S. state provides some sort of Medicaid.  When you read stories that a state has opted out of “Expanded Medicaid” under the Affordable Care Act (ACA) that doesn’t mean they have decided not to fund Medicaid at all.  It only means they will not participate in the expanded program offered by the U.S. Government.  It also means that fewer people will be treated for fewer medical problems.

Every state in the union currently has some sort of Medicaid program.  Medicaid is the largest source of funding for medical and health-related services for lomedicaid logow-income people in the United States. It is means-tested that is jointly funded by the state and federal governments and managed by the states, with each state currently having broad leeway to determine who is eligible for its implementation of the program.  Some states are far more generous than others but none are required to participate in the program.

Medicaid recipients must be U.S. citizens or legal permanent residents, and may include low-income adults, their children, and people with certain disabilities.  Poverty alone does not necessarily qualify someone for Medicaid as poverty guidelines differ from state to state.

How to apply for Medicaid.  

Many states offer the ability to apply for Medicaid directly on their websites. These applications can generally take anywhere from a half an hour to an hour to complete. If your state doesn’t have an online application, you may be able to at least access a copy of it online that you can download and fill out at your convenience. If it doesn’t, you will need to take a trip to your local Department of Social Services and request their assistance with filling out your application. In most cases, you’ll have the option of taking the application with you and bringing it back in, or mailing it back in, or you will be seen immediately, if you wish.  More details can be found here

Do You Qualify for Medicaid?

If the previous link did not answer your questions this link should.

Medicaid Then and Now

Prior to Medicaid expansion on the Affordable Care Act (ACA) of 2010 Medicaid was and is administered as a partnership jointly funded by the federal government and the states, with the feds contributing anywhere from 50 percent to 74 percent of expenses (the average nationwide is 57%). For states who sought to provide care to the disadvantaged and others it was a pretty good deal.

ACA expansion greatly increased the federal investment in state programs.  Under the ACA the federal match rate, starts at 100 percent in 2014 and gradually declines starting in 2017 until it reaches 90 percent for 2022 and beyond.

Unfortunately for those who need Medicaid 26 states have chosen not to participate in the expansion.  They have that option because of a U.S. Supreme court decision that upheld all other aspects of the Affordable Care Act except making the expansion mandatory. Again, Medicaid programs are only available to people with low incomes, limited resources, or certain diseases or disabilities

ACA otherwise known as Obamacare has been the subject of a bitter political battle since long before it was passed into law. The Republican controlled U.S. House of Representatives  believes the law is ineffective and unaffordable.  As a result House Republicans not only voted against it they have unsuccessfully tried to repeal the law 40 times.  The great majority of states that have rejected expansion are Republican controlled.

Let us begin with where the states are with regard to Medicaid expansion.   The following states have said yes to the Medicaid expansion:

Arizona, Arkansas, California, Colorado, Connecticut, Delaware, D.C., Hawaii, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, New Mexico, New York, North Dakota, Oregon, Rhode Island, Vermont, Washington, West Virginia

The following states have said no to the Medicaid expansion.

Alabama, Alaska, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Mississippi, Missouri, Montana, Nebraska, New Hampshire, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, Wyoming

I wish there was a way to tell readers exactly what to expect for their situation but that just can’t be done because there are so many variables.  Medicaid is a complex and often difficult to understand program.  If you are curious about your eligibility the best we can do is to refer you to links for more information but at least you won’t have to spend time searching for them, we’ve done that for you.  Once you begin your search though, be sure you have plenty of time and hot coffee because you will be doing a bit of studying.

National Public Radio has done a tremendous job of sorting out questions and answers about Medicaid.  Here’s just one of their many “Explainers.”

FAQ: Where Medicaid’s Reach Has Expanded — And Where It Hasn’t

October 11, 2013 3:00 PM

This is one of several explainers to help consumers navigate their health insurance choices under the Affordable Care Act, or as some call it, nprObamacare.  For answers to other common questions you can click here Have a question we missed? Send it to  We may use it in a future on-air or online segment.

Could I be eligible for Medicaid now?

The Affordable Care Act greatly expanded the number of people who qualify for Medicaid, the state-run health insurance program for people with low incomes. Previously, it was difficult for anyone other than pregnant women, parents and children to qualify. The law expands eligibility in ways that will allow many more people, including single and childless men or women, to qualify.

How do I know if I’m eligible for Medicaid?

The law extends eligibility to all adults under the age of 65 whose modified adjusted gross incomes fall below just under $16,000 for individuals and $32,500 for a family of four.

In states that decided not to participate in the Medicaid expansion, the rules are different and vary from state to state. About half of the states opted out of the Medicaid expansion, which is something that the U.S. Supreme Court gave them permission to do. In those states, the income cutoff to be eligible for Medicaid is generally much lower than what was set in the Affordable Care Act, so fewer people will qualify. And if you’re a childless adult, you’re most likely not eligible in states that rejected the Medicaid expansion.

To find out the income cutoff in your state, you can check out the tables here

Or, just try signing up for coverage at your health insurance exchange. The exchange will calculate if you are eligible for Medicaid in your state, and if you are, direct you to the proper state agency to get signed up.

What if my state didn’t expand Medicaid?

If your income is too high to qualify for Medicaid under your state’s rules, you can still try enrolling at an insurance exchange. You may not qualify for subsidies, though. The subsidies are for people whose income falls between 100 percent of the ($11,490 for an individual) and 400 percent ($45,960).

If you make too much to qualify for Medicaid but too little to qualify for subsidies on the exchange, then you are exempted from the new mandate to carry health insurance.

If that’s your situation — you’re poor and still have no health insurance — you can still seek health care with other safety net providers, such as federal community health centers and free clinics run by local nonprofits.

If I am sick and unable to work and have no income, can I get a plan on an exchange for free?

If you are disabled and have no income, you most likely won’t be shopping for insurance on the exchanges. Rather, you may qualify for Medicaid. In , if you qualify to collect Supplemental Security Income, or SSI, you also qualify for Medicaid. For more information on Medicaid eligibility and links to your state’s Medicaid office, click here

See other Frequently Asked Questions on Medicaid and the Affordable Care Act:

While I would very much like to be able to provide details about every state’s Medicaid program neither time nor space allow for that undertaking.  I will, by way of this post, try to provide some general guidelines but it will be up to you to determine exactly what your state offers.

Although the federal government sets up general guidelines, each state runs its own Medicaid program. States establish what health care services are covered and which groups of people get coverage. As a result, Medicaid programs vary a great deal from state to state.

Keep in mind, too, that even if you can’t get Medicaid benefits, your child still may be eligible.

More Frequently Asked Questions About Medicaid

Q.        How Much Do Medicaid Programs Cost?

A.        The cost of a Medicaid program depends on the state. Some programs require you to make a small co-payment for medical services in addition to what Medicaid pays.

Q.        What Does Medicaid Cover?

A.        In general, Medicaid programs offer more comprehensive medical coverage than Medicare. They usually include hospital stays, visits to doctors, tests, some home medical care, and more. Again, the specifics vary from state to state.

Q.        What Else Do I Need to Know About Medicaid?

A.        Some people qualify for both Medicare and Medicaid programs. They are called “dual eligibles.” In these cases, Medicaid may pay some of your Medicare fees.

  • If you qualify for both Medicare and Medicaid and enroll in a Medicare Prescription Drug Plan, you are eligible for help in paying your drug plan’s monthly premium, deductible, and co-pays.

To learn more about Medicaid programs, visit the U.S. government’s Centers for Medicare and Medicaid Services (CMS) web site. 

Fiscal Impact of the Medicaid Expansion on State Budgets

Medicaid as of September 4, 2013 The Supreme Court ’s decision on National Federation of Independent Business et al v. Sebelius1 upheld all provisions of the Affordable Care Act (ACA) including the individual responsibility requirement, health insurance exchanges and subsidies, and the Medicaid expansion. However, the Court restricted the federal government’s ability to withhold federal Medicaid funds if a state

Emphasis on Primary Care and on Primary Care Physicians

The Affordable Care Act emphasizes primary care and seeks to increase the number of primary care physicians willing to provide services to Medicaid patients. To that end, Medicaid payments to primary care physicians will increase to 100 percent of the Medicare payment rates for the years 2013 and 2014. Current payment rates for primary care physicians under Medicaid vary markedly from state to state, but on average they are 66 percent of Medicare reimbursement rates.

Physicians who will be receiving the higher rates are those engaged in family practice, general internal medicine and pediatric medicine. As with the cost of making more individuals eligible for Medicaid, the federal government will pay 100 percent of the added costs for payments to primary care physicians. Payment rates after 2014, and the division of responsibility between the federal and state governments to pay them, has not been determined.

Additional Information Resources

Bob Aronson of Bob’s Newheart is a 2007 heart transplant recipient, the founder of Facebook’s nearly 3,000 member Organ Transplant Initiative and the author of most of these donation/transplantation blogs.

You may comment in the space provided or email your thoughts to me at And – please spread the word about the immediate need for more organ donors. There is nothing you can do that is of greater importance. If you convince one person to be an organ and tissue donor you may save or positively affect over 60 lives. Some of those lives may be people you know and love.

Please view our new music video “Dawn Anita The Gift of Life” on YouTube  This video is free to anyone who wants to use it and no permission is needed. 

If you want to spread the word personally about organ donation, we have another PowerPoint slide show for your use free and without permission. Just email me and ask for a copy of “Life, Pass it on.“  This is NOT a stand-alone show; it needs a presenter but is professionally produced and factually sound. If you decide to use the show I will send you a free copy of my e-book, “How to Get a Standing “O” that will help you with presentation skills. 

Also…there is more information on this blog site about other donation/transplantation issues. Additionally we would love to have you join our Facebook group, Organ Transplant Initiative The more members we get the greater our clout with decision makers.

Are Elected Officials in Bed with the Dialysis Industry?

People who are diagnosed as needing organ transplants are end-stage patients.  That means medical science has run out of alternatives to extend life and a transplant is the last and most beneficial approach.  Transplants are not cures but they can offer a considerable extension of life provided the patient adheres to the program and has on-going, expert medical care.

At least twice very day a transplant recipient must take the daily dose of anti-rejection drugs.  They are effective but expensive.  They can run as high as $1,500 a month and if you quit taking them you can and likely will die.  If you are of retirement age or disabled your Kidney transplant is covered by Medicare and most of the cost of the drugs as well.  If you are under 65 and not disabled and diagnosed with End Stage Renal Disease (ESRD) your kidney transplant will still be covered by Medicare but your anti-rejection drugs will only be covered for 36 months and then you are on your own (detailed explanation below).

If after 36 months you go into rejection because you can’t afford the meds, Medicare will pay for dialysis and even pay for another transplant but not for the drugs which would prevent needing either.  The drugs would be a fraction of the cost of the two alternatives that are covered.  At best that is just plain dumb!

Someone said a long time ago that, “If you like either sausage or the law, you should watch neither being made.”  Well, that certainly applies to this issue.  Another of my favorite expressions which also applies here is, “No one’s life, liberty or property are safe when the legislature is in session.”  These two expressions apply perfectly to the anti-rejection medicine silliness.

The entire situation and what to do about it is explained below.

The Current State Of Access to Post transplant Care


Christine S. Rizk, JD, and Sanjiv N. Singh, MD, JD

Virtual Mentor. March 2012, Volume 14, Number 3: 250-255. American Medical Association

This article provides historical perspective on the evolution of coverage for kidney transplant patients and attempts to identify what initiatives would most effectively and efficiently improve their survival.

As of January 24, 2012, in the United States, there were 112,767 waitlist candidates on the various national transplant registries [2]. Of those candidates, 90,563 were waiting for kidneys, but in 2011 only 13,430 kidney transplants were performed [3]. The need for kidneys far outweighs the availability of suitable donor organs, and some postulate that the Patient Protection and Affordable Care Act of 2010 (ACA) may worsen the shortage by eliminating barriers to insurance coverage based on preexisting conditions, lifetime coverage caps, and required periods of pretransplant dialysis [4].

Even more critical from a clinical, economic, and moral perspective is the fact that the additional end-stage renal disease (ESRD) patients now expected to receive transplants by 2014 will be most vulnerable in the posttransplant phase of care. Coverage for pre transplant dialysis and maintenance drugs for ESRD, but not post transplant care, receives strong support in Washington from large dialysis and pharmaceutical companies, which derive significant profits from dialysis, ESRD drugs, and dialysis-related services [5]. For ESRD patients, dialysis is covered by Medicare for life [6].

For posttransplant care, however, Medicare coverage is limited, providing only 80 percent of the cost of immunosuppressive medications for 36 months after transplantation (for those whose Medicare entitlement is based on ESRD) and no coverage thereafter. Despite the fact that effective and long-term immunosuppression is essential for survival of transplant patients [7], the vast majority are left to fund 20 percent of the cost for the first 3 years of immunosuppressive drugs ($13,000 to $15,000 total cost per year per patient) [8], and, for patients under 65 who are not disabled, all of the cost of immunosuppressive drugs thereafter [9].

Not surprisingly, this system leads to noncompliance. Many patients cope with the financial burden by “spreading out” their anti-rejection drugs, taking them less often or not at all [10, 11]. A recent meta-analysis reports that “about 22.6 of 100 adult transplant patients per year fail to take anti-rejection drugs” [12]. If allograft failure occurs due to nonadherence or a patient is considered unable to pay for posttransplant costs, with few exceptions, she is typically not relisted [13, 14]. According to a study focusing on medication nonadherence among transplant patients, nonadherence was more prevalent among kidney recipients than among recipients of other organs and more prevalent in the United States than in Europe [12].

Legislative History

Congress has continually struggled with the tension between supporting low-income patients and controlling the costs of government-funded health care. The legislative history of renal-transplant drug coverage highlights this struggle.

The Social Security Act Amendments of 1965, which created Medicare and Medicaid, initiated medical insurance for seniors, families with dependent children, the blind, and the disabled [15]. At the SSA’s inception, Medicare provided for prescription drugs that were administered in the physician’s office but did not provide coverage for outpatient prescription drugs [14].

In 1972, on the eve of President Richard Nixon’s reelection, after much debate and political pressure to expand health care insurance, amendments were passed that provided increased coverage in specific areas. They specifically designated chronic kidney disease patients “disabled” for the purpose of receiving Medicare coverage but only after at least 3 months of dialysis and only for 12 months after transplantation [16].

Undoubtedly, these amendments were the original and now obviously outdated roots of the notion that posttransplant care benefits should be time-limited. At the time, such a notion was defensible. Dialysis was then a cost-effective and, more importantly, still superior way to extend lives, while kidney transplantation was a risky medical procedure on the frontier of available therapies. In the decades that would follow, however, renal transplantation outpaced dialysis in mortality reduction and overall clinical outcomes [17]. Meanwhile, the number of eligible patients who used dialysis far exceeded expectations, and the ESRD entitlement became quite costly [14].

In the last 3 decades, the dialysis entitlement has remained largely intact while posttransplant entitlements have waxed and waned in small stutters.

  • As a response to the increased costs of dialysis, Congress passed an amendment in 1978 extending Medicare posttransplant coverage from 1 year to 3 years; however, this amendment did not cover the cost of outpatient immunosuppressive medications [14].
  • In 1984, Congress passed the National Organ Transplant Act of 1984 to ban the sale of organs [18]; extended coverage for immunosuppressive drugs was considered but ultimately left out of the bill, mostly due to funding concerns and political bargaining [14].
  • Posttransplant drug coverage gained some traction in the Omnibus Budget Reconciliation Act of 1987 which included Medicare coverage of 80 percent of a kidney transplant recipient’s immunosuppressive drug costs (including outpatient immunosuppressive prescription drugs) for 1 year after transplant [14, 19]. This was eventually extended, in 1997, to cover 36 months of immunosuppressive drug costs [9].
  • In 2000, Congress extended Medicare coverage of immunosuppressive drug costs to the life of the patient, but only for those who are disabled or over 65. This often leaves those patients most at risk for nonadherence and noncompliance—i.e., younger kidney recipients under 65—uninsured after 3 years [14].

Despite decades of legislative history and clinical data revealing the obvious gaps in posttransplant care entitlements, extending the duration of coverage for immunosuppressive-drug costs was not included in the ACA. In a provocative piece published in 2010 in the Clinical Journal of the American Society of Nephrology, Cohen and colleagues assert that “in response to pressure from the corporate dialysis community and their kidney coalition, several members of Congress acted to prevent the patient immunosuppressive provision from being included in the final health care reform package. Some of these opposing voices on Capitol Hill have been generously supported by the large dialysis providers for years” [5].

It is theoretically possible that the ACA’s insurance exchanges will include lifetime coverage for immunosuppressive drugs. These exchanges will not be implemented until 2014, however. Moreover, it is not clear exactly what type of coverage will be offered and whether such lifetime coverage will be offered in the lower-priced options, where it is most needed [9].

Cost Savings for the Federal Government

Continuing the current limitations on coverage of posttransplant medications is actually costing the health care system more money in the long term. Studies have shown that it is less costly to continue covering the cost of immunosuppressive drugs for kidney transplant patients after 36 months than it is to cover the costs of resuming dialysis for the same population. For example, a University of Maryland study concluded that it was more cost-effective to continue covering immunosuppressive drugs than it was to pay for dialysis, finding that “the breakeven point was 2.7 years for all of the cases [it] analyzed and for 30 percent of all patients who did not need to be readmitted to the hospital during the year after their transplant, the breakeven point was only 1.7 years” [10]. A study conducted by the Institute of Medicine (IOM) also concluded that lifetime coverage of immunosuppressive drugs would lead to cost savings because it would reduce nonadherence and thereby improve kidney allograft survival, reducing long-term reliance on dialysis [12].

Current Legislation

The Comprehensive Immunosuppressive Drug Coverage for Kidney Transplants Patients Act of 2011, currently pending in committee in both the House and the Senate, would extend coverage of immunosuppressive drugs for kidney transplant patients for the lifetime of the kidney [20, 21]. The bill is bicameral, bipartisan, and supported by the transplant community [22]. As noted by Cohen et al, however, similar attempts have failed in the past, most recently with the proposed Durbin amendment to the ACA [5]. Similar attempts by Congress in 2003 and 2007 to extend lifetime immunosuppressive coverage also failed in the wake of funding concerns and political jockeying [14].


Extending immunosuppressive drug coverage for the lifetime of kidney patients is a cost-effective way for the federal government to increase the value of health care by improving clinical outcomes for those with ESRD while avoiding the costs of resuming dialysis and allograft failure. Low-income kidney transplant patients currently suffer heavy financial burdens and are denied access to transplant relisting because of their inability to pay for critical drugs. There is a clinical, economic, and moral imperative to, at long last, bridge this coverage gap—a gap that lies at the core of effective transplant care and detracts from the movement for comprehensive coverage begun by the Affordable Care Act.

Transplant Living  suggests you contact your Senators and Congressional Representatives to urge their support of the measure that would extend anti-rejection medication coverage from 36 months to lifetime.

Sample language

Dear Representative :

I am contacting you to request that you cosponsor important legislation for chronic kidney disease patients. H.R. 2969, the “Comprehensive Immunosuppressive Drug Coverage for Kidney Transplant Patients Act of 2011,” was introduced by Representatives Burgess and Kind to help kidney transplant recipients obtain the life-saving immunosuppressive medications that are necessary to maintain the viability of their new kidney.

Individuals with chronic kidney failure require kidney dialysis or a transplant to survive, and are eligible for Medicare regardless of age or other disability. There is no time limit on Medicare coverage for dialysis patients. However, transplant recipients who are not aged or disabled retain Medicare eligibility only for 36 months following their transplant. After their Medicare ends, they often face the challenge of obtaining group health insurance or other coverage, greatly increasing the risk of organ rejection if they cannot afford their required medications. If the transplanted kidney fails, they return to dialysis or receive another transplant, both of which are more costly (Medicare spends more than $77,000 annually on a dialysis patient and about $19,100 per year for a kidney transplant recipient, after the year of the transplant).

H.R. 2969 would extend Medicare Part B eligibility, and only for immunosuppressive medications. Coverage for any other health needs would end 36 months after the transplant, as under current law. The legislation also requires group health plans to maintain coverage of immunosuppressive drugs if they presently include such a benefit in their coverage. Lifetime immunosuppressive coverage will improve long term transplant outcomes, enable more kidney patients who lack adequate insurance to consider transplantation, and reduce the number of kidney patients who require another transplant. Nobody should lose a transplant because they are not able to pay for the drugs to maintain it. On behalf of thousands of transplant recipients, I respectfully request your support of this legislation.



Bob Aronson of Bob’s Newheart is a 2007 heart transplant recipient, the founder of Facebook’s nearly 2,500 member Organ Transplant Initiative and the author of most of these donation/transplantation blogs.

You may comment in the space provided or email your thoughts to me at And – please spread the word about the immediate need for more organ donors. There is nothing you can do that is of greater importance. If you convince one person to be an organ and tissue donor you may save or positively affect over 60 lives. Some of those lives may be people you know and love.

Please view our video “Thank You From the Bottom of my Donor’s heart” on This video was produced to promote organ donation so it is free and no permission is needed for its use.

If you want to spread the word personally about organ donation, we have another PowerPoint slide show for your use free and without permission. Just go to and click on “Life Pass It On” on the left side of the screen and then just follow the directions. This is NOT a stand-alone show; it needs a presenter but is professionally produced and factually sound. If you decide to use the show I will send you a free copy of my e-book, “How to Get a Standing “O” that will help you with presentation skills. Just write to and usually you will get a copy the same day.

Also…there is more information on this blog site about other donation/transplantation issues. Additionally we would love to have you join our Facebook group, Organ Transplant Initiative The more members we get the greater our clout with decision makers.

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