This is the accessible text file for GAO report number GAO-13-177R entitled 'Medicaid: Enrollment and Expenditures for Qualified Individual and Transitional Medical Assistance Programs' which was released on January 11, 2012. This text file was formatted by the U.S. Government Accountability Office (GAO) to be accessible to users with visual impairments, as part of a longer term project to improve GAO products' accessibility. Every attempt has been made to maintain the structural and data integrity of the original printed product. Accessibility features, such as text descriptions of tables, consecutively numbered footnotes placed at the end of the file, and the text of agency comment letters, are provided but may not exactly duplicate the presentation or format of the printed version. The portable document format (PDF) file is an exact electronic replica of the printed version. We welcome your feedback. Please E-mail your comments regarding the contents or accessibility features of this document to Webmaster@gao.gov. This is a work of the U.S. government and is not subject to copyright protection in the United States. It may be reproduced and distributed in its entirety without further permission from GAO. Because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. GAO-13-177R: United States Government Accountability Office: Washington, DC 20548: December 12, 2012: The Honorable Orrin G. Hatch: Ranking Member: Committee on Finance: United States Senate: The Honorable Joseph R. Pitts: Chairman: Subcommittee on Health: Committee on Energy and Commerce: House of Representatives: Subject: Medicaid: Enrollment and Expenditures for Qualified Individual and Transitional Medical Assistance Programs: Qualified Individual (QI) and Transitional Medical Assistance (TMA) are particular programs within Medicaid that are targeted to specific groups of low-income individuals.[Footnote 1] The QI program provides assistance to certain low-income Medicare beneficiaries by paying for their Medicare Part B premiums and is due to expire on December 31, 2012.[Footnote 2] The TMA program offers up to 1 year of additional Medicaid health insurance benefits for certain low-income families who would otherwise lose coverage. Under permanent provisions of the Social Security Act (SSA), Medicaid coverage continues for 4 months for families who would otherwise lose coverage due to an increase in earned income or hours of employment or increased child or spousal support.[Footnote 3] In addition, under a provision expiring on December 31, 2012, families who would otherwise lose Medicaid eligibility because of earned income or hours of employment, or the loss of a time-limited earnings disregard, receive at least 6, and up to 12, months of Medicaid coverage.[Footnote 4] In light of the approaching expiration of the QI program and certain TMA provisions, you asked us to provide more information on the programs' enrollment and expenditures to inform consideration of reauthorization. This report provides information about enrollment and expenditures in both the QI and TMA programs at the national and state levels. To obtain this information, we reviewed relevant legislation and policy guidance issued by the Department of Health and Human Services (HHS), and interviewed officials from the Centers for Medicare & Medicaid Services (CMS)--the agency within HHS that administers the Medicaid program. For information on the QI program, we also examined data from CMS's Medicaid Statistical Information System (MSIS), [Footnote 5] the CMS-64 data set,[Footnote 6] and data published by CMS on the number of individuals potentially eligible for QI. For enrollment, we analyzed data from fiscal years 2006 through 2009, the most recent year of complete data available in MSIS. For expenditures, we analyzed CMS-64 data from fiscal years 2006 through 2011, the most recent year of data available. For the number of potential QI eligibles, we used CMS's annual estimates based on Census data for fiscal years 2006 through 2011.[Footnote 7] According to CMS, the annual estimates of potential QI eligibles are overstated because they do not take into account certain eligibility requirements for QI, such as resource limits. In order to assess the reliability of the data we analyzed, we reviewed relevant guidance and documentation, including CMS forms and data dictionaries, and interviewed CMS officials familiar with Medicaid data. We also reviewed the data for reasonableness and consistency, including screening for missing data, outliers, and obvious errors. We determined that these data were sufficiently reliable for our purposes. For the TMA programs, we sent an electronic survey to the Medicaid Director or his or her designated staff in all 50 states and the District of Columbia to obtain key information about TMA program design, enrollment, and expenditures beginning in 2006 through the most recent year available.[Footnote 8] Where necessary, we followed up with states by email and telephone and ultimately received responses from 45 states. Some states were not able to provide the information we requested, or were not able to provide the information within the timeframes of our work.[Footnote 9] We conducted this performance audit from October 2012 to November 2012 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. In summary, the QI program enrolled about 426,000 individuals nationwide in 2009--the most recent year for which comprehensive enrollment data were available--with expenditures of about $431 million. While QI enrollment increased 30 percent from fiscal year 2006 to fiscal year 2009, program expenditures increased at a slightly faster rate, rising 39 percent during this time.[Footnote 10] On average, one quarter of individuals potentially eligible for the QI program were enrolled during fiscal years 2006 through 2009.[Footnote 11] However, the percentage of eligible individuals enrolled in the program climbed from 21 percent in fiscal year 2006 to 29 percent in fiscal year 2009. CMS does not have comprehensive national data on TMA enrollment and expenditures; the 41 states that had enrollment data reported that over 3.5 million individuals were enrolled in TMA in 2011, the most recent year for which complete enrollment data were reported by the highest number of states.[Footnote 12] Fewer states were able to report TMA expenditure data; however, 32 states reported TMA total expenditures of about $3.9 billion in 2011.[Footnote 13] The enclosures provide more specific information on the QI and TMA programs. Enclosure I summarizes national and state information on QI eligibility, enrollment, and expenditures. Enclosure II provides general information on TMA requirements and state-reported information on certain program features, enrollment, and expenditures. Agency Comments: CMS provided us with technical comments, which we incorporated as appropriate. As arranged with your offices, unless you publicly announce the contents of this report earlier, we plan no further distribution of it until 30 days after its issue date. Copies will then be sent to the Administrator of CMS and other interested parties. In addition, the report will be available at no charge on the GAO website at [hyperlink, http://www.gao.gov]. If you or your staff have any questions about this report, please contact me at (202) 512-7114 or yocomc@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. Major contributors to this report were Susan Anthony, Assistant Director; Hannah Locke; JoAnn Martinez- Shriver; and Samantha Poppe. Signed by: Carolyn L. Yocom: Director, Health Care: Enclosures - 2: [End of section] Enclosure I: Summary of Qualified Individual (QI) Program Enrollment and Expenditures: Since 1998, Medicaid has paid for the Medicare Part B premiums for certain low-income individuals who are not otherwise eligible for Medicaid under the Qualified Individual (QI) program. To be eligible for QI, an individual must be entitled to Medicare Part A, have income of at least 120 percent but less than 135 percent of the federal poverty level (FPL), and have resources valued at or below certain thresholds.[Footnote 14] The amount of federal funding available for this program is limited. The Centers for Medicare & Medicaid Services (CMS) makes allocations to states using a formula that takes into account the number of individuals potentially eligible to enroll in QI in each state. States receive 100 percent federal funding to pay Part B premiums for individuals enrolled in QI to the extent that federal funding does not exceed their allocations. While CMS adjusts funding as needed based on states' projections of their enrollment and expenditures, states must limit enrollment in the QI program so that their spending does not exceed the amount of federal funds allocated to them. Table 1 provides nationwide data on the estimated number of QI eligibles, the number of enrolled individuals, and reported expenditures. Table 2 provides state-specific information on QI enrollment for fiscal years 2006 through 2009. Table 3 provides expenditure information by state for fiscal years 2006 through 2011, the most recent year of expenditure data available. Table 1: Nationwide Qualified Individual (QI) Program Eligibles, Enrollment, and Expenditures: Fiscal year: 2006; Potentially eligible individuals[A]: 1,521,000; Enrolled individuals[B]: 326,000; Percentage enrolled[B]: 21%; Expenditures: $310 million. Fiscal year: 2007; Potentially eligible individuals[A]: 1,518,000; Enrolled individuals[B]: 358,000; Percentage enrolled[B]: 24%; Expenditures: $353 million. Fiscal year: 2008; Potentially eligible individuals[A]: 1,428,000; Enrolled individuals[B]: 381,000; Percentage enrolled[B]: 27%; Expenditures: $411 million. Fiscal year: 2009; Potentially eligible individuals[A]: 1,473,000; Enrolled individuals[B]: 426,000; Percentage enrolled[B]: 29%; Expenditures: $431 million. Fiscal year: 2010; Potentially eligible individuals[A]: 1,446,000; Enrolled individuals[B]: [Empty]; Percentage enrolled[B]: [Empty]; Expenditures: $547 million. Fiscal year: 2011; Potentially eligible individuals[A]: 1,453,000; Enrolled individuals[B]: [Empty]; Percentage enrolled[B]: [Empty]; Expenditures: $660 million. Source: GAO analysis of CMS data. [A] CMS estimates the number of potential QI eligibles using Census data on the number of Medicare beneficiaries who are not enrolled in Medicaid whose incomes are at least 120 percent but less than 135 percent of the federal poverty level. The number of potentially eligible individuals is based on the average of the 3 preceding years; for example, 2006 is based on an average of the number of potential eligibles for 2003 through 2005. According to CMS, the annual estimates of potential QI eligibles are overstated because they do not take into consideration certain eligibility requirements, such as resource limits. [B] [Empty] indicates that data were not available for a particular year. As of October 2012, only 40 states had data in the Medicaid Statistical Information System for fiscal year 2010, and no fiscal year 2011 data were available. [End of table] Table 2: Enrollment in the Qualified Individual (QI) Program by State, Fiscal Years 2006 through 2009: Number of individuals: State: Alabama; Fiscal year: 2006: 14,985; 2007: 16,029; 2008: 16,272; 2009: 14,128. State: Alaska; Fiscal year: 2006: 75; 2007: 103; 2008: 110; 2009: 115. State: Arizona; Fiscal year: 2006: 1,234; 2007: 9,790; 2008: 11,090; 2009: 13,200. State: Arkansas; Fiscal year: 2006: 1,918; 2007: 6,258; 2008: 7,870; 2009: 8,858. State: California; Fiscal year: 2006: 7,314; 2007: 10,043; 2008: 12,132; 2009: 13,779. State: Colorado; Fiscal year: 2006: 2,306; 2007: 2,022; 2008: 2,315; 2009: 2,574. State: Connecticut; Fiscal year: 2006: 7,120; 2007: 7,974; 2008: 8,777; 2009: 9,444. State: Delaware; Fiscal year: 2006: 1,670; 2007: 1,657; 2008: 1,761; 2009: 1,912. State: District of Columbia[A]; Fiscal year: 2006: N/A; 2007: N/A; 2008: N/A; 2009: N/A. State: Florida; Fiscal year: 2006: 35,727; 2007: 34,784; 2008: 39,090; 2009: 46,320. State: Georgia; Fiscal year: 2006: 17,297; 2007: 18,577; 2008: 20,027; 2009: 23,237. State: Hawaii; Fiscal year: 2006: 620; 2007: 615; 2008: 773; 2009: 987. State: Idaho; Fiscal year: 2006: 1,190; 2007: 1,290; 2008: 1,399; 2009: 1,548. State: Illinois; Fiscal year: 2006: 14,504; 2007: 11,835; 2008: 12,702; 2009: 12,892. State: Indiana; Fiscal year: 2006: 6,896; 2007: 7,050; 2008: 6,924; 2009: 6,538. State: Iowa; Fiscal year: 2006: 2,249; 2007: 2,447; 2008: 2,591; 2009: 2,814. State: Kansas; Fiscal year: 2006: 1,946; 2007: 2,277; 2008: 2,585; 2009: 2,972. State: Kentucky; Fiscal year: 2006: 8,695; 2007: 8,678; 2008: 9,450; 2009: 10,762. State: Louisiana; Fiscal year: 2006: 11,311; 2007: 12,861; 2008: 12,897; 2009: 14,103. State: Maine; Fiscal year: 2006: 5,691; 2007: 2,226; 2008: 3,097; 2009: 4,444. State: Maryland; Fiscal year: 2006: 3,615; 2007: 4,086; 2008: 4,428; 2009: 5,211. State: Massachusetts; Fiscal year: 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: 7,332. State: Michigan; Fiscal year: 2006: 8,460; 2007: 9,746; 2008: 10,126; 2009: 10,557. State: Minnesota; Fiscal year: 2006: 3,453; 2007: 3,509; 2008: 3,859; 2009: 4,470. State: Mississippi; Fiscal year: 2006: 9,982; 2007: 9,983; 2008: 9,789; 2009: 11,181. State: Missouri; Fiscal year: 2006: 330; 2007: 253; 2008: 280; 2009: 425. State: Montana; Fiscal year: 2006: 313; 2007: 365; 2008: 443; 2009: 516. State: Nebraska; Fiscal year: 2006: 2,145; 2007: 2,519; 2008: 2,476; 2009: 3,013. State: Nevada; Fiscal year: 2006: 2,648; 2007: 2,671; 2008: 2,961; 2009: 3,305. State: New Hampshire; Fiscal year: 2006: 917; 2007: 990; 2008: 1,164; 2009: 1,536. State: New Jersey; Fiscal year: 2006: 8,638; 2007: 8,408; 2008: 8,053; 2009: 7,686. State: New Mexico; Fiscal year: 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: 188. State: New York; Fiscal year: 2006: 33,273; 2007: 35,186; 2008: 32,483; 2009: 30,887. State: North Carolina; Fiscal year: 2006: 17,121; 2007: 18,674; 2008: 19,592; 2009: 21,939. State: North Dakota; Fiscal year: 2006: 413; 2007: 452; 2008: 485; 2009: 592. State: Ohio; Fiscal year: 2006: 10,277; 2007: 12,993; 2008: 14,485; 2009: 17,020. State: Oklahoma; Fiscal year: 2006: 6,165; 2007: 6,557; 2008: 6,950; 2009: 7,583. State: Oregon; Fiscal year: 2006: 3,385; 2007: 4,293; 2008: 4,840; 2009: 6,312. State: Pennsylvania; Fiscal year: 2006: 19,346; 2007: 20,562; 2008: 21,227; 2009: 23,392. State: Rhode Island; Fiscal year: 2006: 1,898; 2007: 1,809; 2008: 1,943; 2009: 2,072. State: South Carolina; Fiscal year: 2006: 7,329; 2007: 8,183; 2008: 7,156; 2009: 7,243. State: South Dakota; Fiscal year: 2006: 857; 2007: 952; 2008: 1,031; 2009: 1,163. State: Tennessee; Fiscal year: 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]. State: Texas; Fiscal year: 2006: 24,701; 2007: 28,005; 2008: 29,690; 2009: 32,882. State: Utah; Fiscal year: 2006: [Empty]; 2007: 1,041; 2008: 966; 2009: 1,038. State: Vermont; Fiscal year: 2006: [Empty]; 2007: [Empty]; 2008: 2,949; 2009: 2,749. State: Virginia; Fiscal year: 2006: 7,002; 2007: 7,815; 2008: 8,334; 2009: 9,444. State: Washington; Fiscal year: 2006: 5,449; 2007: 5,347; 2008: 5,835; 2009: 6,334. State: West Virginia; Fiscal year: 2006: 3,529; 2007: 4,129; 2008: 4,442; 2009: 5,137. State: Wisconsin; Fiscal year: 2006: 1,642; 2007: 2,045; 2008: 2,572; 2009: 3,097. State: Wyoming; Fiscal year: 2006: 494; 2007: 496; 2008: 504; 2009: 612. State: Total; Fiscal year: 2006: 326,130; 2007: 357,585; 2008: 380,925; 2009: 425,543. Legend: N/A = Not Applicable: Source: GAO analysis of CMS data. Notes: [Empty] indicates that data were not available for a particular year. [A] The District of Columbia does not participate in QI because its Medicaid policies result in all applicants in the QI income range qualifying for a higher level of benefits. [End of table] Table 3: Federal Medicaid Expenditures for the Qualified Individual (QI) Program by State, Fiscal Years 2006 through 2011: State: Alabama; Fiscal year: 2006: $31,171,000; 2007: $16,622,000; 2008: $17,498,000; 2009: $16,475,000; 2010: $14,657,000; 2011: $21,009,000. State: Alaska; Fiscal year: 2006: $41,000; 2007: $106,000; 2008: $109,000; 2009: $97,000; 2010: $27,000; 2011: $316,000. State: Arizona; Fiscal year: 2006: $10,321,000; 2007: $11,467,000; 2008: $11,953,000; 2009: $12,726,000; 2010: $15,482,000; 2011: $17,334,000. State: Arkansas; Fiscal year: 2006: $4,657,000; 2007: $6,194,000; 2008: $7,043,000; 2009: $9,142,000; 2010: $11,487,000; 2011: $13,231,000. State: California; Fiscal year: 2006: $11,336,000; 2007: $12,981,000; 2008: $17,832,000; 2009: $21,745,000; 2010: $27,636,000; 2011: $28,552,000. State: Colorado; Fiscal year: 2006: $1,859,000; 2007: $2,436,000; 2008: $2,568,000; 2009: $2,981,000; 2010: $4,146,000; 2011: $5,305,000. State: Connecticut; Fiscal year: 2006: $6,716,000; 2007: $7,838,000; 2008: $9,212,000; 2009: $10,044,000; 2010: $3,883,000; 2011: $4,522,000. State: Delaware; Fiscal year: 2006: $262,000; 2007: $254,000; 2008: $246,000; 2009: $625,000; 2010: $2,092,000; 2011: $3,378,000. State: District of Columbia[A]; Fiscal year: 2006: N/A; 2007: N/A; 2008: N/A; 2009: N/A; 2010: N/A; 2011: N/A. State: Florida; Fiscal year: 2006: $26,485,000; 2007: $30,147,000; 2008: $32,802,000; 2009: $35,566,000; 2010: $55,327,000; 2011: $63,834,000. State: Georgia; Fiscal year: 2006: $17,646,000; 2007: $17,464,000; 2008: $20,268,000; 2009: $22,582,000; 2010: $27,648,000; 2011: $23,502,000. State: Hawaii; Fiscal year: 2006: [Empty]; 2007: $483,000; 2008: $839,000; 2009: $767,000; 2010: $1,031,000; 2011: $1,286,000. State: Idaho; Fiscal year: 2006: $1,104,000; 2007: $1,364,000; 2008: $1,528,000; 2009: $1,660,000; 2010: $1,825,000; 2011: $2,339,000. State: Illinois; Fiscal year: 2006: $12,844,000; 2007: $14,558,000; 2008: $16,639,000; 2009: $16,113,000; 2010: $20,843,000; 2011: $23,813,000. State: Indiana; Fiscal year: 2006: $5,960,000; 2007: $4,565,000; 2008: $8,559,000; 2009: $4,839,000; 2010: $5,852,000; 2011: $7,283,000. State: Iowa; Fiscal year: 2006: $2,118,000; 2007: $2,478,000; 2008: $2,675,000; 2009: $2,762,000; 2010: $3,348,000; 2011: $4,241,000. State: Kansas; Fiscal year: 2006: $1,435,000; 2007: $1,871,000; 2008: $2,423,000; 2009: $2,750,000; 2010: $3,386,000; 2011: $4,443,000. State: Kentucky; Fiscal year: 2006: $172,000; 2007: $14,917,000; 2008: $9,131,000; 2009: $10,371,000; 2010: $13,459,000; 2011: $15,761,000. State: Louisiana; Fiscal year: 2006: $10,031,000; 2007: $11,438,000; 2008: $13,478,000; 2009: $14,377,000; 2010: $17,320,000; 2011: $20,326,000. State: Maine; Fiscal year: 2006: $3,695,000; 2007: $3,748,000; 2008: $2,494,000; 2009: $3,469,000; 2010: $4,847,000; 2011: $5,649,000. State: Maryland; Fiscal year: 2006: $2,793,000; 2007: $3,556,000; 2008: $4,088,000; 2009: $4,590,000; 2010: $5,883,000; 2011: $7,488,000. State: Massachusetts; Fiscal year: 2006: $3,307,000; 2007: $3,199,000; 2008: $10,231,000; 2009: $7,957,000; 2010: $8,840,000; 2011: $10,784,000. State: Michigan; Fiscal year: 2006: $6,966,000; 2007: $8,537,000; 2008: $10,242,000; 2009: $9,944,000; 2010: $10,854,000; 2011: $15,010,000. State: Minnesota; Fiscal year: 2006: $2,811,000; 2007: $3,585,000; 2008: $3,870,000; 2009: $4,247,000; 2010: $5,261,000; 2011: $6,228,000. State: Mississippi; Fiscal year: 2006: [Empty]; 2007: [Empty]; 2008: $22,307,000; 2009: $10,642,000; 2010: $12,574,000; 2011: $14,834,000. State: Missouri; Fiscal year: 2006: $2,378,000; 2007: $3,319,000; 2008: $4,172,000; 2009: $4,856,000; 2010: $5,870,000; 2011: $5,898,000. State: Montana; Fiscal year: 2006: $560,000; 2007: $787,000; 2008: $643,000; 2009: $1,209,000; 2010: $1,305,000; 2011: $1,591,000. State: Nebraska; Fiscal year: 2006: $1,707,000; 2007: $2,175,000; 2008: $2,289,000; 2009: $2,761,000; 2010: $2,735,000; 2011: $2,489,000. State: Nevada; Fiscal year: 2006: $1,784,000; 2007: $2,187,000; 2008: $2,161,000; 2009: $2,568,000; 2010: $3,396,000; 2011: $4,516,000. State: New Hampshire; Fiscal year: 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: $6,394,000; 2011: $2,306,000. State: New Jersey; Fiscal year: 2006: $8,725; 2007: $9,443; 2008: $9,256; 2009: $8,916; 2010: $9,866; 2011: $10,468. State: New Mexico; Fiscal year: 2006: $1,880,000; 2007: $2,189,000; 2008: $2,577,000; 2009: $2,872,000; 2010: $3,690,000; 2011: $4,368,000. State: New York; Fiscal year: 2006: $32,098,000; 2007: $38,064,000; 2008: $42,222,000; 2009: $35,657,000; 2010: $40,421,000; 2011: $46,178,000. State: North Carolina; Fiscal year: 2006: $14,145,000; 2007: $22,145,000; 2008: $14,352,000; 2009: $20,603,000; 2010: $25,681,000; 2011: $27,744,000. State: North Dakota; Fiscal year: 2006: $343,000; 2007: $443,000; 2008: $467,000; 2009: $540,000; 2010: $658,000; 2011: $724,000. State: Ohio; Fiscal year: 2006: $12,444,000; 2007: $12,783,000; 2008: $18,216,000; 2009: $17,051,000; 2010: $20,903,000; 2011: $25,283,000. State: Oklahoma; Fiscal year: 2006: $5,191,000; 2007: $6,377,000; 2008: $7,189,000; 2009: $7,397,000; 2010: $8,757,000; 2011: $10,469,000. State: Oregon; Fiscal year: 2006: $4,827,000; 2007: $6,759,000; 2008: $7,823,000; 2009: $8,656,000; 2010: $10,785,000; 2011: $12,874,000. State: Pennsylvania; Fiscal year: 2006: $16,312,000; 2007: $19,524,000; 2008: $20,719,000; 2009: $22,568,000; 2010: $26,411,000; 2011: $33,435,000. State: Rhode Island; Fiscal year: 2006: $1,767,000; 2007: $1,550,000; 2008: $1,758,000; 2009: $1,685,000; 2010: $1,829,000; 2011: $3,156,000. State: South Carolina; Fiscal year: 2006: $6,515,000; 2007: $5,121,000; 2008: $8,010,000; 2009: $7,703,000; 2010: $7,520,000; 2011: $10,006,000. State: South Dakota; Fiscal year: 2006: $780,000; 2007: $926,000; 2008: $974,000; 2009: $1,070,000; 2010: $1,298,000; 2011: $1,707,000. State: Tennessee; Fiscal year: 2006: $146,000; 2007: $816,000; 2008: $365,000; 2009: $14,469,000; 2010: $21,392,000; 2011: $18,896,000. State: Texas; Fiscal year: 2006: $19,385,000; 2007: $20,593,000; 2008: $17,859,000; 2009: $18,767,000; 2010: $29,199,000; 2011: $75,288,000. State: Utah; Fiscal year: 2006: $120,000; 2007: $546,000; 2008: $2,538,000; 2009: $1,500,000; 2010: $1,410,000; 2011: $2,751,000. State: Vermont; Fiscal year: 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: $1,377,000; 2010: $10,351,000; 2011: $3,601,000. State: Virginia; Fiscal year: 2006: $5,213,000; 2007: $6,577,000; 2008: $7,420,000; 2009: $8,036,000; 2010: $10,830,000; 2011: $13,428,000. State: Washington; Fiscal year: 2006: $5,098,000; 2007: $5,229,000; 2008: $5,334,000; 2009: $5,902,000; 2010: $7,833,000; 2011: $9,698,000. State: West Virginia; Fiscal year: 2006: $3,110,000; 2007: $3,621,000; 2008: $4,117,000; 2009: $4,514,000; 2010: $5,614,000; 2011: $6,602,000. State: Wisconsin; Fiscal year: 2006: $1,268,000; 2007: $1,981,000; 2008: $2,012,000; 2009: $3,476,000; 2010: $4,395,000; 2011: $5,406,000. State: Wyoming; Fiscal year: 2006: $743,000; 2007: $409,000; 2008: $452,000; 2009: $482,000; 2010: $718,000; 2011: $643,000. State: Total; Fiscal year: 2006: $310,272,000; 2007: $353,370,000; 2008: $410,960,000; 2009: $431,106,000; 2010: $546,967,000; 2011: $659,991,000. Legend: N/A = Not Applicable: Source: GAO analysis of CMS data. Notes: [Empty] indicates that data were not available for a particular year. [A] The District of Columbia does not participate in QI because its Medicaid policies result in all applicants in the QI income range qualifying for a higher level of benefits. [End of table] [End of section] Enclosure II: Transitional Medical Assistance (TMA): Requirements and State Survey Responses Regarding the Program: Since 1988, the Medicaid program has required states to offer at least 6, and up to 12, months of Transitional Medical Assistance (TMA) to certain low-income families who would otherwise lose coverage because of hours of employment or earned income, or the loss of a time-limited earnings disregard.[Footnote 15] Under this provision--set to expire on December 31, 2012--families are entitled to an initial 6 months of Medicaid coverage, and states must provide families with the same level of Medicaid benefits that they were previously receiving. However, under the Social Security Act (SSA), states are given the option of meeting this requirement by using Medicaid funds to pay for a family's premiums or other related costs for employer-based health coverage if it is available.[Footnote 16] After the initial 6-month period, families may continue coverage for an additional 6 months if the family's earnings, minus child care costs, do not exceed 185 percent of the federal poverty limit (FPL), among other requirements. [Footnote 17] Additionally, in the second 6-month period, states may require families with incomes at or above 100 percent of the FPL to pay a premium for the additional coverage.[Footnote 18] States vary widely in the income eligibility levels that families must exceed in order to qualify for TMA--ranging from up to 17 percent of the FPL in Arkansas to 215 percent of the FPL in Minnesota. See table 4 for groupings of states by their respective income eligibility levels. In order to qualify for benefits at the state's applicable eligibility level, under the expiring TMA provision, families must report earnings minus child care costs over the course of both 6-month periods as specified in the statute.[Footnote 19] Table 4: Summary of Transitional Medical Assistance (TMA) Income Eligibility Levels, as a Percentage of the Federal Poverty Level (FPL) in 2012: TMA income eligibility level: Less than 50 percent of FPL: Alabama, Arkansas, Georgia, Idaho, Indiana, Kansas, Louisiana, Mississippi, Missouri, New Hampshire, North Carolina, Oregon, Pennsylvania, Texas, Utah, Virginia, West Virginia; Number of states: 17. TMA income eligibility level: 50 to 100 percent of FPL: Alaska, Florida, Hawaii, Iowa, Kentucky, Michigan, Montana, Nebraska, Nevada, New Mexico, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Washington, Wyoming; Number of states: 17. TMA income eligibility level: More than 100 percent of FPL: Arizona, California, Colorado, Connecticut, Delaware, District of Columbia, Illinois, Maine, Maryland, Massachusetts, Minnesota, New Jersey, New York, Rhode Island, Tennessee, Vermont, Wisconsin; Number of states: 17. Source: GAO analysis of July 2012 data from Kaiser Commission on Medicaid and the Uninsured. Note: This table is based on data for upper income limits of Medicaid eligibility for low-income families under SSA § 1931, codified at 42 U.S.C. § 1396u-1. [End of table] In 2009, the American Recovery and Reinvestment Act of 2009 (ARRA) changed some aspects of TMA coverage for families. In particular, ARRA offered states the option to extend Medicaid eligibility to families for a period of 12 months at the outset--rather than an initial period of 6 months followed by a second 6-month period.[Footnote 20] Additionally, while states were not historically required to report on TMA separately from other Medicaid data, ARRA changed this by adding a new provision that requires all states to collect and submit to the Department of Health and Human Services (HHS), and make publicly available, information on average monthly enrollment and average monthly participation rates for adults and children covered under the expiring TMA provision.[Footnote 21] In light of this requirement, the Centers for Medicare & Medicaid Services (CMS)--the agency within HHS that administers the Medicaid program--has made some initial efforts to collect relevant data from the states. In 2009, CMS issued guidance and provided instructions and a template for state submission of enrollment data, specifying that states begin reporting in July 2010. While CMS officials report having received data from some states, officials indicated that they have not enforced the requirement because of competing agency priorities. We asked state Medicaid officials to provide information about their current TMA program policies and to provide enrollment and expenditure information from 2006 through the most recent year available. Forty- five states responded to the survey.[Footnote 22] While all 45 states provided information about their TMA program policies, fewer states were able to provide complete enrollment or expenditure data. Specifically, 41 states provided at least some years of enrollment data, and 32 states provided at least some years of expenditure data. [Footnote 23] State responses are summarized below. * All but one state reported offering a maximum of 12 months of continued Medicaid coverage through TMA.[Footnote 24] * The states that were able to break out the number of enrollees based on the provisions under which Medicaid coverage is extended generally reported over 90 percent of enrollees were eligible for TMA because of earnings. Other enrollees were eligible for extended Medicaid coverage because of increased child or spousal support as provided for by permanent Medicaid provisions. * Most states reported taking steps to verify the income of TMA enrollees. The verification methods used in these states included self- attestation, electronic data matching, and employer or client verification.[Footnote 25] * Twenty-three states reported implementing an option to pay enrollees' costs associated with employer sponsored insurance in providing continued Medicaid coverage under TMA. * Seventeen states reported that they had access to data on the extent to which TMA enrollees participate in employer-sponsored insurance. [Footnote 26] Forty-one states reported over 3.5 million individuals enrolled in TMA in 2011, the most recent year for which all 41 states reported data. States provided enrollment data for the other 5 years, but generally to a lesser extent. In addition, although states are not required to track TMA expenditures, 32 states reported total TMA expenditures of about $3.9 billion for 2011, the most recent year for which all reporting states provided data. Table 5 summarizes total enrollment and expenditures reported by responding states for 2006 through 2011. Tables 6 and 7 provide state-specific enrollment and expenditure data for these years. Table 5: Total Enrollment and Expenditures for the Transitional Medical Assistance (TMA) Program for All States Reporting Data, 2006 through 2011: Total enrollment (in millions)[A] (number of states providing data); 2006: 2.78 million (N=35); 2007: 3.13 million (N=38); 2008: 3.15 million (N=40); 2009: 3.08 million (N=41); 2010: 3.22 million (N=41); 2011: 3.54 million (N=41). Total expenditures (dollars in billions) (number of states providing data); 2006: $1.80 billion (N=27); 2007: $3.09 billion (N=32); 2008: $2.91 billion (N=32); 2009: $2.86 billion (N=31); 2010: $3.29 billion (N=32); 2011: $3.86 billion (N=32). Source: GAO analysis of state data. Notes: State data are as of November 13, 2012. State officials were asked to provide an unduplicated enrollment number for each year of available data. Alaska and Arizona could not provide unduplicated enrollment data. Twenty-one states reported enrollment data by state fiscal year, 6 reported by federal fiscal year, 12 reported by calendar year and 2 reported an average monthly enrollment. Twenty-two states reported expenditure data by state fiscal year, 4 reported by federal fiscal year, and 6 reported by calendar year. [A] Some states do not separate data based on the provisions under which Medicaid coverage is extended. However, the states that were able to break out the number of enrollees based on the provisions under which Medicaid coverage is extended generally reported over 90 percent of enrollees were eligible for TMA due to earnings. [End of table] Table 6: Enrollment in the Transitional Medical Assistance (TMA) Program by State, Years 2006 through 2011: Number of individuals: State: Alabama; 2006: 3,170; 2007: 2,408; 2008: 1,928; 2009: 2,103; 2010: 2,370; 2011: 1,927. State: Alaska[A]; 2006: 1,740; 2007: 1,811; 2008: 1,833; 2009: 1,902; 2010: 2,168; 2011: 2,889. State: Arizona[B]; 2006: [Empty]; 2007: [Empty]; 2008: 45,445; 2009: 43,836; 2010: 42,843; 2011: 45,562. State: Arkansas; 2006: 5,288; 2007: 4,818; 2008: 4,524; 2009: 3,793; 2010: 3,133; 2011: 3,235. State: California; 2006: 227,419; 2007: 297,103; 2008: 316,787; 2009: 312,139; 2010: 323,300; 2011: 336,635. State: Colorado; 2006: [Empty]; 2007: [Empty]; 2008: 58,817; 2009: 60,152; 2010: 54,697; 2011: 64,643. State: Connecticut; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: Delaware; 2006: 35,061; 2007: 13,168; 2008: 14,940; 2009: 14,179; 2010: 14,351; 2011: 17,585. State: District of Columbia; 2006: 2,917; 2007: 2,342; 2008: 1,762; 2009: 1,287; 2010: 1,140; 2011: 1,332. State: Florida; 2006: 328,912; 2007: 277,890; 2008: 280,906; 2009: 324,094; 2010: 384,227; 2011: 424,312. State: Georgia; 2006: 148,259; 2007: 106,472; 2008: 127,110; 2009: 118,149; 2010: 110,933; 2011: 111,554. State: Hawaii; 2006: 6,151; 2007: 4,850; 2008: 4,808; 2009: 4,536; 2010: 4,892; 2011: 6,271. State: Idaho; 2006: 29,160; 2007: 16,131; 2008: 4,654; 2009: 4,070; 2010: 4,280; 2011: 7,089. State: Illinois; 2006: [Empty]; 2007: 358,910; 2008: 374,673; 2009: 382,085; 2010: 399,244; 2011: 445,481. State: Indiana; 2006: 113,527; 2007: 113,095; 2008: 109,547; 2009: 99,217; 2010: 99,173; 2011: 109,114. State: Iowa; 2006: [Empty]; 2007: 49,961; 2008: 46,569; 2009: 44,342; 2010: 44,358; 2011: 41,180. State: Kansas; 2006: 25,739; 2007: 22,061; 2008: 18,020; 2009: 14,521; 2010: 10,910; 2011: 15,632. State: Kentucky; 2006: 58,574; 2007: 59,821; 2008: 56,374; 2009: 52,162; 2010: 48,590; 2011: 54,119. State: Louisiana; 2006: 23,391; 2007: 27,689; 2008: 29,262; 2009: 28,575; 2010: 25,830; 2011: 24,893. State: Maine; 2006: 22,400; 2007: 23,661; 2008: 23,940; 2009: 21,440; 2010: 20,269; 2011: 23,427. State: Maryland; 2006: 19,424; 2007: 15,744; 2008: 14,186; 2009: 32,412; 2010: 69,080; 2011: 96,945. State: Massachusetts; 2006: 63,376; 2007: 65,120; 2008: 70,208; 2009: 73,528; 2010: 69,696; 2011: 64,886. State: Michigan; 2006: 155,329; 2007: 140,315; 2008: 130,920; 2009: 142,853; 2010: 135,214; 2011: 166,496. State: Minnesota; 2006: 27,607; 2007: 28,846; 2008: 30,108; 2009: 29,121; 2010: 30,036; 2011: 35,359. State: Mississippi; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: 12,356; 2010: 35,946; 2011: 37,348. State: Missouri; 2006: 238,727; 2007: 84,676; 2008: 104,803; 2009: 117,594; 2010: 112,421; 2011: 109,357. State: Montana; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: Nebraska; 2006: 31,335; 2007: 28,060; 2008: 18,443; 2009: 23,928; 2010: 35,448; 2011: 40,903. State: Nevada; 2006: 13,782; 2007: 10,092; 2008: 3,102; 2009: 2,814; 2010: 8,156; 2011: 10,297. State: New Hampshire; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: New Jersey; 2006: 23,066; 2007: 26,084; 2008: 30,889; 2009: 32,973; 2010: 32,739; 2011: 35,627. State: New Mexico; 2006: 59,151; 2007: 56,436; 2008: 52,923; 2009: 53,100; 2010: 52,949; 2011: 50,532. State: New York; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: North Carolina; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: North Dakota[C]; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: Ohio; 2006: 360,876; 2007: 369,752; 2008: 352,192; 2009: 328,838; 2010: 320,639; 2011: 371,193. State: Oklahoma; 2006: 14; 2007: 125; 2008: 469; 2009: 48; 2010: 20; 2011: 86. State: Oregon; 2006: 80,614; 2007: 63,517; 2008: 52,328; 2009: 48,218; 2010: 55,021; 2011: 70,197. State: Pennsylvania; 2006: 223,732; 2007: 277,879; 2008: 294,864; 2009: 251,688; 2010: 233,278; 2011: 240,330. State: Rhode Island; 2006: 19,165; 2007: 15,763; 2008: 12,162; 2009: 9,718; 2010: 9,776; 2011: 8,128. State: South Carolina; 2006: 52,840; 2007: 47,658; 2008: 55,520; 2009: 53,583; 2010: 53,876; 2011: 62,190. State: South Dakota; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: Tennessee; 2006: [Empty]; 2007: 178,188; 2008: 95,687; 2009: 46,018; 2010: 50,559; 2011: 55,669. State: Texas; 2006: 214,713; 2007: 174,581; 2008: 152,595; 2009: 130,002; 2010: 129,332; 2011: 135,068. State: Utah; 2006: 12,180; 2007: 15,155; 2008: 20,808; 2009: 21,807; 2010: 21,486; 2011: 22,846. State: Vermont; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: Virginia; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: Washington; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: West Virginia; 2006: 7,789; 2007: 6,060; 2008: 4,322; 2009: 4,046; 2010: 4,415; 2011: 3,135. State: Wisconsin; 2006: 140,313; 2007: 138,053; 2008: 131,371; 2009: 131,424; 2010: 158,621; 2011: 187,016. State: Wyoming; 2006: 3,944; 2007: 4,081; 2008: 4,005; 2009: 3,691; 2010: 3,760; 2011: 4,013. Total states providing enrollment data: 2006: 35; 2007: 38; 2008: 40; 2009: 41; 2010: 41; 2011: 41. Total for states reporting enrollment: 2006: 2,779,685; 2007: 3,128,376; 2008: 3,153,804; 2009: 3,082,342; 2010: 3,219,176; 2011: 3,544,501. Source: GAO analysis of state data. Notes: State data are as of November 13, 2012. State officials were asked to provide an unduplicated enrollment number for each year. Alaska and Arizona could not provide unduplicated enrollment data. Officials in 21 states reported enrollment data by state fiscal year, 6 reported by federal fiscal year, 12 reported by calendar year, and 2 reported average monthly enrollments. Some states do not separate data based on the provisions under which Medicaid coverage is extended. However, the states that were able to break out the number of enrollees based on the provisions under which Medicaid coverage is extended generally reported over 90 percent of enrollees were eligible for TMA due to earnings: [Empty] indicates that data were not available from the state. [A] For a number of reasons, Alaska does not determine annual, unduplicated enrollment for TMA. Instead, the state tracks monthly TMA enrollment and provided us with the average monthly TMA enrollment for state fiscal years 2006 through 2012. However, a state Medicaid official noted that these data have limitations. For example, the enrollment data have not been adjusted for retroactive eligibility determinations, and for state fiscal years 2006 through 2010, TMA enrollment may be overstated because of the potential overlap between eligibility categories that existed during that time. [B] Arizona Medicaid officials told us that they were not able to provide an unduplicated count. [C] Officials in North Dakota were not able to provide TMA enrollment data for all years; however, they were able to produce a point-in-time enrollment of 6,066 individuals as of September 30, 2012. [End of table] Table 7: Reported Expenditures for the Transitional Medical Assistance (TMA) Program by State, 2006 through 2011: State: Alabama; 2006: $2,102,000; 2007: $1,795,000; 2008: $1,596,000; 2009: $1,599,000; 2010: $1,676,000; 2011: $2,283,000. State: Alaska; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: Arizona; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: Arkansas; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: California; 2006: $140,258,000; 2007: $161,731,000; 2008: $180,819,000; 2009: $139,563,000; 2010: $138,335,000; 2011: $186,278,000. State: Colorado; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: Connecticut; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: Delaware; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: District of Columbia; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: Florida; 2006: [Empty]; 2007: $195,949,000; 2008: $173,440,000; 2009: $194,094,000; 2010: $251,171,000; 2011: $296,136,000. State: Georgia; 2006: $132,323,000; 2007: $25,673,000; 2008: $94,009,000; 2009: $114,709,000; 2010: $97,227,000; 2011: $75,333,000. State: Hawaii; 2006: $8,778,000; 2007: $8,645,000; 2008: $4,568,000; 2009: $9,257,000; 2010: $9,738,000; 2011: $11,217,000. State: Idaho; 2006: $34,349,000; 2007: $21,305,000; 2008: $8,994,000; 2009: $7,820,000; 2010: $10,455,000; 2011: $15,735,000. State: Illinois; 2006: $[Empty],000; 2007: $336,931,000; 2008: $389,190,000; 2009: $439,819,000; 2010: $504,305,000; 2011: $563,039,000. State: Indiana; 2006: $92,055,000; 2007: $99,702,000; 2008: $98,091,000; 2009: $94,301,000; 2010: $92,932,000; 2011: $91,440,000. State: Iowa; 2006: $48,644,000; 2007: $45,857,000; 2008: $45,474,000; 2009: $44,487,000; 2010: $42,130,000; 2011: $45,025,000. State: Kansas; 2006: $23,430,000; 2007: $23,833,000; 2008: $18,823,000; 2009: $16,204,000; 2010: $12,772,000; 2011: $21,785,000. State: Kentucky; 2006: $60,571,000; 2007: $66,954,000; 2008: $70,800,000; 2009: $71,606,000; 2010: $66,000,000; 2011: $74,405,000. State: Louisiana; 2006: $16,059,000; 2007: $18,325,000; 2008: $22,478,000; 2009: $26,285,000; 2010: $24,603,000; 2011: $21,197,000. State: Maine; 2006: $50,593,000; 2007: $57,440,000; 2008: $56,365,000; 2009: $53,855,000; 2010: $51,289,000; 2011: $58,173,000. State: Maryland; 2006: $25,049,000; 2007: $21,517,000; 2008: $19,451,000; 2009: $53,845,000; 2010: $138,587,000; 2011: $193,185,000. State: Massachusetts; 2006: $77,683,000; 2007: $85,291,000; 2008: $101,443,000; 2009: $109,969,000; 2010: $105,848,000; 2011: $100,472,000. State: Michigan; 2006: [Empty]; 2007: $307,621,000; 2008: $151,110,000; 2009: [Empty]; 2010: $251,771,000; 2011: $313,474,000. State: Minnesota; 2006: $39,354,000; 2007: $47,180,000; 2008: $54,867,000; 2009: $57,040,000; 2010: $58,358,000; 2011: $66,827,000. State: Mississippi; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: Missouri; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: Montana; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: Nebraska; 2006: $29,613,000; 2007: $31,556,000; 2008: $28,918,000; 2009: $27,438,000; 2010: $39,823,000; 2011: $50,893,000. State: Nevada; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: New Hampshire; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: New Jersey; 2006: $16,645,000; 2007: $24,851,000; 2008: $33,728,000; 2009: $37,250,000; 2010: $40,074,000; 2011: $43,894,000. State: New Mexico; 2006: $87,946,000; 2007: $95,415,000; 2008: $96,049,000; 2009: $97,414,000; 2010: $93,521,000; 2011: $82,437,000. State: New York; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: North Carolina; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: North Dakota; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: Ohio; 2006: $314,746,000; 2007: $384,472,000; 2008: $339,743,000; 2009: $390,330,000; 2010: $365,884,000; 2011: $525,133,000. State: Oklahoma; 2006: $25,000; 2007: $27,000; 2008: $373,000; 2009: $47,000; 2010: $2,000; 2011: $53,000. State: Oregon; 2006: $93,012,000; 2007: $64,796,000; 2008: $59,659,000; 2009: $58,105,000; 2010: $76,398,000; 2011: $103,688,000. State: Pennsylvania; 2006: $241,658,000; 2007: $323,900,000; 2008: $352,511,000; 2009: $323,874,000; 2010: $299,649,000; 2011: $319,087,000. State: Rhode Island; 2006: $24,865,000; 2007: $22,021,000; 2008: $18,526,000; 2009: $13,407,000; 2010: $12,211,000; 2011: $10,977,000. State: South Carolina; 2006: [Empty]; 2007: $78,952,000; 2008: $83,914,000; 2009: $97,815,000; 2010: $94,104,000; 2011: $117,013,000. State: South Dakota; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: Tennessee; 2006: [Empty]; 2007: $302,074,000; 2008: $160,141,000; 2009: $100,932,000; 2010: $118,499,000; 2011: $139,625,000. State: Texas; 2006: $72,008,000; 2007: $73,745,000; 2008: $82,661,000; 2009: $105,498,000; 2010: $107,592,000; 2011: $125,559,000. State: Utah; 2006: $20,663,000; 2007: $18,291,000; 2008: $18,694,000; 2009: $22,993,000; 2010: $23,868,000; 2011: $18,411,000. State: Vermont; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: Virginia; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: Washington; 2006: [Empty]; 2007: [Empty]; 2008: [Empty]; 2009: [Empty]; 2010: [Empty]; 2011: [Empty]. State: West Virginia; 2006: $9,505,000; 2007: $9,589,000; 2008: $13,337,000; 2009: $10,990,000; 2010: $10,826,000; 2011: $11,368,000. State: Wisconsin; 2006: $128,524,000; 2007: $123,186,000; 2008: $121,724,000; 2009: $121,964,000; 2010: $137,355,000; 2011: $160,679,000. State: Wyoming; 2006: $13,017,000; 2007: $14,519,000; 2008: $12,636,000; 2009: $12,817,000; 2010: $12,743,000; 2011: $12,406,000. State: Total states reporting expenditure data; 2006: $27,000; 2007: $32,000; 2008: $32,000; 2009: $31,000; 2010: $32,000; 2011: $32,000. State: Total for states reporting expenditures; 2006: $1,803,472,000; 2007: $3,093,143,000; 2008: $2,914,130,000; 2009: $2,855,327,000; 2010: $3,289,746,000; 2011: $3,857,227,000. Source: GAO analysis of state data. Notes: State data are as of November 13, 2012. State officials were asked to provide total expenditures, including federal and state portions, for TMA; these data can include expenditures for some or all provisions under which Medicaid coverage is extended. Unless noted, states returned expenditure information for a 12-month period. The boundaries of this period varied, with 22 reporting expenditure data by state fiscal year, 4 reporting by federal fiscal year, and 6 reporting by calendar year. [Empty] indicates that data were not available from the state. [End of table] [End of section] Footnotes: [1] Medicaid, a joint federal-state program that finances health insurance coverage for certain categories of low-income individuals, spent about $389 billion on coverage for eligible enrollees in fiscal year 2010. States administer Medicaid within broad federal guidelines that specify categories of low-income individuals that states must cover and categories that are optional. For example, in 1996, section 1931 of the Social Security Act (SSA) established a new mandatory Medicaid eligibility group of low-income families with children that are eligible to receive TMA coverage. See Pub. L. No. 104-193, § 114,110 Stat. 2105, 2177 (adding section 1931 to the SSA) (codified at 42 U.S.C. § 1396u-1). [2] Medicare is a federal health insurance program for individuals age 65 and over, individuals under the age of 65 with certain disabilities, and individuals with end-stage renal disease. Medicare has four parts, which cover different aspects of care for the population. In general, Medicare Part A covers hospital and inpatient care, Part B covers certain outpatient care, medical supplies, and preventive services, Part C is a managed care coverage option known as the Medicare Advantage program, and Part D provides an optional outpatient prescription drug benefit. The QI program was established by the Balanced Budget Act of 1997. See Pub. L. No. 105-33, § 4732, 111 Stat. 251, 520 (adding new sections 1902(a)(10)(E)(iv) and 1933 to the SSA) (codified at 42 U.S.C. §§ 1396a(a)(10)(E)(iv), 1396u-3). [3] See SSA §§ 1902(e)(1)(A), 1931(c), 406(h) (as in effect on July 16, 1996), codified at 42 U.S.C. §§ 1396a(e)(1)(A), 1396u-1(c). [4] SSA §1925, codified at 42 U.S.C. § 1396r-6. Section 1925 preempts section 1902(e)(1)(A) through December 31, 2012, for families with earned income. SSA § 1902(e)(1)(B), codified at 42 U.S.C. § 1396a(e)(1)(B). We have previously reported that TMA is a key protection offered to families at a critical juncture in their efforts to move from welfare to work. See GAO, Medicaid: Transitional Coverage Can Help Families Move from Welfare to Work, [hyperlink, http://www.gao.gov/products/GAO-02-679T] (Washington, D.C.: Apr. 23, 2002). [5] MSIS is a CMS system that collects eligibility and claims data from states. CMS uses this system to produce eligibility and program characteristics. [6] The CMS-64 data set aggregates each state's expenditures and is used to determine reimbursement to each state for its federal share of Medicaid expenditures. [7] CMS's eligibility numbers are drawn from the Census Bureau Annual Social and Economic Supplement and comprise the number of Medicare beneficiaries who are not enrolled in Medicaid whose incomes are within the income limits established for QI. [8] In this report, we use the term "states" to refer to the 50 states and the District of Columbia. [9] For example, some states do not separate data based on the provisions under which Medicaid coverage is extended. We did not independently verify information reported by states. [10] The increase in expenditures was due in part to increases in Medicare Part B premiums, which rose 9 percent between calendar years 2006 and 2009. [11] We recently reported that enrollment in Medicare Savings Programs like QI has been low historically, partly due to beneficiaries' lack of awareness and cumbersome eligibility determination and enrollment processes. Legislative requirements aimed at boosting enrollment went into effect in 2010. See GAO, Medicare Savings Programs: Implementation of Requirements Aimed at Increasing Enrollment, [hyperlink, http://www.gao.gov/products/GAO-12-871] (Washington, D.C.: Sept. 14, 2012). [12] The 41 states that provided TMA enrollment data represented about 82 percent of nationwide Medicaid enrollment in June 2011. [13] The 32 states that provided TMA expenditure data represented about 68 percent of nationwide Medicaid expenditures in fiscal year 2010. [14] Social Security Act (SSA) §§ 1902(a)(10)(E)(iv), 1933,1905(p), codified at 42 U.S.C. §§ 1396a(a)(10)(E)(iv), 1396u-3, 1396d(p). In most states, in order to qualify for QI, individuals must meet resource limits established for the Low-Income Subsidy program (LIS), a program established to help low-income individuals pay for prescription drugs under Medicare Part D. In 2012, the resource limit for LIS was $6,940 for an individual and $10,410 for a couple. [15] Social Security Act (SSA) §1925, codified at 42 U.S.C. § 1396r-6. Under permanent provisions of the SSA, Medicaid coverage continues for 4 months for families who would otherwise lose coverage because of an increase in earned income or hours of employment or increased child or spousal support. See SSA §§ 1902(e)(1)(A), 1931(c), 406(h) (as in effect on July 16, 1996), codified at 42 U.S.C. §§ 1396a(e)(1)(A), 1396u-1(c). Section 1925 preempts section 1902(e)(1)(A) through December 31, 2012, for families with earned income. [16] SSA § 1925(a)(4)(B), codified at 42 U.S.C. 1396r-6(a)(4)(B). [17] See SSA § 1925(b)(1) and (b)(3)(A)(iii)(III), codified at 42 U.S.C. § 1396r-6(b)(1) and (b)(3)(A)(iii)(III). In 2012, for a family of three, 185 percent of the FPL is $35,317 annually, or $2,943 per month. [18] SSA § 1925(b)(5), codified at 42 U.S.C. § 1396r-6(b)(5). [19] See SSA § 1925(b)(2)(B), codified at 42 U.S.C. § 1396r-6(b)(2)(B). [20] Pub. L. No. 111-5, § 5004, 123 Stat. 115, 503. According to CMS, 13 states selected this option. These states are Alaska, Colorado, Connecticut, Florida, Idaho, Maryland, Montana, New Mexico, New York, Ohio, Oregon, South Dakota, and Wisconsin. [21] States must also report the number and percentage of children who continue eligibility in another Medicaid eligibility group or are enrolled in the State Children's Health Insurance Program, after their TMA eligibility ends. Under the new provision, HHS is responsible for specifying the format, timing, and frequency for this reporting and HHS is required to submit an annual report to Congress on such enrollment and participation rates. SSA § 1925(g), codified at 42 U.S.C. § 1396r-6(g). [22] The 6 states that did not respond to our survey were Connecticut, Montana, New Hampshire, North Carolina, South Dakota, and Vermont. [23] Some states do not separate data based on the provisions under which Medicaid coverage is extended. [24] South Carolina reported TMA coverage for a maximum of 24 months. [25] States reported using a variety of methods to verify income of TMA enrollees. For example, electronic data matching can include the use of state and federal databases to help determine income. Employer and client verification methods can include either party providing check stubs or a written statement including income information. [26] TMA enrollees are allowed to participate in employer-sponsored insurance and in the TMA program at the same time. In these cases, Medicaid is the secondary payer for any costs incurred during the TMA coverage period. [End of section] GAO’s Mission: The Government Accountability Office, the audit, evaluation, and investigative arm of Congress, exists to support Congress in meeting its constitutional responsibilities and to help improve the performance and accountability of the federal government for the American people. GAO examines the use of public funds; evaluates federal programs and policies; and provides analyses, recommendations, and other assistance to help Congress make informed oversight, policy, and funding decisions. GAO’s commitment to good government is reflected in its core values of accountability, integrity, and reliability. Obtaining Copies of GAO Reports and Testimony: The fastest and easiest way to obtain copies of GAO documents at no cost is through GAO’s website [hyperlink, http://www.gao.gov]. Each weekday afternoon, GAO posts on its website newly released reports, testimony, and correspondence. To have GAO e-mail you a list of newly posted products, go to [hyperlink, http://www.gao.gov] and select “E-mail Updates.” Order by Phone: The price of each GAO publication reflects GAO’s actual cost of production and distribution and depends on the number of pages in the publication and whether the publication is printed in color or black and white. Pricing and ordering information is posted on GAO’s website, [hyperlink, http://www.gao.gov/ordering.htm]. Place orders by calling (202) 512-6000, toll free (866) 801-7077, or TDD (202) 512-2537. Orders may be paid for using American Express, Discover Card, MasterCard, Visa, check, or money order. Call for additional information. Connect with GAO: Connect with GAO on facebook, flickr, twitter, and YouTube. Subscribe to our RSS Feeds or E mail Updates. Listen to our Podcasts. Visit GAO on the web at [hyperlink, http://www.gao.gov]. To Report Fraud, Waste, and Abuse in Federal Programs: Contact: Website: [hyperlink, http://www.gao.gov/fraudnet/fraudnet.htm]; E-mail: fraudnet@gao.gov; Automated answering system: (800) 424-5454 or (202) 512-7470. Congressional Relations: Katherine Siggerud, Managing Director, siggerudk@gao.gov: (202) 512-4400: U.S. Government Accountability Office: 441 G Street NW, Room 7125: Washington, DC 20548. Public Affairs: Chuck Young, Managing Director, youngc1@gao.gov: (202) 512-4800: U.S. Government Accountability Office: 441 G Street NW, Room 7149: Washington, DC 20548. [End of document]