States' Implementation of the Patient Protection and Affordable Care Act

U.S. Government Accountability Office

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Medicaid Expansion

The following questions ask for your best judgments, based on current information, of the implications of Medicaid expansion implementation. Briefly, PPACA requires states to expand Medicaid coverage to:

Individuals who were previously ineligible (primarily childless adults) will be covered up to 133 percent of the federal poverty level (FPL) beginning in 2014 with eligibility based on modified gross income (MAGI) and no assets or resource tests.

Newly eligible costs: the federal government would be responsible for 100 percent of the cost of the newly eligible through 2016 with the state contribution gradually increasing to 10 percent by 2020.

Previously covered newly eligible: states that had already covered newly eligible adults up to 100 percent of the FPL in 2010 would see a gradual increase in their federal matching rate for these individuals with the state share capped at 10 percent by 2020.

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State Budget Cycle

1. What budget cycle does your state operate on?

Click one button.

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Annual
Biennial
Biennial and
Annual
Number of respondents
24 13 5 42

Costs and Savings From Implementing Medicaid Expansion

2. To the best of your knowledge, do you think each of the following potential aspects of Medicaid expansion will contribute a net cost or a net savings to your state's budgets from 2012 through 2014, from 2015 through 2017, and from 2018-2020?

For each aspect of Medicaid expansion implementation, click the one button that best characterizes its impact for 2012-2014 taken as a whole, the impact for 2015-2017 taken as a whole, and the impact for 2018-2020 taken as a whole.

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Administration for managing Medicaid enrollment

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Net impact on your state's budgets for FY 2012-2014?

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Cost
Savings
Don't know/Not
applicable
Number of respondents
38 1 3 42

Net impact on your state's budgets for FY 2015-2017?

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Cost
Savings
Don't know/Not
applicable
Number of respondents
36 1 5 42

Net impact on your state's budgets for FY 2018-2020?

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Cost
Savings
Don't know/Not
applicable
Number of respondents
32 2 8 42

Acquisition of new information technology or modifications to existing information technology systems to support Medicaid eligibility determinations and enrollment

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Net impact on your state's budgets for FY 2012-2014?

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Cost
Savings
Don't know/Not
applicable
Number of respondents
37 1 4 42

Net impact on your state's budgets for FY 2015-2017?

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Cost
Savings
Don't know/Not
applicable
Number of respondents
29 3 10 42

Net impact on your state's budgets for FY 2018-2020?

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Cost
Savings
Don't know/Not
applicable
Number of respondents
23 5 14 42

Enrolling previously eligible but not enrolled individuals into Medicaid

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Net impact on your state's budgets for FY 2012-2014?

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Cost
Savings
Don't know/Not
applicable
Number of respondents
35 0 6 41

Net impact on your state's budgets for FY 2015-2017?

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Cost
Savings
Don't know/Not
applicable
Number of respondents
35 3 3 41

Net impact on your state's budgets for FY 2018-2020?

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Cost
Savings
Don't know/Not
applicable
Number of respondents
32 3 6 41

Enrolling newly eligible adults into Medicaid (click here for details)

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Net impact on your state's budgets for FY 2012-2014?

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Cost
Savings
Don't know/Not
applicable
Number of respondents
13 9 20 42

Net impact on your state's budgets for FY 2015-2017?

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Cost
Savings
Don't know/Not
applicable
Number of respondents
22 13 7 42

Net impact on your state's budgets for FY 2018-2020?

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Cost
Savings
Don't know/Not
applicable
Number of respondents
27 9 6 42

Shifting individuals from state-funded coverage into Medicaid

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Net impact on your state's budgets for FY 2012-2014?

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Cost
Savings
Don't know/Not
applicable
Number of respondents
2 14 26 42

Net impact on your state's budgets for FY 2015-2017?

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Cost
Savings
Don't know/Not
applicable
Number of respondents
4 15 22 41

Net impact on your state's budgets for FY 2018-2020?

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Cost
Savings
Don't know/Not
applicable
Number of respondents
4 15 22 41

Shifting existing Medicaid enrollees into health benefit exchanges

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Net impact on your state's budgets for FY 2012-2014?

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Cost
Savings
Don't know/Not
applicable
Number of respondents
1 10 31 42

Net impact on your state's budgets for FY 2015-2017?

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Cost
Savings
Don't know/Not
applicable
Number of respondents
1 12 29 42

Net impact on your state's budgets for FY 2018-2020?

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Cost
Savings
Don't know/Not
applicable
Number of respondents
1 12 29 42

Other enrollment changes - describe in box below table

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Net impact on your state's budgets for FY 2012-2014?

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Cost
Savings
Don't know/Not
applicable
Number of respondents
4 1 34 39

Net impact on your state's budgets for FY 2015-2017?

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Cost
Savings
Don't know/Not
applicable
Number of respondents
4 1 34 39

Net impact on your state's budgets for FY 2018-2020?

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Cost
Savings
Don't know/Not
applicable
Number of respondents
4 1 34 39

Reductions in uncompensated care

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Net impact on your state's budgets for FY 2012-2014?

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Cost
Savings
Don't know/Not
applicable
Number of respondents
5 8 28 41

Net impact on your state's budgets for FY 2015-2017?

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Cost
Savings
Don't know/Not
applicable
Number of respondents
7 12 22 41

Net impact on your state's budgets for FY 2018-2020?

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Cost
Savings
Don't know/Not
applicable
Number of respondents
7 12 22 41

Other aspects of Medicaid expansion implementation - describe in box below table

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Net impact on your state's budgets for FY 2012-2014?

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Cost
Savings
Don't know/Not
applicable
Number of respondents
5 3 28 36

Net impact on your state's budgets for FY 2015-2017?

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Cost
Savings
Don't know/Not
applicable
Number of respondents
6 2 29 37

Net impact on your state's budgets for FY 2018-2020?

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Cost
Savings
Don't know/Not
applicable
Number of respondents
6 2 29 37

IF OTHER ENROLLMENT CHANGES: What are those changes that will contribute to a net cost or savings to your states' budget(s)?

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Data intentionally not reported


IF OTHER ASPECTS OF MEDICAID EXPANSION IMPLEMENTATION: What are those other aspects that will contribute to a net cost or savings to your states' budget(s)?

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Data intentionally not reported


Maintenance of Effort

3. Has your state applied to the Centers for Medicare and Medicaid Services (CMS) for an exemption from the Maintenance of Effort requirement for the period January 1, 2011 through December 31, 2013?

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Yes
No - Skip to
Question 5
Don't know
Number of respondents
6 35 1 42

4. IF "YES:" What is the current status of this application?

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Approved Denied Pending Don't know Number of respondents
2 0 3 1 6

5. Does your state intend to apply for an exemption from the Maintenance of Effort requirement for the period January 1, 2011 through December 31, 2013?

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Yes No Don't know Number of respondents
1 22 16 39

Enrollment Rates

6. What does your state estimate the enrollment rate will be for the newly eligible Medicaid population in each of the following time periods?
Click one button in each row.

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Fiscal year 2014

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0 - 24% 25 - 49% 50 - 74% 75 - 99% 100% Don't know Number of respondents
5 8 13 5 0 10 41

Fiscal years 2015-2017

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0 - 24% 25 - 49% 50 - 74% 75 - 99% 100% Don't know Number of respondents
2 5 10 12 0 12 41

Fiscal years 2018-2020

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0 - 24% 25 - 49% 50 - 74% 75 - 99% 100% Don't know Number of respondents
2 0 7 15 2 15 41

State Budget Development

7. Has your state developed any planning documents that include milestones and/or steps to address the expansion of Medicaid eligibility and the transition to a new eligibility determination system in your state's budget? Planning documents could include, but are not limited to, work plans, timelines, process charts, memos, etc.

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Yes No Don't know Number of respondents
32 10 0 42

8. Now consider the possible uncertainties that could affect the implementation of Medicaid expansion in your state. Does your state budget development process include a risk assessment or gap analysis to address possible uncertainties that could affect implementation of Medicaid expansion in your state?

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Yes No Don't know Number of respondents
7 32 3 42



IF YES: Please briefly describe those uncertainties and the assessment or analyses conducted:

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Data intentionally not reported


9. Does your state budget development process include or consider various implementation scenarios?

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Yes No Don't know Number of respondents
14 26 2 42

Implementation Challenges and Opportunities

10. From a state budget perspective, what are the biggest challenges that impact budget estimates for implementing PPACA Medicaid expansion provisions? Describe up to three challenges in the spaces below. The box will scroll to accommodate your typed answer as needed.

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1st challenge:

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2nd challenge:

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3rd challenge:

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11. What strategies, if any, is your state using to address any of the challenges you described in the previous question?

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Strategy for 1st challenge:

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Strategy for 2nd challenge:

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Strategy for 3rd challenge:

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12. How challenging, if at all, is each of the following factors to the implementation of PPACA's Medicaid expansion provisions?

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State fiscal capacity

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Very challenging
Moderately challenging
Slightly challenging
Not at all challenging
Don't know /
Not applicable
Number of respondents
28 4 4 2 4 42

State share of the states' Medicaid expenditures

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Very challenging
Moderately challenging
Slightly challenging
Not at all challenging
Don't know /
Not applicable
Number of respondents
27 5 3 3 4 42

Local or county share of the states' Medicaid expenditures

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Very challenging
Moderately challenging
Slightly challenging
Not at all challenging
Don't know /
Not applicable
Number of respondents
3 3 5 6 24 41

Federal funding for Medicaid expansion implementation (2017-2020)

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Very challenging
Moderately challenging
Slightly challenging
Not at all challenging
Don't know /
Not applicable
Number of respondents
16 10 5 5 6 42

Other factor(s) - describe in box below table

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Very challenging
Moderately challenging
Slightly challenging
Not at all challenging
Don't know /
Not applicable
Number of respondents
5 1 0 2 14 22

IF OTHER FACTOR(S):

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Data intentionally not reported


13. What opportunities, if any, does Medicaid expansion present for your state?

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14. To what extent, if at all, was any guidance your state received from CMS clear, complete, and received in a timely manner for the development of budget estimates for Medicaid expansion? Select the answer that best characterizes guidance you may have received, regardless of whether your state has yet developed budget estimates for Medicaid expansion.

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Clarity of guidance

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Great extent
Moderate extent
Some extent
Little or no
extent
Don't know /
Not applicable
Number of respondents
2 6 11 16 6 41

Completeness of guidance

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Great extent
Moderate extent
Some extent
Little or no
extent
Don't know /
Not applicable
Number of respondents
2 4 12 17 6 41

Timeliness of guidance

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Great extent
Moderate extent
Some extent
Little or no
extent
Don't know /
Not applicable
Number of respondents
2 1 14 17 7 41

15. Overall, how useful or not useful has the CMS guidance been for the development of budget estimates for Medicaid expansion?

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Very useful
Moderately useful
Slightly useful
Not at all useful
Don't know /
Not applicable
Number of respondents
2 4 20 10 6 42

16. What additional information or guidance, if any, does your state need from CMS or other federal agencies to assist with developing budget estimates for implementing PPACA's Medicaid expansion provisions?

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Comments on Your Medicaid Expansion Answers

17. Do you have any explanations of or comments on any of your answers regarding the budgetary implications of the implementation of Medicaid expansion? Are there any issues we have not addressed that you believe we should consider?

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In addition to Medicaid expansion, the survey also asked questions about health exchanges and their impact on states' budget planning efforts (which we had included as questions 18-32). Because our report focuses only on Medicaid expansion, we include only the responses to the questions about Medicaid expansion. GAO plans to report on health exchanges next year.




Contact Information

33. Who is the person primarily responsible for completing this questionnaire whom we can contact in case we need to clarify a response?

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Contact name:

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Title:

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Email address:

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Telephone number:

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34. Are you done with this questionnaire?
Clicking "Yes" below tells GAO that your answers are final. We will not use your answers unless the "Yes" button is checked when you last exit the questionnaire.

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Yes No Number of respondents
42 0 42

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