• Additional Medicaid questions for the Red-state opt out

    UPDATED to add italicized clarifications about the donut hole and legal immigrants.
    • Timing. When do states have to decide to opt-out?  The expansion is 1/1/2014, but a lot a planning is required.
    • Scope. What are they opting out of? Title II of the ACA? Just the expansion of nondisabled adults to 133% FPL? Can they accept the enhanced reimbursement levels in Medicaid primary care (rising to Medicare levels) while rejecting the rest? Roberts didn’t give these details.
    • Changes. Can a state opt out now and change later, or the other way around?
    • The new donut hole: in opt out states, citizens under 100% FPL can’t qualify for refundable tax credits for coverage under a qualified health plan in the exchanges. So a new donut hole is created: desperately poor parents are covered (in Texas, up to 26% of FPL), then the ever so slightly less poor are not covered (in Texas, 26% – 99% FPL), then tax credits in the exchanges can kick in above 100%.
    • Legal immigrants get the donut, not the hole. The ACA assumed citizens under 100% FPL would have Medicaid, but did not assume that for legal immigrants. So legal immigrants under 100% FPL excluded from Medicaid due to their alien status escape the new donut hole, and are eligible for the exchange subsidies even if below 100% FPL.

    Full employment for health care lawyers. See also Austin’s Medicaid questions.

    The best discussion of the Red state opt out in the amicus briefs was the Health Law & Policy Scholars brief for 11-400.  I was counsel of record. Start on p.23, but esp. pp. 38-42.


    • Kevin
      If someone does not have Medicaid, they cant bring Medicare payment parity to the provider, obviously. That shrinks the size of eligible patients.

      However, why would you think primary care payment is linked to the unrelated Medicaid exchange expansion in yesterday’s decision. The two are distinct in the ACA, no? Current and future Medicaid holders, regardless of how they receive that coverage or in what state, seem disconnected.


    • My in-laws are from China and are here on a green card. They are in their seventies and are not elligible for Medicare or Medicaid. They are healthy now, but we live in constant fear that they may get sick or fall down and break something. My wife and I are so happy that we will finally be able to get them health insurance. The high risk pools were too expensive for us, especially considering they are still healthy at this time.