oversight

Medicaid: Enrollment and Expenditures for Qualified Individual and Transitional Medical Assistance Programs

Published by the Government Accountability Office on 2012-12-12.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

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. 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. 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



           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).



           Page 1                                             GAO-13-177R Medicaid for Certain Populations
spousal support. 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. 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), 5 the CMS-64 data set, 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. 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. 8 Where necessary, we followed up with
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, 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.



Page 2                                              GAO-13-177R Medicaid for Certain Populations
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. 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. 10 On average,
one quarter of individuals potentially eligible for the QI program were enrolled during
fiscal years 2006 through 2009. 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. 12
Fewer states were able to report TMA expenditure data; however, 32 states reported
TMA total expenditures of about $3.9 billion in 2011. 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.




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, 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.



Page 3                                             GAO-13-177R Medicaid for Certain Populations
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
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.




Carolyn L. Yocom
Director, Health Care

Enclosures – 2




Page 4                                      GAO-13-177R Medicaid for Certain Populations
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. 1 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

                                 Potentially              Enrolled
                       eligible individuals            individuals                                             Expenditures
                                           a                     b                                 b
    Fiscal year            (in thousands)         (in thousands)          Percentage enrolled            (dollars in millions)
    2006                              1,521                     326                            21%                         $310
    2007                              1,518                     358                              24                         353
    2008                              1,428                     381                              27                         411
    2009                              1,473                     426                              29                         431
    2010                              1,446                       —                              —                          547
    2011                              1,453                       —                              —                          660
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
The “─” 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.




1
 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.



Page 5                                                          GAO-13-177R Medicaid for Certain Populations
Enclosure I

Table 2: Enrollment in the Qualified Individual (QI) Program by State, Fiscal Years 2006 through 2009

Number of individuals
                                                              Fiscal year
State                                    2006                 2007                2008              2009
Alabama                                14,985               16,029              16,272            14,128
Alaska                                     75                  103                 110                  115
Arizona                                 1,234                9,790              11,090            13,200
Arkansas                                1,918                6,258               7,870             8,858
California                              7,314               10,043              12,132            13,779
Colorado                                2,306                2,022               2,315             2,574
Connecticut                             7,120                7,974               8,777             9,444
Delaware                                1,670                1,657               1,761             1,912
                       a
District of Columbia                      N/A                  N/A                 N/A                  N/A
Florida                                35,727               34,784              39,090            46,320
Georgia                                17,297               18,577              20,027            23,237
Hawaii                                    620                  615                 773                  987
Idaho                                   1,190                1,290               1,399             1,548
Illinois                               14,504               11,835              12,702            12,892
Indiana                                 6,896                7,050               6,924             6,538
Iowa                                    2,249                2,447               2,591             2,814
Kansas                                  1,946                2,277               2,585             2,972
Kentucky                                8,695                8,678               9,450            10,762
Louisiana                              11,311               12,861              12,897            14,103
Maine                                   5,691                2,226               3,097             4,444
Maryland                                3,615                4,086               4,428             5,211
Massachusetts                               —                   —                   —              7,332
Michigan                                8,460                9,746              10,126            10,557
Minnesota                               3,453                3,509               3,859             4,470
Mississippi                             9,982                9,983               9,789            11,181
Missouri                                  330                  253                 280                  425
Montana                                   313                  365                 443                  516
Nebraska                                2,145                2,519               2,476             3,013
Nevada                                  2,648                2,671               2,961             3,305
New Hampshire                             917                  990               1,164             1,536
New Jersey                              8,638                8,408               8,053             7,686
New Mexico                                  —                   —                   —                   188
New York                               33,273               35,186              32,483            30,887
North Carolina                         17,121               18,674              19,592            21,939
North Dakota                              413                  452                 485                  592
Ohio                                   10,277               12,993              14,485            17,020
Oklahoma                                6,165                6,557               6,950             7,583
Oregon                                  3,385                4,293               4,840             6,312
Pennsylvania                           19,346               20,562              21,227            23,392
Rhode Island                            1,898                1,809               1,943             2,072



Page 6                                              GAO-13-177R Medicaid for Certain Populations
Enclosure I

    Number of individuals
                                                                                Fiscal year
    State                                          2006                        2007                  2008                   2009
    South Carolina                                7,329                        8,183                 7,156                 7,243
    South Dakota                                     857                        952                  1,031                 1,163
    Tennessee                                         —                           —                      —                     —
    Texas                                        24,701                    28,005                  29,690                32,882
    Utah                                              —                        1,041                   966                 1,038
    Vermont                                           —                           —                  2,949                 2,749
    Virginia                                      7,002                        7,815                 8,334                 9,444
    Washington                                    5,449                        5,347                 5,835                 6,334
    West Virginia                                 3,529                        4,129                 4,442                 5,137
    Wisconsin                                     1,642                        2,045                 2,572                 3,097
    Wyoming                                          494                        496                    504                   612
    Total                                      326,130                   357,585                  380,925               425,543

Legend: N/A = Not Applicable
Source: GAO analysis of CMS data.

Notes: The “─” 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.




Page 7                                                           GAO-13-177R Medicaid for Certain Populations
Enclosure I

Table 3: Federal Medicaid Expenditures for the Qualified Individual (QI) Program by State, Fiscal Years
2006 through 2011

Dollars in thousands
                                                          Fiscal year
State                        2006         2007            2008            2009        2010          2011
Alabama                    $31,171     $16,622         $17,498          $16,475    $14,657       $21,009
Alaska                         41          106             109              97           27          316
Arizona                     10,321      11,467          11,953           12,726     15,482        17,334
Arkansas                     4,657       6,194           7,043            9,142     11,487        13,231
California                  11,336      12,981          17,832           21,745     27,636        28,552
Colorado                     1,859       2,436           2,568            2,981       4,146        5,305
Connecticut                  6,716       7,838           9,212           10,044       3,883        4,522
Delaware                      262          254             246             625        2,092        3,378
                       a
District of Columbia          N/A          N/A             N/A             N/A         N/A           N/A
Florida                     26,485      30,147          32,802           35,566     55,327        63,834
Georgia                     17,646      17,464          20,268           22,582     27,648        23,502
Hawaii                          —          483             839             767        1,031        1,286
Idaho                        1,104       1,364           1,528            1,660       1,825        2,339
Illinois                    12,844      14,558          16,639           16,113     20,843        23,813
Indiana                      5,960       4,565           8,559            4,839       5,852        7,283
Iowa                         2,118       2,478           2,675            2,762       3,348        4,241
Kansas                       1,435       1,871           2,423            2,750       3,386        4,443
Kentucky                      172       14,917           9,131           10,371     13,459        15,761
Louisiana                   10,031      11,438          13,478           14,377     17,320        20,326
Maine                        3,695       3,748           2,494            3,469       4,847        5,649
Maryland                     2,793       3,556           4,088            4,590       5,883        7,488
Massachusetts                3,307       3,199          10,231            7,957       8,840       10,784
Michigan                     6,966       8,537          10,242            9,944     10,854        15,010
Minnesota                    2,811       3,585           3,870            4,247       5,261        6,228
Mississippi                     —           —           22,307           10,642     12,574        14,834
Missouri                     2,378       3,319           4,172            4,856       5,870        5,898
Montana                       560          787             643            1,209       1,305        1,591
Nebraska                     1,707       2,175           2,289            2,761       2,735        2,489
Nevada                       1,784       2,187           2,161            2,568       3,396        4,516
New Hampshire                   —           —               —                —        6,394        2,306
New Jersey                   8,725       9,443           9,256            8,916       9,866       10,468
New Mexico                   1,880       2,189           2,577            2,872       3,690        4,368
New York                    32,098      38,064          42,222           35,657     40,421        46,178
North Carolina              14,145      22,145          14,352           20,603     25,681        27,744
North Dakota                  343          443             467             540         658           724
Ohio                        12,444      12,783          18,216           17,051     20,903        25,283
Oklahoma                     5,191       6,377           7,189            7,397       8,757       10,469
Oregon                       4,827       6,759           7,823            8,656     10,785        12,874
Pennsylvania                16,312      19,524          20,719           22,568     26,411        33,435




Page 8                                              GAO-13-177R Medicaid for Certain Populations
Enclosure I

    Dollars in thousands
                                                                        Fiscal year
    State                              2006         2007                2008              2009             2010             2011
    Rhode Island                       1,767       1,550               1,758             1,685            1,829            3,156
    South Carolina                     6,515       5,121               8,010             7,703            7,520           10,006
    South Dakota                        780           926                974             1,070            1,298            1,707
    Tennessee                           146           816                365            14,469          21,392            18,896
    Texas                             19,385      20,593              17,859           18,767           29,199            75,288
    Utah                                120           546              2,538             1,500            1,410            2,751
    Vermont                               —            —                   —             1,377          10,351             3,601
    Virginia                           5,213       6,577               7,420             8,036          10,830            13,428
    Washington                         5,098       5,229               5,334             5,902            7,833            9,698
    West Virginia                      3,110       3,621               4,117             4,514            5,614            6,602
    Wisconsin                          1,268       1,981               2,012             3,476            4,395            5,406
    Wyoming                             743           409                452               482              718              643
    Total                           $310,272   $353,370            $410,960          $431,106         $546,967         $659,991

Legend: N/A = Not Applicable
Source: GAO analysis of CMS data.

Notes: The “─” 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.




Page 9                                                           GAO-13-177R Medicaid for Certain Populations
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. 1 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. 2 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. 3 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. 4 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. 5




1
 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.
2
SSA § 1925(a)(4)(B), codified at 42 U.S.C. 1396r-6(a)(4)(B).
3
 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.
4
SSA § 1925(b)(5), codified at 42 U.S.C. § 1396r-6(b)(5).
5
See SSA § 1925(b)(2)(B), codified at 42 U.S.C. § 1396r-6(b)(2)(B).



Page 10                                               GAO-13-177R Medicaid for Certain Populations
Enclosure II

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                                                                              Number of states
 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                                                                                                      17
 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.                                                                                                         17
 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                                                                                        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.


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. 6 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. 7 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.




6
 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.
7
 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).



Page 11                                                                        GAO-13-177R Medicaid for Certain Populations
Enclosure II

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. 8
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. 9 State responses are summarized below.

•     All but one state reported offering a maximum of 12 months of continued
      Medicaid coverage through TMA. 10

•     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. 11

•     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. 12

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

8
 The 6 states that did not respond to our survey were Connecticut, Montana, New Hampshire, North
Carolina, South Dakota, and Vermont.
9
 Some states do not separate data based on the provisions under which Medicaid coverage is
extended.
10
    South Carolina reported TMA coverage for a maximum of 24 months.
11
  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.
12
  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.



Page 12                                           GAO-13-177R Medicaid for Certain Populations
Enclosure II

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

                                            2006          2007          2008           2009             2010              2011
    Total enrollment
                 a
    (in millions)
    (number of states
    providing data)                   2.78 (N=35)   3.13 (N=38)   3.15 (N=40)   3.08 (N=41)      3.22 (N=41)      3.54 (N=41)
    Total expenditures
    (dollars in billions)
    (number of states
    providing data)              $1.80 (N=27) $3.09 (N=32) $2.91 (N=32) $2.86 (N=31) $3.29 (N=32) $3.86 (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.




Page 13                                                            GAO-13-177R Medicaid for Certain Populations
Enclosure II

Table 6: Enrollment in the Transitional Medical Assistance (TMA) Program by State, Years 2006 through
2011

Number of individuals
State                            2006         2007         2008        2009          2010        2011
Alabama                          3,170       2,408        1,928        2,103        2,370       1,927
           a
Alaska                           1,740       1,811        1,833        1,902        2,168       2,889
               b
Arizona                             ─            ─       45,445       43,836       42,843      45,562
Arkansas                         5,288       4,818        4,524        3,793        3,133       3,235
California                    227,419      297,103      316,787     312,139       323,300     336,635
Colorado                            ─            ─       58,817       60,152       54,697      64,643
Connecticut                         ─            ─           ─            ─             ─           ─
Delaware                        35,061      13,168       14,940       14,179       14,351      17,585
District of Columbia             2,917       2,342        1,762        1,287        1,140       1,332
Florida                       328,912      277,890      280,906     324,094       384,227     424,312
Georgia                       148,259      106,472      127,110     118,149       110,933     111,554
Hawaii                           6,151       4,850        4,808        4,536        4,892       6,271
Idaho                           29,160      16,131        4,654        4,070        4,280       7,089
Illinois                            ─      358,910      374,673     382,085       399,244     445,481
Indiana                       113,527      113,095      109,547       99,217       99,173     109,114
Iowa                                ─       49,961       46,569       44,342       44,358      41,180
Kansas                          25,739      22,061       18,020       14,521       10,910      15,632
Kentucky                        58,574      59,821       56,374       52,162       48,590      54,119
Louisiana                       23,391      27,689       29,262       28,575       25,830      24,893
Maine                           22,400      23,661       23,940       21,440       20,269      23,427
Maryland                        19,424      15,744       14,186       32,412       69,080      96,945
Massachusetts                   63,376      65,120       70,208       73,528       69,696      64,886
Michigan                      155,329      140,315      130,920     142,853       135,214     166,496
Minnesota                       27,607      28,846       30,108       29,121       30,036      35,359
Mississippi                         ─            ─           ─        12,356       35,946      37,348
Missouri                      238,727       84,676      104,803     117,594       112,421     109,357
Montana                             ─            ─           ─            ─             ─           ─
Nebraska                        31,335      28,060       18,443       23,928       35,448      40,903
Nevada                          13,782      10,092        3,102        2,814        8,156      10,297
New Hampshire                       ─            ─           ─            ─             ─           ─
New Jersey                      23,066      26,084       30,889       32,973       32,739      35,627
New Mexico                      59,151      56,436       52,923       53,100       52,949      50,532
New York                            ─            ─           ─            ─             ─           ─
North Carolina                      ─            ─           ─            ─             ─           ─
                   c
North Dakota                        ─            ─           ─            ─             ─           ─
Ohio                          360,876      369,752      352,192     328,838       320,639     371,193
Oklahoma                            14         125          469           48           20          86
Oregon                          80,614      63,517       52,328       48,218       55,021      70,197
Pennsylvania                  223,732      277,879      294,864     251,688       233,278     240,330
Rhode Island                    19,165      15,763       12,162        9,718        9,776       8,128




Page 14                                              GAO-13-177R Medicaid for Certain Populations
Enclosure II

    Number of individuals
    State                                    2006            2007           2008             2009           2010        2011
    South Carolina                         52,840          47,658         55,520           53,583         53,876      62,190
    South Dakota                                 ─               ─              ─                  ─           ─              ─
    Tennessee                                    ─       178,188          95,687           46,018         50,559      55,669
    Texas                                 214,713        174,581         152,595          130,002        129,332     135,068
    Utah                                   12,180          15,155         20,808           21,807         21,486      22,846
    Vermont                                      ─               ─              ─                  ─           ─              ─
    Virginia                                     ─               ─              ─                  ─           ─              ─
    Washington                                   ─               ─              ─                  ─           ─              ─
    West Virginia                            7,789          6,060           4,322            4,046         4,415        3,135
    Wisconsin                             140,313        138,053         131,371          131,424        158,621     187,016
    Wyoming                                  3,944          4,081           4,005            3,691         3,760        4,013
    Total states providing
    enrollment data                             35              38             40                  41         41              41
    Total for states reporting
    enrollment                          2,779,685      3,128,376       3,153,804        3,082,342       3,219,176   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
The “─” 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.




Page 15                                                              GAO-13-177R Medicaid for Certain Populations
Enclosure II

Table 7: Reported Expenditures for the Transitional Medical Assistance (TMA) Program by State, 2006
through 2011

Dollars in thousands
State                           2006        2007         2008         2009         2010          2011
 Alabama                      $2,102       $1,795      $1,596       $1,599        $1,676       $2,283
Alaska                             ─            ─           ─            ─            ─               ─
Arizona                            ─            ─           ─            ─            ─               ─
Arkansas                           ─            ─           ─            ─            ─               ─
California                   140,258      161,731     180,819      139,563      138,335       186,278
Colorado                           ─            ─           ─            ─            ─               ─
Connecticut                        ─            ─           ─            ─            ─               ─
Delaware                           ─            ─           ─            ─            ─               ─
District of Columbia               ─            ─           ─            ─            ─               ─
Florida                            ─      195,949     173,440      194,094      251,171       296,136
Georgia                      132,323       25,673      94,009      114,709        97,227       75,333
Hawaii                          8,778       8,645       4,568        9,257         9,738       11,217
Idaho                         34,349       21,305       8,994        7,820        10,455       15,735
Illinois                           ─      336,931     389,190      439,819      504,305       563,039
Indiana                       92,055       99,702      98,091       94,301        92,932       91,440
Iowa                          48,644       45,857      45,474       44,487        42,130       45,025
Kansas                        23,430       23,833      18,823       16,204        12,772       21,785
Kentucky                      60,571       66,954      70,800       71,606        66,000       74,405
Louisiana                     16,059       18,325      22,478       26,285        24,603       21,197
Maine                         50,593       57,440      56,365       53,855        51,289       58,173
Maryland                      25,049       21,517      19,451       53,845      138,587       193,185
Massachusetts                 77,683       85,291     101,443      109,969      105,848       100,472
Michigan                           ─      307,621     151,110            ─      251,771       313,474
Minnesota                     39,354       47,180      54,867       57,040        58,358       66,827
Mississippi                        ─            ─           ─            ─            ─               ─
Missouri                           ─            ─           ─            ─            ─               ─
Montana                            ─            ─           ─            ─            ─               ─
Nebraska                      29,613       31,556      28,918       27,438        39,823       50,893
Nevada                             ─            ─           ─            ─            ─               ─
New Hampshire                      ─            ─           ─            ─            ─               ─
New Jersey                    16,645       24,851      33,728       37,250        40,074       43,894
New Mexico                    87,946       95,415      96,049       97,414        93,521       82,437
New York                           ─            ─           ─            ─            ─               ─
North Carolina                     ─            ─           ─            ─            ─               ─
North Dakota                       ─            ─           ─            ─            ─               ─
Ohio                         314,746      384,472     339,743      390,330      365,884       525,133
Oklahoma                          25           27         373           47             2              53
Oregon                        93,012       64,796      59,659       58,105        76,398      103,688
Pennsylvania                 241,658      323,900     352,511      323,874      299,649       319,087
Rhode Island                  24,865       22,021      18,526       13,407        12,211       10,977




Page 16                                             GAO-13-177R Medicaid for Certain Populations
Enclosure II

 Dollars in thousands
 State                                     2006          2007          2008             2009            2010             2011
 South Carolina                               ─        78,952        83,914          97,815           94,104         117,013
 South Dakota                                 ─              ─             ─               ─                ─                ─
 Tennessee                                    ─      302,074       160,141          100,932          118,499         139,625
 Texas                                   72,008        73,745        82,661         105,498          107,592         125,559
 Utah                                    20,663        18,291        18,694          22,993           23,868           18,411
 Vermont                                      ─              ─             ─               ─                ─                ─
 Virginia                                     ─              ─             ─               ─                ─                ─
 Washington                                   ─              ─             ─               ─                ─                ─
 West Virginia                            9,505         9,589        13,337          10,990           10,826           11,368
 Wisconsin                              128,524      123,186       121,724          121,964          137,355         160,679
 Wyoming                                 13,017        14,519        12,636          12,817           12,743           12,406
 Total states reporting
 expenditure data                            27             32            32              31               32               32
 Total for states
 reporting expenditures               $1,803,472   $3,093,143 $2,914,130        $2,855,327       $3,289,746       $3,857,227
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.
The “─” indicates that data were not available from the state.




(291086)


Page 17                                                          GAO-13-177R Medicaid for Certain Populations
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