As you probably know, Medicaid is a federal program that provides health insurance coverage for individuals who meet certain eligibility requirements. Medicaid provides coverage for a variety of health services, including preventative and hospital care, emergency room visits, and maternity and newborn care.

What you may not know is that the US Department of Health and Human Services recently announced some major changes to Medicaid that could impact the health coverage of millions of Americans for years to come.

Medicaid Expansion

According to, “…You can qualify for Medicaid based on income, household size, disability, family status, and other factors. Eligibility rules differ between states.”

This was true, until the formation of the Patient Protection and Affordable Care Act, also known as Obamacare.

This legislation allowed Medicaid to expand its reach. It began offering free or low-cost healthcare, based primarily on your income level. This opened the door to individuals who wouldn’t qualify otherwise.

Following the passage of Obamacare, if you made less than 138% of the federal poverty level (FPL), you’d qualify for Medicare coverage.

And if your household income was between 100% and 400% of the federal poverty level, you’d be eligible for tax breaks for private insurance plans. You can get these through the health insurance marketplace and exchanges.

Yet, because individual state governments can choose whether to expand Medicaid’s reach, it has become harder for individuals in some states to obtain health coverage.

So what if your state didn’t choose to expand Medicaid, and you don’t qualify solely based on income? Or what if you don’t qualify for federal tax breaks for private healthcare?

Unfortunately, this means you’ll have a harder time finding coverage. And for individuals who fall into this category, health insurance rates have skyrocketed.

However, one positive aspect of these changes is you won’t have to pay a penalty for not having health insurance if your state didn’t expand Medicaid and you can’t afford health coverage. You can read more about this and other exemptions at

New Standards

Major changes known as “The Final Rule” are making their way into the private health insurance sector.

And these private healthcare changes will affect beneficiaries of both Medicaid and the Children’s Health Insurance Program (CHIP). We’ll focus on Medicaid.

Although issued on April 25, it won’t take effect until January 1, 2017. And there are several major changes to be on the lookout for. The four main components of the final rule include:

Improving Quality of Care and Advancing Delivery System Reform

Medicaid hopes to achieve the goal of improving care by establishing a Quality Rating System (QRS). This is a system that will allow states to monitor the performance of their health services.

According to the final rule’s press release, it serves, “To enable states to better measure and manage the quality of care and to assist consumers to shop for plans.”

They are working towards improving the care that beneficiaries receive through the auditing of healthcare plans and workers.

The final rule also seeks to support states’ efforts to advance health care delivery system reform. says it seeks to, “Strengthen the delivery of services under managed care by setting standards for the State and managed care plans related to network adequacy, the rate setting process, and the intersection of both of these pieces to support robust Medicaid managed care programs.”

Mainly, the goal is to improve the way Medicaid plans are distributed and paid for.

Strengthening the Consumer Experience of Care and Key Consumer Projections

Strengthening the consumer experience of care means helping to bridge the gaps in enrolling in a plan. It also means improving the efficiency of services, communication, and the accessibility of care.

It also seeks to make covered services more readily available, and ensure everyone with a plan receives equal help and attention. And, it will help provide services to help with enrollment and disenrollment.

Strengthening Program Integrity by Improving Accountability and Transparency

This rule will improve accountability and transparency with regard to how Medicaid rates are set. It also sets a standard for screenings and enrollment in the program, as well as reducing fraud.  

There will also be the establishment of a medical loss ratio (MLR). According to this “Measures generally how much a managed care plan spends on the provision of covered services compared to the total revenue it receives in capitation payments from the state.”

As of now, Medicaid and CHIP are among the only major health programs that don’t follow MLR standards. The idea is that with these new standards, it will be easier to compare rates across programs.

Aligning Rules Across Health Insurance Coverage Programs

This goal of rules standardization will ultimately extend to Medicare Advantage, Medical Supplement Insurance, and private health insurance plans as well.

Consumer information also needs to be more readily transferred between different health plans. This is especially important when consumers switch health insurance providers.

Other amenities this rule aims to add are a more standardized appeals process across programs. There is also a push towards tighter screening and enrollment practices.


The government can’t implement all the final rule provisions for a few years. But you’ll start to notice small changes by January of 2017.