Medicaid eligibility and enrollment in Missouri

If you are under 65 and don’t have Medicare:

• You can enroll in MO HealthNet via HealthCare.gov, either online or by phone at 1-800-318-2596.
• You enroll online directly through MO HealthNet. The Missouri Department of Social Services Family Support Division can provide assistance.
• You can complete and submit a paper application.

The Missouri Department of Social Services also has information about the managed care plans that are available for MO HealthNet members, and how you can go about selecting one.

If you’re 65 or older or have Medicare, you can use this website to apply for Medicaid.

Many Medicare beneficiaries receive help through Medicaid with the cost of Medicare premiums, co-pays, deductibles, and services Medicare doesn’t cover — such as long-term care.

Our guide to financial assistance for Medicare beneficiaries in Missouri explains these benefits, including Medicare Savings Programs, long-term care benefits, Extra Help, and income guidelines for assistance.

For three years during the COVID pandemic — from March 2020 through March 2023 — states were prohibited from disenrolling anyone from Medicaid. But states can resume disenrollments as early as April 1, 2023, and are required to redetermine eligibility for all Medicaid enrollees during a one-year “unwinding” period that continues into early/mid-2024. Missouri has an FAQ page related to the return to normal Medicaid eligibility redeterminations and renewals.

In Missouri, the first round of disenrollments will come at the end of June 2023. The state will be processing June renewals starting in April — via the ex parte/automatic process, and then in May with renewal letters sent to those whose coverage can’t be automatically renewed. People who are no longer eligible for MO HealthNet, as well as those who fail to respond to a renewal packet, will need to obtain new coverage starting July 1.

This process will continue each month for 12 months, until eligibility has been redetermined for everyone with MO HealthNet coverage. So some enrollees will not receive a renewal notice until late 2023 or early 2024, and their coverage will continue uninterrupted until that point. But over the course of the 12-month unwinding period, an estimated 200,000 Missouri residents are expected to lose MO HealthNet coverage.

People who lose their MO HealthNet coverage during the “unwinding” period will be able to enroll in other coverage at that point. This can be from an employer (if available), Medicare (if eligible), or through the marketplace/exchange (HealthCare.gov). For all three types of coverage, there’s a special enrollment period triggered by the loss of Medicaid. But in general, it’s important to sign up for new coverage as soon as you know that your Medicaid is ending (ie, before the date the Medicaid coverage ends) so that you won’t have a gap in coverage before your new plan starts.

For the groups described above, only an income limit applies. But for Missouri Medicaid applicants whose eligibility is based on their status as aged (65+), blind, or disabled, there are both income and asset limits. This page is a Missouri-specific overview of how this works.

From late 2013 through late 2022, total enrollment in Missouri Medicaid and CHIP grew by about 67%, to 1,409,576 people. And by early 2023, total enrollment stood at nearly 1.5 million people. The COVID pandemic played a significant role in driving enrollment higher, in Missouri as well as nationwide. Enrollment has also grown since the fall of 2021, due to the state’s implementation of Medicaid expansion, which covered nearly 312,000 people as of early 2023 (Missouri’s Medicaid expansion is described in more detail below).

Voters in Missouri approved a Medicaid expansion ballot measure in August 2020 by a margin of about 53 to 47 (the history of the ballot measure is described in detail below). It called for the state to submit a Medicaid expansion state plan amendment to the federal government by March 2021, and for Medicaid expansion to take effect by July 1, 2021.

In keeping with the timeline called for in the ballot measure, the Missouri Department of Social Services (DSS) submitted a proposed Medicaid expansion plan to HHS in February 2021, calling for Medicaid expansion to take effect July 1.

But when state lawmakers passed the 2022 fiscal year budget, they refused to include funding for the state’s portion of the cost of Medicaid expansion. Lawmakers did allocate normal funding for Medicaid (MO HealthNet), but the DSS indicated that it would not change the eligibility criteria for Medicaid coverage, since lawmakers had not expressly allocated funding for that purpose. So the state withdrew the Medicaid expansion state plan amendment that it had submitted to HHS earlier in the year.

A lawsuit ensued, with plaintiffs who would be eligible for Medicaid expansion suing DSS. DSS argued that the ballot initiative itself was unconstitutional, since the state constitution clarifies that ballot measures cannot be used to appropriate state funds. In late June 2021, a circuit court judge ruled that Missouri’s Medicaid expansion ballot measure was unconstitutional because it didn’t include a funding mechanism (it had left that up to lawmakers, as has been the case in other states where Medicaid has been expanded via ballot measure). So Medicaid expansion did not take effect in Missouri on July 1.

The case was appealed, and the Missouri Supreme Court heard oral arguments on July 13, 2021. The following week, the Supreme Court unanimously vacated the lower court’s ruling, and noted that the Medicaid expansion eligibility criteria outlined in Missouri Article IV, Section 36(c) are “now in effect.” That’s the section of the Missouri code that contains the Medicaid expansion language stipulated in the voter-approved ballot measure, including the fact that the new eligibility rules are effective July 1, 2021.

The Supreme Court sent the case back to the Cole County Circuit Court, instructing the court to rule in favor of the plaintiffs and direct the state to expand Medicaid eligibility. That order was issued in August 2021, and the state proceeded with Medicaid expansion as a result. The MO HealthNet website indicated that people eligible for adult Medicaid expansion could submit an application at that point, but that it wouldn’t be processed until at least October 1.

The state noted at that point that the administrative process of expanding Medicaid was expected to take up to 60 days, “due to current staffing capacity and funding restraints,” but clarified that medical costs incurred between the time a person applies and the time their enrollment is processed “may be reimbursed at a later date.” A later FAQ clarified that applications submitted by November 1, 2021 could have coverage backdated to July 1, 2021.

(There is some precedent for this, with the way Medicaid expansion was implemented in Maine in 2019. It was supposed to take effect in July 2018, but was delayed several months due to the governor’s opposition; once it was implemented, coverage was backdated to when people had applied, with retroactive effective dates as far back as July 2018.)

Before MO HealthNet started accepting applications for the newly eligible Medicaid expansion population, the state had very limited Medicaid eligibility for adults. Non-disabled adults without children were not eligible for Medicaid in Missouri regardless of how low their income was, and parents with dependent children were only eligible with incomes that didn’t exceed 22% of the poverty level. Only Texas and Alabama have lower Medicaid eligibility caps, at 18%. There were 127,000 people in the coverage gap in Missouri before Medicaid expansion took effect. They were unable to qualify for Medicaid because the state still had not expanded eligibility for Medicaid coverage, and unable to qualify for premium subsidies in the exchange/marketplace because they earned less than the poverty level. Fortunately, these individuals can now apply for MO HealthNet coverage.

GOP lawmakers in Missouri continued to push back against Medicaid expansion even after it took effect. In February 2022, the Missouri House of Representatives was considering a measure that would have asked voters to weigh in on a constitutional amendment that would make Medicaid expansion subject to annual budget allocations by the state’s legislature. If the measure had gone to the state’s ballot and been approved by voters, GOP lawmakers in Missouri could essentially have unwound Medicaid expansion by continuing to refuse to fund it. Although the measure passed in the Missouri House in 2022, it did not advance in the state Senate.

In states that expand Medicaid, the federal government paid the full cost of expansion through 2016. Starting in 2017, the states gradually started to pay a share of the expansion cost, and states now pay 10% of the cost (the 90/10 split will remain in place going forward). Because of the generous federal funding for Medicaid expansion, states that reject it are missing out on billions of federal dollars that would otherwise be available to provide healthcare in the state.

From 2013 through 2022, Missouri was projected to give up $17.8 billion in federal funding by not expanding Medicaid.

Hospitals in Missouri that treat uninsured patients were especially hard-hit, as their federal disproportionate share hospital funding has started to be phased out (it was supposed to be replaced by Medicaid funding) and the uninsured rate has remained higher than it would have been with Medicaid expansion in place. As a result of Missouri’s decision to opt out of Medicaid expansion, hospitals in the state were projected to lose $6.8 billion between 2013 and 2022.

Fortunately, Medicaid expansion did eventually take effect in Missouri in late 2021. And as described above, Missouri is also receiving additional federal Medicaid funding as a result of the American Rescue Plan and the timing of when the state’s Medicaid expansion took effect.

SB371, introduced in Missouri’s legislature in 2018, called for putting Medicaid expansion on the November 2018 ballot and letting voters decide, but the bill did not advance. A citizen-led effort to get Medicaid expansion on the ballot in Missouri was considered a non-starter in 2018, as it didn’t have the backing of any major groups at that point.

But in 2019, things were different. Healthcare for Missouri picked up the push for a ballot initiative, and received support and funding from The Fairness Project, which helped with the expansion ballot initiatives in other states in recent years.

The ballot initiative was submitted to the state in June 2019, and was approved for the signature-gathering process to begin. Advocates spent the summer determining the feasibility of Medicaid expansion by ballot initiative in Missouri, and announced in September 2019 that they would commit to gathering the 172,000 signatures necessary for the measure to appear on the ballot.

Dozens of petition-signing events took place in communities around the state in the fall of 2019 and early 2020. Although the COVID-19 pandemic put a halt to in-person signature gathering as of March 2020, Healthcare for Missouri announced at that point that they would still be able to submit the necessary number of signatures by the early May deadline, “thanks to a strong and early start to voter signature collections” in 2019.

The signatures had to be submitted by May 3, and Healthcare for Missouri announced on May 1 that nearly 350,000 signatures — almost twice as many as necessary — had been submitted to the Missouri Secretary of State’s office. The Secretary of State certified the signatures a few weeks later, and Governor Mike Parson soon announced that the measure would be on the August 4, 2020 primary ballot, instead of the general election ballot in November.

Parson, who is opposed to Medicaid expansion and the ballot initiative, said that he was placing the measure on the primary ballot in order to give the state more time to implement Medicaid expansion if voters approve it. But supporters of Medicaid expansion, including Parson’s Democratic gubernatorial challenger Nicole Galloway, felt that Parson chose to put the measure on a ballot for a lower turnout election, in hopes that it wouldn’t pass. Oklahoma Medicaid expansion advocates also gathered enough signatures to get an expansion initiative on the ballot in 2020, and Oklahoma’s governor — who is also opposed to Medicaid expansion — also opted to put the ballot initiative on the primary ballot. But voters in both states approved Medicaid expansion, despite the fact that the measures appeared on primary ballots instead of the general election ballots (Oklahoma’s Medicaid expansion took effect July 1, 2021, as scheduled).

Parson made his opposition to Medicaid expansion clear, but he stated that he would “uphold the will of the people” if the Medicaid expansion ballot measure was passed by voters. The Kansas City Star Editorial Board noted in late 2019 that GOP lawmakers in the state could still opt to craft their own version of Medicaid expansion during the 2020 legislative session, incorporating various limitations that could be achieved with an 1115 waiver. But the only Medicaid expansion bills that were introduced in the 2020 session (SB564 and SB603) were introduced by Democrats and did not advance during the session.

A University of Missouri School of Medicine study in 2012 concluded that “Medicaid expansion would be highly beneficial to the Missouri economy and its citizens.” And in June 2014, the Missouri Economic Research and Information Center announced that healthcare job growth in Missouri had slowed considerably since 2012, and was falling behind compared with states that had expanded Medicaid.  Healthcare is the state’s largest employment sector.

Former Governor Jay Nixon was a longtime proponent of Medicaid expansion, although the Republican supermajority in the state’s legislature blocked his efforts in 2012 and 2013.

But Senator Ryan Silvey, a Republican from Kansas City, was on board with Medicaid expansion, noting that “it’s going to be damaging to our hospitals if we don’t do something.” Silvey’s Democratic colleagues were also supportive of expansion. The legislature came close to approving a modified version of Medicaid expansion in the spring of 2014, and Silvey noted that some of the lawmakers who opposed it had since retired, meaning there might be a better chance for successful legislation in 2015.

In December 2014, Senator-elect Jill Schupp introduced SB 125, which called for expansion of Medicaid up to 138% of the poverty level, but it did not advance out of committee.

Several other similar bills were introduced during the 2015 session as well, including HB 153, HB 1351, and HB 474.  But Republican leadership in the Missouri legislature vowed to block any attempts to expand Medicaid during the 2015 session, and none of the bills advanced to a full vote. Bob Onder, a new state senator from St. Charles, made fighting Obamacare — including Medicaid expansion — his primary focus during the 2015 session. When the Supreme Court upheld the legality of subsidies in states like Missouri that use Healthcare.gov, Onder stated that the Court’s ruling was essentially liberal justices taking the opportunity to “rewrite” the ACA in order to “save” it.  There was hope — nationwide — that the Court’s ruling on King v. Burwell to uphold subsidies would galvanize the Medicaid expansion movement, since it indicated — at that time — that the ACA was here to stay. But opposition to Medicaid expansion among Missouri’s legislative leadership remained strong.

Unfortunately, the legislature’s refusal to expand Medicaid meant that hospitals had to cut costs, and in June 2015, Mercy Hospital announced 127 job cuts in Springfield.