Page 1 GAO-13-454R Transitional Medical Assistance

United States Government Accountability Office

Washington, DC 20548

March 15, 2013

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: Additional Enrollment and Expenditure Data for the Transitional 

Medical Assistance Program

Transitional Medical Assistance (TMA) is a Medicaid program that offers up to 1 year 

of additional Medicaid health insurance benefits for certain low-income families who 

would otherwise lose coverage. Specifically, under TMA provisions that are subject 

to reauthorization, 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 months and up to 12 months of Medicaid coverage.1

However, because little is known about TMA enrollment and expenditures within 

each state, you had asked us to provide more information to inform deliberations on 

reauthorization.2 To this end, we issued a report in December 2012, which included 

information about states’ TMA program policies, enrollment, and expenditures 

beginning in 2006 through the most recent year available.3

 

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, 2013, for families with earned income. SSA § 1902(e)(1)(B) (codified at 42 U.S.C. 

§ 1396a(e)(1)(B)). 

2

These TMA provisions were reauthorized most recently through December 31, 2013, by the 

American Taxpayer Relief Act of 2012, Pub. L. No.112-240, § 622, 126 Stat. 2313 (2013).

3

See GAO, Medicaid: Enrollment and Expenditures for Qualified Individual and Transitional Medical 

Assistance Programs, GAO-13-177R (Washington, D.C.: Dec. 12, 2012).
 Page 2 GAO-13-454R Transitional Medical Assistance

To obtain the information for our December 2012 report, 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 their respective TMA 

programs.4 While 45 states responded to at least a portion of the survey, some 

states were not able to provide the information we requested, or were not able to 

provide the information within the time frames of our work.5

After we completed the analysis for the December 2012 report, four states that had 

responded to our survey provided additional information. Specifically, two states 

(Virginia and Washington) provided TMA enrollment data, and four states (Arkansas, 

North Dakota, Virginia, and Washington) provided TMA expenditure data. You asked 

us to update the survey results to include these data. With these states included,

TMA enrollment in 2011 totaled over 3.7 million in the 43 states that provided 

enrollment data, and TMA expenditures in 2011 totaled about $4.1 billion in the 

36 states that provided expenditure data, which is about $241 million higher than 

what we originally reported. Enclosure I provides updated state-reported information 

on TMA enrollment and expenditures.

However, our December 

report noted that for 2011, 41 states reported TMA enrollment of over 3.5 million 

individuals, and 32 states reported TMA total expenditures of about $3.9 billion.

This update is based on our work for the December 2012 report and our analysis of 

the subsequent survey responses, and was conducted 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. The prior work 

and this update were conducted from October 2012 through March 2013.

– – – – – 

For further information regarding this report, please contact me at (202) 512-7114 or 

yocomc@gao.gov. Copies of this report will 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. 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

Enclosure

 

4

In this report, we use the term “states” to refer to the 50 states and the District of Columbia.

5

We did not independently verify information reported by states.
Enclosure I

 Page 3 GAO-13-454R Transitional Medical Assistance

Transitional Medical Assistance (TMA) 

Updated State Survey Responses

The following tables on Transitional Medical Assistance (TMA) enrollment and 

expenditures include states that provided additional data subsequent to our 

December 2012 report.1

Table 1: Reported Enrollment in the Transitional Medical Assistance (TMA) Program by State, 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

Alaska 1,740 a 1,811 1,833 1,902 2,168 2,889

Arizona ─ b ─ 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

 

1

See GAO, Medicaid: Enrollment and Expenditures for Qualified Individual and Transitional Medical 

Assistance Programs, GAO-13-177R (Washington, D.C.: Dec. 12, 2012). The states that provided 

additional data are Arkansas, North Dakota, Virginia, and Washington. Ultimately, 45 states 

responded to the survey. The 6 states that did not respond to our survey were Connecticut, Montana, 

New Hampshire, North Carolina, South Dakota, and Vermont.
Enclosure I

 Page 4 GAO-13-454R Transitional Medical Assistance

Number of individuals

State 2006 2007 2008 2009 2010 2011

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 ─ ─ ─ ─ ─ ─

North Dakota ─ c ─ ─ ─ ─ ─

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

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 ─ ─ ─ ─ ─ 20,042

Washington ─ ─ ─ ─ ─ 145,992

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 43

Total for states 

reporting enrollment 2,779,685 3,128,376 3,153,804 3,082,342 3,219,176 3,710,535

Source: GAO analysis of state data.

Notes: State data are as of March 2013. State officials were asked to provide an unduplicated enrollment number for each 

year. Alaska and Arizona could not provide unduplicated enrollment data. Officials in 22 states reported enrollment data by 

state fiscal year, 6 reported by federal fiscal year, 13 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.
Enclosure I

 Page 5 GAO-13-454R Transitional Medical Assistance

Table 2: 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 13,031 12,301 10,369 8,466 7,697 6,711

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 ─ ─ ─ 18,627 20,603 20,561

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
Enclosure I

 Page 6 GAO-13-454R Transitional Medical Assistance

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 ─ ─ ─ ─ ─ 33,292

Washington ─ ─ ─ ─ ─ 180,417

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 28 33 33 33 34 36

Total for states 

reporting expenditures $1,816,503 $3,105,443 $2,924,499 $2,882,421 $3,318,046 $4,098,208

Source: GAO analysis of state data.

Notes: State data are as of March 2013. 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 23 

reporting expenditure data by state fiscal year, 5 reporting by federal fiscal year, 7 reporting by calendar year, and for 1 state, 

the period covered was unclear.

The “─” indicates that data were not available from the state.

In addition, our prior report noted that 23 states reported implementing an option to 

provide continued Medicaid coverage under TMA by paying enrollees’ costs 

associated with employer-sponsored insurance. We have updated this information to 

identify the 23 states that indicated use of this option: Alabama, Colorado, the 

District of Columbia, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, 

Massachusetts, Minnesota, Missouri, Nevada, New Jersey, New York, North 

Dakota, Oregon, Pennsylvania, Rhode Island, South Carolina, Texas, Washington, 

and Wyoming.

(291125)
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