BOISE (AP) — Not nearly as many Idaho residents have signed up through Monday for Medicaid under the state’s voter-approved expanded coverage compared to the number of those eligible.

About 52,000 people have signed up out of an estimated 91,000 who meet requirements. Enrollment started Nov. 1, with coverage beginning Wednesday. But enrollment is year-round, so state officials expect more people to sign up.

Lori Wolff, deputy director of the Idaho Department of Health and Welfare, said she had expected about 60,000 people to have signed up at this point. She said one factor that might be causing procrastination is those who sign up for Medicaid will be covered for doctor visits that occurred earlier in the same month.

“Some people don’t think about it until they need services,” she said. “They may be waiting until they go to the doctor.”

Voters authorized Medicaid expansion last year with an initiative that passed with 61% of the vote after years of inaction by state lawmakers. But lawmakers earlier this year added restrictions requiring five waivers from the U.S. Department of Health and Human Services’ Centers for Medicare and Medicaid Services.

Waivers are required when states want to deviate from Medicaid rules. Federal officials have yet to approve any of Idaho’s requested waivers. Wolff said the uncertain status of waivers is not likely having an effect on people signing up for coverage.

“I have not sensed that level of confusion,” she said. “We try to make sure we’re very clear. I don’t think that’s a big factor.”

The expansion provides Medicaid to people earning up to a maximum of 138% of the federal poverty level. That maximum is about $17,000 a year for one person and $35,500 for a family of four.

Of Idaho’s estimated 1.8 million residents, about 286,000 as of Sept. 1 were covered by Medicaid, according to the Department of Health and Welfare.

If the anticipated 91,000 people sign up under Medicaid expansion, it would cost Idaho about $400 million, with the federal government paying 90%.

Of the five waivers, four of the waivers have been submitted so far.

Idaho in October submitted a waiver requiring patients to get referrals from primary physicians before they can get family planning services such as birth control, abortions or pregnancy care.

Idaho submitted a work requirement waiver in September requiring recipients age 19 to 59 to work 20 hours a week to remain eligible for Medicaid. There are exemptions for medical conditions.

The Centers for Medicare and Medicaid Services in August rejected a “choice” waiver request Idaho submitted as incomplete that would allow Idaho residents who qualify for the expansion to choose to stay on the state’s health insurance exchange.

Idaho Health and Welfare officials are working with federal officials to supply the necessary information.

A similar choice waiver is on hold because federal officials have told the state it may not be necessary.

A final wavier that’s been submitted would allow Medicaid recipients to receive inpatient treatment for mental health and substance abuse disorders at a freestanding psychiatric hospital. Currently, those services are only available in the psychiatric unit of a full-service hospital.

The waivers can take 12 to 18 months, with final decisions occurring after coverage starts and potentially changing who is covered. State officials have said they will work through those issues as they arise.