Modern Era Medicaid: Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP as of January 2015

Executive Summary

1. Indiana, Oklahoma, and Utah provide more limited coverage to some childless adults under Section 1115 waiver authority.

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2. R. Garfield, et al., “The Coverage Gap: Uninsured Poor Adults in State that Do Not Expand Medicaid – An Update,” Kaiser Family Foundation, November 2014.

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3. J. Guyer, T. Schwartz, S. Artiga, “Fast Track to Coverage: Facilitating Enrollment of Eligible People into the Medicaid Expansion, Kaiser Commission on Medicaid and the Uninsured, November 2013.

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4. Smith, V., et al.., “Medicaid in an Era of Health and Delivery System Reform: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2014 and 2015,” Kaiser Commission on Medicaid and the Uninsured, October 14, 2014, https://www.kff.org/report-section/medicaid-in-an-era-of-health-delivery-system-reform-eligibility-and-enrollment/

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5. The Medicaid and CHIP Payment and Access Commission, “Report to the Congress on Medicaid and CHIP,” June 2014.

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Introduction

1. As in past reports, information is not included for low income seniors or people with disabilities covered by Medicaid.

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Medicaid and CHIP Eligibility

1. The ACA established new standards for determining eligibility based on tax law in order to align coverage across the insurance affordability programs, including Medicaid, CHIP and subsidies in the health insurance marketplaces. MAGI rules establish specific guidelines for counting income and household size, although there are some exceptions in determining Medicaid eligibility only. States can no longer use asset tests in determining eligibility and were required to convert their pre-ACA eligibility levels accounting for the use of income disregards and deductions to the new MAGI standards, which were implemented on January 1, 2014. A standard five-percentage point disregard applies to the upper eligibility limits in determining MAGI-based eligibility. MAGI rules apply only to coverage for children, pregnant women, parents and the new expansion adult group, not to seniors or the disabled.

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2. The newly elected governor in Pennsylvania has indicated plans to move to the state option for expansion.

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3. Indiana, Oklahoma, and Utah provide more limited coverage to some childless adults under Section 1115 waiver authority.

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4. R. Garfield, et al., “The Coverage Gap: Uninsured Poor Adults in State that Do Not Expand Medicaid – An Update,” Kaiser Family Foundation, November 2014.

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Enrollment and Renewal Processes

1. J. Edwards, et al., “Reducing Paperwork to Improve Enrollment and Retention in Medicaid and CHIP,” Medical Institute at United Hospital Fund, October 2009.

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2. J. Guyer, T. Schwartz, S. Artiga, “Fast Track to Coverage: Facilitating Enrollment of Eligible People into the Medicaid Expansion, Kaiser Commission on Medicaid and the Uninsured, November 2013.

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Eligibility and Enrollment Systems

1. CMS announced its plan in a letter dated October 28, 2014 from Cindy Mann, Director of the Center for Medicaid and CHIP Services, to the American Public Human Services Association and the National Association of Medicaid Directors. http://ccf.georgetown.edu/wp-content/uploads/2014/10/Letter-to-APHSA-and-NAMD-from-Cindy-Mann-10-28-14-.pdf

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2. Smith, V., et al.., “Medicaid in an Era of Health and Delivery System Reform: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2014 and 2015,” Kaiser Commission on Medicaid and the Uninsured, October 14, 2014, https://www.kff.org/report-section/medicaid-in-an-era-of-health-delivery-system-reform-eligibility-and-enrollment/

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3. Letter from Cindy Mann, October 28, 2014, op cit.

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Premiums and Cost-Sharing

1. CHIP rules also limit the amounts that may be charged to enrollees. For families earning less than 150 percent of FPL, premiums cannot exceed $19 per month depending on income and family size while co-payments and other cost-sharing limits are slightly higher than Medicaid. No limits apply to families with income above 150 percent of the FPL, except the total annual cost-sharing cap of five percent of income, which applies to all CHIP enrollees.

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2. An interim study published in November 2013 compares the pre-ACA eligibility levels with the MAGI-converted levels. For more information see, “Getting into Gear for 2014: Shifting New Medicaid Eligibility and Enrollment Policies into Drive.”

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3. If states charge premiums in Medicaid, they must provide a 60-day grace period because cancelling coverage due to nonpayment of premiums. Additionally, they are prohibited from locking beneficiaries out of coverage or making them repay outstanding amounts in order to re-enroll. See 42 CFR 447.55.

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Looking Ahead

1. CMS posts state-by-state, monthly Medicaid and CHIP application and enrollment data, which can be found at http://medicaid.gov/medicaid-chip-program-information/program-information/medicaid-and-chip-enrollment-data/medicaid-and-chip-application-eligibility-determination-and-enrollment-data.html.

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2. L. Clemans-Cope, et al., “Increase in Medicaid under the ACA Reduces Uninsurance, According to Early Estimates,” The Urban Institute, June 25, 2014.

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