Medicaid and CHIP Eligibility and Enrollment Policies as of January 2021: Findings from a 50-State Survey

During the coronavirus pandemic, Medicaid has played a key role in providing coverage to millions of people who have lost their jobs or their health coverage. In addition, provisions included in the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief and Economic Security (CARES) Act require states to maintain eligibility standards and provide continuous enrollment in Medicaid until the end of the public health emergency (PHE) in order to qualify for enhanced federal Medicaid funding. This report provides data on state Medicaid and CHIP eligibility levels and presents a snapshot of key aspects of state enrollment and renewal procedures in place during the COVID-19 PHE based on information from the 19th annual survey of Medicaid and CHIP program officials in the 50 states and DC. The report includes policies for children, pregnant women, parents and other non-elderly adults whose eligibility is based on Modified Adjusted Gross Income (MAGI) financial rules. Key findings from the survey include the following.

• In 2021, Medicaid and CHIP eligibility is largely unchanged from 2020 as a result of maintenance of eligibility (MOE) requirements. State eligibility levels across all groups remained steady throughout 2020 due to the FFCRA’s increased FMAP and MOE provisions. Children and pregnant women continue to be covered at higher income levels while the coverage gap for low-income adults persists in the 14 states that have not implemented the expansion. In October 2020, Nebraska became the 37^th state, including the District of Columbia, to implement the Medicaid expansion following its adoption through a ballot initiative in 2018. Voters in Missouri and Oklahoma approved similar initiatives in 2020 and will implement the expansion later in 2021.
• Even with the MOE, most states are renewing coverage when possible and taking other steps to prepare for the end of the PHE. Most states are renewing coverage when they are able to confirm ongoing eligibility through electronic data sources. Two-thirds of states processing renewals also indicate they are sending renewal forms or requests for information when they are unable to renew coverage automatically through other data sources. Although states may not now terminate coverage for lack of response or ineligibility, sending renewal requests enables states to extend coverage for those who respond with proof that they remain eligible. In addition, just over a third of states have established a new 12-month renewal period when processing a change in circumstances that results in a new eligibility pathway. As states prepare for the end of the PHE, more than one-third are continuing or plan to take proactive steps to update enrollee mailing addresses. These actions will help to reduce backlogs and minimize coverage disruptions at the end of the PHE. Only 17 states reported an increase in new applications since the beginning of the COVID-19 PHE.  This could be because of smaller than expected declines in employer-sponsored insurance, drops in applications at the beginning of the pandemic due to office closures, and the elimination of reapplications (where an individual loses coverage, often due to procedural reasons, then reapplies a short time later) due to the MOE requirements.
• Administrative actions and Congressional proposals will have implications for Medicaid coverage and enrollment as well as for state efforts to plan for resuming normal operations after the PHE. In a letter to Governors, the Biden administration noted that the PHE is likely to extend for the entirety of 2021 and promised a 60-day notice before the PHE is terminated or is allowed to expire. In December 2020, CMS released guidance outlining how states are expected to unwind emergency authorities and resume normal eligibility and enrollment processing after the end of the PHE. Although the extension of the PHE gives states more time to prepare for it to end, it is possible CMS will issue additional clarifying guidance, which would affect states’ planning efforts. The administration also recently announced it will revise Medicaid waiver demonstration policy and rescind guidance related to work requirements and may also revise demonstration policy related to capped financing. In addition, the latest COVID relief legislative package includes provisions to provide states the option to extend coverage for pregnant women to 12 months postpartum in both Medicaid and CHIP and to provide financial incentives for non-expansion states to adopt the Medicaid expansion. The eligibility and enrollment policies presented here provide a baseline for assessing changes states may make in response to these federal policy shifts.