Introduction

In the closing days of 2020, Congress enacted and the President signed into law the No Surprises Act, providing new federal consumer protections against surprise medical bills.  The measure was included in omnibus legislation funding the federal government for fiscal year 2021 and providing stimulus relief for the COVID-19 pandemic.  Its enactment followed nearly two years of Congressional debate over competing approaches to the problem that, at times, appeared to be deadlocked.

The No Surprises Act contains key protections to hold consumers harmless from the cost of unanticipated out-of-network medical bills.  Surprise bills arise in in emergencies – when patients typically have little or no say in where they receive care.  They also arise in non-emergencies when patients at in-network hospitals or other facilities receive care from ancillary providers (such as anesthesiologists) who are not in-network and whom the patient did not choose.

Surprise bills lead the list of affordability concerns for many families; 2 in 3 adults say they worry about unexpected medical bills, more than the number worried about affording other health care or household expenses.  Surprise bills can number in the millions each year.  Among privately insured patients, an estimated 1 in 5 emergency claims and 1 in 6 in-network hospitalizations include at least one out-of-network bill.  A health plan that generally doesn’t cover out-of-network care, such as an HMO, might deny a surprise bill entirely.    Or plans might pay a portion of the bill, but leave the patient liable for balance billing – the difference between the undiscounted fee charged by the out-of-network provider and the amount reimbursed by the private health plan.¹    Balance billing on surprise medical bills can reach hundreds or even thousands of dollars.   Surprise medical bills are not a problem today under public programs – Medicare and Medicaid – that prohibit balance billing.

The new law takes effect for health plan years beginning on or after January 1, 2022 and it applies to nearly all private health plans offered by employers (including grandfathered group health plans and the Federal Employees Health Benefits Program), as well as non-group health insurance policies offered through and outside of the marketplace. The new law contains other related provisions, including a requirement for health plans to keep network provider directories up to date.  This brief summarizes key provisions of the No Surprises Act and issues that could arise during implementation.

Consumer Protections Under Federal Law

The law contains key provisions to protect consumers against the cost of surprise medical bills.

Health plans must cover surprise bills at in-network rates.  The law requires private health plans to cover surprise medical bills for emergency services, including air ambulance services, as well as out of network provider bills for services rendered at in-network hospitals and facilities.  An advisory committee will be appointed to recommend options for protecting patients against surprise ground ambulance bills.

The law requires surprise bills must be covered without prior authorization and in-network cost sharing must apply.  In-network cost sharing for surprise bills will be based on a “recognized amount,” which in most cases will be the median in-network payment amount under the plan for the same or similar services.

The law also requires that federal external appeal rights apply if consumers feel their health plan has not correctly identified and covered a surprise medical bill.  A 2011 federal regulation temporarily limited the scope of denied claims eligible for external appeal to those denied on the basis of medical necessity or similar clinical considerations, pending data on the volume of appeals requested; in 2015 this limited eligibility was made permanent.  Transparency data reported by federal marketplace health plans show consumers appeal less than 0.2% of denied claims, and seek external appeal even more rarely.

Balance billing is prohibited. Out-of-network providers for emergency services are not allowed to balance bill patients beyond the applicable in-network cost sharing amount for surprise bills.  This same requirement applies to out-of-network providers who render non-emergency services at an in-network hospital or other facility.  An exception applies for certain non-emergency services if providers gives prior written notice at least 72 hours in advance and obtain the patient’s written consent.  The notice must indicate the provider does not participate in-network, provide a good faith estimate of out-of-network charges, and include a list of other participating providers in the facility whom the patient could select.  This exception does not apply for ancillary services (such as anesthesia) or diagnostic services (such as radiology and lab) nor to other services or providers the Secretary may specify in regulation.

Out-of-network providers cannot send patients bills for excess charges. Importantly, the law specifies that providers “shall not bill, and shall not hold patients liable” for an amount that is more than the in-network cost sharing amount for such services.   The “shall not bill” language did not appear in earlier bill versions, and constitutes an additional element of consumer protection under the new law.  Essentially it puts the burden on out-of-network providers to determine a patient’s insurance status and the applicable in-network cost sharing for the surprise medical bill.  Absent the “shall not bill” language, nonparticipating providers might continue to bill patients for the full amount, and only later refund excess amounts when and if patients learn surprise billing protections apply.

Specific oversight and enforcement activities are required. With respect to private health plans, enforcement of the No Surprises Act generally follows the same rules that apply under the Affordable Care Act (ACA).  States may enforce federal requirements against health plans they regulate (non-group health plans and fully-insured employer-sponsored plans), with federal fallback enforcement required if it is determined that states are failing to substantially enforce.  The federal government has primary responsibility for oversight and enforcement with respect to self-insured group health plans, which today cover about half of all people with job-based coverage, and which states are preempted from regulating under the Employee Retirement and Income Security Act (ERISA).   The Secretaries of Labor and Treasury (which share enforcement over ERISA plans) must audit a sample of plans each year to ensure that plans are covering surprise bills and applying in-network cost sharing correctly. The Secretary must report annually to Congress on findings from the audit process.   In addition, by July 1, 2021, Secretaries from 3 federal departments (Health and Human Services, Labor, and Treasury) must establish a process for receiving complaints of violations of surprise bill protections by private health plans and issuers.

Enforcement with respect to health care providers and facilities also begins with the states. In cases where a state fails to substantially enforce the law’s provider requirements, the federal government will enforce. The Secretary of Health and Human Services must establish a complaints process for violations of surprise billing protections by health care providers and facilities.  Under federal enforcement, civil money penalties of up to $10,000 per violation can be applied to health care providers and facilities.

A number of states have enacted surprise medical bill protections for the plans they regulate.  State surprise medical bill laws are not preempted unless they prevent the application of federal law.

Resolving Payment Amount for Surprise Bills

As Congress debated this issue, there was general, bipartisan consensus about consumer protections, but significant disagreement about how to resolve the payment amount for surprise, out-of-network medical bills.  Some favored use of an independent dispute resolution process (IDR) to resolve every surprise bill and giving weight to the nonparticipating provider’s undiscounted charge.  The Congressional Budget Office (CBO) said such an approach would be inflationary, driving up health plan costs.  Others favored establishment of a benchmark payment, based on the health plan’s median in-network payment amount, to determine payment for most surprise medical bills. The CBO said this approach would tend to limit payment for surprise bills and significantly reduce health plan costs and the federal deficit.

The final compromise permits access to IDR for any surprise medical bill following a 30-day period when the plan and provider try to negotiate a payment amount.  The IDR process follows so-called baseball-style arbitration rules; each party submits a final offer, and within 30 days the IDR entity determines which offer is most reasonable.  The IDR decision is binding, and the losing party must pay the cost of the arbitration process. In making its determination, the IDR may consider a number factors, including the plan’s median in-network rate for the service; but it may not consider the undiscounted provider charge or the amount public programs (such as Medicare) would pay for the service. This approach is intended to minimize reliance on the IDR and encourage all parties to submit reasonable bids.  The CBO estimated the law will lower payments to some providers, resulting in a reduction of private health plan premiums between 0.5% and 1% on average, and – because the federal government subsidizes most private insurance directly or through tax preferences – reducing the federal deficit by $17 billion over 10 years.

Other Provisions

The law includes several other provisions to help consumers get information in advance about how their health plan will work in practice, and to promote transparency of medical care prices generally.

Health plans must provide an advanced explanation of benefits.  Also beginning in 2022, consumers can request advance information about how services will be covered before they are provided.  For scheduled services, consumers can submit requests and, generally within three business days, the health plan must provide written information including about whether the provider/facility participates in-network, and a good faith estimate of what the plan will pay and what patient cost liability may be.

Health plans must provide transitional continuity of coverage when a provider leaves the network.  The law requires health plans and issuers to notify enrollees when a provider/facility leaves the plan network while it is providing ongoing care.  In certain cases, health plans must also provide transitional coverage for up to 90 days or until treatment ends (whichever is earlier) at in-network rates.  The transitional coverage requirement applies to treatment for serious or complex health conditions, institutional or inpatient care, nonelective surgery, pregnancy, and care for patients with terminal illness.

Health plans must maintain accurate provider network directories.   Health plans and issuers must establish a verification process to update provider directory information at least every 90 days. They also must respond within 1 business day to requests from individuals about whether a provider or facility is in-network.  This information becomes binding.  Consumers who rely on incorrect information conveyed by plans or posted in directories are entitled to have services covered with in-network cost sharing applied.  Providers and facilities are also required to provide timely updates to health plans when the content of their directory information changes.

Health plans must disclose information about broker commissions. Individual health insurance plans, including short-term limited duration insurance, must disclose to enrollees the amount of direct and indirect compensation paid to brokers for that enrollment.  Plans must also report information on broker compensation annually to the Secretary.  This disclosure must be made before the individual finalizes plan selection.    Disclosure of broker and consultant commissions is also required for group health plans.

Implementation Issues

The first implementation deadline specified in the law is July 1, 2021.  By then, the federal government must publish regulations establishing the methodology used by group health plans and issuers to determine the in-network cost sharing amounts for surprise bills and the information that plans and issuers must share with non-participating providers and facilities.  In most cases the in-network cost sharing amount will be based on a health plan’s median in-network rate paid for a given service in 2019, with that amount (also called the “qualifying amount”) indexed for subsequent years. Regulations will also need to specify alternate methods for determining qualifying amounts for new plans and services with no established rates in 2019.

Also by July 1, 2021, HHS must have established a complaints process for consumers to report surprise medical bill problems. The law appropriates $500 million in funding for implementation.

It remains to be seen how new consumer protections will work in practice. The law establishes stiff penalties for violation of balance billing prohibitions, requires a consumer complaints process, and grants appeal rights to consumers whose health plans do not appropriately recognize and cover surprise medical bills.  Even so, experience shows consumers rarely avail themselves of complaints and appeals rights.  As noted above, in 2019 consumers appealed about 63,000 of the more than 40 million medical claims denied by federal marketplace insurers.  That year, the total number of complaints against health insurers compiled by the National Association of Insurance Commissioners (NAIC) was less than 40,000.  Federal implementation could specify a role for statewide consumer assistance programs (CAPs), established under the ACA, to help patients navigate new protections.  By law CAPs must help consumers resolve insurance problems and file appeals.  Health plans are also required already to include contact information for CAPs on all claims denial notices.  Forty CAPs were established in 2010 and provided individual assistance to 207,000 consumers in the first year; 36 CAPs are still in place.  Congress has not appropriated funding for CAPs since 2010, although it is possible that a portion of funds appropriated to implement the No Surprises Act could be used to support consumer assistance.

Implementation strategies could also consider ways to prevent violations in the first place.  It is common practice today for nonparticipating providers to bill patients directly and leave to them to work out claims submission and reimbursement with their insurer.  The No Surprises Act seems to put the burden on nonparticipating providers to deal directly with their patients’ health plans.  Regulations could clarify such a requirement, along with tools to carry it out.  Out-of-network providers will need to obtain permission – also called assignment of benefits – from patients in order to deal directly with their health plans, as state surprise billing laws generally require.

Implementers will need to establish and monitor IDR capacity in real time.  The law requires the federal government to ensure a sufficient number of independent dispute resolution entities (IDRE) are certified to ensure the timely and efficient provision of determinations. Potentially millions of surprise bills may arise each year and it is unclear how many of those might be resolved by the IDR process, vs. by health plan/provider negotiation and settlements.  Congress intended to incentivize health plans and providers to settle on their own, minimizing reliance on the IDR process.  The IDR process also requires a “cooling off” period; the party that initiates IDR cannot seek IDR again with the same party for the same service for 90 days.  How these incentives work in practice remains to be seen. The federal IDR system is similar to that established in New York, where 1,148 surprise medical bills were resolved by IDR in 2018, up from 149 cases in 2015 when the program opened.  The state system has jurisdiction over only a small portion of all surprise medical bills, as ERISA preempts state regulation of self-funded employer plans, which cover most privately insured individuals.²  Presumably, regulations will provide a way for the federal government to monitor sufficiency of IDR system capacity and make needed changes promptly.

Federal implementers will need to consider the number and type of IDR entities to engage.  State surprise medical bill resolution systems have followed different approaches to establish IDR capacity.  In New York, for example, the state contracts with several IDR entities, including independent review organizations (IROs) that also conduct independent claims review under the state’s external appeals law.  IROs contract with board certified physicians and other insurance contract experts to perform expert claims reviews.  Fees charged by IDRE organizations typically range from $300 to $600.  Other state surprise medical bill programs rely on individual mediators and arbitrators to provide IDR services.  The Texas Department of Insurance, for example, contracts with more than 200 individual attorneys to provide IDR services for surprise bills.  Their fixed fees per case range from $270 to $6,000.  In addition to IDR fees (which the losing party pays) the law requires the federal government to establish a federal administration fee for the program, another important implementation detail.

Implementation must also guard against conflict of interest in the IDR process.  The No Surprises Act prohibits IDREs from having “a material familial, financial, or professional relationship” with either party.  Conflicts may arise if IDR organizations also have contracts with employer health plans to conduct external appeals for denied claims.  Unlike state external review systems, where the state contracts with independent review organizations, federal guidelines require employer-sponsored plans to contract with at least three accredited IROs and rotate assignment of external appeals among them.

Substantial data collection and monitoring is required.  By law the IDR process must be transparent.  The Secretary is required to post online information quarterly on the number of surprise bills that go to the IDR process, the cost of the process, and amounts paid to each IDR entity.  In addition, for each surprise bill that goes to the IDR process, the Secretary must post information about the identity of the parties involved, the nature and geographic location of the service provided, the payment amounts offered by each party, which party prevailed, and the length of time involved in making the determination.

In addition, Congress required regular reporting on the impact of the new law on health care prices, provider participation in health plan networks, and other outcomes.  Congress is specifically interested in how the new law affects health care markets.  For example, if the new law results in payments for out-of-network claims that are “too high,” there could arise a disincentive for providers to participate in health plan networks.  By contrast, if it payments are too low, there could arise a disincentive for health plans to pay competitive rates to keep providers in network.  The law requires the Secretary of HHS, in consultation with the Attorney General and the Federal Trade Commission, to study and report annually to Congress on how the law affects competition in health care markets, as well as the laws impact on overall health costs and on access to health care services, especially in rural areas and other professional shortage areas. It also requires study and report by the Government Accountability Office (GAO) to collect data and report on the law’s impact on provider network participation rates and the adequacy of provider networks.  In addition, GAO is required to report on how the law impacts prices charged for health services and changes in patient out-of-pocket costs.

Beyond requirements in the No Surprises Act, the federal government has broad general authority to require reporting on surprise medical bill claims under ACA transparency data reporting provisions.  Use of this authority could help in tracking trends in surprise medical bills that do not use the IDR process.

1. The Affordable Care Act requires private health plans to cover out-of-network emergency services and to apply in-network cost sharing to such claims.  The Affordable Care Act also sets standards for a reasonable amount that plans must pay for out-of-network emergency services, but it does not prohibit balance billing by out-of-network emergency care providers. ↩︎
2. In addition, as of that year, New York’s surprise medical bill law did not apply to hospital charges for emergency services. ↩︎

Updated analysis of state-reported data as of February 1, 2021 on COVID-19 vaccinations, cases, and deaths by race/ethnicity is now available.

Based on nearly half of states reporting vaccination data by race/ethnicity, Black and Hispanic people continue to receive smaller shares of vaccinations compared to their shares of cases and deaths and compared to their proportions of the total population. In all 23 states reporting data, Black people account for a smaller share of vaccinations compared to their share of cases and smaller than (equal to in Vermont) their share of deaths. In 21 states reporting data on Hispanic people, the share of vaccinations among Hispanic people is smaller than their share of COVID-19 cases and also in their share of deaths with the exception of Missouri and Vermont.

Vaccination patterns may change as more data is available and more parts of the country gain greater access to vaccines. To date half of states are not yet reporting vaccinations by race/ethnicity. In 8 of the 23 reporting states, race/ethnicity is unknown for a quarter of vaccinations, including Texas and Virginia where over 40% of vaccinations have unknown race/ethnicity.

Beyond tracking data, KFF continues to produce analysis on racial equity in vaccination distribution and our news reporting at KHN also has shown that vaccination is lagging by various measures for people of color.

Additional Data Available Through Online Vaccine Monitor Dashboard

As vaccination efforts ramp up across the country, the KFF COVID-19 Vaccine Monitor examines where the public is getting its relevant information.

Large shares of the public report that they are getting at least a fair amount of vaccine information from television news, including cable (43%), network (41%) and local (40%) television, and from friends and family (40%). Somewhat fewer get at least a fair amount of information from social media (31%), a doctor, nurse, or other health care provider (31%) and other sources.

There are differences in people’s sources of vaccine information based on how enthusiastic they are about getting a vaccine.

Among those who say they “definitely will not” get a vaccine (13% of the public), the most-cited media source for at least a fair amount of vaccine information is social media (40%), followed by cable (37%), network (32%) and local (28%) television. Most likely, the vaccine hesitant are self-selecting social media information sources they are comfortable with.

Those who want to “wait and see” how the vaccine is working for others before getting it (31% of the public) are about equally likely to say they are getting at least a fair amount of relevant information from social media (37%) as cable (37%), network (36%) and local (41%) television.

In contrast, those who want to get the vaccine as soon as they can (41% of the public) are about twice as likely to say they have gotten at least a fair amount of information about the vaccine from cable news (51%) as from social media (25%) This may in part reflect generational differences in media consumption, as older Americans on average are more enthusiastic about getting vaccinated and less likely to turn to social media for vaccine information.

Available through the Monitor’s new online dashboard, the analysis also examines sources of vaccine information by age, race and ethnicity, and urban, suburban and rural communities; by cable networks including Fox, MSNBC and CNN; and by social media platforms including Facebook and Twitter. It may be that people self-select news sources that they feel reinforce their views rather than the sources leading to those views.

The KFF COVID-19 Vaccine Monitor is an ongoing research project tracking the public’s attitudes and experiences with COVID-19 vaccinations. Using a combination of surveys and qualitative research, this project tracks the dynamic nature of public opinion as vaccine development and distribution unfold, including vaccine confidence and hesitancy, trusted messengers and messages, as well as the public’s experiences with vaccination.

The new KFF Women’s Health Survey, a nationally representative survey of women and men, finds that a majority of women (56%) and 40% of men believe passing a law that prevents people who have committed domestic violence from having a gun should be a top policy priority for the new Congress and administration among a list of potential women’s health policy priorities.

Creating policies that ensure people are not discriminated against because of their gender identity or sexual orientation also ranked high as a priority with nearly half of women (48%) and more than one-third of men (36%) say this issue is a top priority. (On President Biden’s first day in office, he signed an executive order to prevent discrimination based on gender identity or sexual orientation.)

The survey found that top policy priorities differed by age. For example: paid time off following the birth or adoption of a child is ranked a top priority by 34% of men and 50% of women ages 18-49, compared with 18% of men and 37% of women ages 50-64.

On January 28th, President Biden signed a memorandum directing the Department of Health and Human Services to review the Trump administration rule that led to a decline in participating clinics and patients served under the Title X federal family planning program. Four in ten women (41%) and one in four men (23%) say providing more public funding to support access to family planning services and birth control is a top priority.

A majority of Black women (61%) say requiring states to allow women enrolled in public programs like Medicaid to keep their health coverage for a full year after childbirth should be a top priority for federal lawmakers, making it the highest priority issue for Black women.

For additional findings read the full brief, Public Perspectives on Women’s Health Policy Priorities for the Biden-Harris Administration and Congress. More results from the KFF Women’s Health Survey will be released in the coming weeks.

MethodologyKFF has conducted the KFF Women’s Health Survey approximately every four years since 2001 to provide a look into the range of women’s health care experiences, especially those that are not typically addressed by most surveys. KFF’s latest Women’s Health Survey surveyed 3,661 women and 1,144 men ages 18-64 between November 19 and December 17, 2020.

In January 2021, the number of deaths from COVID-19 increased so rapidly that it has clearly become the number one cause of death in the U.S., with an average of more than 3,000 people per day dying of COVID-19 in the U.S. as of Jan. 26. That number is significantly higher than other leading causes of death and is nearly 50% higher than the next leading cause. Heart disease, which is typically the number one cause of death in the U.S. each year, leads to the death of about 2,000 Americans per day, and cancer claims about 1,600 American lives per day.

The chart above combines data on COVID-19 mortality rates from KFF’s tracker with data from the Center for Disease Control (CDC) on weekly counts of death by jurisdiction and cause of death. COVID-19 deaths in the chart represent the average daily deaths in January 2021 (as of January 26, 2021). Deaths from other causes represent the weighted daily mortality rate averaged over MMWR weeks 1-52 during the year 2020. This CDC dataset does not include deaths due to accidents (which, before the pandemic, were typically the third leading cause of death, after heart disease and cancer), nor does it include suicides (which were typically the tenth leading cause of death before the pandemic). To avoid double-counting, the dataset excludes deaths confirmed to have an underlying cause of COVID-19. The chart could, however, understate the severity of COVID-19 because some of those deaths may have been misclassified as other causes. There were many more deaths in 2020 than expected, and confirmed COVID-19 cases only accounted for about three in four excess deaths.

With two vaccines available now in the United States that are more than 90% effective at preventing illness from the virus, these data are just one more way of illustrating the urgency of expediting COVID-19 vaccination. While the number of new COVID-19 cases appears to have taken a turn for the better in the latter half of January, it is difficult to know what the future holds, particularly with the potential spread of new variants.

Source

COVID-19 is the Number One Cause of Death in the U.S. in Early 2021

Here’s our recap of the past week in the coronavirus pandemic from our tracking, policy analysis, polling, and journalism.

The world surpassed 100 million COVID-19 cases this week, with the United States accounting for a quarter of them. The U.S. also accounts for one-fifth (433,200) of the world’s nearly 2.2 million reported deaths.

A new analysis shows that COVID-19 is currently the number one cause of death in the country. As of January 26, 2021, an average of more than 3,000 people per day died of COVID-19 in the U.S. this month, nearly 50% higher than the next leading cause.

The COVID-19 Vaccine Monitor reports the public’s eagerness to get a vaccine is rising across racial and ethnic groups, though Republicans and rural residents remain the most reluctant groups.  Nearly half (47%) of the public want to get the vaccine as soon as they can or have already been vaccinated. That is significantly higher than the third (34%) of the public in the most-eager “as soon as possible” category in December.

Data and analysis related to vaccine acceptance and hesitancy, trusted messages and messengers, demographic breakouts, and people’s experiences, are now featured in a new dashboard for the Monitor. The dashboard will be updated regularly to reflect the latest data and current issues.

As KHN reports on the challenge of ramping up vaccine production, Drew Altman dives into the discussion about how many vaccinations are needed, and by when, for herd immunity. Here are his estimated goalposts on the calendar and what it would take to vaccinate 70% of the country’s population by then:

July 4 → 2.4 million doses/day

Labor Day → 1.9 million doses/day

Jan 1, 2022 → 1.2 million doses/day

Reporting from KHN continues to show that vaccination is lagging for Black Americans and highlights the lack of data about who is being vaccinated. But there are disparities long before the point of getting shots in arms. KFF analysts this week examined why racial diversity within COVID-19 vaccine clinical trials is important, the clinical trial participation barriers among people of color, and examine the racial/ethnic composition of clinical trial participants for the Pfizer-BioNTech and Moderna coronavirus vaccines.

President Biden issued an executive order this week to reopen enrollment into the Affordable Care Act’s marketplaces for a special period in order to reduce the number of uninsured during the ongoing pandemic. An analysis finds that nearly 9 million uninsured Americans could get free or subsidized health insurance with the reopening. Another brief looks at opportunities to expand health coverage enrollment during the pandemic.

Here are the latest coronavirus stats from KFF’s tracking resources:

Global Cases and Deaths: Total cases worldwide stand at 101.5 million this week – with an increase of 3.9 million new confirmed cases in the past seven days. There were approximately 99,500 new confirmed deaths worldwide, bringing the total for confirmed deaths to nearly 2.2 million.

U.S. Cases and Deaths: Total confirmed cases in the U.S. approached 25.8 million this week. There was an increase of about 1.1 million confirmed cases between Jan. 21 and Jan. 28. Approximately 22,800 confirmed deaths in the past week brought the total in the United States to 433,200.

State Social Distancing Actions (includes Washington D.C.) that went into effect this week:

Extensions: CO, DE, IN, NH, NC, SC, WY

Rollbacks: CA, IL, NM, ND, OH, WY

The latest KFF COVID-19 resources:

• KFF COVID-19 Vaccine Monitor: Nearly Half of the Public Wants to Get a Vaccine as Soon as They Can or Has Already Been Vaccinated (News Release, Report)
• How Quickly We Need To Ramp Up Vaccinations To Get To Herd Immunity (Full Column, Axios Column)
• Marketplace Eligibility Among the Uninsured: Implications for a Broadened Enrollment Period and ACA Outreach (News Release, Issue Brief)
• Key Issues for State Medicaid Programs When the COVID-19 Public Health Emergency Ends (Issue Brief)
• Racial Diversity within COVID-19 Vaccine Clinical Trials: Key Questions and Answers (Issue Brief)
• Opportunities and Resources to Expand Enrollment During the Pandemic and Beyond (Issue Brief)
• COVID-19 is the Number One Cause of Death in the U.S. in Early 2021 (Issue Brief)
• Analyzing Recent Trends in Medicaid/CHIP Applications: What We Do and Do Not Know (Issue Brief)
• Updated: COVID-19 Coronavirus Tracker – Updated as of January 29 (Interactive)
• Updated: State Data and Policy Actions to Address Coronavirus (Interactive)

The latest KHN COVID-19 stories:

• Why Even Presidential Pressure Might Not Get More Vaccine to Market Faster (KHN, Daily Beast)
• ‘We’re Not Controlling It in Our Schools’: Covid Safety Lapses Abound Across US (KHN)
• Poll: Nearly Half of American Adults Now Want the Covid Vaccine — ASAP (KHN)
• Remdesivir, Given to Half of Hospitalized Covid Patients in U.S., Is Big Win for Gilead — Boosted by Taxpayers (KHN, SF Chronicle)
• Big Business Boosts Vaccine Effort, but It’s ‘Complex Choreography’ to Get Shots in Arms (KHN, NPR)
• Vaccine Ramp-Up Squeezes Covid Testing and Tracing (KHN, LA Times)
• Amid Covid Health Worker Shortage, Foreign-Trained Professionals Sit on Sidelines (KHN, US News)
• If I Have Cancer, Dementia or MS, Should I Get the Covid Vaccine? (KHN, CNN)
• California’s Top Hospital Lobbyist Cements Influence in Covid Crisis (KHN, LA Times)
• Anti-Vaccine Activists Peddle Theories That Covid Shots Are Deadly, Undermining Vaccination (KHN, CNN)
• Lost on the Frontline: New this week (KHN, The Guardian)
• Readers and Tweeters Fight Stigma and Salute Front-Line Workers (KHN)
• Huge Gaps in Vaccine Data Make It Next to Impossible to Know Who Got the Shots (KHN, The Guardian)
• As Vaccine Rollout Expands, Black Americans Still Left Behind (KHN, NBC News)
• Can the US Keep Covid Variants in Check? Here’s What It Takes (KHN, NBC News)
• Vaccination Chaos Fuels Push to Recall Newsom (KHN, Daily Beast)
• New Covid Cases Plunge 25% or More as Behavior Changes (KHN)
• Kids Already Coping With Mental Disorders Spiral as Pandemic Topples Vital Support Systems (KHN, NPR)
• Pandemic Sends a Couple Into Indefinite Long Distance Though Just Miles Apart (KHN, NPR)
• At Colorado’s Rural Edges, Vaccines Help Assisted Living Homes Crack Open the Doors (KHN, Denver Post)
• Journalists Stay on Top of Rocky Vaccine Rollout (KHN)

This data note discusses changes in the number of applications for Medicaid/CHIP coverage during the coronavirus pandemic. Application data include new applications for coverage that are received by state Medicaid/CHIP agencies and (if relevant) the State Based Marketplace; in many states, applications also include renewals and redeterminations. Data are from the Centers for Medicare and Medicaid Service (CMS) Performance Indicator Project, which is designed to track enrollment and an array of other measures to assess states’ Medicaid program performance. However, CMS has mostly focused on monthly enrollment totals, and other measures are either not publicly available or are not included in monthly summaries from CMS, though CMS recently highlighted changes in applications (see Methods box for more details about the data).

Enrollment in Medicaid/CHIP has increased steadily by more than 6 million individuals (9%) from February to September 2020, though it’s difficult to tease out the effects of the economic crisis with people losing their jobs from the requirement that states maintain coverage for people already enrolled in Medicaid during the public health emergency (PHE). The total number of Medicaid/CHIP applications has decreased by more than 150,000 (-6%) in the same time period, which might on the surface suggest that fewer people are applying for coverage even in the face of large job and income losses, but data limitations – in particular, the fact that application statistics do not distinguish between new signups and renewals – make it difficult to draw any clear conclusions.

For the median state, which is more stable than using the national total, the number of applications peaked in March 2020 (+12% from February) with a sharp decline in May 2020 (-22% from February), and applications only began increasing again in June and July 2020 (-16% and -13% from February) before leveling off in recent months (Figure 1). The decrease in applications is likely due to a number of factors and likely includes a reduction in renewals and redeterminations as well as the effects of lockdowns and closures due to the pandemic.

While the continuous coverage provisions of the FFCRA likely played a role in the decline of applications, it is difficult to parse out the impact based on the data available. In exchange for receiving an enhanced federal match rate on Medicaid spending, state Medicaid agencies must ensure continuous coverage for those enrolled as of March 2020. Initial guidance from CMS also specified that states could not move enrollees to a new eligibility category. As a result, most states likely stopped or slowed processing renewals. While states still could not disenroll people from Medicaid, some states may have started to process renewals over the summer contributing to an uptick in applications. States could start a new 12-month renewal period if all other eligibility criteria can be verified. These renewals could help stagger renewals at the end of the PHE. Available data do not identify new applications from renewals or redeterminations, and it is difficult to identify their role in declining application totals. In more recent guidance effective November 2, 2020, CMS reversed earlier guidance and specified that states are required to transition most enrollees determined ineligible for their current coverage to different coverage pathways for which they are eligible if such a transition is in the same tier of coverage (but cannot disenroll individuals). It is possible that this revised guidance could contribute to increases in application data in the upcoming months.

The declines in applications could also reflect challenges related to social distancing measures and office closures during the pandemic. Although all states provide online application options, the median state reported that 55% of Medicaid/CHIP applications completed online, suggesting that a large share of applicants rely on telephone, mail, or in-person applications. Office closures due to the pandemic could have limited some peoples’ options for filing Medicaid/CHIP applications, especially if they have limited access to the internet. It is also possible that prolonged changes in the economy and adaptations to provide better assistance and process new applications may have contributed to the increase in applications after the sharp decline in May. Timely information on the mode of applications is not currently available in national data sets, although it could help identify whether there have been changes in the modes that people apply for Medicaid/CHIP.

There is wide variation in application trends across states, with the majority of states seeing a decline from February 2020 (Figure 3). Variation in the number of applications is likely related to state-specific policies, economic conditions within states, and even seasonal patterns, such as open enrollment for federal and state-based health insurance marketplaces. Nebraska, for example, has seen a large increase in applications (67%) from February to September 2020, which the state attributed to early applications for the new Medicaid expansion program that began coverage in October 2020, according to a recent CMS Medicaid and CHIP Enrollment Trend Snapshot. Kentucky saw even larger growth, with a 224% increase in applications from February to September 2020, although the reason behind this increase is unclear. The majority of states (34 out of 49 with complete data) reported a decline in the number of Medicaid/CHIP applications since February 2020, with the lowest state (DC) seeing a 55% decline in applications in this time period (Figure 2).

In this Viewpoint for the Journal of the American Medical Association (JAMA), KFF’s Tricia Neuman and co-author Richard G. Frank of Harvard Medical School explain that the looming 2024 insolvency of the Medicare Hospital Insurance Trust Fund cannot be ignored for long.