The latest Kaiser Health Tracking Poll finds the public’s views souring on the Affordable Care Act (ACA) in November, with about half having an unfavorable view of the law and a third having a favorable view, a gap that was seen only once before, during the Republican presidential primaries in 2011. This negative shift in opinion comes amid heavy news coverage of the website problems plaguing the law’s online health insurance exchanges and stories about individuals being dropped from their insurance coverage because their plans don’t meet minimum requirements set by the ACA, stories that were followed closely by more than half the American public this month. The partisan divide on the law continues, but support among Democrats dropped sharply this month after rallying in September and October. Views among women also shifted this month, and for the first time in Kaiser tracking, the share of women with an unfavorable view outnumbered those with a favorable view by a large margin (48 percent versus 32 percent). Visibility of the health insurance exchanges increased among the public overall in November, but reaching the uninsured with information remains a challenge – about four in ten uninsured say they’ve heard nothing at all about the new marketplaces to date, and two-thirds say they still don’t have enough information about the law to know how it will impact them. Still, nearly six in ten of those who currently lack coverage say they plan to get insurance in 2014.

Overall Views Of The ACA Take A Negative Turn

Amid heavy news coverage of HealthCare.gov’s website problems and stories about individuals being dropped from their insurance plans, the American public’s overall views of the ACA took a negative turn in November. This month, roughly half (49 percent) say they have an unfavorable view of the law and a third (33 percent) have a favorable view. In nearly four years of Kaiser tracking on the law, the gap between negative and positive views (currently 16 percentage points) has been this large only once before, in October 2011 (17 percentage points) when the ACA was getting lots of negative attention in the Republican presidential primaries and the country was focused on the upcoming election and the Occupy Wall Street movement.

Views of the law shifted more negative this month among most demographic groups, but the drop was sharpest among Democrats. After rebounding in September and October, the share of Democrats viewing the law favorably stands at 55 percent in November, closer to where it had been earlier in 2013.

Women, who have historically been evenly divided on the law, registered their most negative views on the law to date, with 48 percent saying they have an unfavorable view of the law and 32 percent favorable. The gap between unfavorable and favorable views among women is up 15 percentage points since last month.

This negative shift in views of the law may be driven more by concern about the law’s impact on the country overall than on one’s personal situation. While a plurality says they don’t think the law will make much difference for their own families (a share that hasn’t changed much over the past year), the share saying the country will be worse off under the law reached a new high in Kaiser polling this month. Forty-three percent now say the law will leave the country worse off (up from 38 percent last month), compared with 34 percent who think the country will be better off and 15 percent who say it won’t make much difference.

More Than Half Paying Attention To News About Website Problems And Dropped Coverage

This negative shift in views comes at a time when the public reports paying close attention to news stories related to the ACA. Over half (55 percent) say they have followed news about website problems with the health law’s online insurance marketplaces “very” or “fairly” closely (roughly equal to the share who reported following these stories in October). The same share reports paying close attention to news stories about people being dropped from their health insurance. Attention to both of these news stories trails behind attention to reports about U.S. economic conditions.

The public’s evaluation of the news coverage they’ve seen is somewhat mixed. More than half say news coverage of the law has been mostly about politics and controversies, while fewer than one in ten say it’s been mostly about how the law will impact people and three in ten say it’s been a mix of the two. While four in ten say the news coverage they’ve seen has been mostly balanced, almost twice as many believe coverage is biased against the law as say it is biased in favor (33 percent versus 17 percent).

Visibility Of Health Insurance Marketplaces Increases, But Reaching The Uninsured With Information Remains A Challenge

Just over a month into open enrollment in the ACA’s health insurance exchanges, visibility of the new marketplaces has increased. This month, 42 percent of the public say they have heard “a lot” or “some” about the health insurance marketplace, twice the share who reported hearing as much in September. Among the uninsured, a key target group for outreach, visibility of the exchanges has also increased since September (from 15 percent to 29 percent), though it remains lower than among the general public.

Reaching the uninsured with information remains a challenge – 38 percent of those without insurance say they have heard “nothing at all” about the health insurance marketplace, and two-thirds (65 percent) still feel they do not have enough information about the law to understand how it will impact them and their family. Advertising is one way the uninsured may learn about the law, and this month, 35 percent of the uninsured say they saw at least one ad providing information about how to get coverage.

Despite the information challenge, nearly six in ten (58 percent) of the uninsured say they plan to get health insurance in 2014, while a third (34 percent) say they won’t get coverage and 8 percent are unsure.

Historical Lessons From Medicare Part D?

Since October 1, many journalists and others have drawn parallels between the ACA’s troubled rollout and the Medicare “Part D” prescription drug benefit, which some say had a similarly rocky launch in 2006. Among seniors, the program was unpopular at first; 50 percent had an unfavorable view of the program and 28 percent a favorable view in December 2005, just before enrollment began. In November 2006, when the first year enrollment was complete and most of those who enrolled had some experience using their new plans, views were more positive, with 42 percent of seniors expressing a favorable view of the program and 34 percent an unfavorable one.

The latest Kaiser Health Tracking poll finds that seven years later, the Medicare Part D benefit is quite popular: 63 percent of seniors view it favorably and just 14 percent view it unfavorably. Among those who are enrolled in a prescription drug plan, 85 percent say their experiences using the benefit have been positive, including six in ten (59 percent) who say they’ve been “very” positive.

Of course, it is far too early to tell what will happen to public opinion on the ACA as it moves through the next phase of implementation, but the Medicare Part D experience suggests that it is not unusual for a new law of this sort to be poorly perceived at the outset.

This Kaiser Health Tracking Poll was designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF) led by Mollyann Brodie, Ph.D., including Liz Hamel, Bianca DiJulio, and Jamie Firth. The survey was conducted November 13-18, 2013, among a nationally representative random digit dial telephone sample of 1,204 adults ages 18 and older, living in the United States, including Alaska and Hawaii (note: persons without a telephone could not be included in the random selection process). Computer-assisted telephone interviews conducted by landline (602) and cell phone (602, including 342 who had no landline telephone) were carried out in English and Spanish by Princeton Data Source under the direction of Princeton Survey Research Associates International (PSRAI). Both the random digit dial landline and cell phone samples were provided by Survey Sampling International, LLC. For the landline sample, respondents were selected by asking for the youngest adult male or female currently at home based on a random rotation. If no one of that gender was available, interviewers asked to speak with the youngest adult of the opposite gender. For the cell phone sample, interviews were conducted with the person who answered the phone. KFF paid for all costs associated with the survey.

The combined landline and cell phone sample was weighted to balance the sample demographics to match estimates for the national population using data from the Census Bureau’s 2011 American Community Survey (ACS) on sex, age, education, race, Hispanic origin, nativity (for Hispanics only), and region along with data from the 2010 Census on population density. The sample was also weighted to match current patterns of telephone use using data from the July-December 2012 National Health Interview Survey. The weight takes into account the fact that respondents with both a landline and cell phone have a higher probability of selection in the combined sample and also adjusts for the household size for the landline sample. All statistical tests of significance account for the effect of weighting.

The margin of sampling error including the design effect for the full sample is plus or minus 3 percentage points. Numbers of respondents and margin of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margin of sampling errors for other subgroups are available by request. Note that sampling error is only one of many potential sources of error in this or any other public opinion poll.

This last of three case studies examining key operational aspects of coordinated care initiatives in Medicaid focuses on Rhode Island’s Chronic Care Sustainability Initiative (CSI). This multi-payer, patient-centered medical home (PCMH) initiative includes the one Medicaid health plan in the state and the commercial health plans, one of the largest of which has many Medicaid as well as commercial enrollees. These payers provide practices that participate in the CSI with financial incentives and practice transformation resources to develop a sustainable model of patient-centered chronic care for adults. The payers use a common contract with the practices that specifies uniform requirements and performance metrics, and they pay practices a uniform monthly per capita care management fee to support nurse care managers, who are integral to Rhode Island’s model. These fees and other investments in practice transformation also help finance data infrastructure at the practice level that is necessary to support a PCMH. CSI policy development and practices are guided by a multi-stakeholder group in a governance structure shaped by the consensus-oriented style and leadership of Rhode Island’s health insurance commissioner. The Office of the Health Insurance Commissioner (OHIC) and the Executive Office of Health and Human Services (EOHHS), where the Medicaid program resides, convene the project jointly.

KEY THEMES

The common contract is central to the multi-payer system. When multiple payers use a common contract, practices face uniform metrics, requirements, and incentives, and can invest in practice improvements that benefit all patients. In the CSI, common contract specifications were developed through a consensus process that included plans and providers. Because an OHIC representative was present at the meetings, antitrust restrictions that would otherwise have barred this process could be waived.

Medicaid participation in a multi-payer initiative presents opportunities and challenges. Because Medicaid is a large purchaser, leveraging its impact matters. Medicaid plan and provider experience in serving high-need populations has benefited the initiative. At the same time, plans and practices with sizeable Medicaid patient panels face challenges, as performance metrics are not risk-adjusted. However, the CSI rewards safety-net practices if they get “half-way to the goal.”

Combining a collaborative model with a mandate is useful. Multi-payer initiatives require buy-in. Even beginning as a voluntary pilot, the CSI might have been hard to launch without the health insurance commissioner’s leadership. Plans acknowledged that the subsequent mandate to participate probably helped move the PCMH effort forward statewide, but, importantly, consensus-style governance has lent acceptability to the mandate. Because the mandate operates through the OHIC, it covers commercial insurers, but it does not extend to self-insured employers or public purchasers. However, the Medicaid plan has always participated, and commercial plans must now pay practices care management fees for their Medicaid as well as their commercial members.

Collaboration requires time, effort, and leadership. The operation of a multi-payer initiative requires plans, practices, and purchasers to make significant commitments of time, focus, and effort on an ongoing basis. Active stakeholder leadership and engagement are necessary to build trust among parties and confidence that aligned action can advance shared goals for patient care and delivery system performance.

Multi-payer initiatives and practice transformation require infrastructure and entail new costs. Convening meetings, collecting data centrally to aggregate across payers, and other activities required to manage a multi-payer initiative all cost money. In addition to the overhead and infrastructure costs to manage the system are significant costs for developing infrastructure at the practice level for data collection and analytics, and for other changes, such as integration of nurse care managers. Care management payments to practices provide critical financing to support such transformation. With the expiration of federal grant funds to support health information technology, maintaining adequate funding is challenging.

Maintaining payer support may require evidence of savings. Health plans’ willingness to provide practices with additional support may ultimately depend on a demonstrated return on investment – evidence that investing in primary care is not only improving patient care, but also generating savings somewhere in the system. Some payers wondered whether payment to practices should be more strongly tied to their performance on clinical process and outcome metrics.

Practice transformation is the beginning, not the end, of system change. The CSI has focused mainly on what goes on in primary care practices, but, ultimately, performance should be measured not just at the practice level, but at the system level, using metrics like aggregate rates of hospitalization and emergency department use. At this writing, hospitals were not yet at the CSI table, but, more recently, the state has been engaging hospitals and has added performance measures on hospital use that are tied to payment.

LOOKING AHEAD

Rhode Island has been successful in engaging plans, providers, and purchasers in a broad medical home initiative. A multi-payer system, including Medicaid in this case and several others nationwide, translates into important advantages for practices and providers, giving them a common, aligned set of goals, performance metrics, practice transformation resources, and incentives. Rhode Island’s ability to implement the CSI was enhanced by engaged leadership, a mixed regulatory-collaborative approach, the state’s small size, and the small number of major payers. Even under these conducive conditions, the organizational commitment, investment, and resources required to develop and implement a multi-payer PCMH initiative have been extensive, and mustering the necessary financing is a formidable, ongoing challenge. While the CSI model may not be feasible in other states, or may need adaptation, it illustrates the potential to leverage Medicaid’s role as a payer to transform health care delivery. Ultimately, to succeed most fully in improving care and reducing costs, multi-payer initiatives will need to extend beyond the sphere of primary care to engage specialists, hospitals, and others in the medical neighborhood. As the ACA expansion of coverage takes effect, and states and other entities seek to improve care delivery and orient payment toward performance, both the scale and momentum of multi-payer initiatives like the CSI can be expected to grow.

In recent years, a growing number of states have undertaken major delivery system reforms in Medicaid, seeking to improve care coordination and health outcomes for Medicaid beneficiaries, and to reduce spending growth in the program. To help inform the development of such initiatives in other places, the Kaiser Commission on Medicaid and the Uninsured worked with Mathematica Policy Research to examine key operational features of coordinated care initiatives in Medicaid in three states – Colorado, North Carolina, and Rhode Island. This issue brief focuses on Rhode Island’s Chronic Care Sustainability Initiative (CSI), a multi-payer, statewide patient-centered medical home (PCMH) initiative. Because Medicaid is the largest health care purchaser in the state, the program’s participation in Rhode Island’s initiative is one crucial source of its leverage.

The information and perspectives presented here are based on a review of CSI program documents and on telephone interviews with the program managers, two large participating health plans, and two participating practices with Medicaid patients — a community health center, and an office-based practice with both commercially-insured and Medicaid patients.

The CSI, which launched in 2008, had its origins in Rhode Island’s participation in a 2006 foundation-funded initiative that aimed to align public purchasers, private purchasers, and health plans in regional partnerships to more effectively leverage improvements in care for people with chronic conditions.¹  Rhode Island has used this multi-payer strategy to support the PCMH model statewide.²  With strong leadership from the state’s health insurance commissioner, a multi-stakeholder group determined that the pilot program should align quality improvement and financial incentives among purchasers, health plans, and providers; improve chronic care in primary care settings; and make primary care a more attractive and viable specialty in Rhode Island.³  The idea was to use the leverage of the state’s large capitated health plans and Medicaid’s major role as a purchaser to drive the desired improvements.

Participating payers

Since the beginning, the CSI has included the two largest commercial health plans in the state – Blue Cross & Blue Shield of Rhode Island (BCBS) and UnitedHealth Care (UHC) – and the state’s one Medicaid health plan, Neighborhood Health Plan of Rhode Island (NHP). (UHC has many Medicaid as well as commercial members.) These payers provide practices that participate in the CSI with financial incentives and practice transformation resources to develop a sustainable model of patient-centered chronic care for adults.

Originally a voluntary pilot, the CSI was formalized in 2011 by state legislation, sponsored by the health insurance commissioner, mandating that all state-regulated (i.e., commercial) health plans participate. In 2012, Rhode Island required all commercial plans with Medicaid contracts to participate in the CSI. As a result, these plans are now required to pay supplemental care management fees to participating practices not just for their commercial enrollees, but also for their Medicaid enrollees if the practice serves at least 200 of them. Medicare began to participate in the initiative when CMS selected Rhode Island for the Multi-Payer Advanced Primary Care Practice (MAPCP) demonstration in July 2011. Therefore, participating practices now receive supplemental payments for Medicare beneficiaries, Medicaid beneficiaries in managed care (about 60% of the total Medicaid population), and privately insured patients. Because the CSI does not include Medicaid patients who are enrolled in the state’s fee-for-service primary care case management (PCCM) program, the PCCM program was outside the scope of this study. However, we were told that, like CSI practices, primary care providers in the PCCM program receive supplemental fees to support nurse care managers, and that the state uses the same performance metrics in both programs. In addition, the Executive Office of Health and Human Services (EOHHS), where the Medicaid program resides organizationally, is a co-convener of the project with the Office of the Health Insurance Commissioner (OHIC) and has taken a more active role in the initiative in recent years. State Medicaid officials attend CSI meetings and the program provides non-financial support for the initiative.

Participating practices

Practices must be selected for the CSI in order to receive supplemental payments from plans. Initially, in 2008, five primary care practices identified as “champions” were selected to participate. Eight more practices were added in 2010, three were added in 2012, and consistent with the state’s strategic plan, 20 practices were added in 2013, including several multi-site practices. The initiative now includes 36 practices, 48 practice sites, and 297 physicians serving an estimated 250,000 Rhode Islanders, approximately 25% of the state’s total population. Under the strategic plan, another 20 practices will be added in each of the next four years and the initiative is slated to serve more than 500,000 patients.  At the end of 2012, Medicaid managed care enrollees accounted for about 25% of patients in CSI practices, commercial enrollees constituted 51%, Medicare Advantage enrollees made up 9%, and Medicare fee-for-service beneficiaries made up 15%.⁴ 

Core features

The following elements are central to the multi-payer medical home initiative:

A common developmental contract, which all health plans use with participating practices.⁵  Appendix 1 outlines key elements of the developmental contract: supplemental payments, required practice improvements, performance metrics, and staging of the contract provisions as practices come on line.

A uniform per member per month (PMPM) fee for care coordination, which all plans pay participating practices, and which help finance the practice infrastructure needed to support a PCMH. Practices can also earn additional performance incentive payments.

Practice transformation investments, to support the addition of a nurse care manager, in particular. These investments also support the development and use of electronic health record (EHR)-based performance metrics, and participation in learning collaboratives.

A multi-stakeholder leadership group, which guides CSI policy development and practice transformation.

Governance, authority, and operational management

The health insurance commissioner’s leadership and Rhode Island’s small size and long history of collaboration among major stakeholders have had a defining influence on the CSI’s development and structure. All those interviewed considered the health insurance commissioner’s leadership to have been instrumental in engaging commercial insurers in the initiative and enabling them to develop a common contract. The fact that many of the key actors in the CSI go back years together has also been helpful. The medical directors from several health plans trained together, the health insurance commissioner was formerly the director of NHP, and the current Medicaid medical director was the original CSI project staff person.

Governance. Governance of the CSI was structured to be collaborative and participatory.⁶  A large Steering Committee and a smaller Executive Committee set strategic direction for the CSI and are responsible for its overall governance; they include representation from the three major stakeholder groups – providers, payers, and purchasers (i.e., employers and Medicaid). The Steering Committee develops consensus on major issues, such as chronic conditions to be targeted, metrics, and payment strategies. While not required to do so, the Executive Committee also operates by consensus. Appendix 2 shows the governance structure, which, besides the Steering Committee and an Executive Committee, includes Working Committees on data and evaluation; practice training support and transformation; practice reporting; payment reform/contracting; and service expansion and integration. The purpose and scope of these Working Committees are outlined in Appendix 3.

The governance structure has remained largely unchanged, although it is now being refined and more formally constituted. In 2013, a Patient Advisory Subcommittee is being introduced to serve as the voice of patients and families and provide advice and input to the Steering and Executive Committees.⁷  In addition, a new Marketing and Communications Subcommittee is charged with increasing awareness of PCMH among employers and labor unions, increasing patient participation in PCMH practices; supporting the Patient Advisory Subcommittee, and conducting liaison with other community agencies.

Authority. A broader goal of the health insurance commissioner’s is to increase the role of primary care in health care delivery. Operationally, his strategy is to shift Rhode Island’s “primary care spend” from 8% of total health care spending currently, to 30%. To move in this direction, he has required state-regulated insurers to increase the share of their premiums spent on primary care by 1 percentage point per year over the period 2010-2014. Insurer investments in the CSI (e.g., their supplemental payments to participating practices) count toward this required annual increase. The health insurance commissioner has also interpreted his authority to allow him to require plans to contribute to the overhead costs of the data and related infrastructure for the CSI; these costs have grown recently because the federal Beacon Community Program, which provided grants for health information technology and other infrastructure, has ended. Insurer expenditures on these costs also count toward the primary care spend goal.

Operational management. The OHIC, with the support of a staff person then at the state’s Quality Improvement Organization (and now the state’s Medicaid medical director), was responsible for appointing the original Steering Committee and managing CSI’s day-to-day operations. At that time, staffing for the initiative was minimal— just two full-time staff funded by a foundation grant and the health plans. The Rhode Island Foundation, the state’s only community foundation, later served as a vehicle for accepting and handling external funding support for the CSI, and also provided office space for the program. When the original staff left in 2011, the state issued a competitive solicitation for project direction and project management support, and the contract was awarded to Commonwealth Medicine, the medical school at the University of Massachusetts.

Infrastructure. Substantial infrastructure is needed for the CSI to work. Essential components include:

• Support (staff and facilities) for governance, coordination, and convening;

• Technical support to assist practices in constructing all-payer, EHR-based clinical metrics and using them to improve performance;

• Development of interim all-payer, claims-based metrics (e.g., all-cause hospitalizations; ED use) until a permanent, consistent data base that integrates EHR clinical data can be developed;

• Coaching in practice transformation, particularly for practices newly entering the PCMH; and

• An annual Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey of patients in CSI practices.

For part of the CSI’s history, the Beacon grant provided crucial financing to the Rhode Island Quality Institute (RIQI) for some of these infrastructure costs (except for the first item).^8 9  With Beacon’s expiration, the costs are now being transferred to the CSI itself and payers are being asked to cover more of them. (The RIQI will continue to do portions of the work related to data collection and analysis, but practice transformation services are no longer procured through the RIQI.) As the CSI expands to include more practices, the needs for infrastructure development and funding will grow. In 2013, the annual cost of administering CSI will be $2.2 million, up from about $0.5 million for its first contract, which started in December 2011.¹⁰  About half of the total budget will go to organizations providing support to the RIQI for work previously funded under the Beacon grant.¹¹  In early 2013, Rhode Island received a federal grant for up to $1.6 million under the Center for Medicare and Medicaid Innovation (CMMI) State Innovation Models (SIM) initiative, which is designed to foster state-based models for multi-payer payment and health care delivery system transformation.¹²  Interviewees expressed hope that the award will allow the CSI to develop a more permanent operating model suitable to a broad-based permanent program.

The common contract is central to the multi-payer model. The common developmental contract was not easily developed, but its use is central to the CSI. The consistency across all payers of a core set of required metrics, and fixed supplemental payments to practices tied to performance expectations, align the incentives and goals that practices face, and encourage practices to pool the supplemental revenues from all their payers to invest in improvements that benefit all their patients. Interviewees representing practices favored having common metrics over different metrics for four or five different payers, and they pointed out that common metrics also reduce overhead costs for practices.

The common requirements were developed through a consensus process involving participating stakeholders (largely plans and providers). Plans had to be willing to modify their existing contract requirements, at least to some extent. For example, a plan might have to give up “home-grown” requirements of its own in favor of the common contract’s emphasis on NCQA accreditation. Similarly, national firms with common requirements across their health plans had to be willing to make exceptions for a plan operating in Rhode Island if the firm’s and the CSI’s requirements differed. Because of anti-trust laws that limit health plans’ ability to discuss pricing with each other, the deliberations that produced consensus on certain requirements of the common contract would not have been feasible except for the health insurance commissioner’s central convening authority. Specifically, the common developmental contract requires health plans to make a uniform contribution to practices to finance infrastructure-building. Such payments are legally considered to be pricing-related, but the discussion could take place as long as it was convened by OHIC.

Medicaid participation in a multi-payer system presents opportunities and challenges.

Leverage and experience. Because Medicaid is such a large purchaser in Rhode Island – it accounts for a substantial share of health care costs in the state – the ability to leverage the program is integral to the CSI’s impact. Although the majority of adults in Rhode Island are commercially insured, Medicaid is the dominant source of coverage in some CSI practices and covers a substantial share of patients in others. As Medicaid plan officials see it, an important gain from the CSI is that, with all payers at the table, Medicaid and commercial plans can learn from each another. Small plans get what one interviewee described as “a brain trust of medical directors committed to improving quality and re-engineering change in office-based care.” CSI principals say that the initiative has benefited significantly from the experience of plans and safety-net providers serving Medicaid patients, as they have been leaders in quality improvement and have a greater understanding of what it takes to coordinate care, often among many providers, for populations with complex needs for health services and other supports. The CSI provides a framework and environment for consultation and sharing of knowledge and ideas, and helps to avoid the problem of “reengineering a system that works for only one-third of [a] health plan’s members.”

Patient mix differences and fair payment. CSI plans and practices with a sizeable share of Medicaid patients face some unique challenges. Performance metrics are not currently risk-adjusted, possibly because of delays in data acquisition and a lack of resources and expertise to develop a methodology. The RIQI is now taking on the methodological work for risk-adjustment through a subcontract with Research Triangle Institute. Compared with the privately insured, Medicaid patients are more likely to have mental health co-morbidities as well as socioeconomic hardships that contribute to poorer health outcomes. In addition, a substantial share of the patients served by community health centers participating in the CSI are uninsured, making management of their care more challenging and performance benchmarks harder to achieve. (Health centers generally include the uninsured in their performance metrics because they operate on a philosophy that all patients are treated the same and that performance metrics need to be practice-wide, not payer-specific.) Recognizing the potentially higher risk profile of Medicaid and uninsured patients, and seeking to be fair to practices, the CSI established a “half-way to the goal line” approach that rewards practices with incentive payments if they get half-way to the performance benchmark relative to where they started. Stakeholders speaking from a Medicaid perspective praised this measure as a constructive compromise that rewards practices and providers in the safety-net space for their progress toward CSI goals. They expressed concern that plans not view the practices to which this policy applies as “slackers,” but highlighted that the consensus-oriented governance of the CSI provides a structure for discussing and resolving issues that have different implications for different stakeholders.

Combining a collaborative model with a mandate is useful.

Consensus helps legitimate authority. Getting multiple payers to work together on a unified strategy requires a lot of buy-in. Having the CSI pilot begin on a voluntary basis almost certainly helped foster willingness to participate. But even the voluntary initiative might well have been harder to achieve without Rhode Island’s long history of collaboration and what stakeholders describe as the talented leadership of the health insurance commissioner. The health plan representatives who were interviewed do not like the requirement to participate, but acknowledged that the mandate was probably valuable to the effort to extend the chronic care initiative to all adults statewide. By pairing a mandate for commercial insurer participation with a consensus-oriented approach to governance, the state is able to exert leverage that is needed to direct health plans to do some things differently and to spend money in ways that, except for the primary care spend requirement, they would not. It is likely that one reason private insurers have accepted the mandate is that, while their participation is required, they are also part of the consensus process that determines the specific requirements of the initiative.

The locus of authority determines its reach. Because the mandate to participate in the CSI operates through the OHIC, it does not reach all plans or purchasers in the state. The OHIC’s authority covers commercial insurers, but does not extend to self-insured employers or to public purchasers. Although the legislative mandate does not apply to the Medicaid plan, this plan has participated voluntarily in the CSI from the beginning, and, since 2012, the state has required all health plans with Medicaid contracts to pay the supplemental care management fees to practices on behalf of their Medicaid as well as their commercial enrollees, if the practice serves at least 200 of their Medicaid members. The CSI mandate does not apply to the Medicare program, but Medicare participates under the aegis of the Multi-payer Advanced Primary Care Practice (MAPCP) demonstration.

Collaboration requires time and effort and leadership.

Stakeholder commitment. The development and operation of a governance process that is based on consensus decision-making require heavy investments of time by many parties, and a strong commitment to work together to hammer out common goals and objectives and implement the initiative. Ongoing operation of the CSI succeeds because its key stakeholders — plans, practices, and purchasers — continually commit significant time, focus, and effort to the enterprise. To illustrate, the administrator of one participating family medicine practice with eight providers reported that she routinely attends five different CSI-related meetings monthly, as well as ad hoc meetings. Collectively, two or three other individuals in the practice attend another five to six meetings each month on data, reporting, care management, and other topics.

Engaged leadership. Leadership from all the stakeholder groups has been critical to the CSI’s success. Even in a state with a collaborative tradition, there exist competing interests, gaps in trust, and other sources of tension between parties that must be addressed. Individual stakeholders with different perspectives must, through dialogue and other interaction, gain confidence in the other participants and the fairness of the project to perceive an alignment between their own goals and interests and the initiative’s aims. The CSI management team highlighted plan and provider engagement in the initiative as a key to building increased trust between these two groups. Conversations facilitated by the learning collaboratives helped to give plans confidence in providers’ commitment to practice transformation and the use of metrics to drive change, and to give providers confidence that plans are paying them fairly and giving them the data they need to improve care management.

Broad-scale initiatives and practice transformation both require infrastructure.

Overhead costs. Convening meetings, collecting and reporting data centrally for aggregation across payers, and providing assistance to help practices change, are all overhead costs that require funding. Perhaps because the CSI started out as a small pilot, such costs were underestimated initially. Also, because administrative and staff support for the initiative was limited early on, development of a formal organizational structure (e.g., by-laws) was delayed. Funding constraints also led the CSI to rely on different financing approaches for learning collaboratives at different times, rather than on an established and stable means of support.

The timing of the Beacon grant to Rhode Island was fortunate. The overlap between the needs of the CSI and the purposes of the grant – to link development of EHRs to clinical practice improvement and enhanced outcomes – gave the state access early on to substantial support to build infrastructure. However, such grants are not routine and they are typically time-limited. With the Beacon grant’s termination, the CSI health plans are providing additional funding for infrastructure (over and above their care management payments to practices) for at least one year, but there is concern about their ability and willingness to maintain this support over time, particularly if the amount required of them grows. Some expressed the view that, because more work on the data infrastructure was not accomplished earlier, progress was delayed and opportunities were lost, adding to health plans’ and practices’ current costs. For example, if the infrastructure for the exchange of clinical data had been more developed, CSI would not have to invest as much now in claims-based “work-arounds” to analyze costs across all payers.

Costs of practice-level infrastructure-building. Like other efforts to develop patient-centered models of primary care, the CSI generates new needs for spending – to manage the multi-payer effort, collect data, create metrics and reporting processes, and support practice transformation. Primary care practices need to set up systems to track data relevant to the metrics they must report and integrate these metrics into their performance improvement programs. The supplemental payments to participating practices provide critical additional funding to support other required practice changes as well, such as expanded use of nurse care managers who can spend more clinical time with patients. One practice manager reported that the supplemental payments have allowed her to fund a nurse care manager, hire a full-time quality assistant who can do “deeper dives” into the data (e.g., to understand outliers), and keep the practice open longer hours. Some practices had already made some of the needed investments before the supplemental payments became available, but even for these practices that are farther along, the care management fees help finance intensified efforts and additional staff time to participate in learning collaboratives with other practices.

At least some of the CSI practices are finding the supplemental payments insufficient to cover all the costs involved in participating. They explained that they continue to participate for the good of their patients, whom they see getting better care because of the practice changes spurred by the initiative. Consensus is lacking on what level of support participating practices require. Sponsors of similar initiatives elsewhere can also anticipate debate about the appropriate levels of payment to support the practice-level infrastructure needed to support patient-centered care.

Maintaining payer support for CSI may require evidence of savings.

Those we interviewed noted that the health care environment is very fluid in Rhode Island, as it is elsewhere in the nation. The practices that participated in the CSI from the outset were early adopters of change who were philosophically committed to its success; the practices joining now may not be as committed to doing what is necessary internally to develop clinical data and use them to improve performance, although they should be able to benefit from the experience of the established practices. Health plans say that their willingness to provide practices with additional support ultimately depends on a demonstrated return on investment. In today’s payment reform environment, they say, they need evidence that investing in primary care is not only improving patient care and patient experience, but also generating savings somewhere in the system. Some payers wondered aloud whether practices should have more “skin in the game” – that is, whether their payment should be more strongly tied to their performance on clinical process and outcome metrics. It could be that the ability to maintain support for these kinds of initiatives will require settling the return-on-investment question, challenging though that may be.

Practice transformation is the beginning, not the end, of system change.

There was agreement that, ultimately, performance should be measured not just at the level of individual practices, but also at the system level, using metrics like aggregate ED, hospitalization, and readmission rates. Clearly, hospitals are integral to true systemic change. At this writing, hospitals were not yet at the CSI table, and stakeholders reported that they were still relatively traditional, with a primary focus on filling beds; they added that ACO development and hospital acquisition of practices remained limited in the state. As a consequence, the CSI has been focused mainly on what goes on in primary care practices. More recently, however, the state says it has been engaging hospitals, and has added performance measures on hospitalization and ED use that are tied to payment. One interviewee placed the CSI in the broader context of system transformation this way: “I think we’re working towards a system that is more integrated and will address the whole triple aim. Has that been proved yet? I don’t know. I think we’re still walking down the road. We certainly can’t continue in this [current] system. I think this (medical home model) has more optimism around it than other types of approaches. But…we’re not there yet. This is new territory.”

Rhode Island has been successful in engaging health plans, providers, and purchasers in a multi-payer collaboration to support PCMHs, with the goal of improving chronic care for all Rhode Island adults. The leverage exerted by a multi-payer strategy, including Medicaid in this case and several others nationwide, translates into important advantages for practices, giving them a common, aligned set of goals, metrics and performance benchmarks, practice transformation resources, and incentives, across payers and purchasers, to support practice changes that will benefit all their patients.

Rhode Island’s ability to implement the CSI was enhanced by a number of factors. The distinctive leadership of the health insurance commissioner, and his preference for collaboration around policy goals rather than a purely regulatory approach, were crucial. In a different state context, mandating payer participation and the “primary care spend” could be more challenging. The small number of major payers in the state also helped, and the fact that many stakeholders knew each other and understood each other’s goals made it easier for them to “get on same page.” In addition, many Rhode Island practices and providers serve patients with a mix of health insurance, and may be receptive to participating in an initiative that standardizes the requirements and incentives they face from different payers.

But while Rhode Island has some distinctive attributes, the state has confronted some challenges and issues that are likely to be common to states pursuing multi-payer initiatives. Rhode Island’s need to identify new resources for implementation, and the finding that buy-in is important to maintain support for the initiative, are lessons useful to states broadly. The kinds of tensions between plans, practices, and providers that have required negotiation in Rhode Island are pretty universal; other states may wish to consider whether the inclusive and consensus-oriented approach to development and governance that Rhode Island adopted might help bridge differences and build trust among the stakeholders in their environments.

The reality that system-level health improvements and cost savings require change beyond the sphere of primary care is also not unique to Rhode Island, and states generally can benefit from CSI leadership’s observation that specialists, hospitals, and others in the medical neighborhood must also be engaged for multi-payer medical home initiatives to succeed most fully. While the CSI model may not be feasible in other states, or may warrant adaptation, it demonstrates how Medicaid’s role as a major payer can be leveraged to transform health care delivery and payment. As the ACA expansion of coverage brings more Americans into the health care system, and states and other entities seek to improve care delivery and orient payment toward performance, both the scale and momentum of multi-payer efforts like the CSI can be expected to grow.

Appendix 1: CSI Common Developmental Contract, April 2012

Appendix 2: CSI Governance Structure

Source: CSI-RI: Strategic Planning, Final Plan, February 21, 2013. http://www.pcmhri.org/files/uploads/CSI_Strategic_Plan_Summary%20March%202013.pdf

Appendix 3: CSI Working Committees: Purpose and Scope

Source: CSI-RI: Strategic Planning, Final Plan, February 21, 2013. http://www.pcmhri.org/files/uploads/CSI_Strategic_Plan_Summary%20March%202013.pdf

1. Regional Quality Improvement Initiative, Center for Health Care Strategies. Available at http://www.chcs.org/info-url_nocat3961/info-url_nocat_show.htm?doc_id=377021 ↩︎
2. Case Study: Rhode Island Pilots Innovative, Cross-Payer Patient-Centered Medical Home Model, Center for Health Care Strategies, July 2009. Available at http://www.chcs.org/publications3960/publications_show.htm?doc_id=985380 ↩︎
3. Ibid. ↩︎
4. Quarterly MAPCP report on Rhode Island (quarter ending December 31, 2012). Provided to authors by CSI management staff.   ↩︎
5. The mechanism is actually a common contract amendment that all payers incorporate into their existing contracts with practices.  ↩︎
6. Rhode Island Chronic Care Sustainability Initiative (CSI-RI) Governing Structure, December 2006. Available at http://www.chcs.org/publications3960/publications_show.htm?doc_id=534883  ↩︎
7. CSI-RI: Strategic Planning, Final Plan, February 21, 2013. Available at http://www.pcmhri.org/files/uploads/CSI_Strategic_Plan_Summary%20March%202013.pdf ↩︎
8. Rhode Island Beacon Community Program: 2012 Annual Report, Rhode Island Quality Institute, December 5, 2012. Available at http://www.pcmhri.org/files/uploads/Rhode%20Island%20Beacon%20Community%20Program%20Annual%20Report_FINAL12-21-12.pdf ↩︎
9. Rhode Island Quality Institute (Fact Sheet, last updated November 29, 2012), Office of the National Coordinator for Health Information Technology. Available at http://www.healthit.gov/sites/default/files/beacon-factsheet-ri.pdf ↩︎
10. University of Massachusetts program office communication. ↩︎
11. Under a major subcontract to the University of Massachusetts, the Rhode Island Quality Institute will continue quality measurement and reporting tasks, utilization measurement (working with Research Triangle Institute), and administration of an annual Consumer Assessment of HealthCare Providers and Systems (CAHPS) survey. The University of Massachusetts will develop additional subcontracts, the largest of which will involve support for training and technical support for practices. Another will allow the program to develop and pilot two community health teams to help small practices become PCMHs. Others will support evaluation, grants management, marketing, and similar specialized needs. The remainder of the funds will be used to support the current staff at the University of Massachusetts and expand staff to handle the selection and training of new practices sites and increased needs for coordination. ↩︎
12. http://innovation.cms.gov/initiatives/State-Innovations-Model-Design/ ↩︎

On January 1, 2014, many key provisions of the Affordable Care Act (ACA) will start to go into effect, including the expansion of Medicaid to low-income adults and the launch of new Medicaid eligibility and enrollment processes, which are designed to move toward a coordinated enrollment system across health coverage programs, including Medicaid, CHIP, and the new Health Insurance Marketplaces. Over the past year, states have made steady and significant progress preparing for these changes, but readiness varies considerably as 2014 nears, and implementation work and ongoing process improvements will continue into the foreseeable future. To provide greater insight into the status of implementation, this report provides an overview of key state Medicaid eligibility and enrollment policies slated to go into effect based on data released by the Centers for Medicare and Medicaid Services (CMS). (See the Appendix Tables for state-specific data.)

Medicaid Eligibility as of January 2014

The ACA, as enacted, expands Medicaid to nearly all adults at or below 138 percent of the federal poverty level (FPL) as of January 1, 2014. This expansion, however, was effectively made a state option as a result of the Supreme Court ruling on the constitutionality of the ACA, and as of October 24, 2013, 26 states, including DC, are moving forward with the expansion, while the remaining 25 states are not moving forward at this time (Figure ES-1). There is no deadline for states to adopt the expansion, and several states are still actively considering it.

Eligibility levels for parents and other adults will significantly increase in states implementing the Medicaid expansion, while large coverage gaps will remain in states not expanding at this time. In the 26 states expanding Medicaid, the median eligibility threshold for parents will increase from 106 to 138 percent of the FPL and the median limit for adults without dependent children will significantly rise from 0 to 138 percent of the FPL (Figure ES-2). However, many poor parents and other adults will remain ineligible in the 25 states not expanding at this time. In 21 states, parent eligibility levels will remain below 100 percent of the FPL, with eligibility levels below half of poverty in 14 states. Overall, the median eligibility level for parents in these states will be just 47 percent of the FPL and only Wisconsin will provide full Medicaid coverage to adults without dependent children. Parents and other adults with incomes above these limited Medicaid eligibility levels but below 100 percent of the FPL will fall into a coverage gap, since they will earn too much to qualify for Medicaid but too little to qualify for premium tax credits in the Marketplaces, which begin at 100 percent of the FPL. This gap will leave nearly five million uninsured adults without a new coverage option.

Coverage for children and pregnant women through Medicaid and CHIP will remain strong in 2014. More than half of the states (30, including DC) will cover children in families with incomes at or above 250 percent of the FPL and 20, including DC, will cover children in families with incomes at or above 300 percent of the FPL. Moreover, despite some eligibility reductions for pregnant women, as of January 1, 2014, 32 states, including DC, will cover pregnant women at or above 200 percent of the FPL. As such, while coverage for parents and childless adults will markedly improve in states implementing the Medicaid expansion, their median eligibility level will still remain lower than that of children and pregnant women (Figure ES-3). These disparities in eligibility across groups will be even starker in states that are not expanding Medicaid.

Connecting People to Coverage through Streamlined Enrollment Processes

The ACA envisions seamless and timely access to the continuum of health coverage options regardless of where or how someone applies. To achieve these objectives, the ACA establishes new expectations for simplifying the application process, coordinating enrollment, and moving toward paperless verification of eligibility. These include state adoption of a single streamlined application that screens for all health coverage options, electronic transfers of accounts between agencies to facilitate transitions across health coverage programs, and reliance on trusted sources of electronic data rather than requesting paper documentation to verify eligibility criteria.

As of October 1, 2013, 43 of 50 reporting states have deployed a single, streamlined application through their Medicaid agency. The seven remaining reporting states are in the process of developing their single, streamlined application, and nearly all anticipate having it in place by January 2014. In the interim, these states are utilizing their existing Medicaid applications and individuals who may be eligible for premium tax credits are being directed to apply through the federal Marketplace. Among the 43 Medicaid agencies that have a single streamlined application as of October 1, 2013, all had a paper version available while 36 had an online version. Looking ahead, states will continue work to make the application available through multiple modes, including online, phone, in-person, or mail. Moreover, in 32 states, further revisions will be made to their single streamlined application to meet the ACA standards, for example, by removing questions that are not relevant to eligibility.

The ability to electronically transfer individual accounts between state Medicaid/CHIP agencies and Marketplaces to coordinate enrollment is in various stages of development. Among the 17 states with State-based Marketplaces (SBMs), all but two (2) have an integrated or linked technology system that determines eligibility for all insurance affordability options and facilitates the next steps for enrollment. However, in states using the Federally-Facilitated Marketplace (FFM), electronic transfers of individual accounts between the FFM and Medicaid/CHIP agencies are essential for coordinating enrollment. Due to ongoing technological challenges with the FFM, these transfers have been delayed and alternative strategies have been put into place. For example, until the FFM can begin transferring electronic accounts to state Medicaid and CHIP agencies, it is sending batches of basic data on individuals the FFM has determined or assessed as potentially eligible for Medicaid/CHIP. Similarly, if a state Medicaid/CHIP agency is unable to transfer an account to the FFM, it can direct individuals to apply directly through the FFM. Moving forward, implementing electronic account transfers will be key to minimizing burdens on consumers and ensuring they are successfully enrolled in the coverage for which they are eligible regardless of where they apply, providing “no wrong door” access to coverage envisioned by the ACA.

States are submitting verification plans to CMS that outline the electronic data sources and procedures they will use to verify eligibility criteria. As of November 15, 2013, 35 verification plans have been approved by CMS and made publicly available. States continue to have the option to accept self-attestation without additional verification for non-financial eligibility criteria except for Social Security Numbers, citizenship, and immigration status, which states are required to verify under law. The majority of reporting states will rely on self-attestation of state residency (28 of 35), and household composition (33 of 35), while fewer will do so for age and date of birth (13 of 35). The remaining states will either verify these criteria to determine eligibility or post-enrollment. For income, states must verify financial information from an electronic data source; however, this can be done post-enrollment after the state determines eligibility based on the individual’s attestation. All 35 reporting states will verify income through electronic sources, with 30 states doing so to determine eligibility and five (5) states verifying income post-enrollment. In addition, 23 states will conduct routine ongoing post-enrollment checks of financial information, although consumers also are required to report changes that may affect eligibility.

New Options to Facilitate Enrollment and Renewal

CMS has offered states five strategies to facilitate processing applications for large numbers of people who become newly eligible for Medicaid on January 1 and the transition to new enrollment processes. All of the approaches are intended to promote enrollment and retention, while minimizing administrative burdens for states. They include early adoption of MAGI-based eligibility standards, extending renewal periods for existing enrollees, enrolling eligible Supplemental Nutrition Assistance Program participants in Medicaid based on available data, enrolling parents in Medicaid based on their children’s eligibility information, and providing 12-month continuous eligibility for parents and other adults. A state may adopt any of these facilitated enrollment approaches regardless of whether it plans to implement the Medicaid expansion. Nearly half (25) of states have taken up the option to extend renewals, 15 have adopted MAGI early, five (5) are enrolling individuals based on SNAP data, and three (3) are using eligibility data for children to enroll their parents (Figure ES- 4). Overall, 30 states have adopted at least one of the strategies, and 11 have adopted two or more of these approaches. Three (3) states (NJ, OR, and WV) have adopted four of the five.

Conclusion

Looking ahead to 2014, coverage for parents and other adults will significantly improve in the 26 states implementing the Medicaid expansion and eligibility levels for children and pregnant women will remain strong across states. As such, as the ACA is fully implemented, Medicaid offers the potential to significantly reduce the number of uninsured. Outreach and enrollment efforts will be key for increasing coverage and it will be important for these efforts to be ongoing throughout the year since Medicaid enrollment is not limited to the Marketplace’s open enrollment period. In contrast to gains in states expanding Medicaid, large coverage gaps will remain in the states that do not expand, leaving millions of poor uninsured adults without access to a new coverage option.

To date, states have made meaningful progress in implementing key provisions of the ACA to provide streamlined Medicaid eligibility and enrollment processes, but readiness varies considerably. Moreover, the technology problems that have hampered the launch of open enrollment through the new Marketplaces, particularly the federal Marketplace (HealthCare.gov), have led to delays in coordination across Medicaid, CHIP, and Marketplace coverage. However, even with these early implementation challenges, some states have been successfully enrolling people in Medicaid and several have gotten a significant jump-start through the facilitated enrollment strategies offered by CMS. In the coming months, work will continue to deploy new processes and systems to move toward the ACA’s vision of a simplified, consumer-friendly experience. As such, January 2014 will represent the first step toward a modernized, streamlined system to connect individuals to expanded coverage options as established through the ACA, but fully achieving that vision will require time, persistence, and a commitment to continual program improvement.

As the first day of coverage under the Affordable Care Act (ACA) approaches, states are continuing work to modernize their procedures and systems to implement key provisions of the law to simplify enrollment in Medicaid and CHIP and coordinate with the new Health Insurance Marketplaces, which opened their doors on October 1, 2013. Beginning January 1, 2014, low-income adults will become newly eligible for Medicaid in the 26 states that have chosen to implement the ACA’s Medicaid expansion. Additionally, all states will transform their processes to align eligibility requirements for Medicaid, CHIP, and premium tax credits in the Marketplaces, streamline and modernize the application experience, and move toward a coordinated enrollment system across health coverage programs. Over the past year, states have made steady and significant progress preparing for these changes, but readiness varies considerably as 2014 nears, and work on implementation and process improvements will continue into the foreseeable future. This report provides an overview of key state Medicaid eligibility and enrollment policies that will be in effect as of January 1, 2014, based on data released by the Centers for Medicare and Medicaid Services (CMS). The data provide insight into who will be eligible for Medicaid and CHIP across states and how individuals will enroll in coverage. (See Appendix Tables 1 through 9 for state-specific data on policies.)

Background

Throughout the last year, political divides continued over the ACA, but the law remains in place. With open enrollment for coverage through the new Marketplaces beginning on October 1^st, the country is turning its attention to how the ACA is implemented, including a number of key provisions that impact Medicaid and CHIP eligibility and enrollment.

As enacted, the ACA extends Medicaid to nearly all adults at or below 138 percent of the federal poverty level (FPL) as of January 1, 2014. However, as a result of the Supreme Court ruling on the ACA, implementation of the Medicaid expansion is now effectively a state option. As of October 24, 2013, 26 states, including DC, are moving forward with the expansion (Figure 1). In some cases, CMS is working with states to develop expansion approaches under Section 1115 waiver authority (Box 1). There is no deadline for states to adopt the expansion, and several states are still actively considering the option. However, states delaying the expansion will miss out on the opportunity to receive the 100 percent federal funding for newly eligible individuals available in calendar years 2014 through 2016.

Regardless of state decisions to expand Medicaid, all states must implement new streamlined enrollment processes under the ACA. These procedures are designed to align eligibility determinations for Medicaid, CHIP, and premium tax credits in the Marketplaces. They also aim to establish a faster, more consumer-friendly enrollment experience, provide individuals multiple avenues to apply, and rely on electronic data instead of paper documentation to verify information where possible. To implement these new processes, almost all states are building new Medicaid eligibility and enrollment systems or conducting major upgrades of their existing systems. The federal government has provided time-limited 90 percent federal funding to support this system development work. CMS issued a final set of rules for these eligibility and enrollment changes in July 2013, providing guidelines for states as they were rewriting policies, revamping business processes, and developing their systems.

To further assist states in implementing the Medicaid provisions of the ACA, CMS offered new opportunities to facilitate enrollment. In May, the administration provided states five (5) new targeted enrollment and renewal strategies. These options are designed to help states accommodate application and enrollment increases as they transition to the new eligibility rules, with the hope of easing the administrative burden for states and simplifying the process for consumers.

To date, states have made significant progress in implementing these Medicaid and CHIP provisions but readiness varies considerably. Moreover, the technology problems that have hampered the launch of open enrollment through the new Marketplaces, particularly the federal Marketplace (HealthCare.gov), have led to challenges and delays with new processes designed to coordinate enrollment for Medicaid, CHIP, and Marketplace coverage. With 2014 quickly approaching, state implementation work remains in high gear and the coming weeks are important for states to meet specific milestones. States that will not be able to implement all of the new processes within the timeline established by the law are working with CMS to develop mitigation plans designed to help ensure individuals can still connect to coverage. Even with these early implementation challenges, some states have been successfully enrolling people into Medicaid as they have addressed technological glitches with their state Marketplace websites. Moreover, several states have gotten a significant jump-start through the facilitated enrollment strategies offered by CMS.

Conversion to Modified Adjusted Gross Income to Determine Financial Eligibility

The ACA changes how financial eligibility will be determined for many Medicaid beneficiaries, standardizing the approach across states as well as health insurance affordability programs. Beginning January 2014, financial eligibility for parents, pregnant women, children, and the expansion adults will be based on Modified Adjusted Gross Income (MAGI), as defined in the Internal Revenue Code. The move to MAGI for these non-elderly, non-disabled groups will result in some changes from current Medicaid rules related to calculating family size and income and will largely align Medicaid financial eligibility determinations with the standards used to determine eligibility for premium tax credits and cost-sharing reductions in the new Marketplaces.¹  Aligning the determination requirements across all insurance affordability programs is intended to promote seamless coordination and avoid gaps or overlaps in eligibility.² 

To carry out the transition to MAGI, states must convert their existing Medicaid and CHIP eligibility levels for these groups to MAGI-equivalent levels. Today there is significant variation across states and eligibility categories in how income disregards and deductions are applied to determine if an individual meets the financial eligibility requirements for Medicaid or CHIP. For example, a state often disregards certain income from an individual’s gross income (e.g., $90 for a working parent), deducts certain expenses (e.g., childcare), and then compares the result to a net income standard.³  When states transition to MAGI, they will discontinue the use of these disregards and deductions; instead, they will use the MAGI-equivalent income threshold that takes into account states’ previous use of disregards and deductions and apply a standard disregard of five percentage points of the federal poverty level in certain circumstances (Box 2). States worked with CMS to develop their converted MAGI levels using one of three available methods.⁴ 

The MAGI converted thresholds are intended to approximate states’ existing eligibility levels in the aggregate to prevent individuals from losing coverage due to the transition to MAGI. While MAGI converted thresholds differ from existing levels, they are designed to result in roughly the same number of people being eligible under the new standard as would have been eligible under the old standard (Box 3). In some cases, the converted thresholds will be the income eligibility limits in place as of January 1, 2014. For example, in most of the states not implementing the Medicaid expansion, the income limit for parents will be the MAGI conversion of their existing parent eligibility level. The MAGI converted thresholds will also be used for a number of other purposes, including 1) maintaining Medicaid and CHIP eligibility levels for children through October 1, 2019, as required by the ACA; 2) establishing minimum eligibility thresholds for parents, pregnant women, and other adults;⁵  3) determining the income levels at which premiums will apply; and 4) calculating the availability of the enhanced matching rate for newly-eligible adults.

States that had previously aligned children’s coverage levels across the different age groups merged the groups for conversion purposes in order to preserve the alignment. Otherwise, states were required to convert each eligibility category separately, including their Medicaid thresholds for infants, children ages one to five, and children ages six to eighteen. If the amount of the average disregards and/or the original threshold differed between the groups, disparate converted levels across the ages could result, as is seen in 18 states (Appendix Table 1). States have an opportunity to standardize their eligibility thresholds by adjusting the level for the older group to match that of the younger group, but only until December 31, 2013.⁶ 

Income Eligibility Limits as of January 1, 2014

Beginning in 2014, as part of the continuum of coverage, the ACA expands Medicaid to nearly all adults with incomes at or below 138 percent of the FPL. Moreover, the ACA requires states to maintain eligibility thresholds for children that are at least equal to those they had in place at the time the law was enacted through September 30, 2019. To help preserve the base of coverage upon which the ACA expansions build, states were also required to maintain eligibility levels for other groups, but this requisite will end on January 1, 2014.

Eligibility levels for parents and childless adults will significantly increase in the 26 states, including DC, that are expanding Medicaid to adults. Fifteen (15) of the 26 states moving forward with the Medicaid expansion already cover parents at or above the poverty level through Medicaid, but adults without dependent children are eligible for full Medicaid coverage in just nine (9) of these states (AZ, CO, CT, DE, DC, HI, MN, NY, and VT), of which only six (6) cover them at or above poverty (Appendix Table 2). In the expansion states, eligibility levels will increase for parents in 16 states and for childless adults in 24 states. Overall, the median eligibility threshold for parents in these states will increase from 106 to 138 percent of the FPL, while the median threshold for adults without dependent children will increase from 0 to 138 percent of the FPL. Three (3) states (CT, DC, and MN) will cover parents above the new expansion level of 138 percent of the FPL (Figure 2) and the District of Columbia and Minnesota will cover adults without dependent children above this level (Figure 3), although Minnesota will reduce eligibility levels for parents relative to its 2013 levels. In addition, four (4) other states (NJ, NY, RI, and VT) that previously extended Medicaid eligibility to parents with incomes above 138 percent of the FPL are reducing eligibility to 138 percent of the FPL as of January 2014; many of these parents will be eligible for tax credits to purchase coverage through the new Marketplaces.

In the 25 states not expanding Medicaid at this time, many poor parents and other adults will remain ineligible for coverage. In 21 of the states, eligibility levels for parents will be below 100 percent of the FPL, with eligibility levels remaining below half of poverty in 14 states. In addition, Maine and Wisconsin will reduce eligibility for parents from 133 to 105 percent of the FPL and 200 to 100 percent of the FPL, respectively, as the requirement to maintain coverage ends on January 1, 2014. Adults without dependent children generally will remain ineligible for full Medicaid coverage in non-expansion states. Overall, in these 25 states, the median eligibility level for parents will be just 47 percent of the FPL, with only four (4) states (AK, ME, TN, and WI) covering parents with incomes at or above poverty; only Wisconsin will provide full Medicaid coverage to adults without dependent children. Parents and other adults with incomes above these limited Medicaid eligibility levels but below 100 percent of the FPL will fall into a coverage gap, which will leave nearly five million uninsured adults without access to a new coverage option (Box 4).

Coverage for children through Medicaid and CHIP will remain strong in 2014, with the median eligibility level at 255 percent of the FPL. More than half of the states (30, including DC) will cover children in families with incomes at or above 250 percent of the FPL and 20, including DC, will cover children in families with incomes at or above 300 percent of the FPL (Figure 5 and Appendix Table 1). Moreover, 18 states currently covering older children up to 133 percent of the FPL in separate CHIP programs will shift coverage for these children to Medicaid, as the ACA establishes a minimum Medicaid eligibility level of 138 percent of the FPL for all children up to age 19.⁷  Prior to the ACA, states were required to cover children up to age 6 with incomes up to 133 percent of the FPL through Medicaid, but the minimum eligibility level for older children was 100 percent of the FPL. This shift from CHIP to Medicaid must occur regardless of whether the state is expanding Medicaid to adults; states will continue to receive the enhanced CHIP matching rate for uninsured children in this income group. CMS has been assisting states with this shift and, in some cases, may permit an alternative transition approach, such as at a child’s next regularly scheduled renewal rather than by January 1, 2014.

Despite two (2) states reducing eligibility, most will continue to cover pregnant women above the federal minimum standards. As of January 1, 2014, the median eligibility level for pregnant women will be 203 percent of the FPL, with 31 states, including DC, covering pregnant women at or above 200 percent of the FPL (Figure 6 and Appendix Table 3). Two states, Oklahoma and Virginia, will reduce eligibility for pregnant women from 185 to 133 percent of the FPL and 200 to 143 percent of the FPL, respectively, as the requirement to maintain coverage ends on January 1, 2014. Louisiana has also indicated plans to reduce eligibility for pregnant women as of January 1, 2014, but this change was not reflected in the data from CMS as of November 15, 2013.⁸ 

Eligibility for parents and other adults will continue to lag behind that of children and pregnant women. While coverage for parents and childless adults will markedly improve in states implementing the Medicaid expansion, their median eligibility levels will still remain significantly lower than that of children and pregnant women. These disparities in eligibility across groups will be even starker in states that are not expanding Medicaid (Figure 7).

The ACA envisions seamless and timely access to the continuum of coverage options regardless of where or how someone applies. To achieve these objectives, the ACA establishes new expectations for simplifying the application process, coordinating enrollment, and moving toward paperless verification of eligibility. Many of these changes accelerate successful state strategies in harnessing technology to make the process work better for both individuals and state agencies.

Applying for Coverage

The ACA requires Medicaid, CHIP, and the new health insurance Marketplaces to adopt a single, streamlined application that screens eligibility for all coverage options. To this end, HHS created a consumer-tested model application, which states can customize to better fit their programs. For example, states can substitute state agency names, logos, and phone numbers. States can also eliminate questions that aren’t applicable, such as how long a child has been uninsured in a state that does not impose a waiting period in CHIP. Alternatively, states may develop their own single, streamlined application, subject to HHS approval. However, alternative applications may only include questions relevant to the eligibility and administration of all of the insurance affordability programs, and only for individuals who are applying for coverage.

Most states (43) will use a state alternative online application, while seven (7) will adopt the HHS model online application. Fewer states (30) are using or plan to use a state alternative for their paper application (Figure 8). In 32 of the states using an alternative application, the version that is initially available will need further revisions to fully comply with the ACA standards, for example, by removing questions that are not relevant to eligibility. Notably, in 15 states, multi-benefit applications are available that allow individuals to simultaneously apply for health coverage and other benefits such as food or childcare assistance. Like the alternative application, a multi-benefit application must ask the relevant questions for all health insurance affordability programs. It must also clearly indicate which questions are optional for determining eligibility for health insurance coverage only.

State Medicaid agencies are required to make the single streamlined application available through multiple modes, including online, by phone, and on paper by January 1, 2014. As of October 1, 2013, 43 of 50 reporting states have deployed a single, streamlined application through their Medicaid agency, with 43 state Medicaid agencies having a paper version in place and 36 having launched an online version. The seven (7) remaining reporting states are in the process of developing their single, streamlined applications with nearly all anticipating completion by January 1, 2014 (Appendix Table 4). In the interim, these states are continuing to utilize their existing Medicaid applications and individuals who may be eligible for premium tax credits are being directed to apply through the federal Marketplace.⁹  Looking ahead states will continue work to make the single streamlined application available through all required modes, although some state agencies may not have all of these avenues available until later in 2014. In these cases, CMS is working with states to develop mitigation plans to help ensure consumers can connect to coverage.

Coordinating Enrollment Across Health Coverage Programs

Coordination between Medicaid, CHIP, and the Marketplace will be key for achieving the ACA’s no wrong door approach to coverage. States have the option to decide whether the Marketplace (State-based (SBM) or Federally-facilitated (FFM)) will determine eligibility for Medicaid and CHIP or assess potential eligibility and send the case to the Medicaid and CHIP agency for a final determination.¹⁰  To facilitate coordination across programs and prevent individuals from having to provide information more than once, state agencies and Marketplaces are expected to electronically transfer an account with all of the individual’s information promptly and without undue delay and are not allowed to request any information or documentation that the individual has already provided.

Coordination processes will vary based on whether the Marketplace has the authority to assess or determine Medicaid eligibility. For example, if an individual applies through a Marketplace that determines Medicaid/CHIP eligibility, the Marketplace will make a final eligibility determination and transfer the account of any eligible individual to the Medicaid/CHIP agency for enrollment, without a second review of eligibility. In contrast, if an individual applies through a Marketplace that assesses Medicaid/CHIP eligibility, it will transfer the account for any individual assessed as potentially eligible for Medicaid/CHIP for a final determination by the Medicaid/CHIP agency. If determined eligible for Medicaid/CHIP, the individual will be enrolled. If determined ineligible for Medicaid/CHIP, the agency will transfer the individual’s account back to the Marketplace for a review of eligibility for premium tax credits. As a result, some individuals may be transferred back and forth between coverage programs before they are determined eligible. Among the 34 federal or partnership Marketplace states, as well as Idaho and New Mexico (which are initially relying on the FFM to handle Marketplace eligibility and enrollment), the FFM will assess Medicaid/CHIP eligibility in 24 states and make final Medicaid/CHIP eligibility determinations in 12 states. In seven (7) of these 12 states, the FFM will make determinations temporarily until the state’s Medicaid/CHIP eligibility system is able to meet the ACA requirements (Appendix Table 5).

The ability to electronically transfer individual accounts between state Medicaid/CHIP agencies and the Marketplaces is in various stages of development. All but two (2) of the 17 states with SBMs share an integrated or linked technology system that determines eligibility for all insurance affordability options and facilitates the next steps for enrollment. However, in states using the FFM, electronic transfers of individual accounts between the Marketplace and Medicaid/CHIP agencies are essential for coordinating enrollment. Due to ongoing technological challenges with the FFM, these transfers have been delayed. As such, alternative strategies have been put into place. For example, until the FFM can begin transferring electronic accounts to state Medicaid and CHIP agencies, it is sending batches with basic data on individuals the FFM has assessed as potentially eligible for Medicaid/CHIP. Similarly, if a state Medicaid/CHIP agency is unable to screen for premium tax credits and transfer the account to the FFM it can advise potentially-eligible individuals to apply directly through the FFM. Moving forward, implementing electronic account transfers will be key to minimizing burdens on consumers and ensuring that they only need to submit a single application, as envisioned by the ACA’s no wrong door approach to coverage.

Verification of Eligibility Criteria

Beginning in January 2014, states are expected to rely on trusted electronic data sources rather than paper documentation to verify eligibility. Only when information cannot be obtained through an electronic data source or is not ‘‘reasonably compatible’’ with information provided by the consumer can additional information, including paper documentation, be requested. To facilitate electronic verification, states are expected to establish data linkages with federal and state data sources. A federal data hub provides access to information from multiple federal agencies including the Internal Revenue Service (IRS), the Social Security Administration (SSA), and the Department of Homeland Security (DHS). In addition, states are commonly accessing databases that collect state wage information, unemployment compensation information, vital statistics, and eligibility data for other public programs. Ultimately the goal is for these data interfaces to provide real-time or immediate access to data, however, in some cases, data may continue to be exchanged in a process that “batches” requests for information for multiple people on a daily or other periodic basis. In these instances, data is also returned in batches, which may result in a lag before the requested data is available and can be used to verify eligibility. When this is the case, states may pend or hold the application until the data is received and reviewed. Alternatively, some states may use the data to verify eligibility after they have enrolled the individual based on his/her self-attestation.

States are submitting verification plans to CMS, which outline the electronic data sources and procedures they will use to verify eligibility criteria. For the majority of states, the heightened reliance on electronic verification requires a redesign of business practices to implement a real-time, data-driven approach to verification. Each state must file a plan with CMS describing the agency’s verification policies and procedures including the data sources used at application and renewal, the frequency of data checks, and how the state determined the usefulness of electronic data sources.¹¹  While there is no formal process for federal approval, the verification plans are used to confirm state implementation of the new standards established by the ACA, and will be used for quality and audit purposes going forward.¹²  As of November 15, 35 verification plans have been approved and made publicly available.

States continue to have the option to accept self-attestation for all non-financial eligibility criteria except where otherwise required by statute. Under law, states must verify Social Security Numbers (SSNs), citizenship, and immigration status. For other non-financial aspects of eligibility (e.g., state residency, age/date of birth, and household composition), states have more flexibility and may choose 1) to rely on self-attestation without additional verification, 2) rely on self-attestation to make the eligibility determination and verify post-enrollment, or 3) verify data to determine eligibility. For pregnancy, states must accept self-attestation, although they may request verification if multiple babies are expected. If states verify non-financial eligibility criteria, they are expected to use electronic data and eliminate or minimize requirements for paper documentation at both application and renewal. Even in states accepting self-attestation without further verification, the state may have access to electronic data for some people (for example, if the consumer is also enrolled in SNAP), which may be used to confirm eligibility.¹³  Moreover, states always have the option to verify any data that it considers questionable. All 35 reporting states will verify SSNs, citizenship, and immigration status through federal data sources as required by law. Most states plan to rely on self-attestation of state residency (28 of 35) and household composition (33 of 35). In contrast, the majority of the reporting states (22 of 35) plan to verify age and date of birth, with 18 verifying data to make the eligibility determination and 4 doing so post-enrollment (Figure 9 and Appendix Table 6).

For income, states must verify financial information from an electronic data source; however, this can be done post-enrollment after the state determines eligibility based on the individual’s attestation.¹⁴  States also may accept self-attestation for certain types of income that cannot be verified through an electronic source. All 35 reporting states will verify income through electronic sources, with 30 states doing so to determine eligibility and five (5) states verifying income post-enrollment (Figure 9 and Appendix Table 7). In addition, 23 states will be conducting routine ongoing post-enrollment checks of financial information to identify changes in income over time, although the frequency of these checks varies. Consumers are still required to report changes that may impact their eligibility.

States are relying on a variety of data sources to verify eligibility criteria. States have latitude to determine if a particular income data source is “useful” but neither the age nor cost of obtaining the data can be used as a reason to continue requiring paper documentation. SSNs and citizenship will be verified via an electronic match with the SSA, while immigration status will be verified through the DHS Systematic Alien Verification for Entitlements (SAVE) database. Frequently-used data sources for other non-financial eligibility criteria include the SSA, the Public Assistance Reporting Information System (PARIS), and state databases, such as the Department of Motor Vehicles (DMV), vital statistics, and public assistance records for Temporary Assistance to Needy Families (TANF) and SNAP. The most common data sources that states will use to verify income at application, renewal and post-enrollment include the IRS, SSA, state wage data, state unemployment data and commercial databases that provide payroll information for some employers, such as TALX (also known as the Work Number) (Appendix Table 8).

States may set “reasonable compatibility” standards to address situations in which self-attested income and electronic sources are inconsistent. In Medicaid and CHIP, data are always considered reasonably compatible if the individual’s self-attested income and the electronic data source are both at, below, or above the income standard—in these cases, the difference does not impact eligibility. In cases where self-attested income is above the standard and electronic data are below, or vice versa, states have flexibility to define when inconsistencies between the two sources are considered reasonably compatible. If the difference between the electronic data and the consumer’s self-attestation is within the reasonable compatibility standard, the self-attestation is used. If the data are not reasonably compatible under this standard, the state may accept a reasonable explanation of the difference and/or request paper documentation of income

• For cases in which self-attested income is below the income standard, but electronic data sources show income above the standard, 27 of the 35 reporting states have set a reasonable compatibility standard. If the data are not within the reasonable compatibility standard, 26 of the 35 states will ask for a reasonable explanation of the difference before requesting paper documentation, while nine (9) will always request paper documentation to verify income.

• For cases in which self-attested income is above the income standard, but electronic data sources show income below the standard, the vast majority of states are not setting a reasonable compatibility standard. Thirty (30) of 35 reporting states will accept the self-attestation, deny Medicaid eligibility, and screen for eligibility for premium tax credits, regardless of the size of the discrepancy between the attestation and the electronic data source. One state (NJ) will also accept self-attested income if the difference is no more than 10 percent, the state’s reasonable compatibility standard. Given that individuals may overstate their income if they are not aware that certain income and pre-tax contributions (e.g., dependent care expenses) should not be counted, this policy may result in a Medicaid denial and determination for premium tax credits even though the individual is, in fact, eligible for Medicaid. Three (3) states ask for a reasonable explanation of the difference before requesting paper documentation, while two (2) will always require paper documentation to verify income and process the eligibility determination.

To facilitate processing applications for large numbers of people who become newly eligible for Medicaid on January 1, CMS has offered states five strategies to help manage the transition. Highlighted in a May 17, 2013 letter to state officials,¹⁵  these approaches are intended to promote enrollment and retention, while smoothing the administrative burden as states shift to new eligibility processes. A state may adopt any of these facilitated enrollment approaches regardless of whether it plans to implement the Medicaid expansion, and as of October 1, a number of states have taken up at least one of these options (Figure 10 and Appendix Table 9).

Overall, 30 states have adopted at least one of the strategies, and 11 have adopted two or more of these approaches. Three (3) states (NJ, OR, and WV) have adopted four of the five. These strategies include:

• Extending Renewal Periods. The ACA protects individuals currently enrolled in Medicaid from losing coverage solely as a result of the conversion to MAGI-based eligibility until March 31, 2014 or their next renewal date (whichever is later). To abide by this provision, states would need to apply both the new MAGI rules and the existing rules to determine eligibility for those whose coverage is up for renewal between before March 31, 2014. To avoid this duplication of effort, CMS offered states the option to extend renewal dates beyond this three-month transition period and begin applying only MAGI-based eligibility rules to all regularly scheduled renewals beginning on April 1, 2014. States have flexibility to structure how the delays will take place, for example, by delaying renewals for 90 days, as long as they establish a reasonable timeframe within which the renewals will be completed. Twenty-five (25) states have taken up this strategy, many adopting it over a longer timeframe than those scheduled for the first quarter of 2014.

• Early Adoption of MAGI Eligibility. Through the initial months of open enrollment (October through December 2013), all individuals applying for or renewing Medicaid/CHIP coverage should have their eligibility determined under existing rules and also be assessed for eligibility using the new MAGI-based methodologies to determine if they will be eligible for coverage as of January 1, 2014. To avoid having to utilize two sets of eligibility rules, and possibly two different eligibility systems during this time, CMS offered states the option to adopt the MAGI methodology as of October 1 for all eligibility determinations going forward, which 15 states accepted.¹⁶ 

• Enrolling Eligible Supplemental Nutrition Assistance Program (SNAP) Participants in Medicaid. This temporary option is available to states through the end of 2015, and allows them to use data available from SNAP (also known as food stamps) to enroll eligible participants in Medicaid. To qualify for SNAP, a household’s gross income cannot generally exceed 130 percent of the FPL, which aligns well with the new Medicaid threshold of 138 percent of the FPL, although states may use this option for a subset of SNAP participants. Because SNAP enrollment data include verified information for many of the criteria necessary to determine Medicaid eligibility, a state can use that information along with a signed letter or phone call as a Medicaid application and enroll individuals once certain non-financial information, including citizenship or immigration status, is verified. Five (5) states (AR, IL, NJ, OR, and WV) have adopted this approach.

• Enrolling Parents in Medicaid Based on their Children’s Eligibility Data. In 2010, 3.5 million uninsured parents who could gain Medicaid coverage under the ACA expansion already had a child who was enrolled in Medicaid or CHIP.¹⁷  CMS offered states a temporary opportunity to expedite the enrollment of these parents. States can adopt this option by reactivating recent parent applications that have been denied or by reviewing children’s cases to identify eligible parents and requesting any additional information needed to make an eligibility determination. States may also send parents a pre-populated application or ask for additional information from the parent on the child’s renewal form. Three (3) states (NJ, OR, and WV) have moved forward with this approach.

• 12-Month Continuous Eligibility for Parents and Other Adults. States have long had the option to provide 12-month continuous eligibility for children regardless of certain changes in family circumstances, including fluctuations in income. Almost half of states (23) have adopted this option in Medicaid, strengthening the continuity of care and promoting ongoing coverage of children. CMS has offered to extend this effective retention strategy to adults and is working on implementation details.¹⁸ 

Two of these strategies, enrolling eligible SNAP participants and enrolling parents based on their children’s eligibility data, allow states to get a jump-start on their Medicaid expansions by significantly streamlining the process and utilizing data already available to states. Experiences in the four states that have already launched these strategies indicate they can be highly successful in connecting people to coverage, reaching a significant share of adults eligible for the Medicaid expansion while minimizing burdens for both eligibility staff and individuals and reducing traffic through enrollment systems. Overall, in these four states, over 223,000 individuals have been enrolled through these strategies as of November 15, 2013.¹⁹ 

Looking ahead to 2014, coverage for parents and other adults will significantly improve in the 26 states implementing the Medicaid expansion and eligibility levels for children and pregnant women will remain strong across states. As such, as the ACA is fully implemented, Medicaid offers the potential to significantly reduce the number of uninsured. Outreach and enrollment efforts will be key for increasing coverage and it will be important for these efforts to be ongoing throughout the year since Medicaid enrollment is not limited to the Marketplace’s open enrollment period. In contrast to gains in states expanding Medicaid, large coverage gaps will remain in the states that do not expand, leaving millions of poor uninsured adults without access to a new coverage option.

To date, states have made meaningful progress in implementing key provisions of the ACA to provide streamlined Medicaid eligibility and enrollment processes, but readiness varies considerably. Moreover, the technology problems that have hampered the launch of open enrollment through the new Marketplaces, particularly the federal Marketplace (HealthCare.gov), have led to delays in coordination across Medicaid, CHIP, and Marketplace coverage. However, even with these early implementation challenges, some states have been successfully enrolling people in Medicaid and several have gotten a significant jump-start through the facilitated enrollment strategies offered by CMS. In the coming months, work will continue to deploy new processes and systems to move toward the ACA’s vision of a simplified, consumer-friendly experience. As such, January 2014 will represent the first step toward a modernized, streamlined system to connect individuals to expanded coverage options as established through the ACA, but fully achieving that vision will require time, persistence, and a commitment to continual program improvement.

1. A number of income sources, such as child support and Social Security benefits, which are currently counted for Medicaid eligibility, are excluded from taxable income and MAGI-based determinations. States also take a different approach to determining the size of family, often based on who is applying for benefits. But under the new MAGI rules, household size will be based on the tax-filing unit, with all individuals claimed as dependents included when determining that taxpayer’s family size. ↩︎
2. Despite the attempt at coordination, there will be cases in which the definitions of household and income will not align across the various coverage programs. For example, Medicaid/CHIP eligibility will still be based on monthly income, whereas eligibility for premium credits in the Marketplace will be based on annual income. Additionally, certain types of income, such as educational grants, are not included when determining eligibility in Medicaid, but are when determining eligibility for Marketplace coverage. The household composition, such as for married couples, may also be counted differently in Medicaid. However, there is a safe harbor provision for individuals and families who are determined ineligible for Medicaid by the Medicaid agency, but are found to have income below 100 percent of the FPL based on the methods used by the Marketplace. In such cases, Medicaid eligibility will be determined using the tax definition (i.e., what was used by the Marketplace), allowing the applicant(s) to secure coverage in Medicaid and avoid a gap in coverage. ↩︎
3. Note that not all states apply earnings disregards or other deductions and may simply use a gross income standard. ↩︎
4. CMS provided states with the option of using the HHS-standardized method or a state-proposed alternative for calculating the MAGI-equivalent standards. Most states used a standard model that simulated the average value of disregards and deductions for families with net income within 25 percentage points of a state’s upper eligibility limit. This value is expressed as a percentage of the FPL and added to the state’s existing eligibility level to create the new MAGI-equivalent standard. Alternatively, states could take this same approach using their own administrative data on the use of disregards and deductions. States could also work with HHS to develop their own methodology to more adequately fit unique circumstances, for example, to account for unusual disregards. Of the 46 MAGI conversion plans available, just three (3) states (AK, NE, and NV) chose this alternative approach. C. Mann, Director of Centers for Medicaid and CHIP Services letter to State Health Officials and State Medicaid Directors, SHO #12-003 (December 28, 2012). ↩︎
5. In an attempt to simplify eligibility categories, the ACA collapses many of the existing ones into three broad groups: parents, pregnant women, and children under age 19. States will set income eligibility standards for parents, pregnant women, and children subject to federally specified minimums and maximums. The minimum eligibility level for parents is tied to states’ historical eligibility levels for Aid to Families with Dependent Children, while the minimum level for pregnant women and children generally is 133 percent of the FPL, although may be higher in some states for pregnant women. ↩︎
6. In order to equalize their eligibility thresholds, states would need to use a “less restrictive methodology” for determining income, effectively disregarding the income between the two converted thresholds for the older children. This option, under section 1902(r)(2), is no longer available with the switch to the new MAGI methodology on January 1, 2014. ↩︎
7. While the new mandatory minimum eligibility threshold is 133 percent of the FPL, the standard five percentage point of the FPL disregard is included to represent the highest threshold at which an older child may be eligible for Medicaid. ↩︎
8. Louisiana Department of Health and Hospitals. “Changes to Medicaid Eligibility Criteria Effective January 1.” Friday, August 16, 2013 available at: http://www.dhh.louisiana.gov/index.cfm/newsroom/detail/2854 ↩︎
9. Colorado and Maine are using a two-step process, where those who may be eligible for premium tax credits are directed to additional questions that will need to be answered to determine eligibility for premium tax credits in the marketplace. These states are considered by CMS to have a single, streamlined application. ↩︎
10. If a Marketplace is operated by a non-governmental agency, the authority to conduct final Medicaid determinations is limited to MAGI-based determinations. In some cases in which the Marketplace is operated by a governmental agency, the Marketplace may be able to make non-MAGI determinations or enter into contracts with government agencies to do so. ↩︎
11. Verification Plan Template – Guidance and Instructions; Phase I – MAGI-based Eligibility. ↩︎
12.  CMS eligibility audits through the Payment Rate Error Measurement (PERM) review and Medicaid Eligibility Quality Control (MEQC) evaluate whether eligibility determinations are made in accordance with state policy. Verification plans and other documents describing state policies and procedures are the basis for conducting the audits. ↩︎
13.  These states are counted under the “Self-Attestation Accepted at Application without Additional Verification” column, as this is the process they will use for the majority of their population. ↩︎
14.  Section 1137 of the Social Security Act requires states to have in effect an income and eligibility verification system. 42 CFR 435.948(a)(1) requires states to verify information (to the extent the agency determines such information is useful), related to wages, net earnings from self-employment, unearned income and resources from the State Wage Information Collection Agency (SWICA), the Internal Revenue Service (IRS), the Social Security Administration (SSA), the agencies administering the State unemployment compensation laws, the State administered supplementary payment programs under section 1616(a) of the Act, and any State program administered under a plan approved under Titles I, X, XIV, or XVI of the Act. ↩︎
15.  C. Mann, Director of Centers for Medicaid and CHIP Services letter to State Health Officials and State Medicaid Directors, SHO #13-003 (May 17, 2013). ↩︎
16.  Note that Pennsylvania is adopting the early MAGI option in its Medicaid program only. ↩︎
17.  M. Heberlein, et al., “Medicaid Coverage for Parents under the Affordable Care Act,” Georgetown University Center for Children and Families (June 2012). ↩︎
18.  The option was in Arkansas’ waiver application, but because the state could not secure the 100 percent federal match for these adults for their full-year of coverage, the state chose not to go forward. The newly eligible matching rates is only applicable for individuals who meet the statutory eligibility requirements, and as such is not available to those individuals who remain enrolled but whose income or other eligibility criteria changes over the year in ways that would make them no longer eligible under the category. New York had pre-existing waiver approval to extend 12-month continuous eligibility to parents and New Mexico included the policy for all adults in its recently approved waiver, but neither state has yet implemented it. ↩︎
19. J. Guyer, et al., “Fast Track to Coverage: Facilitating Enrollment of Eligible People into the Medicaid Expansion,” Kaiser Commission on Medicaid and the Uninsured (November 2013). ↩︎

Beginning January 1, 2014, millions of low-income parents and other adults will become newly eligible for coverage in states implementing the Affordable Care Act’s (ACA’s) expansion of Medicaid to adults with incomes at or below 138% of the federal poverty level (FPL).¹  To help states launch the expansion and efficiently enroll eligible individuals, CMS has offered states a series of facilitated enrollment options. These options include strategies, referred to as “fast track enrollment” in this issue brief, that allow states to enroll eligible individuals into coverage using data already available from their Supplemental Nutrition Assistance programs (SNAP) and/or their Medicaid or Children’s Health Insurance Program (CHIP) programs for children. These strategies complement the array of other pathways currently in place to connect Medicaid-eligible individuals to coverage, which include applying directly through state Medicaid agencies or through the new Marketplaces established by the ACA. To date, these fast track enrollment strategies have been implemented in four states: Arkansas,²  Illinois, Oregon, and West Virginia. New Jersey also recently secured approval to implement fast track enrollment and is scheduled to begin implementation in November.

This issue brief provides an overview of the new “fast track” enrollment options, including how they have been implemented, their impacts, and key lessons learned. It is based on a series of interviews with state officials in Arkansas, Illinois, Oregon, and West Virginia conducted by Manatt Health Solutions and the Kaiser Commission on Medicaid and the Uninsured. In sum it finds that

• Arkansas, Illinois, Oregon, and West Virginia together have already enrolled more than 223,000 people in coverage through these “fast track” options;

• Through these enrollment gains all four states reached a significant share of adults who will be eligible for the Medicaid expansion, providing a major one-time boost toward their enrollment goals;

• While implementing the fast track initiatives required upfront investments of time and effort, they paid off by simplifying the application and enrollment process for individuals and staff, as well as by reducing pressures on new eligibility and enrollment systems.

• The fast track initiatives have been positively received by both consumers and state enrollment staff.

Background

On May 17, 2013, the U.S. Department of Health and Human Services (HHS) sent a letter to State Medicaid Directors and State Health Officials advising them of options available to facilitate the enrollment of eligible individuals into Medicaid.³  Two of the options, referred to as “fast track” enrollment in this brief, allow states to use data that they already have on hand to identify and enroll eligible people into Medicaid.⁴  The fast track options draw on earlier experiences with Express Lane Eligibility and share many key elements with the deemed enrollment of Medicaid beneficiaries into the low-income subsidy for Medicare Part D.⁵  They provide states with an efficient way to make progress toward their Medicaid enrollment goals at a time when they are busy implementing the Medicaid expansion; establishing or coordinating with new Marketplaces; and launching new eligibility and enrollment systems. States can apply for approval to use either of these options at any time prior to the end of calendar year 2015. Specifically, under the new “fast-track” enrollment options states may:

• Use SNAP data to identify people who are likely eligible for Medicaid. SNAP generally provides benefits to individuals with incomes up to 130% FPL and uses a rigorous process to verify eligibility. As a result, it provides a source of reliable information to identify individuals who meet income eligibility criteria under the Medicaid expansion.⁶  While there are some modest differences in the definition of income in Medicaid versus SNAP, under the new enrollment option, states may obtain a time-limited waiver to rely on SNAP findings to identify individuals who are eligible for Medicaid. When using SNAP data to facilitate Medicaid enrollment, states still must determine eligibility for non-financial components of eligibility, such as citizenship, in accordance with Medicaid requirements.

• Identify parents who are likely eligible for Medicaid based on their children’s enrollment in coverage. Nearly all parents expected to be eligible under the Medicaid expansion to adults have a child who already is enrolled in Medicaid or CHIP or could be enrolled.⁷  As a result, existing information about low-income families with children enrolled in Medicaid represents a robust source of data to identify parents eligible for the Medicaid expansion. Although the ACA changes how income will be counted for Medicaid, under this enrollment option, states can obtain a time-limited waiver that allows them to use existing information for families whose children are already enrolled in Medicaid to identify parents who will qualify for the Medicaid expansion.⁸  As with the SNAP option, states must gather and evaluate any additional data needed to determine if these parents meet non-financial Medicaid eligibility rules, such as citizenship and immigration status requirements.

Under both of these fast track enrollment options, the existing data sources jump-start the enrollment process by helping states identify income-eligible individuals. However, the options stop short of allowing states to automatically enroll SNAP beneficiaries or parents of Medicaid or CHIP children into Medicaid. States must take additional steps to ensure that individuals want to be enrolled in coverage and that the state has all of the necessary information to verify eligibility. For example, states must secure an application signature from eligible individuals; provide them with information on their rights and responsibilities; and verify their non-financial eligibility for coverage in accordance with Medicaid standards.  In addition, within a year of their initial enrollment (or earlier if they report a change in circumstances), states must evaluate fast track enrollees using the new Medicaid income and household composition rules.

Findings

Adoption of fast track enrollment

As of November 15, 2013, five states with Medicaid expansions have received approval to use the fast track enrollment options, as shown in Table 1 below. (In Arkansas, the state is implementing a premium assistance model that allows Medicaid funds to be used to purchase Qualified Health Plans (QHPs) through the Marketplace for newly eligible adults.) All five use SNAP data to identify Medicaid-eligible individuals, and three (New Jersey, Oregon, and West Virginia) have also adopted the strategy to use Medicaid enrollment data for children to reach eligible parents. As of early November, four of the five states have implemented fast-track enrollment. New Jersey plans to begin implementation in mid-November. As noted, states may apply for approval to use either of these options at any time prior to the end of calendar year 2015, so additional states may take up the strategies moving forward.

Implementing Fast Track Enrollment

While there are a number of variations in how the four states implemented the fast track enrollment options, they all followed several basic steps, which include the following:

1. Identify eligible individuals within existing, approved data sources. All four states examined their SNAP enrollment data to identify individuals eligible for Medicaid. Two states (Oregon and West Virginia) also used their existing data on families with children enrolled in Medicaid to identify eligible parents (Table 2). Using these data sources, all four states selected individuals with incomes at or below the Medicaid expansion income limit who were not already enrolled in Medicaid. Arkansas, Oregon, and West Virginia included both parents and adults without dependent children (or “childless adults”) below the income eligibility limit. In contrast, Illinois solely focused on identifying eligible childless adults. The states used the fast track enrollment strategies primarily to reach adults eligible for the Medicaid expansion as of January 2014. However, Arkansas and West Virginia also elected to use fast-track to reach already eligible children who were not yet enrolled in Medicaid, who could begin receiving coverage immediately. Similarly, in some cases, these strategies also connected currently eligible parents to coverage.

2. Send eligible individuals a streamlined enrollment form.  After identifying eligible individuals, the states sent them a letter and a simple one- or two-page enrollment form (see Box 1). Individuals were required to answer a handful of questions about non-financial eligibility for coverage as needed to allow the states to verify their citizenship or immigration status, sign the form to indicate they wanted coverage and that they were aware of their rights and responsibilities, and then return it to the state.⁹  In some instances, the enrollment form asks for a few additional pieces of information, such as whether an individual has coverage through an alternative source (to facilitate third party liability recovery efforts) or if a person is of American Indian descent (to assess whether he or she can be enrolled in managed care). People can return the form through the mail and, in Oregon and West Virginia, they also have the option to call a toll-free number and provide the necessary information and a telephonic signature over the phone.

3. Verify non-financial eligibility for coverage. After receiving the forms back, states verify the citizenship status of the individuals in accordance with Medicaid standards. In general, these standards require states to electronically verify the person’s status using the federal data services hub and, if citizenship cannot be established through this means, to rely on a paper verification process.¹⁰  Similarly, for non-citizens, if immigration has not yet been verified, the state will seek to verify status through available electronic data sources, or paper documentation when electronic data are not available. If citizenship or immigration information cannot be verified, the person is found ineligible for Medicaid. States used a variety of strategies to streamline the processing of the returned enrollment forms.  For example, West Virginia and Arkansas included bar codes on the forms so that eligibility workers could easily scan them into the state’s eligibility system when they were returned. Arkansas, Illinois and Oregon used their central processing units or set up a special team to verify and confirm eligibility. Illinois officials noted that having a handful of key people working on the initiative enabled them to quickly identify and resolve issues and allowed their other eligibility workers to focus on broader ACA implementation efforts.

4. Confirm eligibility.  After states complete the verification process, they send eligible people a notice confirming their eligibility and advising them that their coverage becomes effective starting January 1, 2014. Illinois and Oregon also included enrollment cards in this mailing. Officials noted that although individuals were advised that coverage would not begin until January 1, some consumers thought their coverage was immediately effective and tried to use it upon receiving their eligibility confirmation. To minimize this problem, the states highlighted the January 1, 2014 effective date of coverage whenever possible, often mentioning it multiple times in the same letter to consumers. West Virginia is attempting to avoid this confusion among consumers by waiting until closer to the effective coverage date to send eligibility confirmations and enrollment cards. In the interim, it is notifying consumers that it has received their enrollment form and that they will receive their determination in December 2013. 

5. Facilitate enrollment into health plan. In Illinois and West Virginia, Medicaid beneficiaries generally are provided with services through a fee-for-service delivery system. In Oregon, however, adults enrolled in the Medicaid expansion select a coordinated care organization from which to receive services while in Arkansas they select a QHP offered through the Marketplace. As such, both of these states also provide individuals information on how to select a plan with their enrollment confirmation. If new enrollees do not select a plan within the state’s required timeframe, they are automatically enrolled in a plan by the state. All four states view fast track enrollment primarily as a time-limited strategy for facilitating early enrollment into their new Medicaid expansion. In the weeks and months remaining in 2013, Arkansas, Oregon and West Virginia are conducting “second round” mailings and/or calling people who did not respond to the first mailing to ensure the correspondence was not overlooked or misplaced. They also are developing procedures to address changes in circumstances prior to January 1, 2014 and planning to re-verify that fast track enrollees are not already enrolled in Medicaid shortly before their coverage goes into effect on January 1, 2014. At this point, none of the four states are planning to use fast track on an ongoing basis.

Enrollment Outcomes to Date

To date, approximately 223,000 people in these four states have been enrolled in Medicaid through these fast-track enrollment efforts. Enrollment numbers range from 35,500 in Illinois to 63,465 in Arkansas (Table 3). These numbers in Arkansas and West Virginia include some currently eligible children who were immediately connected to coverage through these initiatives. The states are continuing to process all returned enrollment forms, so these enrollment numbers will likely continue to increase as the states finalize verification and processing of all returned forms. Through these enrollment gains, the fast track enrollment strategies have enabled all four states to make significant progress in reaching and enrolling individuals eligible under the Medicaid expansion. For example, the number of people determined eligible for Medicaid through fast track in less than two months represents 18% of Illinois’ first-year Medicaid enrollment goal of 200,000 and one-quarter of the total coverage goal of 250,000 in Arkansas. In Oregon, state officials report that fast track enrollment has reduced the number of uninsured people in the state by 10% in less than one month.

All four states had robust response rates among individuals who received the fast track enrollment letters. Response rates to the initial letters and enrollment forms varied from 27% in Oregon to 46% in West Virginia. State officials noted that they were surprised and encouraged by these high levels of response. Moreover, since Arkansas, Oregon, and West Virginia sent or plan to send a follow-up letter or communication to individuals that did not respond to the initial letter, these response rates may continue to increase. For example, eligibility workers in Arkansas and West Virginia are calling people at home if they did not respond to the initial letter. In Arkansas, eligibility workers reported having a hard time reaching people by phone but, when they did, roughly 90% indicated they wanted the coverage. Since the state accepts telephonic signatures for the fast track enrollment form, eligibility workers are able to promptly enroll people over the phone. Other factors may also impact the response rate in these states including the level of unmet need for health care services and the states’ Medicaid eligibility levels prior to the Medicaid expansion.

Lessons Learned

Each state took some steps to tailor its fast track initiative to its unique circumstances, including the structure of its eligibility rules and enrollment system and its overall ACA communication and outreach efforts. However, some common “lessons learned” can be drawn from the four states’ experiences.

While implementing these fast track initiatives required upfront investments of time and effort, they paid off with substantial coverage gains while minimizing the burden on individuals, staff, and enrollment systems. As noted, implementing the fast track enrollment strategies did require upfront investments of time and effort to identify the target populations and send out and process enrollment forms. However, state officials unequivocally indicated that these investments were worth it.  From the state perspective, they generated substantial gains in coverage in a short time frame while minimizing burdens on individuals, eligibility workers, and enrollment assisters and reducing traffic to the new Marketplace enrollment systems.

The fast track initiative has been a positive experience for both consumers and state enrollment staff. As indicated by the high response rate to the fast track enrollment letters, consumers were highly motivated to enroll through this streamlined approach. State officials reported that consumers expressed gratitude for both the availability of coverage under the expansion and the ease of the fast track enrollment process, sometimes by attaching thank you notes to their enrollment forms. Enrollment staff also welcomed the streamlined enrollment approach, and state officials indicated that eligibility workers felt positive about being able to quickly confirm eligibility for many consumers who they would have denied in the past under eligibility rules prior to the Medicaid expansion.  Finally, state officials highlighted that fast track enrollment has helped to acclimate their eligibility workers to the new, data-driven approach to evaluating Medicaid eligibility required by the Affordable Care Act.

The fast track enrollment initiative can be integrated into broader ACA outreach and enrollment initiatives. To varying degrees, the four states sought to integrate their fast track enrollment initiatives into broader ACA outreach and enrollment efforts. For example, Oregon adopted a marketing-based approach to implementing its fast track initiative — it developed a special section on its web site to share information, trained Navigators and other assisters on fast track, designed consumer-friendly forms, and included a marketing brochure along with the enrollment form it sent to consumers.¹¹   Arkansas used its state Marketplace logo, “Get In,” on its enrollment form to help ensure that consumers would connect fast track enrollment with the state’s larger initiatives to enroll people into Medicaid and Marketplace coverage. It also included a note on its enrollment form alerting consumers that other uninsured family members who were not being enrolled under the fast track initiative can still apply for new coverage options online.

In conclusion, the experience of these four states demonstrates that fast track strategies represent a highly effective enrollment option for states. By using data already available to them and drawing on their expertise with eligibility and enrollment systems, these four states have been able to jump-start enrollment into their Medicaid expansions, enrolling more than 221,000 people in just two months. As result, they have made substantial progress toward their Medicaid enrollment goals while minimizing burdens on individuals, staff, and enrollment systems.

1. The Affordable Care Act requires states to apply a 5 percentage point of the FPL disregard to the new adult group, effectively increasing the income threshold for the Medicaid expansion from 133% to 138% of the federal poverty level (FPL). ↩︎
2. Arkansas is using a premium assistance model for its coverage expansion.u00a0 Under the model, known as the u201cprivate optionu201d within the state, Arkansas is using Medicaid funds to enroll newly eligible adults into Qualified Health Plans (QHPs) offered through its new Marketplace. ↩︎
3. State Health Official Letter.  Centers for Medicare & Medicaid Services.  May 2013.  Available at: http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO-13-003.pdf. ↩︎
4. Other options included in the May 2013 letter, but not discussed in this paper include: 1) implementing the early adoption of Modified Adjusted Gross Income (MAGI), 2) extending Medicaid renewals scheduled to take place during the first calendar year of 2014, and 3) adopting 12-month continuous eligibility for parents and other adults. ↩︎
5. Under Express Lane, an option established by the Children’s Health Insurance Program Reauthorization Act, states may use information from programs such as SNAP, Temporary Assistance for Needy Families (TANF), Head Start, and Women, Infants, and Children (WIC) to identify children who meet Medicaid criteria so that families do not have to resubmit the same information to multiple programs. As with the new fast track enrollment option, states still must verify citizenship and immigration status in accordance with Medicaid standards.  Similarly, after the Medicare Modernization Act established the Medicare Part D benefit and an accompanying low-income subsidy program, the Department of Health and Human Services elected to deem “partial benefit” Medicaid beneficiaries as eligible for the low-income subsidy program. While the eligibility rules for the low-income subsidy differ from those used in Medicaid, HHS determined that it would be administratively efficient to simply deem these individuals as automatically eligible for the low-income subsidy. ↩︎
6. According to HHS’s May 17th letter, “Recent studies by both the Center on Budget and Policy Priorities and the Urban Institute find that, despite the differences in household composition and income-counting rules, the vast majority of non-elderly, non-disabled individuals who receive SNAP benefits are very likely also to be financially eligible for Medicaid.” ↩︎
7. Martha Heberlein, et. al. “Medicaid Coverage for Parents under the Affordable Care Act.” Georgetown University Health Policy Institute Center on Children and Families, June 2012. Available at: http://ccf.georgetown.edu/wp-content/uploads/2012/08/Medicaid-Coverage-for-Parents.pdf. ↩︎
8. Under the ACA, financial eligibility determinations for Medicaid, CHIP, and premium tax credits and cost sharing reductions for Marketplace coverage will be based on Modified Adjusted Gross Income (MAGI). MAGI is based on IRS definitions of what counts as income after selected deductions are taken into account. ↩︎
9. States are required to comply with Medicaid citizenship verification requirements when processing fast track applications.  As a result, states must re-verify the citizenship status of fast track applicants using Medicaid (rather than SNAP) procedures.  In addition, those states (Oregon and West Virginia) that are enrolling the parents of Medicaid children in coverage must verify their citizenship or immigration status in accordance with Medicaid requirements. ↩︎
10. The federal data services hub connects states to common federal data sources (including but not limited to Social Security Administration, Internal Revenue Service, and Department of Homeland Security) to verify consumer application information for income, citizenship, and immigration status. ↩︎
11. Fast Track to Oregon Health Plan Materials are available at: http://www.oregon.gov/oha/healthplan/pages/fast-track.aspx. ↩︎

In July 2012, the U.K. Government and the Bill & Melinda Gates Foundation – in partnership with the United Nations Population Fund (UNFPA), civil society organizations, developing countries, donor governments, the private sector, and multilateral organizations – co-sponsored the London Summit on Family Planning, an effort to provide voluntary family planning services to an additional 120 million women and girls in developing countries by 2020 through new commitments. A key step in assessing progress towards these commitments is tracking expenditures for family planning.  While all financing sources are critical to helping to scale-up the response, donor governments provide a significant share of global funding for family planning services.¹ 

This analysis establishes a baseline level of funding in 2012 that can be used to track total international assistance funding levels for family planning over time as well as specific donor government progress in meeting London Summit on Family Planning commitments.  It examines funding for family planning provided by the 24 governments who were members of the Organisation for Economic Co-operation and Development (OECD), Development Assistance Committee (DAC) in 2012. Of these, eleven made specific commitments at the Summit to increase funding for family planning including: Australia, Denmark, the European Commission, France, Germany, Japan, Korea, the Netherlands, Norway, Sweden, and the U.K.²  In addition, there are several other donor governments, particularly the United States and Canada, which, while not making specific commitments at the Summit, also provide funding for family planning activities. In general, family planning services are defined to include the following activities: counseling; information, education and communication activities; delivery of contraceptives; capacity building and training.  In addition, family-planning-related activities funded in the context of other official development assistance sectors (e.g. education, civil society) are reflected in this analysis. Key findings include (also, see Table):

• In 2012, donor governments provided US$899.8 million for bilateral family planning programs and an additional US$432.3 million in core contributions to the UNFPA.
• The U.S. was the largest bilateral donor providing US$485.0 million and accounting for more than half (54%) of total bilateral funding in 2012. The U.K. (US$99.4 million, 11%) was the second largest bilateral donor followed by the Netherlands (US$65.5 million, 7%), France (US$49.6 million, 6%), and Germany (US$47.6 million, 5%).
• The eleven who made specific commitments at the Summit accounted for US$371.8 million (41%) of total donor government disbursements for family planning in 2012.
• Sweden (US$66.3 million) was the largest donor to UNFPA followed by Norway (US$59.4 million), the Netherlands (US$49.0 million), and Denmark (US$44.0).
• While complete funding data for 2013 are not yet available, two donor governments (the U.K. and Norway) have already budgeted increased levels of funding for family planning in 2013; U.K. family-planning-specific funding is estimated to be approximately US$103 million, a 5% increase over prior year levels, and the Norwegian budget provides approximately $25 million in new family planning-specific funding. In addition, while family-planning-specific funding data is not yet available, the Netherlands increased budgeted funding in 2013 for “Sexual and Reproductive Health & Rights, including HIV/AIDS” to US$504.1 million. The increases by the U.K. and the Netherlands fulfill their London Summit commitments.

In the wake of the commitments made during the London Summit, timely and accurate tracking of donor financing for family planning takes on new urgency. The data presented in this analysis should be considered a work in progress as donor governments refine existing methodologies to track funding for family planning activities. As we continue to track donor government funding for family planning in future years, we will aim to provide additional detail and trend analyses.

Introduction

Access to family planning (FP) services has a significant impact on the health and wellbeing of women and girls, and on global health and development more broadly. Family planning – the ability of individuals and couples to determine their desired number of children as well as the timing of and spacing between births – can help prevent pregnancy-related health risks, reduce infant mortality, and help in the prevention of sexually transmitted diseases such as HIV/AIDS.³  Currently, it is estimated that more than 200 million women worldwide would like to delay or stop childbearing, but they do not have access to contraceptives.⁴  The international community has long recognized the importance of improving access to family planning services. In 1994, at the International Conference on Population and Development (ICPD), 179 governments committed to a 20-year plan of action aimed at providing, among other things, universal access to family planning and sexual and reproductive health services and reproductive rights. Additionally, in 2005, a specific target on reproductive health was added to Millennium Development Goal (MDG) 5, four years after the MDGs were first adopted by Member States of the United Nations.  More recently, in July 2012, the U.K. Government and the Bill & Melinda Gates Foundation, in partnership with UNFPA, civil society organizations, developing countries, donor governments, the private sector, and multilateral organizations met at the London Summit on Family Planning and made commitments aimed at providing voluntary family planning services to an additional 120 million women and girls in developing countries by 2020 (see Box 1).

Findings

Bilateral Assistance

Donor government bilateral assistance for family planning includes both actual funding amounts provided (e.g., cash transfers) as well as other types of transactions and activities (e.g., technical assistance) and products (e.g., commodities). In 2012, donor governments are estimated to have disbursed⁸  US$899.8 million in bilateral funding for family planning activities (see Table & Annex).

The United States (US$485.0 million) was the largest bilateral donor in 2012 accounting for more than half (54%) of total bilateral assistance (see Figure 1). The U.K. (US$99.4 million, 11%) was the second largest bilateral donor followed by the Netherlands (US$65.5 million, 7%), France (US$49.6 million, 6%), and Germany (US$47.6 million, 5%).

The eleven donor governments that made commitments at the London Summit on Family Planning (Australia, Denmark, the European Commission, France, Germany, Japan, Korea, the Netherlands, Norway, Sweden, and the U.K.) accounted for US$371.8 million (41%) of total donor government disbursements for family planning in 2012.

Multilateral Assistance

While the majority of donor government assistance for family planning is provided bilaterally, donors also provide support for family planning activities through multilateral organizations, such as the United Nations Population Fund (UNFPA). Created in 1969, UNFPA supports sexual and reproductive health activities in many low- and middle-income countries and was a key partner in the London Summit on Family Planning (see Box 3).

In 2012, donor governments provided US$432.3 million in core contributions to UNFPA.⁹  Sweden was the largest donor (US$66.3 million, 15%) followed by Norway (US$59.4 million, 14%), the Netherlands (US$49.0 million, 11%), Denmark (US$44.0 million, 10%), the U.K. (US$31.8 million, 7%), and the U.S. (US$30.2 million, 7%) (see Figure 2).

While it was not possible to calculate an adjusted “family planning share” of UNFPA’s 2012 budget and attribute a portion of a donor government’s UNFPA contribution to family planning specific activities,¹⁰  it is important to note the relative balance between a donor’s core-contributions to UNFPA and its bilateral funding for family planning. For instance, three of the ten donor governments profiled provided a larger contribution to UNFPA than their bilateral disbursement: Denmark, Norway, & Sweden.

The eleven donor governments that made commitments at the London Summit on Family Planning (Australia, Denmark, the European Commission, France, Germany, Japan, Korea, the Netherlands, Norway, Sweden, and the U.K.) accounted for US$311.7 million (71%) of total core-contributions to UNFPA in 2012.

Conclusion & Looking Ahead to 2013

The data provided in this analysis provide a baseline level of donor government funding for FP activities in low- and middle-income countries. At the London Summit on Family Planning donors made commitments totaling $2.6 billion in additional funding for family planning.¹¹  While most donor governments have yet to finalize 2013 funding levels, preliminary data indicate two donor governments (the U.K. and Norway) have increased funding for family planning in 2013: U.K. family-planning-specific funding is estimated to be approximately US$105 million, a 5% increase over 2012 levels, and Norway has budgeted approximately $25 million in new family planning-specific funding. In addition, while family-planning-specific funding is not yet available, the Netherlands increased funding in 2013 for “Sexual and Reproductive Health & Rights, including HIV/AIDS” to US$504.1 million. The increases by the U.K. and the Netherlands fulfill their London Summit commitments. As donor governments conclude the 2013 fiscal year, it will be important to track funding for family planning activities in order to determine whether the London Summit commitments are being met.

Bilateral and multilateral data on donor government assistance for FP in low- and middle-income countries were collected from multiple sources.  The research team collected bilateral assistance data directly for 10 governments: Australia, Canada, Denmark, Germany, France, the Netherlands, Norway, Sweden, the United Kingdom, and the United States during the first half of 2013.  Data represent the fiscal year 2012 period for all governments except for Denmark and Germany (data are from FY/CY 2011).  Direct data collection from these donors was desirable because they represent the preponderance of donor government assistance for family planning and the latest official statistics – from the Organisation for Economic Co-operation and Development (OECD) Creditor Reporting System (CRS) (see: http://www.oecd.org/dac/stats/data – are from 2011 and do not include all forms of international assistance (e.g., funding to countries such as Russia and the Baltic States that are no longer included in the CRS database).  In addition, the CRS data may not include certain funding streams provided by donors, such as FP components of mixed-purpose grants to non-governmental organizations.   Where donor governments were members of the European Union (EU), the research team ensured that no double-counting of funds occurred between EU Member State reported amounts and EC reported amounts for international FP assistance. Data for all other OECD DAC member governments – Austria, Belgium, the European Union, Finland, Greece, Ireland, Italy, Japan, Korea, Luxembourg, New Zealand, Portugal, Spain, and Switzerland – who collectively accounted for less than 2 percent of bilateral family planning disbursements, were obtained from the OECD CRS and are from calendar year 2011.

For purposes of this analysis, funding was counted as family planning if it met the OECD CRS purpose code definition: “Family planning services including counselling; information, education and communication (IEC) activities; delivery of contraceptives; capacity building and training.” In addition, family-planning-related activities funded in the context of other official development assistance sectors (e.g. education, civil society) are reflected in this analysis. Project-level data were reviewed for Canada, Denmark, France, Germany, the Netherlands, Norway, Sweden, and the United Kingdom to determine whether all or a portion of the funding could be counted as family planning. Family-planning-specific funding totals for Australia and the United States were obtained through direct communications with government representatives. Funding attributed to the United Kingdom represents budgeted disbursements. Funding totals presented in this analysis should be considered preliminary estimates approved by representatives of the 10 donor governments who were contacted directly.

It was difficult in some cases to disaggregate bilateral family planning funding from broader reproductive and maternal health totals, as the two are sometimes represented as integrated totals. In addition, family-planning-related activities funded in the context of other official development assistance sectors (e.g. education, civil society) have in the past remained largely unidentified.  For purposes of this analysis, we worked closely with the largest donors to family planning to identify such family-planning-specific funding where possible (see Annex for detailed data table).

Bilateral funding is defined as any earmarked (FP-designated) amount. U.S. bilateral “enacted” data, or “commitments”, correspond to amounts appropriated for the 2012 fiscal year. UNFPA contributions from all governments correspond to amounts received during the 2012 calendar year, regardless of which contributor’s fiscal year such disbursements pertain to.

With some exceptions, bilateral assistance data were collected for disbursements. A disbursement is the actual release of funds to, or the purchase of goods or services for, a recipient.  Disbursements in any given year may include disbursements of funds committed in prior years and in some cases, not all funds committed during a government fiscal year are disbursed in that year. In addition, a disbursement by a government does not necessarily mean that the funds were provided to a country or other intended end-user. Enacted amounts represent budgetary decisions that funding will be provided, regardless of the time at which actual outlays, or disbursements, occur. In recent years, most governments have converted to cash accounting frameworks, and present budgets for legislative approval accordingly; in such cases, disbursements were used as a proxy for enacted amounts.  In the U.S. case, both enacted and disbursement data were available for analysis.

UNFPA core contributions were obtained from United Nations Executive Board documents; however, we were unable to determine what share of these core contributions are attributable to family planning specifically (since such funding is also used to support broader reproductive health and related efforts). To date, UNFPA family planning activities have often been reported as part of broader categories, including reproductive health and maternal and child health, as well as part of larger multisectoral efforts, including those in education, human rights, and capacity building.  It is expected that such disaggregation will be available in the future and UNFPA reports that it is currently working to develop such a methodology for doing so. Other than contributions provided by governments to UNFPA, un-earmarked general contributions to United Nations entities, most of which are membership contributions set by treaty or other formal agreement (e.g., the World Bank’s International Development Association or United Nations country membership assessments), are not identified as part of a donor government’s FP assistance even if the multilateral organization in turn directs some of these funds to FP.  Rather, these would be considered as FP funding provided by the multilateral organization, as in the case of the World Bank’s efforts, and are not considered for purposes of this report.

The fiscal year period varies by country.  The U.S. fiscal year runs from October 1-September 30. The Australian fiscal year runs from July 1-June 30.  The fiscal years for Canada and the U.K. are April 1-March 31.  Denmark, France, Germany, the Netherlands, Norway, and Sweden use the calendar year.  The OECD uses the calendar year, so data collected from the CRS for other donor governments reflect January 1-December 31. Most UN agencies use the calendar year and their budgets are biennial.

All data are expressed in US dollars (USD).  Where data were provided by governments in their currencies, they were adjusted by average daily exchange rates to obtain a USD equivalent, based on foreign exchange rate historical data available from the U.S. Federal Reserve (see: http://www.federalreserve.gov/).  Data obtained from UNFPA were already adjusted by UNFPA to represent a USD equivalent based on date of receipts.

1. UNFPA, Financial Resource Flows for Population Activities Report 2011, 2013. ↩︎
2. Family Planning 2020, London Summit on Family Planning: Summaries of Commitments, May 2013. ↩︎
3. WHO, Family Planning Fact Sheet, updated May 2013. ↩︎
4. Guttmacher Institute/UNFPA, Adding It Up: Costs and Benefits of Contraceptive Services Estimates for 2012, June 2012. ↩︎
5. While the OECD CRS database and the Resource Flows project, a joint collaboration between UNFPA and the Netherlands Interdisciplinary Demographic Institute (NIDI), both provide data on donor government funding for family planning activities, the latest available data from both sources is from 2011. Additionally, the CRS data, which is incorporated into the Resource Flows database, does not include all forms of assistance (e.g., funding to countries such as Russia and the Baltic States that are no longer included in the CRS database), and may not include certain funding streams provided by donors, such as family planning components of mixed-purpose grants to non-governmental organizations. ↩︎
6. Since 2012, 4 other governments have become DAC Members: The Czech Republic, Iceland, the Slovak Republic, and Poland. ↩︎
7. OECD, The List of CRS Purpose Codes, 2011. ↩︎
8. A disbursement is the actual release of funds to, or the purchase of goods or services for, a recipient. An enactment represents a budgetary decision that funding will be provided, regardless of the time at which an actual outlays, or disbursement, occurs. Therefore, disbursements in any given year may include funds committed (enacted) in prior years and in some cases, not all funds committed (enacted) during a government fiscal year are disbursed in that year. While most donor governments examined disburse enacted amounts within the same year, the U.S. government does not and may disburse enactments over multiple years. For instance, in FY 2012, U.S. bilateral enacted funding for family planning activities totaled $638.5 million, while disbursements totaled $485 million. ↩︎
9. UNFPA’s revenue in 2012 totaled $981.4 million, of which US$437.5 million was provided by donor governments as direct contributions in support of UNFPA’s core activities (core-contributions). An additional US$530.1 million was provided by donors in support of specific activities implemented by UNFPA (where this funding was provided by donor governments to UNFPA in support of specific family planning activities, it was counted as part of that donor government’s bilateral funding amount). ↩︎
10. At the time of publication, while the analytic team was able to identify specific family planning activities within bilateral programming (except as otherwise noted), it was not able to do so for UNFPA’s core annual funding. To date, UNFPA family planning activities have often been reported as part of broader categories, including reproductive health and maternal and child health, as well as part of larger multisectoral efforts, including those in education, human rights, and capacity building.  It is expected that such disaggregation will be available in the future and UNFPA reports that it is currently working to develop such a methodology for doing so. ↩︎
11. UNFPA, World Population Day Marked with Renewed Push to Expand Family Planning Access Around the Globe, July 2012.   ↩︎