The issues of loneliness and social isolation gained more attention during the onset of the COVID-19 pandemic and continue to have relevance in the age of social media and artificial intelligence and in the context of an aging society. Loneliness and social isolation are associated with a number of poor mental and physical health conditions. For example, recent research suggests a causal relationship between loneliness and the onset of depression. Social isolation can also be linked to riskier substance use and is a risk factor for suicide and self–harm. In addition to mental health conditions, loneliness and social isolation are associated with cardiovascular disease and cognitive decline.

Several efforts have been underway to increase awareness of and address loneliness and isolation through policy. In 2023, the Surgeon General issued an advisory on loneliness that includes strategies to advance social connection. Also in 2023, the National Strategy for Social Connection Act was introduced, which would increase education, awareness, and research on social connection, and create an office to advise the President and federal agencies on the impact of loneliness and how to improve social infrastructure and community engagement. Other bills propose standardizing the definition and measurements of loneliness, and addressing loneliness among elderly adults. Several state and local-level initiatives have also been taken, and in 2024, San Mateo County in California became the first county to declare loneliness as a public health emergency. A common strategy across many of these efforts involves improving social connectedness. Social connectedness can mitigate loneliness and have a protective effect on mental health. However, strategies to address loneliness are generally tailored to elderly adults and may not effectively address loneliness among young individuals – a population that has increasingly experienced loneliness over time. At a time when social development is critical, young people are spending less time in-person with their peers, have high engagement with social media, and many work or attend school remotely.

This brief examines loneliness and social support networks by age, race, ethnicity, and other factors based on data from the 2023 KFF Racism, Discrimination and Health Survey, a large, nationally representative survey based on responses from over 6,000 adults. Key takeaways include:

One in six (15%) adults report feeling always or often lonely in the past year, rising to about three in ten (31%) among young adults ages 18-29. While at least one in five young adults say they are always or often lonely, the shares are higher among young Black adults (35%) and young White adults (33%) than they are among young Hispanic (24%) or young Asian adults (22%). About one in five or more women, low-income adults, and LGBT adults also report feeling frequently lonely in the past year.

Black, Hispanic, and Asian adults are somewhat less likely than White adults to report having a robust local support network. Just over four in ten Black adults (44%) and half of Hispanic and Asian adults (50% each) say they have at least a fair amount of friends and family nearby who they can ask for help or support compared to over half (56%) of White adults.

There is a strong relationship between feelings of loneliness, local support networks, and physical and mental health and well-being. Across racial and ethnic groups, adults who say they are always or often lonely are more likely to report fair or poor physical and mental health compared to those who report less frequent loneliness. Similarly, adults who say they have many friends or family nearby who they can ask for help or support when they need it are about half as likely as those with less robust support networks to report frequent loneliness as well as poor or fair mental or physical health status.

The Prevalence of Loneliness

One in six adults (15%) say they always or often felt lonely in the past year, including larger shares of LGBT adults (33%), adults under age 30 (31%), lower income adults (23% of those with household incomes under $40,000) and Black women (22%).¹  Across racial and ethnic groups, adults ages 18-29 report loneliness at much higher rates than older adults. Overall, about three in ten(31%) adults under age 30 say they are always or often lonely, at least twice the share who report this among older age groups. While at least one in five young adults say they are always or often lonely, the shares are higher among young Black adults (35%) and young White adults (33%) than they are among young Hispanic (24%) or Asian adults (22%). Among adults of all ages, Black adults are somewhat more likely than White adults (19% vs. 14%) to report feeling frequently lonely in the past year.

Additionally, adults living in lower income households (less than $40,000 annually) are about three times as likely to report frequent loneliness as are those who live in higher income households ($90,000 or more) (23% vs. 7%). This difference is largely driven by higher rates of loneliness among low-income White and Black adults compared to their counterparts with higher incomes. Conversely, reports of feeling always or often lonely are similar across income among Asian and Hispanic adults.

There are also differences by gender and LGBT identity when it comes to loneliness. Overall, women (18%) are more likely than men (13%) to say they have felt always or often lonely in the past year. Across women, Black women (22%) are more likely to report loneliness than are White (17%), Hispanic (16%), or Asian (15%) women. Across racial and ethnic groups, LGBT adults are about twice as likely as non-LGBT adults to say they felt always or often lonely in the past year. For more on LGBT adults’ experiences with discrimination and health care disparities, see KFF’s previous report.

Social Support Networks

Most adults say they are at least somewhat satisfied with the number of meaningful connections they have with other people. While few adults (14%) say they are dissatisfied with their connections, similar to patterns of loneliness, shares are higher among lower income adults (17%), adults with fair or poor physical health (22%), adults younger than 30 (19%), and LGBT (19%) adults.

Black, Hispanic, and Asian adults are somewhat less likely than White adults to report having a robust local support network. Overall, about half (53%) of adults say they have a lot or a fair amount of friends and family members living nearby who they can ask for help or support, while the other half (47%) say they have just a few or no friends or family in their nearby support network. Black (44%), Hispanic (50%), and Asian (50%) adults are somewhat less likely than White (56%) adults to say they have at least a fair amount of people in their local support network. Among Asian and Hispanic adults, support networks do not vary much by age. In contrast, among Black adults, support networks increase with age, while among White adults, they decrease with age.

Among White and Hispanic adults, those with higher household incomes are more likely to say they have more local support than those with lower household incomes. However, racial differences in support networks are also evident among adults with higher incomes, as Black adults with household incomes of $90,000 or more annually (47%) are less likely White (66%) adults at that income level to say they have a strong social support network.

Among Black, Hispanic, and White adults, living in a racially concordant neighborhood (one where people say at least half or more of the people living there share their racial/ethnic background) is not associated with having a stronger local support network.

Loneliness, Social Support Networks, and Mental and Physical Health are Strongly Associated

There is a strong association between feelings of loneliness and self-reported mental and physical health status. Across racial and ethnic groups, adults who say they are always or often lonely are more likely to report fair or poor physical and mental health compared to those who report less frequent loneliness. About half (54%) of adults who say they are frequently lonely report fair or poor mental health status compared to about one in ten (11%) who say they are not often lonely. Similarly, adults who say they are frequently lonely are about twice as likely to report fair or poor physical health compared to those who are less frequently lonely (33% vs. 17%), a pattern that holds across racial and ethnic groups.

Adults who say they have a limited local support network are about twice as likely as those with stronger support networks to report frequent feelings of loneliness as well as fair or poor mental and physical health. Adults who say they have just a few or no close friends or family nearby who they can ask for help or support are more likely than those with at least a fair amount of support nearby to report feeling always or often lonely in the past year (21% vs. 10%). About one in four adults (24%) with just a few or no family or friends nearby report fair or poor mental health compared to about one in ten (11%) adults with a fair amount or a lot of local support, a pattern that persists across racial and ethnic groups. A similar pattern exists when it comes to physical health status.

The Survey on Racism, Discrimination, and Health was designed and analyzed by researchers at KFF. The survey was conducted June 6 – August 14, 2023, online and by telephone among a nationally representative sample of 6,292 U.S. adults in English (5,706), Spanish (520), Chinese (37), Korean (16), and Vietnamese (13).

The sample includes 5,073 adults who were reached through an address-based sample (ABS) and completed the survey online (4,529) or over the phone (544). An additional 1,219 adults were reached through a random digit dial telephone (RDD) sample of prepaid (pay-as-you-go) cell phone numbers. Marketing Systems Groups (MSG) provided both the ABS and RDD sample. All fieldwork was managed by SSRS of Glen Mills, PA; sampling design and weighting was done in collaboration with KFF.

Sampling strategy:

The project was designed to reach a large sample of Black adults, Hispanic adults, and Asian adults. To accomplish this, the sampling strategy included increased efforts to reach geographic areas with larger shares of the population having less than a college education and larger shares of households with a Hispanic, Black, and/or Asian resident within the ABS sample, and geographic areas with larger shares of Hispanic and non-Hispanic Black adults within the RDD sample.

The ABS was divided into areas (strata) based on the share of households with a Hispanic, Black, and/or Asian resident, as well as the share of the population with a college degree within each Census block group. To increase the likelihood of reaching the populations of interest, strata with higher incidence of Hispanic, Black, and Asian households, and with lower educational attainment, were oversampled in the ABS design. The RDD sample of prepaid (pay-as-you-go) cell phone numbers was disproportionately stratified to reach Hispanic and non-Hispanic Black respondents based on incidence of these populations at the county level.

Incentives:

Respondents received a $10 incentive for their participation, with interviews completed by phone receiving a mailed check and web respondents receiving a $10 electronic gift card incentive to their choice of six companies, a Visa gift card, or a CharityChoice donation.

Community and expert input:

Input from organizations and individuals that directly serve or have expertise in issues facing historically underserved or marginalized populations helped shape the questionnaire and reporting. These community representatives were offered a modest honorarium for their time and effort to provide input, attend meetings, and offer their expertise on dissemination of findings.

Translation:

After the content of the questionnaire was largely finalized, SSRS conducted a telephone pretest in English and adjustments were made to the questionnaire. Following the English pretest, Cetra Language Solutions translated the survey instrument from English into the four languages outlined above and checked the CATI and web programming to ensure translations were properly overlayed. Additionally, phone interviewing supervisors fluent in each language reviewed the final programmed survey to ensure all translations were accurate and reflected the same meaning as the English version of the survey.

Data quality check:

A series of data quality checks were run on the final data. The online questionnaire included two questions designed to establish that respondents were paying attention and cases were monitored for data quality including item non-response, mean length, and straight lining. Cases were removed from the data if they failed two or more of these quality checks. Based on this criterion, 4 cases were removed.

Weighting:

The combined cell phone and ABS samples were weighted to match the sample’s demographics to the national U.S. adult population using data from the Census Bureau’s 2021 Current Population Survey (CPS). The combined sample was divided into five groups based on race or ethnicity (White alone, non-Hispanic; Hispanic; Black alone, non-Hispanic; Asian alone, non-Hispanic; and other race or multi-racial, non-Hispanic) and each group was weighted separately. Within each group, the weighting parameters included sex, age, education, nativity, citizenship, census region, urbanicity, and household tenure. For the Hispanic and Asian groups, English language proficiency and country of origin were also included in the weighting adjustment. The general population weight combines the five groups and weights them proportionally to their population size.

A separate weight was created for the American Indian and Alaska Native (AIAN) sample using data from the Census Bureau’s 2022 American Community Survey (ACS). The weighting parameters for this group included sex, education, race and ethnicity, region, nativity, and citizenship. For more information on the AIAN sample including some limitations, adjustments made to make the sample more representative, and considerations for data interpretation, see Appendix 2.

All weights also take into account differences in the probability of selection for each sample type (ABS and prepaid cell phone). This includes adjustment for the sample design and geographic stratification of the samples, and within household probability of selection.

The margin of sampling error including the design effect for the full sample is plus or minus 2 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. Appendix 1 provides more detail on how race and ethnicity was measured in this survey and the coding of the analysis groups. For results based on other subgroups, the margin of sampling error may be higher. All tests of statistical significance account for the design effect due to weighting. Dependent t-tests were used to test for statistical significance across the overlapping groups.

Sample sizes and margins of sampling error for other subgroups are available by request. Sampling error is only one of many potential sources of error and there may be other unmeasured error in this or any other public opinion poll. KFF public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.

 

1. Survey respondents were asked how often they felt lonely in the past 12 months, based on a 5-point response scale: always, often, sometimes, rarely, or never. ↩︎

Medicaid is an important source of health and long-term care coverage for low-income people ages 65 and older and those with disabilities. Seniors and people with disabilities account for less than one in four Medicaid enrollees but over half of Medicaid spending. The Medicaid pathways in which eligibility is based on old age or disability are known as “non-MAGI” pathways because they do not use the Modified Adjusted Gross Income (MAGI) financial methodology that applies to children, pregnant individuals, parents, and other non-elderly adults with low incomes. In addition to considering income and age or disability status, non-MAGI eligibility pathways usually require people to demonstrate that they have limited savings and other financial resources (e.g., assets). Medicaid enrollees who use long-term services and supports (LTSS) must also meet requirements related to their functional needs which are generally measured in terms of the ability to perform activities of daily living such as eating and bathing. Because nearly all non-MAGI pathways are optional, eligibility levels vary substantially across states.

Between March 2020 and March 2023, there was a three-year pause on disenrollments, resulting in the largest ever number of enrollees in Medicaid and the lowest ever uninsured rate. Starting in April 2023, states began renewing eligibility for all enrollees as the COVID-related Medicaid continuous enrollment period ended (referred to as the “unwinding”), resulting in 23 million disenrollments as of June 2024. KFF’s recent survey of people who had lost coverage revealed that one quarter of those who were disenrolled remained uninsured, and many reported disruptions in their access to health care.

Even though seniors and people with disabilities often live on fixed incomes and are unlikely to experience eligibility changes, more cumbersome eligibility requirements relative to other groups could result in more people losing coverage. Loss of Medicaid coverage poses unique challenges for seniors and people with disabilities, people who are likely to have high health care spending and rely on Medicaid for coverage of LTSS. Civil rights complaints alleging discrimination against people with disabilities for failure to prioritize their special needs during unwinding have been filed in Colorado, Texas, and Washington D.C.

In this context, KFF’s Survey of Medicaid Financial Eligibility & Enrollment Policies for Seniors & People with Disabilities was conducted in March 2024 by KFF and Watts Health Policy Consulting. The survey sheds light on states’ eligibility, enrollment, and renewal policies for seniors and people with disabilities as of June 2024. Overall, 49 states and the District of Columbia (hereafter referred to as a state) responded to the survey, though response rates to specific questions varied (Florida was the only state that did not respond). Responses were supplemented with publicly available information and information from KFF’s 2022 survey when available. The Appendix tables contain detailed state-level data.

Key takeaways include:

Eligibility policies. The only mandatory eligibility pathway for seniors and people with disabilities is for people who receive Supplemental Security Income (SSI), which limits people to $943 per month in income and no more than $2,000 in savings and other financial assets.

• Unlike Medicaid enrollees who qualify through MAGI pathways, most non-MAGI enrollees must document limited assets. All non-MAGI enrollees under age 65 must also establish that they have a qualifying disability, high health care spending, or need for LTSS.
• Just over half of states offer coverage for seniors and people with disabilities to people with incomes above the SSI limit (Figure 1).
• States are more likely to expand eligibility for people who use long-term services and supports (LTSS). People who are eligible for Medicaid LTSS must also demonstrate that they meet functional requirements for eligibility, which generally require attestation from a medical provider about people’s ability to perform the activities of daily living. Most states offer coverage under the Katie Beckett pathway for children with significant disabilities (adopted by 43 states) and the Special Income Rule for people with LTSS needs with incomes up to 300% of SSI (adopted by 42 states).
• Medicaid enrollees using institutional LTSS must generally contribute nearly all monthly income to the cost of their care, except for a small “personal needs allowance” to cover expenses such as soap, toothbrushes, clothing, and discretionary spending. There are 24 states with personal needs allowances up to $50, 20 states between $50 and $100, and only 7 states with personal needs allowances greater than $100.

Enrollment policies. Most states (38) now use the same processes to determine income eligibility for all Medicaid enrollees regardless of what pathway they are applying through, but the need to document assets when applying for non-MAGI Medicaid may make non-MAGI applications more onerous (Figure 1).

• In states where income eligibility requirements for non-MAGI pathways differ from those of MAGI pathways, non-MAGI pathways tend to be more cumbersome.
• All states but California require many seniors and people with disabilities to demonstrate that their assets are below Medicaid eligibility limits, and asset eligibility processes are often more cumbersome. For example, when self-reported levels of income and assets differ from electronic sources, 25 states require paper documentation of income levels, and 32 states require paper documentation of assets. California eliminated the asset test beginning this year.

Renewal policies. To prepare for and simplify the unwinding process, states made wide-ranging changes to their renewal processes, many of which may be retained and may help states comply with requirements in the April 2024 final eligibility rule.

• All responding states reported that they only renew eligibility annually for non-MAGI populations and that in-person interviews are no-longer required (Figure 1).
• Nearly all states (47) provide enrollees with 30 days to return renewal information and a 90-day reconsideration period when information is returned following a procedural disenrollment; and 46 states have made changes to increase the rate of ex parte renewals for non-MAGI enrollees. (With ex parte renewals, states automatically renew eligibility using electronic data sources.)

Enrollment and Renewal Policies for Seniors and People with Disabilities

Within broad federal rules, states have discretion when establishing Medicaid application and enrollment policies, which tend to be more complicated for seniors and people with disabilities. Medicaid eligibility through the MAGI pathways is generally based only on income, age, and pregnancy/ family status, but seniors and people with disabilities applying for Medicaid through one of the “non-MAGI” pathways must usually also meet requirements related to financial assets, disability status, and often, their need for long-term services and supports (LTSS) or health care spending. Beyond setting the eligibility criteria, states make a host of other decisions about the application and enrollment process. For example, states decide whether to verify self-reported income and asset limits before enrollment or to issue conditional enrollment and then verify the income and asset amounts afterwards. States have discretion in how to respond when self-reported income and assets differ from the amounts shown in electronic data sources and in what type of documentation they require from applicants. After applicants are determined eligible, they must periodically renew their eligibility, and states have discretion in developing renewal policies.

States’ policies for enrolling people in Medicaid and renewing their coverage have been a focus of policymaker attention given pressures on eligibility workers stemming from the unwinding. The unwinding of continuous enrollment led to an unprecedented volume of eligibility work that came at a time when most states were experiencing workforce shortages and a lack of experience among newly hired staff. To support states encountering significant operational challenges and to protect eligible enrollees from inappropriate coverage losses, CMS provided states with technical assistance and a range of strategies aimed at streamlining the renewal process including allowing states to use section 1902(e)(14)(A) waiver authority. Some strategies are broad, but some are targeted specifically for non-MAGI populations. Beyond changes stemming from the unwinding, states are also updating enrollment and renewal processes to meet new requirements in a April 2024 final eligibility rule, many of which aim to streamline non-MAGI enrollment and renewal policies.

At enrollment, most states (38) use the same processes to determine income eligibility for Medicaid enrollees regardless of whether they are applying through MAGI or non-MAGI pathways (Figure 2). As part of the Medicaid application, all states require applicants to report their estimated income and then, applicants’ self-reported income is compared with income from electronic sources such as the Social Security Administration and Federal Data Services hub. Where state policies vary is in what happens when self-reported (or self-attested) income levels differ from the amounts returned from electronic data sources (Table 1). Federal rules specify that states must accept self-reported values if they are “reasonably compatible” with values from the data source (e.g., if reported income and the state’s electronic data source are both below, at, or above the income eligibility limit). With approval from CMS, states may elect an expanded “reasonable compatibility standard,” such as a percentage or dollar amount. For example, if a state elected a 10% reasonable compatibility standard, if an applicant’s self-reported income is below the eligibility threshold and the data source is above the threshold, but within 10% of the self-reported amount, the data are considered reasonably compatible, and the applicant is determined eligible for Medicaid.

Among the 12 states in which processes differ between MAGI and non-MAGI pathways, states generally have more cumbersome requirements for non-MAGI applicants. For example, 7 states reported that they have a “reasonable compatibility standard” between 10% and 50% for MAGI applicants but no similar standard for non-MAGI applicants; and 5 states reported that MAGI applicants may submit a reasonable explanation of differences, but non-MAGI applicants must submit paper documentation when the income estimates differ.

In all states but California, many seniors and people with disabilities must demonstrate that their assets are below Medicaid eligibility limits, and asset eligibility processes are sometimes administratively more cumbersome than income eligibility processes (Table 1). As of January 1, 2024, California eliminated asset tests for all Medicaid applicants, in part to reduce the administrative burden on applicants and the state. All states must verify income and asset eligibility, but they may do so either before or after enrollment. Most states verify income and asset eligibility before enrollment, but 9 states conditionally enroll applicants based on self-reported income prior to verification whereas only 5 states conditionally enroll applicants based on self-reported assets. Similarly, more states have expanded the reasonable compatibility standards for income purposes (32 states) than asset purposes (6 states). Regulations finalized in April 2024 clarify that reasonable compatibility standards apply to both income and assets, which may reduce those differences in future years. When self-reported data are not compatible with electronic data sources, 25 states require paper documentation of applicants’ income, but 32 states require paper documentation for applicants’ assets. Non-MAGI individuals can submit documents through the following modes: mail (49), local office (49), fax (48), online portal (44), email (37), and mobile devices (18), and 12 states allow individuals to submit documents through any of the six modes listed above.

Few states permit health care providers or other entities to determine non-MAGI eligibility prior to a formal application and approval, a practice known as “presumptive eligibility” (Table 1). Including Florida’s answer to the 2022 survey, there are 10 states that allow hospitals and 3 states allowing a different type of entity to do presumptive eligibility for non-MAGI populations, including the Department of Health in Tennessee, Division of Public Health in Delaware, and local health departments in Georgia. No states reported that providers such as pharmacies, nursing facilities, or home health care providers could do presumptive eligibility.

Many changes to streamline enrollment and renewals expedite the unwinding process and conform with new requirements in the April 2024 final eligibility rule (Figure 3, Table 2). The new rule prohibits states from requiring applicants or enrollees to do in-person interviews and from renewing coverage more frequently than once per year, two practices that had historically been applied to non-MAGI applicants and enrollees. All responding states now report that they do not require in-person interviews and that they only renew coverage for non-MAGI populations on an annual basis. All states also reported adopting one or more of the following practices that will be required under the new rule in 2027.

• 49 states provide a reconsideration period of 90-days or longer if information is returned after a procedural disenrollment.
• 48 states provide enrollees with at least 30 days to return signed forms and required information.
• 38 states send pre-populated renewal forms and Georgia sends pre-populated renewal forms when requested.

To streamline the unwinding process, 39 states reported that 1902(e)(14)(A) Medicaid waivers had helped increase the number of “ex parte” renewals for non-MAGI enrollees, in which states automatically renew eligibility using electronic data sources before requiring the enrollee to submit forms or documents (Figure 4, Table 3). Ex parte renewals reduce administrative burdens for enrollees and state agencies. Prior to the unwinding, most states reported a higher percentage of renewals being completed for MAGI enrollees than for non-MAGI enrollees, likely on account of the greater administrative requirements associated with non-MAGI eligibility. The 1902(e)(14)(A) waiver option allows states to waive various federal requirements for renewal processes. When asked which waivers had been the most helpful in increasing ex parte renewals, the highest number of states (21) reported waivers to renew eligibility when no information is available about enrollees’ assets from the state’s electronic system. (North Carolina reported adopting that waiver but has not yet implemented it.) Smaller numbers of states reported that the most helpful waivers allowed them to renew eligibility based on eligibility for the Supplemental Nutrition Assistance Program (16 states), renew coverage without regard to asset limits (12 states), and renew coverage for enrollees with stable incomes without checking data sources (11 states). A small number of states reported that the most helpful waivers permitted renewing coverage for people automatically if they had no income or assets in electronic data sources (Alaska and Indiana) or if their incomes were below the federal poverty level (FPL), which is $1,255 for an individual in 2024 (California and Minnesota).

Nearly all states reported considering or planning to continue renewal policies that had been implemented to facilitate renewals during the unwinding and nearly half of states (24) reported planning to continue more than 5 changes (Figure 5, Table 4). The most common changes were efforts to increase ex parte renewals (46 states), followed by increased direct outreach (40 states), new ways for enrollees to update their contact information (30 states), and engagement with community-based organizations (30 states). Over half of states (28) engaged managed care organizations to help with the renewal process and 27 states enhanced online functionalities in their enrollment systems. Other changes states reported include engaging organizations other than managed care or community-based organizations (Connecticut), implementing strategies for returned mail (Minnesota), providing more information about what is required for renewals (Vermont), and sending text messages to remind enrollees of renewals (Washington and Wisconsin).

Primary Medicaid Eligibility Pathways for Seniors and People with Disabilities

The only non-MAGI pathway that states are required to cover is people receiving supplemental security income (SSI), but there is a wide array of additional groups that can be covered at state option (Box 1). Beyond SSI, the main non-MAGI pathways to full Medicaid eligibility include state options to expand coverage to low-income people with disabilities; medically needy individuals who “spend down” by deducting incurred medical expenses from their income; Katie Beckett children with significant disabilities living at home; and adults who use long-term services and supports (LTSS). Each group has different rules about income and assets, making eligibility complex.

In 2024, the most common optional non-MAGI eligibility pathways were those for people who use LTSS and required an institutional level of care (Figure 6, Table 5). The two primary eligibility pathways for people who use LTSS include Katie Beckett coverage for children who have significant disabilities and require an institutional level of care but are living at home (43 states) and the special income rule, which covers other people who require an institutional level of care and have incomes up to 300% of the SSI benefit rate (42 states). There are 34 states offering medically needy coverage and 28 states that have extended eligibility for seniors and people with disabilities who have income above the SSI eligibility thresholds.

All states provide Medicaid to people with SSI, and just over half (28) of states expand coverage for people with income above SSI limits (Figure 7 and Table 6). The maximum SSI federal benefit amount is $943 per month for an individual and $1,415 for a couple in 2024, which is 75% of the federal poverty level (FPL), but over half of states now cover people with incomes greater than the SSI rate, including 18 states with coverage at the FPL and 9 states with coverage between 75% and 100% of the FPL. With eligibility at 138% FPL, California is the only state to offer coverage to people with incomes greater than the FPL ($1,732 for an individual). Most states set asset limits at $2,000 for an individual and $3,000 for a couple, although several states have established higher limits, and California and Arizona reported not having asset limits.

There are two mechanisms states can use to increase eligibility levels for seniors and disabilities: First, some states supplement the federal SSI benefit with additional payments, which increases the total SSI benefit and results in higher income limits for Medicaid enrollees. Second, states may adopt the 100% FPL coverage group to cover people with incomes greater than the SSI limit but lower than the poverty level. Louisiana reported adopting the 100% FPL coverage pathway but sets eligibility for that pathway at SSI levels.

In terms of enrollment, there are three ways that states elect to enroll SSI recipients into Medicaid. In 35 states, the Social Security Administration determines eligibility for Medicaid when establishing SSI eligibility. There are 8 Section 209(b) states which use financial or functional eligibility criteria that are more restrictive than the federal SSI rules, but no more restrictive than the rules the state had in place in 1972 when SSI was established. The remaining 7 states use SSI criteria to determine eligibility but do not auto-enroll recipients into Medicaid. When asked why they did not use auto-enrollment, states reported that the process is too cumbersome to implement or they have requirements beyond SSI eligibility such as an application and/or interview.

More than half (34) of states have medically needy pathways to Medicaid eligibility, but most income eligibility levels are low—usually below 50% of the FPL (Figure 8 and Table 7). If states offer medically needy coverage, they must offer it to pregnant women and children, so all 34 states offer medically needy coverage to pregnant women and children, 32 states offer it to seniors and people with disabilities, and 21 offer it to low-income parents. Income limits for medically needy coverage are low because the income limits often reflect income after payment of medical expenses and because when states created their medically needy programs, most states linked income eligibility to the income limits for cash assistance programs. Among states with medically needy programs, 15 states use a dollar threshold to determine income eligibility, 12 states use a percentage of the FPL, and 6 states use another basis. The median income limit is $504 or 40% of the FPL, and many states limit enrollees to $2,000 in assets.

Unlike other Medicaid eligibility pathways, states are not required to cover mandatory benefits in their medically needy programs, and they require enrollees to re-establish eligibility as frequently as once per month (Table 7). For most Medicaid eligibility groups, there are benefits that states are required to offer to all enrollees, but states may choose which benefits to cover in the medically needy programs. Among the 34 states that offer medically needy programs, 25 states reported covering nursing facility services. In other states, nursing facility services would not be covered and people’s spending on nursing facility care would not count as health care spending for the purposes of establishing eligibility. Given the high costs of nursing facility care, the exclusion of nursing facility coverage may have a significant impact on people’s ability to qualify through this pathway, but individuals that need nursing facility care may be eligible for Medicaid through another LTSS pathway. Medically needy coverage also requires individuals to periodically reestablish eligibility by incurring sufficient medical and LTSS expenses to reduce their countable income to the state’s medically needy income level. The timeframe for these “budget periods” ranges from 1 month (9 states) to 1 year (2 states). The most common budget period is 6 months (12 states).

Most states adopt the Katie Beckett option to cover children with significant disabilities who live in the community or provide coverage through a comparable waiver program (Figure 9 and Table 8). In 2024, 43 states reported offering Katie Beckett coverage, with Washington currently pursuing coverage through an 1115 waiver, which will bring the total number of states with coverage back to 44 as was the case in 2022. Among those states, 17 states offer coverage through the state plan, 21 states offer coverage through a waiver, and 5 states have both waiver and state plan options. The most common income limit is $2,829 (used by 31 states), which equals 300% of the SSI benefit rate or 225% of the FPL. All states except for Massachusetts update income limits annually. Most states limit individuals to $2,000 in assets but 7 states have no limits (California, Hawaii, Illinois, Kansas, Minnesota, North Dakota, and Wisconsin).

Most states (42) adopt the special income rule and offer Medicaid coverage to people with incomes up to 300% of the SSI benefit rate ($2,829 per month for an individual in 2024) for people who need LTSS (Table 8). When adopting the special income rule, states may determine whether to adopt it for people using institutional LTSS, such as nursing facility care, and separately, whether to adopt it for people using home- and community-based services (HCBS), such as personal care. In 2021, KFF estimated that over 5.6 million people used Medicaid LTSS, and that most of them received HCBS. Among the 42 states that extend Medicaid to people who use LTSS, 41 states adopt the special income rule for institutional LTSS and 41 states adopt the rule for HCBS. As in 2022, Massachusetts was the only state to report adopting the special income rule for HCBS but not institutional care and New Hampshire was the only state to report adopting the rule for institutional care but not HCBS. Delaware is the only state that adopts the special income rule but sets income eligibility limits below 300% SSI, setting eligibility at 250% of the federal poverty level instead instead ($2,358 in 2024). (In all states, institutionalized individuals are treated as single-person households after eligibility has been established.)

For Medicaid enrollees who are eligible for Medicaid because they use LTSS, most states (37) limit the value of applicants’ homes to the federal minimum level ($713,000 in 2024), but all states disregard some home equity when calculating the home’s value (Table 9). In 2024, federal rules specified that if states place limits on applicants’ home values, those limits must be between $713,00 and $1,071,000. There are 11 states that set the home equity limit at the maximum level and 2 states that use a limit in between the federal minimum and maximum. Those amounts are updated annually based on changes in SSI benefit rates and the consumer price index. California has no home equity limit on principal residence. When estimating the value of the home, all states disregard some home equity for LTSS eligibility. When and how limits on home equity apply, is often complicated. For example, if the Medicaid enrollee has a spouse or child who is under 21, blind, or disabled living in the home, it is exempt from home equity limits and does not count towards the limit of people’s assets. In other circumstances—notably, when an enrollee is living in a nursing facility and does not intend to return home—the home may instead be counted as an asset for determining financial eligibility.

Once eligible for Medicaid, individuals using institutional care generally must contribute nearly all monthly income to the cost of their care, except for a small “personal needs allowance,” which was $55 in the typical state in 2024 (Figure 10, Table 9). Personal needs allowances are intended to cover costs that Medicaid does not pay for, ranging from personal hygiene supplies such as soap and toothbrushes to clothing to self-care such as haircuts. Any discretionary spending—such as purchasing gifts for loved ones or travel—would also come from the personal needs allowance. In 2024, the median monthly personal needs allowance for a Medicaid enrollee residing in an institution is $55, up from $50 in 2022. There are 24 states with personal needs allowances up to $50, 20 states between $50 and $100, and only 7 states with personal needs allowances greater than $100. Such limited personal needs allowances leave nursing facility residents with few resources for purchasing necessities, and generally, no income to cover discretionary expenses.

Personal needs allowances are generally higher for individuals receiving HCBS in recognition that enrollees living in their homes continue to incur costs such as rent, electricity, and food. The median monthly allowance for individuals receiving HCBS waiver services is $2,829 in 2024, which equals 300% of the SSI benefit rate and was reported by 20 states. There were 20 states that reported personal needs allowances below that rate and 2 states that reported allowances above that rate. (In some states, personal needs allowances differ across the HCBS waivers. KFF asked states to report the allowance associated with the waiver that had the highest enrollment.)

In early 2023, states began final preparations for the end of the pandemic-related Medicaid continuous enrollment provision following passage of the Consolidated Appropriations Act (CAA) of 2023, which lifted the requirement effective March 31, 2023. During the three-year pause on Medicaid disenrollments, Medicaid and CHIP enrollment grew by 32% from 71.3 million to 94.1 million, resulting in the largest ever number of enrollees in Medicaid, which, along with enhanced subsidies in the Affordable Care Act (ACA) Marketplaces, contributed to the lowest ever uninsured rate. The CAA also extended and phased out the enhanced federal Medicaid matching funds that states received during the pandemic through the end of 2023. All states were expected to initiate their first month of renewals no later than April 2023, although some states did not process their first disenrollments until June or July.

The 22^nd annual survey of state Medicaid and CHIP programs officials conducted by KFF and the Georgetown University Center for Children and Families in March 2024 presents a snapshot of actions states have taken to improve systems, processes, and communications during the unwinding, as well as key state Medicaid eligibility, enrollment, and renewal policies and procedures in place as of May 2024. The report focuses on policies for children, pregnant individuals, parents, and other non-elderly adults whose eligibility is based on Modified Adjusted Gross Income (MAGI) financial eligibility rules (information on policies for populations that qualify for Medicaid on the basis of age or disability—non-MAGI populations—is captured in a separate brief). Overall, 49 states and the District of Columbia responded to the survey, although response rates for specific questions varied (Florida was the only state that did not respond). For purposes of this report, the District of Columbia is counted as a state.

Key Takeaways

• All states report taking action to improve automated, also known as ex parte, renewal rates during the unwinding and plan to continue these strategies post unwinding. Forty-two states adopted 1902(e)(14)(A) waiver flexibilities to increase ex parte renewal rates for MAGI populations, while 39 states improved system rules and 22 states expanded the number of data sources they use to conduct ex parte reviews. In addition, 35 states process ex parte renewals on a mostly automated basis, which required system upgrades in some states. Among the 42 states that adopted 1902(e)(14)(A) waivers to increase ex parte rates for MAGI populations, allowing ex parte renewals for individuals with $0 income and with low income in some circumstances and using SNAP or TANF eligibility to confirm ongoing Medicaid eligibility were cited as the most useful waivers, and many states would like to make these permanent. CMS has extended the 1902(e)(14)(A) waivers through June 2025.
• All states made changes to simplify or streamline the renewal process and they want to keep many of the changes in place after the unwinding period ends. In addition to improving ex parte processes, some states also made more targeted changes to revise renewal notices (22 states), simplify the renewal form (10 states), and extend the time to respond to renewal notices (7 states) that should make it easier for enrollees to complete the renewal process in the future.
• States cite outreach to enrollees and engagement of health plans and community groups among the strategies that improved unwinding outcomes. States boosted direct outreach to enrollees through multiple modes, including text, email, and automated calls, and 37 states plan to maintain the enhanced outreach post unwinding. Additionally, over two-thirds (34) of states expect to continue engaging health plans and/or community-based organizations in the renewal process. States also note that these organizations played an important role in amplifying outreach and providing community-based assistance.
• Several states are taking steps to improve coverage for children and pregnancy, including by increasing eligibility levels, providing continuous eligibility, and eliminating premiums for children’s coverage. In 2024, two states increased eligibility levels for children and/or pregnancy coverage and eight states extended coverage to certain immigrant children and/or pregnant individuals, and three states did both. Eighteen states have eligibility levels above the median for both children (255% FPL) and pregnancy (210% FPL). Building on the experience of continuous enrollment, several states have adopted or are pursuing multi-year continuous eligibility for young children, and there has been widespread adoption of 12-month postpartum coverage. And since 2020, ten states have eliminated or are poised to eliminate premiums for children’s coverage.

As the unwinding comes to an end, there is a lot to learn from state experiences during the past year. States made numerous policy and systems changes to improve the renewal process and they plan to maintain many of those changes. Additionally, the Eligibility and Enrollment final rule CMS issued earlier this year simplifies many eligibility and enrollment processes for Medicaid and CHIP by eliminating certain enrollment barriers in CHIP; facilitating transitions between coverage programs; and aligning enrollment and renewal requirements for most individuals in Medicaid. It makes some temporary policy changes permanent and will require additional changes over the next 36 months. CMS has also extended 1902(e)(14)(A) waivers through June 2025 while it continues to assess whether any waivers can be made permanent under other authority. Collectively, these changes to renewal and ex parte processes as well as eligibility expansions mean that the return to “routine” operations will not mean return to pre-pandemic operations. The impact these changes may have on continuity of coverage and churn and on overall Medicaid enrollment will be seen over the coming years.

Detailed Summary

The Unwinding and Post-Unwinding

The timeline for completing all unwinding-related renewals has been extended beyond June 2024 in at least ten states. On May 31, 2024, CMS released preliminary estimates of when states will complete unwinding renewals. While most states are expected to complete renewals by June, Illinois, Kentucky, Michigan, New Jersey, and Wisconsin will finish in July while Alaska, District of Columbia, Hawaii, North Carolina, and South Carolina will finish in August or later. New York’s completion month is still under development. Although it had been expected that all states would complete the unwinding by June 2024, some states voluntarily pushed out the deadline for returning renewals by a month or more to conduct targeted outreach and give enrollees more time to return renewal forms. Other states were required to pause disenrollments to correct a system glitch or address another issue that was uncovered during the unwinding.

Most states (41) have frontline eligibility staff vacancies while somewhat fewer states (32) report call center staff vacancies. Workforce challenges in most states have had a significant or moderate impact on the states’ ability to manage application and renewal workloads. Approximately two-thirds of states report moderate to significant impacts related to eligibility staff vacancies, recruitment, training, and retention. However, states report that the impact of workforce issues on call centers has been more modest.

All but four states are interested in maintaining flexibilities that have been most useful to simplifying renewal processes. Nearly all states adopted at least one 1902(e)(14)(A) waiver and most states would like to make some of the waivers permanent. Topping the list were two waivers CMS has already made permanent through the recently finalized Eligibility and Enrollment Rule – accepting updated contact information from Medicaid health plans, the USPS National Change of Address Database (NCOA) and/or mail returned with an in-state forwarding address from the USPS without further verification. States are also interested in continuing to enroll or renew individuals based on SNAP and/or TANF eligibility (25 states) and to renew coverage when no income data is reported (29 states) or reported income is below the poverty level (17 states). Given the positive impact some strategies have had on renewal outcomes, CMS has extended their use through June 2025 while the agency determines which can be implemented on a longstanding basis under other authorities. Additionally, certain 1902(e)(14)(A) waivers will need to be maintained as mitigation strategies in states with processes that do not fully comply with federal renewal requirements.

Most states (41) report they plan to continue improved communication with enrollees and/or engagement of health plans and community groups. States cite communications and the involvement of health community organizations as strategies that improved unwinding outcomes, including increased outreach to enrollees (37 states) and engaging health plans in the renewal process (31 states). Half of the states cited providing new ways for enrollees to update contact information (27 states); engaging community-based organizations in the renewal process (26 states); and maintaining enhanced online account functionality (26 states) as changes they intend to keep.

Data reporting has been important for monitoring the unwinding, and while half of states were uncertain about continuing to post renewal data or had planned to stop reporting, new guidance from CMS continues state monthly renewal outcome reporting. The CAA requires states to report renewal data and requires CMS to make the data public but only through June 2024. While data posted by CMS lag by 2-to-3 months, most states (42) post their own renewal-related data on a timelier basis. At the time of the survey, 15 states confirmed that they will continue reporting these data after the unwinding period ends, while 22 states were uncertain, and five states responded that they would not continue posting the data. However, on May 30, 2024, CMS issued new guidance stating that states are expected to continue reporting renewal monthly outcome data and encouraging states to maintain data dashboards or other timelier posting of data.

One-third of states (16) plan to resume periodic data checks that can lead to churn for low-wage earners. With continuous eligibility no longer in effect (except for children and pregnancy coverage), states may opt to conduct periodic data checks to identify potential changes in income or circumstances that could affect eligibility. Periodic data checks can exacerbate churn since low-income wage earners experience frequent fluctuations in income during the year. And, although states have the option to push out renewal dates for 12 months if ongoing eligibility is confirmed through a mid-year data check, only 3 of the 16 states plan to do so. Additionally, 7 of the 16 states provide only ten days for enrollees to respond to a request for information following a periodic data check although known delays in mail delivery can make it challenging for enrollees to submit information before coverage is terminated. Beginning in June 2027, in accordance with the Eligibility and Enrollment rule, states will be required to provide 30 days for enrollees to respond to requests for information, which aligns with the current rule for renewals.

Lessons Learned

States cited changing or unclear federal guidance, workforce issues, and the sheer volume of work as the top three challenges they faced during the unwinding. Other challenges centered on systems issues—the need to make systems changes and/or upgrades quickly to respond to the changing landscape or to implement new renewal flexibilities and fix limitations or problems with existing systems that hindered states’ ability to process renewals efficiently. States also noted difficulties engaging enrollees in the renewal process and communicating effectively about the renewal requirements and process.

Despite the challenges states faced, they made many changes to simplify and improve the renewal process, including improved outreach and enrollee communication, improved engagement with stakeholders and community organizations, and increased ex parte renewal rates. States also noted improved systems automation and building the infrastructure for data reporting and transparency as significant accomplishments in addition to streamlined renewal processes.

Systems and Online Tools

Most system improvements have been focused on increasing state ex parte renewal processes. Using reliable data to verify ongoing eligibility at renewal, known as ex parte or automated renewals, decreases the paperwork burden on states and enrollees while reducing gaps in coverage and extra work associated with re-enrollment of eligible people losing coverage for procedural reasons. All states have taken steps in the past two years to increase ex parte rates that include expanding data sources used for ex parte reviews and improving other system rules. In addition, 42 states reported adopting one or more 1902(e)(14)(A) waivers to improve ex parte rates for MAGI populations. Flexibilities allowed during the unwinding have helped states increase ex parte renewals rates and improve overall renewal outcomes.

Nearly all states (49) have online accounts with similar features but there are differences in requirements for setting up accounts and resetting passwords. Online accounts are a first step in applying for coverage since no state offers the ability to apply online without an account. Most online accounts provide a range of features for individuals, including checking their application status, viewing notices, reporting changes, renewing coverage, and uploading scanned or electronic verification documents. These accounts must be secure to protect personal information, and more than half of states (29) require new users to go through an identity verification process before setting up an account. In the 28 states that require multi-factor authentication, this security measure is required to set up an account in 25 states, to reset the password in 22 states, and every time the account is accessed in 13 states. The process for resetting the account password varies as well; users can reset passwords online by answering security questions (32 states) or through a link sent via email or text (33 states). In 29 states, users may contact the Medicaid call center to reset the password.

Eligibility and Enrollment Policies

Several states have expanded eligibility for children and pregnancy coverage, and two states newly adopted the Medicaid expansion in 2023. Arizona, Maine, and North Dakota expanded child eligibility levels over the past year while the median eligibility level remained unchanged. The median income eligibility for pregnancy coverage rose from 207% to 210% FPL with expansions in North Dakota, Nevada, and Tennessee. Several states newly waived the five-year waiting period for Medicaid and CHIP coverage for lawfully residing immigrant children and pregnant people (Georgia and New Hampshire) and for just pregnant people (North Dakota, Nevada, and Rhode Island). Adults with income up to 138% FPL are now eligible for Medicaid expansion in North Carolina and South Dakota.

Several states have made changes to children’s Medicaid and CHIP coverage. As of January 2024, all states are now required to keep children continuously enrolled for a full year with limited exceptions. However, 13 states are seeking to provide continuous eligibility beyond 12 months for young children. Additionally, since 2020, eight states (California, Colorado, Illinois, Maine, Maryland, Michigan, New Jersey, North Carolina) have eliminated their premiums or enrollment fees for children; Utah will eliminate premiums in July and Delaware has a pending request with CMS to eliminate premiums in its CHIP program. In the Eligibility and Enrollment regulation CMS made several changes to CHIP, including prohibiting new waiting and lock-out periods and requiring states with existing waiting and lock-out periods to eliminate them by June 2025.

Introduction

The Consolidated Appropriations Act of 2023 (CAA), enacted in December 2022, ended the pandemic-era Medicaid continuous enrollment policy effective March 31, 2023, setting in motion final planning and preparations for the unwinding by state agencies and CMS. The CAA also phased down the enhanced FMAP through December 2023. To be eligible, states needed to meet specific maintenance of effort requirements including complying with federal renewal requirements, maintaining eligibility and enrollment procedures, taking actions to update contact information and address returned mail, and reporting specific data. During the three-year pause in Medicaid disenrollments, Medicaid and Children’s Health Insurance Program (CHIP) enrollment grew by 32% from 71.3 million to 94.1 million, resulting in the largest ever number of enrollees. The unwinding of continuous enrollment and the unprecedented volume of eligibility work required coordination across federal and state governments, health plans, providers, and community-based organizations; careful planning; close monitoring; and rapid response to try to mitigate loss of Medicaid coverage among individuals remaining eligible.

In this context and with most states still conducting unwinding renewals, the 22nd annual survey of state Medicaid and CHIP program officials conducted by KFF and the Georgetown University Center for Children and Families in March 2024 presents a snapshot of actions states have taken to improve systems, processes, and communications during the unwinding, as well as key state Medicaid eligibility, enrollment, and renewal policies and procedures in place as of May 2024. The report focuses on policies for children, pregnant individuals, parents, and other non-elderly adults whose eligibility is based on Modified Adjusted Gross Income (MAGI) financial eligibility rules. Overall, 49 states and the District of Columbia responded to the survey, although response rates for specific questions varied (Florida was the only state that did not respond).(Back to top)

The Unwinding and Post-Unwinding

While the unwinding period was expected to end for all states by June 2024, in ten states, the timeline for completing renewals has been extended beyond June 2024. With all states initiating their first monthly batch of renewals no later than April 2023, it was expected that the unwinding would be complete by June 2024. However, due to concerns over high rates of procedural disenrollments, 15 states voluntarily pushed out the deadline for returning renewals by a month or more to conduct targeted outreach and give enrollees more time to complete and return renewal forms. Other states were required to pause procedural disenrollments and/or implement CMS-approved mitigation strategies as a temporary tactic to address areas of non-compliance with federal renewal requirements or other issues discovered during the unwinding. On May 31, 2024, CMS released preliminary estimates of when states will complete unwinding renewals. While most states are expected to complete renewals by June, Illinois, Kentucky, Michigan, New Jersey, and Wisconsin will finish in July while Alaska, District of Columbia, Hawaii, North Carolina, and South Carolina will finish in August or later. New York’s completion month is still under development.

Most states (41) have frontline eligibility staff vacancies while somewhat fewer states (32) report call center staff vacancies. States experienced a significant or moderate impact because of eligibility staff vacancies (32 states), the need to recruit frontline eligibility staff (29 states), retaining staff (29 states), and training new workers (27 states) (Figure 2). Fewer states reported significant or moderate impacts from call center vacancies (17 states), recruiting additional call center personnel (17 states), retaining call center staff (18 states), and training new personnel (13 states).

Over the past two years, all states have taken at least one action to improve ex parte renewal rates. Forty-two states adopted waiver flexibilities, while 39 states updated system rules and 22 states expanded the number of data sources they use to conduct ex parte reviews (Figure 3). A dozen states changed the order in which the state accesses various data sources to increase the number of reviews that produce a data match, and nine states revised limits on the age of data used to improve ex parte renewal rates. Among the 42 states that adopted 1902(e)(14)(A) waivers to increase ex parte rates for MAGI populations, nearly all (37) states reported that the flexibility allowing for ex parte renewals for individuals with $0 income in some circumstances was among the most helpful waivers. Other waivers that states said were most helpful were using SNAP eligibility to confirm ongoing Medicaid eligibility (26 states) and allowing ex parte renewals for individuals with low-income (23 states).

The unwinding has accelerated state efforts to automate ex parte renewals, with 48 states reporting that most or some renewals are conducted by the system, including 35 states that have mostly automated ex parte renewals (Figure 4). Only two states (Delaware and Pennsylvania) report largely manual ex parte processes. However, fewer states report mostly automated processing of applications. While 48 states are able to determine eligibility in real-time at application (defined as 24 hours or less), only 37 states indicate that most or some real-time determinations of new applications are processed automatically by the eligibility system. The remaining 11 states report manual processes for real-time determinations at application, which generally only occur when an individual applies in person or by phone and the eligibility worker can verify eligibility immediately.

Although not required to do so, 22 of the 28 reporting states that operate separate CHIP programs transition a child enrolled in Medicaid to CHIP if the state has reliable data through the ex parte process that verifies the child’s eligibility for CHIP (Figure 5). In contrast, seven states do not transfer children from Medicaid to the state’s separate CHIP program if the family does not return the Medicaid renewal form. Automatically transferring an eligible child from Medicaid to the separate CHIP can help promote continuity of coverage for children. The recently finalized Eligibility and Enrollment Rule requires states to ensure seamless transitions between Medicaid and CHIP effective June 4, 2024.

Post-Unwinding

Most states (42) are interested in maintaining 1902(e)(14)(A) waiver flexibilities that have been most useful to streamlining renewal processes and outcomes (Figure 6). The waiver strategies cited by the largest numbers of states – accepting updated contact information as verified from USPS sources (reported by 34 states) and health plans (reported by 29 states) – have already been made permanent through the Eligibility and Enrollment Rule. CMS currently is reviewing all other waiver strategies to determine which can be implemented on a longstanding basis under other authorities. In the meantime, these temporary strategies have been extended through June 2025 to protect enrollees from inappropriate terminations as states complete their unwinding periods and address any backlogs in processing new applications and re-enrollments. Other waiver strategies that states are interested in continuing include enrolling or renewing individuals based on SNAP and/or TANF eligibility (25 states) and renewing coverage when no income data is reported from state data sources (29 states) or reported income is below the poverty level (17 states).

All states boosted communications and/or engagement with community groups, and most are considering or plan to continue many of these changes beyond the unwinding period. Topping the list of strategies to maintain are increased outreach to enrollees (37 states) and engaging health plans in the renewal process (31 states). Half of the states (27) said they plan to maintain new ways for enrollees to update contact information; 26 states plan to both continue engaging community-based organizations in the renewal process and maintain enhanced online account functionality (Figure 6).

Data reporting has been important for monitoring the unwinding, and while half of states were uncertain about continuing to post renewal data or had planned to stop reporting, new guidance from CMS continues monthly renewal outcome reporting. The CAA requires states to report renewal data and for CMS to make the data public but only through June 2024. While these data help CMS quickly pinpoint concerning trends, the 2- to 3-month lag in public posting by CMS makes it less useful for rapid response by Medicaid stakeholders. Nonetheless, this is the first time that comparable renewal data for all states have been publicly available. Medicaid stakeholders can access the state’s unwinding data on a timelier basis in 42 states that post their own data. At the time the survey was fielded, only 15 of those states confirmed that they were planning to continue posting these data after the unwinding period ends while 22 states were uncertain, and five states responded that they would not continue posting the data. However, on May 30, 2024, CMS released additional guidance stating that states are expected to continue reporting monthly renewal outcomes data to CMS, along with other metrics related to applications and fair hearings. CMS also encouraged states to maintain public dashboards and timelier posting of data after the unwinding period ends.

About a third of states (17) report that enhanced efforts to update enrollee contact information helped reduce returned mail rates while most states (30) did not have data to confirm. The CAA required states to update enrollee contact information and make a good faith effort to address returned mail; similar requirements will become permanent in December 2025 under the Eligibility and Enrollment Rule. States must implement (or retain) processes to regularly obtain information and to update contact information from reliable sources without further verification. If information is received from a reliable source, the state must accept the information as reliable, update the case record, and notify the enrollee of the change. The rule establishes that reliable data sources include mail returned by the United States Postal Service (USPS) with an in-state forwarding address; the USPS National Change of Address (NCOA) database; contracted managed care organizations, prepaid health plans, and primary care case management entities (PCCM); and other data sources identified by the agency and approved by the Secretary.

Lessons Learned

States cited changing or unclear federal guidance, workforce challenges, and the sheer volume of work as the top three challenges they faced during the unwinding (Figure 7). Other challenges centered on systems issues—the need to make systems changes and/or upgrades quickly to respond to the changing landscape or to implement new renewal flexibilities and limitations or problems with their existing system that hindered states’ ability to process renewals efficiently. States also noted challenges with engaging enrollees in the renewal process and communicating effectively about the renewal requirements and process.

Despite the challenges states faced, they made many changes to simplify and improve the renewal process, including improved outreach and enrollee communication, improved engagement with stakeholders and community organizations, and increased ex parte renewal rates (Figure 7). States also noted Improved systems automation and building the infrastructure for data reporting and transparency as significant accomplishments as well as streamlined renewal processes.

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Systems and Enrollment Processes

Eligibility System Integration and Administration

Twenty-two states operate their own State-Based Marketplaces (SBM) but only ten of those states have integrated Medicaid and CHIP into their SBM eligibility systems (Figure 8). Nine SBM states operate an SBM eligibility system that is separate from the MAGI-Medicaid system and three SBM states (Arkansas, Georgia, and Oregon) use the Federally-Facilitated Marketplace (FFM) system – Healthcare.gov – along with the 29 states that rely solely on the federal marketplace. Of the 32 states that use the FFM, nine states (Alabama, Alaska, Arkansas, Louisiana, Missouri, Montana, North Carolina, West Virginia, and Wyoming) accept a Medicaid determination from the FFM based on the state’s eligibility rules (though Missouri is only temporarily accepting determinations from the FFM). The remaining states allow the FFM to assess Medicaid eligibility and process an account transfer from the FFM as a new application.

Progress in integrating non-MAGI and non-health programs into the Medicaid and CHIP eligibility system took a back seat to unwinding system changes. In preparing for the unwinding, system changes to facilitate renewals became the highest priority for states. An integrated system makes it easier for individuals to apply for multiple benefits and increases administrative efficiency by aligning eligibility tasks and sharing data. Most states delinked those programs in building new MAGI-based systems required by the ACA but had been making steady progress in re-integrating non-MAGI and non-health programs into their new MAGI-based Medicaid systems. With the priority on system changes needed to manage the unwinding, the count of states with other program eligibility integrated in state MAGI-based eligibility systems remained steady: non-MAGI Medicaid in 36 states; SNAP and TANF in 28 states, and childcare subsidies in 15 states (Figure 9). Of the ten states with an integrated Marketplace and MAGI-based Medicaid system, only Kentucky and Rhode Island have integrated non-MAGI Medicaid and non-health programs into their SBM systems.

The agency and staff responsible for Medicaid determinations vary across states. While Medicaid agencies can delegate eligibility determinations to another government agency that maintains personnel standards on a merit basis, the Medicaid agency remains responsible for oversight and adherence to federal rules. In 25 states, the Medicaid agency is responsible for processing applications and renewals, while the state’s sister Human Services agency does so in 20 states. In two states (Illinois and Virginia), the responsibility is shared between the two agencies, while the SBM administers Medicaid and CHIP eligibility in Maryland and New York. In 37 states, only state workers process both applications and renewals while a smaller number of states use only county workers for processing applications (6 states) and renewals (4 states). Both state and county workers process Medicaid applications in seven states and renewals in nine states. States may use contractors to assist with administrative tasks related to processing Medicaid applications and renewals but may not delegate determinations to external contractors. With the volume of work during the unwinding period, 29 states reported they currently use contractors to provide administrative support to Medicaid eligibility staff and 21 said they will continue to use contractors when the unwinding period ends.

In 2023, Maine and North Carolina transitioned all child enrollees from the state’s separate CHIP program to a CHIP-funded Medicaid expansion program, bringing the total number of M-CHIP states to 21. Since 2020, a total of five states, including Illinois, Kentucky (which was approved in July 2023 retroactive to July 2022), and Wyoming have transitioned from a separate CHIP to M-CHIP. Rules governing administration of and eligibility processing in separate CHIP programs differ from Medicaid. States may choose to cover all uninsured children eligible for CHIP in Medicaid (known as M-CHIP), through a separate CHIP program only (2 states), or through a combination of a separate CHIP and M-CHIP (28 states). Covering CHIP children in Medicaid streamlines administration and provides all children with child-focused EPSDT Medicaid benefits and other Medicaid protections, including limitations on cost-sharing, while operating a separate CHIP allows states to alter benefit packages and delivery systems and provides more flexibility to impose premiums and cost sharing. Although separate CHIP programs have more flexibility in benefit design, half of the 30 states with separate CHIP programs provide EPSDT benefits to all children.

Income Verification

States use a variety of data sources to determine income eligibility; these sources are critical to processing real-time applications and ex parte renewals. States have flexibility in choosing the data sources and age of the data that are used to comply with ACA requirements in first attempting to determine eligibility using reliable data available to the state before requiring paper documentation from the individual. Most states use the state unemployment database (44 states) or the state wage database (42 states), while 38 use commercial databases (e.g., TALX or the Work Number) and 37 states access SNAP data (Figure 10). Fewer states use IRS data (19 states) or state tax department data (6 states). State limitations on the age of the data vary by source. In most states, the age of data is restricted to less than 12 months but can be less than three months, which may lessen the state’s ability to determine eligibility in real-time (less than 24 hours) or renew coverage on an ex parte basis.

Most states (39) verify income eligibility before determining eligibility at application. All states must verify income eligibility but may opt to do so either prior to or post enrollment. Eleven states base a preliminary determination on the applicant’s attestation of income and verify post-enrollment.

Most states (39) also apply a reasonable compatibility standard to account for differences in reported income and data sources. If reported income and the state’s electronic data source are both below, at, or above the income eligibility limit, the state must accept the finding without reconciling the difference. Additionally, with approval from CMS, states may set a reasonable compatibility standard – that is an acceptable level of variance, as either a percentage of income or a specific dollar amount to account for any difference between the individual’s income attestation and the income data source. For example, in a state with a 10% reasonable compatibility standard, if an applicant’s attestation of income is below the eligibility threshold and the data source is above the threshold, but within 10% of the attestation, the attestation and data source are considered reasonably compatible, and the applicant is determined eligible.

Two-thirds of states (39) apply reasonable compatibility standards when the individual’s attestation is below the income eligibility limit and the data source is above the threshold. When data are not reasonably compatible, states have the option to accept a reasonable explanation (such as I lost my job), which 28 states do, while 22 states require documentation. Eleven states do not apply a reasonable compatibility standard but ask for explanation or require documentation if attested income differs from the data source. When the income attestation is above the eligibility limit and the data source is below, most states (38) accept the individual’s attestation, determine the individual ineligible, and transfer the account to the Marketplace.

Applications, Online Accounts, and Community-Assister Portals

In most states, online MAGI Medicaid applications also allow individuals to apply for non-MAGI Medicaid, as well as other benefits and/or Marketplace subsidies. In 41 states, individuals can apply for both MAGI and non-MAGI-based Medicaid using the same online application portal. Nearly one-third of states have integrated SNAP (31 states) and TANF (29 states) in their online Medicaid applications while 18 states also use their multi-benefit applications to enable families to apply for child care assistance. Of the 19 SBM states with their own SBM eligibility systems, 15 allow applicants to use the same application for Marketplace premium tax credits. That leaves just two states with an online application that is limited to MAGI-based Medicaid. While all states, except Colorado, allow individuals to apply with an electronic signature through a smartphone or tablet, 40 states have taken steps to ensure that applications are mobile-friendly, up from 31 states in 2023.

States offer a variety of ways to submit documentation when eligibility cannot be confirmed through data sources. All states accept documents through the mail; other mechanisms include dropping off at a local office (49 states), through the online account (47 states), via fax (48 states), through email (36 states) or through the state’s mobile app (12 states).

States are maximizing the features of online accounts to assist new applicants and enrollees in monitoring and managing their coverage. To apply online, applicants must first set up an online account as no state offers an online application that is separate from online account management. Beyond allowing enrollees to apply, the 49 states with online accounts offer a range of features including renewing coverage (48 states), reviewing application status (47 states), viewing notices (47 states), reporting changes (45 states), uploading documents (44 states), and authorizing third party access (31 states) (Figure 11). Seventeen states have integrated a Chatbot feature in their online accounts. In the 47 states that allow users to view notices through their online accounts, 34 states report that notices are available indefinitely while 12 states indicate that notices are time-limited, generally available for one to four years, though three states allow notices to only be viewed for less than a year. In the 42 states that permit enrollees to submit renewal documents after a procedural termination, 28 allow individuals to submit renewal information at least 90 days after being procedurally disenrolled, which aligns with the 90-day reconsideration period during which an individual who was procedurally disenrolled may submit needed information without completing a new application.

The 49 states with online accounts have similar features but there are differences in requirements for setting up accounts and resetting passwords. Online accounts must be secure to protect personal information, though security features can create barriers to accessing accounts for some enrollees. More than half of states (29) require new users to go through an identity verification process before setting up an account. In addition, in the 28 states that require multi-factor authentication, this security measure is required to set up an account in 25 states, to reset the password in 22 states, and every time the account is accessed in 13 states (Figure 12). The process for resetting the account password varies as well with many states (32) offering more than one way; users can reset passwords online by answering security questions in 32 states, through a link sent via email or text in 33 states, or by contacting the Medicaid call center in 29 states.

Half of the states (26) have a portal for assisters and community groups to submit facilitated applications (Figure 13). These portals are available to a range of entities depending on the state, including federal and state navigators and application assisters, community health centers, hospitals and other providers, managed care organizations, and community-based organizations that help those in need of assistance with applying for and renewing Medicaid and CHIP coverage. All 26 states with a separate community assistance portal allow assisters to submit applications and most states allow assisters to review application status (23 states) and upload documents (21 states), but other features are more limited. Assisters are permitted to submit renewal information through the portal in 18 states; report changes in circumstances or update mailing addresses in 17 states; and view notices, actions required by the enrollee, and view renewal dates in 15 states. Secure assister portals create administrative efficiencies by allowing assisters to perform tasks that facilitate enrollment and renewal and providing a mechanism for states to monitor assister performance.

Renewal Processes and Changes in Circumstances

Nearly all states (45) initiate ex parte data processes at least 60 days prior to the end of an individual’s renewal period. States are required to provide MAGI-based enrollees with at least 30 days to return renewal forms or provide needed information. Thus, ex parte processes need to be initiated with sufficient time to check available data sources, determine which renewals can be automatically redetermined, and generate notices or print and mail renewal forms to enrollees whose ongoing eligibility cannot be redetermined automatically. About a quarter of states (13) initiate the ex parte process 90 days in advance of the end of the renewal period, 9 states initiate between 60 and 90 days, nearly half of the states (23) initiate ex parte data matches 60 days in advance while 3 states do so between 45 and 60 days.

Almost all states send out pre-populated renewal notices with enough lead time to ensure that enrollees have 30 or more days to respond. In some states, renewal forms and notices are generated automatically after the system has attempted an ex parte review. Three-quarters of states send out notices from 40 to 60 days (41 states) in advance, and 5 states send out forms from roughly 75 to 90 days in advance. Three states send out renewal notices 30 days before the renewal is due, which is the federal minimum requirement. Due to potential mail delays, sending forms further in advance may give enrollees more time to respond.

States offer several ways for enrollees to check their renewal dates, and provide renewal date information to health plans, providers, and navigators or other assisters to increase outreach about renewals. During the unwinding knowing one’s renewal date became important since many enrollees were not required to complete a renewal during the 3-year pause on disenrollments. In 44 states, enrollees can access their renewal date by contacting the call center, and in 43 states, enrollees can find the date in their online account. Enrollees can find their renewal date in their mobile app in 12 states. Nearly half of the states (24) use text messages to remind enrollees of their renewal date, and 11 states provide other mechanisms including mail or through the managed care plan or a local office. Minnesota and Rhode Island created an online renewal lookup tool to facilitate access to renewal dates. States also provide access to information that includes enrollees’ renewal dates to health plans (36 states), federally qualified health centers (15 states), pharmacists (9 states), other Medicaid providers (17 states), and navigators and/or assisters (18) states. These entities may share renewal information with members, patients, and clients of upcoming renewal dates to encourage them to complete and return the form.

One-third of the states (16) plan to conduct periodic data matches between renewals to identify changes in circumstances (Figure 14). States may only conduct renewals once a year for MAGI enrollees, but without continuous eligibility, states are required to act on reported changes in circumstances that affect eligibility, most often relating to income. States may opt to conduct periodic data checks to identify changes, which are more likely to impact low-income wage earners who experience frequent income fluctuations during the year. In these cases, enrollees may churn off and back onto coverage, creating gaps in access and continuity of care, as well as creating additional work for eligibility staff. If ongoing eligibility is confirmed through a mid-year data check, states have the option to push out renewal dates for 12 months but only 3 of the 16 states that conduct periodic data matches do this even if the state has all the information needed to do so. Additionally, nearly half of these states (7) provide only ten days for enrollees to respond to a request for information although known delays in mail delivery can make it challenging for enrollees to submit information before coverage is terminated. The Eligibility and Enrollment rule will require states to provide 30 days for enrollees to respond to requests for information beginning in June 2027, which aligns with the current rules for renewals.

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Medicaid and CHIP Eligibility

Child eligibility remains the highest for all MAGI eligibility groups, with the median children’s upper eligibility level holding steady at 255% FPL. Three states expanded children’s eligibility levels–Arizona increased eligibility from 205% FPL to 230% FPL in its separate CHIP program, Maine raised eligibility from 213% FPL to 305% FPL, while North Dakota expanded child eligibility to 205% FPL, up from 175% FPL. With the increased eligibility in North Dakota, Idaho now has the lowest eligibility level for children at 190% FPL and is the only state with a child eligibility level below 200% FPL. New York still has the highest child eligibility level at 405% FPL. As of May 2024, 20 states cover children at or above 300% FPL (Figure 15).

The median eligibility limit for pregnancy coverage in Medicaid and CHIP increased to 210% FPL with eligibility expansions in three states. Nevada, North Dakota, and Tennessee all increased eligibility levels for pregnancy coverage; Tennessee implemented the most significant change, increasing the pregnancy eligibility level from 200% FPL to 255% FPL. As of May 2024, 36 states provide pregnancy coverage to individuals with income at or above 200% FPL. Eligibility levels range from 138% FPL in Idaho and South Dakota to 380% FPL in Iowa. However, Iowa recently passed legislation that will reduce eligibility for pregnancy and infant coverage in Medicaid, lowering the eligibility levels to 215% FPL effective January 1, 2025 (infants will be covered up to 307% FPL in the state’s separate CHIP program). The CAA made permanent the option for states to extend Medicaid postpartum coverage to 12 months. As of June 2024, 47 states have implemented the 12-month extension.

North Carolina and South Dakota newly implemented the Medicaid expansion and now cover adults with incomes up to 138% percent FPL, leaving ten states without Medicaid expansion. South Dakota voters passed a ballot initiative in 2022 and the state implemented coverage in July 2023. In May 2023, North Carolina passed legislation to adopt Medicaid expansion and coverage began in December 2023, making it the first state to implement Medicaid expansion via legislative action, rather than a ballot initiative, since Virginia in 2018. As of May 2024, parents and adults without dependent children with incomes at or below 138% FPL ($20,783 per year for an individual; $35,632 for a family of three in 2024) are covered in 41 states.

In states that have not implemented Medicaid expansion, median eligibility for parents decreased to 34% FPL. Five of the remaining non-expansion states (Florida, Georgia, Mississippi, Texas, and Wyoming) use fixed dollar thresholds to determine income eligibility for parents and caretaker relatives (Tennessee recently received CMS approval to set parent eligibility at 105% FPL rather than base eligibility on a fixed dollar amount). Dollar thresholds are not routinely updated so the equivalent federal poverty level eligibility threshold decreases over time as the federal poverty level increases to account for inflation. In 2024, Mississippi was the only state to adjust its dollar threshold, from $480 per month to $492 for a family of three. Eligibility for parents and caretaker relatives ranges from a low of 15% FPL in Texas to 105% FPL in Tennessee and 100% in Wisconsin, with median eligibility at 34% FPL for the ten non-expansion states (Figure 16). Of the ten states that have not implemented Medicaid expansion, Wisconsin is the only one that provides coverage to adults without dependent children based on income eligibility, setting eligibility at the same level as parents (100% FPL) through a section 1115 waiver. In September 2023, Georgia implemented a waiver to cover parents who do not qualify for section 1931 parent/caretaker eligibility and childless adults with incomes up to 100% FPL if they meet a work and premium requirement as conditions of initial and continued eligibility.

Non-expansion states have lower median eligibility levels for all MAGI Medicaid groups. Although no non-expansion state covers adults without dependent children, these states also have lower median eligibility levels for children (234% FPL compared to 266% FPL in expansion states), for pregnancy coverage (203% FPL compared to 213% FPL), and for parents (34% FPL compared to 138% FPL) (Figure 17).

As of May 2024, 45 states have adopted federally funded options to extend coverage to some immigrant children and/or pregnant individuals (Figure 18). Most lawfully residing immigrants must wait five years after they obtain qualified status before they can enroll in Medicaid or CHIP. However, states have the option to waive the five-year waiting period for lawfully residing children and pregnant people. As of May 2024, 37 states have adopted this option for children and 31 states have taken up the option for pregnant people in Medicaid, as have six of the seven states using CHIP to cover pregnant adults. All states covering recent lawful residents during pregnancy, except North Dakota and Wyoming, have adopted the option for children as well. Michigan is planning to eliminate the waiting period for children and pregnant individuals in August and Indiana plans to do so in 2025. In addition, states can provide pregnancy coverage regardless of immigration status through the From Conception to the End of Pregnancy (FCEP) option in CHIP. Twenty-four states provide this coverage, including two states (Maryland and New York) and the District of Columbia that newly adopted the FCEP option in 2023 and early 2024. Almost a dozen states (11) are also providing 12 months of postpartum coverage for FCEP enrollees using CHIP health services initiative funds or state funds, and one state (Maryland) is providing four months of postpartum coverage.

States are increasingly using state-only funds to extend coverage or limited benefits to some immigrant children, pregnant individuals, and other adults who do not have federal pathways to coverage. Thirteen states now cover all income-eligible children regardless of immigration status using state funds, although Connecticut only covers children under age 13 and Utah, which newly implemented this coverage, caps the number of children who can be enrolled. Vermont and New Jersey also provide state-funded coverage to pregnant people who do not qualify for federal funding, although New Jersey’s coverage is limited to pre-natal care. As of May 2024, ten states use state-only funds to cover other immigrant adults who are otherwise ineligible, including three states (California, District of Columbia, and Oregon) that cover all income-eligible adults regardless of immigration status.

Two states, Illinois and Michigan, newly implemented family planning expansion programs, increasing the median eligibility level for these programs to 210% FPL. Thirty-three states now use federal funds through a state plan option or waiver to cover family planning only services. Oklahoma also expanded eligibility for its family planning program from 138% FPL to 210% FPL, which aligns with eligibility levels for pregnancy coverage in the state. As of May 2024, eligibility levels ranged from 138% FPL in Louisiana to 306% FPL in Wisconsin.

Most states suspend Medicaid coverage for adults (45 states) during incarceration (Figure 19). Federal law provides that incarceration status does not preclude eligibility for Medicaid. However, Medicaid benefits are limited to inpatient services requiring at least a 24-hour stay in a medical institution. Since passage of the ACA, more individuals entering and leaving carceral settings are eligible for Medicaid. In response, more states have opted to suspend rather than terminate coverage for adults to facilitate reinstatement of coverage upon release. New rules that went into effect on October 24, 2019 prohibit states from terminating coverage for eligible juveniles. The CAA requires states to suspend rather than terminate Medicaid coverage for all individuals who are incarcerated starting January 1, 2026.

All children in Medicaid and CHIP are now protected from mid-year churn with mandatory 12-month continuous eligibility while 13 states are taking additional steps to provide multi-year continuous eligibility for children. Twelve-month continuous eligibility was a longstanding state option for children although only about half the states had adopted the policy in Medicaid. As of January 2024, all states are now required to keep children continuously enrolled for a full year with limited exceptions for moving out of state or requesting voluntary disenrollment. However, 13 states are seeking to provide continuous eligibility beyond 12 months for young children, which promotes continuity of coverage and access to care during the early development period. New Mexico, Oregon, and Washington have federal approval to cover eligible children continuously from birth to age six, while ten other states have submitted section 1115 waivers or are in the process of developing waivers to implement multi-year continuous eligibility for young children (Table 2). Oregon has also received federal approval to cover children over the age of six and all adults for two continuous years. Nine other states also cover or are proposing to cover targeted adult groups for continuous periods, including three states that provide multi-year continuous eligibility and six states that provide 12-month continuous eligibility to all or some adults (Massachusetts provides both 12-month continuous eligibility for all adults and 24-month continuous eligibility to adults experiencing homelessness).

Nine states have retained waiting periods before an uninsured child is eligible for CHIP, down from 38 states a decade ago. CHIP waiting periods are a mechanism to discourage families from dropping group insurance to enroll in CHIP. Citing little evidence of substitution of coverage and temporary coverage options available to CHIP-eligible children during a waiting period, the Eligibility and Enrollment final rule eliminates CHIP waiting periods effective June 2025.

Premiums and Non-Payment Policies for Children

Twenty-one states charge premiums for children (Figure 20). States cannot impose premiums in Medicaid or M-CHIP for children with income below 150% FPL but are permitted to charge premiums in their separate CHIP programs with family incomes as low as 133% FPL. Under federal rules, the maximum out-of-pocket costs for all enrolled members of families can be required to pay is limited to no more than 5% of total family income, which states must track to ensure families do not pay more than the cap. During the COVID-19 public health emergency, most states that charged premiums suspended or waived them for some or all enrollees. As of May 2024, premiums remain suspended in four states (Arizona, Delaware, Georgia, and Vermont). California, Colorado, Illinois, Maine, Maryland, Michigan, New Jersey, and North Carolina all removed CHIP premiums since 2020, and Utah will eliminate premiums in July but will increase other cost-sharing requirements at the same time. Delaware is awaiting CMS approval to discontinue premiums entirely and Vermont has suspended premiums indefinitely.

Premium amounts and periodicity vary by state. States may impose premiums on a monthly, quarterly, or annual (also known as an enrollment fee) basis. Most states (17) that charge premiums do so monthly while one state charges quarterly premiums (NV) and 2 states (AL and TX) require an annual enrollment fee. Premiums can be family-based (7 states) or charged per child, either with a family maximum that limits the amount of premiums a household pays (10 states) or without a family cap (3 states). As of May 2024, the maximum premium or enrollment fee for one child ranges from $15 in Idaho to $159 in Missouri. The premium amount often varies by income level. Six states charge premiums to children with family incomes below 150% FPL. New York eliminated premiums for the lowest income band in 2022, so premiums now begin at 222% FPL instead of 160% FPL.

New federal rules will affect states’ current policies for non-payment of premiums, including for the nine states that have lockout periods. As part of the CAA, 12-month continuous eligibility for children in Medicaid and CHIP became mandatory for all states. With this change which went into effect January 1, 2024, states are no longer allowed to disenroll individuals for non-payment of premiums after initial enrollment. In the Eligibility and Enrollment regulation CMS made several changes to CHIP, including prohibiting states from locking enrollees out of coverage as a penalty for non-payment of premiums. While new lockout periods cannot be established in states that do not have them, states that currently impose a lockout have until June 2025 to eliminate the policy. As of May 2024, eight states have a lock-out period, with seven imposing the maximum allowable lock-out period of 90 days (Indiana, Kansas, Louisiana, Missouri, Nevada, Pennsylvania, and Washington). Since 2020, Massachusetts and Wisconsin have eliminated lock-out periods in CHIP.(Back to top)

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