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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With the rise of social media use and growing concerns about health misinformation that accelerated during the COVID-19 pandemic, there has been increased attention to the role that various social media platforms play in the dissemination of health information, both accurate and inaccurate. Previous KFF polling has found that while few adults say they put a lot of trust in health information they come across on social media, those who use social media more frequently for health advice are more likely to believe false statements about issue like COVID-19 vaccines, reproductive health, and gun safety. This new KFF Health Misinformation Tracking Poll focuses on health and election-related information on the popular social media app TikTok in light of recent developments related to the platform.

In late April, President Joe Biden signed into a law a bill that would ban TikTok in the U.S. if its Chinese-owned parent company does not sell the platform within a year. The bill passed both chambers of Congress with bipartisan support, with many lawmakers, including President Biden, largely citing national security risks. At the same time, some media reports have documented the spread of various different types of health misinformation on the app, including misinformation related to prescription birth control.

Key Findings

• Most adults who use TikTok report seeing health-related content on the app, with the largest shares saying they’ve seen content about mental health (66%) and weight loss (66%). Younger users are particularly likely to report being exposed to health information on TikTok, with large shares of users ages 18-29 reporting seeing advice or information about several different health topics on the app, including mental health (91%), weight loss (79%), while many other younger users report seeing advice or information about abortion (59%), and birth control (52%).
• While about four in ten TikTok users say they trust information about health issues they see on the app, just one in eight say they have ever talked to a doctor (13%) or sought mental health treatment (12%) at least in part because of something they saw on TikTok. Larger shares of younger users ages 18-29 say they trust health information on TikTok (53%), and younger users are also more likely than older users to say they followed up with a doctor (19%) or sought mental health treatment (26%) due to content they’ve seen on the app.
• Most TikTok users say the content they’ve seen on the app has not affected their confidence in science and scientists, birth control, or vaccines. Overall, about one in seven users say content on TikTok has made them “less confident” (15%) in the safety and effectiveness of vaccines and a similar share (12%) say it has made them “more confident.” Among Republican TikTok users, however, a larger share say content on the app has made them “less confident” in vaccines (24%) rather than “more confident” (7%).
• When it comes to TikTok content centered on election issues, most users report either not seeing content related to these issues or seeing content that is a mix of different opinions on these topics. For the most part, TikTok users who identify as Democrats and Republicans report seeing a somewhat different mix of political content on the platform. On the issue of abortion, however, TikTok users across the political spectrum are much more likely to say the content they see on the app is mostly pro-choice or supportive or abortion rights rather than anti-abortion or supportive of abortion restrictions. Even among Republican TikTok users, the share who say they mostly see pro-choice content on the app is roughly three times the share who say they mostly see anti-abortion content (17% v. 5%).

TikTok Use and Exposure to Health Information

Just under half of adults say they use the social media app TikTok, including at least six in ten younger adults, Black adults, and Hispanic adults. About four in ten (44%) adults say they use TikTok, including larger shares of younger adults ages 18-29 (66%) and ages 30-49 (54%) and fewer adults ages 50 and older (27%). The app is more popular among people of color with about six in ten Hispanic adults (63%) and Black adults (62%) saying they use TikTok compared to about one-third of White adults (34%). Women are more likely than men to use say they use TikTok (47% v. 40%).

Similar shares – or at least four in ten – Democrats, independents and Republicans report using TikTok. About one in five adults (18%) report using the app every day, including nearly four in ten adults ages 18 to 29 (37%) and a similar share of Hispanic adults (36%).

Most TikTok users report seeing health-related content on the app, including a majority who say they’ve seen information or advice about mental health (66%) or weight loss (66%). About four in ten TikTok users say they’ve seen information or advice about vaccines (42%) on the platform, while about a third say the same about abortion (36%), prescription drugs (34%), and birth control (34%). Younger TikTok users are more likely than older users to say they’ve seen some of these topics on TikTok, with larger shares of users ages 18 to 29 saying they’ve seen information or advice about mental health (91%), weight loss (79%), abortion (59%), or birth control (52%). Women are more likely than men who use TikTok to say they have seen information or advice about mental health (71% v. 61%) or birth control (41% v. 25%) on the app. About half of women of reproductive age – or those ages 18 to 49 – report seeing information or advice on TikTok about prescription birth control on (54%) or abortion (48%). Democrats (35%) and independents (41%) who use TikTok are more likely than Republican users (23%) to report seeing information or advice about birth control on the app; however, similar shares across partisans report seeing information about most of these other subjects.

Perhaps not surprisingly, there is a relationship between frequency of TikTok use and the amount of health-related content people report seeing on the app. Adults who use TikTok “every day” are more likely than those who use the app monthly or less often to say they’ve seen information or advice about each of the health-related topics included in the survey. Notably, larger shares of younger adults and women report using the app every day compared to older adults and men, respectively, which may at least partially explain why these groups report seeing more health-related content on the app.

Trust and Conversations about Health Information on TikTok

Fewer than half of TikTok users say they trust information about health issues that they see on the app, but younger users, Black adults, and Hispanic adults report higher levels of trust. Overall, four in ten TikTok users say they trust information they see about health issues on TikTok at least “somewhat,” including 9% who say they trust such information a “great deal.” Most users say they trust health information on TikTok “not much” (36%) or “not at all” (23%).

TikTok users between the ages of 18-29 are more likely than older adults to say they trust health information on TikTok, with about half (53%) of these younger adults saying they trust information about health issues on the app at least somewhat – including one in six (17%) who say they trust health information on TikTok “a great deal” – compared to smaller shares of older TikTok users. Similar shares of women and men who use TikTok say they trust information about health issues that they see on the app.

Among those who report using TikTok every day (18% of all adults), six in ten (58%) say they trust information about health issues they see on the app at least “somewhat.” Adults who use the app less frequently are less likely than daily users to report trusting health information they see on TikTok. Notably, daily TikTok users are disproportionately made up of younger adults ages 18 to 29.

Few TikTok users overall and across demographics say they’ve talked to a doctor or sought mental health treatment because of something they saw on the app, but younger users and women are more likely than older users and men to report doing so. About one in eight adults who use TikTok say they have ever talked to a doctor or other health care provider at least in part because of something they saw on TikTok (13%) or decided to seek mental health treatment at least in part because of something they saw on the app (12%). Younger users are more likely than older adults to report either of these, with a quarter (26%) of TikTok users between the ages of 18 and 29 saying they decided to seek mental health treatment and one in five (19%) saying they talked to a doctor or health care provider because of something they saw on the app. Among TikTok users, women are about twice as likely as men to say they talked to a doctor or health care provider (17% v. 7%) or decided to seek mental health treatment due to something they saw on the app (15% v. 8%). The share who report talking to a doctor or seeking mental health treatment at least partly because of something they saw on TikTok rises to about one in five among those who use TikTok every day (20% and 18%, respectively). Nonetheless, most of these daily users say they have not followed up with a doctor or sought mental mental health treatment due to content they’ve seen on the app.

While most TikTok users say content they’ve seen on the app has not affected their confidence in science and scientists, prescription birth control, or the safety and effectiveness of vaccines, users are more likely to say content on the app has made them more confident in science and scientists rather than less confident. At least seven in ten TikTok users say information they’ve seen on the app has not affected their confidence in the safety of prescription birth control (76%), the safety and effectiveness of vaccines (73%), or science and scientists (70%).

When it comes to trust in science and scientists, TikTok users are nearly three times as likely to say content they’ve seen on the app has made them more confident in science and scientists rather than less confident (22% vs. 8%). By contrast, when it comes to confidence in prescription birth control and the safety and effectiveness of vaccines similar shares of TikTok users say content they’ve seen on the app has made them more confident as less confident (12% each for birth control, 12% and 15% for vaccines). Similar shares of women and men – including women of reproductive age under the age of 50 — who use TikTok say content on the app has made them either more or less confident in prescription birth control, with about three in four saying it has not made a difference.

Most TikTok users across demographics say content on the app has not affected their confidence in the safety and effectiveness of vaccines, however Republicans are more likely to say TikTok content has made them less confident in vaccines rather than more confident. Overall, about one in seven users say content on TikTok has made them “less confident” (15%) in the safety and effectiveness of vaccines and a similar share (12%) say it has made them “more confident.” For most groups across age, partisanship, race and ethnicity, the shares saying TikTok content increased their confidence in vaccines is similar to the share who say it decreased their confidence.

However, one group breaks with this pattern: Republican TikTok users are about three times as likely to say content on the app has made them “less confident” in the safety and effectiveness of vaccines rather than “more confident” (24% v. 7%).

Vaccine misinformation may affect parents’ confidence in vaccinating their young children, and recent KFF polling has shown that about a quarter of parents report believing false information about measles vaccines. Just under one in five (17%) parents who use TikTok say content they’ve seen on the app has made them “less confident” in the safety and effectiveness of vaccines while a similar share of parents say it has made them “more confident” (11%). However, most parents who use TikTok say the content they’ve seen on the app hasn’t affected their confidence in the safety and effectiveness of vaccines.

Election Issues on TikTok

As the 2024 presidential election approaches, TikTok users may be exposed to election-related topics and one-sided political discourse, particularly as growing shares of U.S. adults report regularly getting their news from the app. However, like other social media platforms, the content users see on their TikTok feeds may vary from person-to-person, as it is curated by the app’s proprietary algorithm.

When it comes to TikTok content centered on some key election issues, including the presidential candidates, abortion, guns, and immigration, most users report either not seeing content related to these issues or seeing content that is a mix of different opinions on these topics. For the most part, TikTok users who identify as Democrats and Republicans report seeing a somewhat different mix of political content, particularly when it comes to presidential candidates, but these patterns are not universal across the topics included in the survey.

It’s important to note that this survey measures self-report views of TikTok content, which may not necessarily match up with other studies that look at actual content in users’ video feeds.

Overall, few TikTok users report mostly seeing one-sided content related to the presidential candidates, but slightly larger shares say the content they see on the app is mostly pro-Donald Trump or anti-Joe Biden rather than mostly pro-Biden or anti-Trump, with even larger tilts toward pro-Trump or anti-Biden content among Republican users and young adults. The shares of TikTok users who say the content they see on the app is mostly Pro-Donald Trump or anti-Joe Biden (14%) is slightly higher than the share who say the content they see is mostly pro-Joe Biden or anti-Donald Trump (10%), with one in three (34%) saying the content they see is a mix of both viewpoints, and four in ten saying they don’t see content related to either Trump or Biden on TikTok.

Perhaps not surprisingly, Republican TikTok users are about three times as likely to say the content they see is mostly pro-Trump/anti-Biden rather than pro-Biden/anti-Trump (29% v. 10%), while Democrats are about twice as likely to say the content they see mostly favors Biden rather than Trump (16% vs. 7%).

Notably, TikTok users ages 18 to 29 and Hispanic TikTok users are about twice as likely to say most of the content they see is pro-Trump or anti-Biden rather than pro-Biden or anti-Trump (21% vs. 11% for young users and 18% vs. 8% for Hispanic adults).

Across partisanship and other demographics, the share of TikTok users who say the content they see on the app is mostly pro-choice or supportive of abortion rights (24%) is far larger than the share who say the content they see is mostly anti-abortion or supportive of abortion restrictions (4%). The share of TikTok users who say they mostly see pro-choice content rises to four in ten (42%) among those ages 18 to 29 – larger than the shares who say the same among those ages 30 to 49 (22%) and 50 and older (8%). These younger users are also more likely than older adults to report seeing any abortion-related content on TikTok.

Few users across partisan groups (including just 5% of Republicans) report seeing mostly anti-abortion content on TikTok, though Democrats who use TikTok are more likely than Republican users to say the content they see is mostly pro-choice of supportive of abortion rights (32% v. 17%).

Overall, men and women who use TikTok are each much more likely to report seeing mostly pro-choice content than to say they see mostly anti-abortion content. While about three in four (27%) women who use TikTok say the content they see is mostly pro-choice, this rises to about one-third (34%) among women ages 18 to 49.

Despite these differences, most users – including at least half across partisanship, age, and gender – say the content they see related to abortion on TikTok is either a mix of both pro and anti-abortion viewpoints (22%) or they don’t see this content related to abortion at all (50%).

Most TikTok users who report seeing gun-related content on the app say they see a mix of viewpoints, but Democrats and younger users are more likely to report seeing mostly anti-gun content. One quarter of TikTok users say they see a mix of gun-related viewpoints on the app, while about one in ten each say they mostly see pro-gun content (8%) or anti-gun content (10%) and over half (57%) report not seeing gun-related content on TikTok.

Democrats who use TikTok are about twice as likely to say they mostly see anti-gun content as opposed to pro-gun content on the app (16% v. 7%). Younger TikTok users ages 18 to 29 are about twice as likely to say they mostly see anti-gun content than pro-gun content (18% v. 9%), while other age groups report seeing either viewpoint in similar shares.

Among all TikTok users, and across these demographic groups, most users say the content they see is either a mix of both pro and anti-gun or say they do not see gun-related content on the app.

TikTok users report seeing a mix of immigration-related content on the app, with no clear differences by partisanship. For immigration-related content, somewhat larger shares of TikTok users say the content they see is mostly pro-immigration (15%) compared to those who say they mostly see anti-immigration content (10%). Most users, however, say the content they see is either a mix of both pro and anti-immigration viewpoints (27%) or they don’t see this content on TikTok (47%). Despite often bitter partisan debates over the country’s approach to immigration policy (an issue that has ranked high among voters’ top issues ahead the 2024 election) among Democrats, independents and Republicans who use TikTok, similar shares say the content they see on the app is either mostly pro-immigration or anti-immigration, with at least one in five across these groups saying they see a mix of viewpoints.

Younger TikTok users ages 18 to 29 are about twice as likely to say the content they see on the app is mostly pro-immigration rather than anti-immigration (25% v. 13%), but among older age groups, similar shares report seeing either mostly pro-immigration content or mostly anti- immigration content.

This KFF Health Tracking Poll/Health Misinformation Tracking Poll was designed and analyzed by public opinion researchers at KFF. The survey was conducted April 23-May 1, 2024, online and by telephone among a nationally representative sample of 1,479 U.S. adults in English (1,396) and in Spanish (83). The sample includes 1,201 adults (n=65 in Spanish) reached through the SSRS Opinion Panel either online (n=1,176) or over the phone (n=25). The SSRS Opinion Panel is a nationally representative probability-based panel where panel members are recruited randomly in one of two ways: (a) Through invitations mailed to respondents randomly sampled from an Address-Based Sample (ABS) provided by Marketing Systems Groups (MSG) through the U.S. Postal Service’s Computerized Delivery Sequence (CDS); (b) from a dual-frame random digit dial (RDD) sample provided by MSG. For the online panel component, invitations were sent to panel members by email followed by up to three reminder emails.

Another 278 (n=18 in Spanish) interviews were conducted from a random digit dial telephone sample of prepaid cell phone numbers obtained through MSG. Phone numbers used for the prepaid cell phone component were randomly generated from a cell phone sampling frame with disproportionate stratification aimed at reaching Hispanic and non-Hispanic Black respondents. Stratification was based on incidence of the race/ethnicity groups within each frame.

Respondents in the phone samples received a $15 incentive via a check received by mail, and web respondents received a $5 electronic gift card incentive (some harder-to-reach groups received a $10 electronic gift card). In order to ensure data quality, cases were removed if they failed two or more quality checks: (1) attention check questions in the online version of the questionnaire, (2) had over 30% item non-response, or (3) had a length less than one quarter of the mean length by mode. Based on this criterion, two cases were removed.

The combined cell phone and panel samples were weighted to match the sample’s demographics to the national U.S. adult population using data from the Census Bureau’s 2023 Current Population Survey (CPS), September 2021 Volunteering and Civic Life Supplement data from the CPS, and the 2023 KFF Benchmarking survey with ABS and prepaid cell phone samples. The demographic variables included in weighting for the general population sample are sex, age, education, race/ethnicity, region, civic engagement, frequency of internet use, political party identification by race/ethnicity, and education. The sample of registered voters was weighted separately to match the U.S. registered voter population using parameters above plus recalled vote in the 2020 presidential election by county quintiles grouped by Trump vote share. Both weights account for differences in the probability of selection for each sample type (prepaid cell phone and panel). This includes adjustment for the sample design and geographic stratification of the cell phone sample, within household probability of selection, and the design of the panel-recruitment procedure.

The margin of sampling error including the design effect for the full sample is plus or minus 3 percentage points and is plus or minus 4 percentage points for registered voters. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and 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.