In late 2020, Congress passed and President Trump signed the No Surprises Act establishing new federal protections for consumers from surprise medical bills. The law became effective in 2022. A significant component of the law was to hold consumers harmless for surprise, out-of-network medical bills by creating a process where the medical provider and health plan would negotiate a payment for the service provided or end up in an independent dispute resolution (IDR) process.

This analysis examines the share of out-of-network surprise billing disputes initiated through the federal IDR process in the first year of the No Surprises Act. About 1 in 8 of these disputes resulted in payment determinations. The federal government recently proposed several changes, with the goal of making the IDR process more efficient and increasing early communication between the parties.

The analysis is available through the Peterson-KFF Health System Tracker, an online information hub that monitors and assesses the performance of the U.S. health system.

More than 10 million people have been disenrolled from Medicaid, based on data available from 50 states and the District of Columbia as of November 1, 2023. Disenrollment rates range from 65% in Texas to 10% in Illinois, according to KFF’s ongoing tracking. Differences in state renewal policies and system capacity likely explain some of this variation.

Some disenrolled individuals are regaining Medicaid coverage. As a result, overall declines in Medicaid enrollment will be less than the number of people disenrolled.

Other disenrolled individuals may have enrolled in, or be eligible for, other coverage, such as ACA Marketplace plans or employer coverage. The Medicaid unwinding could have implications for enrollment in the marketplaces:

• New flexibilities will extend Marketplace enrollment opportunities. Under a new, temporary “Medicaid Unwinding Special Enrollment Period,” available in the Federal Marketplace, Healthcare.gov, and in some state-based Marketplaces, people losing Medicaid between March 31, 2023, and July 31, 2024, can apply to the Marketplace with an attestation of Medicaid or CHIP loss and select a new plan within 60 days (90 days starting January 2024) of applying. In other State-based Marketplaces, people will have up to 120 days from the date of their Medicaid disenrollment to apply for Marketplace coverage.
• Marketplace enrollment could increase for the fourth straight year. The number of people who enrolled in Marketplace coverage earlier this year reached 15.7 million, surpassing prior record-setting years in 2021 and 2022.
• However, enrollment challenges may arise. Those who are not aware of their options for Marketplace coverage could be left uninsured. KFF’s updated Marketplace subsidy calculator and 300+ FAQs can help people purchase insurance.

“While Medicaid disenrollments are currently climbing at a fast rate, we don’t yet know how the unwinding will impact broader coverage trends,” says Jennifer Tolbert, director of the State Health Reform and Data Program at KFF. “There are several paths to health coverage for those who are no longer eligible for Medicaid – through the Marketplace and its subsidies, employers, or Medicare. The big question now is if people will find and navigate to other coverage or if they will become uninsured.”Overall, 35% of people with a completed Medicaid renewal have been disenrolled in reporting states, while 65% have had their coverage renewed. As of October, states have reported renewal outcomes for three in ten of all people who were enrolled in Medicaid in March 2023 and for whom states must redetermine eligibility during the unwinding.

Children currently account for about four in ten (39%) Medicaid disenrollments in the 20 states reporting age breakouts. At least 1,881,000 children had been disenrolled out of 4,841,000 total disenrollments in the 20 states.The data in KFF’s Medicaid Enrollment and Unwinding Tracker come from a variety of sources, including baseline and monthly reports that states submitted to the Centers for Medicare & Medicaid Services (CMS), state websites, and data released by CMS.

On September 21, 2023, the Centers for Medicare and Medicaid Services (CMS) finalized a rule that is intended to help low-income Medicare beneficiaries gain access to Medicaid coverage of Medicare premiums and often, cost sharing, through the Medicare Savings Programs. The new Medicaid rule will streamline the Medicaid application process for the Medicare Savings Programs, in part, by further automating the application process for people with Medicare’s Part D Low-Income Subsidy and automatically enrolling some Medicare beneficiaries, including those who receive Supplemental Security Income. After the effects of the rule are fully in place, in 2029, CMS expects the rule to increase enrollment in the Medicare Savings Programs by nearly 1 million. New enrollments include people who enroll in the Medicare Savings Programs because of the rule and additional months of coverage among people who would have enrolled anyway but now face fewer administrative barriers to doing so and gain more months of coverage. The final rule is one component of a larger proposed rule that would make broader changes to Medicaid eligibility.

What do the Medicare Savings Programs cover for low-income Medicare beneficiaries?

Through Medicaid, the Medicare Savings Programs cover premiums and, in most cases, cost sharing for Medicare beneficiaries who meet financial eligibility requirements. The programs provide coverage of Medicare premiums and cost sharing to Medicare beneficiaries with incomes below the federal poverty level ($1,235 for an individual in 2023) and financial resources below 300% of the limit for Supplemental Security Income ($9,090 for an individual in 2023, unlike Supplemental Security Income, asset limits for the Medicare Savings Programs are adjusted for inflation and increase each year). Medicare beneficiaries with incomes between 100% and 135% of the federal poverty level ($1,660 for an individual) who meet the same requirements for financial resources are eligible for coverage of Medicare premiums but only receive coverage of Medicare cost sharing if the state chooses to provide it. The federal eligibility thresholds for the Medicare Savings Programs are minimum levels and states may elect to offer coverage to people with incomes or assets that exceed federal minimums, which had been done by 17 states in 2022. When states expand coverage or eligibility, the federal government continues to pay the federal share of the costs.

Among the 12.5 million people with Medicare and Medicaid, nearly all participate in the Medicare Savings Programs, and nearly three quarters also receive full Medicaid benefits. Most people who have both Medicare and Medicaid are also enrolled in the Medicare Savings Programs. There are some people who have full Medicaid and Medicare but do not qualify for the Medicare Savings Programs. In such cases, states may choose whether to cover Medicare premiums and cost sharing or not. In 2020, 73% of people with both Medicare and Medicaid were also eligible for the full range of Medicaid benefits that are not otherwise covered by Medicare, such as long-term services and supports and non-emergency medical transportation.

Eligibility for the Medicare Savings Programs can be quite complicated—which often leads to varying participation rates across the states and coverage loss among Medicare beneficiaries within their first year of Medicare-Medicaid enrollment. Nationally, 16% of all Medicare beneficiaries were enrolled in the MSPs, but KFF found that the in 2019, the rate ranges from 7% in North Dakota to 33% in the District of Columbia. Variation across the states can be attributed to differences in eligibility criteria, poverty rates, and application processes that could make it more difficult for beneficiaries in some states to apply. Recent KFF analysis also shows that among Medicare enrollees who have full Medicaid benefits, 28% lost Medicaid coverage at some point during their first year of enrollment. Among Medicare enrollees who enrolled in the Medicare Savings Program but not full Medicaid, 17% lost that coverage within the first year.

How would the new Medicaid eligibility rule affect dual-eligible individuals’ enrollment and spending?

CMS expects the new Medicaid eligibility rule to increase enrollment of dual-eligible individuals by nearly 1 million person-years in 2029 (Figure 1). Person-years of enrollment equal the number of months of additional enrollment in the Medicare Savings Programs divided by 12. They include people who newly enroll in the program but also additional months of enrollment among people who would already enroll but now have additional months of coverage. CMS estimates that the new rule will increase Medicaid spending by $4.2 billion and Medicare spending by $1.9 billion. New Medicaid spending includes spending on Medicare premiums and cost sharing and in some cases, spending for full Medicaid benefits for newly enrolled individuals. New Medicare spending reflects CMS’ assumption that coverage of Medicare cost sharing will result in use of more Medicare-covered services.

The final rule improves alignment between the Medicare Savings Programs and applications for Medicare’s Part D Low-Income Subsidy program (LIS), resulting in an additional 0.5 million person-years of enrollment. Medicare beneficiaries with low income and limited assets receive help paying for prescription drugs through LIS. To increase participation in LIS, people who enroll in the Medicare Savings Programs are automatically enrolled in LIS, but people in LIS are not automatically enrolled in the Medicare Savings Programs. Instead, the Medicare Improvements for Patients and Providers Act of 2008 requires the Social Security Administration to send LIS applications to states and requires states to treat those data as an application for the Medicare Savings Programs.

Despite the requirement for states to use LIS data to initiate an application to the Medicare Savings Programs, the application process is often not streamlined because the two programs have different methods for measuring income and financial resources. For example, the Medicare Savings Programs include the following forms of income and assets that are excluded from the LIS definition: interest and dividends, non-liquid resources, certain burial funds, whole life insurance, and in-kind support and maintenance. The final rule notes that most Medicare beneficiaries in LIS have limited income and assets from those sources but documenting their value can be quite cumbersome for applicants. To address such barriers to enrollment in the Medicare Savings Programs, the rule makes the following changes to the application process:

• The rule encourages states to adopt the LIS definitions for defining financial eligibility, in which case the LIS application would include all required information for an application to the Medicare Savings Program.
• Starting April 1, 2026, states that elect to keep their methods for defining financial eligibility, rather than use the LIS criteria, would be required to accept applicants’ self-reported values for all financial resources that are not included with the LIS application. All applicants whose self-reported values are within state eligibility criteria would be enrolled in the Medicare Savings Programs.
• If states have data that are not compatible with applicants’ self-reported amounts, they may ask for additional information prior to enrolling applicants.
• States may also request further documentation after enrollment as part of the post-enrollment eligibility verification process.
• States that require applicants to submit documentation of financial resources beyond what is required for an LIS application will be required to take a more active role in helping applicants find the appropriate materials, including directly contacting financial or fiduciary institutions in some circumstances.

The rule also requires states to automatically enroll Medicare beneficiaries with Supplemental Security Income into the Medicare Savings Programs, resulting in 0.3 million new person years of enrollment in 2029. The financial eligibility criteria for Supplemental Security Income are lower than that of the Medicare Savings Program for people with income below 100% of the federal poverty level. Thirty-three states and the District of Columbia already automatically enroll Medicare beneficiaries with Supplemental Security Income into Medicaid. Starting October 1, 2024, all states would be required to enroll Medicare beneficiaries with Supplemental Security Income in the Medicare Savings Program. Other provisions in the rule that would have smaller effects on enrollment include modifying the definition of family size for determining eligibility and making the effective date of coverage earlier for certain Medicare beneficiaries who must pay a premium for Medicare’s hospital insurance. (Most Medicare beneficiaries do not pay a premium for hospital insurance, also known as “Part A,” but do pay a premium for medical insurance or “Part B.”)

The final rule also requires states to provide LIS applicants with information about the availability of full Medicaid benefits. In the proposed rule, there was a requirement for states to use the LIS data to initiate an application for full Medicaid benefits, but that provision is not included in the final rule. In providing required information in the final rule, CMS explained that it dropped the provision because Medicaid applications generally require more information and disclosures than are included in the LIS application. Such disclosures include notification from states to applicants that Medicaid may recover the costs of providing certain Medicaid services from the estates of deceased Medicaid enrollees, a practice known as “estate recovery.” Estate recovery is prohibited in the Medicare Savings Programs and therefore, not disclosed on the application. The final rule requires states to provide LIS applicants with information about the availability of Medicaid benefits and an opportunity to provide further information needed to complete an application. That requirement may increase enrollment in Medicaid beyond the effects resulting from a streamlined MSP application.

What are key issues to watch?

It is unknown how states will respond to the new rule, but it may increase the number of states that increase or eliminate limits on financial assets when determining eligibility for the Medicare Savings Programs. Most children and adults under age 65 who are eligible for Medicaid qualify on the basis of income but are not subject to limits on assets. Prior to the Affordable Care Act, in most states, adults needed to be over age 65, a parent, or have a significant disability to qualify for Medicaid, but the Affordable Care Act expanded Medicaid coverage to nearly all adults with incomes up to 138% of the federal poverty level. As of October 2023, 40 states and the District of Columbia had adopted that expansion. When Medicaid enrollees eligible through the expansion (or less often, eligible because they are parents) turn 65 and become eligible for Medicare, they reach a coverage cliff and must start paying Medicare premiums and cost sharing. The Medicare Savings Programs can blunt the effects of losing Medicaid for people who quality—especially those who have coverage of both premiums and cost sharing—but some people with incomes within the Medicare Savings Program eligibility range have assets that render them ineligible.

As of November 2022, 11 states had completely eliminated counting assets when determining eligibility for the Medicare Savings Programs, and starting January 1, 2024, California will not count assets when determining eligibility for all Medicaid applicants. California is also increasing income eligibility for all groups to 138% of the federal poverty level to align with eligibility for younger adults. That change is expected to increase enrollment of people who are ages 65 or older or have a disability.

By encouraging states to adopt income and asset requirements that are at least as permissive as the LIS requirements, the final rule on the Medicaid Savings Programs may incentivize states to reconsider existing income and asset limits. Some states may align with the LIS definitions, but others may further increase limits on income or eliminate asset limits to maintain coverage for people who are aging into Medicare.

The final rule includes several pieces from a much larger proposed rule on Medicaid eligibility, that could have additional coverage implications for people who are eligible for Medicaid because they are age 65 or older or have a disability. It is unknown when the remainder of the rule will be finalized or what the provisions of the final rule will be, but they are expected to simplify the application and eligibility renewal processes. States are currently renewing eligibility for all Medicaid enrollees after a 3-year period of continuous enrollment and during this unwinding, millions of people are being disenrolled, many on account of the renewal procedures. Although simplified application and renewal procedures are not in place for the unwinding, in the future, the rule on the Medicare Savings Programs and other forthcoming rules may increase enrollment and make it easier to obtain and retain coverage for people with Medicaid.

A recent KFF survey found one-in-three people with Marketplace coverage say it is somewhat or very difficult to find a plan that meets their needs. With ACA enrollment beginning November 1, KFF has updated its most-used Marketplace tools and published an explainer on key changes and issues to watch in this year’s open enrollment season.

Tools for Open Enrollment>> KFF’s Health Insurance Marketplace Calculator provides estimates of 2024 health insurance premiums and subsidies for people purchasing their own insurance in the Marketplaces. Users can enter their age, income, zip code, and family size to check their eligibility for Marketplace subsidies or Medicaid and estimate their premium costs. The calculator reflects the premiums available in local markets and the impact of the enhanced tax credits available through 2026.>> The Marketplace FAQs cover a wide range of topics related to obtaining or renewing health insurance in the Marketplace. It has been updated to include information about expanded Marketplace enrollment opportunities for people who have lost Medicaid coverage due to the Medicaid unwinding. More than 200 of the FAQs are available in Spanish.

What to Watch for Open EnrollmentEven after a decade of operation, there continue to be changes in the Marketplaces. KFF’s new explainer highlights nine key changes and issues to watch in the 2024 open enrollment period, including a look at the impact of the 5% average rise in unsubsidized premiums as well as who will be affected by this year’s state-level policy changes and the new auto-reenrollment policy on Healthcare.gov.

KFF also offers an overview of the financial assistance available for people purchasing their own coverage, including premium tax credits and cost-sharing subsidies and has updated select State Health Facts indicators with relevant data.

Open enrollment runs November 1 through January 15 for healthcare.gov and most state-run marketplaces. Organizations assisting consumers are encouraged to link to KFF’s Marketplace FAQs. Each question and answer can be shared individually by direct link.

With the start of the 2024 Affordable Care Act open enrollment, the Marketplaces have been operating for a full decade and are heading into their eleventh year. This year’s open enrollment season will last from November 1, 2023 to January 16, 2024 in most states and longer in some state-based marketplaces. (Due to the federal holiday on January 15, state marketplaces are allowed to extend the deadline for Open Enrollment to January 16.) Even after a decade of operation, there continue to be changes in these markets. Here’s what to watch in 2024:

1. Unsubsidized premiums in the ACA Marketplaces are rising due in part to inflation. Premiums are rising by an average of 5% in 2024 for the second-lowest cost silver plan (the benchmark against which subsidies are calculated). Premiums for the lowest cost bronze plans (the least expensive plans on the Marketplaces) are similarly rising 6%. (State-level data are available here). An earlier KFF analysis of premium rate filings found the primary drivers of premium growth heading into 2024 are rising prices paid to health care providers, driven in part by inflation in the rest of the economy, and a rebound in utilization coming out of the pandemic. However, other factors like the reduced use of COVID-related care are having a downward effect on premiums. Although unsubsidized premiums are rising, the Inflation Reduction Act’s temporary enhancement of subsidies continues to make the vast majority of Marketplace shoppers eligible for financial help with the cost of coverage. These subsidies cap how much enrollees must spend on a benchmark silver plan premium as a share of their household income, meaning that most enrollees will be sheltered from the increases in the sticker price of the premium.

2. 2024 could be another record-setting year for enrollment. The number of people who enrolled in Marketplace coverage earlier this year reached 15.7 million, surpassing prior record-setting years in 2021 and 2022. During the pandemic, state Medicaid programs suspended annual renewal requirements for Medicaid and kept everyone continuously enrolled. Now, states are resuming renewal requirements and will end Medicaid coverage if people are no longer eligible or if they do not complete renewal forms (sometimes called “procedural reasons”). So far this year, more than 9.5 million adults and children have been disenrolled from Medicaid and CHIP, mostly due to procedural reasons, and millions more will likely be disenrolled in the coming months. Some may find themselves eligible for Marketplace subsidies, further boosting enrollment in the coming year, though there may be challenges in ensuring people losing Medicaid are aware of their options for coverage through the Marketplaces.

3. Insurer participation in 2024 will be more robust than in recent years. There are more insurers entering new markets than there are plans exiting from the Marketplace. Notably, Oscar Health is withdrawing from the California individual insurance market after profits fell short of expectations. Cigna is also exiting from Kansas’s and Missouri’s markets. At the same time, other insurers are entering several states, such as California, Colorado, Delaware, Indiana, Maryland, Nevada, New Jersey, New Mexico, Oklahoma, Pennsylvania, South Carolina, Utah and Wisconsin.

4. State-level policy changes will affect what coverage some residents are eligible for, how much it costs, and how they sign up. For example, Virginia plans to start using its own enrollment platform with the 2024 open enrollment cycle, rather than relying on the federal Healthcare.gov platform. California will begin offering additional cost-sharing reduction subsidies that eliminate deductibles and lower other out-of-pocket expenses for about 4 in 10 Covered California enrollees. Massachusetts is increasing the income limit for additional state subsidies. Washington is allowing undocumented immigrants to enroll in Marketplace plans with state income-based subsidies starting in 2024. And North Carolina will expand Medicaid starting December 1, 2023, to residents with incomes up to 138% of the poverty level. Some low-income people enrolled in Marketplace plans in North Carolina will move to Medicaid.

5. A new auto-reenrollment policy on Healthcare.gov will save some consumers money on their deductibles. People who are enrolled in Marketplace plans now and who do not act during Open Enrollment to renew or change their coverage will, in many cases, be automatically reenrolled by the Marketplace on December 16 so coverage will continue in 2024. In the past, people were usually automatically re-enrolled in the same plan. This year, the federal Marketplace (healthcare.gov) will first check to see if people currently enrolled in bronze plans have income at or below 250% of the federal poverty level, which would make them eligible for a cost-sharing reduction, or CSR, plan. If these individuals do not act by December 15 to select another plan or renew their bronze plan coverage for 2024, the Marketplace will automatically re-enroll them in a silver level plan offered by the same insurer and with the same provider network if the premium for that silver plan (taking into account APTC) will be the same or lower than their bronze plan. Deductibles and other cost sharing in silver CSR plans are much lower than in bronze plans. Those who are automatically re-enrolled in this way but want to select a different plan will still have until the end of Open Enrollment (January 15, 2024) to make a change.

6. Marketplace shoppers will have extra time to submit proof of income. Marketplaces automatically check trusted data sources (such as the IRS and Social Security) to verify the income of enrollees. If the Marketplace cannot verify the income on a given application, the applicant may be asked to submit more documentation. Until this year, the Marketplace has given people 90 days to submit requested documentation, but regulators noticed many people were missing this deadline. Starting this fall, Marketplace shoppers will be given an automatic 60-day extension (for a total of 150 days) to submit documentation of their income. This change applies to all Marketplaces, including those run by states. Coverage will continue during this period, but financial assistance may be reduced or terminated if the requested documentation is not received by the deadline.

7. Young adults turning 26 in 2024 will have until the next open enrollment to move off of their parents’ Marketplace plans. Private health plans must permit young adults the option of remaining covered as a dependent under their parent’s policy until they turn age 26. Starting in 2024, though, federal Marketplace health plans will officially not be allowed to terminate coverage for young adult dependents mid-year on their 26th birthday. Instead, they will have to continue the dependent coverage through the end of the calendar year. The federal Marketplace has already been keeping these individuals on the plan until the end of the year, and then automatically enrolling them in their own exchange coverage the following year, but this rule codifies that practice.

8. Some people will have a chance to sign up or change plans outside of the open enrollment window. In states that use Healthcare.gov, the federal government is making changes to some special enrollment periods (SEPs) that allow certain people to sign up for coverage outside of the Open Enrollment period. Generally, state-based marketplaces can also offer these and other SEPs but don’t have to. These special enrollment periods differ depending on the qualifying reason:

Medicaid disenrollment: Under a new, temporary “Medicaid Unwinding Special Enrollment Period” people losing Medicaid between March 31, 2023 and July 31, 2024 can apply to the Marketplace, check the box attesting to the fact that they lost Medicaid or CHIP, and select a new plan within 60 days of applying for Marketplace coverage. In the long-run an additional, permanent change was made to extend the amount of time people disenrolled from Medicaid have to sign up for Marketplace coverage, from 60 days following loss of Medicaid to at least 90 days. In addition, like last year, people with low incomes will still be able to sign up for Marketplace coverage or change plans throughout the year. This “low-income special enrollment period (SEP)” is available to people in HealthCare.gov states who are eligible for premium tax credits and whose 2024 income will be no more than 150% of the federal poverty level ($21,870 for a single person, $37,290 for a family of 3). Coverage will begin the first day of the following month.

Natural disasters: People recently affected by natural disasters, such as the Maui wildfires, are eligible for an exceptional circumstances SEP that will give them more time to apply for Marketplace coverage. To be eligible they must live in or have moved away from an area designated by the Federal Emergency Management Association (FEMA) as eligible for individual or public assistance.

Loss of other coverage SEP: People who lose other coverage, such as job-based plans or Medicaid, are eligible for a special enrollment period to join the Marketplace, and people who anticipate loss of other coverage are eligible to apply for Marketplace coverage up to 60 days in advance of the date current coverage will end.  In the past, when people applied for this coverage loss SEP in advance, new marketplace coverage would take effect on the first day of the month after current coverage ends.  However, sometimes, current coverage ends in the middle of a month, leaving a gap in coverage of several days or weeks.  Starting in 2024, to avoid this gap in coverage, people applying in advance for the coverage loss SEP can ask to have marketplace coverage take effect on the first day of the month that current coverage ends.

Pandemic: During the Public Health Emergency (PHE), every county in the USA had a FEMA designation that made people eligible for the exceptional circumstances SEP due to COVID. However, since the PHE has ended, this COVID SEP is no longer available.

9. Tax credit recipients must again file tax returns to maintain eligibility for subsidies. It has long been the case that people who receive advanced premium tax credits (APTC) in a year must file their federal tax return the following spring in order to continue receiving an APTC. This “file and reconcile” requirement was temporarily waived during the pandemic, but it is back in force with a change. Now people who fail to file and reconcile for two consecutive years will be ineligible for APTC the following year.

With the eleventh Marketplace Open Enrollment underway, attention is focused on the experiences of consumers when they try to enroll in this type of coverage. With an overwhelming number of plans to choose from in some Marketplaces, complicated rules to determine eligibility for financial assistance, and a limited window of time to make plan selections, it is not a surprise that problems persist.

Across a variety of measures, people with Marketplace coverage were more likely than people with other sources of health coverage to express difficulties in shopping for and enrolling in their health plan, according to data from the 2023 KFF Survey of Consumer Experience with Health Insurance.

While there have been some changes to ease the process of plan selection, subsidy determination, and enrollment, there is a high degree of churn in and out of Marketplace coverage, and enrollment difficulties continue for many consumers.

Experiences Signing Up for Marketplace Coverage

The KFF Survey of Consumer Experiences with Health Insurance is a nationally representative survey of 3,605 U.S. adults with health insurance. Of those surveyed, 880 adults were enrolled in Marketplace coverage, including in states that offer coverage on the federal platform (healthcare.gov) as well as states that operate their own Marketplace (state-based Marketplaces or SBMs). The survey, fielded from February 21, 2023 to March 14, 2023, asked a series of questions about Marketplace enrollees’ experiences when they signed up for their health insurance coverage.

More than one-third (35%) of those with Marketplace coverage found it somewhat or very difficult to find a plan that meets their needs.

Making an appropriate choice among plan options is often difficult. Finding an appropriate plan among the choices available is a problem for over a third of Marketplace enrollees surveyed. About twice as many Marketplace enrollees (35%) said they had a somewhat or very difficult time finding a plan that meets their needs compared to those with Medicare (15%), Medicaid (19%) or Employer-sponsored plan (17%) enrollees.

Applying for coverage and financial assistance

One in four (25%) Marketplace enrollees said it was either very or somewhat difficult to complete the application or enrollment process. That is compared to 12% of people with Medicare and 12% of people with employer-sponsored coverage who indicated difficulty in enrolling. Twenty percent (20%) of people with Medicaid indicated either a very or somewhat difficult application or enrollment process.

One in three people with Marketplace coverage (32%) said it was either very or somewhat difficult to figure out if their income qualified them for financial assistance compared to 20% of Medicaid enrollees, 16% of ESI enrollees, and 14% of those with Medicare.

Comparing options

A large share (41%) of people with Marketplace coverage said it was very or somewhat difficult to compare the doctors, hospitals, and other health care providers you could see for each option compared to fewer adults with Employer-sponsored coverage (32%), Medicaid (27%) and Medicare (19%) who said the same.

Nearly one in three adults with Marketplace coverage (31%) found it very or somewhat difficult to compare copays and deductibles under their plan options, and one in four (25%) found it very or somewhat difficult to compare monthly premiums.

Looking Forward

As the Marketplace has reached record high enrollment in recent years, its importance as a coverage option continues to grow. Nine in ten Marketplace enrollees receive some form of financial assistance through premium tax credits, often with cost sharing reductions as well. Marketplace coverage is unique as it often operates as a transitional source of coverage for millions of people when they find themselves ineligible for employer-sponsored coverage or coverage such as Medicaid or Medicare. There is a high degree of churn in and out of Marketplace coverage, and those signing up for the first time for this coverage will be unfamiliar with the process. In addition, there is likely some variation in consumer sign up experiences across different Marketplaces, as some state Marketplaces have more effective outreach and enrollment strategies.

This survey captures the experience of people who made it through the sign-up process and enrolled. An earlier KFF survey found 6 in 10 uninsured people who tried to sign up for Medicaid or Marketplace coverage said it was somewhat or very difficult to find a plan that met their needs. Even for those familiar with sign-up requirements, complicated and ever-changing rules for Marketplace plan selection and enrollment can make it difficult for many people to find an affordable plan that includes needed providers, even with financial assistance. Efforts to address common problems have developed over time, and will likely continue to focus on these key areas:

Option overload. According to CMS, consumers on the healthcare.gov platform had on average more than 113 plan options to choose from for the 2023 plan year. Too many plan choices with few obvious differences have the potential to result in poor consumer plan selection. Requirements restarted last year for most Marketplaces to have standardized plan options, called “Easy Pricing” plans, combined with a new requirement for 2024 and beyond to limit the number of non-standardized plans available, could help to reduce plan overload. However, these requirements might not reduce the number of choices enough to make a big difference for consumers. New rules for Open Enrollment in federal Marketplace plans this year will automatically reenroll certain individuals with bronze plan coverage into silver plans, where they will receive cost sharing help.

Difficult comparisons. Changes in the works for the coming Marketplace year seek to improve consumers’ ability to understand and compare plans. New plan marketing rules would prevent plans from having deceptive or misleading plan names that do not accurately describe plan attributes. For instance, a plan can no longer have as a marketing name, “$0 cost sharing” plan if only certain services are available for no cost sharing for only a certain number of visits.

Tricky transitions. This Open Enrollment will coincide with the Medicaid unwinding, which is resulting in the largest Medicaid coverage losses in the history of the program. The ability to transition from Medicaid to Marketplace coverage without coverage gaps will test the eligibility and enrollment processes put in place by the Affordable Care Act. New special enrollment opportunities are now available for Medicaid beneficiaries to move to Marketplace coverage. Transitions from employer-sponsored coverage to Marketplace coverage can also prove difficult, including a multi-step process to determine whether a full-time employee with access to employer coverage can qualify for Marketplace financial assistance, and limited standardized information for these employees about how to enroll in Marketplace coverage. For example, a Department of Labor Employer Notice, designed to provide employees with information about Marketplaces, has not been updated to provide information about last year’s changes concerning the “family glitch.”

One-on-one help from Marketplace assisters, including Navigators, will continue to serve a valuable role, alongside efforts to streamline and simplify Marketplace enrollment and educate consumers on the sign- up process.

While most people with Medicare are adults age 65 or older, Medicare also covers millions of younger people who qualify for Medicare based on having a long-term disability, or diagnosis with End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS, also known as Lou Gehrig’s disease). In 2022, 7.7 million people under age 65 with disabilities were covered by Medicare, representing 12% of all Medicare beneficiaries. Younger beneficiaries who qualify for Medicare because of disability are more likely than those who qualify based on age to have lower incomes and education levels, to be Black or Hispanic, and to be in worse health.

Medicare covers the same benefits for people of all ages, regardless of how they qualified for Medicare, and Medicare coverage options and financial assistance programs are generally the same – the main exception being that people under age 65 with disabilities do not have a guaranteed issue right to purchase Medigap supplemental policies. However, perhaps related to their different pathways to Medicare eligibility and because the program was originally designed to cover older adults, with coverage for younger people with disabilities added later, Medicare generally does not work as well for people under age 65 with disabilities. This conclusion is based on KFF analysis of surveys dating back to 2008 but not more recent than 2019. According to previous analysis, beneficiaries under age 65 with disabilities have reported worse access to care, more cost concerns, and lower satisfaction with care than those age 65 or older.

To get a more current understanding of how Medicare is working for older adults and younger people with disabilities, this brief analyzes data from the 2023 KFF Survey of Consumer Experiences with Health Insurance, a nationally representative survey of 3,605 U.S. adults with health insurance. This brief focuses specifically on the 885 adults with Medicare, including 165 adults under the age of 65 with disabilities.

This analysis provides a window into the challenges facing people with disabilities as they navigate the health insurance system by focusing on the experiences of younger adults on Medicare who qualify for the program due to having a long-term disability. The analysis highlights the ways in which beneficiaries under age 65 with disabilities may be less well served by the Medicare program than older beneficiaries. (While people with disabilities are also included among the population of Medicare beneficiaries age 65 or older, the survey sample is insufficient to focus on this group specifically.) People with disabilities who are covered by private insurance or Medicaid are likely to face similar challenges using their coverage. Insights from this analysis could help to inform efforts to strengthen the Medicare program, particularly for younger adults with disabilities.

Key Takeaways

• Overall, people with Medicare are more satisfied with their health insurance coverage than adults with other types of insurance, but among people with Medicare, those under age 65 with disabilities are less likely than those age 65 or older to give positive ratings to the overall performance of their insurance coverage (79% vs. 92%) and some features of it, such as the quality and availability of providers.
• Overall, a majority of Medicare beneficiaries under age 65 with disabilities say they experienced a problem with their health insurance in the last year (70%), compared to half (49%) of those age 65 or older. This includes a larger share of those under age 65 with disabilities who say they experienced denials or delays in getting prior approval (27% vs. 9%) or insurance not paying for care they received that they thought was covered (24% vs. 8%).
• A relatively small share of all Medicare beneficiaries who said they had a problem with health insurance in the past year reported difficulty accessing care as a direct result of these problems, but access problems were more likely to be reported by Medicare beneficiaries under age 65 with disabilities than those 65 or older. At least one in five Medicare beneficiaries under age 65 with disabilities who reported problems say they were unable to receive recommended treatment (24%) or experienced significant delays in receiving medical care or treatment (21%), compared to very small shares of those 65 or older who said the same (6% for both).
• Medicare beneficiaries under 65 with disabilities were more likely to experience difficulty with the health insurance enrollment process and comparing insurance options compared to beneficiaries age 65 or older, including figuring out if their income qualifies them for financial assistance (30% vs. 11%).
• Cost concerns related to insurance are an issue for Medicare beneficiaries of all ages, particularly when it comes to monthly premiums and out-of-pocket costs for prescription drugs, but a larger share of people with Medicare under age 65 with disabilities than those age 65 or older report certain problems. More than one in three people with Medicare under age 65 with disabilities report they had a problem paying a medical bill in the past 12 months (35%), compared to one in ten (9%) of those 65 or older. People with Medicare under age 65 with disabilities were also more likely to report delaying or going without specific health care services due to cost, such as dental care (42% vs. 24%), prescription drugs (18% vs. 10%), and doctor visits (14% vs. 4%).
• About half of people with Medicare under age 65 with disabilities self-report fair or poor physical health, compared to 19% of those age 65 or older, since, by definition, people under age 65 qualify for Medicare based on having a long-term disability. The higher rate of poorer self-reported health among beneficiaries under age 65 could contribute to a higher rate of health insurance problems.
• Three in 10 people with Medicare under age 65 with disabilities self-report fair or poor mental health status, compared to 1 in 10 (9%) of those age 65 or older, and a larger share also report problems related to mental health care availability and access, including reporting that there was a mental health therapist or treatment they needed that wasn’t covered by insurance (27% vs. 7%), and being unable to receive mental health services or medication in the past year they thought they needed (18% vs. 5%).

Satisfaction with Coverage

People with Medicare are more satisfied with their health insurance coverage than those with employer-sponsored insurance, Marketplace coverage, and Medicaid. And while majorities of people with Medicare of all ages rate Medicare positively, those under age 65 with disabilities are less likely than older beneficiaries to give positive ratings to Medicare and some features of it. While 92% of beneficiaries age 65 or older rate Medicare’s performance positively, a smaller share, but still a majority (79%) of Medicare beneficiaries under 65 with disabilities rated Medicare’s performance as excellent or good (Figure 1). A smaller share of Medicare beneficiaries under 65 with disabilities than those 65 or older rated both the availability and the quality of doctors, hospitals, and other medical providers as excellent or good.

Problems with Health Insurance

Overall, a somewhat smaller share of people with Medicare than people with employer-sponsored insurance, Marketplace coverage, or Medicaid report experiencing any problems with their health insurance in the past 12 months (51% compared to 60%, 56%, and 58%, respectively). Among Medicare beneficiaries, a majority (70%) of those under age 65 with disabilities say they experienced any problem, compared to half (49%) of those 65 or older. Because a larger share of beneficiaries under age 65 with disabilities report that they are in fair or poor physical and mental health and have severe chronic conditions compared to beneficiaries age 65 or older (Appendix Figure 1), those under age 65 with disabilities may be more likely to have multiple encounters with the health care system during the year and encounter specific problems when they do.

For example, more than one-fourth (27%) of Medicare beneficiaries under age 65 with disabilities said their health insurance denied or delayed prior approval for a treatment, service, visit, or drug before they received it, compared to just under one in 10 (9%) beneficiaries 65 or older (Figure 2). Similarly, a larger share of beneficiaries under 65 with disabilities than those 65 or older reported that their insurance didn’t pay for care they received that they thought was covered (24% vs. 8%). But one problem, in particular, was reported by a similar share of both groups: 34% of beneficiaries under age 65 with disabilities and 26% of those age 65 or older reported that insurance didn’t cover or required a high copay for a prescription drug.

To the extent that people under 65 with disabilities are seeking medical care more often, or seeking more specialized medical care, than those age 65 or older, insurance problems could be exacerbated for those under age 65 who are enrolled in Medicare Advantage plans, which may have limited networks of doctors and hospitals and can impose prior authorization requirements on Medicare-covered services. (Due to sample size limitations, this analysis by age group is not able to be stratified by enrollment in traditional Medicare and Medicare Advantage.)

Experiences with Enrollment and Comparing Options

Medicare beneficiaries under age 65 with disabilities are more likely to experience difficulty with the Medicare enrollment process and comparing Medicare coverage options compared to beneficiaries age 65 or older. The percentage of beneficiaries under 65 with disabilities who had difficulty enrolling in Medicare (26%) or figuring out if their income qualified them for financial assistance (30%) was substantially larger than among those 65 or older (10% and 11%, respectively) (Figure 3). Similarly, nearly a quarter of those under 65 with disabilities reported that it was somewhat or very difficult to find insurance to meet their needs (23%), compared to 14% of those age 65 or older. This difficulty could reflect the wide array of coverage options that Medicare beneficiaries face, including the choice of whether to enroll in traditional Medicare or Medicare Advantage, and choosing among Medicare Advantage and Part D drug plan options. It might also reflect difficulties among low-income beneficiaries related to enrolling in Medicaid, the Medicare Savings Programs, or the Part D Low-Income Subsidy program for additional benefits and financial assistance.

Understanding of Insurance

Overall, a smaller share of people with Medicare than those with other types of insurance report difficulty understanding various aspects of health insurance, but among those with Medicare, a larger share of people under 65 with disabilities than those age 65 or older say they find it difficult to understand various aspects of health insurance. Specifically, Medicare beneficiaries under 65 with disabilities are more likely to say they have difficulty understanding specific insurance terms such as “deductible” and “prior authorization” (34% vs. 17%), how much they will have to pay out-of-pocket when they use health care (32% vs. 18%), insurance statements outlining whether care will be covered and how much insurance will pay (31% vs. 17%), and how to find information on which providers are covered in their insurance network (28% vs. 13%) (Figure 4).

Consequences of Problems with Health Insurance

Overall, a relatively small share of Medicare beneficiaries who said they had any problem with health insurance in the past 12 months reported delays getting (9%) or being unable to get medical care (9%) as a direct result of these problems, but these access problems were more likely to be reported by Medicare beneficiaries under age 65 with disabilities than those 65 or older. Among the 70% of people under age 65 with disabilities with Medicare who said they had a problem with insurance in the past 12 months, nearly one fourth (24%) reported they were unable to receive care in the past 12 months as a direct result of these problems. By comparison, among the 49% of people age 65 or older on Medicare, 6% reported being unable to receive care as a result (Figure 5). Similarly, among Medicare beneficiaries who had a problem with their insurance in the past year, a much larger share of those under age 65 with disabilities than those age 65 or older reported delays in receiving care in the past 12 months due to health insurance problems (21% vs. 6%).

Experiences Related to Mental Health Care

People with Medicare under age 65 with disabilities are more likely than those age 65 or older to report problems related to mental health care availability and access. Three in 10 (30%) of Medicare beneficiaries under age 65 with disabilities self-report fair or poor mental health status compared to 9% of those age 65 or older, making it more likely that they would seek mental health treatment (Appendix Figure 1). This could be a factor in greater dissatisfaction among people with Medicare under age 65 with disabilities when it comes to both the availability and quality of mental health therapists and professionals covered by their insurance: those under 65 with disabilities are more likely than those 65 or older to rate insurance as fair or poor when it comes to the availability (37% vs. 20%) and the quality (35% vs. 16%) of mental health providers covered by insurance (Figure 6).

Furthermore, more than a quarter (27%) of Medicare beneficiaries under 65 with disabilities reported there was a mental health therapist or treatment they needed that wasn’t covered by insurance, and nearly 1 in 5 (18%) said they were unable to receive mental health services or medication in the past year they thought they needed. Substantially smaller shares of beneficiaries age 65 or older reported these problems (7% and 5%, respectively). (Due to sample size restrictions, this analysis by age group is not able to be stratified by mental health status or limited to those who rate their mental health as fair or poor).

Affordability Concerns

Cost concerns related to insurance are an issue for Medicare beneficiaries of all ages, particularly when it comes to monthly premiums and out-of-pocket costs for prescription drugs. Overall, around one-fourth of Medicare beneficiaries gave their insurance a “fair” or “poor” rating on these measures. However, some cost concerns are experienced by a larger share of people with Medicare under age 65 with disabilities than those age 65 or older, which is likely related to a substantially greater percentage of those under age 65 with disabilities having incomes below 200% of poverty compared to those age 65 or older (77% vs. 44%) (Appendix Figure 1). For example, 36% of those under 65 with disabilities gave a negative rating to their insurance when it comes to the out-of-pocket cost they have to pay to see a doctor, compared to 19% of those 65 or older (Figure 7). Similarly, over one-third (35%) of people under age 65 with disabilities said that in the past year they had problems paying or were unable to pay any medical bills, compared to one in 10 (9%) of those age 65 or older.

Overall, a small share of Medicare beneficiaries report delaying or going without doctor’s visits or prescription drugs in the past year due to cost, but these percentages increase somewhat when it comes to services that Medicare doesn’t cover, especially dental care. Nearly one fourth (24%) of Medicare beneficiaries age 65 or older say they delayed or went without dental care in the past year due to cost, and this share rises to 42% among those under age 65 with disabilities (Figure 8). Similarly, larger shares of people with Medicare under age 65 with disabilities than those age 65 or older say they delayed or went without vision services, which are also not covered by Medicare (25% vs. 13%), prescription drugs (18% vs. 10%), and doctor’s office visits (14% vs. 4%) in the past year because of cost.

Conclusion

Results from the 2023 KFF Survey of Consumer Experiences with Health Insurance show people with Medicare are more satisfied with their health insurance coverage than those with other types of insurance, but among people with Medicare, those under age 65 with disabilities are less likely than those age 65 or older to rate Medicare positively when it comes to the overall performance of their insurance and various features of it. Medicare beneficiaries under age 65 with disabilities are more likely than those age 65 or older to experience access and cost problems when using their insurance.

Because a larger share of people with Medicare under age 65 with disabilities report that they are in fair or poor physical and mental health and have severe chronic conditions compared to people age 65 or older, those under age 65 with disabilities may be more likely to have multiple encounters with the health care system during the year and encounter problems when they do. And with a greater share of beneficiaries under age 65 with disabilities than those 65 or older having relatively low incomes, people under age 65 are more likely to have problems affording health care costs.

Addressing areas of particular concern for beneficiaries under age 65 with disabilities – including policies that address issues related to provider access and availability, improve the process of comparing plans and enrolling, enhance understanding of various features of Medicare, including out-of-pocket costs and provider network restrictions (for Medicare Advantage plans), and improve access to financial assistance programs that help with affordability – could lead to better experiences with Medicare for beneficiaries under age 65 with disabilities.

Following the Supreme Court’s ruling overturning Roe v. Wade, uncertainty has emerged over whether the right to contraception could also be limited. Justice Thomas’ concurring opinion in Dobbs renewed attention and raised the possibility that other Supreme Court precedents relying on the same principles as Roe, such as the right of people to obtain contraceptives, could also be overturned. In response, legislative bodies at the state and federal level have debated, and in some cases enacted, protections for contraception.

A new KFF analysis finds that across the United States, 13 states—California, Colorado, Florida, Illinois, Massachusetts, Michigan, Minnesota, New Jersey, New Mexico, Oregon, Rhode Island, Vermont, and Washington—and the District of Columbia have specific legal or constitutional protections for the right to contraception. In addition, two states (Nevada and Maryland) have started the process of adding a constitutional amendment.

Except for Florida, none of the states that ban or severely restrict access to abortion have state level policies on the books protecting the right to obtain contraceptives, leaving access to some methods vulnerable to future attempts to limit them.  

Fundamental misunderstandings about how contraceptives work—particularly intrauterine devices (IUDs) and emergency contraceptive pills—increase the likelihood that legislators and regulatory agencies might conflate abortion and contraception, and potentially restrict people’s ability to access these methods in some states. A February KFF poll indicates that 73% of people incorrectly think emergency contraceptive pills can end a pregnancy in its early stages when they cannot. Additionally, studies suggest some people wrongly believe that IUDs work primarily by preventing implantation of a fertilized egg in the uterine lining.

Leading medical organizations define pregnancy to begin at the implantation of a fertilized egg. Some state abortion bans, however, define pregnancy to begin at the moment of fertilization and define embryonic cells as people. These definitions, coupled with the misinformation that certain contraceptives can end a pregnancy, have been interpreted, in some circumstances, to restrict access to or payment for those methods.

Read the brief, “The Right to Contraception: State and Federal Actions, Misinformation, and the Courts,” which explains how misinformation about contraceptives and how pregnancy is defined in state abortion bans may impact contraceptive access and outlines the legal protections some states have established to affirm the right to obtain contraceptives.

In this JAMA Health Forum column, KFF’s Drew Altman and Larry Levitt examine how the complexity of the health care system  – with all of its red tape – can be as big a problem for patients as the traditional big three problems of costs, quality and access, and makes those problems worse. The column also explores how simplifying the system not only could ease patients’ frustrations but also help to address those other challenges.

Prior to marriage equality, LGBTQ people had limited access to dependent health benefits compared to opposite-sex couples as there were no requirements that they be offered in the workplace. Some employers aimed to mediate this disparity, in part, by offering unmarried couples domestic partner health insurance benefits. Questions have since been raised about whether these benefits would remain following marriage equality and civil rights decisions. In this data note, based on KFF’s 2023 Employer Health Benefit Survey, we assess the current status of domestic partner health insurance benefit offerings for same-sex spouses against this backdrop.

Access to employer-sponsored health insurance for same-sex couples was fundamentally transformed by the Supreme Court rulings on same-sex marriage (United States v. Windsor, in 2013, which permitted states to perform same-sex marriages and Obergefell v. Hodges, in 2015, which made same-sex marriage legal nationwide). Marriage equality brought with it new access to certain benefits for LGBTQ people, including dependent health insurance. In addition, a more recent Supreme Court case, Bostock v. Clayton County (2020), held that federal civil rights law prohibiting sex discrimination in employment includes protections based on sexual orientation or gender identity.¹  Together, these decisions mean that access to same-sex spousal employment benefits are likely required when they are also offered to opposite-sex couples by moderate-sized employers.² 

In the early 2000’s, prior to the state and federal marriage decisions, about one-third of large firms offered domestic partner health insurance benefits to same-sex couples. The share of large firms offering same-sex domestic partner health benefits increased from 34% in 2011 to 42% in 2012, the year prior to the Windsor decision, potentially reflecting greater attention to the rights of LGBTQ people as marriage equality was being debated nationwide.

Since that time, there have been no significant year-to-year changes in the share of firms offering same-sex couples domestic partner health benefits, with 45% of firms offering in 2023. In other words, following the Supreme Court decisions securing protections for LGBTQ people, the share of firms offering same-sex domestic partner health benefits has not declined, as might have been expected.

It is likely that firms continue to make this coverage available because it provides employees with a benefit irrespective of marital status, and may allow employers that historically offered domestic partner benefits to continue to make a statement about equity. In addition, some states, such as California, require certain employers to offer such coverage. Further, because almost all (96%) employers require some employee contributions toward dependent coverage, employers do not absorb the full cost of providing this benefit, which may increase their willingness to offer access. For employees, the retention of domestic partner health insurance coverage benefits while also offering coverage to same-sex spouses provides broader options for coverage in households regardless of marital status.

1. These protections, provided via Title VII of the Civil Rights Act, apply to employers with at least 15 workers. ↩︎
2. In 2023, almost all (99%) large firms in the U.S report offering dependent health coverage. ↩︎