Over six months after the expiration of pandemic-era enrollment protections, at least 27 million Medicaid enrollees—or roughly one-in-three enrollees across the country—have completed their state’s eligibility renewal process for the program. Over 18 million people have had their coverage renewed and over 10 million have been disenrolled, as of November 8, 2023.

New KFF focus groups look beneath the numbers at the experiences of enrollees who have gone through the Medicaid renewal process. Drawing from five focus groups with adults in Arizona, Florida and Pennsylvania who had their coverage renewed or who were disenrolled, the focus groups probed enrollees’ experiences with Medicaid, awareness of the end of the continuous enrollment provision, experiences renewing their coverage in recent months, and—if they were disenrolled—their efforts to regain Medicaid or transition to other coverage. Insights from focus group participants highlight both where processes are working well and where policies and systems create administrative barriers to maintaining Medicaid coverage for those who remain eligible.

Among the key takeaways:

• Most participants who successfully renewed their Medicaid coverage found the process quick and easy, especially when done online. However, some participants reported barriers to completing or submitting paperwork and faced long processing times. Some also experienced problems with understanding notices and other communications from the states, as well as challenges getting through to call centers.
• Participants who were disenrolled lost their coverage for a variety of reasons, and some did not know why they had been disenrolled. Several said they did not receive any notices from the state and did not realize they had lost their coverage until they went to fill a prescription. After losing Medicaid, some participants reenrolled in Medicaid quickly while some obtained coverage through their employer or the Marketplace. People no longer eligible for Medicaid and without access to employer coverage should generally be eligible for subsidized coverage through the ACA Marketplace, though some may fall into the “coverage gap” in states that have not expanded Medicaid under the ACA. Some participants, however, became uninsured. For example, one participant’s postpartum coverage was terminated despite still being eligible, and she could not get her coverage reinstated. Another said Marketplace premiums were unaffordable. Several who lost coverage faced substantial out-of-pocket costs for medically necessary care or went without care because they could not afford it.
• Participants said Medicaid enables them to access health care services, mental health services, and medications for themselves and their children with limited out-of-pocket costs and often keeps them healthy enough to work. Awareness that Medicaid coverage had been protected during the pandemic and that disenrollments had begun again in their state varied among participants.
• Many participants said that losing Medicaid would be harmful due to loss of access to needed prescriptions and treatments. They believed that losing Medicaid would cause a serious decline in their physical and mental health and expressed anxiety at the thought of no longer having Medicaid coverage for themselves or their children.

As unwinding continues, these enrollee experiences can help inform policy makers about opportunities to improve communication and outreach, simplify notices, provide assistance with renewals including through call centers, and help enrollees who were disenrolled regain Medicaid if eligible or transition to other coverage if no longer eligible.

With open enrollment underway, Medicare beneficiaries have until December 7th to review and select their coverage for 2024. They also have a lot of options to choose from, as two new KFF analyses show.

For many beneficiaries, the first decision is whether to enroll in traditional Medicare (often with supplemental coverage and a stand-alone prescription drug plan) or Medicare Advantage, the private plans sponsored by insurance companies that now cover more than half of all eligible Medicare beneficiaries. One new analysis shows that the typical beneficiary has a choice of 43 Medicare Advantage plans as an alternative to traditional Medicare for 2024. That is the same number available as in 2023, but more than double the number of plans offered in 2018, which shows how this market is attractive to both enrollees and insurers. In addition, the typical person covered under traditional Medicare can choose among 21 Medicare stand-alone prescription drug plans (PDPs), the second analysis shows. The number of PDP options for 2024 is lower and the number of Medicare Advantage prescription drug plan (MA-PD) options is higher than in any other year since Part D started, reflecting the broader trend toward Medicare Advantage. New for 2024 in all Medicare Part D plans, both stand-alone PDPs and MA-PDs, is the elimination of the 5% coinsurance requirement for catastrophic coverage, a provision in the Inflation Reduction Act that essentially functions as a new out-of-pocket limit on Part D drug expenses. That can translate into savings of thousands of dollars for enrollees who take expensive drugs. The two new analyses provide an overview of the Medicare Advantage and Medicare Part D marketplace for 2024, including the latest data and key trends. Medicare’s open enrollment period began Oct. 15 and runs through Dec. 7.

Medicare Advantage

Nearly 31 million Medicare beneficiaries—51% of all eligible beneficiaries—are enrolled in Medicare Advantage plans, which are mostly HMOs and PPOs offered by private insurers.Of the 43 Medicare Advantage plans that the typical beneficiary can choose from in their local market, 36 plans offer Part D drug coverage, on average.

The average Medicare beneficiary can choose from plans offered by eight firms in 2024, one fewer than in 2023.

Two-thirds (66%) of Medicare Advantage plans will not charge an additional premium beyond Medicare’s standard Part B premium in 2024, the same as in 2023. In addition, 19% of Medicare Advantage plans will offer some reduction in the Part B premium (also known as “money back”) in 2024, similar to 2023.

In 2024, nearly all plans (97% or more) offer some vision, fitness, hearing, or dental benefits as they have in previous years, though the scope of coverage for these services varies.

Part D

In 2023, more than half of all people with Medicare Part D coverage (56%) are enrolled in Medicare Advantage plans and 44% in stand-alone drug plans.

While the market for Part D coverage overall remains robust, for the average beneficiary the number of stand-alone drug plan options for 2024 is lower and the number of Medicare Advantage plans with drug coverage options is higher than in any other year since Part D started. The total number of stand-alone drug plans (709) and firms offering these plans (11) have declined from 2023.

The analysis also shows that, on average, monthly premiums for drug coverage are substantially higher for stand-alone plans compared to Medicare Advantage plans with drug coverage. While the average premium for stand-alone drug plans is projected to increase for 2024 for PDPs, it is expected to remain stable for Medicare Advantage plans with drug coverage.

Two-thirds of Part D stand-alone drug plan enrollees (excluding Low-Income Subsidy recipients)– close to 9 million enrollees–will see their monthly premium increase in 2024 if they stay in their current plan, while 4.4 million (34%) will see a premium reduction if they stay in their current plan.

Beneficiaries who receive Part D Low-Income Subsidies will have access to fewer premium-free (benchmark) plans in 2024 than in any year since Part D started. Due to changes in benchmark plan availability, an estimated 2.4 million LIS enrollees – half of all LIS enrollees in PDPs – need to switch plans during the 2023 open enrollment period if they want to be enrolled in a premium-free benchmark plan in 2024.

 Related Resources:

• What to Know about the Medicare Open Enrollment Period and Medicare Coverage Options
• Marketing Private Medicare Plans
• An Overview of the Medicare D Prescription Drug Benefit

During the Medicare open enrollment period from October 15 to December 7 each year, people with Medicare can enroll in a plan that provides Part D prescription drug coverage, either a stand-alone prescription drug plan (PDP) for people in traditional Medicare, or a Medicare Advantage plan that covers all Medicare benefits, including prescription drugs (MA-PD). In 2023, 50.5 million of the 66 million people covered by Medicare are enrolled in Part D plans, with more than half (56%) enrolled in MA-PDs and 44% in PDPs. This issue brief provides an overview of Part D plan availability and premiums in 2024 and key trends over time. (An overview of the 2024 Medicare Advantage market is also available.) (See Methods box for details on the analysis).

Part D Highlights for 2024

• The average Medicare beneficiary has a choice of close to 60 Medicare plans with Part D drug coverage in 2024, including 21 Medicare stand-alone drug plans and 36 Medicare Advantage drug plans. While the market for Part D coverage overall remains robust, the number of PDP options for 2024 is lower and the number of MA-PD options is higher than in any other year since Part D started. The total number of PDPs (709) and firms offering these plans (11) have decreased from 2023.
• Medicare beneficiaries who receive Part D Low-Income Subsidies (LIS) will have access to fewer so-called “benchmark” PDPs in 2024 than in any year since Part D started, with three benchmark plans available out of the average 21 PDPs available overall for 2024. Benchmark plans are PDPs available to LIS enrollees for no monthly premium. The reduction in the number of benchmark plans for 2024 is largely the result of PDPs offered by Cigna, Humana, and CVS Health qualifying as benchmark plans in far fewer regions in 2024 compared to 2023. An estimated 2.4 million LIS enrollees – half of all LIS enrollees in PDPs – need to switch plans during the 2023 open enrollment period if they want to be enrolled in a benchmark plan in 2024.
• Although the Inflation Reduction Act included a premium stabilizationprovision that capped annual growth in the Part D base beneficiary premium at 6%, the law did not apply this 6% cap to individual plan premiums that enrollees pay. The Part D base beneficiary premium of $34.70 for 2024 is based on standardized bids submitted by PDPs and MA-PDs to cover basic Part D benefits in 2024, while actual Part D plan premiums vary across plans and may be higher or lower than the base beneficiary premium, depending on several factors. The estimated average enrollment-weighted monthly premium for Medicare Part D stand-alone drug plans is projected to be $48 in 2024, based on current enrollment, up 21% from $40 in 2023. This increase is driven by higher expected plan costs to provide the Part D benefit in 2024, including a new cap on enrollees’ out-of-pocket spending above the catastrophic threshold rather than requiring them to pay 5% coinsurance, as in prior years. After accounting for enrollment choices by new enrollees and plan changes by current enrollees, the actual average weighted PDP premium for 2024 is likely to be lower than the estimated weighted average of $48.
• Monthly premiums for drug coverage are substantially higher for PDPs compared to MA-PDs – five times higher, on average, in 2024 (based on unweighted amounts). While the average premium is projected to increase between 2023 and 2024 for PDPs, it is expected to remain stable (and low, or even zero) for MA-PDs. MA-PD sponsors can use rebate dollars from Medicare payments to lower or eliminate their Part D premiums, but there is no equivalent rebate system for PDPs.
• Average monthly premiums for the 14 national PDPs are projected to range from under $1 to $108 in 2024. Premium variation across plans is in part related to whether plans offer basic or enhanced benefits and the value of benefits offered, as well as variation in the underlying costs that plans incur for their enrollees. Among the national PDPs, average monthly premiums are increasing for 12 PDPs, including 4 PDPs with increases greater than $20 and 3 with increases between $10 and $20.
• Most PDP enrollees will face much higher cost sharing for brands than for generic drugs in 2024, as in prior years, including coinsurance for non-preferred drugs of 50% (the maximum coinsurance rate allowed for the non-preferred drug tier) in 6 of the 14 national PDPs. PDP enrollees in 9 of the 14 national PDPs will also face coinsurance, rather than copays, for preferred brands, ranging from 15% to 25%, and coinsurance for specialty tier drugs ranging from 25% in 7 of the national PDPs to 33% in 2 national PDPs. Coinsurance can mean less predictable out-of-pocket costs than copayments. In a change from prior years, however, beneficiaries in 2024 will no longer be required to pay 5% coinsurance once they qualify for catastrophic coverage, due to a provision in the Inflation Reduction Act that eliminated this cost-sharing requirement.

Part D Plan Availability

For 2024, the Average Medicare Beneficiary Has Fewer Stand-alone Drug Plan Options Than in Prior Years but More Medicare Advantage Drug Plan Options

The Part D market for 2024 offers the average Medicare beneficiary fewer choices for drug coverage from stand-alone prescription drug plans than in prior years but more choices for coverage from Medicare Advantage drug plans. The average Medicare beneficiary has a choice of close to 60 options for Part D coverage in 2024, including 21 PDPs and 36 MA-PDs (Figure 1). Since 2020, the number of PDPs available to the average beneficiary has decreased by 25% while the number of MA-PDs has increased by 57%.

Of the 21 PDPs available to the average beneficiary in 2024, 14 are national PDPs – that is, available in all 34 PDP regions nationwide (Appendix Table 1). This is a reduction of two national PDPs from 2023, the result of one plan sponsor (Elixir Insurance) pulling out of the Part D market entirely and an AARP-branded PDP sponsored by UnitedHealthcare no longer being offered in all 34 regions in 2024. The 270,000 enrollees in Elixir’s PDPs (as of March 2023) will need to select a new Part D plan from a different plan sponsor during the 2023 open enrollment period if they want their Part D coverage to continue in 2024.

A Total of 709 Medicare Part D Stand-Alone Prescription Drug Plans Will Be Offered by 11 Firms in 2024, the Lowest Number of PDPs and Firms Offering These Plans Since Part D Started

In 2024, a total of 709 PDPs will be offered by 11 firms in the 34 PDP regions (plus another 10 PDPs in the territories), a decrease of 92 PDPs (-11%) from 2023, and the lowest number of PDPs available in any year since Part D started in 2006 (Figure 2). The number of firms sponsoring stand-alone drug plans is decreasing from 15 firms in 2023 to 11 firms in 2024, the smallest number since the Medicare benefit was launched in 2006.

Despite the reduction in PDP availability overall, beneficiaries in each state will have a choice of multiple PDPs, ranging from 15 PDPs in New York to 24 PDPs in Alabama and Tennessee, plus multiple MA-PDs offered at the local level (Figure 3, Appendix Table 2).

Premiums

Although the Inflation Reduction Act included a premium stabilization provision that capped annual growth in the Part D base beneficiary premium at 6% beginning in 2024, the base beneficiary premium is not the same as the amount that Part D enrollees pay for coverage, and the law did not cap the growth in individual plan premiums to 6%. The Part D base beneficiary premium of $34.70 for 2024 is based on standardized bids submitted by PDPs and MA-PDs to cover basic Part D benefits in 2024. (Absent the premium stabilization provision, the 2024 base beneficiary premium would have increased by 20% to $39.35, reflecting a higher average plan bid for offering Part D coverage in 2024 compared to 2023.) Actual Part D plan premiums for 2024 vary across plans, may be higher or lower than the base beneficiary premium, and may be increasing by more or less than 6% (or even decreasing).

The estimated national average monthly PDP premium is projected to be $48 in 2024, a 21% increase from $40 in 2023, weighted by June 2023 enrollment. This higher average projected premium is driven by higher expected plan costs to provide the Part D benefit in 2024, including a new cap on enrollees’ out-of-pocket spending above the catastrophic threshold rather than requiring them to pay 5% coinsurance, as in prior years. This change is based on a provision in the Inflation Reduction Act.

Comparing monthly premiums for Part D coverage between stand-alone PDPs and MA-PDs shows the competitive advantage that MA-PDs have over PDPs when it comes to the premiums that enrollees pay for drug coverage. On an unweighted basis, monthly premiums for drug coverage are substantially higher for PDPs compared to MA-PDs – five times higher, on average in 2024 ($60 vs. $12) (Figure 4). Moreover, between 2023 and 2024, the unweighted average premium is increasing for PDPs, while remaining stable for MA-PDs. MA-PD sponsors can use rebate dollars from Medicare payments to lower or eliminate their Part D premiums and/or offer other extra benefits, but there is no equivalent rebate system for PDPs. According to MedPAC, Medicare Advantage monthly rebates per enrollee have more than doubled over the last five years, from $95 in 2018 to $196 in 2023.

It is likely that, after accounting for enrollment choices by new enrollees and plan changes by current enrollees, the actual average weighted PDP premium for 2024 will be lower than the estimated weighted average of $48 but well above the average MA-PD premium. In 2023, the enrollment-weighted average monthly portion of the premium for drug coverage in MA-PDs is $10, compared to $40 for PDPs.

Average Monthly Premiums for the 14 National PDPs Are Projected to Range from Less Than $1 to $108 in 2024

PDP premiums will vary widely across plans in 2024, as in previous years. Among the 14 national PDPs, there is a difference of more than $1,200 in average annual premiums between the highest-premium PDP and the lowest-premium PDP. At the high end, the monthly premium for Humana Premier Rx Plan (the 10^th largest plan by overall enrollment) will be $108, totaling nearly $1,300 annually. At the low end, the monthly premium for Wellcare Value Script (the second largest plan) will average $0.40, or $5 annually (Figure 5). In addition to Humana Premier Rx Plan, two other national PDPs will charge monthly premiums of more than $100 in 2024: AARP Medicare Rx Preferred, the fourth largest plan ($106), and CVS Health’s SilverScript Plus, the 12^th largest plan ($103).

Two-Thirds of Part D Stand-alone Drug Plan Enrollees Without Low-income Subsidies Will Pay Higher Premiums in 2024 If They Stay in Their Current Plan

Two-thirds of Part D stand-alone plan enrollees (66%) – 8.6 million of the 12.9 million Part D PDP enrollees who are responsible for paying the entire premium (which excludes Low-Income Subsidy (LIS) recipients) – will see their monthly premium increase in 2024 if they stay in their current plan, while 4.4 million (34%) will see a premium reduction if they stay in their current plan (Figure 6).

Compared to 2023, more Medicare Part D stand-alone drug plan enrollees will see their monthly premium either increase or decrease by $10 or more if they stay in their same plan in 2024 (Figure 7). For 2024, 4.8 million non-LIS PDP enrollees (37%) will see a premium increase of $10 or more per month – or at least $120 more annually if they remain in their current plan – compared to 2.1 million enrollees (16%) in 2023.

Among the 14 national PDPs, average monthly premiums are increasing for 12 PDPs, including 7 PDPs (having a combined 3.9 million non-LIS enrollees) with increases exceeding $10:

• AARP Medicare Rx Walgreens (+$30, from $30 to $60)
• SilverScript Plus (+$29, from $74 to $103)
• Humana Premier Rx (+$25, from $83 to $108)
• Cigna Extra Rx (+$22, from $63 to $85)
• SilverScript Choice (+$16, from $33 to $49)
• Cigna Secure Rx (+$14, from $33 to $47)
• Humana Basic Rx Plan (+$14, from $37 to $51)

Another 1.6 million non-LIS PDP enrollees (12%) will see a monthly premium reduction of $10 or more for 2024, compared to under 150,000 (1%) for 2023. This largely reflects a premium reduction for the second largest PDP, Wellcare Value Script, where the average monthly premium will decrease by $9, from $10 in 2023 to less than $1 in 2024. These amounts are averaged over the 34 PDP regions; enrollees in this plan in 16 of the 34 regions will see a premium reduction of $10 or more.

Over half (56%) of non-LIS enrollees (7.3 million) are projected to pay monthly premiums of at least $40 if they stay in their current plans, or nearly $500 annually, including 2.1 million (16% of non-LIS enrollees) projected to pay monthly premiums of at least $100, or at least $1,200 annually. These estimates are higher than the comparable estimates for 2023, when 40% of non-LIS PDP enrollees (5.3 million) were projected to pay at least $40 per month, including 1.6 million paying $100 or more, if they stayed in their plans.

Cost Sharing

Part D Enrollees Pay Much Higher Cost Sharing for Brands and Non-preferred Drugs Than for Generic-Tier Drugs, and a Mix of Copays and Coinsurance for Different Formulary Tiers

In 2024, as in prior years, Part D enrollees will face much higher cost-sharing amounts for brands and non-preferred drugs (which can include both brands and generics) than for drugs on a generic tier, and a mix of copayments and coinsurance for different formulary tiers. The typical five-tier formulary design in Part D includes tiers for preferred generics, generics, preferred brands, non-preferred drugs, and specialty drugs.

Among all PDPs, median standard cost sharing in 2024 for different types of drugs is (Figure 8):

• Generics: $0 for preferred generics and $5 for other generics
• Preferred brands: a copayment of $47 or coinsurance of 21% for preferred brands (up from $44/17% in 2023)
• Non-preferred drugs: 46% coinsurance for non-preferred drugs, which can include both brands and generics (an increase from 45% in 2023; the maximum allowed is 50%)
• Specialty drugs: 25% coinsurance for specialty drugs (the same as in 2023; the maximum allowed is 33%)

Among the 14 national PDPs, 9 PDPs will charge $0 for preferred generics in 2024, but copays of $40 to $47 or coinsurance of 16% to 25% for preferred brands, and coinsurance ranging from 39% to 50% for non-preferred drugs; 6 out of the 14 national PDPs are charging the maximum 50% coinsurance for non-preferred drugs. Coinsurance for specialty tier drugs ranges from 25% to 33% in these plans, with 7 of the 14 national PDPs charging 25% and 2 charging 33%. (Plans that charge the full deductible amount cannot charge more than 25% for specialty tier drugs.)

Low-Income Subsidy Plan Availability

In 2024, a Smaller Number of Part D Stand-Alone Drug Plans Will Be Premium-Free to Enrollees Receiving the Low-Income Subsidy Than in Any Year Since Part D Started

Through the Part D LIS program, enrollees with low incomes and modest assets are eligible for assistance with Part D plan premiums and cost sharing. More than 13 million Part D enrollees are receiving LIS, including 8.3 million (62%) in MA-PDs and 5.2 million (38%) in PDPs.

In 2024, a smaller number of PDPs will be premium-free benchmark plans – that is, PDPs available for no monthly premium to Medicare Part D enrollees receiving the Low-Income Subsidy (LIS) – than in any year since Part D started, with 126 premium-free benchmark plans, or less than 20% of all PDPs in 2024 (Figure 9). The number of benchmark plans available in 2024 will vary by region, from two to seven (Appendix Table 2).

PDPs offering basic benefits qualify to be benchmark plans if they have premiums below the benchmark amount in a given region. The benchmark is calculated as a weighted average of the beneficiary premiums for basic drug coverage offered by both PDPs and MA-PDs in a given region (calculated before taking MA rebates into account). (MA-PD premiums are included in this calculation even though MA-PDs do not qualify as benchmark plans.)

The reduction in the number of benchmark plans for 2024 is largely the result of PDPs offered by Cigna, Humana, and CVS Health qualifying as benchmark plans in far fewer regions in 2024 compared to 2023: Cigna Secure Rx (from 34 down to 16 regions); Humana Basic Rx Plan (from 27 down to 11 regions); and CVS Health’s SilverScript Choice (from 34 down to 11 regions).

On average (weighted by 2023 Medicare enrollment), LIS beneficiaries have three benchmark plans available to them out of the average 21 PDPs available overall for 2024 – the lowest average number of benchmark plan options in any year since Part D started. All LIS enrollees can select any plan offered in their area, but if they enroll in a non-benchmark plan, they must pay some portion of their chosen plan’s monthly premium.

In 2024, half (49%) of all LIS PDP enrollees who are eligible for premium-free Part D coverage (2.4 million LIS enrollees) will pay Part D premiums averaging $15 per month unless they switch or are reassigned by CMS to premium-free plans. Among this group are the 1.9 million LIS enrollees in Cigna Secure Rx, Humana Basic Rx Plan, or CVS Health’s SilverScript Choice in the regions where these PDPs will no longer qualify as benchmark plans. These enrollees will need to switch plans for 2024 if they want to remain in a benchmark (premium-free) plan.

Discussion

The overall market for Part D coverage remains robust based on the overall number of plan options, but recent years have seen a growing divide in the Part D plan market between stand-alone PDPs, where the number of plans has generally been trending downward over time in conjunction with a reduction in PDP enrollment, and MA-PDs, where plan availability and enrollment have experienced steady growth.

The average weighted monthly premium for PDPs in 2024 will increase substantially over the 2023 amount (based on current enrollment), while premiums for drug coverage offered by MA-PDs are likely to remain stable (and low or zero). Provisions in the Inflation Reduction Act to make the Part D benefit more generous – such as the elimination of the 5% coinsurance requirement for catastrophic coverage taking effect in 2024 – will help lower out-of-pocket costs for enrollees, but with these changes, it could become harder for some Part D plan sponsors to offer low-priced coverage, particularly sponsors of stand-alone drug plans. MA-PD sponsors have a competitive advantage in this regard because they can use rebate dollars from Medicare payments to lower or eliminate their Part D premiums. The premium imbalance between PDPs and MA-PDs could be exacerbated as plans assume greater liability for high drug costs above the catastrophic threshold in 2025 with a $2,000 cap on out-of-pocket spending. To keep Part D premiums low in the face of rising costs for the basic Part D benefit, Medicare Advantage plans may end up using more of their rebate dollars to buy down the Part D premium. This could mean less rebate money available for other benefit enhancements or lower profits, depending on the amount of rebates plans receive in the future.

The increasing availability of low- or zero-premium MA-PDs, combined with the aggressive marketing of Medicare Advantage plans and the appeal of other features of these plans, such as supplemental benefits, could tilt enrollment even more towards Medicare Advantage plans in the future. Monitoring trends in Part D plan availability and enrollment could inform policymakers in considering whether or how to ensure continued availability of competitively priced stand-alone Part D drug plans for the millions of Medicare beneficiaries in traditional Medicare.

Appendix Tables

The House Committee on Appropriations released its FY 2024 Labor, Health and Human Services, Education, and Related Agencies (Labor HHS) appropriations bill on July 13, 2023 and accompanying report on November 3, 2023. The Labor HHS appropriations bill includes funding for U.S. global health programs provided to the Centers for Disease Control and Prevention (CDC) and funding for global health research activities provided to the National Institutes of Health (NIH). Total global health funding at CDC and NIH through the Labor HHS bill is not yet known, as funding for some programs at NIH is determined at the agency level rather than specified by Congress in annual appropriations bills. Funding for global health programs at CDC totals $371 million, which is $322 million (47%) below the FY23 enacted level ($693 million), $394 million (52%) below the President’s FY24 request ($765 million), and $322 million (47%) below the Senate level ($693 million). The bill would eliminate all funding for global HIV programs at CDC and reduce funding for global public health protection compared to the enacted level; other program areas are flat funded compared to enacted levels. See the table below (downloadable table here) for additional detail on global health funding. See other budget summaries and the KFF budget tracker for details on historical annual appropriations for global health programs.

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.