Efforts to Increase Marketplace Enrollment During Open Enrollment Could Boost Medicaid Coverage, Too

As the ninth open enrollment period for the Health Insurance Marketplaces begins, enhanced Marketplace premium help along with increased funding for outreach and enrollment assistance mean there are more affordable coverage options for the millions of people who remain uninsured and more help available to connect those individuals to coverage. During the open enrollment period, which runs from November 1 through January 15 in the federal Marketplace (in states that operate their own Marketplaces, 9 have the same dates, 7 extend open enrollment to January 23 or 31, and 2 shorten it to December 15), advertising and outreach campaigns encourage new consumers to apply for Marketplace coverage and existing consumers to renew their coverage. Importantly, efforts to facilitate enrollment in the ACA Marketplaces will also identify low-income individuals who are eligible for Medicaid. In 2020, there were 27 million non-elderly uninsured people, and a majority were eligible for financial assistance through the ACA Marketplaces or Medicaid.

In 2020, 7.0 million uninsured people were eligible for Medicaid. Over six in ten of these people are adults (31%, or 2.2 million) or children (30%, or 2.1 million) living in the 33 states in which the ACA Marketplace is federally-operated (FFM) or state-operated but the state uses the federal Healthcare.gov platform (SBM-FP). Another 29% (2.0 million) are adults in states that fully operate their own marketplaces (SBM), while only 10% (0.7 million) are children in SBM states (Figure 1).

Under enrollment simplification processes established by the ACA, states must provide a single application for Medicaid, CHIP, and Marketplace coverage, thereby establishing a “no wrong door” application process for ACA coverage. This process means that the Marketplaces will screen or assess individuals’ eligibility for all health coverage programs, including Medicaid and CHIP, and individuals will be enrolled in or referred to the program for which they are eligible regardless of how they apply. Most states utilizing the FFM do not authorize the FFM to make final Medicaid eligibility determinations for most groups, but instead conduct full eligibility determinations for individuals after the FFM assesses them as eligible for Medicaid. The states that operate SBMs typically have a single integrated system through which individuals can apply for and renew Medicaid, CHIP and Marketplace coverage.

During the Marketplace special enrollment period (SEP) that ran from February 15 to August 15, 2021, over half a million people applying for marketplace coverage in FFM states, or 13% of all applicants, were assessed or determined eligible for Medicaid. That share is up from the 8% of applicants (or 836,451 people) who were assessed or determined eligible for Medicaid in FFM states during the 2020 Marketplace open enrollment period (which closed in December 2019). Increased advertising and outreach during the SEP coupled with the availability of zero-premium silver plans plans for those with incomes up to 150% of the federal poverty level (FPL) may have contributed to a larger share of lower income people applying for Marketplace coverage, including those who appeared to qualify for Medicaid in their states. The report did not include data from SBM states; the number of people determined eligible for Medicaid during the SEP would no doubt have been larger if it had.

Enhanced funding for outreach, advertising, and in-person assistance during the Marketplace open enrollment period can also raise awareness of Medicaid and promote Medicaid enrollment. For the 2022 open enrollment period, the Biden administration has launched expansive advertising and outreach campaigns to educate consumers on the availability of both Marketplace and Medicaid coverage. It has also increased funding for Navigators in the federal Marketplace seven-fold from $10 million in 2020 to $80 million in 2021. The enhanced Navigator funding will mean more staff to assist both Marketplace and Medicaid applicants.

The Build Back Better Act currently under consideration in Congress would provide a coverage pathway for the over 2 million people in the Medicaid coverage gap in the dozen states that have not expanded Medicaid under the ACA, allowing them to purchase subsidized coverage in the Marketplaces beginning in 2022. Unlike their counterparts in Medicaid expansion states, individuals currently in the coverage gap will not be eligible for Medicaid; however, funding in the legislation for targeted outreach to these newly eligible individuals may also reach those who are currently eligible for Medicaid but not enrolled, leading to overall gains in Medicaid enrollment.