Medicaid and CHIP Eligibility, Enrollment, and Cost Sharing Policies as of January 2019: Findings from a 50-State Survey

Introduction

This 17th annual survey of the 50 states and DC provides data on Medicaid and CHIP eligibility, enrollment, renewal, and cost sharing policies as of January 2019 and changes implemented in 2018. The report is based on a telephone survey of state Medicaid and CHIP program officials conducted by the Kaiser Family Foundation and the Georgetown University Center for Children and Families during January 2019. It includes findings in three key areas: Medicaid and CHIP Eligibility, Enrollment and Renewal Processes, and Premiums and Cost Sharing. State-specific information is available in Appendix Tables 1-20. The report includes policies for children, pregnant women, parents, and other adults under age 65 (who are determined eligible based on Modified Adjusted Gross Income (MAGI) financial eligibility rules); it does not include policies for groups eligible through Medicaid eligibility pathways for seniors and individuals eligible based on a disability (non-MAGI groups).

Evolution of Medicaid Eligibility and Enrollment

Medicaid has expanded over time to fill gaps in coverage and provide a broad base of coverage for the low-income population. Historically, Medicaid eligibility was tied to cash assistance and limited to low-income individuals in certain categories, including children, pregnant women, parents, seniors, and individuals with a disability. Over time, Congress gradually expanded Medicaid eligibility for children, and it was formally delinked from cash assistance in 1996. Following this delinking and the enactment of CHIP in 1997, many states continued to expand eligibility for children and pregnant women. Moreover, many states pursued innovative outreach and enrollment efforts to help mitigate coverage losses associated with delinking Medicaid from cash assistance and facilitate enrollment of eligible but uninsured children and pregnant women under the broader eligibility rules. However, eligibility for parents remained limited and other nondisabled adults were excluded from the program regardless of income. The ACA filled these coverage gaps by expanding Medicaid to low-income adults with incomes up to 138% FPL and providing enhanced federal funding to states for expansion coverage.

In addition, the Medicaid and CHIP enrollment and renewal experience has evolved from a paper-based, cumbersome process to a modernized, streamlined approach. Prior to the ACA, Medicaid enrollment processes in many states reflected the program’s historic ties to cash assistance. As of January 2013, over half of states imposed an asset test on parents, and some still required parents to complete a face-to-face interview at enrollment or renewal. Applications could only be completed by mail or in-person in a number of states and eligibility determinations could sometimes take days or weeks. The ACA accelerated the adoption of new data-driven enrollment and renewal processes that align and coordinate with the Marketplaces. These processes allow individuals to connect to coverage more quickly and conveniently and reduce the paperwork burden on states and individuals. The streamlined enrollment and renewal policies apply to all states regardless of whether they expanded Medicaid under the ACA. Many of the ACA policies built on innovations states implemented to facilitate enrollment when they expanded coverage for children following the enactment of CHIP. This previous state experience and research showed that complex enrollment processes with burdensome requirements create barriers for eligible individuals to obtain and maintain coverage and increase administrative burdens and costs for states.1,2

Executive Summary Medicaid and CHIP Eligibility