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Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost-Sharing Policies as of January 2016: Findings from a 50-State Survey

Looking Ahead

States’ Medicaid and CHIP eligibility policies and enrollment and renewal processes will play a key role in reaching the remaining low-income uninsured population and keeping eligible individuals enrolled over time. Together, these survey findings show that:

Medicaid and CHIP continue to be central sources of coverage for the low-income population, but access to coverage varies widely across groups and states. Medicaid and CHIP offer a base of coverage to low-income children and pregnant women nationwide. Eligibility for adults has grown under the Medicaid expansion, but remains low in states that have not expanded. Overall, eligibility continues to vary significantly by group, with coverage available to children and pregnant women at higher income levels relative to parents and other adults. Eligibility also varies across states, and these differences have increased as a result of state Medicaid expansion decisions. Given this variation, there are substantial differences in individuals’ access to coverage based on their eligibility group and where they live.

Upgraded state Medicaid systems help eligible individuals connect to and retain coverage over time, provide gains in administrative efficiencies, and offer new options to support program management. One key outcome of the ACA has been the significant modernization of states’ Medicaid eligibility and enrollment systems. Although state implementation of new eligibility systems got off to a rocky start in 2014, as of 2016, states have implemented system enhancements and processes to increasingly support real-time, data driven eligibility determinations and automatic, paperless renewals of coverage as envisioned by the ACA. The higher-functioning systems in states help eligible individuals connect to coverage more quickly and easily, keep eligible individuals enrolled over time, reduce paperwork burdens, and lead to increased administrative efficiencies as paper-based processes move to an electronic, automated environment. Moreover, the modernized systems offer new options to support program management. For example, states may have increased data reporting capabilities and expanded options to connect Medicaid with other systems and programs. Further, as systems and processes become more refined over time, states may be able to manage enrollment more efficiently, allowing for resources to be refocused on other activities. Looking ahead, states will continue to fully operationalize the streamlined enrollment and renewal processes outlined in the ACA and build on their developments to date to increase the use of technology, expand functionality, smooth out coordination across coverage programs, and integrate non-health programs into their new systems.

There remain key questions about how recent changes in eligibility and enrollment may be affected by a range of factors moving forward. Funding for CHIP is set to expire in 2017, raising key questions about the future of the program and what might happen in its absence. In addition, the ACA maintenance of effort provisions for children’s coverage end in 2019. State Medicaid expansion decisions will likely continue to evolve over time, and it remains to be seen how they might be affected by the gradual reduction in federal funding for newly eligible expansion adults, which begins to phase down in 2017 when it reduces to 95%. Pending proposals in current budget reconciliation legislation would roll back the Medicaid expansion to adults and eliminate the maintenance of effort requirements in 2017. Outside of these potential changes, it also will be important to examine how the Section 1115 waivers that allow states to charge adults premiums and monthly contributions are affecting coverage and program administration, particularly given that waiver authority is provided for research and demonstration purposes.

Premiums and Cost-Sharing Tables

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Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.