Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost Sharing Policies as of January 2017: Findings from a 50-State Survey

Looking Ahead

The findings of this 15th annual report illustrate the central role that Medicaid and CHIP play in covering low-income children and families today. They also show how the ACA expanded Medicaid’s role for low-income adults and led to modernization and streamlining of eligibility systems and enrollment processes. As debate over the future of the ACA, potential broader changes to Medicaid, and CHIP reauthorization unfold, these findings provide a baseline against which future policy changes may be measured. Looking ahead, these findings suggest:

Given the significant role of Medicaid and CHIP across states, changes to these programs could affect coverage for many of the nation’s low-income families. As the findings illustrate, Medicaid and CHIP serve as the base of coverage for low-income children and pregnant women across all states. The findings also show how Medicaid’s role for low-income adults has expanded in the 32 states, including DC, that have implemented the ACA Medicaid expansion. Since the ACA was enacted through October 2016, net Medicaid and CHIP enrollment has grown by over 17 million people, increasing total enrollment to over 74 million enrollees.1 These enrollment gains have helped to reduce the nation’s uninsured rate to a record low of 10% in for the overall population under age 65, and to bring the children’s uninsured rate to 5% as of June 2016.2 As such, changes to Medicaid or CHIP would affect many low-income families. The outcome of debate around reauthorization of CHIP will have particularly important implications children and pregnant women given the key role CHIP plays complementing Medicaid to support their coverage across states. Loss of CHIP funding could put this coverage at risk and would create funding gaps for states. If the Medicaid expansion was eliminated under a repeal of the ACA, many low-income parents and other adults would lose eligibility and potentially become uninsured, depending on what other coverage options may be available. Moreover, broader changes to the financing structure of Medicaid, coupled with reductions in federal Medicaid funding, could affect coverage for all groups of enrollees.

The ACA included changes in Medicaid eligibility, enrollment, and renewal policies and processes in all states, which could potentially be affected by a repeal of the ACA. The ACA established new standards for eligibility, enrollment, and renewal processes that accelerated state efforts to modernize and streamline their systems and processes to utilize electronic data, reduce paperwork requirements for individuals, and increase administrative efficiency for states. For most states, this has been a multi-year effort that has involved significant investments of time, staff, and resources, using available federal funding for system upgrades. State work has involved developing new business procedures; writing new state administrative rules; training staff; and designing and deploying complex eligibility systems. The administrative structure in some states has been transformed through these changes, with increasing efficiencies gained through automation leading to changing needs and roles for eligibility staff. It remains to be seen which of these policies or processes could be affected by a repeal of the ACA. However, reverting back to pre-ACA policies or implementing new policies would likely require major investments of time, staff, and resources. Moreover, changes to the Marketplaces could affect Medicaid eligibility systems and enrollment processes because the systems are interwoven in all states. For example, if SBM enrollment systems were dismantled, those states would need to move Medicaid eligibility decisions to a new system or potentially revert to an old system, if one has been maintained.

States are using available program options to expand access to coverage, further streamline enrollment and renewal processes, and charge premiums and cost sharing in Medicaid and CHIP. Under current program rules, states can choose from a range of options to expand coverage for many groups and further streamline enrollment and renewal processes beyond the new standardized processes included in the ACA. States have taken up many of these options, particularly to expand access to coverage for children and pregnant women. Most states also are using options to charge premiums and cost sharing to some Medicaid and CHIP enrollees. However, in most cases, states largely target premiums and above-nominal cost sharing to enrollees with relatively higher incomes. The program options available to states, states’ responses to these options, and the role of waivers could be affected by a repeal of the ACA or as part of broader efforts to restructure Medicaid.

Premiums and Cost Sharing Tables

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