It’s that time again – the release of the annual 50-state survey on Medicaid and CHIP eligibility, enrollment, renewal and cost-sharing policies conducted by the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families. Today, my co-authors from Kaiser – Samantha Artiga, Jessica Stephens, and Alexandra Gates – along with Joe Touschner from CCF, and I released the 2015 survey findings via webinar. We were joined by several federal and state officials, to discuss the findings, including Vikki Wachino of the Center for Medicaid and CHIP Services at CMS, Rex Plouck of the Ohio Governor’s Office of Health Transformation, Linda Nablo of the Virginia Department of Medical Assistance Services and Judith Arnold of the New York State Health Department.
One year into implementation, it is clear that the Affordable Care Act (ACA) has broadened Medicaid’s base of coverage for the low-income population and accelerated state efforts to move from outdated, paper-driven enrollment processes to a new modernized enrollment experience. Highlights of the key findings include:
- The long-standing gap in coverage for adults has been eliminated in the 28 states that expanded Medicaid but persists in the 23 non-expansion states where parents are covered at a median eligibility of 45% of the federal poverty level ($8,906 for a family of 3) and non-disabled adults without dependent children remain ineligible. To put this in perspective, a single parent in Texas or Alabama with two children cannot get Medicaid if she earns just a little more than $300 per month. Furthermore, in most non-expansion states, parent eligibility is based on a dollar threshold, which is not updated on a routine basis, resulting in eligibility levels that erode over time relative to the cost of living.
- On the good news front, coverage for children remains strong with a median eligibility of 255% FPL. More than half the states (28) now cover lawfully residing immigrant children. Moreover, the number of states making kids wait for coverage – that is, requiring a child to be uninsured for a period of time before enrolling in CHIP – has declined from 38 to 18.
- Overall, states have made significant progress in offering online and telephone applications. All states, except Tennessee, now have an online application, up from 37 states just two years ago. In that same period, the number of states allowing individuals to apply over the phone has tripled from 15 to 47.
- Reflecting the low incomes of parents and adults in Medicaid, most states (40) only charge nominal cost-sharing, and not premiums. On the other hand, due to the relatively higher income levels in CHIP, 27 (of 36) states with separate CHIP programs charge premiums for children, while about half of the states assess cost-sharing for children in Medicaid or CHIP. However, in a number of states, the income level above which premiums (7 states) and cost-sharing (14 states) start was effectively raised by the transition of children ages 6 – 18 with income between 100% and 138% FPL from CHIP to Medicaid.
This has been a challenging time for state Medicaid agencies. Implementing the ACA’s MAGI (modified adjusted gross income) standards is a paradigm shift for anyone familiar with pre-ACA Medicaid policy. MAGI is not just a new way of determining income and household size. It required states to convert their existing eligibility levels while other ACA provisions call for states to establish linkages to trusted data sources to verify eligibility and to move toward paperless enrollment and renewal processes. As such, even though states have made considerable progress, implementation will continue in 2015 and beyond.
Key to achieving the ACA’s vision of data-driven, streamlined, coordinated access to affordable coverage options is the deployment of sophisticated, interconnected information technology systems. To this end (and spurred by the permanent extension of 90% federal support for IT development), enhancements to eligibility and enrollment system functionality will continue for the foreseeable future. Top priorities for states in 2015 include establishing or refining paperless renewal processes, widening their use of electronic data sources, and improving seamless coordination of coverage between Medicaid/CHIP and the Marketplaces.
Given the fast-paced policy environment leading up to when the ACA’s key coverage provisions went into effect on January 1, 2014, an abbreviated report based on publicly available data was published last year. This year, we resumed conducting interviews with key state Medicaid and CHIP policy experts (to whom we are immensely grateful) to provide a broader look at ACA implementation. The policy environment continues to rapidly change and improve on a week-to-week basis, making it tricky to capture a complete, up-to-the-minute picture of certain swiftly evolving processes such as renewals, verification using data sources, and account transfers between coverage sources. Nonetheless, the 2015 survey creates a new baseline for measuring ongoing progress and improvements in Medicaid and CHIP in future years as states continue to modernize their programs.