Another ACA Double Win for States and Families: Aligning Medicaid Coverage for Children of All Ages

Imagine you’re a parent with a pre-schooler and a 9 year-old child, earn $20,000 a year  (105% FPL) and live in Georgia. Your younger child qualifies for Medicaid coverage but has to renew coverage every six months. Your older child qualifies for CHIP coverage with a monthly premium of $10 but only has to renew coverage every 12 months. When you renew your younger child’s Medicaid coverage, you can do so over the telephone or online. But for your older child, you must respond to a renewal notice that is sent in the mail.

Confused? You bet ya! No wonder we have “churn” in public coverage programs.

Eliminating different Medicaid eligibility levels based on a child’s age – aka “stairstep eligibility” – is one of the many improvements inspired by the Affordable Care Act’s (ACA) vision for streamlined and simplified eligibility. There are two facts that are important to note on this topic:

1)   Aligning Medicaid coverage at 133% FPL for children of all ages is required of all states as of January 1, 2014.[i] The recent Supreme Court ruling on the ACA was explicitly limited to covering adults in Medicaid and does not affect the elimination of stairstep eligibility for kids. In a recent letter to governors, Secretary Sebelius confirms that the ruling only impacts the agency’s ability to take away a state’s current Medicaid funding if it does not participate in the Medicaid expansion to low-income adults. All other Medicaid provisions of the law stand.

2)   States that currently receive the enhanced CHIP match for children ages 6-19 between 100% and 133% FPL will continue to receive the higher federal match when these children are shifted to full Medicaid coverage.[ii]

Why is this a win for families?

  • Families will no longer have to maneuver two sources of coverage, two sets of rules regarding eligibility, enrollment and renewal, and differing benefit levels, cost-sharing and provider networks.
  • All children with family income up to 133% FPL will receive the guarantee of Medicaid’s EPSDT (early and periodic screening, diagnosis and treatment) services, the “gold standard” of coverage for kids according to the Academy of Pediatrics.. While some states provide EPSDT services in CHIP, there is no requirement to do so.
  • Their families will be protected by rules that limit cost-sharing in Medicaid more so than CHIP.

Why is this a win for states?

  • Administering coverage on a whole family basis is more efficient and cost-effective.
  • Aligned eligibility is easier to describe in outreach materials and program information.
  • Aligned eligibility cuts down on calls from families, providers and application assistors who are confused by the differing rules.
  • Their aligned eligibility will help reduce churn, enabling states to maintain more continuous coverage and enhancing their ability to measure quality and health outcomes.

Eliminating the stairstep is not an expansion of eligibility for children. Every state already covers children well above 133% FPL through a combination of Medicaid and CHIP. It is simply a smart policy decision that makes life easier for everyone.

[i] ACA §2001(a)(5)(B) Conforming Amendments.


[ii] Federal Register / Vol. 77, No. 57 / Friday, March 23, 2012 / Rules and Regulations / Page 17149.



Tricia Brooks is a Research Professor at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.