This 17th annual KFF survey and key resource for Medicaid stakeholders reports eligibility, enrollment, renewal and cost-sharing policies in place as of January 2019 for children, pregnant women, parent/caretakers, and low-income adults in Medicaid and CHIP. Like the previous year, for the most part states continued to refine their efforts in delivering a streamlined, data-driven enrollment and renewal experience, albeit at a slower pace as systems and processes have matured.
As the nation’s health care safety net, Medicaid has been key to covering children and filling the coverage gap that exists for low-income individuals, many of whom work for employers that do not provide employees with health insurance and don’t earn enough to afford private health insurance.
In the year following multiple, unsuccessful efforts to repeal the Affordable Care Act, a top highlight of the report is the 2018 uptick in Medicaid expansion activity. Five additional states adopted or implemented the expansion, resulting in a total of 37 states that have done so. In non-expansion states, with the exception of Wisconsin, low-income adults without dependent children are not eligible for coverage. The only adults eligible for coverage in those states are very low-income parents with the median income eligibility for parents at 40% FPL (or $8,532 for a family of three). And in most of the states, coverage is eroding over time because eligibility levels are based on a static dollar threshold while the federal poverty level is updated annually based on the changes in the consumer price index.
Reflecting ACA policies, all states have implemented more streamlined enrollment and renewal processes, regardless of whether they have adopted the ACA Medicaid expansion. As of January 2019, individuals can apply online for Medicaid in all states for the first time (yes, Tennessee finally launched their Medicaid systems and online application). Most states can complete real-time determinations (within 24 hours) (46 states) and automated renewals (46 states). These modernized, streamlined processes can facilitate individuals’ ability to enroll in and maintain coverage and reduce state administrative burdens. And most states report improvements in at least one area of operations compared to prior to the ACA, including time and accuracy in processing applications and renewals, ratio of eligibility workers to caseload, and administrative costs.
Looking ahead, one important question is whether there will be continued advances to expand coverage and streamline enrollment or whether emerging policies will erode coverage gains and enrollment simplifications realized under the ACA. The Administration is promoting new Medicaid eligibility requirements, including work requirements, which have never previously been approved for the program. These provisions require complex and costly documentation and administrative efforts that would likely increase barriers to coverage and lead to coverage losses among eligible individuals. Other factors outside of Medicaid may also be contributing to enrollment declines among eligible individuals, including shifting immigration policy and state implementation of stricter, more frequent eligibility reviews. Together, these regressive policies have resulted in the first increase in uninsured children in more than a decline and a significant drop in child enrollment in Medicaid and CHIP. While we’ll have to wait until the American Community Survey data is released in September to know the full impact, it is clear that forces seeking to undermine the ACA are a threat to our nation’s historic progress in covering children