Waiver authorities granted through Section 1115 demonstrations are meant to be experiments that serve the objectives of the Medicaid program—namely, promoting access to health coverage. But what exactly does this look like? In some very welcome news, there has been a recent uptick in the number of states requesting to expand continuous eligibility through Section 1115 waivers. Illinois, New Jersey, New York, Oregon, and Washington are all in the process of considering or requesting changes that would expand 12-month continuous eligibility to adults or implement multi-year continuous eligibility.
Twenty-four states offer 12-month continuous eligibility to all children enrolled in CHIP and Medicaid through State Plan Amendments, but currently, there is no SPA option for states to provide continuous eligibility for children beyond one year or to adult beneficiaries. Section 1115 demonstrations are a pathway to provide these benefits, and two states—Montana and New York—have received approvals for Section 1115 waivers that provide 12-month continuous coverage to all Medicaid adults, although Montana has since eliminated this benefit. Multi-year continuous eligibility for children, however, is an emerging policy goal. Oregon is the first state to formally request CMS approval for it, and Washington is poised to become the second, assuming the provision remains in the state’s waiver application following the state comment period.
Here’s the Latest Progress:
On May 27th, Illinois Governor J.B. Pritzker signed a Medicaid omnibus bill into law that seeks to expand 12-month continuous eligibility to all adults enrolled in the program. The legislation requires the state to request CMS approval no later than July 1, 2022, in order to receive federal matching funds for this policy. If CMS approves Illinois’ request under Section 1115 authority, Illinois will become the third state to receive such approval and join New York as one of two states with currently-active waivers for 12-month continuous eligibility for adults.
In its demonstration application submitted to CMS in February, New Jersey requested that its FamilyCare demonstration expand 12-month continuous eligibility (which the state already provides to children enrolled in Medicaid and CHIP) to all adults who qualify for Medicaid based on their Modified Adjusted Gross Income (MAGI). This includes most adult beneficiaries in the state.
As previously mentioned, New York is the only state with a currently-approved Section 1115 waiver extending 12-month continuous eligibility to all adults enrolled in Medicaid. There is now a push in New York for multi-year continuous eligibility for young children. A bill under consideration in the New York Senate would provide continuous eligibility for children under the age of three whose families’ incomes do not exceed 200 percent FPL. The bill has passed the Senate Health Committee and the Senate Finance Committee but has not yet received a floor vote in either the Senate or Assembly and is subject to revision. If it becomes law, the state would request to amend its Section 1115 demonstration to include this provision in order to receive federal matching funds.
Oregon’s demonstration application, submitted to CMS on March 3rd, would be the largest expansion of continuous eligibility in the country. If approved, Oregon would provide some form of multi-year continuous eligibility to all Medicaid beneficiaries beginning as soon as mid-2023. For children under the age of six, Oregon proposes continuous eligibility from the time of a child’s enrollment through the end of the month in which their sixth birthday falls. For children six and up and adults, the state waiver requests approval to provide two-year continuous eligibility. These changes would double the current period of continuous eligibility for beneficiaries ages 6-18 and offer continuous eligibility for the first time to adult beneficiaries in Oregon.
On May 12th, Washington posted its Medicaid Transformation Project Section 1115 waiver extension application for state public comment. In the application, the state proposes to provide continuous eligibility for children from birth until the age of six. Currently, Washington provides 12-month continuous eligibility to all children under 19 through the state plan option. The state comment period for this extension application is open through June 13.
Why Does it Matter?
As CCF’s Tricia Brooks and Allexa Gardner highlight, continuous eligibility drives more efficient health spending, improves short- and long-term health outcomes, mitigates the impact of income volatility on access to care, and promotes health equity. Continuous eligibility provisions can be particularly critical for ensuring that infants and young children have consistent access to health care during a developmental period in which recommended screenings and check-ups are most frequent. My colleagues have recently blogged about the benefits that continuous eligibility would have on school readiness and children’s coverage rates, particularly for children of color who experience disproportionate rates of health disparities.
In light of these findings, CMS should approve New Jersey, Oregon, and Washington’s requests to expand continuous eligibility and take steps to make it easier for more states to implement similar measures. As my colleagues explained in their report on continuous eligibility, the creation of state plan options for multi-year continuous eligibility for children and 12-month continuous eligibility for adults would also help prevent gaps in health coverage and help address health disparities. And while these policies have already shown promising results, the proposed Section 1115 demonstrations could yield further evidence of their positive impact on churn, health disparities, and school readiness among other factors. New York’s demonstration providing 12-month continuous eligibility to adults has already shown decreases in both inpatient hospital admissions and per member per month costs, and Montana’s has shown improvements in administrative efficiency. Evaluations of demonstrations like these will lay the groundwork even further for incorporating promising new policies as SPA options—just the way that Section 1115 demonstrations are supposed to work.
With the end of the public health emergency continuous coverage protections looming, there is no time like the present for states to strengthen continuity of coverage by taking up available opportunities to adopt continuous eligibility and for federal policymakers to streamline the process by offering more SPA options.