Medicaid Expansions

The ACA has created new health insurance coverage opportunities for millions of low-income Americans. Many of these individuals, however, are likely to "churn" in and out of eligibility for Medicaid and marketplace coverage due to fluctuating income and changing family circumstances. Adults who change health insurance coverage are less likely to have a usual source of care and may delay care during coverage transitions. This brief outlines key steps that states can take to reduce the potential gaps in coverage caused by churn. It includes examples from states that have begun to address this issue and outlines concrete strategies for states to mitigate the impact of coverage transitions.

The Affordable Care Act expands Medicaid in 2014 to millions of low-income adults in states that choose to participate in the expansion. Since 2010 California, Connecticut, Minnesota, and Washington, D.C., have taken advantage of the law’s option to expand coverage earlier to a portion of low-income childless adults. Using administrative records, the authors documented that the ramp-up of enrollment was gradual and linear over time in California, Connecticut, and D.C. Enrollment continued to increase steadily for nearly three years in the two states with the earliest expansions.

Presumptive eligibility is a Medicaid policy option that permits states to authorize specific types of "qualified entities," such as federally qualified health centers, hospitals, and schools, to screen eligibility based on gross income and temporarily enroll eligible children, pregnant women, or both in Medicaid or the Children’s Health Insurance Program (CHIP). The Affordable Care Act extends presumptive eligibility beyond children and pregnant women and expands the role of hospitals in determining eligibility presumptively. Given the current status of ACA implementation, presumptive eligibility may be an important tool to expedite access to coverage as states fine-tune their business processes and tweak new eligibility and enrollment systems.

The Centers for Medicare & Medicaid Services (CMS) recently established twelve new Medicaid and CHIP eligibility and enrollment performance indicators for states to report beginning in October 2013. These indicators provide insight into the performance of new eligibility and enrollment policies established under the Affordable Care Act (ACA). In December 2013, CMS released initial reports for a subset of the indicators. This brief provides an overview of the new performance indicators; the initial data; and the opportunities and challenges associated with reporting, analyzing, and interpreting the data.

Since 2009, the eight states participating in the Maximizing Enrollment program have worked to increase enrollment and retention of eligible children into Medicaid and the Children’s Health Insurance Program (CHIP) and to establish and promote best practices in streamlining eligibility and enrollment systems, policies and procedures to share with other states. This report, the second in a series of reports highlighting lessons learned from Maximizing Enrollment, examines how states brought a set of strategies together into a tapestry of change management that supported the states’ overall health coverage vision and goals for streamlining systems, policies and procedures.