Medicaid Expansions

The ACA allows hospitals to use preliminary information to enroll people who appear eligible for Medicaid into coverage on a temporary basis. The goal of this “presumptive eligibility” (PE) option for hospitals is to quickly and efficiently enroll eligible people into Medicaid while insuring immediate health care costs are covered. While presumptive eligibility is not a new concept in Medicaid, the ACA for the first time gives hospitals – rather than states – the authority to decide whether to participate in PE. This issue brief, prepared by Manatt Health Solutions, describes the flexibility available to states to establish training and performance standards for hospitals conducting PE determinations, and discusses approaches states may want to consider as they develop standards.

Prior to the ACA, one key reason a number of states used Section 1115 waiver authority was to expand Medicaid coverage to low-income adults who could not otherwise be covered under federal rules. The ACA’s Medicaid expansion to nearly all low-income adults at or below 138% FPL, and the significant federal funding provided to states for this expansion, fundamentally alters the role of Section 1115 waivers in expanding coverage to adults. Through guidance and recent waiver approvals in three states, CMS has identified some of the parameters related to the use of waivers to expand coverage to adults in light of the ACA’s Medicaid expansion. This brief provides an overview of the potential role of Section 1115 waivers to expand coverage since the enactment of the ACA and key themes in recently approved and proposed coverage expansion waivers.

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.

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 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.

In this recent release, CMS proposes the methodology and data sources necessary to determine federal payment amounts made to states that elect to establish a Basic Health Program (BHP). The BHP program, which is scheduled to begin in January 2015, will offer health benefits coverage to low-income individuals otherwise eligible to purchase coverage through the health insurance marketplaces. Comments on the proposed funding methodology are due by January 22, 2014.

Recently, HHS and CMS have reported new eligibility and enrollment data for the marketplaces created by the ACA, as well as for Medicaid and CHIP, providing some of the timeliest data on Medicaid enrollment that has ever been captured along with preliminary information on how early ACA implementation is impacting Medicaid enrollment. However, currently, there is no single data source that provides comprehensive information on Medicaid enrollment. As such, to gain a full picture of enrollment in Medicaid, it is important to look across the different enrollment paths connecting people to the program today. This brief provides an overview of these different enrollment paths and national level data available to date on enrollment through these avenues.

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.

States with Partnership or Federally Facilitated Marketplaces (FFM) are coordinating closely with the federal government on Medicaid eligibility and enrollment. Each state Medicaid agency has chosen whether the Marketplace will only assess, or whether it will also determine Medicaid eligibility for individuals who apply through the Marketplace. This brief outlines the responsibilities of the FFM in assessing or determining Medicaid eligibility, explains the differences between these two models, and examines the rationales behind two states’ choices.

Due to the ACA’s new eligibility verification rules, states have developed plans outlining Medicaid and CHIP eligibility verification procedures. This chart highlights key elements from states’ verification plans, such as which eligibility factors are verified through electronic data and the specific data sources states are using, as well as whether self-attestation is accepted for some eligibility factors. The chart also contains information about how states will determine reasonable compatibility, which is how they will resolve issues if there are discrepancies between electronic data sources and information provided by applicants.