What Worked and What's Next? Strategies in Four States Leading ACA Enrollment Efforts
Introduction & Background
The two primary ways the ACA increases coverage are through the creation of new Health Insurance Marketplaces that offer health insurance plans and advanced premium tax credits to help offset the cost of coverage for moderate-income individuals and the expansion of Medicaid to low-income adults. States have options with regard to how they implement these expansions. They can establish their own SBM, default to the FFM, or build a Marketplace in partnership with the federal government. As enacted, the ACA also required all states to expand Medicaid to nearly all adults with incomes at or below 138% FPL ($27,310 for a family of three in 2014) beginning January 2014, but the June 2012 Supreme Court ruling on the ACA effectively made this expansion a state option. As of July 2014, 27 states including the District of Columbia are implementing the Medicaid expansion in 2014.3
Regardless of their implementation choices for the ACA coverage expansions, all states must also implement streamlined Medicaid enrollment processes that offer individuals multiple options to apply (including online, by phone, in person, and by mail), rely on electronic data to verify information, and seek to provide real-time eligibility determinations. These processes are designed to be coordinated across Medicaid, the Children’s Health Insurance Program (CHIP), and Marketplace coverage to create a “no wrong door” enrollment system. Whether an individual applies directly to Medicaid or through a Marketplace, he or she is to be enrolled in the program for which he or she is eligible. To implement these new processes, many states have needed to make significant upgrades to antiquated Medicaid enrollment systems or build new systems.
The four study states—Colorado, Connecticut, Kentucky, and Washington—vary geographically and demographically (See Appendix Table 1). However, all four states elected to build their own SBM4 and implemented the full Medicaid expansion as of January 2014, with three of the four states (Colorado, Connecticut, and Washington) using available options to get an early start on extending Medicaid to adults. Moreover, all four states achieved significant enrollment in both their Marketplace and Medicaid programs over the course of the 2014 open enrollment period. Medicaid gains, in particular, were very strong, far exceeding the national average and outpacing some of the states’ growth estimates. As discussed below, stakeholders credit this enrollment success to a range of strategies employed for their marketing and branding campaigns; outreach and enrollment initiatives; consumer assistance networks; and overall systems, operations, and leadership. Looking ahead, the study states are focused on an array of future priorities and continued improvements to further build upon their successes to date.