Medicaid and CHIP Eligibility, Enrollment, and Cost Sharing Policies as of January 2019: Findings from a 50-State Survey

Looking Ahead

Looking ahead, one key question is whether there will be continued advances to expand coverage and streamline enrollment processes or whether emerging policy changes will erode coverage gains and enrollment simplifications realized under the ACA.

Additional states may expand Medicaid, which would increase access to coverage for low-income adults and have positive effects on care and state budgets and economies.¹ Several new governors who were elected in 2018 ran on platforms to expand Medicaid. Further, the success of recent ballot initiatives to expand could spark similar action in other states. However, voter-approved ballot measures may face barriers to implementation based on state law requirements, efforts to block or amend the policies by legislators or governors, or legal challenges.² Ongoing litigation related to the constitutionality of the ACA also could influence state decisions to expand. However, if states attach waiver provisions such as work requirements or other restrictions to expansion, the positive reach and impact would be limited. Recently, some states have indicated interest in a partial expansion to an income level below 138% FPL with the ACA enhanced federal match rate.³ Relative to full expansion, partial expansions could limit coverage and potentially increase federal costs. While states can pursue waivers to extend coverage to a lower income level without access to the enhanced federal match, no waivers to allow an enhanced match for a partial expansion have been approved to date, and guidance from the previous administration prohibited the use of the enhanced match for “partial expansions.”

Renewed CHIP funding protects children’s eligibility levels through 2027, but states that extend eligibility above 300% FPL will have the option to reduce eligibility starting in October 2019. When Congress continued funding for CHIP in 2018, it retained the MOE provision that requires states to preserve Medicaid and CHIP eligibility and enrollment policies for children. However, starting in October 2019, the MOE only applies to children’s coverage up to 300% FPL. At that time, states can maintain coverage for children above this income level and still receive federal matching funds, but will newly have the option to reduce eligibility to 300% FPL. This change in the scope of the MOE coincides with the beginning of the phase-out of the 23-percentage point temporary boost in federal CHIP matching rates available between 2016 and 2019. This boost will be reduced by half (11.5 percentage points) in 2020 and then rates revert to the traditional enhanced CHIP match rate in 2021, leaving states to resume paying a larger share of CHIP costs.

Emerging state and federal policies to add Medicaid eligibility requirements could erode the coverage gains and enrollment simplifications realized under the ACA. The Trump Administration is promoting new Medicaid eligibility requirements through waivers and its proposed budget and has approved a growing number of waiver requests from states, including work requirements, which have never previously been approved for the program. Some states are no longer moving forward with implementing waiver provisions following a change in leadership in the 2018 elections,^4,5 while other states are considering adding waiver provisions.^6,7,8,9 Research shows that these types of requirements create barriers for eligible individuals to obtain and maintain coverage and increase administrative burdens and costs for states.^10,11 As such, they will likely dampen potential coverage gains and lead to coverage losses that would erode the coverage increases realized under the ACA. States’ implementation of waiver provisions could be affected by ongoing legal challenges to the Administration’s authority to approve work requirements and other restrictive measures in Arkansas and Kentucky.

Other policy changes may lead to coverage losses among eligible low-income families and growing burdens on states. In 2017, coverage gains stalled and began to reverse for the first time since the implementation of the ACA and Medicaid enrollment of adults and children declined in 2018.^12,13,14 Some of the decline in Medicaid enrollment could reflect the improving economy. However, some factors may be leading to enrollment declines among eligible individuals. While states’ growing use of technology and automation has led to improvements for individuals and states, there are concerns emerging in some states that eligible individuals may be losing coverage due to process-related issues.^15,16,17 Further, other policy changes outside of Medicaid could be dampening enrollment. For example, the Trump administration substantially decreased funding for outreach and enrollment assistance, which is pivotal for helping eligible individuals get and stay enrolled in coverage. In addition, shifting immigration policies, including the proposed rule to make changes to public charge policy, will likely lead to broad decreases in participation in Medicaid among legal immigrant families and their primarily U.S.-born children and increase administrative burdens on states.¹⁸ Twenty states reported they would need to change applications, forms, or other guidance, conduct additional staff training, and/or increase outreach and education to immigrant families if the public charge rule is finalized, while most of the remaining states indicated they could not yet determine how the rule would impact their operations.