Medicaid and CHIP Eligibility, Enrollment, and Cost Sharing Policies as of January 2020: Findings from a 50-State Survey

Looking Ahead

Prior to the COVID-19 outbreak, the federal government and some states were taking actions to add eligibility requirements and increase eligibility verification for Medicaid coverage. The administration approved waivers in several states to allow work requirements and other eligibility restrictions and released guidance for new “Healthy Adult Opportunity” demonstrations that would allow for such requirements and other changes. Recent court decisions set aside or struck down work requirements and suggested that similar approvals are likely to be successfully challenged in litigation. The administration also indicated plans to increase eligibility verification requirements as part of program integrity efforts. Outside of Medicaid, other policy changes were also contributing to downward trends in coverage, including decreased federal funding for outreach and enrollment and shifting immigration policies. However, given increasing health care needs stemming from COVID-19, states and Congress are taking action to expand eligibility, expedite enrollment, promote continuity of coverage, and facilitate access to care.

States can take a range of actions under existing rules to facilitate access to coverage and care in response to COVID-19. They can take some of these actions quickly without federal approval. For example, they can allow self-attestation of eligibility criteria other than citizenship and immigration status and verify income post enrollment. They can also provide greater flexibility to enroll individuals who have small differences between self-reported income and income available through data matches. Further, they can suspend or delay renewals and periodic data checks between renewals. States can take other actions allowed under existing rules by submitting a state plan amendment (SPA, which is retroactive to the first day of the quarter submitted). Changes states can implement through a SPA include expanding eligibility, adopting presumptive eligibility, providing 12-month continuous eligibility for children, and modifying benefit and cost sharing requirements, among others. Beyond these options, states can seek additional flexibility through Section 1135 and Section 1115 waivers.

The Families First Coronavirus Response Act provides additional options for states and access to increased federal funding subject to states meeting certain eligibility and enrollment requirements. Specifically, it provides coverage for COVID-19 testing with no cost sharing under Medicaid and CHIP (as well as other insurers) and provides 100% federal funding through Medicaid for testing provided to uninsured individuals for the duration of the emergency period associated with COVID-19. The law also provides states and territories a temporary 6.2 percentage point increase in the federal matching rate for Medicaid for the emergency period. To receive this increase, states need to meet certain requirements including: not implementing more restrictive eligibility standards or higher premiums than those in place as of January 1, 2020; providing continuous eligibility for enrollees through the end of the month of the emergency period unless an individual asks to be disenrolled or ceases to be a state resident; and not charging any cost sharing for any testing services or treatments for COVID-19, including vaccines, specialized equipment or therapies.