Key Implementation Issues: Eligibility and Enrollment

The ACA envisions a “no wrong door” eligibility and enrollment system for consumers in each state to efficiently connect to the appropriate coverage option. To reach this vision, the ACA introduces a simplified eligibility methodology, called Modified Adjusted Gross Income (MAGI), and requires a seamless system for enrollment and renewal. Some challenges and considerations for states as they implement eligibility and enrollment provisions include:

  • Developing policies and processes for coordinating across Medicaid, CHIP, and the health insurance marketplaces.
    • New York is an “Early Innovator” state working towards a highly coordinated and simplified enrollment system which offers a consumer-friendly experience and more automated eligibility determination for Medicaid, CHIP, and the marketplace.
    • Oklahoma is a leading state in streamlining and modernizing enrollment systems and is the first state to successfully implement real-time online enrollment for Medicaid.
    • State Experiences with Express Lane Eligibility: Policy Considerations and Possibilities for the Future: This State Health Reform Assistance Network issue brief discusses states’ option to use express lane eligibility, a tool that allows states to use components or entire determinations of other human service means-tested programs, such as the Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF), to determine eligibility in Medicaid and CHIP.
    • Coordinating Human Services Programs with Health Reform Implementation: This Center on Budget and Policy Priorities toolkit offers resources and steps for state leaders to consider regarding integrating health care reform and human services programs.
  • Upgrading or replacing eligibility system technology to ensure that families can enroll in coverage—potentially in different coverage programs for each family member—through a single application process.

    • Addressing Coverage Challenges for Children Under the Affordable Care Act: This Urban Institute report presents an analysis of some of the complex coverage scenarios children may face, including instances of Medicaid or CHIP eligible children with marketplace eligible parents; Medicaid, CHIP, or marketplace eligible children with parents that have employer-sponsored insurance or are not legal citizens; and children with at least one absent parent.
  • Developing policies to monitor and minimize disruptions in health insurance coverage.

    • A Centers for Medicare and Medicaid Services State Health Official letter provides guidance on states’ option to implement the CHIPRA provision to cover legally present immigrant children and pregnant women in CHIP or Medicaid.
    • A final July 2013 rule (Federal Register Vol. 78 No. 135) sets a limit on CHIP waiting periods of no more than 90 days for separate-CHIP programs. This limit, which aligns with similar maximum waiting period limits in the marketplace, will require that some states make changes to their existing waiting periods. States have the option to shorten waiting periods to less than 90 days, eliminate waiting periods, or allow for waiting period exemptions in cases where coverage is too expensive, a family is below a given income level, or where coverage is not comprehensive. In 2012, Vermont eliminated the 30-day waiting period for its CHIP program and instead monitors for crowd-out using data collected in a state-administered survey. In 2013, Colorado enacted legislation to eliminate its 3-month CHIP waiting period and Pennsylvania did the same for its 6-month waiting period.
    • States could transition children between 100 and 133 percent from CHIP to Medicaid before the January 1, 2014 deadline. New York made this transition in 2011 and used express lane eligibility to simplify the transition process.


Additional State Resources

New: California: This form facilitates enrollment in Medi-Cal coverage for former foster youth.  This form clearly and succinctly explains that the Affordable Care Act allows former foster youth to receive Medi-Cal benefits at no share-of-cost until they reach the age of 26, without requiring proof of income.

Alabama FFM Flier for ALL Kids parents: The Alabama chapter of the American Academy of Pediatrics and Arise Citizens’ Policy Project created an educational flier targeted to parents whose children are covered by ALL Kids, the Alabama CHIP program. This straightforward one-pager informs these parents that given their income, they are likely qualified for Marketplace tax subsidies. The flier also includes information about and lists resources for assistance with enrollment.

Montana: Primarily for internal use, the Montana Department of Public Health and Human Services has developed an ACA Playbook providing resources related to outreach, eligibility, and enrollment; training tools for navigators, assistors, field offices, and other policy workers; and other documents regarding the implementation of the Affordable Care Act in Montana.

California: On January 1, 2013, California began the first phase of transitioning 875,000 children from the state’s separate-CHIP program, Healthy Families, to the state’s Medicaid program, Medi-Cal. This website provides access to analyses, fact sheets, and other in-depth resources related to California’s transition.

Washington: will be expanding Medicaid to 133 percent FPL effective January 1, 2014, and anticipates up to 800,000 children, pregnant women, and families will need to be rescreened under new eligibility rules.

NASHP Resources

Paving an Enrollment Superhighway: Bridging State Gaps Between 2014 and Today:This NASHP issue brief frames the ACA’s vision for an enrollment superhighway in 2014 and discusses how states can achieve this vision.

Other Resources

2014 Medicaid Eligibility Transition Toolkit for States: This State Health Reform Assistance Network toolkit identifies issues and decisions states will face as they convert to new eligibility standards in 2014.
Aligning Eligibility for Children: Moving the Stairstep Kids to Medicaid: This Kaiser Family Foundation issue brief examines how the transition of children with incomes up to 133 percent FPL from CHIP to Medicaid will affect children and families and looks to New York and Colorado for lessons learned through their early transitions.
CMS Frequently Asked Questions: Medicaid/CHIP Affordable Care Act Implementation: This CMS guidance offers states options for implementing section 2101(f) of the Affordable Care Act, which provides that states maintain coverage under a separate-CHIP for children who lose Medicaid eligibility due to the elimination of income disregards under the new Modified Adjusted Gross Income (MAGI) methodology.

Converting to MAGI, What Does It Really Mean for Kids? This Georgetown Center for Children and Families blog post walks through an example of how MAGI may impact a family with two children.

Explaining Health Reform: The New Rules for Determining Income Under Medicaid in 2014: This Kaiser Family Foundation brief summarizes the new MAGI eligibility rules and compares it to current income counting rules.

Federal Requirements and State Flexibilities for Verifying Eligibility Criteria: This State Health Reform Assistance Network brief summarizes key verification requirements laid out in the ACA and federal regulations and highlights potential state flexibility when verifying eligibility for Medicaid, CHIP, or subsidies in the marketplaces.

Work Support Strategies: Streamlining Access, Strengthening Families: In 2012, Urban Institute chose six states (Colorado, Idaho, Illinois, North Carolina, Rhode Island, and South Carolina) to receive a three-year grant funding their efforts to design, test, and implement an integrated approach for delivering supports to low-income families, including health care coverage.