State Enrollment Experience: Implementing Health Coverage Eligibility and Enrollment Systems Under the ACA

The Patient Protection and Affordable Care Act (ACA) included new eligibility and enrollment requirements, which have presented states with significant implementation opportunities and challenges. Although states had choices about whether to host a health insurance exchange or expand Medicaid, the ACA required all states to make major changes to Medicaid eligibility policy, including adding mandatory coverage of new groups, implementing streamlined eligibility and renewal , incorporating new eligibility and verification requirements, and coordinating enrollment systems with exchanges.

As a result, states had to create or significantly update existing systems, collaborate and coordinate with other state and federal agencies, and develop new processes to support enrollment. States implemented these changes within a constrained timeframe, with much activity occurring between the Supreme Court ruling in NFIB v. Sebelius in summer 2012 and the first open enrollment period in fall 2013. In addressing the challenges of ACA implementation, many states and federal agencies were highly innovative, developing approaches that set a new standard for promoting effective enrollment in public programs.

Drawing on key informant interviews and ongoing engagement with states between 2013 and 2015, this brief examines states’ early experiences implementing ACA’s eligibility and enrollment requirements; highlights promising practices and lessons learned; provides some context on the state experience; and concludes with possible areas of focus for future enrollment and implementation efforts. With the recent Supreme Court decision in King v. Burwell, there is new momentum for state and federal agencies to learn from early experiences with ACA implementation to further improve enrollment systems in future years. This brief offers reflections to support continued growth and movement.

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