In 2020, Congress passed the Families First Coronavirus Responce Act (FFCRA). FFCRA did a lot of things. One of the big things it did was support state budgets and health coverage by increasing the Federal Matching Assistance Percentage (FMAP). FMAP is the percentage of allowed program costs that the federal government pays. It is determined by a state’s income. Typically it ranges from a floor of 50% to just under 80%. FFCRA did two big Medicaid things. First it increased the FMAP across the board by 6.2% percentage points. Secondly, it required states that accepted this bump payment to not disenroll folks. This continuous coverage requirement ended in the last budget agreement. States have started to redetermine enrollees this spring.
Early projections expected ~15 million people to lose Medicaid coverage. Many folks would receive coverage elsewhere because their lives changed. However a decent percentage of this 15 million people who lost Medicaid would need to find new coverage. Many would be eligible for the ACA.
The problem is that historically the Medicaid to ACA interface is not too good. Earlier this year, in JAMA Network Open Chris Frenier and Adrianna McIntyre looked at where pre-pandemic Minnesota Medicaid enrollees found coverage in the year after they lost Medicaid coverage:
Six months after leaving Medicaid, 17.6% of children had enrolled in commercial group coverage, and 2.2% of children had enrolled in individual coverage. Among children, 48.7% did not have identifiable MN APCD coverage at 6 months, decreasing to 29.8% after 12 months, largely because of Medicaid reenrollment; 51.2% of children who left the program were reenrolled 1 year later.
Among adults, 50.1% did not have identifiable coverage 6 months after Medicaid exit, decreasing to 39.1% at 12 months. The share of adults covered by commercial coverage after 12 months was 13.6% for group plans and 5.9% for individual plans. The share who had returned to Medicaid at 12 months was 32.8%.
Just over 2% of kids and just under 6% of adults who lost Medicaid coverage in Minnesota enrolled in the Minnesota exchange in the year after coverage loss.
Maybe this data is old. Maybe there was low awareness in 2017 and the Minnesota state based marketplace imposed idiosyncratic administrative burdens that it had not thought about? Maybe things changed?
Well….
Amy Lotven at Inside Healthcare reports on new CMS data from the Medicaid unwinding
New CMS data , quietly released in late August, show about 178,000 consumers chose a qualified health plan (QHP) through state or federal exchanges after losing Medicaid and CHIP coverage in the first two months of the Medicaid unwinding
As more adults are redetermined out of Medicaid, states should be aggressively linking these newly uninsured or likely to be uninsured folks to the ACA. There, they are likely to face higher premiums and more cost-sharing.
Lobo
Would the next step be an administrative bridge to the ACA from Medicaid to ease the loss of coverage friction?
David Anderson
@Lobo: Yep, but there are big implementation challenges starting with premium tax credits are effectively a loan which is cancellable/forgiveable if incomes hit certain criteria for the next tax filing. Things gets legally squicky to obligate people to a loan that they might not have consented to.
Martin
@Lobo: California is doing this now. I can’t speak to its effectiveness, but I have seen a bit how it works.
When I retired we got a policy on the exchange – basically the coverage we had from my employer, but in CA the application process for ACA is this same as for Medicaid (MediCal). There’s a whole additional thing you need to do for MediCal, which we didn’t want to do knowing we wouldn’t be qualified because of our net worth, and that turned out to be a difficult thing to not do. CA *really* wants everyone who touches either MediCal or ACA to be applied to both, and they’ve been working around the edges to make sure that if you are eligible for one, you would be eligible for the other apart from income/assets. So extending coverage for this group or that group and tapping into state funds where the feds forbid coverage and all that. The idea seems to be that when you contact the state during open enrollment or some qualifying life event, the state can determine which you should be on and just switch you because you’ve already done the paperwork for both, so you should automatically fall up onto the exchange or fall down on to MediCal. I don’t know if that actually *works* but they are activity trying to make it work.
I’m not sure what it looks like if you are Medicare/Medicaid dual eligible – I can imagine that’s a whole other set of policy challenges, but we aren’t old enough to have run into that.