ACA Now

Implementation Status

2011-2013

Prior to January 2013, CMS issued a final rule in February 2011 in which it detailed the allotment methodology and states’ FY 2009-2015 CHIP allotments pursuant to the ACA and other statutory changes.  In March 2012, CMS issued a final regulation further effectuating much of these changes and also clarified the application of certain ACA requirements in a subsequent FAQ document issued in the spring of that year.  HHS continues to award Medicaid and CHIP performance bonuses on a FY basis to states pursuant to the CHIPRA (and as financially enhanced via the ACA), as detailed more fully here.

On Jan. 7, 2013, CMS posted a grant opportunity titled “Connecting Kids to Coverage Outreach and Enrollment (Cycle III)”.  A teleconference for prospective applicants was held on January 16.  The deadline to apply was Feb. 21, 2013.

CMS has since provided additional details regarding this provision in a proposed rule (and corresponding informational bulletin) released on Jan. 14, 2013.

In April 2013, CMS issued a FAQ that seeks to provide additional guidance to states regarding CHIP coverage for children who lose Medicaid eligibility due to the elimination of income disregards as a result of states’ transition to Modified Adjusted Gross Income (MAGI) income eligibility guidelines.

On July 10, HHS announced nearly $32 million in grants to 41 state agencies, community health centers, school-based organizations and non-profit groups under the Connecting Kids to Coverage Outreach and Enrollment Grants (Cycle III) – originally funded under CHIPRA and continued under the ACA – to enroll and retain children in Medicaid and CHIP coverage, including those who are eligible but not enrolled.  A list of grantees is available in a CMS fact sheet; an HHS release provides a general overview of the grants.

On July 26, CMS posted a notice designating the final FY 2013 federal Children’s Health Insurance Program (CHIP) allotments for each state, DC, territory, and commonwealth that are available for expenditure beginning on Oct. 1, 2012.  Note that the notice addresses this provision of the ACA, which calls for a one-time appropriation of roughly $15.4 billion in the first half of FY 2015 – thus describing some of the aggregate federal allotment adjustment determinations made as a result of recent legislative changes.

Note that October 2013 Medicaid and CHIP monthly application and eligibility data (as of Dec. 3, 2013) are available here. The November 2013 Medicaid and CHIP monthly application and eligibility data (as of Dec. 20, 2013) are available here. The December 2013 Medicaid and CHIP monthly application and eligibility data (as of Jan. 22, 2014) are available here. In guidance released on November 29, 2013 regarding new flexibility extended to states to use account transfer flat files transmitted by the Federally Facilitated Marketplace (FFM) to enroll individuals in Medicaid and CHIP, addresses the interactions of this new flexibility with the mandatory transition to MAGI.

On Dec. 27, CMS issued a set of FAQs addressing questions regarding ACA funding for the new adult group, coverage of former foster care children, and CHIP financing questions.

2014

In a Feb. 5, 2014 HHS blog post commemorating the five-year anniversary of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) – and in advance of the upcoming expiration on September 30, 2015 of the current Children’s Health Insurance Program (CHIP) legislative authorization – HHS highlighted new data that shows how the federal CHIPRA investment has translated to fewer uninsured low-income children under Medicaid and CHIP, while streamlining the programs generally through options to provide 12-months continuous eligibility (CE) and Express Lane Eligibility (ELE).

On May 1, HHS announced updated ACA enrollment data as of March 31, as well as others obtaining special enrollment periods through April 19. According to an updated Medicaid and CHIP enrollment report released in tandem with the broader Marketplace-focused update, 4.8M additional individuals enrolled in Medicaid and CHIP compared to before October 2013 (reflecting those in the newly and existing eligible groups). CMS also notes that “another approximately 1 million individuals gained coverage through an early expansion of Medicaid to low-income adults in seven states before January 1, 2014.” An agency fact sheet is posted here on the Medicaid and CHIP data, providing additional context. State-level tables highlighting Marketplace enrollment-related information are available here.

On a related note, on May 12, CMS issued a fact sheet highlighting the availability of new resources under its Connecting Kids to Coverage National Campaign to remind parents and other stakeholders of the opportunity to enroll eligible children, year round, in Medicaid and CHIP. A full listing of these resources – which include free print materials, Public Service Announcements, and social media-related ideas – are available here.

On June 4, CMS posted updated Medicaid and CHIP enrollment data for the month of April 2014. As of the latest data, enrollment under the programs continues to grow, with roughly six million more Medicaid and CHIP enrollees as compared to the period immediately preceding the initial open enrollment period under the ACA.

On July 1, CMS issued fact sheets to assist consumers in understanding their coverage options under Medicaid and CHIP. On July 11, HHS announced in a new Medicaid Moving Forward report (additional details here) that, as of last May, enrollment under Medicaid and CHIP grew by roughly 6.7 million individuals – or roughly 11.4% compared to the July-September 2013 baseline period.

On Aug. 8, CMS released monthly data on Medicaid and CHIP enrollment for June 2014. Data indicate Medicaid/CHIP enrollment is up by 7.2 million, compared to July-September 2013 (the pre-Marketplace open enrollment baseline period) in 48 states reporting both data points (excluding CT, ME, ND).

On a related note, on Aug. 27, HRSA’s Office of Rural Health Policy (ORHP) announced the availability of (non-competitive) expansion supplemental funds to support existing Small Health Care Provider Quality Improvement program grantees. Under this program, funds will be used by grantees to, among other things, “increase the number of uninsured individuals enrolled into the Health Insurance Marketplaces or other available sources of insurance, such as Medicaid and the Children’s Health Insurance Program.”

Key updates in September 2014 include:

• On Sept. 3, CMS issued a press release highlighting new data published by the agency in Health Affairs highlighting the decline in the projected number of uninsured – from 45 million in 2012 to 23 million in 2023 – due to the ACA coverage expansions.
• On a related note, on Sept. 16, CMS issued an informational bulletin on the “timeframes and requirements for amending Medicaid Alternative Benefit Plans (ABPs).” The guidance addresses situations in which “states are in full or partial alignment between the ABP benefit package and the state’s approved Medicaid state plan package for other categorically or medically needy eligible” while relaying updates about “expectations for public and tribal notification [and] the system to use for state plan amendment (SPA) submissions.”
• On Sept. 22, CMS reported that over 67 million individuals were enrolled in Medicaid and CHIP at the end of July 2014 (including new and existing eligible individuals in expansion and non-expansion states).

In its Oct. monthly update, CMS announced (detailed enrollment report) that approximately “8.7 million additional Americans now have coverage through Medicaid and CHIP” since the beginning of open enrollment in August of last year. Medicaid has more than 67.9 million enrollees as of August 2014. The new numbers demonstrate roughly a 15 percent increase over the average monthly enrollment for July through September 2013.

At its Oct. 30-31 meeting, MACPAC discussed the future of CHIP relative to the program’s upcoming authorization; details here. In late Nov. 2014, CMS released the FY 16 Medicaid FMAPs, as well as the new ACA-enhanced FMAPs (eFMAPs) for CHIP pursuant to this provision.  The state-specific percentages, delineated at Table 1 of the document, take effect on Oct. 1, 2015. Also, on a related note, on Dec. 3, 2014, the House Energy & Commerce convened a hearing on the future of CHIP in light of the program’s upcoming reauthorization.

On Nov. 19, HHS announced that Medicaid and CHIP enrollment increased by roughly 9.1 million individuals. A detailed monthly enrollment report is available here.

On a related note, on Dec. 9, in response to a Congressional request to assess the adequacy of access to care for Medicaid managed care enrollees, the OIG released a report (full report here; summary here) titled, “Access to Care: Provider Availability in Medicaid Managed Care.” The report focuses on the availability of providers for enrollees and specifically examines whether providers accepted new patients, as well as patient wait times for an appointment. In its report, the OIG recommended that CMS work with states to address: timely access to providers, accuracy of plan information, network adequacy in light of enrollee needs, and plan compliance to existing state standards.

On Dec. 18, CMS released updated Medicaid and CHIP enrollment figures (detailed data; blog post) for the month of Oct. 2014. According to the latest figures, an estimated 9.7 million additional individuals enrolled in Medicaid and CHIP during the month of Oct. – a 17% leap from the Jul.-Sept. 2014 monthly enrollment baseline period prior to Marketplace open enrollment. State-specific monthly enrollment data begins on p. 9 of the enrollment report. Additionally, CMS noted that, as of Oct. 2014, 26 states plus DC opted to expand Medicaid pursuant to the ACA – and, in Jan. 2015, the addition of Pennsylvania will make 27 states (plus DC). HHS also points to the administration’s recent release of broader data on increasing coverage trends, which “show that the drop in the nation’s uninsured rate so far this year is the largest over any period since the early 1970s.”

2015

On a related note, on Jan. 23, 2015, CMS issued state-reported (unduplicated) Medicaid enrollment figures – data, available here, that states began reporting via the Medicaid Budget and Expenditure System (MBES) beginning on Jan. 1, 2014. The quarterly enrollment figures – spanning the Jan.-Mar. 2014 period – “identif[y] the total number of Medicaid enrollees and, for states that have expanded Medicaid, provides specific counts for the number of individuals enrolled in the new adult eligibility group, also referred to as the ‘VIII Group.’” CMS notes further that the report “include[s] state-by-state data for this population as well as a count of individuals whom the state has determined are newly eligible for Medicaid.” CMS plans to “post the enrollment data for subsequent quarters in the upcoming months.” For additional details, see here.

Of note, on Feb. 23, CMS released updated monthly Medicaid and CHIP enrollment figures (detailed data; and blog post) for the month of December 2014. According to the latest figures, nearly 10.8 million additional individuals enrolled in Medicaid and CHIP during the month of December 2014 – an 18.6% leap from the July-September 2013 pre-Marketplace open enrollment timeframe. Nov. 2014 monthly Medicaid and CHIP enrollment figures were also made available earlier in the month (detailed data; blog post). Also in late Feb., CMS issued an extension of an existing information collection pertaining to the agency’s assessment of Medicaid eligibility changes under the ACA.

On Mar. 16, ASPE released an analysis estimating that 16.4 million uninsured individuals have gained health insurance as a result of ACA coverage provisions since 2010. The report also examines coverage gains among ethnic and minority populations and among young adults. Technical notes on ASPE’s analysis are available here.

On Mar. 20, HHS announced that Medicaid and CHIP enrollment increased by about 11.2 million as of Jan. 2015, or roughly 19% since the Exchanges opened. See also: report and fact sheet.

On Mar. 23, ASPE released two fact sheets highlighting the economic impacts of Medicaid expansion and uncompensated care since the ACA’s passage; see here and here, respectively.

On Mar. 27, GAO released a study (highlights) comparing coverage and cost-sharing among selected CHIP plans and Marketplace QHPs. The five-state study was conducted in Colorado, Illinois, Kansas, New York, and Utah.

On Mar. 30, GAO released a report contemplating the effect of CHIP on children’s health coverage and access, while outlining key issues for the Congress to consider as part of deliberations pertaining to an extension of federal CHIP funding.

On a related note, on Apr. 6, CMS issued a proposed rule extending the application of certain provisions of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) to coverage offered by Medicaid managed care organizations (MCOs), Medicaid Alternative Benefit Plans (ABPs), and CHIP. A press release on the proposed rule is available here and a fact sheet here. Comments on the proposed rule are due by Jun. 9.

On Apr. 16, the Medicare Access and CHIP Reauthorization Act of 2015 was signed into law (P.L. 114-10), which included at Title III several provisions that would extend CHIP for an additional two years (through FY 2017) at the 23% enhanced match for states pursuant to the ACA.

2018

In early February, Congress passed a bipartisan budget deal that extends government funding until Mar. 23, 2018 and raises budget caps for two years, allowing the omnibus appropriations process to proceed. Among other things, the law provides four additional years of CHIP funding. Combined with a six-year extension enacted through the most recent Continuing Resolution (CR), this means the CHIP program will be extended for a full decade, through FY 2027 (CBO: -$260m/10y).