Advanced Premium Tax Credits​

• Advanced Premium Tax Credits, enacted through the Affordable Care Act, allowed consumers with household incomes between 100 percent and 400 percent of the Federal Poverty Limit (FPL) to lower their monthly health care plan premium costs when purchasing ACA Marketplace coverage. Starting in 2021, the American Rescue Plan Act temporarily enhanced subsidy amounts, and the Inflation Reduction Act extended the subsidy enhancements through 2025. The expiration of these enhanced subsidies in 2025 poses a threat to enrollment as 91 percent of total Marketplace enrollees receive APTCs as of February 2023. An Urban Institute study found that the lapse of APTCs would increase the number of uninsured Americans by 3.1 million. The Coalition supports the extension of enhanced APTCs beyond 2025.

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Automatic Enrollment

• Autoenrollment policies can bridge the persistent enrollment gap and promote equity and health for those needing care. The Coalition has developed an autoenrollment policy that supports the enrollment of eligible individuals and families, protects patient choice, and preserves program integrity. The Coalition’s legislative proposal would allow states to pilot efforts to automatically enroll eligible individuals in $0 premium coverage, which could include Medicaid/CHIP or Marketplace plans. See the Coalition’s automatic enrollment principles here.

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Medicaid Churn

• In the last pre-pandemic year with churn data (2018), 11.2 percent of full-benefit children and 12.1 percent of adults were disenrolled from Medicaid and then subsequently re-enrolled within one year. To reduce these unnecessary disenrollments among full-benefit children, Congress recently enacted a 12-month Continuous Eligibility (CE) mandate in the Consolidated Appropriations Act of 2023. Effective January 1, 2024, 12-month CE is now in place for all children enrolled in Medicaid and CHIP. The Enrollment Coalition is exploring opportunities to further reduce churn among vulnerable populations. New Commonwealth Fund data shows that if all states had adopted 12-month CE for Medicaid adults in 2024, an average of 451,000 more adults would be enrolled in any given month, a 1.3 percent increase. Furthermore, the CE policy would have reduced the number of number uninsured individuals in an average month by 267,000.

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1902(e)14 Waivers

• During the Medicaid continuous eligibility unwinding period following the end of the COVID-19 Public Health Emergency, states have been adopting Section 1902(e)14 waivers that provide Medicaid agencies with temporary flexibilities to facilitate redeterminations and reduce procedural terminations. These flexibilities are set to expire at the end of 2024. The Coalition is advocating CMS and Congress make permanent the existing flexibilities that have reduced the number of procedural terminations during the unwinding period.

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Transitions of Coverage

• According to the Medicaid and CHIP Payment and Access Commission (MACPAC), only about 3 percent of all adult and child beneficiaries who were disenrolled from Medicaid and CHIP enrolled in Exchange coverage within a year after disenrolling. Most individuals who moved from Medicaid to the exchange had a gap in coverage and these gaps were longer for racial and ethnic minorities. When individuals currently enrolled in Medicaid lose coverage, they are at risk for lacking care options which may contribute to adverse health outcomes. The Enrollment Coalition supports and advocates for policies that streamline coverage transitions and reduce barriers to enrollment.​​

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Exception to OMB Circular A-87

• We believe states and consumers would benefit from a time-limited exception to OMB’s cost allocation requirements, which would allow states to leverage investments in eligibility and enrollment systems across multiple programs. In 2011, HHS and USDA issued an exception (to OMB Circular A-87) to encourage states to leverage the technology investments for streamlined enrollment in the ACA to modernize eligibility and enrollment for other safety-net benefits. Reviving this time-limited tool would be an important step enabling the creation of data connections between state agencies, especially as they are preparing for Medicaid redeterminations after the end of the PHE. States could use a cost exception to:     

  • connect health programs to external sources of data that can verify eligibility without requiring individuals and families to complete repetitive paperwork;  

  • leverage federal technology investments that will be made to improve access to unemployment to also improve access to health and social services; and 

  • simultaneously enroll eligible individuals into health coverage as well as other programs for which they are eligible by improving data matching, establishing more robust referral mechanisms, streamlining business processes, and notifying program participants of their potential eligibility for other benefits.

• By promoting more integration of IT systems across health and social services programs through the A-87 exception, HHS can encourage states to reimagine how to deliver government services for the 21st century.