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Reconciling House and Senate Health Reform Proposals: Eligibility, Enrollment, and Retention

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Document date: January 13, 2010
Released online: January 13, 2010


For health reform legislation to maximize coverage among low-income, uninsured Americans, the administrative details for subsidies need to make enrollment and retention simple, seamless, and as automatic as possible for consumers.

Neither the House nor the Senate health reform bill extends to Medicaid the streamlined procedures that apply to other subsidies. And with multiple subsidy systems operating under reform, consumers could easily fail to receive coverage for which they qualify.

To avoid such difficulties, lawmakers could establish, for all subsidy systems, a single, streamlined system for eligibility determination, enrollment, and retention that minimizes the need for consumers to complete paperwork.

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If policymakers want health reform legislation to maximize health coverage among low-income, uninsured Americans who qualify for help, eligibility rules for all subsidies—Medicaid, the Children's Health Insurance Program (CHIP), and premium and cost-sharing assistance in the exchange—need to make enrollment and retention simple, seamless, and as automatic as possible for consumers.

The eligibility rules and procedures contained in the Patient Protection and Affordable Care Act, passed by the Senate (Senate bill), and the Affordable Health Care for America Act, passed by the House (House bill), include many promising elements. However, neither bill extends to Medicaid the streamlined enrollment procedures that will help consumers receive subsidies in the exchange. With Medicaid accounting for 41 percent of the coverage expansion forecast by the Congressional Budget Office (CBO), a failure of Medicaid to achieve its goals could undermine the overall effectiveness of reform. And with multiple subsidy systems operating under either version of the legislation, consumers could easily fall between the cracks and fail to receive coverage.

To avoid such difficulties, this analysis suggests that health coverage among uninsured Americans who qualify for subsidies could be maximized through a policy that includes the following components:

  • The streamlining provisions contained in Section 1413 of the Senate bill, which require a single application form and eligibility system for all subsidies under reform (Medicaid, CHIP, and subsidies in the exchange) and which take other steps to base eligibility on government data whenever possible, thereby reducing the need for consumers to complete forms before receiving or retaining coverage;
  • The corrections to that section contained in Senate Amendment 3167, which apply to Medicaid the same streamlined procedures for eligibility and enrollment that are planned for the exchange; and
  • A compromise between annual eligibility periods in the Senate bill and "real time" eligibility updates in the House bill that establishes annual subsidy eligibility, as a general rule, while making exceptions for essential mid-year adjustments.

(End of excerpt. The entire report is available in PDF format.)

Topics/Tags: | Economy/Taxes | Health/Healthcare

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