Under current law, states must reassess (PDF) enrollees’ eligibility for Affordable Care Act (ACA) Medicaid expansion coverage every 12 months. As part of Congress’s reconciliation plans, the House of Representatives’ Committee on Energy and Commerce (PDF) has proposed bill text to increase the frequency of mandatory eligibility checks for expansion enrollees to every 6 months, beginning October 1, 2027. At the time of writing, the House Budget Committee subsequently advanced the bill, though negotiations continue.
More-frequent redeterminations would increase rates of Medicaid churn (PDF)—disenrollment followed by reenrollment in less than a year—which reduces enrollees’ access to care, adds to enrollees’ paperwork hassles, and increases administrative costs for state Medicaid agencies, health plans, and providers.
States can already disenroll adults who become ineligible between annual redeterminations, but most remain eligible throughout the year
Unlike children, Medicaid-enrolled adults in nearly every state are not entitled to 12 months of continuous enrollment. Beneficiaries are required to report to the state any changes in circumstances affecting their eligibility between annual redeterminations, and states must act on those reports. Many states also periodically check wage data and data from other public programs to verify that enrollees still qualify.
Nearly all Medicaid-enrolled adults remain eligible from one year to the next. Data are not available about month-to-month fluctuations in eligibility among ACA expansion enrollees. But data for all nonelderly Medicaid-enrolled adults from the Urban Institute’s Health Insurance Policy Simulation Model show that 87 percent of adults with Medicaid coverage still meet eligibility requirements a year after they enroll. This pattern holds true regardless of income at enrollment: 98 percent of those with no or very low incomes, 89 percent of those with incomes below the federal poverty level, and 79 percent of those with incomes above the federal poverty level remain eligible a year later.
Nonelderly adults enrolled in Medicaid because of low incomes already experience high rates of churn. Many Medicaid coverage losses are not caused by the person becoming ineligible. Instead, they are procedural disenrollments (i.e., disenrollment without being declared ineligible by the state, such as because the enrollee has not received redetermination information in the mail or has not responded to requests for information within the timeframe requested by the state).
Increasing the frequency of regular redeterminations, as the House proposal would do, would create more opportunities for missing mail, higher burdens of obtaining and submitting paperwork, and a greater chance of losing coverage despite remaining eligible.
Some people losing Medicaid may qualify for subsidized Marketplace coverage, but changes to Marketplace enrollment processes (PDF) advanced by congressional committees could make such transitions harder to navigate. Those who try to regain lost Medicaid coverage or seek other coverage would also find less assistance available to navigate enrollment and reenrollment processes because of recent federal funding cuts for health insurance navigators.
More-frequent redeterminations would harm enrollees and burden states, health plans, and providers
Evidence indicates that more-frequent redeterminations are associated with higher rates of churn. This is reinforced by recent evidence that the inverse is true, as the pandemic-related Medicaid continuous coverage requirement temporarily eliminated churn and was associated with reductions in uninsurance.
Coverage lapses—even if they are short—can affect health care access and health outcomes. People with coverage gaps experience reduced continuity of care and worse health, face delays in care, and end up with greater risks of emergency department visits and hospitalizations after they are reenrolled.
People whose health care would be disrupted are not the only ones who would be unnecessarily burdened by more-frequent redeterminations. States’ bureaucratic responsibilities would grow, as they would have to double the number of redeterminations they conduct for expansion enrollees each year. Given state variation in the use of automatic data matching during redeterminations (and thus the number of redeterminations caseworkers conduct manually), the increase in workload could vary widely.
Administrative costs of disenrolling and then reenrolling people who later return to the program would also grow. Moreover, since the federal government reimburses states for half of the administrative costs incurred for running their Medicaid programs and 90 percent (PDF) for changes to eligibility and enrollment systems, many of these additional costs would be paid by the federal government. New health needs that would arise and worsen during coverage lapses could also end up being more costly (PDF) in the long run.
Health plans would need to handle more paperwork, and efforts to hold health plans accountable for their quality of care would be hampered by fewer people being continuously enrolled. Providers would also have to verify coverage more often.
With more-frequent redeterminations, millions of expansion enrollees, including those in key subgroups like parents and women of reproductive age, would be at greater risk of coverage loss and churn, diminishing Medicaid expansion’s benefits for enrollees, providers, and state budgets.
Let’s build a future where everyone, everywhere has the opportunity and power to thrive
Urban is more determined than ever to partner with changemakers to unlock opportunities that give people across the country a fair shot at reaching their fullest potential. Invest in Urban to power this type of work.
