Understanding State Medicaid Enrollment Numbers and What They Tell Us About the ACA Rollout

State Medicaid enrollment reports show that about 90,000 more Floridians were enrolled in Medicaid in February 2014 than in September 2013, five months earlier and just prior to the start of the open enrollment period for the Health Insurance Marketplace. While this represents an increase of 2.7%, which is somewhat smaller than expected, a number of factors contribute to this number:

1. Medicaid enrollment was increasing before open enrollment, but slowly. Medicaid enrollment increased dramatically during the recession, but now has almost completely leveled off during Florida’s sustained recovery. The small rate of enrollment increase prior to October 1 was likely more attributable to the fact that Florida’s population is aging and increasing than to any
other factor.

2. Different eligibility groups were affected differently by the new Affordable Care Act (ACR)-related changes (other than Medicaid expansion). Even without expansion, individuals who are currently eligible for Medicaid were affected by the new
ACA provisions in very different ways, depending on how they qualify for the program. Medicaid-eligible Floridians consist of three distinct groups:

a. Those who are unaffected by the ACA in any significant way. Floridians whose eligibility is based on the fact that they are disabled, elderly, or in the care of the state were essentially unaffected by the ACA, and that is reflected in stable enrollment numbers.

For instance, the number of SSI recipients (who automatically qualify for Medicaid) increased by only 0.5%. Furthermore, preschool age children enrollment was almost unchanged, decreasing by less than one percent (0.7%). Enrollment of the Medicare recipients who receive only financial help with premiums and copayments from Medicaid was also relatively stable.

b. Those who lost their former Medicaid eligibility, but almost certainly gained coverage elsewhere. Enrollment in a few categories actually decreased during the 5-month period. In particular, enrollment in the children and families portion of the Medically Needy program plummeted 30 percent. (Medically Needy recipients are those who are over the regular income limit for Medicaid, but meet all other eligibility requirements. They only qualify for short-term coverage for the portions of those months in which they have catastrophic medical expenses.) In this case, the reduction in the Medically Needy caseload is good news, because the coverage they had was so limited and because most of these recipients now qualify for full Medicaid or for coverage in the Marketplace.

c. Those who are newly eligible for Medicaid due to smaller ACA-related changes. Most importantly, ACA-related coverage gains were made in two categories. First, more than 32,000 additional parents were enrolled in the primary children- and family-related eligibility categories. While not a huge numerical increase, the amount is relatively significant among this subgroup. The number
likely includes some who became eligible under the new “MAGI” income counting and calculation rules 2 (again, these do not only apply to the elderly and disabled), especially because the so-called “asset test” was eliminated and because some income sources like child support are no longer counted as income. (By comparison, fewer than 3,000 more children were added in these categories, because children were far more likely to have been eligible already.)

Second, school-aged children just above the poverty line have benefitted the most from the ACA, as the Medicaid income limit for this group was increased from 100 to 138 percent of the federal poverty level. (This group’s eligibility was not affected by the Supreme Court decision that made Medicaid expansion optional for states.) In fact, more than 51,000 children were enrolled in this new eligibility category since January. (Note: March enrollment numbers have been released after this document was completed, and 84,000 such children now have Medicaid coverage.)

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Although this income group was already eligible for coverage through CHIP (specifically, the Florida Healthy Kids program), they were not enrolled. These children are enrolling now because, among other factors: 1) their parents are applying for coverage through the Marketplace, and 2) unlike with CHIP, their parents do not have to pay premiums in Medicaid. (Eventually, some children who are in Florida Healthy Kids now will be transferred to Medicaid, but that transition has not occurred yet.)

3. The current numbers are by no means the end of the story. Although the 90,000 enrollment increase is smaller than expected, this number will increase as the state works through a large backlog of applications sent from the federal Marketplace. In addition,
enrollment in Medicaid and CHIP are open year-round, and so new applications can be accepted in those programs.

On the other hand, the MAGI-based income system was set up to be neutral overall with respect to enrollment numbers. Some who were ineligible pre-MAGI are now eligible; others who were eligible pre-MAGI may lose it when their coverage is up for renewal (all renewals due in January, February and March were postponed).

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In general, Floridians will continue to see a moderate increase in the number of Floridians accessing Medicaid coverage, but not enough to make a significant dent, either in terms of a reduction in Florida’s uninsurance rate or an increase in the state Medicaid budget. The real need continues to be for the legislature to approve Medicaid expansion, a decision which would produce a net savings in state spending over the next decade, while providing access to coverage to more than a million uninsured Floridians.

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