Step One: Get Covered. Step Two: Stay Covered.

By Sophie Stern

Here at Enroll America, we have focused—relentlessly—on making sure consumers have the information and the help they need to get covered. But we don’t just want consumers to get covered; we want them to stay covered, too. Research shows that staying covered improves health outcomes and reduces state administrative costs. But there’s more to staying covered than keeping track of that health insurance card.

So why would an otherwise eligible consumer be at risk for losing their coverage? People’s lives can be complicated, and many individuals and families will encounter “qualifying life events” throughout the year, such as losing a job, getting a promotion, or a experiencing a change in family size, that could cause their eligibility for coverage programs to change.

An Urban Institute study found that nearly one in three individuals eligible for Medicaid or financial help through the marketplaces may change coverage from one year to the next (also see a new infographic from the Center for Healthcare Strategies). This movement may result in interruptions in health care—certain services or providers may no longer be covered when transitioning from one coverage program to another— or the loss of coverage completely, even when the individual remains eligible for some form of coverage or financial assistance.

While there are certain things consumers need to do to maintain their coverage (see our recent issue brief), there are also steps stakeholders can take now to help consumers navigate changes in eligibility and avoid gaps in coverage:

  • Enrollment assisters and other stakeholders working with consumers can equip individuals who are on the cusp of eligibility for Medicaid or marketplace coverage—and thus more likely to be at risk for mid-year eligibility changes—with the necessary resources, such as materials on how to report changes to the marketplace or Medicaid throughout the year and information on special enrollment periods, to help them navigate potential movement between health coverage programs.
  • Providers can work with health issuers and the marketplace to guarantee that their organization is included in the provider network for both Medicaid and marketplace health plans, so that when consumers move from one form of coverage to another, they can keep their provider.
  • Health issuers can offer similar products through Medicaid and the marketplace so that benefits and provider networks are aligned for consumers as they move between health coverage programs.
  • Advocates can push for state policies that promote ongoing coverage, such as 12-month continuous eligibility. This option allows individuals eligible for Medicaid or the Children’s Health Insurance Program (CHIP) to remain enrolled regardless of qualifying life events that occur throughout the year, such as an increase in household income that would otherwise make them ineligible for coverage. In the past, this option was only available to kids enrolled in Medicaid or CHIP; however, states now have the option to expand this continuous eligibility policy to Medicaid-eligible adults.

And some states and health issuers have already begun to take action:

  • Nevada is working with Medicaid managed care companies to ensure that they are offering similar plans through Nevada Health Link.
  • Washington State is encouraging health issuers participating in the Washington Health Benefit Exchange to offer identical plans to Medicaid enrollees.
  • Delaware is requiring issuers offering coverage through ChooseHealth Delaware to cover certain Medicaid benefits for a set period of time for consumers transitioning from Medicaid if the benefits are not already covered. This policy is aimed at helping these individuals avoid interruptions in care for ongoing medical treatment.
  • In 32 states and the District of Columbia, individuals whose eligibility fluctuates between Medicaid and the marketplace will have the option to keep their coverage if enrolled in a health plan that is offered in both markets.
  • There is a significant overlap of issuers offering both marketplace and Medicaid plans in certain states: 100 percent overlap in Hawaii, 80 percent overlap in Minnesota and New Mexico, 77 percent overlap in Wisconsin, 75 percent overlap in Indiana and Pennsylvania, and a 73 percent overlap in Texas.

While stakeholders across the country are working to help consumers avoid interruptions in health care or coverage, there is still a lot of work to be done. We will be closely monitoring this issue, so stay tuned for more information in the coming weeks and months.

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