362 Holding Health Insurance Marketplaces Accountable 2015
Furthermore, several states are actually seeking to shift populations currently covered by Medicaid to Marketplace-based coverage with subsidies.
Some states have narrowed Medicaid eligibility by lowering income caps in
order to shift adults currently covered by Medicaid to the Marketplaces.195
The effect of these actions is to eliminate Medicaid coverage as subsidized
private insurance coverage becomes available through the Marketplaces.
Another approach to utilizing Marketplaces to cover Medicaid beneficiaries
is called “premium assistance.”196 Under this approach, individuals remain
Medicaid beneficiaries but, instead of receiving coverage from the state,
they receive financial assistance to purchase private insurance on the Mar-
ketplaces.197 At least two states, Arkansas and Iowa, have obtained a waiver
from HHS allowing the state to cover the newly eligible Medicaid expansion population, through premium assistance.198 It is clear that throughout
the country the Marketplaces, in various ways, are playing an increasingly
important role in the lives of Medicaid beneficiaries.
A. HHS Regulations Seek to Extend Medicaid Due Process Protections to
Marketplace Applicants and Beneficiaries
Given the significant role that the Marketplaces have in making Medicaid eligibility decisions and in administering the tax-credits, HHS issued
regulations announcing an explicit policy choice to streamline the Medicaid
and Marketplace applications.199 This “no wrong door” policy is intended to
“ensure that no matter where applicants submit the single, streamlined application during the initial open enrollment period, they will receive an eligibility determination for all insurance affordability programs and be able
to enroll in appropriate coverage for 2014, if eligible, without delay.”200
195. See, e.g., DASH ET AL., supra note 189, at 20 (“New York will fully subsidize premiums for parents with incomes up to 150 percent of the federal poverty level and who are
currently covered by the state’s Medicaid program but who will transition to exchange coverage in 2014.”).
196. KAISER FAMILY FOUND., MEDICAID EXPANSION THROUGH PREMIUM ASSISTANCE:
ARKANSAS, IOWA, AND PENNSYLVANIA’S PROPOSALSCOMPARED 1 (2013) [hereinafter
PREMIUM ASSISTANCE], available at http://kaiserfamilyfoundation.files.wordpress.
198. Sarah Kliff, The Feds Sign off on Expanding Medicaid to 100,000 Iowans, WASH.
POST, Dec. 10, 2013, available at http://www.washingtonpost.com/blogs/wonkblog
/wp/2013/12/10/the-feds-sign-off-on-expanding-medicaid-to-72000-iowans/; see generally
PREMIUM ASSISTANCE, supra note 196, at 1 (detailing the proposals of Arkansas and Iowa).
199. See 45 C.F.R. § 155.405 (West, WestlawNext through Nov. 6, 2014; 79 FR 66265)
(“The Exchange must use a single streamlined application to determine eligibility and to collect information necessary for: (1) Enrollment in a QHP; (2) Advance payments of the premium tax credit; (3) Cost-sharing reductions; and (4) Medicaid, CHIP, or the BHP, where
200. Medicaid, Children’s Health Insurance Programs, and Exchanges, 78 Fed. Reg.