Overlapping Eligibility and Enrollment: Human Services and Health Programs Under the Affordable Care Act. Assumptions regarding pre-ACA pathways


The simulation assumes that individuals age 19 and older would only have two pathways to Medicaid eligibility—having MAGI under 138 percent of poverty, or having mandatory coverage via SSI receipt.

However, children are modeled as eligible for Medicaid if they are eligible either under the ACA rules or through any prior pathway other than the Medically Needy pathway. This is an approximation of the “maintenance of effort” (MOE) requirements, but not a simulation of those requirements since it is not yet known exactly how states will convert their current pathways to use MAGI income. In other words, the simulation of MOE eligibility for children above 138 percent of poverty uses current (2010) measures of income, not the MAGI-equivalent measure that will actually be used under the ACA.

Note that when determining who among the population with income greater than 138 percent of poverty is covered by the child MOE requirement, we treated all persons under 19 who are eligible in 2010 as MOE-eligible under the ACA. This was done even if the 2010 pathway is an “adult” pathway (e.g. a pregnancy pathway, the 1931 parent pathway, and some waiver pathways). Also, persons over 138 percent of poverty who are age 19-20 may be eligible as Ribicoff children, or eligible though their state’s option percent-of-poverty coverage of children (even though they are classified as adults in the tables).

The Medically Needy pathway is assumed to no longer be needed since individuals previously covered through Medically Needy could generally be eligible under ACA rules without the need for spend-down, and since the ACA is assumed to result in universal coverage where no citizen or legal resident has high medical bills.45

Procedurally, the different treatment of the pre-ACA pathways for adults vs. children was modeled by performing two TRIM3 Medicaid simulations. The primary simulation simulated eligibility under the ACA (including MOE for children) but turned off all pathways through which adults could become eligible except for the 138-percent-poverty and SSI receipt pathways. In a second simulation, all pathways were set to their 2010 levels. If a child was ineligible in the first simulation but eligible in this second simulation through any pathway other than Medically Needy, he or she was considered to be eligible under the ACA (via the ACA’s MOE requirement for children). In effect, this second simulation captures those children above 138 percent of poverty who would be eligible under the MOE requirement but only via a pathway that can also be used by adults (primarily the 1931 pathway, but also some state optional coverage of people with disabilities) – child-only pathways have the MOE requirement simulated in the primary simulation.

The results shown in Table 1 and the bullets that immediately precede Table 1 differ from other results in that these particular results are limited to Medicaid. They include neither eligibility for separate CHIP programs nor eligibility for HIM subsidies. To exclude from our Medicaid eligibility estimates children who will qualify for coverage under separate CHIP programs, we applied the FPL thresholds listed for children’s Medicaid coverage under both Title XIX and Title XXI programs as listed by the Kaiser Family Foundation’s statehealthfacts.org46 to reflect the findings of the Georgetown Center for Children and Families and the Kaiser Commission on Medicaid and the Uninsured concerning financial eligibility rules in effect in January 2013.47 Children with incomes above those thresholds, defined using each state’s pre-ACA income disregards and other income methodologies, were excluded from our estimates of Medicaid-eligible children.48 We then consulted statehealthfacts.org to determine that California is the only additional state that has passed legislation that, before 2014, will shift children above 133 percent FPL from a separate CHIP program into a Medicaid program funded through Title XXI.49 As a result, for California children, we assumed that, in 2014 and later years, children with incomes at or below the FPL threshold of the state’s previous separate CHIP program will qualify for Medicaid. Children with incomes above that threshold, determined using the state’s pre-ACA CHIP income disregards and other methodologies, were excluded from these estimates of Medicaid eligibility.

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