Warner, Kaine & Colleagues Urge Biden Administration to Help Streamline Health Insurance Enrollment for Low-Income Families

WASHINGTON, D.C. – U.S. Senators Mark R. Warner and Tim Kaine joined Senator Chris Van Hollen (D-MD) and 13 of their Senate colleagues in urging the Biden Administration to help streamline health insurance enrollment for low-income families. In their letter to U.S. Health and Human Services Secretary (HHS) Xavier Becerra and Centers for Medicare and Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure, the senators urged the Administration to support state-level “Easy Enrollment” initiatives, which make it easier for uninsured, low-income families to sign up for health insurance by allowing them to sign up when filing their state income tax returns. Nearly 30 million Americans do not have health insurance and, as of this year, about 18 million who are eligible for programs like Medicaid, the Children’s Health Insurance Program (CHIP), and Advanced Premium Tax Credits still aren’t covered. State-based Easy Enrollment programs aim to close this gap. The senators called on HHS and CMS to address administrative barriers that reduce the efficiency of states’ Easy Enrollment programs, in order to make it easier for low-income families to access health care.

In 2020, the Virginia General Assembly passed legislation establishing an Easy Enrollment program. The first phase of Virginia’s Easy Enrollment program started this year and checks for Medicaid and CHIP eligibility.

“Easy Enrollment efforts ultimately aim to let uninsured tax filers request automatic enrollment in Medicaid, CHIP, or zero-premium Marketplace coverage, but these initiatives are facing unnecessary bureaucratic obstacles. To reach as many eligible uninsured as possible, these states seek to limit the need for people who have already filed their tax returns to complete further paperwork before obtaining health care coverage,” they wrote.

To help states streamline their Easy Enrollment initiatives, the senators urge the Administration to allow states to:

• Verify filers’ financial eligibility for programs like Medicaid or the Children’s Health Insurance Program (CHIP).
• Confirm their citizenship status using existing electronic records.
• Waive tax reconciliation penalties for consumers who choose to automatically enroll in zero-premium Marketplace plans after they have enrolled in health care coverage.

The senators note, “With these three flexibilities, States could strengthen Easy Enrollment programs so that numerous uninsured people who are already known to be U.S. citizens could choose to be enrolled automatically into Medicaid, CHIP, and Marketplace plans, based on qualifying income shown on their state income tax returns.”

“Given the large and growing number of states pursuing Easy Enrollment initiatives, we recommend that CMS develop one or more templates making it easy for states to obtain federal approvals needed to maximize coverage gains from this promising approach. In the meantime, we urge the Administration to work proactively with states and to quickly approve state proposals to take the above steps. Easy Enrollment requires coordinating policy and operations between state health and tax agencies, so planning for 2024 Easy Enrollment has already begun. Clear and early guidance showing federal support for automating enrollment, as outlined in this letter, would give our states and others the confidence to innovate boldly and effectively in closing America’s large, persistent, and inequitable enrollment gap,” the senators concluded.

Senators Warner, Kaine, and Van Hollen were joined in sending this letter by Senators Martin Heinrich (D-NM), Ben Ray Luján (D-NM), Angus King (I-ME), Cory Booker (D-NJ), Ben Cardin (D-MD), Bob Casey (D-PA), Elizabeth Warren (D-MA), Michael Bennet (D-CO), Alex Padilla (D-CA), John Hickenlooper (D-CO), John Fetterman (D-PA), Bob Menendez (D-NJ), and Ed Markey (D-MA).

The senators’ full letter is available here and below.

Dear Secretary Becerra and Administrator Brooks-LaSure:

We are writing to urge the Biden-Harris Administration to strengthen its efforts to support state initiatives to automate the enrollment of eligible, uninsured families into health programs for which they qualify.

Such initiatives address a serious problem: America’s enrollment gap. Roughly two-thirds of our country’s uninsured residents – more than 18 million people -- qualify for but are not enrolled in Medicaid, the Children’s Health Insurance Program (CHIP), or low-cost Marketplace plans bought with advance premium tax credits (APTCs). Thanks to the Inflation Reduction Act, most people in the enrollment gap qualify for zero-premium insurance but are not enrolled, often because of administrative barriers or because they do not know about available health programs. People of color and workers without college degrees make up a disproportionate share of uninsured families caught in the enrollment gap.

To close that gap, ten states that, together, include one-third of America’s Medicaid-eligible uninsured population—California, Colorado, Illinois, Maine, Maryland, Massachusetts, New Jersey, New Mexico, Pennsylvania, and Virginia—have enacted “Easy Enrollment” programs that let families use state income tax returns to jumpstart health care enrollment. Uninsured tax filers can check a box asking to have their return information forwarded to state health agencies to see if their families qualify for free or low-cost insurance. Easy Enrollment efforts ultimately aim to let uninsured tax filers request automatic enrollment in Medicaid, CHIP, or zero-premium Marketplace coverage, but these initiatives are facing unnecessary bureaucratic obstacles. To reach as many eligible uninsured as possible, these states seek to limit the need for people who have already filed their tax returns to complete further paperwork before obtaining health care coverage.

President Biden signed an Executive Order on his first day in office calling on federal agencies to overcome “potential barriers that underserved communities and individuals may face to enrollment.” In its effort to implement this executive order, the Office of Management and Budget (OMB) highlighted the importance of lightening the administrative burdens families face. OMB also reported that “administrative burdens…do not fall equally on all…, leading to disproportionate underutilization of critical services…often by the people and communities who need them the most.” The President thus signed an additional Executive Order calling on federal agencies “to the maximum extent permitted by law… to ensure eligible individuals are automatically enrolled in…critical benefit programs.”

By leveraging income-tax filing to streamline and automate enrollment, Easy Enrollment programs could reach most of America’s uninsured families. In 2021, 94% of uninsured adults filed federal income tax returns, including 90% of uninsured adults with incomes below 150% of the federal poverty level, 93% of uninsured people of color, and 93% of uninsured adults who never graduated high school.

The Administration has compiled a remarkable track record bringing health insurance to an ever-widening circle of families in America. To build on that record, we urge the Centers for Medicare & Medicaid Services (CMS) and the Treasury Department to issue guidance allowing three flexibilities for state Easy Enrollment programs, all of which are well within current statutory and regulatory authority:

• States should be allowed to verify citizenship through electronic records, without requiring families to submit redundant paperwork. Applicants for health programs must complete forms attesting, under penalty of perjury, to U.S. citizenship or satisfactory immigration status. To facilitate auto-enrollment efforts, CMS should waive that requirement under Social Security Act §1115 and Affordable Care Act §1411(c)(4)(B) when a state has already confirmed that an uninsured applicant is a U.S. citizen, based on matches between identifying information on the tax return and federally approved sources of citizenship data.

• States should be allowed to base financial eligibility for Medicaid on state income tax records. Financial eligibility for Medicaid reflects current income. A state implementing the option for “Express Lane Eligibility,” or ELE, can qualify children as financially eligible based entirely on information from other income-based programs or the family’s state income tax return. CMS should make clear that it is willing to grant §1115 waivers permitting states to use ELE’s tax return option to establish financial eligibility, not just for children, but for adults as well.

• States should be allowed to have tax reconciliation penalties waived for consumers they automatically enroll into zero-premium Marketplace plans. Someone enrolled into a zero-premium plan may owe federal tax reconciliation payments if their annual income turns out to exceed expected levels. For states to reliably promise that zero-premium plans will truly cost enrollees nothing, CMS and the Treasury Department should make clear that ACA §1332 allows waivers of tax reconciliation for people the state auto-enrolls into such plans.

With these three flexibilities, States could strengthen Easy Enrollment programs so that numerous uninsured people who are already known to be U.S. citizens could choose to be enrolled automatically into Medicaid, CHIP, and Marketplace plans, based on qualifying income shown on their state income tax returns.

Given the large and growing number of states pursuing Easy Enrollment initiatives, we recommend that CMS develop one or more templates making it easy for states to obtain federal approvals needed to maximize coverage gains from this promising approach. In the meantime, we urge the Administration to work proactively with states and to quickly approve state proposals to take the above steps. Easy Enrollment requires coordinating policy and operations between state health and tax agencies, so planning for 2024 Easy Enrollment has already begun. Clear and early guidance showing federal support for automating enrollment, as outlined in this letter, would give our states and others the confidence to innovate boldly and effectively in closing America’s large, persistent, and inequitable enrollment gap.

Sincerely, 

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