Marketplaces and Medicaid Enrollment: Highlights from The Commonwealth Fund's New Issue Brief

April 21, 2016

Last week The Commonwealth Fund published a new issue brief on the role of health insurance marketplaces in Medicaid enrollment. ITUP took a closer look, broke down some of the key takeaways, and outlined what’s true for California.


Under the ACA, states that have a state-based marketplace (SBM) must enable their marketplace to make final Medicaid eligibility determinations. But states that have a federally facilitated marketplace (FFM) – or at least use the FFM IT platform – can either have the FFM make final determinations or have the FFM simply assess and refer to the state Medicaid agency to make final determinations.

Rusty on health insurance marketplaces and all their acronyms? Here’s a quick refresher based on Kaiser Family Foundation’s definitions:

  • Federally-Facilitated Marketplace (FFM): HHS performs all marketplace functions. Consumers apply for and enroll in coverage through
  • State-Partnership Marketplace (Partnership): These states may administer in-person consumer assistance functions while HHS performs the remaining marketplace functions. Consumers apply for and enroll in coverage through Think of these as hybrids.
  • Federally-Supported State-Based Marketplace: These states are considered to have a state-based marketplace, and are responsible for performing all marketplace functions, except that the state relies on the FFM IT platform. Consumers apply for and enroll in coverage through Think of these as essentially SBMs, except for the IT part.
  • State-Based Marketplace (SBM): These states are responsible for performing all marketplace functions. Consumers apply for and enroll in coverage through marketplace websites established and maintained by the states. Here in the Golden State, Covered California is an SBM.

ITUP developed the table below using Kaiser Family Foundation’s review of marketplace models by state. The table is organized by Medicaid expansion status, and shows what type of marketplace each state uses, as well as how Medicaid eligibility is determined. (Note that SBMs do not rely on the FFM IT platform in any way and are required to enable Medicaid eligibility determinations as shown in the far right column.)

expansion vs nonexpansion 5


Highlights from The Commonwealth Fund’s Issue Brief

  • Most states that use the FFM or FFM IT platform (i.e., FFMs, Partnerships, or Federally Supported SBMs) choose to limit the FFM role to assessment and referral, instead of determination. As you will see in Commonwealth’s Figure 5 below, FFMs that determine eligibility tend to have higher Medicaid enrollment compared to those that only assess and refer to Medicaid agencies.
  • Among Medicaid expansion states, SBMs tend to have higher Medicaid enrollment growth, possibly because they must integrate Medicaid eligibility determination into the marketplace. (See Commonwealth Exhibit 4.)
  • Among expansion states, Federally Supported SBMs (NV, NM, OR) also had high Medicaid enrollment growth, suggesting that regardless of whether a state or federal IT enrollment platform is used, a state-based marketplace can establish better  communication and coordination between the state’s Medicaid program and the marketplace. (See Commonwealth Exhibit 4.)


  • Among expansion states that are either full FFMs or hybrid FFM Partnerships, those that determine eligibility have higher Medicaid enrollment rates. (See Commonwealth Exhibit 5.)



Enrollment in California’s SBM

California’s state-based exchange, Covered California, works with the state and counties to determine eligibility and facilitate enrollment for individuals eligible for Medi-Cal. Covered California is one single entry point – consumers can apply online and get a determination of whether they are eligible for exchange coverage and related federal assistance (tax credits and cost-sharing reductions) or eligible for Medi-Cal based on income. CalHEERS, a system jointly developed by Covered California and the state Medicaid agency, Department of Health Care Services, supports the calculations of eligibility through the exchange, and at other entry points, including county social service agencies. County social services agencies evaluate Medi-Cal eligibility for individuals with eligibility factors other than income, such as disabled and elderly persons, and are ultimately responsible for final verification of Medi-Cal eligibility.