Research has consistently shown that health insurance coverage surveys underestimate the number of people enrolled in Medicaid and the extent of this “Medicaid undercount” varies greatly across surveys and states. Among these surveys that measure health insurance coverage, the American Community Survey (ACS) has been shown to have a smaller Medicaid undercount, which is one of the reasons that SHADAC typically relies on this survey to track state-level health insurance coverage.

The “Medicaid undercount” refers to the discrepancies that exist between survey estimates of enrollment in Medicaid and the number of enrollees that are actually reported in state and national administrative data.

With 2021 ACS data being given its normal, official release by the Census Bureau following COVID-19 pandemic-related disruptions, SHADAC is again using the ACS as our primary data source for monitoring state-level health insurance coverage. However, as we and other data users have begun analyzing the 2021 ACS data, it has become apparent that the extent of the ACS’ Medicaid undercount was larger in 2021 than in prior years.

Given the evidence of a greater Medicaid undercount in the 2021 ACS, it is important for users to understand the undercount in the ACS when interpreting coverage estimates. In this brief, we review the research regarding the Medicaid undercount in the ACS, provide estimates of how the undercount varies across states, discuss the impact of assigning single coverage for those with multiple sources on the Medicaid undercount in the ACS, and provide guidance on how to understand health insurance coverage data in the 2021 ACS.

Related SHADAC Resources

Medicaid Undercount Doubles, Likely Tied to Enrollee Misreporting of Coverage (Issue Brief)
Understanding the Undercount of Medicaid Enrollees in the 2020 CPS (SHADAC Blog)
Medicaid Expansion and the Medicaid Undercount in the ACS (Research Article)
Medicaid Undercount Project (Collaborative Study)

Updated January 2023.

An overview of the states with 1332 reinsurance waivers approved, withdrawn, or pending:

For additional in-depth state-level detail, click on the table below, or, scroll further for a timeline of 1332 Waiver reinsurance proposal developments.

TIMELINE OF 1332 WAIVER REINSURANCE PROPOSAL DEVELOPMENTS

12-9-2022 CMS approves Washington’s 1332 waiver application. CMS approved Washington state’s 1332 waiver application for the expansion of marketplace enrollment eligibility as well as state-funded premium subsidies for all Washington residents regardless of immigration status.

12-1-2022 CMS approves Wisconsin’s 1332 waiver extension application. CMS approved Wisconsin’s 1332 waiver extension application which continues the operation of their reinsurance program “Wisconsin Healthcare Stability Plan.” An actuarial analysis found that the program reduced premiums by 13.2% on average since inception.

9-2-2022 CMS determines Wisconsin’s 1332 waiver extension application complete.  CMS determined Wisconsin’s 1332 waiver extension application was complete, beginning a 180-day period before the agency must either approve or deny the waiver extension requestion.

8-16-2022 CMS approves Idaho’s 1332 waiver application.  CMS approved Idaho’s 1332 waiver application for the creation of a high-risk reinsurance pool for individuals with certain conditions

7-17-2022 CMS approves Oregon’s 1332 waiver extension application. CMS approved Oregon’s 1332 waiver extension application to extend the “Oregon Reinsurance Program” from 2023 through 2027.

7-1-2022 Oregon submits 1332 waiver extension application. Oregon submits a five-year extension of their 1332 waiver establishing the “Oregon Reinsurance Program.” This waiver seeks approximately $54 million in funding per year through 2027.

6-15-2022 CMS determines Washington’s 1332 waiver complete. CMS determined Washington’s 1332 waiver complete, beginning a 180-day period before the agency must either approve or deny the waiver request.

6-3-2022 CMS determines Idaho’s 1332 waiver complete.  CMS determined Idaho’s 1332 waiver application was complete, beginning a 180-day period before the agency must either approve or deny the waiver request.

5-12-2022 Washington submits 1332 waiver application to CMS. Washington state submits their 1332 waiver application to CMS. If approved, this waiver will expand access to qualified health plans for Washington residents who were previously ineligible due to immigration status.

5-5-2022 Idaho submits 1332 waiver application to CMS. Idaho submits their 1332 reinsurance waiver application to CMS. This reinsurance waiver looks to reduce premiums by creating a high-risk reinsurance pool for individuals with certain medical conditions such as chronic or rare diseases.

5-5-2022 CMS determines Oregon’s 1332 waiver complete. CMS determined Oregon’s 1332 waiver application as complete, beginning a 180-day period before the agency must either approve or deny the waiver request.

4-29-2022 CMS suspends Georgia’s 1332 waiver. CMS suspended Georgia’s 1332 waiver, known as the “Georgia Access Model,” due to an insufficient corrective action plan requested the department. The application looked to waive the operation of a health insurance exchange in favor of private sector outreach programs.

4-1-2022 Idaho releases draft of 1332 waiver application. Idaho released a draft 1332 waiver application that would waive the requirement to consider all exchange market members a single risk pool to create the “Idaho Individual High Risk Reinsurance Pool.” This reinsurance risk pool covers individuals with certain medical conditions and would be funded through a one-time deposit of $25 million as well as an annual premium tax allotment. The waiver anticipates at least a 7% reduction in premiums.

3-31-2022 Washington releases draft of 1332 application. Washington state released a draft 1332 waiver application that looks to expand access of Qualified Health Plans and Qualified Dental Plans on their state-based marketplace to all Washington residents, regardless of immigration status starting in 2024. This waiver would also expand the state-funded portion of the premium tax credit to those newly eligible for plan enrollment up to 250% FPL.

8-13-2021 CMS approves Colorado’s 1332 waiver extension application. CMS approved Colorado’s 1332 waiver extension application for continued pass-through funding of its state-based marketplace program. The reinsurance program features a reinsurance corridor of $30,000000 - $400,000. The program uses geographically based coinsurance tiers, which are planned to go from a range of 45%-85% in 2020 down to 43%-73% in 2022. Colorado is targeting a 19.2% reduction in premiums in the first two years of the five-year program extension.

6-3-2021 CMS requests updated analysis of Georgia’s previously approved 1332 waiver. CMS requests an updated actuarial analysis of Georgia’s previously approved 1332 waiver in light of Executive Order 13985, instructing the department to assess systematic barriers to people of color or underserved groups, as well as the American Rescue Plan Act of 2021.

6-01-2021 Wisconsin submits letter of intent for 1332 waiver extension to CMS. Wisconsin submitted a letter of intent to apply for a five-year extension of its existing 1332 waiver without any significant changes.

5-28-2021 CMS determines Colorado’s 1332 waiver extension complete. CMS determined Colorado’s 1332 waiver extension application was complete, beginning a 30-day Federal public notice and comment process period and 90-day period before the agency must approve or deny the waiver extension.

4-30-2021 Colorado submits 1332 waiver extension application to CMS. Colorado submitted a 1332 waiver extension application for approval and continued pass-through funding.  Colorado’s program aims to maintain the reinsurance corridor of $30,000 - $400,000. The program uses geographically based coinsurance tiers, which are planned to go from a range of 45%-85% in 2020 down to 43%-73% in 2022. Colorado is targeting a 19.2% reduction in premiums in the first two years of the five-year program extension.

3-25-2021 Alaska submits letter of intent to apply for 1332 waiver extension to CMS. Alaska submitted a letter of intent to apply for a five-year extension of its existing 1332 waiver without any substantive changes to the existing program.

3-02-2021 Oregon submits letter of intent to apply for 1332 waiver extension to CMS. Oregon submitted a letter of intent to apply for a five-year extension of its existing 1332 waiver without any significant changes.

11-10-2020 Colorado submits letter of intent to apply for 1332 waiver extension to CMS. Colorado submitted a letter of intent to apply for a five-year extension of its existing 1332 waiver without any substantive changes to the existing program.

11-01-2020 CMS approves Georgia’s 1332 waiver application. CMS approved Georgia’s 1332 waiver application for pass-through funding of its state-based reinsurance program and for approval of a substantial modification to its insurance marketplace. The reinsurance program features a reinsurance corridor of $20,000 – $500,000 with an average coinsurance rate of 27 percent but which varies by rating area. The state expects the program will result in a decrease in premiums of 10 percent for the 2022 plan year.

10-02-2020 Maine submits letter of intent to amend its 1332 waiver to CMS. Maine submitted a letter of intent to amend its program to extend the reinsurance program to a pooled individual and small group market.

8-05-2020 CMS approves New Hampshire’s 1332 waiver application. CMS approved New Hampshire’s 1332 waiver application for pass-through funding of its proposed state-based reinsurance program. The program features a reinsurance corridor of $60,000 and a $400,000 with a coinsurance rate of 74 percent. If enacted, the state expects the program will result in an average decrease in premiums of 8 percent in the 2021 plan year.

7-24-2020 CMS approves Pennsylvania’s 1332 waiver application. CMS approved Pennsylvania’s 1332 wavier application for pass-through funding of its proposed state-based reinsurance program. The program features a reinsurance corridor of $60,000 – $100,000 with a coinsurance rate of 60 percent. If enacted, the state expects the program will result in an average decrease in premiums of 4.6% in the 2021 plan year.

7-9-2020 Georgia releases updated draft of 1332 waiver application. Georgia released an updated draft 1332 waiver application that includes a new timeline to reflect the requested pause of CMS’ preliminary review of Phase II of 1332 waiver application for reinsurance for expeditious review. The new draft still features a reinsurance corridor of $20,000 – $500,000 with a coinsurance rate of 27 percent. If enacted, the state expects the program will result in an average decrease in premiums of 10 percent in the 2022 plan year.

5-13-2020 CMS determines New Hampshire’s 1332 waiver complete. CMS determined that New Hampshire’s 1332 waiver application was complete, beginning a 180-day period before the agency must either approve or deny the waiver request.

4-21-2020 New Hampshire submits draft of 1332 waiver application to CMS. New Hampshire submitted a waiver application seeking federal approval and pass-through funding for a state-based reinsurance program. New Hampshire’s new proposed reinsurance program targets a 16 percent reduction in premiums for the 2021 plan year, features a reinsurance corridor of $60,000 – $400,000 with a coinsurance rate of 75 percent, and is funded by a per-member per-month assessment on insurers of 0.6% of the previous year’s second-lowest cost silver plan. If enacted, the state expects the program will result in an average decrease in individual market premiums of 16 percent in the 2021 plan year.

3-12-2020 CMS determines Pennsylvania’s 1332 waiver complete. CMS determined that Pennsylvania’s 1332 waiver application was complete, beginning a 180-day review period before the agency must either approve or deny the waiver request.

2-11-2020 Pennsylvania submits 1332 waiver application. Pennsylvania submitted its 1332 wavier application for approval and pass-through funding of its proposed state-based reinsurance program. The program features a reinsurance corridor of $60,000 – $100,000 with a coinsurance rate of 60 percent. If enacted, the state expects the program will result in an average decrease in premiums of 4.6% in the 2021 plan year.

2-6-2020 CMS determined Phase 1 (reinsurance) of Georgia’s 1332 waiver application complete. CMS determined that the first phase of Georgia’s 1332 waiver application concerning reinsurance was complete, beginning a 180-day review period for the state’s waiver.

2-5-2020 Georgia requested CMS to pause preliminary review of Phase II of 1332 waiver application for reinsurance for expeditious review. Governor Kemp requested that CMS review Phase 1 and Phase 2 of Georgia’s 1332 waiver application separately to ensure that the Georgia would have adequate time ahead of its annual rate filing period.

1-6-2020 New Hampshire releases revised draft 1332 waiver application for reinsurance. New Hampshire released a new waiver application seeking federal approval and pass-through funding for a state-based reinsurance program. The state had previously released a draft waiver application July 2017 but had not submitted its waiver to CMS. New Hampshire’s new proposed reinsurance program targets a 16 percent reduction in premiums for the 2021 plan year, features a reinsurance corridor of $60,000 – $400,000 with a coinsurance rate of 75 percent, and is funded by a per-member per-month assessment on insurers of 0.6% of the previous year’s second-lowest cost silver plan.

12-23-2019 Georgia submits 1332 waiver application to CMS. Georgia submitted its 1332 waiver application to CMS seeking approval for its reinsurance program along with other proposed changes to its health insurance market. The state’s reinsurance program will be funded by pass through funding along with money from the state’s general fund.

11-14-2019 Pennsylvania releases draft 1332 waiver application. Pennsylvania released a draft 1332 Waiver application seeking approval from CMS for a proposed state-based reinsurance program. The proposed program is targeting a decrease in average premiums of between 4.9% – 7.5% in 2021 and will be funded by a 3% fee on health and dental insurance premiums offered on Pennsylvania’s state exchange in addition to pass-through funding.

11-4-2019 Georgia releases draft 1332 waiver application. Georgia released a draft 1332 Waiver application, which among other provisions, seeks CMS approval and federal pass-through funding for a state-based reinsurance program. Georgia’s proposed reinsurance program has a reinsurance corridor of $20,000 – $500,000 with geographically based coinsurance tiers ranging from 15% through 85%. The program is targeting a 10% state-wide reduction in premiums.

8-26-2019 CMS approves Rhode Island’s 1332 waiver application. CMS approved Rhode Island’s 1332 Waiver application, which seeks approval and federal pass-through funding for a state-based reinsurance program. Rhode Island’s program is aiming to reduce premiums in the state by 5.9% in 2020, which it expects to increase enrollment by 0.9%. The program’s reinsurance corridor is relatively narrow at $40,000 – $97,000 with a 50% coinsurance rate. It will be funded by $8.3 million in 2020 in state funding, coming from penalties from the Rhode Island’s individual coverage mandate, in addition to $6.4 million in federal pass-through funding.

8-20-2019 CMS approves Delaware’s 1332 waiver application. CMS approved Delaware’s 1332 Waiver application, seeking approval and pass-through funding for its state-based reinsurance program. The reinsurance program targets a 13.7 percent reduction in premiums for 2020, which the state anticipates could increase the number of insured residents by up to 2.3 percent. The program will be funded by $6.9 million in state funding from a 1.00%–2.75% assessment on issuers’ premium tax liability along with an anticipated $20.0 million in federal pass-through funding.

8-16-2019 CMS approves Montana’s 1332 waiver application. CMS approved Montana’s 1332 Waiver application for its state-based reinsurance program. The program targets an 8 percent decrease in in premiums for 2020 and is funded by an assessment on major medical health insurance premiums, in addition to $22.1 million in federal pass-through funding requested for 2020.

7-31-2019 CMS approves North Dakota’s 1332 waiver application. CMS approved North Dakota’s 1332 Waiver application seeking approval for its reinsurance program. North Dakota’s reinsurance program targets a 20 percent reduction in premiums for 2020 and is funded by an assessment on the small and large group insurance market in addition to anticipated federal pass-through funding.

7-31-2019 CMS approves Colorado’s 1332 waiver application. CMS approved Colorado’s 1332 Waiver application seeking approval and funding for its reinsurance program, which targets a state-wide average premium decrease of 16 percent, though the targeted premium reduction varies by rating area. The program will be funded by a fees assessed on Colorado hospitals, premium tax revenues, a fee on insurance carriers, and the state’s general fund, in addition to anticipated federal pass-through funding.

7-18-2019 CMS determines Delaware’s application complete. After reviewing Delaware’s 1332 waiver application, CMS determined that the application was complete, starting the clock on a 180-day review period before the agency must either approve or deny the waiver request.

7-15-2019 CMS determines Rhode Island’s application complete. After reviewing Rhode Island’s 1332 waiver application, CMS determined that the state’s application was complete. CMS has 180 days a 180-day review period before the agency must either approve or deny the waiver request.

7-10-2019 Delaware submits 1332 Waiver application. Delaware submitted its 1332 Waiver application seeking CMS approval of its individual market reinsurance program. The state is requesting $6.9 million in pass-through funding for 2020, approximately a quarter of the projected cost of the reinsurance program, which has a corridor of $65,000 – $215,000 and a coinsurance rate of 75 percent. The program will be funded by the state with a 1.00% – 2.75% assessment on issuers’ premium tax liability for the previous year.

7-8-2019 Rhode Island submits 1332 Waiver application. Rhode Island submitted its 1332 Waiver application seeking approval for its proposed reinsurance program and $6.4 million in pass-through funding for 2020. Rhode Island is targeting a 5.9% decrease in premiums for 2020 resulting from its reinsurance program, which will have an attachment point of $40,000, a cap of $97,000, and a coinsurance rate of 50%. The state will provide funding for the program using penalties collected from its proposed state health insurance coverage mandate.

7-1-2019 CMS determines Montana’s Waiver application complete. After reviewing Montana’s 1332 waiver application, CMS determined that the state’s application was complete. CMS has a 180-day review period before the agency must either approve or deny the waiver request.

6-19-2019 Montana submits 1332 Waiver application. Montana submitted its 1332 Waiver application seeking program approval and $22.1 in pass-through funding for its proposed reinsurance program in 2020. The state is targeting an 8% net premium decrease for 2020 with its reinsurance program, which will have a reinsurance corridor of $40,000 – $101,750 with a coinsurance rate of 60%. The state will provide $12.4 million in funding in addition to the anticipated federal pass-through funding.

6-5-2019 CMS determines North Dakota’s Waiver application complete. After reviewing North Dakota’s 1332 waiver application, CMS determined that the state’s application was complete. CMS has a 180-day review period before the agency must either approve or deny the waiver request.

6-5-2019 CMS determines Colorado’s Waiver application complete. After reviewing Colorado’s 1332 waiver application, CMS determined that the state’s application was complete. CMS has a 180-day review period before the agency must either approve or deny the waiver request.

6-5-2019 Delaware releases draft 1332 Waiver application. Delaware released a draft 1332 Waiver application seeking Federal approval and pass-through funding for a proposed reinsurance program. Details of the program, such as the proposed reinsurance corridor and coinsurance rate have not been finalized, but the state anticipates that the program will need $7.4 million in state funding and $36.4 million in federal pass-through funding. Delaware anticipates that the program will reduce 2020 individual market premiums by 20% and will increase individual market enrollment in the state by 3.2%.

5-20-2019 Colorado submits 1332 Waiver application. Colorado submitted its 1332 Waiver application seeking approval and pass-through funding for its reinsurance program. The submitted waiver also changes the parameters of the reinsurance program, increasing the amount of pass-through funding requested to $162.8 million and decreasing the amount of state-only funding to $87.0.

5-15-2019 Montana releases draft 1332 Waiver application. Montana released its draft waiver application for public comment, seeking Federal approval and pass-through funding for a proposed reinsurance program. Montana’s enacting legislation for the program specifies a coinsurance rate of between 50% and 80%, an attachment point no less than $40,000 and a cap of no more than $1 million. The state has yet to specify how much it anticipates the program will reduce 2020 premiums, but it anticipates that the program will generate between $10 million and $20 million in federal pass-through funding in 2020.

5-10-2019 North Dakota submits 1332 Waiver application. North Dakota submitted its 1332 Waiver application seeking approval and pass-through funding for its reinsurance program.

4-23-2019 North Dakota releases draft 1332 Waiver application. North Dakota’s Insurance Department released a Draft 1332 Waiver application seeking Federal approval and pass-through funding for a state-based reinsurance program. Per the Waiver application and enacted legislation, an assessment will be conducted on small and large group health insurers to fund the state portion. North Dakota is requesting $25.8 million in annual pass-through funding in 2020.

4-16-2019 Colorado releases draft 1332 Waiver application. Colorado’s Division of Insurance released a draft 1332 waiver application seeking Federal pass-through funding for its state-based reinsurance program. The reinsurance program targets three tiers of premium decreases based on groupings of Geographic Rating Areas, ranging from 15–20% to 30–35% reductions in 2020 premiums. The program is anticipated to cost a total of $236.2 million in 2020, $117.5 million of which Colorado is requesting as pass-through funding. The remaining $118.7 million will be funded through an assessment on Colorado hospitals and a potential assessment on insurers.

11-30-2018 CMS sets New Jersey and Wisconsin pass-through funding for 2019. New Jersey was lately notified by CMS that the state will receive $180.2 million in pass-through funding for its newly approved reinsurance program, a drop from the requested $218 million as part of its waiver application and approval. CMS also notified Wisconsin that the state would receive $127.7 million in pass-through funding for reinsurance in the 2019 calendar year, after initial estimates of $166 million in funding were included in the state's waiver application.

11-30-2018 CMS sets Maine and Maryland pass-through funding for 2019. CMS notified Maine that the state would receive $65.3 million in pass-through funding for reinsurance in calendar year 2019, an increase from the $59.6 million the state was estimated to receive upon waiver approval in July 2018. Maryland is set to receive $373.4 million in pass-through funding for its 2019 year reinsurance program, nearly $70 million more than the $304 million it was approximated to receive as of its waiver approval in August 2018.

11-30-2018 CMS sets Alaska, Minnesota, and Oregon pass-through funding for 2019. CMS notified Alaska that the state would receive an estimated $68.7 million in pass-through funding for reinsurance in the 2019 calendar year. CMS had initially determined that Alaska would receive $61.5 million in pass-through funding for the state’s reinsurance program. Minnesota was also recently notified that it will receive approximately $84.7 million in pass-funding for calendar year 2019, a sizeable drop from the initial CMS estimate of $183.9 million. Oregon will receive $41.8 million in pass-through funding for its reinsurance program, roughly $6 million more than the $35.7 million it was set to receive as of its waiver approval.

8-22-2018 CMS approves Maryland’s 1332 Waiver application. CMS approved Maryland’s 1332 Waiver application seeking federal approval and pass-through funding for the state’s proposed reinsurance program. Maryland’s reinsurance program targets a 30% reduction in premiums and is funded by a 2.75% assessment on most health insurance plans and Medicaid managed care organizations in addition to federal pass-through funding.

8-16-2018 CMS approves New Jersey’s 1332 Waiver application. After just over one month of review, CMS approved New Jersey’s 1332 Waiver application seeking approval for its reinsurance program. New Jersey’s reinsurance program targets a 15% reduction in premiums for 2019. The reinsurance program is funded in part by penalties collected under New Jersey’s state-level individual insurance coverage mandate. CMS will determine pass-through funding amounts for the reinsurance program by the end of October 2018.

7-30-2018 CMS approves Maine’s 1332 Waiver application. CMS approved Maine’s 1332 Waiver application that sought federal approval for its state-based reinsurance program. The agency took less than two months to review and approve the waiver since determining it was complete the first week of June. As with Wisconsin, the amount of pass-through funding for the reinsurance program will be determined by the end of October 2018.

7-29-2018 CMS approves Wisconsin’s 1332 Waiver application. After less than three months of review, CMS approved Wisconsin’s 1332 Waiver application seeking approval for its state-based reinsurance program. The approval letter specifies that the amount of pass-through funding will be determined by CMS by the end of October 2018.

7-13-2018 CMS determines New Jersey’s Waiver application complete. After reviewing New Jersey’s 1332 waiver application, CMS determined that the state’s application was complete. CMS has a 180-day review period before the agency must either approve or deny the waiver request.

7-5-2018 CMS determines Maryland’s Waiver application complete. After a review of Maryland’s 1332 waiver application, CMS determined that the state’s application was complete. This determination marks the start of the required 180-day decision-making period, which gives the agency until January 2019 to approve or deny Maryland’s waiver request.

7-2-2018 New Jersey submits final 1332 Waiver application. New Jersey’s Department of Banking and Insurance submitted the state’s 1332 Waiver application for approval and funding for a state-based reinsurance program. The program targets a 15% reduction in premiums. New Jersey set a corridor of $40,000 ­– $215,000 with a reinsurance rate of 60% / 40%. The state anticipates a net federal savings of $218 million in 2019 and will provide an additional $105.8 million in state funding for 2019.

6-8-2018 CMS determines Maine’s Waiver application complete. After reviewing Maine’s 1332 Waiver application, CMS made a preliminary determination that the state’s Waiver application was complete. This determination of completeness marks the beginning of the 180-day Federal decision-making period, giving CMS until approximately December 2018 to approve Maine’s application.

5-31-2018 New Jersey releases Draft 1332 Waiver application. New Jersey’s Department of Banking and Insurance released a Draft 1332 Waiver application seeking Federal approval and pass-through funding for a state-based reinsurance program. Per the Waiver application’s authorizing legislation, the state is targeting a 10–20 percent reduction in 2019 premiums. In addition to pass-through funding, the reinsurance program will be funded by penalties collected under New Jersey’s state individual health insurance coverage mandate. The program’s proposed coinsurance rates, reinsurance corridors, and a pass-through funding request amount are to-be-determined based on forthcoming actuarial analysis.

5-31-2018 Maryland submits 1332 Waiver application. Maryland submitted its 1332 Waiver application to CMS. The application seeks approval for a state reinsurance program along with pass-through funding. Maryland expects the program to reduce 2019 premiums by 30 percent and will be funded by a 2.75% assessment on health insurance premiums in addition to federal pass-through funding.

5-9-2018 Maine submits 1332 Waiver application. Maine submitted its 1332 Waiver application to CMS, seeking approval and pass-through funding for its proposed reinsurance program, the Maine Guaranteed Access Reinsurance Association (MGARA). The state expects MGARA to result in a nine percent net decrease in 2019 premiums.

5-9-2018 CMS determines Wisconsin’s Waiver application complete. After reviewing Wisconsin’s 1332 Waiver application, CMS made a preliminary determination that the state’s Waiver application was complete. This determination of completeness marks the beginning of the 180-day Federal decision-making period, giving CMS until approximately November 2018 to approve Wisconsin’s application.

4-20-2018 Maryland releases Draft 1332 Waiver application seeking approval for reinsurance program. The Maryland Health Benefit Exchange, the state’s ACA Marketplace released a Draft 1332 Waiver application seeking federal approval of and pass-through funding for a traditional, state-based reinsurance program. The proposed reinsurance program has a cap of $250,000 with an 80 percent coinsurance rate; the attachment point is to be determined based on stakeholder feedback. For 2019, Maryland is seeking $97 million in pass-through funding in addition to $365 million in state funding provided by a 2.75% assessment on Maryland health plans and Medicaid MCOs based on annual net premiums. The state anticipates that the program will reduce 2019 individual market premiums by approximately 30 percent.

4-18-2018 Wisconsin submits 1332 Waiver Application to CMS. Wisconsin submitted its 1332 Waiver Application to CMS for approval. The state is seeking $166 million in pass-through funding with the remainder of the funding for the $200 million program coming from Wisconsin’s general fund. The state expects the program to decrease 2019 premiums by 10.6% relative to baseline (a 5.4% decrease from 2018) and increase individual market enrollment by 0.8%. The state is proposing a 50% coinsurance rate for 2019, though the coinsurance rate could be set between 50% and 80% in subsequent years, as allowed by statute.

4-9-2018 Louisiana releases Draft 1332 Waiver Application seeking approval for reinsurance program. Louisiana’s Department of Insurance released a detailed description of its proposed 1332 Waiver Application seeking federal approval for a state-based reinsurance program, the Louisiana Health Reinsurance Association (LHRA). Louisiana is seeking $103.5 million in federal pass-through funding for 2019 in addition to $24.8 million in state funding coming from a proposed per-member assessment on Louisiana health insurers. The state has yet to determine the assessment rate, reinsurance corridor, and coinsurance rate.

4-2-2018 Maine releases Draft 1332 Waiver Application to reinstate its condition-specific reinsurance program. Maine released actuarial analysis and a summary of its draft 1332 Waiver Application, seeking approval to reinstate its pre-ACA reinsurance program, Maine Guaranteed Access Reinsurance Association (MGARA) along with $35 million in federal pass-through funding for 2019 to complement $59.6 million in state funding. MGARA is a condition-specific reinsurance program that automatically pays a portion of claims in a specific corridor ($47,000 – $77,000) for covered individuals with one or more of eight specified health conditions or on a voluntary basis for other covered members with claims in the corridor. The state estimates that reinstating MGARA would reduce 2019 individual market premiums by about 9% relative to what they would be without the program.

3-13-2018 Wisconsin releases Draft 1332 Waiver Application. Wisconsin released a draft of its 1332 Waiver Application, seeking $170 million in federal pass-through funding for its state reinsurance program, the Wisconsin Healthcare Stability Plan (WIHSP). The state anticipates that
if approved, WIHSP would reduce 2019 individual market premiums by 10% relative to premiums if the plan were not approved.

2-6-2018 CMS sets Alaska and Oregon pass-through funding for 2018. CMS notified Alaska that the state would receive an estimated $58.5 million in pass-through funding for reinsurance in the 2018 calendar year. CMS had initially determined that Alaska would receive $48.3 million in pass-through funding for the state’s reinsurance program. Oregon will receive $54.5 million in pass-through funding for its reinsurance program, nearly $19 million more than the $35.7 million it was set to receive as of its waiver approval.

1-26-2018 CMS sets Minnesota pass-through funding for 2018. CMS notified Minnesota that the state would receive an estimated $130.7 million in pass-through funding for the state’s reinsurance program in calendar year 2018. This was $8.5 million less than the $139.2 million specified in CMS’s initial waiver approval.

11- 2017 Idaho released its draft 1332 and 1115 Waiver Applications. Idaho released draft 1332 and 1115 Waiver Applications for public comment. The proposed program is a novel combination of a new Medicaid eligibility category for individuals below 400% FPL with complex medical conditions; a state-funded, condition-specific individual market high-risk pool; and extending individual-market premium tax credits and cost-sharing reductions to individuals below 100% FPL. The state projects that their proposal will cover an additional 21,000 individuals while reducing total federal expenditures by $2 million.

10-23-17 Iowa withdrew its 1332 Waiver Application. Iowa’s Insurance Commissioner Doug Ommen withdrew the state’s 1332 Waiver Application, citing overly restrictive 1332 Waiver requirements that prevented the state from implementing its Stopgap plan under terms that would be workable for the state.

10-19-17 CMS provided Iowa guidance on funding for its 1332 Waiver Application. CMS responded to Iowa’s 1332 Waiver application, giving the state guidance on how and when pass-through funding amounts would be calculated. In its letter to Iowa, CMS stated that could only pass through the amount of funding that CMS would have provided in subsidies had Iowa not implemented its 1332 waiver. Because the amount of pass-through funding Iowa requested was larger than the amount that Iowans would have otherwise received in subsidies, the state would have needed make up the difference in state-only funding in order to make its waiver federal deficit neutral.

10-19-17 CMS approved Oregon’s 1332 Waiver. CMS has approved Oregon’s 1332 Waiver Application. The waiver Specific Terms and Conditions (STC) state that the state will receive pass-through funding for its reinsurance program but do not list a specific amount of funding. CMS will specify the amount of available pass-through funding no later than December 30, 2017 as long as the state provides CMS with the necessary information to calculate pass-through funding by November 14, 2017.

10-16-17 Minnesota accepted 1332 Waiver terms. Minnesota Governor, Mark Dayton officially accepted the Specific Terms and Conditions for the state’s 1332 Waiver, though he reasserted his strong disagreement with CMS’s interpretation of federal law that led to its decision to not pass through federal savings on funding for the state’s Basic Health Plan (BHP), MinnesotaCare. Gov. Dayton specified that in signing the STCs, he was not waiving Minnesota’s right to the full amount of its federal BHP funding based on the state’s argument outlined in an October 3 memo to CMS. 

9-29-17 Oklahoma withdrew its 1332 Waiver Application. Oklahoma notified CMS that it was withdrawing its 1332 Waiver Application. Oklahoma blamed CMS for missing a mutually-agreed-upon September 25 deadline for approval necessary for the state to implement its reinsurance program before the 2018 plan year. CMS had previously determined the application to be complete and indicated that approval would be forthcoming by the September 25 deadline. The state plans to seek a 1332 Waiver for reinsurance in future years.

9-22-17 CMS approved Minnesota’s 1332 Waiver. CMS has approved Minnesota’s 1332 Waiver Application, giving the state $139 million in pass-through funding for reinsurance in 2018, and a total of $1 billion in funding over five years. This is the amount the federal government will save in premium tax credits and cost-sharing reduction payments due to Minnesota’s reinsurance program. However, as Gov. Mark Dayton anticipated in a September 19 letter to Secretary Price, CMS will not pass through the money it will save on funding for the state’s Basic Health Program (BHP), MinnesotaCare since BHP funding is based on 95% of the amount of premium tax credits and cost-sharing reductions that would have been provided to BHP enrollees. Though CMS does not specify how much funding the state will lose for MinnesotaCare, Gov. Dayton claims that the state would lose $369 million in BHP funding over two years, more than it would gain in pass-through funding for reinsurance. The state has 30 days from receipt of the approval letter to accept or reject the terms of approval.

9-17-17 Iowa submitted an amendment to its 1332 Waiver.  Iowa provided a supplement to its 1332 Iowa Stopgap Measure to increase the cost sharing subsidies available to individuals with incomes between 133–150% FPL. The state expects that the additional subsidy will increase participation of young, healthy individuals in its individual market, improving the risk pool and keeping premiums down. Because of this improved risk pool, the state is decreasing its reinsurance pass-through funding request from $80 million to $70 million.

9-11-17 CMS Determines Oregon’s Waiver Application complete. CMS determined that Oregon’s 1332 waiver application was complete, beginning a 180-day period before the agency must either approve or deny the waiver request.

8-31-17 Oregon submitted its 1332 Waiver Application. Oregon’s waiver seeks pass-through funding for its reinsurance proposal. $90 million in annual state funding for reinsurance plan is paid for through a 0.3% assessment levied on major medical premiums and through excess fund balances in two state programs. The state is seeking more than $30 million annually in federal pass-through funding. The reinsurance plan has a coinsurance rate of 50% and a cap of $1 million. The attachment point is to be determined.

8-16-17 Oklahoma submitted its 1332 Waiver Application. The Department of Health and Human Services submitted Oklahoma’s 1332 waiver, the Individual Health Insurance Market Stabilization Program (OMSP). The OMSP will have a broad corridor of $15,000 – $400,000 and will be largely funded with federal pass-through funding, with a smaller portion coming from a state assessment on health insurers.

8-1-17 Minnesota released preliminary individual market premiums. The Minnesota Department of Commerce published anticipated premium increases by health plans with and without reinsurance. With state reinsurance, plans expect that 2018 premiums could be modestly higher (largest increase 11.4%) to substantially lower (largest decrease 40.8%) than 2017 premiums. Without state reinsurance, plans project much larger increases in 2018 premiums.

7-19-17 New Hampshire released its Draft 1332 Waiver Application. The New Hampshire Department of Insurance released a draft of its 1332 Waiver application for public comment. The waiver proposes a traditional reinsurance program with a corridor of $45,000 – $250,000 and a 40% / 60% coinsurance rate. The application seeks $12.8 million in federal pass-through funding.

7-14-17 Oklahoma released its Draft 1332 Waiver Application. The Oklahoma Department of Insurance released a draft of its 1332 Waiver Application for public comment. Oklahoma’s 1332 waiver proposal includes reinsurance along with broader reforms to its individual market. The state is awaiting further actuarial analysis before determining its reinsurance plan’s corridor, coinsurance rate, and level of pass-through funding. Oklahoma’s proposal is a traditional reinsurance plan funded by assessments on health insurers.

7-7-17 CMS approved Alaska’s 1332 Waiver Application. CMS notified Alaska that its 1332 Waiver Application had been approved. The state was awarded $48.3 million in federal pass-through funding in 2018, and a total of $322 million over five years.

1-17-17 CMS determined Alaska’s 1332 waiver application complete. CMS determined Alaska’s 1332 waiver application complete. This determination of completeness marks the beginning of the 180-day Federal decision-making period. The agency has a 180-day review period before the agency must either approve or deny the waiver request.

12-29-2016 Alaska submitted its 1332 Waiver Application. This waiver application seeks federal pass-through funding for its reinsurance proposal. The state previously passed the Alaska Reinsurance Program (ARP) which appropriated $55 million in state funding for reinsurance in 2017. This decreased premium growth from an anticipated 42% to 7.3%. The state expects this waiver will save the federal government $51.6 million in APTC.

Suggested Citation:

State Health Access Data Assistance Center (SHADAC). Resource: 1332 State Innovation Waivers for State-Based Reinsurance [Internet]. University of Minnesota, Minneapolis (MN) [cited ADD DATE]. Available from: http://www.shadac.org/publications/resource-1332-state-innovation-waivers-state-based-reinsurance

Medicaid and Children’s Health Insurance Plan (CHIP) programs have played a key role in responding to the COVID-19 pandemic, providing an important safety net for health insurance coverage for millions of people during this unprecedented public health crisis. The Families First Coronavirus Response Act enacted the continuous coverage requirement, which provides a 6.2 percentage point increase in federal matching funds for states that maintain continuous Medicaid enrollment until the end of the public health emergency. Subsequently, administrative records show that enrollment in Medicaid and CHIP has grown substantially.

However, key federal surveys such as the American Community Survey have failed to show the extent of this growth in the population with Medicaid/CHIP coverage. This brief describes our analysis of these estimates, focused on the size of the “Medicaid undercount”, the misalignment between survey estimates of self-reported Medicaid coverage, and enrollment counts obtained from Medicaid/CHIP administrative data.

The Medicaid undercount in the 2021 American Community Survey (ACS) was larger than in earlier years, which we believe was tied, at least in part, to the Medicaid continuous coverage requirement. In the brief, we also present analysis of two years of linked data from the Current Population Survey Annual Social and Economic and Supplement (CPS ASEC). Our results suggest that despite having continuous coverage, many enrollees may not have known they were still covered by Medicaid.

Related Resources

• SHADAC Blog: Understanding the Undercount of Medicaid Enrollees in the 2020 Current Population Survey Health Insurance Coverage Data
• Research Article: Medicaid Expansion and the Medicaid Undercount in the American Community Survey
• Past SHADAC Project: Medicaid Undercount Project

Collecting and monitoring data on Medicaid enrollees that is broken down by race, ethnicity, and language (REL) is an essential first step in assessing health disparities as well as identifying strategies for improvement in state Medicaid programs. Although all state Medicaid agencies and most U.S. territories collect self-reported data on REL from applicants during the eligibility and enrollment process, many states continue to face longstanding and persistent challenges in collecting complete, accurate, and granular data on REL.

In this issue brief prepared for State Health and Value Strategies with funding from the Robert Wood Johnson Foundation, SHADAC researchers Emily Zylla, Elizabeth Lukanen, and Hannah Geressu provide an overview of federal REL data collection standards, and examine Medicaid application questions, answer options, and instructional language used by Medicaid programs in all 50 states, the District of Columbia, and five U.S. territories. This serves as an update to SHADAC’s previous brief, providing up-to-date information on Medicaid REL data collection among the states and extending the analysis to include the District of Columbia and the five territories.

Access the full brief for more information on state-level Medicaid REL data collection.

Related Reading
Previous version: Collection of Race, Ethnicity, Language (REL) Data in Medicaid Applications: A 50-state Review of the Current Landscape

SHVS Brief: Collection of Sexual Orientation and Gender Identity (SOGI) Data: Considerations for Medicaid and Spotlight on Oregon (Update forthcoming)

SHVS Expert Perspective: Exploring Strategies to Fill Gaps in Medicaid Race, Ethnicity, and Language Data