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Medicaid and CHIP Maintenance of Effort
(MOE): Requirements and Responses

Evelyne P. Baumrucker
Analyst in Health Care Financing
May 25, 2011
Congressional Research Service
7-5700
www.crs.gov
R41835
CRS Report for Congress
P
repared for Members and Committees of Congress
c11173008

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Medicaid and CHIP Maintenance of Effort (MOE): Requirements and Responses

Summary
State revenues declined during the recent economic recession (December 2007 through June
2009) and have not fully recovered. At the same time, the recession increased the number of
individuals meeting Medicaid’s income eligibility standards. States are faced with tough decisions
about where to direct their increasingly limited funds.
This state fiscal condition is a reason the American Recovery and Reinvestment Act of 2009
(ARRA, P.L. 111-5; and subsequently extended in P.L. 111-226) included a temporary increase to
Federal Medical Assistance Percentage (FMAP) rates. As a condition of the receipt of the federal
Medicaid matching funds made available under ARRA, states were required to maintain their
Medicaid programs with the same eligibility standards, methodologies, or procedures for
Medicaid through June 30, 2011. This provision is referred to as the ARRA Maintenance of Effort
(MOE) requirement.
The ARRA MOE provisions were extended and expanded in the Patient Protection and
Affordable Care Act as modified by the Health Care and Education Reconciliation Act of 2010
(PPACA, P.L. 111-148 as modified by P.L. 111-152). PPACA’s MOE provisions were designed to
ensure that individuals eligible for Medicaid or the State Children’s Health Insurance Program
(CHIP) did not lose coverage in the period between the date of enactment of PPACA (March 23,
2010) and the implementation of the state health insurance exchanges (expected in 2014).
Because states are prohibited from curbing the cost of Medicaid through restricting eligibility
standards due to the MOE requirements included in ARRA and PPACA, states have focused cost
containment strategies on reducing provider rates, making changes to their benefit packages, or
implementing limitations on the use of benefits. However, states want greater flexibility to
restrain their Medicaid expenditures through eligibility restrictions.
This report summarizes the MOE requirements enacted under ARRA and PPACA and what these
requirements have meant for states in terms of their actions to restrict Medicaid and/or CHIP
eligibility. It also summarizes recent legislative activity to repeal the MOE requirements.

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Medicaid and CHIP Maintenance of Effort (MOE): Requirements and Responses

Contents
Introduction ................................................................................................................................ 1
Background on the Medicaid and CHIP Programs ....................................................................... 2
Maintenance of Effort Requirements Under ARRA, as Extended................................................. 3
Medicaid Maintenance of Effort Requirements Under PPACA .................................................... 4
State Actions ......................................................................................................................... 5
CHIP Maintenance of Effort Requirements Under PPACA .......................................................... 6
State Actions ......................................................................................................................... 6
Recent Legislative Activity ......................................................................................................... 6

Contacts
Author Contact Information ........................................................................................................ 7
Acknowledgments ...................................................................................................................... 7

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Medicaid and CHIP Maintenance of Effort (MOE): Requirements and Responses

Introduction
State revenues declined during the recent economic recession (December 2007 through June
2009) and have not fully recovered.1 This decline in revenue continues to place considerable
strain on state budgets. As a result, nearly all states made spending cuts—both to public programs
and for public employees.2 At the same time, the recession increased the number of individuals
meeting Medicaid’s income eligibility standards.3 This resulted in higher program enrollment and
therefore higher state spending on Medicaid benefits.4 Given declining state tax revenue, in
conjunction with requirements in all states but Vermont for balanced operating budgets, states are
faced with tough decisions about where to direct the limited funds.
This state fiscal condition is a reason the American Recovery and Reinvestment Act of 2009
(ARRA, P.L. 111-5 as extended) included a temporary increase to the Federal Medical Assistance
Percentage (FMAP) rates to help states maintain their Medicaid programs and free up funds that
states would have otherwise used for Medicaid to address other state budgetary needs.5 As a
condition of the receipt of the federal Medicaid matching funds made available under the ARRA
FMAP provision, states were required to maintain their Medicaid programs with the same
eligibility standards, methodologies, or procedures for Medicaid through June 30, 2011 (i.e., the
end of the ARRA temporary FMAP adjustment period). This provision is referred to as the
Maintenance of Effort (MOE) requirement.
With the enactment of the Patient Protection and Affordable Care Act as modified by the Health
Care and Education Reconciliation Act of 2010 (PPACA, P.L. 111-148 as modified by P.L. 111-
152), the ARRA MOE provisions were extended and expanded. PPACA’s MOE provisions were
designed to ensure that individuals eligible for Medicaid or the State Children’s Health Insurance
Program (CHIP) did not lose coverage in the period between the date of enactment of PPACA
(March 23, 2010) and the implementation of the state health insurance exchanges (expected in
2014).6 Generally, beginning in 2014, Medicaid-eligible adults who were no longer protected by

1 State tax revenues at the national level were still 7.5% lower in the third quarter of 2010 than in the same quarter of
2008. Source: L. Dadayan and D. Boyd, State Tax Revenues Gained New Strength in Fourth Quarter: Every Quarter of
2010 Showed Growth, But Recession’s Harsh Impact will Linger, State Revenue Report Number 82, The Nelson A.
Rockefeller Institute of Government, Albany, New York, February 2011.
2 Vernon K. Smith, Ph.D., Kathleen Gifford, and Eileen Ellis (Health Management Associates), et al., Hoping for
Economic Recovery, Preparing for Health Reform: A Look at Medicaid Spending, Coverage and Policy Trends,
Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2010 and 2011, Kaiser Commission on
Medicaid and the Uninsured, Executive Summary, Washington, DC, September 2010, http://kff.org/medicaid/upload/
8105_ES.pdf.
3 Eligibility for Medicaid is means-tested. Applicants must meet certain income and sometimes asset tests to qualify.
For more information about Medicaid eligibility see, CRS Report RL33202, Medicaid: A Primer.
4 Source: Christopher J. Truffer, F.S.A, John D. Clemm, Ph.D., A.S.A., M.A.A.A., and Christian J. Wolfe, et al., 2010
Actuarial Report on the Financial Outlook for Medicaid
, Office of the Actuary, Centers for Medicare and Medicaid
Services, U.S. Department of Health and Human Services, Washington, DC, December 21, 2010.
5 Medicaid is jointly funded by the federal government and the states. The federal government’s share of most
Medicaid service costs is determined by the federal medical assistance percentage (FMAP), which varies by state and is
determined by a formula set in statute. For more information on Medicaid FMAP, See CRS Report RL32950,
Medicaid: The Federal Medical Assistance Percentage (FMAP), by Evelyne P. Baumrucker and Alison Mitchell.
6 Exchanges will not be insurers, but will provide qualified individuals and small businesses with access to private
health insurance options. For information about the private insurance provisions in the federal health reform law, see
CRS Report R40942, Private Health Insurance Provisions in the Patient Protection and Affordable Care Act (PPACA),
by Hinda Chaikind, Bernadette Fernandez, and Mark Newsom.
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Medicaid and CHIP Maintenance of Effort (MOE): Requirements and Responses

MOE would presumably have access to subsidized coverage through state exchanges.7 Under the
PPACA MOE, with certain exceptions, states are required to maintain their Medicaid and CHIP
programs until 2014 with the same eligibility standards, methodologies, or procedures in place as
of March 23, 2010. For Medicaid and CHIP-eligible children up to age 19, the MOE requirement
extends through September 30, 2019.8 Failure to comply with these requirements would result in
the loss all federal Medicaid matching funds.
Because states are prohibited from curbing the cost of Medicaid through restricting eligibility
standards due to the MOE requirements included in ARRA and PPACA, over the past few years,
states have focused cost containment strategies on reducing provider rates, making changes to
their benefit packages, or implementing limitations on the use of benefits.9 However, with the
approach of the June 30, 2011, phase-out of the enhanced federal Medicaid funding under ARRA,
states have been seeking congressional relief from the MOE requirements.10 States want greater
flexibility to restrain their Medicaid expenditures through eligibility restrictions.
This report summarizes the MOE requirements enacted under ARRA and PPACA and what these
requirements have meant for states in terms of their actions to restrict Medicaid and/or State
Children’s Health Insurance Program (CHIP) eligibility. It also summarizes recent legislative
activity to repeal the MOE requirements.
Background on the Medicaid and CHIP Programs
Medicaid is a means-tested individual entitlement program that finances the delivery of primary
and acute medical services as well as long-term care to more than 68 million people (FY2010)
who meet both income and categorical eligibility criteria. While Medicaid is considered a
mandatory program in federal budget terms, states choose whether to participate, and all 50
states, the District of Columbia, and the territories do. The federal and state governments share
the cost of Medicaid. States are reimbursed by the federal government for a portion (the “federal
share”) of a state’s Medicaid program costs. In FY2010, Medicaid spending totaled
approximately $406 billion, with a federal share of $274 billion and a state share of $132 billion.
As a condition of receipt of any federal financial participation (FFP), states must meet their state

7 PPACA’s coverage provisions related to the expansion of Medicaid eligibility and establishment of health insurance
exchanges were designed to be mutually exclusive. In other words, as long as a person is eligible for Medicaid and can
enroll in a state Medicaid program, that person may not enroll in an exchange plan, nor access the premium credits and
cost-sharing subsidies available in the exchanges. See CRS Report R41210, Medicaid and the State Children’s Health
Insurance Program (CHIP) Provisions in PPACA: Summary and Timeline
, coordinated by Julie Stone.
8 This MOE provision does not prohibit states from cutting Medicaid in other ways, such as by reducing provider
reimbursement rates or by eliminating optional benefits. States are not prohibited from expanding Medicaid coverage
during the MOE period.
9 The Crunch Continues: Medicaid Spending, Coverage and Policy in the Midst of a Recession Results from a 50-State
Medicaid Budget Survey for State Fiscal Years 2009 and 2010, Kaiser Commission on Medicaid and the Uninsured,
September 2009, available at http://www.kff.org/medicaid/upload/7985.pdf.
10 Under PPACA, states that have, or are projected to have, a budget deficit, may be exempted from the PPACA MOE
requirements, but only with respect to individuals who are non-pregnant, non-disabled adults who are eligible for
medical assistance under a state plan or waiver of a state plan, and whose income exceeds 133% of the federal poverty
level (FPL). To date, states have not pursued the PPACA MOE exemption as they did not want to lose access to funds
made available through the ARRA FMAP increase. With the expiration of the ARRA FMAP provision, states will no
longer be eligible for the increase in federal matching funds made available under the ARRA FMAP increase, and thus
may begin to seek CMS approval for the PPACA exemption.
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share requirements, have a plan for medical assistance approved by the Secretary of Health and
Human Services (HHS), and comply with Medicaid program rules.
CHIP was established by the Balanced Budget Act of 1997 (P.L. 105-33) and was recently
reauthorized by the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA,
P.L. 111-3). CHIP provides health coverage to uninsured, low-income children in families with
annual income above Medicaid eligibility thresholds. When certain conditions are met, CHIP
coverage is also available to pregnant women and parents. In FY2010, there were approximately
7.7 million children and 347,143 adults (ever enrolled) in CHIP, and the estimated annual cost to
the federal and state governments was roughly $11.4 billion in FY2010, with a federal share of
$8.0 billion and a state share of $3.4 billion.
As with Medicaid, CHIP is funded jointly by the federal government and the states, and is
administered by the states. Also like Medicaid, CHIP is considered a mandatory spending
program in terms of the federal budget. However, rather than being considered an individual
entitlement, CHIP operates as a capped entitlement to states. States with approved CHIP plans
that comply with program rules and that meet their state share requirements are entitled to a
portion of a national annual appropriation. All 50 states, the District of Columbia, and the
territories choose to participate in the CHIP program.
Maintenance of Effort Requirements Under ARRA,
as Extended

During the most recent recession, Congress provided additional economic stimulus funding to
states, including a temporary increase to the Federal Medical Assistance Percentage (FMAP) rate
that defines the federal government’s share of a state’s expenditures for most Medicaid services.
The temporary FMAP increase enacted under ARRA was later extended by P.L. 111-226. The
temporary FMAP increase runs for 11 quarters, from the first quarter of FY2009 through the third
quarter of FY2011 (i.e., October 2008 through June 2011), subject to certain requirements,
including a Maintenance of Effort (MOE) requirement.11
The ARRA MOE provision generally requires states with Medicaid programs in effect on July 1,
2008, to maintain their programs with the same eligibility standards, methodologies, or
procedures for Medicaid through June 30, 2011 (i.e., the end of the ARRA temporary FMAP
adjustment period). Failure to comply with the MOE requirements means a state would lose its
increase in its federal Medicaid matching funds made available under the ARRA FMAP
provision. Section 5001(f)(1)(B) and (C) permits states that have restricted their “eligibility
standards, procedures, or methodologies” to reinstate them in any quarter to begin receiving the
temporary FMAP increase. In addition, those states that reinstated their “eligibility standards,
procedures, or methodologies” prior to July 1, 2009, received the increase for the first three
quarters of FY2009. States were required by HHS to attest that they met the eligibility

11 For more information on ARRA’s temporary FMAP increase, see CRS Report RL32950, Medicaid: The Federal
Medical Assistance Percentage (FMAP)
. The ARRA MOE requirement is found in § 5001(f) of the American
Recovery and Reinvestment Act of 2009 (ARRA, P.L. 111-5) and was later extended by the Education, Jobs and
Medicaid Assistance Act (P.L. 111-226).
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requirements.12 HHS indicated that four states (Mississippi, North Carolina, South Carolina, and
Virginia) were ineligible when funding estimates were first released on February 23, 2009, but
those states have since been cleared to receive the FMAP increase. A more recent study found that
the ARRA requirements resulted in 14 states reversing and 5 states abandoning planned
restrictions to eligibility.13
Under the Children’s Health Insurance Program Reauthorization Act (CHIPRA) of 2009, a
number of states were required to move their childless adult populations out of CHIP by
December 31, 2009, and could apply to have them enrolled under a Medicaid waiver. However,
ARRA FMAPs were not originally available for these childless adults because they had not been
eligible for Medicaid on July 1, 2008 (as stated above). Under P.L. 111-226, states can now
receive ARRA FMAPs for non-pregnant childless adults in Medicaid who would have been
eligible for CHIP based on standards in effect on December 31, 2009. It appears that Idaho,
Michigan, and New Mexico will benefit from this provision.14
Medicaid Maintenance of Effort Requirements
Under PPACA

The Patient Protection and Affordable Care Act (PPACA, P.L. 111-148), as amended by the
Health Care and Education Reconciliation Act of 2010 (P.L. 111-152), made significant changes
to Medicaid and extended federal financing for CHIP through FY2015.15 The most noteworthy
change begins in 2014, or sooner at state option, when states are required to expand Medicaid
eligibility to individuals under age 65 with income up to 133% of the federal poverty level (FPL)
(effectively 138% FPL with the Modified Adjusted Gross Income or MAGI 5% FPL income
disregard). At the same time, with certain exceptions, PPACA requires states to maintain current
Medicaid and CHIP eligibility levels.16
Under PPACA, the ARRA MOE provisions were extended and expanded. PPACA’s MOE
provisions were designed to ensure that Medicaid and CHIP-eligible individuals did not lose
coverage in the period between the date of enactment of PPACA (March 23, 2010) and the
implementation of the state health insurance exchanges (expected in 2014). The PPACA Medicaid
MOE provision generally requires that states with Medicaid programs in effect on March 23,
2010, maintain their programs with the same eligibility standards, methodologies, or procedures
until the health insurance exchanges are operational. Additionally, the Medicaid MOE for
Medicaid-eligible children up to age 19 continues until September 30, 2019. Failure to comply
with the PPACA MOE requirements would result in a loss of all federal Medicaid matching funds

12 See http://www.hhs.gov/recovery/fmapprocess.html.
13 See Kaiser Commission on Medicaid and the Uninsured, State Fiscal Conditions and Medicaid, September 2009,
available at http://www.kff.org/medicaid/upload/7580-05.pdf.
14 CRS analysis of eligibility information under their special terms and conditions (STCs) of the Section 1115 waivers
associated with these states.
15 For more information about the Medicaid provisions in PPACA, see CRS Report R41210, Medicaid and the State
Children’s Health Insurance Program (CHIP) Provisions in PPACA: Summary and Timeline
, coordinated by Julie
Stone.
16 The PPACA MOE requirements are found in § 2001(b) of the Patient Protection and Affordable Care Act as
modified by §10201 of the Health Care and Education Reconciliation Act of 2010 (PPACA, P.L. 111-148 as modified
by P.L. 111-152); and § 2101(b) as modified by §10203(c)(2)(A)(i)- §10203(c)(2)(A)(iv) of PPACA.
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for that state. This differs from the ARRA MOE requirement, under which states that do not
comply would only lose access to the additional federal funds made available through the
increase in the FMAP rate.
Section 2001(b)(3) provides for an exemption to this MOE requirement for states that have, or are
projected to have, a budget deficit, but only with respect to individuals who are non-pregnant,
non-disabled adults who are eligible for medical assistance under a state plan or waiver of a state
plan, and whose income exceeds 133% FPL (or 138% FPL with the MAGI income counting
disregard). No state has sought an exemption from the PPACA MOE requirement under this
authority to date.17 This MOE provision does not prohibit states from cutting Medicaid in other
ways, such as by reducing provider reimbursement rates or by eliminating optional benefits.
States are not prohibited from expanding Medicaid coverage during the MOE period.
State Actions
Arizona had planned to “scale back eligibility” for parents and childless adults under its Medicaid
Section 1115 waiver,18 but the state did not take these actions. Initially, Arizona concluded that
the changes would violate the MOE requirements in PPACA.19 However, later, in a February 15,
2011, letter to the governor of Arizona,20 the Secretary of HHS ruled that the MOE provision in
PPACA does not require Arizona to renew its Section 1115 waiver demonstration as is, beyond its
expiration date of September 30, 2011. According to Secretary Sebelius’s letter, any reduction in
eligibility associated with the expiration of Arizona’s demonstration “for individuals whose
eligibility derives from the demonstration” would not constitute a violation of PPACA’s MOE
requirements.21
In March 2011, Governor Brownback, of Kansas, sent a letter to the Secretary of HHS requesting
approval to block grant the state’s Medicaid program, and seeking “a complete waiver of the
Maintenance of Effort (MOE) requirements.”22 On March 30, 2011, the Secretary of HHS
responded to the governor by saying, “I look forward to learning more details about your
proposals.”23 To date, a formal waiver proposal submission detailing Governor Brownback’s
proposal is not publicly available.

17 For additional information on the interaction of ARRA MOE provisions and the PPACA MOE provisions during the
period between January 1, 2011 through June 30, 2011, see February 25, 2011 CMS State Medicaid Director Letter Re:
Maintenance of Effort
SMDL# 11-001 ACA # 14 available at https://www.cms.gov/smdl/downloads/SMD11001.pdf.
18 Letter from Maria Coury to Steven Rubio, CMS, March 18, 2010 available at http://www.azahcccs.gov/shared/
Downloads/News/WaiverNotice_Final.pdf. Also see February 3, 2010 letter from Governor Brewer to Secretary
Sebelius regarding the state’s request to scale back on their Medicaid adult coverage, at http://azgovernor.gov/dms/
upload/PR_020311_SebeliusLetter.pdf.
19 See letter from Arizona Health Care Cost Containment System (AHCCCS) Director Thomas J. Betlach to Governor
Janice K. Brewer, March 25, 2010, http://www.azahcccs.gov/reporting/Downloads/HealthCareReform/
GovernorBrewerLetter_03-25-10.pdf.
20 See http://azgovernor.gov/dms/upload/PR_021511_SebeliusLetter.pdf.
21 Additional information on the interaction of Section 1115 waivers and the ARRA and PPACA MOE requirements is
addressed in the following State Medicaid Director Letter available at https://www.cms.gov/smdl/downloads/
SMD11001.pdf.
22 See http://media.khi.org/news/documents/2011/03/10/Health_Care_Waiver_Request_Letter.pdf.
23 See http://media.khi.org/news/documents/2011/04/08/
Secretary_Sebelius_Response_to_KS_Governor_Brownback_033011.pdf.
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CHIP Maintenance of Effort Requirements Under
PPACA

This CHIP-specific MOE provision generally requires states to maintain income “eligibility
standards, methodologies and procedures” in effect as of March 23, 2010 through September 30,
2019, as a condition of receiving federal matching payments under Medicaid. Specifically, with
the exception of waiting lists for enrolling children in CHIP or enrolling CHIP-eligible children in
exchange plans when federal CHIP funding is no longer available, states cannot implement
eligibility standards, methodologies, or procedures that are more restrictive than those in place on
the date of enactment of PPACA. However, states can expand their current income eligibility
levels—that is, states can enact less restrictive standards, methodologies, or procedures.
State Actions
Prior to PPACA, Arizona planned to “eliminate the KidsCare [CHIP] program effective June 15,
2010.”24 However, the state did not take these actions. Arizona does, however, have HHS
approval to freeze its CHIP program enrollment because Arizona’s CHIP enrollment freeze was
in place prior to the enactment of PPACA (i.e., effective January 1, 2010). In a letter dated May
17, 2010 from Victoria Wachino, the Director of the Family and Children’s Health Programs
Group at the Centers for Medicare and Medicaid Services (CMS), to Ms. Monica Coury, the
Assistant Director of the Office of Intergovernmental Relations for the state’s Arizona Health
Care Cost Containment System (AHCCCS), CMS stated:
Prior to the enactment of the Affordable Care Act, Arizona had an approved State Plan to
freeze enrollment and had stopped enrolling new children in CHIP pursuant to its eligibility
freeze. Since the enrollment freeze was an eligibility procedure in place as of the March 23,
2010, MOE date, we do not believe that the continuation of the enrollment freeze would be a
change in Arizona’s eligibility procedures that would trigger an MOE violation.25
Recent Legislative Activity
To obtain fiscal reprieve, some states have pondered either dropping out of Medicaid entirely or
scaling back on eligibility.26 Recently, states have been seeking congressional relief from the
MOE requirements, to provide them with greater flexibility to restrain Medicaid expenditures
through eligibility restrictions. On May 3, 2011, the House of Representatives introduced H.R.
1683, the State Flexibility Act, which would repeal the MOE requirements for Medicaid and
CHIP included in ARRA and PPACA.

24 Letter from Arizona Health Care Cost Containment System (AHCCCS) Assistant Director Monica Coury to Moe
Gagnon, CMS, March 18, 2010, http://www.azahcccs.gov/shared/Downloads/News/Cover_Letter_KC_Elim.pdf.
25 See http://www.azahcccs.gov/reporting/Downloads/Legislation/2010seventh/12_7_2010AZ_CHIPltr0001.pdf, and
http://www.azahcccs.gov/reporting/Downloads/Legislation/2009fifth/
CMS_clarification_re_enrollment_freeze_5_17_10.pdf.
26 For example, see “States’ Woes Spur Medicaid Drop-Out Talk,” Emily Ramshaw, The Texas Tribune, November 12,
2010.
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CBO and the staff of the Joint Committee on Taxation (JCT) estimated that enacting H.R. 1683
would reduce the federal deficit by approximately $2.1 billion over the 2012-2021 period.27 Their
estimate includes the net impact on direct spending and revenues from changes in enrollment in
Medicaid, CHIP, health insurance purchased through exchanges, and employer-based health
insurance. Of this amount, CBO estimates that federal Medicaid spending would decline by
roughly $1.5 billion over the five-year period (2012-2016), with no additional savings or costs
occurring in next five years of the budget window. For CHIP, CBO estimates that federal
spending would decline by an estimated total of $8.8 billion over 10 years. The Medicaid and
CHIP savings would be largely offset by increased enrollment in employer-sponsored plans and
additional exchange subsidies.28
With regard to enrollment, CBO estimates that H.R. 1683 would reduce Medicaid and CHIP
enrollment by about 400,000 individuals in 2013, of which approximately 300,000 would become
uninsured and 100,000 would enroll in employer-based coverage. In 2014, individuals would be
eligible for Medicaid based on the new income requirements established in PPACA, eliminating
the impact of repealing MOE requirements on Medicaid enrollment. In 2016, CBO estimates that
CHIP enrollment would decline by about 1.7 million individuals, while employer-based insurance
would increase by 700,000. Relative to current law projections, approximately 300,000
individuals would become uninsured in 2016.

Author Contact Information

Evelyne P. Baumrucker

Analyst in Health Care Financing
ebaumrucker@crs.loc.gov, 7-8913


Acknowledgments
The author would like to thank Alexandra Rothenberger, a former intern with the Congressional Research
Service, for her work on an earlier draft of this report.


27 CBO cost estimate of H.R. 1683, May 11, 2011, available at http://www.cbo.gov/ftpdocs/121xx/doc12184/
hr1683.pdf.
28 CBO’s estimate includes increased costs of about $8.1 billion over 2012-2021 (numbers may not add due to
rounding) for premium and cost-sharing subsides for health insurance offered through the exchanges, as well as
reduced revenues reflecting the change in the mix of compensation provided to workers between taxable wages and
salaries and nontaxable health insurance benefits.
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