Friday, November 19, 2021

Signposting likely Medicaid eligibility without muddling the message

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The Missouri Medicaid expansion  -- mandated by referendum, denied funding by the state legislature, and enacted only after the Missouri Supreme Court so ordered -- is off to a slow start, with the administration of Republican Governor Mike Parson declining to do much outreach. Enrollment of those rendered newly eligible by ACA expansion criteria began on October 1.

News of the slow start led me to check whether has been retooled to tell Missouri visitors who use the site's see plans and prices tool that they're likely eligible for Medicaid if they input an income below the eligibility threshold. is not the primary means by which people enroll in Medicaid, but it's a "no wrong door" channel.

Yes, has has been updated. That's not surprising -- it's had to absorb about a dozen late Medicaid expansions.  But the check underscored to me that messaging on the site for those likely eligible for Medicaid (in all expansion states) could be clearer.  

Here's what you see if you input an income below the eligibility threshold (here, $17,000 for a solo applicant in zip code 63111 in St. Louis): 

This could be worse: the app does tell you that you may be eligible for Medicaid (it would be nice if the technology could cut out CHIP when no children's ages are input, but let's not be fussy...) and invite you to learn more.

But there's a fair amount of visual and grammatical interference here. The messaging presumes that the user has a grasp of the difference between "plans" and "Medicaid or CHIP." The messaging about "plans" (unsubsidized!) takes up more space and arguably commands more visual attention than the information about Medicaid and CHIP.  The pronoun "they" in "They won't be covered" doesn't have a clear antecedent, and doesn't "agree with" a solo antecedent, unless she's blessed with gender sensitivity with regard to pronouns.

Contrast the messaging and visual display for a likely Medicaid-eligible visitor to HealthSherpa, the dominant commercial Direct Enrollment platform:

Two features stand out: 

1) There is no mention of marketplace plans, since the prospective enrollee does not qualify for a subsidy (if he entered his income correctly) 

2) There is a very large "continue" button., in contrast, invites the user only to "learn more about Medicaid and CHIP," without so much as an invitation to start an application. 

Less important but also helpful: the page refers to the name of the state Medicaid program, MO HealthNet, rather than "Medicaid." The latter carries a stigma to many ears -- and for that very reason, many states brand their Medicaid programs with different names. has come a long way since its launch in fall 2013. It's got a clearer interface and is easier to use than most state-based exchanges. But HealthSherpa, which accounted for 23% of enrollment (via the Direct Enrollment interface, and mostly through brokers) in 2021, has continued to hone a more streamlined, better-signposted interface.  

P.S. Even more importantly, in states that have refused to expand Medicaid and so have a "coverage gap" (offer no help) to applicants with incomes below the poverty line, HealthSherpa tells shopper how high their income needs to be to qualify for marketplace subsidies ($12,880 for an individual) - - and doesn't.


  1. As you have pointed out in various ways in this post and other posts, poor and often intentionally misleading information from both the government and private sources is a problem, and it often makes the U.S. health insurance system quite the minefield.

    Thus, around the financial minefield problem that ACA expanded Medicaid coverage and other ordinary non-long-term-care Medicaid coverage is estate recovered in many states for people receiving that "coverage" while 55+, the notice of that recovery is either missing or muddled on the exchanges and applications.

    Given the existence of that estate recovery, a clear understandable notice would be:

    "If at any time in the future the state estimates your income as under 138% of the Federal Poverty Level, you will be automatically switched to expanded Medicaid. In that case, your estate will be liable for either a fixed annual capitation payment, or all medical bills that were paid out, at the state's option.

    If you wish to avoid these financial consequences, you can do so by choosing to apply for an unsubsidized ACA plan, which is always an option to you, if you can afford it. Choose the separate.pdf application 'with no help paying costs from the government', or similarly apply at the website and check 'I want no help paying costs from the government'."

    Instead of a clear useful notice, such as the above, the Federal-exchange notice of the recovery is apparently omitted, as on the .pdf version here: (Medicaid relevant notices are on paginated p. 7, and you will note nothing about the recovery.)

    A case where the state has its own exchange, (and does exercise its Federally-granted option to do the estate recovery of expanded Medicaid and other non-long-term-care Medicaids for people 55+), is Massachusetts.

    In that case, as the .pdf version of the application shows, ( ), the notice is easy to miss, as it is buried as item (10) right in the middle of two full pages of notices (on adobe p. 20-21), most of which are benign "you agree that we can check your finances with your employer, etc." type of stuff.

    Further, that Massachusetts notice requires a person to understand the structure of the ACA (e.g. who gets Medicaid and expanded Medicaid vs. normal on-exchange insurance), and even if they do, requires the person to hire a lawyer to figure out what is "the extent permitted by law".

    And, as well, if they want to try to avoid the recovery, to figure out from somewhere that they do have an option of paying full price for an unsubsidized on-exchange plan. (ACA rules prevent a person from getting a subsidized ACA plan if they are eligible for expanded Medicaid or any other Medicaid, but allow a person to get a non-subsidized one at full cost.)

    Is the notice from private commercial sources any better? Well, a few weeks ago, in response to your positive reviews of information as provided by HealthSherpa, I took a look a that site, focusing on the issue of whether they warned of estate recovery on Medicaid and expanded Medicaid, and I didn't see it. (You can correct me if I missed it, or they added it since.)

  2. Appendix:

    For those unfamiliar with the issue of estate recovery in many states of ACA expanded Medicaid for people 55+, Andrew has covered it at least twice. One such blog post of his is this:

    and between the post and the comments, you will find the issue decently explained, with some references as well.


    (Separately, although for the subject of Andrew's post, Missouri, whether Medicaid estate recovery hits expanded Medicaid in Missouri is not easy to find, a person I know researched this over the phone, and indicated that Missouri does recover expanded Medicaid. Further, they indicated they had researched that a few years ago, it did NOT estate recovery non-long-term-care Medicaids, but apparently switched to recovering non-long-term-care Medicaids for people 55+ in response to the expansion of Medicaid.)

    1. Thank you Mr. Spier for all your posts about this. Do the states that recover ACA expansion attempt to recover 100%, or just the 10% of the cost that wasn't reimbursed by the Feds? It's outrageous either way, but unbelievably egregious if they are trying to get 100%.