By Jocelyn Guyer

After an intensive few weeks spent lugging around binders filled with the latest proposed rule on Medicaid and CHIP, we’ve finally done it!  Here is our very best shot at a concise(ish) list of the top issues of concern for kids in the proposed rule.  Comments are due this Thursday and, if you can swing it, we encourage you to jump in on the action. Here’s our draft comments to help you meet the deadline.

Develop a contingency plan for states not ready by October 1, 2013

The show starts on October 1, 2013.  That’s when the initial open enrollment period begins for Exchange coverage, as well as the date on which states are supposed to be able to start taking action on the single, streamlined application for Medicaid and CHIP purposes (though coverage won’t be effective until January 1, 2014 for those who are being made newly-eligible by the ACA).  I don’t think we are the only folks feeling some anxiety about the state of preparations.  So, we recommend that HHS adopt a clear timeframe and set of procedures for ensuring states are ready to go. And, if a state isn’t ready in time, we recommend it be required to accept the federally-facilitated Exchange’s (FFE’s) determination of who is eligible for Medicaid and CHIP until it can develop its own system (in compliance with federal law, please).

Eliminate CHIP waiting periods

This one was a no brainer for inclusion in our “top eight” list.  In a post-ACA universe where everyone is expected to have health insurance, it makes no sense to require uninsured children to wait up to 90 days to enroll in CHIP.  It would only delay children’s access to needed care and create confusion and hardship for families.  While HHS says these kids can temporarily enroll in APTC-funded coverage, we see no evidence that either the federal government or states have the enrollment systems in place to actually make this happen.  So, we recommend that the final rule get rid of CHIP waiting periods entirely.

Hold onto and improve those new “certified application counselors”

Let’s admit it.  Even those of us who work in health policy sometimes lose track of some of the eligibility and enrollment rules that apply in Medicaid, CHIP and subsidized Exchange coverage (really, it is so rare).  Just imagine being a family trying to navigate this universe. The proposed rule creates a new certified application counselor program (CAC) for Medicaid and CHIP with a parallel or coordinated program in the Exchange that should help. We strongly encourage HHS to retain the program in the final rule and strengthen it.  We want to make sure that community application counselors have the training and tools they will need to help people, including in communities where many people are limited English proficient.

Ensure that the babies of all women enrolled in Medicaid or CHIP are automatically signed up for coverage for the first year of life.

Congress has passed laws – on more than one occasion, we’d note – aimed at making sure that babies born to pregnant women covered by Medicaid or CHIP are auto-enrolled in coverage for their first, critical year of life.  We want this one to be done exactly right – no babies should slip through the cracks.  So, we recommend that the final rule apply to all babies born to women covered by Medicaid or CHIP, including those whose moms were covered under an §1115 waiver or as targeted low-income children in CHIP.  And, even if a mom moves to another state during her baby’s first year of life, we think the final rule should make it clear that her baby still can get Medicaid or CHIP.  Finally, HHS should clarify – though, goodness, we wish they didn’t have to – that states shouldn’t cut babies off of coverage when they turn one without first checking whether they remain eligible for Medicaid, CHIP, or, soon, subsidized Exchange coverage.

Provide former foster care children with a secure source of coverage up to age 26 even if they move to a new state

When Senator Mary Landrieu described her ACA provision requiring states to cover former foster care youth in Medicaid up to age 26, she said: “I was proud to work on a provision that Leader Reid included in this bill to ensure that every young person who ages out of the foster care system will be able to stay on Medicaid until the age of 26 starting in 2014 (italics added).”  So, we were deeply concerned to see that the proposed rule leaves it up to states to decide whether they want to provide Medicaid to former foster care youth who move to their jurisdiction from another state.  Not only do we think that Congress intended for all former foster care youth to receive secure coverage, including those who move to a new state, but we believe that the statutory language allows for such an interpretation.

Retain and strengthen the proposed simplifications to paper-based documentation of citizenship

All we can say is thank goodness and finally!  HHS has proposed to clean up the wretchedly complicated paper-based requirements for citizenship verification put into place in 2006. These requirements have proven burdensome and costly over the years, and resulted in the denial and delay of coverage for numerous citizen children, pregnant women and parents. While most people will have their citizenship status verified electronically in the months and years ahead, we’ll still need a paper-based backup. So, a big thanks to HHS for proposing a more realistic system for paper documentation.  Anyone else looking forward to the day when it will be just a bad memory that people were supposed to send their actual driver’s license – the original, not a copy — through the mail to show they were citizens?

Adopt a more inclusive definition of “lawfully present”

The definition of the term “lawfully present” can be a life-or-death matter, determining which immigrants will be eligible for affordable health care coverage. We support the most inclusive definition possible, that all who are lawfully present for immigration purposes should be considered lawfully present for purposes of health care and coverage.  In light of the high stakes associated with having health insurance, we don’t think this is a time to give undue weight to administrative considerations, such as ease of electronic verification through the DHS SAVE system, when defining “lawfully present.” An inclusive definition, of all those who are lawfully present, best fulfills the ACA’s goals of expanding access to affordable health coverage.

Clarify that the cost-effectiveness test for premium assistance includes the cost of cost-sharing protections

As states consider new options with respect to the intersection of public and exchange based coverage, it is essential that a strong cost-effectiveness test be applied to ensure that taxpayer dollars are spent wisely and that beneficiaries do not lose important benefits and cost-sharing protections should a state pursue this route.  So, we recommend that the final rule be crystal clear that the cost of a cost-sharing wraparound is included in the cost effectiveness test, as we think Congress intended.

For the more formal version of these comments with all of the gory details and legal and policy justifications, again, here’s the link.    And if you think we missed something important or got anything wrong, please let us know and quickly.