This article examines changes in children’s eligibility for Medicaid and SCHIP and their effect on coverage. Between 1996 and 2001, the number of children eligible for public insurance programs nearly doubled, and the number of children enrolled in public coverage grew during the post-expansionary period (2001-2005), even as eligibility levels remained steady.

This report reviews discussion during the 2007 SCHIP reauthorization debate on the number of children who are uninsured but eligible for Medicaid or SCHIP. It shows that the Congressional Budget Office concluded that there are between 5 and 6 million children, which is in sharp contrast to estimates recently by the Bush Administration indicating there were only 1.1 million eligible but uninsured children. This brief describes the methodologies underlying the two sets of estimates that have been at the center of the controversy.

This brief addresses coverage patterns among SCHIP-eligible children and their policy implications. It estimates that close to 2 million children who are eligible for SCHIP remain uninsured. Most SCHIP enrollees do not have access to employer-sponsored health insurance, and about four in ten SCHIP enrollees live with a parent who is uninsured. The study concludes that if SCHIP is not adequately funded, millions of eligible children will remain uninsured and that other children who lose SCHIP coverage will likely become uninsured. 

In an analysis based on the 2005 Current Population Survey, the authors estimate that approximately 80 percent of the uninsured are currently eligible for public health insurance coverage or live in families with income below 300% of the federal poverty level. The report states that policy options to reduce the number of uninsured will vary depending on if the population is eligible for public coverage or if financial assistance is needed to obtain coverage.

In an analysis based on the 2005 Current Population Survey, the authors estimate the share of uninsured Americans eligible for coverage through Medicaid or SCHIP. Seventy-four percent of uninsured children were found to be eligible for public coverage. The report states that reducing the number of uninsured among those eligible for public programs will require extensive outreach efforts and simplified enrollment and redetermination procedures.

The authors estimate that there are 4.5 million uninsured children who are eligible but not enrolled in Medicaid or SCHIP. This study estimates how health services utilization and expenditures for the eligible but unenrolled compare with those of children who are already enrolled and finds that the children who are unenrolled would be about 25% less costly than those children currently enrolled.

In early 2007, eleven focus groups were conducted with low-income parents in Chicago, Houston, Los Angeles and Miami. This report explores their perceptions, motivations, and experiences enrolling their children in Medicaid and SCHIP.

This study recruited uninsured Latino children and their parents from community sites in Boston to examine the effect community case managers have on the process of obtaining and keeping health insurance coverage among Latino children. Children assigned a case manager were about eight times more likely to obtain health insurance than children who received only traditional Medicaid and SCHIP outreach and enrollment assistance. Children with case managers also had higher rates of continuous coverage, they obtained health insurance in less time, and their parents were significantly more satisfied with the process of obtaining coverage. 

This report presents the findings of a survey of eligibility rules, enrollment and renewal procedures and cost-sharing policies in Medicaid and SCHIP for children and families in effect in the 50 states and the District of Columbia in July 2004. The report shows that the reintroduction by states of procedural barriers have made it harder for eligible children to enroll and stay enrolled in coverage. It documents the impact these procedural barriers have on enrollment in states.

This report contains the results of case studies and qualitative interviews with state and local officials as part of a congressionally mandated evaluation of SCHIP. Over the first three years of the program’s implementation, states experienced rapid growth in enrollment due, in part, to extensive outreach campaigns and a simplified enrollment process. Case study respondents regard SCHIP as a successful program, providing low-cost, comprehensive benefits and improved access to care for enrollees.

This paper examines outreach efforts to increase take-up of public programs among the Medicaid-eligible population in California.  Outreach efforts studied include bilingual application assistance and state-wide English- and Spanish-language television campaigns. The results indicate that outreach efforts targeted toward Asian and Hispanic children had the largest effects in increasing enrollment and that increasing Medicaid enrollment before a child gets sick leads to a decline in the number of hospitalizations for conditions that could have been avoided if treated with timely primary care. Another version of this paper, Got Health? Advertising, Medicaid and Child Health, is also available.

The Children’s Health Insurance Program Reauthorization Act (CHIPRA) of 2009 has the potential to transform children’s health care in the United States. This report analyzes selected provisions of the legislation that involve outreach and enrollment, as well as child health quality and measurement. Using input from interviews with a range of stakeholders and a panel of experts, the report provides a set of recommendations for the federal government officials charged with implementing CHIPRA.

On July 6, 2009, HHS Secretary Kathleen Sebelius and Medicaid Director Cindy Mann announced a request for a first round of outreach grant proposals funded through CHIPRA. This brief provides an overview of the grants and the requirements for applicants.

This paper proposes a policy of effortless enrollment that uses existing information from the tax system and other secure government databases to enroll eligible families in Medicaid and CHIP without the need for those families to complete an application or renewal form. The effortless enrollment policy is expected to cover more than 8 million uninsured children and adults, while saving about $3.2 billion in administrative costs each year.

Automated enrollment strategies have achieved remarkable results with a range of public and private benefit programs, dramatically increasing program participation while lowering ongoing operating costs and reducing erroneous eligibility determinations. CHIPRA should make such steps much easier for states to take in helping eligible but uninsured children obtain and retain health coverage.

In 2006, NASHP convened a symposium of state and national child health coverage experts from the public and private sectors to focus on lessons learned over the decade since SCHIP was enacted. This paper revisits the discussions to provide more concrete information for states seeking to take the next step in enrolling more uninsured children who are eligible for Medicaid or SCHIP, but not enrolled.

Overall, more than one-third of the states (19 states) took steps last year to increase access to health coverage for low-income children, pregnant women, and parents –- including 15 states that authorized or implemented coverage expansions. At the same time, 10 states enacted at least one measure to restrict access. The data from this report is also available at Facts and Statistics.

This policy brief discusses several short-term options for strengthening Medicaid at time when the economic recession has increased demand for the program and constrained state budgets. It details potential steps such as increasing federal funding, easing enrollment barriers and temporarily expanding coverage

This report highlights states' innovative use of health information technology in their Medicaid and SCHIP programs to improve their ability to reach and enroll eligible children, improve the quality of care for children, increase communications with families, and continue to modernize their programs. Although many of these efforts are still in their early stages, findings to date indicate improvements in access to care, care coordination, case management, and administrative efficiency.

SCHIP reauthorization in 2007 provides an opportunity for Congress to adopt policies that help assure that children can gain the coverage they need and for which they already qualify. To make progress, the cost concerns of states must be addressed and new tools for identifying and enrolling eligible uninsured children must be implemented. This issue brief describes the barriers to covering additional uninsured but eligible children, as well as the options for addressing them.

Children fail to enroll and/or lose coverage primarily due to misinformation, difficult enrollment and renewal procedures, and inefficient administrative practices. This report explores how technological innovations can be applied to remove these impediments for Medicaid and SCHIP enrollment and retention, while at the same time making the programs more efficient.

This report illustrates the many creative and collaborative ways the Covering Kids & Families coalitions worked to break down barriers to public health coverage for low-income children and adults. From 1997-2002, these coalitions encouraged the adoption of outreach, simplification, and coordination strategies across the states. 

As Congress began to debate SCHIP reauthorization in 2007, policymakers examined what prevents eligible children from enrolling in either SCHIP or Medicaid. In February 2007, the Alliance for Health Reform held a briefing to discuss the success of state outreach, enrollment, and retention efforts, as well as the role of community and private sector partners. A transcript of the briefing is provided; for additional resources, see the Alliance for Health Reform.

By focusing efforts on those children that are eligible for public coverage, up to 95% of the uninsured children can be covered. This report details a 10-step plan for opening doorways to Medicaid and SCHIP coverage for all of these eligible children.

This article outlines the efforts states have undertaken to enroll and retain eligible children in Medicaid and SCHIP. Among the successful changes are simplified eligibility procedures, the use of community-based application assistance (help from schools, child-care providers, and faith-based organizations in understanding and applying for the programs), streamlining enrollment procedures between Medicaid and SCHIP, and reaching out to eligible families to encourage them to enroll. The authors urge states to continue making it easier for families to enroll and renew coverage for their children in public programs by eliminating waiting periods, enrolling children through other benefit programs such as food stamps, and continuing outreach programs.

The CHIP law enacted in 2009 includes a number of important program and financing changes that affect both Medicaid and CHIP. One important change is that CHIPRA extends the requirement to document citizenship that applies in Medicaid to CHIP as well. At the same time, the new law modifies current requirements to reduce the paperwork burden on families and states and helps ensure that eligible children and others are enrolled and receive the health care they need without delay.

The DRA of 2005 included a provision that requires individuals to provide proof of their United States citizenship and identity when applying for (or renewing) health coverage under the Medicaid program. In 2009, CHIPRA extended the documentation requirement to children applying for the CHIP. This paper reviews the parameters of the requirement and describes the mechanisms that are available to states for confirming citizenship.

This report examines the impact that citizenship documentation rules have had on coverage stability in the public programs of seven states—Alaska, Arizona, Kansas, Louisiana, Ohio, Virginia, and Washington—and it finds that the rules have made the getting and keeping of children and families' coverage more difficult. The new requirements increased the complexity, administrative burden, and costs of enrollment and renewal in each state, and in some cases the rules even compromised other processes.

Three-quarters of all health centers continue to experience significant problems with the citizenship documentation requirements. Nearly one-half of health centers continue to report that disruptions and delays continue to affect their ability to arrange for specialty care and many affected centers report increased costs. The authors found that despite the fact that the DRA documentation requirements do not apply to SCHIP when administered as a separate program, one-third of health centers located in states with separate SCHIP programs reported that citizenship documentation requirements are being applied to SCHIP applicants.

Due to recent changes in federal law through the Deficit Reduction Act of 2005, individuals who declare that they are citizens for Medicaid eligibility purposes must present documentation that proves citizenship and documents personal identity. This report discusses issues related to Medicaid citizenship documentation, as well as proposed legislation that would affect the requirement.

Data from three states, Alabama, Kansas, and Virginia, show that white and African American children are much more likely than Hispanic children to have their Medicaid coverage delayed, denied, or terminated as a result of a citizenship documentation requirement that took effect in July 2006. These data provide further evidence that the requirement, purportedly aimed at preventing undocumented immigrants from improperly obtaining Medicaid, is instead overwhelmingly affecting U.S. citizens who are eligible for the program.

States reported that the citizenship documentation requirement resulted in barriers to access to Medicaid for some eligible citizens. Twenty-two of the 44 states reported declines in Medicaid enrollment due to the requirement, and a majority of these states attributed the declines to delays in or losses of Medicaid coverage for individuals who appeared to be eligible citizens. Of the remaining states, 12 reported that the requirement had no effect and 10 reported they did not know the requirement’s effect on enrollment.

This policy brief presents the initial results of the impact on health centers and their patients of federal Medicaid changes contained in the Deficit Reduction Act of 2005, that require applicants and recipients to document their citizenship. The results suggest that the requirements have caused a nationwide disruption in coverage for health center patients, with more than 90% reporting enrollment difficulties. The authors estimate that the documentation requirements will eliminate Medicaid coverage for between 2.2 and 6.7 percent of patients.

This study finds that the new Medicaid citizenship documentation requirements have had a much broader impact than expected, adversely affecting thousands of citizen children. The state has seen a significant decrease in the number of children enrolled in Medicaid in Virginia; 4-6 month delays in obtaining Medicaid coverage for Virginia children; an inability of citizen children to obtain medical care; and a dramatic increase in emergency room utilization by those caught up in lengthy eligibility determinations. The requirements have also increased costs and administrative burdens to state and local government agencies, requiring additional tax dollars.

This report shows that the Medicaid citizenship requirement is creating a barrier to health-care coverage for U.S. citizens—especially children—who are eligible for health insurance through Medicaid. In the eight months following implementation of the new requirement, an increasing number of states are reporting marked declines in Medicaid enrollment, particularly among low-income children, as well as significant increases in administrative costs as a consequence of the requirement.

This report provides an overview of the Medicaid citizenship requirement that took effect July 1, 2006. It details how it will effect an estimated 38 million current Medicaid beneficiaries, as well as an additional 10 million applicants, that are subject to the new requirement.

On July 6, 2006, the Centers for Medicare & Medicaid Services released interim final regulations implementing the new documentation requirement for Medicaid beneficiaries. This brief details the final regulations, as well as the risks to those affected.