Policy Options: How to Regain Momentum on Medicaid/CHIP Enrollment

See our full blog series on evidence-based policies available to policymakers to prevent more eligible children from losing health coverage.

As Say Ahhh! readers know, we began reporting on the precipitous drop in Medicaid and CHIP enrollment earlier this year after child enrollment had declined by more than half a million kids, which has now grown to more one million fewer children. Low-income children historically lack access to affordable private insurance, and there was scant evidence to suggest that had changed. So, we anticipated that many of these children would show up among the ranks of the uninsured. The release of the Census Bureau’s top-line health insurance data for 2018 confirmed our fears that the number of uninsured children would rise. In fact, there were 425,000 more uninsured children in 2018 compared to 2017, according to the Current Population Survey (CPS).

In May, we released a report that analyzed the enrollment decline and discussed various contributing factors. The brief also summarized a number of strategies and steps that states can take to ensure that all eligible children are able to enroll and retain coverage, including these policy options:

12-Month Continuous Eligibility

Low to moderate-income families experience substantial fluctuations in income from month-to-month. According to the U.S. Financial Diaries Project, they experienced an average of 2.5 months in which income fell by more than 25 percent, and 2.6 months in which income was 25 percent higher than average. As a result, many families with children covered by Medicaid and CHIP may churn in and out of coverage. A key policy to mitigate churn is for states to implement 12-month continuous eligibility for children.

12-month continuous eligibility can be adopted through a straightforward state plan amendment. Nearly one-third of states (32) have adopted the policy in Medicaid and/or CHIP, although eight of those states offer it only to more moderate-income children in CHIP. Ensuring continuity of coverage for children can improve child health outcomes, avoid increased health care costs that occur during or after coverage gaps, and provide a more accurate picture of the quality of care children receive in Medicaid. The current push toward more frequent and stricter reviews of eligibility in a number of states makes it even more critical to protect children from the inevitable churn that results when states put administrative barriers between children and health coverage. 

Express Lane Eligibility

Families living in or near poverty are often eligible for other means-tested public assistance such as the Supplemental Nutrition Assistance Program (SNAP). By adopting Express Lane Eligibility (ELE), states may use the findings from other public programs to verify Medicaid eligibility. This strategy eliminates duplication of administrative effort and protects families from having to jump through more hoops and provide the same information to multiple agencies.

Like 12-month continuous eligibility, ELE can be adopted through a state plan amendment. States may use ELE to enroll and/or renew eligibility Medicaid and/or CHIP. How the policy is implemented – such as using technology to automate the process – makes a difference in the overall results but a national evaluation has found that ELE can increase enrollment and retention.

Presumptive Eligibility

States that struggle with new eligibility system implementation or other changes may have significant backlogs in processing new applications. Additionally, children often lose Medicaid and CHIP at renewal for a variety of administrative – not eligibility-related – reasons. The resulting delays or gaps in coverage put children’s health at risk and may drive up costs when care is delayed.

Using presumptive eligibility (PE), states train qualified entities to assess Medicaid and/or CHIP eligibility and temporarily enroll children while the regular application is being processed. PE is also an excellent tool for re-enrolling children who have lost coverage due to administrative glitches and red tape. Afterall, there are many reports of families not knowing that their children have been disenrolled until they show up at the doctor’s office. Like the other policies featured in this blog, PE can be adopted through a state plan amendment. States have a choice of qualified entities but health care providers top the list since they are most likely to encounter eligible children who are uninsured and in need of care. Getting that care quickly can nip health problems in the bud before they become more extensive and expensive to treat.

Other Policy Options

There are other policy options that states may adopt to promote enrollment and retention. For example, states should examine their cost-sharing policies. Premiums are a known barrier to enrollment and some states impose lockouts – a period of time a child cannot re-enroll following nonpayment of premiums – that contribute to churn. A number of states also require that children be uninsured for a specified period of time before they are eligible for CHIP, although there is no federal requirement to delay enrollment. Since 2014, 22 states actually eliminated their waiting periods. Last but not least, states can expand coverage to lawfully residing immigrant children without imposing the five-year waiting period.

This is the second post in our blog series highlighting the many opportunities available to regain enrollment momentum and reduce the number of uninsured children. In future blogs, we’ll dive into other ways states can connect all eligible children with coverage by boosting outreach and consumer assistance, maximizing the use of technology, and enhancing state procedures and processes.

Tricia Brooks is a Research Professor at the Center for Children and Families (CCF), part of the McCourt School of Public Policy at Georgetown University.