Improving State Administration and Procedures to Regain Medicaid/CHIP Enrollment Momentum for Kids

As Say Ahhh! readers know, in May, we released a comprehensive report showing that child enrollment dropped by nearly 1 million children in 38 states in 2018 and have continued to track the growing enrollment decline in Medicaid and CHIP. Data recently released by the U.S Census Bureau underscores the need to for policymakers to focus on this alarming trend for children’s health coverage showing the number of uninsured children increased for the second year after a decade of gains.

In addition to discussing various factors contributing to the decline, our report summarized a number of strategies and steps that states can take to reverse the negative enrollment trend. In this blog series, we are taking a closer look at the policies and actions that are proven to promote enrollment and retention. This fifth installment focuses on ways to improve state processes and procedures, while increasing state administrative efficiency.

Improve State Processes and Procedures

Improve Notices – Notices have been a long-standing problem in Medicaid. Among the issues, beneficiaries report receiving confusing notices or multiple, conflicting notices. Agencies should work with literacy experts and field test notices directly with consumer groups and consumers to ensure that families are able to understand the purpose of the notice and what action, if any, is required of them. For example, community health centers are great places to test the effectiveness of notices. While beneficiaries are waiting to see a provider, they can be asked to read a notice and relay what they think it means. In New Hampshire, we teamed up with Walmart to provide nominal gift cards as an incentive for participation.

Perform Quality Control – Notices get lost in transit or never actually sent due to system glitches. State should have quality monitoring processes in place to ensure that batches of mail are generated and processed appropriately.

Be Proactive in Keeping Addresses Up-to-Date – Just because a family has moved doesn’t mean their children are no longer eligible. A number of states are automatically terminating coverage when mail is returned even when they don’t offer online accounts or have high functioning call centers for families to easily report address changes. There are a variety of services or software available to update addresses so states can avoid the expense of printing and mailing letters to out-of-date residences while sparing families the problem of losing coverage for their children due to out of date addresses. States can also use claims data and work with providers or managed care plans to assist in keeping addresses up to date and promote continuity of coverage.

Send Follow-Up Reminders – When beneficiary action is required, sending reminders via mail, email, and/or phone can improve the response rate to ensure that eligible children don’t lose coverage. Electronic or phone communications are attractive from a cost perspective and have become a preferred method of communication for many families.

Eliminate Auto-Closures – Automation of eligibility determinations in real time and ex-parte (automated) renewals make sense when the determination results in enrollment. However, using automated systems to cut eligible children off health coverage puts children at risk. States have an obligation to review available data to determine if beneficiaries qualify for another category of coverage before coverage is terminated. Systems that automatically close cases before checking other public benefits and claims data to assess and verify ongoing eligibility are contributing to the loss of coverage for eligible children.

Enlist the Help of Providers and Managed Care Organizations – Managed care plans have a vested interest in maintaining ongoing coverage for eligible children. Enlisting their help in reaching out to families to assist with the renewal process can improve retention. Many states have systems in place for providers to check the enrollment status of patients. Adding features for providers to submit address changes would be useful.

Reject Aggressive Tactics to Conduct Frequent Reviews – Low-income families move frequently and experience significant income volatility. The ACA was intended to smooth out eligibility by moving to 12-month renewal periods but when states aggressively troll for data to identify changes that are often temporary they exacerbate the problem of churn in which children cycle on and off Medicaid or CHIP. While states have an obligation to act on information they receive that impacts eligibility, there is no requirement to aggressively seek information to identify discrepancies or changes as some conservative interests are pushing. Hiring third party contractors to rack up administrative costs will inevitably result in the loss of coverage for some children.

Adopt a Culture of Coverage – The experience of states that embrace a culture of coverage is evident in coverage and retention rates. Take Louisiana, for example, a state that achieved success in keeping eligible children enrolled at renewal. Through a variety of tactics outlined in this brief, Louisiana saw less than 1 percent of children losing coverage at renewal due to procedural reasons.

This is final installment on our blog series on opportunities for states to regain enrollment momentum and reduce the number of uninsured children. In the series, we’ve outlined many policies and strategies that states can adopt and implement to ensure that eligible children are enrolled and can retain their access to health care without gaps in coverage. But ultimately, the question is one of political will and leadership. Providing children with health care is critical to their success in school and in life; it’s also essential to bending the health care cost curve by investing in keeping children healthy and a smart investment in our nation’s future workforce. How we approach public coverage for children and low-income families says a lot about who we are as a nation. We can and should do better.

Tricia Brooks
Tricia Brooks is a Research Professor at the Georgetown University McCourt School of Public Policy’s Center for Children and Families

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