What Can States Do to Reduce Risk of Children Unfairly Losing Health Insurance

In part 1 of this blog series, my colleague and report co-author Joan Alker, explained the dire consequences if states don’t put in the time and effort to get renewals right when the Medicaid continuous coverage provision is lifted. This blog will focus on how we developed risk assessments for children in all 50 states and D.C. and what can be done to improve their odds of retaining the health coverage they need to succeed.  We started by looking at proven policies that promote enrollment and retention, as well as state administrative procedures that have a significant impact on Medicaid enrollment and churn. We also know that CHIP program design also makes a difference so we took that into account as well.

We choose 5 of these factors where data was available on a 50-state (+ D.C.) basis to assess the potential risk for churn or loss of health coverage. The more risk factors a state has, the more likely children will experience a gap or lose health coverage.

  • 34 states operate separate CHIP programs, which often means that children may face transition barriers, including handoffs to a separate entity, different plans or provider networks, and ineligibility for children with special health care needs who use Medicaid to provide wraparound services.
  • 27 states do not have 12-month continuous eligibility in Medicaid; these children may make it through renewal, but are at risk for loss of coverage between renewals due to temporary income fluctuations or periodic data searches that may identify discrepancies that are not accurate – case-in-point – what is going on in Missouri recently with LexisNexis address searches identifying people with the same name in other states.
  • A state’s success in conducting administrative or ex parte renewals using data sources available to the state, such as quarterly wage data, creates administrative efficiencies while reducing procedural disenrollments. In this analysis, we identify states not conducting ex parte renewals, or whose administrative renewal success rate is less than 50 percent or are unable to report the share of renewals conducted administratively.
  • Premiums and affordability are known barriers to all types of health insurance. It’s an even more significant barrier for families with income below twice the poverty.

States were given a red flag for each of the five factors that put children at higher risk of experiencing disruptions in coverage or becoming uninsured. The states with five flags are Delaware, Georgia, Florida, Missouri, Nevada, and Texas. However, children in every state could inappropriately lose health coverage when the continuous coverage requirement is lifted.

Potential Barriers for Children Transitioning from Medicaid to CHIP

Unfortunately, limited availability of state-level data precludes incorporating administrative procedures that promote stability in coverage in this analysis. For example, children are at less risk in states that follow up with enrollees through multiple modes of communications when action is required. Our goal was to highlight known risks but it’s important to point out that in a state with proven enrollment and retention policies but poor administrative processes, a child could face more risk than indicated by this analysis. Likewise, a child in a state that has not adopted proactive enrollment and retention policies but has effective administrative processes in place, may face a lower risk.

For example, Ohio has good enrollment and retention policies but has contracted with a third-party vendor to conduct data searches to identify potential ineligibles that would be prioritized for renewals and not just those with an increase in income. These kinds of data searches can quickly go awry, as evidenced by the recent Missouri experience. Missouri’s contract with LexisNexis has mistakenly flagged people with the same name who live in a different state resulting in the state sending termination notices to Missourians who have not moved and remain at their original address. These families now have to send proof of residency to the state to retain coverage, which puts additional administrative burden on families and state workers. On the other hand, Massachusetts has not adopted many of the enrollment and retention policies that promote coverage. Yet, the state has consistently had one of the lowest child uninsured rates in the country.

There are many strategies and actions that states can take now -- particularly since it appears we can assume that the PHE will be extended again on or before April 16. These actions fall into two broad buckets: administrative and the approach to resuming normal operations.

On the administrative side, states should:

  • Maximize use of existing data sources to confirm ongoing eligibility for as many people as possible now to reduce backlogs of pending actions
  • Take advantage of new guidance from CMS to work with MCOs on updating addresses and supporting the renewal effort
  • Enhance processes to follow-up with enrollees via multiple communication modes when action is required to avoid a loss of coverage. (We know that kids routinely lose coverage when Medicaid renewals take place, sometimes just because the renewal letter gets lost in the mail.)
  • Conduct outreach campaigns to reach enrollees directly and through plans, providers, other assistance programs like SNAP, and community-based organizations that serve children and families

In terms of how states approach and manage the unwinding:

  • It is critical that states balance the timeline for resuming routine operations with the size of the backlog of pending actions and workforce capacity. States that have high success rates in conducting ex parte renewals will have a smaller backlog of work that has been delayed and may be able to move more quickly.
  • There is a lot of talk about transparency and accountability in government but not as much action. States should be transparent in sharing their unwinding plans and be accountable by timely reporting of key performance metrics to monitor the unwinding, including call center statistics and the share of disenrollments due to procedural reasons.
  • Most importantly, unreasonable call wait times and increasing loss of coverage due to procedural reasons should trigger action by the state and oversight from CMS. States should be prepared to slow down the process or hit the pause button and take time to review and refine the plan and state processes to avoid large numbers of children and adults from becoming uninsured.

Millions of Children May Lose Medicaid: What Can Be Done to Help Prevent Them From Becoming Uninsured?