Kaiser - Holding Steady, Looking Ahead Medicaid and CHIP Report

8/8/2019 Kaiser - Holding Steady, Looking Ahead Medicaid and CHIP Report

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medicaid

kaisercommiss ion o n

uninsureda n d t h e

HOLDINGSTEADY,LOOKINGAHEAD:

ANNUALFINDINGSOFA50STATESURVEYOFELIGIBILITYRULES,

ENROLLMENTANDRENEWALPROCEDURES,ANDCOSTSHARING

PRACTICESINMEDICAIDANDCHIP,20102011

Preparedby:MarthaHeberlein,TriciaBrooks,andJocelynGuyerGeorgetownUniversityCenterforChildrenandFamiliesandSamanthaArtigaandJessicaStephensKaiserCommissiononMedicaidandtheUninsuredTheHenryJ.KaiserFamilyFoundationJanuary2011


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medicaid


kaisercommission

The Kaiser Commission on Medicaid and the

Uninsured provides in format ion and analys is

on heal th care coverage and access for the

low- income populat ion, wi th a special focus

on Medicaid s ro le and coverage of the

uninsured. Begun in 1991 and based in the

Kaiser Fami ly Foundat ion s Washington, DC

of f ice, the Commission i s the largest

operat ing program of the Foundat ion. The

Commission s work i s conducted by

Foundat ion s ta f f under the guidance of a b i -

par t i san group of nat ional leaders and

exper ts in heal th care and publ ic pol icy .

J a m e s R . T a l l o n

C h a i r m a n

D i a n e R o w l a n d , S c . D .

E x e c u t i v e D i r e c t o r


3/88

medicaid

kaisercommission o n


HOLDINGSTEADY,LOOKINGAHEAD:

ANNUALFINDINGSOFA50STATESURVEYOFELIGIBILITYRULES,

ENROLLMENTANDRENEWALPROCEDURES,ANDCOSTSHARING

PRACTICESINMEDICAIDANDCHIP,20102011

Preparedby:MarthaHeberlein,TriciaBrooks,andJocelynGuyerGeorgetownUniversityCenterforChildrenandFamiliesandSamanthaArtigaandJessicaStephensKaiserCommissiononMedicaidandtheUninsuredTheHenryJ.KaiserFamilyFoundationJanuary2011


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ACKNOWLEDGEMENTSTheauthorsextendourdeepappreciationtothestateofficialswhosogenerouslysharedtheirexpertiseandtimewithusbyparticipatinginthissurveyandhelpingustounderstandthenuancesanddetailsoftheirprograms. Thisworksimplywouldnotbepossiblewithoutthemandwegreatlyappreciatetheirimportantcontributions,especiallyinatimeofstrainedresources. TheauthorsalsowouldliketothankDonnaCohenRossforherworkonthenineearlieriterationsofthisannualsurvey,whichestablishedthestrongfoundationonwhichthisyear'ssurveybuilds. WealsoextendthankstoQursumQasim,internwiththeGeorgetownUniversityCenterforChildrenandFamilies,forherassistanceindatacollection.


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TableofContents

ExecutiveSummary.......................................................................................................1

I. Introduction......................................................................................................5II. PolicyandFiscalContextin2010.......................................................................5III. AboutthisSurvey..............................................................................................7IV. SurveyFindings..................................................................................................8

A.MedicaidandCHIPEligibility............................................................................. 9B.EnrollmentandRenewalPoliciesandProcedures............................................ 15C.PremiumandCostSharingRequirements........................................................ 20

V. Discussion..........................................................................................................21VI. Conclusion.........................................................................................................23VII. TrendandStatebyStateTables........................................................................25


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Figure 1

Number of States Improving Access to HealthCare Coverage, January 2010 January 2011

13

10

65

14

12

1

3

Total Children Pregnant Women Parents/Other Adults

Eligibility Enrollment/Renewal Procedures

SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the

Georgetown University Center for Children and Families, 2011.

ExecutiveSummaryIntroductionOverthepastyear,asthenationsattentionwasfocusedonthecountryscontinuingeconomic

problemsandthedebateoverthepassageofbroaderhealthcarereform,MedicaidandtheChildrens

HealthInsuranceProgram(CHIP)continuedtoplaytheircentralroleofprovidingcoveragetomillionsof

peoplewhootherwiselackaffordablecoverageoptions. In2010,thisrolewasmorepronouncedthan

everasfamilieslosingtheirjobsandaccesstoemployerbasedcoverageturnedtopublicprogramsin

growingnumbers. WithoutMedicaidandCHIP,manymoreindividualswouldhavebecomeuninsured,

addingtothe50millioncurrentlywithoutcoverage.Basedonasurveyofstateofficialsinall50states

andtheDistrictofColumbiaconductedbytheKaiserCommissiononMedicaidandtheUninsuredand

theGeorgetownUniversityCenterforChildrenandFamilies,thistenthannualreportprovidesan

overviewofstateactionsoneligibilityrules,enrollmentandrenewalprocedures,andcostsharing

practicesinMedicaidandCHIPduring2010,aswellasthestatusofcoverageasofJanuary1,2011,for

children,parents,pregnantwomen,andothernondisabledadults.

Asthesurveyfindingsillustrate,families

couldturntoMedicaidandCHIPbecause

nearlyallstatesheldsteadyormade

targetedimprovementsintheireligibility

andenrollmentrulesin2010,withatotal

of13statesexpandingeligibilityand14

statesmakingimprovementsin

enrollmentandrenewalprocedures

(Figure1). Thisstrikingstabilityinpublic

programscanbedirectlyattributedtothe

federalgovernmentsdecisionbothto

providetemporaryMedicaidfiscalrelief

tostatesthroughJune2011,andto

requirestatestomaintaintheirMedicaid

andCHIPeligibilityrulesandenrollment

proceduresuntilbroaderhealthreform

goesintoeffect.

During2010,statesalsowerestartingtolookaheadtoimplementationoftheAffordableCareAct(ACA)

and,insomeinstances,totakeadvantageofearlyoptionstoimproveMedicaidcoverage. Health

reformprovidesabroadexpansionincoveragethatwilltakeeffectin2014,includingextending

Medicaidtoanewnationaleligibilityfloorof133percentofthefederalpovertylevel($24,352fora

familyofthreeand$14,404foranindividualin2010). However,itisimportantforstatestobegintaking

stepsnowtoaddressthetechnologicalchangesnecessarytodeveloptheonline,consumerfriendly

enrollmentprocessenvisionedundertheACA. Althoughtherehasbeensomeprogressin2010,the

surveyhighlightsthatstatesstillhaveasignificantamountofworktobepreparedin2014. Looking

ahead,itwillbeimportantforstatepolicymakerstocontinuemovingforwardonimplementationwhile

sustainingthegainsandprogressmadeincoveragetodate.


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Figure 2

Childrens Eligibility for Medicaid/CHIP by Income,January 2011

AZAR

MS

LA

WA

MN

ND

WY

ID

UTCO

OR

NV

CA

MT

IA

WIMI

NE

SD

ME

MOKS

OHIN

NY

IL

KY

TN

NC

NH

MA

VT

PA

VAWV

CT

NJ

DE

MD

RI

HI

DC

AK

SC

NM

OK

GA

TX

IL

FL

AL


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Whilestateshavemadesignificantprogressinexpandingcoverageforchildren,eligibilityfortheir

parentscontinuestolagfarbehind. In2010,onlyonestate(CO)expandedMedicaidcoveragefor

parents.AsofJanuary1,2011,33states

donotcoverparentsupto100percentof

thefederalpovertylevel($18,310fora

familyofthreein2010). Themedian

eligibilitythresholdforparentsremainsat

64percentofthefederalpovertylevel

and16stateslimiteligibilitytobelow50

percentofthefederalpovertylevel

($9,155forafamilyofthreein2010).In

theabsenceoffurtherexpansions,these

restrictiveeligibilitylevelswillleavemost

uninsured,lowincomeparentswithout

anaffordablecoverageoptionuntilthe

healthreformexpansiongoesintoeffect

in2014(Figure3).

LowincomeadultswithoutdependentchildrenremainineligibleforMedicaidinthevastmajorityof

states. UndertheACA,Medicaideligibilitywillbeexpandedtoaminimumof133percentofthefederal

povertylevel,endingthehistoricexclusionofnondisabled,nonpregnantadultswithoutdependent

childrenfromtheprogram. WhilethischangeisnotrequiredtobeineffectuntilJanuary1,2014,states

havetheoptionofmovingearlytocovertheseadults. In2010,ConnecticutandtheDistrictofColumbia

tookadvantageofthisoptionandmovedlowincomeadultstheyhadpreviouslyservedthroughstate

fundedprogramstoMedicaid. Further,Californiareceivedapprovalin2010forawaivertocontinue

andexpandcountycoverageinitiativesservinglowincomeadults. However,evenwiththese

expansions,asofJanuary1,2011,onlysevenstates(AZ,CT,DE,DC,HI,NY,andVT)provideMedicaidor

Medicaidequivalentbenefitstoadultswithoutdependentchildren. Additionalstatesoffermore

limited

coverage

to

these

adults,

but

in

most

states,

low

income

adults

without

children

do

not

have

accesstopubliccoverageregardlessoftheirincome.

Statesadoptedimprovementsintheirenrollmentandrenewalproceduresin2010thathelpedto

reduceburdensonfamilies,streamlineadministrativeprocesses,andachieveprogramefficiencies. In

makingtheseimprovements,statesoftenturnedtooptionsprovidedbyCHIPRA.Specifically,29states

tookadvantageoftheCHIPRAoptiontomoreefficientlyandaccuratelyverifycitizenshipstatusby

relyingonanelectronicdatamatchwiththeSocialSecurityAdministration(SSA).Asmaller,butstill

notablenumberofstates,movedaheadwithothersimplificationmeasuresincludingtheCHIPRA

ExpressLaneEligibilityoption,aswellaslongstandingstrategiessuchaspresumptiveeligibilityand

continuouseligibilityforchildren. Manyappeartohavedonesoatleastinparttoqualifyforthe

MedicaidperformancebonusesincludedinCHIPRA. Thesebonusesprovideafinancialrewardand

recognitiontostatesthathaveimplementedatleast5of8simplificationpoliciesandthathavereachedspecificenrollmenttargetsforchildreninMedicaid.TheAdministrationencouragedstatesintheir

effortsbylaunchingtheConnectingKidstoCoverageChallenge,apartnershipofnationalandstate

organizationscommittedtoenrollingallfivemillionuninsuredbuteligiblechildreninpublicprograms.

Figure 3

Medicaid Eligibility for Working Parents by Income,January 2011

IL

AZAR

MS

LA

WA

MN

ND

WY

ID

UTCO

OR

NV

CA

MT

IA

WIMI

NE

SD

ME

MOKS

OHIN

NY

KY

TN

NC

NH

MA

VT

PA

VA

WV

CT

NJ

DE

MD

RI

HI

DC

AK

SC

NM

OK

GA

TX

FL

AL

50% - 99% FPL (17 states)


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Figure 4

Status of Online Applications forState Medicaid Programs, January 2011

51

3229

8

Available Online ElectronicSubmission

Electronic Signature IncomeDocumentation Not

Requested

Notes: In some states the online application is only available for children applying for coverage.

SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and theGeorgetown University Center for Children and Families, 2011.

Statescontinuedworktomodernizetheirprogramsandbeginpreparingforhealthreform

implementationbyfocusingontechnologicalimprovements.Anumberofstatesmadeprogram

improvementssuchasofferingapplicationsthatcanbesubmittedonline. Despitethisearlywork,the

surveyfindingshighlightthatstateshavealongwaytogotodeveloptheintegrated,technologydriven,

webbasedeligibilitysystemsforMedicaid,CHIP,andsubsidizedExchangecoveragethatareenvisioned

andrequiredunderreform.Forexample,allstates,includingDC,posttheirMedicaidapplications

online,butonly32accepttheelectronicsubmissionofthoseapplications. Amongthe32thataccept

electronicsubmission,29allowforthe

useofanelectronicsignature,butonly8

donotroutinelyaskfamiliestosubmit

paperdocumentationofinformationvia

mailorfaxbeforecheckingotherdata

sourcestoverifyeligibility(Figure4).In

lightofaruleproposedbythe

Administrationattheendof2010to

providestateswitha90percentmatching

ratetopreparetheirMedicaideligibility

systemsforhealthreformandthe

likelihoodofadditionalguidanceand

fundingopportunitiesinthemonths

ahead,itcanbeexpectedthatnextyears

surveywillshowmoredevelopmentsin

thisarea.

ConclusionAsimplementationofbroaderhealthreformmovesforward,thefindingsofthissurveydescribethe

foundationforcoverageoflowincomefamiliesandindividualsthroughMedicaidandCHIP. These

programswillplayanevenmoresubstantialroleintheyearstocome,particularlywiththeexpansionin

coverage

for

low

income

adults.

Valuable

lessons

can

be

learned

from

how

states

have

streamlined

and

simplifiedtheirenrollmentandrenewalproceduresintheseprograms,andwhileadditional

improvementswillbenecessarytofurthertransformMedicaidandCHIPinordertofulfillthepromiseof

reform,theyprovideasoundplatformonwhichtobegin.

Lookingahead,statesfacethechallengeofimplementingreformwhileatthesametimedealingwith

significantbudgetpressuresduetothenationscontinuingeconomicproblemsandthecorresponding

increasedneedforMedicaidandCHIP. Tocontinueforwardprogressonreformandkeepthe

foundationsolid,itwillbeimportanttofocusonsustainingthecoveragegainsandprogressmadeto

dateeveninthefaceofthesechallenges. Healthreformhasthepotentialtomarkedlyreducethe

numberofuninsuredandprovidesstatesnewopportunitiestomodernize,streamline,andcontinueto

improvetheirMedicaidprograms. Whilesomeofthemostsignificantchangesinhealthreformdonot

go

into

effect

until

2014,

it

is

important

for

states

to

lay

the

groundwork

now.

In

2010,

there

were

initial

signsofstateMedicaidagenciespreparingforhealthreformimplementation,butmoreactivitycanbe

expectedin2011.

4


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I. Introduction

Thepastyearmarkedthepassageofbroadhealthreform,whichwillexpandcoveragetomillionsof

uninsuredindividualsbeginningin2014. However,ongoingeconomicproblemspersistedthroughout

2010,continuingtoplacepressuresonfamiliesandstatebudgetsandleadingtocontinuedgrowthin

thenumberofuninsuredadults. Thistenthannualreportprovidesanoverviewofchangesmadeto

stateeligibilityrules,enrollmentandrenewalprocedures,andcostsharingpracticesinMedicaidand

CHIPin2010,aswellasasnapshotofpoliciesinplaceasofJanuary1,2011. Itisbasedonasurveyof

stateofficialsconductedbytheKaiserCommissiononMedicaidandtheUninsuredandtheGeorgetown

UniversityCenterforChildrenandFamiliesinall50statesandtheDistrictofColumbia.

ThesurveyfindingshighlightthatMedicaidandCHIPeligibilityruleswereremarkablystablein2010,

allowingtheseprogramstocontinuetoplaytheircentralroleofofferingcoveragetomanylow and

moderateincomefamilies. Thisrolewasmorepronouncedthaneverinthelastyear,asfamilies

increasinglyturnedtoMedicaidandCHIPastheylostjobsandaccesstoemployersponsoredinsurance.

Withouttheseprograms,manymoreindividualswouldhavebecomeuninsured. Thestrikingstabilityin

publicprogramscanbedirectlyattributedtothefederalgovernmentsdecisiontobothprovide

temporaryMedicaidfiscalrelieftostatesthroughJune2011,andtorequirestatestomaintaintheir

MedicaidandCHIPeligibilityrulesandenrollmentproceduresuntilbroaderhealthreformgoesinto

effect. Moreover,in2010,anumberofstateswentbeyondmaintainingcoveragetoimplement

targetedexpansionsandimprovementsintheirprogramsdesignedtoincreasecoverage,drawdown

additionalfederalmatchingfunds,and/orachieveprogramefficiencies.

Thereportbeginswithareviewofthefiscalandpolicyenvironmentinwhichstatesmadedecisions

aboutMedicaidandCHIPcoveragein2010. Itthenpresentsthemajorsurveyfindingsoneligibility

rules,enrollmentandrenewalprocedures,andcostsharingpractices,providingdataonstatepoliciesas

ofJanuary1,2011,andidentifyingchangesthatoccurredthroughout2010. Thereportconcludeswitha

discussionofthepolicyimplicationsofthefindings,focusingonthechallengesandopportunitiesfacing

states

as

they

continue

to

cope

with

budget

pressures

and

the

increased

demand

for

Medicaid

and

CHIP

andbegintoimplementreform.

II. PolicyandFiscalContextin2010

Overtheyears,stateshavemadesignificantprogressinbothexpandingcoverageandstreamlining

eligibilityandenrollmentprocessesinMedicaidandCHIP,withmostgainsbenefitingchildren. Asthey

haveachievedthisprogress,theprogramshavealsoadaptedtochangesinhealthcare,suchasthe

increaseduseofmanagedcare,andvaryingeconomicandpoliticalenvironments. In2010,state

decisionsaboutMedicaidandCHIPeligibilityrulesandenrollmentproceduresoccurredinthecontextof

multiplefactors,asdiscussedbelow.

Despitethereturnofweakeconomicgrowthin2010,theimpactofthedeepestrecessionsincethe

GreatDepressionpresentedanongoingchallengetofamiliesandstates.1 StateMedicaidandCHIP

programscontinuedtoexperienceincreaseddemandforcoverageasfamilieslosingtheirjobsand

accesstoemployerbasedcoverageturnedtopublicprogramsingrowingnumbers. Theresulting

growthinMedicaidandCHIPenrollmentprovidedmuchneededcoveragetolowincomefamilies,

slowingthegrowthintheuninsuredrate,particularlyforchildren,forwhomtheuninsuredrateactually

declined.2 Withouttheseprograms,manymoreindividualswouldbeuninsuredthanthe50million

today. However,theenrollmentgrowthalsoaddedpressuretoalreadystressedstatebudgets.3


11/88

EnhancedfederalmatchingfundsforMedicaidwereprovidedthroughout2010,withtherequirement

thatstatesmaintaintheireligibilityandenrollmentproceduresasaconditionofreceivingthese

funds. RecognizingtheincreaseddemandsonMedicaidandCHIPatatimewhenstateswerestilldealingwithsubstantiallydiminishedrevenuesandunprecedentedbudgetshortfalls,Congressprovided

significantfiscalrelieftostatesundertheAmericanRecoveryandReinvestmentAct(ARRA)of2009.

ThelegislationprovidedstateswithatemporaryincreaseinthefederalshareofMedicaidpayments

(i.e.,theFederalMedicalAssistancePercentageorFMAP)fromOctober1,2008throughDecember

31,2010. InAugust2010,CongresspassedanextensionoftheenhancedFMAPthroughJune2011,

althoughatalowerlevel. Asaconditionofreceivingtheenhancedfederalfunds,statesmaynotadopt

morerestrictiveMedicaideligibilityrulesandenrollmentproceduresthanwereineffectonJuly1,

2008.4 Forexample,theycannoteliminateeligibilityforMedicaidbeneficiariescoveredatstateoption,

lowertheincomethresholdforMedicaidcoverage,oradoptproceduresthatmakeitharderforeligible

peopletoenrollincoverage(e.g.,byimposingafacetofaceinterviewrequirementorrequiringpeople

torenewtheircoveragemorefrequently.)5 However,statesarenotbarredbythismaintenanceof

effort(MOE)requirementfromcuttingbackonbenefits,reimbursementratesorotheraspectsof

Medicaidand,asdocumentedelsewhere,manydidsoin2010inanefforttoaddressbudgetproblems.6

BroadhealthcarereformwasadoptedthroughtheAffordableCareAct(ACA)inMarch2010,andis

designedtoaddressthegrowinguninsuredproblembyexpandingcoveragethroughthecreationofa

newcontinuumofaffordableoptions.UndertheACA,Medicaideligibilitywillbeextendedtoanational

floorof133percentofthefederalpovertylevel,endingthehistoricexclusionofnondisabled,non

pregnantadultswithoutdependentchildrenfromtheprogram. Whilethischangeisnotrequiredtobe

ineffectuntilJanuary1,2014,underreform,stateshavetheoptionofmovingearlytocoverthese

adults. IndividualswithincomeaboveMedicaidthresholdswithoutaccesstoothercoveragewillbe

eligibleforcoveragethroughnewHealthBenefitExchanges,andthosewithincomeupto400percentof

thefederalpovertylevelwillbeeligibleforsubsidiesintheformofadvancetaxcreditstopurchase

coveragethroughtheseExchanges.

Beyond

expanding

coverage

options,

the

ACA

sets

out

a

strong

vision

for

consumer

friendly,

web

based

eligibilityandenrollmentsystemsthatwillenablefamiliestoapplyforMedicaid,CHIP,andExchange

subsidiesthroughonesimplifiedprocess. Thegoalistocreateanowrongdoorapproachtocoverage

thatoffersmultiplewaystoapply(online,overthephone,viamail,orinperson)andensuresthatno

matterhowafamilychoosestoapplyfororrenewcoverage,theyarescreenedforandenrolledinthe

appropriateprogramwithouthavingtotakeanyadditionalsteps. Aspartofcreatingaseamless

enrollmentsystem,theACAmakessignificantchangesinMedicaidrulesformanybeneficiaries,

includingeliminatingtheassettestandevaluatingeligibilityusinganIRSbaseddefinitionofincome(i.e.,

ModifiedAdjustedGrossIncomeorMAGI),whichwillalsobeusedtodetermineeligibilityfor

Exchangesubsidies.

WithpassageoftheACA,CongressalsoadoptedanotherMOErequirementaimedatensuring

MedicaidandCHIPcoverageremainstableuntilimplementationofthemajorcoverageexpansions.

UnderthisMOE,asaconditionofreceivingfederalMedicaidfunding,statesarerequiredtomaintain

eligibilityandenrollmentpoliciesinplaceasofMarch23,2010(whentheACAwasenacted)until

January1,2014foradultsanduntilSeptember30,2019forchildreninbothMedicaidandCHIP.Thereis

oneexceptioninthelawthatallowsthehandfulofstatesthatcoveradultsabove133percentofthe

federalpovertyleveltoreduceeligibilityiftheyarefacingadocumentedbudgetdeficit.

6


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In2010,effortsalsoremainedfocusedoncoveringuninsuredchildrenandtakingadvantageofthe

optionsandincentivesprovidedthroughthepassageoftheChildrensHealthInsuranceProgram

ReauthorizationActin2009(CHIPRA). TheAdministrationlaunchedtheConnectingKidstoCoverage

Challenge,amajorinitiativetoengagestakeholdersineffortstoenrollthefivemillionuninsured

childrenwhoareeligiblebutnotcoveredbyMedicaidandCHIP.7 Theefforthaspulledtogetherabroad

coalitionofpartners,rangingfromgovernorstonationaladvocacyorganizations. Aspartofthenational

outreacheffort,HHSalsoinitiatedGetintheGame,GetCovered,acampaignthatbringscoaches,

schools,families,andcommunitiestogetherinsevenpilotstatestogeteligiblechildrenenrolled.8

III. AboutthisSurvey

ThisreportpresentsthemajorfindingsoftheKaiserCommissiononMedicaidandtheUninsuredstenth

annualsurveyofeligibilityrules,enrollmentandrenewalprocedures,andcostsharingpracticesin

MedicaidandCHIP. ThefindingsaddressthepoliciesimplementedinstatesasofJanuary1,2011and

thechangesadoptedbystatesthroughout2010. ThesurveywasconductedbytheKaiserCommission

onMedicaidandtheUninsuredandtheGeorgetownUniversityCenterforChildrenandFamilies

throughindepthtelephoneinterviewswithstateMedicaidandCHIPofficials;thedatawereverified

throughfollowupcommunicationsviaemailandphone. (PriorsurveyswereconductedbytheKaiser

CommissiononMedicaidandtheUninsuredwiththeCenteronBudgetandPolicyPriorities.)

InlightofthebroadexpansioninMedicaidthroughhealthreform,additionalquestionswereaddedto

thisyearssurveytoincludemoreinformationonpoliciesforadults. Moreover,recognizingthe

importantupgradesandimprovementsstateswillneedtomaketotheireligibilityandenrollment

systemstoprepareforreform,thisyearssurveyalsoaddedquestionsdesignedtoobtainmore

informationaboutwherestatesystemsaretodayandprogressbeingmadeasstatesbegintolook

forwardtoimplementingreform. Inaddition,thisyearssurveycontinuestotrackstateadoptionof

newoptionsprovidedbyCHIPRA. Insomeinstances,thedataaremoreextensiveandspecificfor

children,primarilybecausestateshavetargetedtheirexpansionsandstreamliningeffortstothis

population.

For

state

specific

information,

see

the

tables

at

the

end

of

the

report.


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Figure 5

Number of States Improving Access to Health

Care Coverage, January 2010 January 2011

13

10

65

14

12

1

3

Total Children Pregnant Women Parents/Other Adults

Eligibility Enrollment/Renewal Procedures



IV. SurveyFindings

Astheeconomicdownturncontinuedtostrainhealthcoveragein2010,MedicaidandCHIP

maintainedtheircentralroleofofferingaffordablecoverageoptionstolow andmoderateincome

families. Nearlyallstates(49,includingDC)heldsteadyormadetargetedimprovementsintheir

MedicaidandCHIPeligibilityandenrollmentrulesin2010. Atotalof13statesmovedforwardwith

eligibilityexpansionsand14statesmadeimprovementsinenrollmentandrenewalprocedures(Figure

5). Further,morethanhalfofstates(29states)adoptednewefficienciesintheirapplicationprocesses

byusinganelectronicdatamatchwiththeSocialSecurityAdministration(SSA)toverifythecitizenship

statusofapplicants.

ThisstrikingstabilityinMedicaidandCHIP

eligibilityandenrollmentpoliciesin2010

canbedirectlyattributedtotheMOE

requirementsandtheenhancedfederal

matchingrateprovidedtostates

throughout2010andextendedthrough

June2011(seeMaintenanceofEffort

box). Withouttheseprovisions,many

statesalmostcertainlywouldhave

neededtoturntocutbacksincoveragein

2010asaresultofcontinuingbudget

pressures. Overthepastyear,only2

statesmadeeligibilityrelatedreductions

andnostatemadeadversechangesto

enrollmentandrenewalprocedures.

Changesinpremiumandcostsharingpoliciesin2010occurredinbothdirections,with4statesreducing

or

eliminating

charges

for

enrollees

and

8

states

increasing

or

adding

charges.

Overall,

the

premium

and

costsharingchangesweremodest.

Maintenance of Effort Requirements in the ARRA and ACA

ARRA provided states with a temporary increase in the federal share of Medicaid payments (i.e., theFMAP) from October 1, 2008 through December 31, 2010. In August 2010, Congress passed anextension of the enhanced FMAP through June 2011, although at a lower level. As a condition ofreceiving the enhanced federal funds, states may not adopt more restrictive Medicaid eligibility rules andenrollment procedures than were in effect on July 1, 2008.Under the ACA, as a condition of receiving federal Medicaid funding, states must maintain eligibility and

enrollment policies in place as of March 23, 2010 (when the ACA was enacted) until January 1, 2014 foradults and until September 30, 2019 for children in both Medicaid and CHIP. There is one exception inthe law that would allow the handful of states that cover adults above 133 percent of the federal povertylevel to reduce eligibility for these adults if they are facing a documented budget deficit.

8


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A. MedicaidandCHIPEligibility

Thirteen(13)(CA,CO,CT,DC,DE,KS,MN,MT,NE,NC,OR,TN,andWI)stateswentbeyond

maintainingcoveragetoimplementtargetedeligibilityexpansionsin2010. Theseexpansionsvariedin

sizeandscope,withafewstatesimplementingbroaderexpansionsandimprovements(seeSpotlight

box). Mostoftheexpansionsaffectedchildren,although,notably,threestatesmovedaheadtocover

lowincomeadultsthroughMedicaid. Further,buildingoninitialstepstakenin2009,statescontinued

toadopttheCHIPRAoptiontocoverimmigrantchildrenandpregnantwomenwhohavebeenlawfully

residingintheU.S.forlessthanfiveyears. PriortoCHIPRA,stateswerebarredfromusingfederal

MedicaidorCHIPfundstocoverlawfullyresidingimmigrantchildrenandpregnantwomenduringtheir

firstfiveyearsinthecountry.

Only2statesimplementedeligibilityrestrictionsin2010. ArizonacappedenrollmentinitsCHIP

programandNewJerseystoppedenrollingparentscoveredthroughaCHIPwaiver. Theseactionswere

notsubjecttotheARRAMOEandwereimplementedbeforetheACAMOE(whichextendedthe

protectionstoCHIP)becameeffective.

Spotlight on State Expansions and Simplifications in 2010

While many states focused their efforts on targeted changes, a few states took broader actions in 2010:

Colorado implemented a wide-ranging expansion, reaching many low- and moderate-incomechildren and families. As part of the states Healthcare Affordability Act of 2009, Colorado expandedeligibility for children (from 205 to 250 percent of the federal poverty level), pregnant women (from 200 to250 percent of the federal poverty level), and parents (from 60 to 100 percent of the federal povertylevel) in May 2010. In addition, to ease enrollment burdens placed on families, the state moved topaperless verification of income for children and parents. Next in line will be an expansion to adultswithout dependent children and adoption of 12-month continuous eligibility for children in Medicaid.

In joining the Connecting Kids to Coverage Challenge, Ohio fast-tracked simplification measures

and earned a performance bonus. When accepting the Secretarys challenge to enroll all eligiblechildren in coverage, in March 2010, the Governor announced that the state would implementpresumptive eligibility, 12-month continuous eligibility, and Express Lane Eligibility. By April 1,presumptive eligibility and 12-month continuous eligibility were up and running. As a result of this quickwork, as well as having increased enrollment in Medicaid, the state secured a performance bonus ofmore than $12 million in 2010.

Oklahoma used technology to streamline the application and renewal processes and help thestate go green by significantly reducing paperwork. In September 2010, the state launched a newonline enrollment system, allowing individuals to apply for coverage over the internet. Eligibility isdetermined in real-time and those found eligible are enrolled automatically and without delay(contingent on the receipt of any verification not available electronically). Enrollees can also use thesystem to review, update, and renew their coverage at any time, effectively creating a rolling renewalopportunity that allows enrollees to extend their coverage forward an additional 12 months whenever

they update their information. The state has also created an easy-to-use web-based tool for hospitals todirectly enroll infants born to mothers covered by Medicaid.

With a focus on children, Oregon made a number of advancements to expand coverage. InFebruary 2010, the state expanded childrens eligibility from 200 to 300 percent of the federal povertylevel and gave families above 300 percent of the federal poverty level the ability to buy into the programat full cost. Oregon also created a new office dedicated to rolling out an aggressive outreach andmarketing campaign and implemented some targeted simplification measures designed to reduceadministrative barriers to enrollment, such as the SSA match and Express Lane Eligibility.


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Figure 6

Childrens Eligibility for Medicaid/CHIP by Income,January 2011

AZAR

MS

LA

WA

MN

ND

WY

ID

UTCO

OR

NV

CA

MT

IA

WIMI

NE

SD

ME

MOKS

OHIN

NY

IL

KY

TN

NC

NH

MA

VT

PA

VAWV

CT

NJ

DE

MD

RI

HI

DC

AK

SC

NM

OK

GA

TX

IL

FL

AL


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CHIPRA Helped Shape State Activity in 2010

A number of options and incentives established when CHIPRA was enacted in February 2009 helped shapestate actions on eligibility and enrollment procedures in 2010.

11

In 2010, 15 states were awarded a total of $206 million in performance bonuses, more than double

the total award of $75 million in 2009. Ten (10) of the states (AL, AK, IL, KS, LA, MI, NJ, NM, OR, andWA) had previously received bonuses in 2009, and 5 states (CO, IA, MD, OH, and WI) were first-timerecipients. CHIPRA encourages and rewards states for enrolling and retaining the lowest-income uninsuredchildren who were already eligible for Medicaid through a performance bonus incentive. To earn a bonus,states must implement at least 5 of 8 simplification measures and meet specific enrollment targets. Thebonus is designed to ease the fiscal impact on states of the increased enrollment in Medicaid and recognizesuccessful enrollment and retention efforts.

12

CHIPRA PERFORMANCE BONUS AWARDS

2009 2010

Number of States Awarded Bonus 10 15

Median Individual State Award ($ in millions) $3.9 $10.5

Total Amount Awarded ($ in millions) $75.4 $206.2

By far, the most prevalent streamlining and efficiency measure implemented by states in 2010 wasthe electronic data match with the Social Security Administration (SSA) to verify citizenship. Morethan half of the states (29) adopted the option in Medicaid for children, 27 adopted it in Medicaid for parents,and 21 adopted it in CHIP. CHIPRA extended citizenship verification requirements to CHIP, but also gavestates the new option to use an electronic data match with SSA to confirm the citizenship status of thoseapplying for Medicaid and CHIP instead of relying on a paperwork-intensive process.13

In 2010, 6 states implemented Express Lane Eligibility (ELE). In an effort to avoid requiring families toprovide the same information to multiple programs and to achieve administrative efficiencies, ELE allowsstates to use income and other eligibility findings from another assistance program as evidence of eligibilityfor Medicaid and CHIP. (Citizenship and immigration status must be separately verified.) Among theapproved ELE initiatives, Alabama, Iowa, and Louisiana are partnering with SNAP (Supplemental Nutrition

Assistance Program, formerly food stamps) while New Jersey and Maryland are using data from their staterevenue agencies, and Oregon is working with the free and reduced-price school lunch program.

Building on activity from 2009, states continued to take up the new CHIPRA option to cover lawfully-residing immigrant childrenand pregnant women. Prior to CHIPRA, states were barred from usingfederal Medicaid or CHIP funds to cover lawfully-residing immigrant children and pregnant women duringtheir first five years in the country. CHIPRA gave states the option to eliminate this five-year bar. In 2010,6 states (DE, MN, MT, NE, NC, and WI) adopted the option to eliminate the bar for children and 5 states(DE, MN, NE, NC, and WI) did so for pregnant women. In a number of instances, these populations werepreviously covered with state-only funds.

ReflectingtheMOErequirements,enrollmentremainedopenforchildreninnearlyallstates

throughout2010.AsofJanuary1,2011,50states,includingDC,enrolluninsuredchildrenwhomeet

thestateseligibilitycriteriaforMedicaidandCHIP. ThesoleexceptionisArizona,whichhasnot

enrolledanynewchildrenintoitsCHIPprogramsinceestablishinganenrollmentfreezeinDecember

2009. DespitethestrongMOEprotectionsintheACA,ArizonawasallowedtoretainitsCHIPenrollment

freezethroughout2010becauseitalreadywasineffectandoperationalwhenthebillwassignedinto

lawonMarch23,2010.14 (TheMOEprotectiondid,however,blockthestatefrommovingforwardwith

planstoeliminateitsCHIPprogram.) Asnoted,Tennesseehadanenrollmentfreezeinplaceduringthe

firstfewmonthsof2010,butbeganacceptingnewenrolleesagainonMarch1,2010,andhassincekept

enrollmentopen.


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Figure 7

Eligibility for Pregnant Women in Medicaid/CHIPby Income, January 2011

AZAR

MS

LA

WA

MN

ND

WY

ID

UTCO

OR

NV

CA

MT

IA

WI

NE

SD

ME

MOKS

OHIN

NY

IL

KY

TN

NC

NH

MA

VT

PA

VA

WV

CT

NJ

DE

MD

RI

HI

DC

AK

SC

NM

OK

GA

TX

IL

FL

AL

185% FPL (16 states)

133% - 184% FPL (11 states)

>185% FPL (24 states, including DC)

MI

Notes: The federal poverty line (FPL) for a family of three in 2010 is $18,310 per year.


Figure 8

Median Medicaid/CHIP Eligibility Threshold for Children,Pregnant Women, Parents, and Non-Disabled Adults,

January 2011

241%

185%

64%

37%

0%

Children Pregnant Women Working Parents Jobless Parents Childless Adults

Minimum Medicaid Eligibility under Health Reform133% FPL ($24,353 for a family of 3 in 2010)


MoststateshaveawaitingperiodforCHIPforatleastsomechildren,butitoftenis3monthsorless.

FederallawrequiresstatestoadoptprovisionstoensurethatCHIPdoesnotsubstitutefororcrowd

outprivateinsurance. Tomeetthisrequirement,statesoftenrequirechildrentobeuninsuredfora

periodoftimebeforetheycanenrollinseparateCHIPprograms.15 AsofJanuary1,2011,41stateshave

waitingperiodsforsomeoftheirchildren,with20ofthesestatesusingwaitingperiodsof3monthsor

less. StatesfrequentlyexcludethelowestincomechildrenfromCHIPwaitingperiodsandtypically

includegoodcauseexemptionsthatallowachildtoenrollincoveragerightaway(forexample,forthe

deathofaparentorlossofajob). In2010,2states(SCandWV)shortenedtheamountoftimeduring

whichchildrenarerequiredtobeuninsuredbeforeenrollingincoverage. Two(2)otherstates(IAand

KS)implementedwaitingperiodsfornewexpansiongroups.

Coverageforpregnantwomenremainedlargelystablein2010,withsomeimprovements. Overall,as

ofJanuary1,2011,40states,includingDC,coverpregnantwomeninfamilieswithincomeatorabove

185percentofthefederalpovertylevelthroughMedicaidorCHIP($33,874forafamilyofthreein

2010)(Figure7). Inaddition,14states

haveadoptedtheoptiontocoverunborn

childrenusingCHIPfunds,whichallows

themtoprovidecaretopregnantwomen.

Withregardtochangesin2010,Colorado

expandedcoverageforpregnantwomen

from200to250percentofthefederal

povertylevel. Moreover,5states(DE,

MN,NE,NC,andWI)adoptedtheoption

tocoverlawfullyresidingimmigrant

pregnantwomenwithoutafiveyear

waitingperiod,bringingthetotalnumber

ofstatescoveringthesepregnantwomen

to17asofJanuary1,2011. Nine(9)of

these

states

previously

provided

this

coveragewithstateonlyfunds.

EligibilityforParentsandOtherAdults

Whilestateshavemadesignificant

progressinexpandingandimproving

coverageforchildren,coveragefor

parentsandotheradultslagsfarbehind

(Figure8).Thisdynamiccontinuedin

2010,asstatesmadeveryfewexpansions

incoverageforlowincomeparentsand

otheradults. Thesemodest

improvementsdidnotchangethereality

thatmostuninsured,lowincomeadults

remainineligibleforMedicaidinmost

states.

12


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Figure 9

Medicaid Eligibility for Working Parents by Income,January 2011

IL

AZAR

MS

LA

WA

MN

ND

WY

ID

UTCO

OR

NV

CA

MT

IA

WIMI

NE

SD

ME

MOKS

OHIN

NY

KY

TN

NC

NH

MA

VT

PA

VA

WV

CT

NJ

DE

MD

RI

HI

DC

AK

SC

NM

OK

GA

TX

FL

AL

50% - 99% FPL (17 states)


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Figure 10

Coverage of Childless Adults byScope of Coverage, January 2011

AZAR

MS

LA

WA(closed)

MN

ND

WY

ID

UT*

(closed)CO

OR*

NV

CA

MT

IA

WI(closed)

MI

NE

SD

ME

MOKS

OHIN(closed)

NY

IL

KY

TN

NC

NH

MA

VT*

PA

(closed)

VA

WV

CT*

NJ

DE

MD

RI

HI*(closed)

DC*

AK

SC

NM

(closed)

OK

GA

TX

FL

AL

Premium Assistance (4 states)

More Limited than Medicaid (14 states)

No Coverage (26 states)

Medicaid Comparable (7 states including DC)

Closed denotes enrollment closed to new applicants

* CT, DC, HI, & VT also offer coverage more limited than Medicaid; OR & UT also offer premium assistance with open enrollment.

SOURCE: Based on the preliminary results of a national survey conducted by the Kaiser Commission on Medicaid and the

Uninsured and the Georgetown University Center for Children and Families, 2011.

Evenwiththeseadvancements,asof

January1,2011,only7statesprovide

MedicaidorMedicaidcomparable

coveragetochildlessadults(AZ,CT,DE,

DC,HI,NY,VT)(Figure10). Fourteen(14)

statesonlyprovidetheseadultsmore

limitedcoveragewithfewerbenefits,

highercostsharing,and/orenrollment

caps. Anadditional4statessolelycover

childlessadultsthroughapremium

assistanceprogramthatislimitedto

individualswhomeetemployment

relatedeligibilityrequirements.

Three States Moved Early to Extend Medicaid to Low-Income Adults in 2010

Under health reform Medicaid eligibility will expand to a national floor of 133 percent of the federal povertylevel, providing coverage to millions of low-income adults who had previously been excluded from theprogram. The Medicaid expansion will go into effect as of January 1, 2014, and will be predominantlyfinanced with federal funds through a higher federal matching rate for those made newly eligible for

coverage under reform.16

As of April 2010, states have the option to extend Medicaid coverage to low-income adults early, but they will receive their regular federal matching rate for the coverage until thehigher rate becomes available in 2014.In 2010, three states extended Medicaid coverage to low-income adults. In all of these cases, the stateshad previously provided coverage to adults through fully state- or locally-funded programs. By expandingMedicaid coverage, the states were able to bolster the coverage while at the same time achieving statesavings by drawing down federal dollars.

Connecticut took up the new option under reform to extend Medicaid to adults with incomesup to 56 percent of the federal poverty level. The state moved adults it had previously beencovering through a state general assistance program to the new Medicaid adult option effective April1, 2010.

The District of Columbia also took up the new Medicaid option, combined with a waiver, tocover adults with incomes up to 200 percent of the federal poverty level. DC phased-in theexpansion, first extending Medicaid to 133 percent of the federal poverty level as of July 1, 2010, andbeginning to transfer adults from its locally-funded HealthCare Alliance program to Medicaid.Subsequently, the District obtained a waiver to extend coverage to 200 percent of the federal povertylevel, and beginning December 1, 2010, transferred most of the remaining HealthCare Allianceenrollees to Medicaid.

California obtained a waiver that enabled it to continue and strengthen existing county adult

coverage initiatives, as well as to potentially phase-in additional initiatives in more counties.This coverage will be provided through two programs, the Medicaid Coverage Expansion for adultswith family income at or below 133 percent of the federal poverty level and the Health Care CoverageInitiative for adults with family income between 134 to 200 percent of the federal poverty level.

A few other states, including Minnesota, also have pending plans to take advantage of the new option toprovide Medicaid coverage to adults. However, in the absence of significant expansions over the nextfew years, in most states, low-income adults will remain ineligible for Medicaid and without access to anyaffordable coverage options until the broad expansion goes into effect in 2014.

14


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Figure 12

Coordination Between Child and Parent

Simplification Measures in Medicaid, January 2011

49 50 48

12

19

49

4446

24

7

12

45

No Interview atApplication

No Interview atRenewal

No Asset Test IncomeDocumentationNot Requestedat Application

IncomeDocumentationNot Requested

at Renewal

12-MonthRenewal Period

Children Parents


Figure 11

Simplified Enrollment and Renewal Procedures for

Children in Medicaid and CHIP, January 2011

13

18

12

23

49

47

50

49

Presumptive Eligibility

Income Documentation Not Requested at Renewal

Income Documentation Not Requested at Application

12-Months Continuous Eligibility

12-Month Renewal Period

No Asset Test

No Face-to-Face Interview at Renewal

No Face-to-Face Interview at Application

Notes: Totals reflect adoption in both Medicaid and CHIP, if the state has a separate CHIP program.



B. EnrollmentandRenewalPoliciesandProcedures

Statescontinuedtoadoptimprovementsintheirenrollmentandrenewalproceduresin2010,

reducingburdensonfamiliesandstreamliningadministrativeprocesses.Experienceovertimein

expandingcoveragetochildrenhighlightsthateligibilityexpansionsalonearenotenoughtoget

individualscovered. Togetandkeepeligibleindividualsenrolled,itisimportantforcoverageoptionsto

bepromotedthroughoutreachandaccompaniedbyimprovementsandsimplificationstothe

application,enrollment,andrenewalprocesses. Buildingontheseearlylessons,in2010,14states(AL,

CO,CT,IA,LA,MD,MT,NE,NJ,NY,OH,OR,SC,andWV)continuedtomakegainsinstreamlining

procedures,particularlyforchildren. Theseencompassedavarietyofdifferentactionsacrossstates,

suchasmovingtoadministrativeverificationofinformationratherthanaskingfamiliestosubmitpaper

documentation,utilizingExpressLaneEligibility,adoptingpresumptiveeligibilityandcontinuous

eligibility,aswellaseliminatingassettestandfacetofaceinterviewrequirements. Overall,stateshave

madesignificantstridesforwardinsimplificationforchildren(Figure11). However,theprogressmade

foradultshasbeenmorelimited(Figure12). Asstatesmoveforwardonreform,itwillbeimportantto

alignthesepoliciesandprocedures.

Statesarebeginningtousetechnologyininnovativeandcosteffectivewaystoimproveapplication,

enrollment,andrenewalprocedures(seeTechnologybox,nextpage). In2010,anincreasingnumber

ofstatesbeganusingelectronicdatamatchestoobtainorverifyinformationatenrollmentand/orrenewal. Further,somestatesarebeginningtoutilizemorerobustonlinesystemswithapplicationand

accountmanagementcapabilities. Thesetypesofstreamliningmeasuresincreaseadministrative

efficiencyandaccuracy,importantbenefitsforstatescurrentlydealingwithreducedstaffandfinancial

resourcestomanagetheirprograms. Theyalsohelpbegintobuildthebasethatwillbenecessaryfor

statestosuccessfullyimplementtheintegrated,webbasedeligibilityandenrollmentsystemstheywill

needtoprovideunderreform. However,statesstillhaveasignificantamountofworktodotoprepare

forreform.


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The Role of Technology in Medicaid and CHIP Eligibility Systems:

Improvements and Challenges AheadStates increasingly are using technology in helpful ways to streamline and simplify eligibility andenrollment in Medicaid and CHIP, with several states leading the way with significant innovations.

However, there still are many opportunities for improvement and, looking forward, states have muchwork to prepare their systems for health reform.Online application forms are evolving into true electronic applications. Going into 2011, more thanhalf of states (32) offer an online application that can be submitted electronically, while 14 states offeronline renewals. In a few states, such as Wisconsin and Oklahoma, more robust web-based systemsthat are reflective of what will be required under health reform have emerged. These systems allowindividuals to assess their eligibility for benefits, apply for and renew coverage, update pertinentinformation, and pay premiums.Increasingly, states are using data from state and private wage databases, state tax agencies,and federal agencies to verify aspects of eligibility rather than requiring families to submit paperdocumentation. As of January 1, 2011, for children applying for or renewing Medicaid, 12 states do not

routinely ask families to submit paper documentation at application and 19 states do not do so atrenewal. These states first seek to verify information through other data sources and only require afamily to submit paper documentation if they are unable to administratively verify the information. Somestates still have yet to implement administrative verification processes and a number of states continueto request paperwork from families at application and renewal despite having the capability to verifyincome administratively. Continued progress in adopting administrative verification procedures will bekey as states look toward 2014, when enrollment and renewal processes are expected to becomepaperless under health reform. While the momentum is growing to incorporate more technology into Medicaid and CHIPeligibility processes, it will be important for states to increase the pace of improvements to beready for health reform in 2014. Given the current status of state eligibility systems and processes,many states will need to make large-scale upgrades and improvements to fulfill the promise of coverageand meet requirements under reform. In preparation for 2014, states have an opportunity to more fullyalign enrollment policies and renewal practices to streamline the rules on which enhanced eligibility andenrollment systems will be built. This will help lay the groundwork for and facilitate the creation of theseamless, integrated enrollment process across Medicaid, CHIP, and the Exchange that is requiredunder reform. States also face opportunities and challenges of potentially integrating enrollment withother public assistance programs.Federal funding for Exchange IT systems and Medicaid/CHIP eligibility systems will boost stateefforts. In early 2011, HHS will award Innovator grants to up to 5 projects for the design andimplementation of Exchange eligibility and enrollment systems. Additionally, a proposed rule to provide90 percent federal funding for improvements or upgrades to Medicaid eligibility systems will help statesinvest in the enhanced functionality that will be required by health reform. Both funding opportunitiesemphasize the importance of states sharing technology as it is developed and adopted.

16


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Figure 13

Status of Online Applications for StateMedicaid and CHIP Programs, January 2011

Notes: In some states the onlin e application is only available for chil dren applying for coverage. There are 38 separate CHIPprograms.

51

3229

8

38

2723

8

Available Online ElectronicSubmission

Electronic Signature IncomeDocumentation Not

Requested

Medicaid Separate CHIP (38 Total)


Figure 14

Adoption of the Social Security Administration (SSA)Data Match to Verify Citizenship, January 2011

29

21

27

Medicaid(Children)

Separate CHIP(38 Total)

Medicaid(Parents)


Number of States:

ApplicationProcedures

MoststatesofferjointMedicaidandCHIPapplicationsandsimplifiedfamilybasedapplications. Asof

January1,2011,36ofthe38stateswithseparateCHIPprogramsuseajointapplicationformthatallows

themtosimultaneouslyevaluatechildrenforeligibilityinMedicaidandtheseparateCHIPprogram,and

31statesuseajointMedicaidandCHIPrenewalform. Further,29states,includingDC,offerasimplified

familyapplicationthatenablesparentstoapplyforcoveragewiththeirchildrenwithoutcompleting

additionalformsorsteps. Underhealthreform,allstateswillneedtoofferasingleapplicationthatcan

beusedforMedicaid,CHIP,andExchangecoverage.

Whileallstatesmaketheirapplication

availableonline,fewerallowforthe

applicationandenrollmentprocesstobe

completedelectronically. Abouttwo

thirdsofthestatesallowforthe

electronicsubmissionofapplicationswith

mostoftheseacceptingelectronic

signaturesratherthanrequiringfamilies

tomailorfaxinasignedform(Figure13).

However,only8statesdonotaskfamilies

tosubmitpaperdocumentationof

incomeviamailorfax.Further,in3states

(AK,MI,andWV)theelectronic

applicationsareonlyavailablefor

childrenscoverage.

In2010,morethanhalfofstates

adoptedthenewCHIPRAoptiontomore

efficiently

and

accurately

verify

citizenshipstatusbyrelyingonan

electronicdatamatchwiththeSSA.

Twentynine(29)states,includingDC,

adoptedthisoptionforchildrenin

Medicaid,21adopteditinCHIP,and27

adopteditforparentsinMedicaid(Figure

14). Further,anadditional15states

reportedthattheyplantobeginusingthe

optioninMedicaidand/orCHIPin2011.

Otheranalysisofstateexperiencewith

thenewoptionfindsthatitishighly

effectiveinverifyingcitizenshipin94

percentofcases,whilesignificantlyeasing

theadministrativeworkloadofeligibility

officesandeliminatingunnecessary

paperworkforfamilieswithoutsacrificingaccuracy.17

Overtheyears,asmallbutgrowingnumberofstateshavebeguntoelectronicallyverifyapplication

datausingstateandprivatewagedatabases.In2010,Coloradostoppedaskingfamiliestosubmit


23/88

paperworktoverifyincomeatbothapplicationandrenewal. Asaresult,asofJanuary1,2011,12states

donotroutinelyrequestpaperdocumentationoffamilyincomeforchildrenapplyingforMedicaid,10

haveadoptedthispolicyforchildreninCHIP,and7dosoforparentsinMedicaid. Thesestatesinstead

firstseektoverifytheinformationthroughotheravailabledatasources.Evenmorestateshaveadopted

apaperlessverificationpolicyatrenewal19forchildreninMedicaid,14forchildreninCHIP,and12

forparentsinMedicaid.Six(6)states(AL,IA,LA,MD,NJ,andOR)tookupthenewCHIPRAoptiontoimplementExpressLaneEligibility(ELE)in2010. Further,additionalstatesexpressedaninterestinadoptingELEbutareawaitingfurtherguidancefromCMS. ELEallowsstatestouseafindingofincomeandothereligibilitycriteria

foranotherpublicassistanceprogramasevidenceofeligibilityforMedicaidorCHIP. Todate,the6

statesareusingdataprovidedbySNAP(SupplementalNutritionAssistanceProgram,formerlyfood

stamps),freeandreducedpriceschoollunchprograms,and/orstaterevenueagenciestodetermine

incomeandothercomponentsofeligibilityforMedicaidandCHIP.Thereisvariationinwhoconductseligibilitydeterminationsacrossstates. Inmoststates,MedicaidandCHIPeligibilitydeterminationsareconductedbyastateworker. However,in13Medicaidprograms

and7CHIPprogramsdeterminationsaremadebycountyworkersinacountyrunoffice. Where

determinationscurrentlyaremadewillhaveimportantimplicationsforstatesastheyconsiderhowto

designintegratedenrollmentprocessesandsystemsunderreform.

Inmoststates(44,includingDC),theMedicaideligibilitysystemisthesamesystemusedforotherassistanceprogramssuchasSNAP(formerlyfoodstamps)andTANF. ConnectingfamiliesapplyingforMedicaidandCHIPtootherpublicprogramsisimportanttoensurethattheyreceiveallneeded

benefits,aswellastoreduceduplicationofeffortbyfamiliesandstateagencies. However,application

requirementsdifferacrossprogramsand,assuch,combiningapplicationandenrollmentprocesses

acrossprogramscanimpacttheextenttowhichtheprocessissimplified. Asstateslookforwardto

reform,itwillbeimportantforthemtoconsidertheopportunitiesandchallengesofconnectingtoother

assistance

programs

while

also

creating

an

integrated

system

with

Medicaid,

CHIP,

and

Exchange

coverage. EnrollmentRequirementsandProceduresWiththeadditionofIowa,Montana,andOhioin2010,asofJanuary1,2011,13statesusepresumptiveeligibilitytoenrollchildreninbothMedicaidandCHIPand3additionalstatesapplythepolicytoMedicaidonly. Further,31statesusepresumptiveeligibilitytoenrollpregnantwomenincoveragefollowingConnecticutsadoptionoftheoptionin2010. Presumptiveeligibilityempowers

certainqualifiedentities,suchashospitalsorcommunityhealthcenters,tomakepreliminaryeligibility

decisionssochildrenandpregnantwomencangetcarewhiletheycompletetheregularMedicaidand

CHIPapplicationprocess. TheACAextendedtheoptiontousepresumptiveeligibilitytoenrolladults

(previouslythepolicyoptionwasonlyavailableforchildrenandpregnantwomen)andwillauthorize

hospitalsthatareMedicaidproviderstomakepresumptiveeligibilitydeterminationsin2014.

NearlyallstateshaveeliminatedtheassettestforchildreninMedicaidandCHIP. AsofJanuary1,2011,only3Medicaidprograms(SC,TX,andUT)and2separateCHIPprograms(MOandTX)continueto

examineafamilysassetswhendeterminingchildrenseligibilityforcoverage.Thenumberofstateswith

noassettestforpregnantwomenremainedsteadyat44states,includingDC,in2010. Forparents,New

Yorkbecamethe24thstate,includingDC,toeliminateitsassettestrequirement. Thislagswellbehind

18


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thenumberofstatesthathaveeliminatedtheassettestforchildren,andshowsthatthereismuch

progresstobemadebetweennowand2014whenstatesmustdroptheassettestformostpopulations

inMedicaid.

Similarly,nearlyallstateshaveeliminatedthefacetofaceinterviewrequirementforchildrenat

applicationandrenewal. WithNewYorkseliminationoftheinterviewatenrollmentandrenewalfor

childrenandparentsapplyingforMedicaidin2010,asofJanuary1,2011,onlyMississippiand

Tennesseecontinuetorequirefacetofaceinterviewsforchildrenatapplication,andonlyMississippi

requiresoneatrenewal. In2010,Nebraskaalsoeliminateditsinterviewrequirementatenrollmentand

renewalforparents(thestatealreadyhadeliminatedtherequirementforchildren). Followingthe

changesinNewYorkandNebraska,only7statesrequireafacetofaceinterviewwhenparentsapply

fororrenewcoverage.

RenewalRequirementsandProcedures

AsofJanuary1,2011,allbut2states(GAandTX)havea12monthrenewalperiodforchildren,the

maximumperiodallowedunderfederallaw. Duringa12monthrenewalperiod,familiesareexpectedtoreportchangesintheircircumstancestothestate,buttheyotherwisedonotneedtocompleteadditionalpaperworktocontinuecoverageuntiltheendoftherenewalperiod. Fortyfive(45)states,

includingDC,alsoprovideparentswitha12monthrenewalperiod. However,afewofthesestates

requireparentstosubmitaformperiodicallywithintherenewalperiodtoconfirmtheirincome. While

notascomprehensiveasafullreviewoftheirongoingeligibility,therequirementtosubmitformsinthe

midstofa12monthrenewalperiodincreasesthepaperworkburdenforparents.

Almosthalfofstatesgoastepfurtherthananannualrenewalperiodbyproviding12month

continuouseligibilityforchildren. Through12monthcontinuouseligibilityastatecanguaranteethata

childscoveragewillcontinuefor12monthsevenifhisorherfamilycircumstanceschange. Withthe

additionofOhioin2010,atotalof23statesprovide12monthcontinuouseligibilityintheirMedicaid

programs

and

28

states

provide

it

in

their

CHIP

programs

as

of

January

1,

2011.

Providing

this

stability

in

healthinsurancecoveragehelpstoensurecontinuouspreventive,primary,andconditionbasedcare,

whichultimatelycanimprovehealthoutcomes. Itcanalsoreduceadministrativeburdensbylimiting

thenumberofenrollmentsandreenrollmentsastatehastoprocess. Statescurrentlydonothavea

readilyavailableoptiontoprovidecontinuouseligibilitytoparentsandotheradultsinMedicaid.18

Statesareincreasinglyofferingmore

methodsforfamiliestorenewcoverage.

In2010,3states(AL,LA,andNJ)began

usingExpressLaneEligibilityprocessesto

renewcoverageforchildreninMedicaid.

Forexample,Louisianaisusing

enrollmentinSNAP(formerlyfood

stamps)todetermineongoingeligibility

atrenewalofchildrenenrolledin

Medicaid. Moreover,asofJanuary1,

2011,16statesseektoadministratively

renewchildrensMedicaidcoverageby

relyingonincomeinformationavailable

fromothersourcesratherthanasking

Figure 15

Renewal Methods for Children in StateMedicaid and CHIP Programs, January 2011

Notes: States that all ow for administrative renewal seek to renew coverage by rel ying on income information available from oth er

sources rather than asking families to resubmit information. In these states, families are generally sent a pre-populated form with thedata the state has available and either take no action or sign and return the form to renew coverage.

1615

14

3

12 12

15

AdministrativeRenewal

Telephone Online Express Lane

Medicaid Separate CHIP (38 Total)


0


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Figure 16

30

$9

$15

$27

$37

$42

Total RequiringPayment

101% FPL 151% FPL 201% FPL 251% FPL 301% FPL

Median Monthly Premiums at Specified IncomeLevels Among States with Premiums in Childrens

Health Coverage Programs, January 2011

Number ofStates

ChargingPremiums

8 18 28 20 12

Notes: Premiums listed at 201%, 251%, and 301%, i nclude states whose upper income levels are 200%, 250%, and 300%respectively. Does not include states that charge annual enrollment fees.SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and theGeorgetown University Center for Children and Families, 2011.

familiestoresubmitinformation,and12allowforadministrativerenewalsinCHIP.Inthesestates,

familiesaregenerallysentaprepopulatedformwiththedatathestatehasavailableandeithertakeno

actionorsignandreturntheformtorenewcoverage.Further,15Medicaidprogramsand12CHIP

programsallowfamiliestorenewbyphone,while14Medicaidprogramsand15CHIPprogramsoffer

onlinerenewals(Figure15).

C. PremiumandCostSharingRequirements

Overallchangesinpremiumsandcostsharingwererelativelylimitedin2010.Atotalof4states(CT,

DE,IA,andKY)madepositivechangesinpremiumandcostsharingpolicieseitherbyreducingor

eliminatingchargesorexemptingadditionalenrolleesfromthecharges.Ontheotherhand,8states(AZ,

CT,IN,MA,NC,NH,NJ,andPA)increasedoraddedpremiumandcostsharingchargesintheirprograms.

Mostofthechangesinbothdirectionsweremodest.

PremiumsandCostSharingforChildren

During2010,only3states(CT,KY,andOR)madechangesintheirpremiumpoliciesforchildren.

KentuckyeliminatedpremiumsinitsCHIPprogram,whileConnecticutmovedintheoppositedirection

in2010byincreasingCHIPpremiums,theonlystatetodoso. (Thedearthofstatesincreasingpremiums

mayreflectthatCMScoulddetermine

thatsuchincreasesviolateACAsMOE

requirements.19)Further,whenOregon

implementeditsexpansioninCHIP

coveragefrom200to300percentofthe

federalpovertylevel,itrequiredpremium

paymentsforthenewexpansiongroup.

Inlightofthesechanges,asofJanuary1,

2011,30stateschargepremiumsand4

states

charge

annual

enrollment

fees

in

theirchildhealthprograms. However,

fewstatesrequirepaymentsbyfamilies

livingatorverynearthefederalpoverty

line,withonly8statesrequiringrelatively

limitedpremiumsforchildrenat101

percentofthefederalpovertylevel

(Figure16).

Morethanhalfofstateschargingpremiumsforchildren(17of30states)givefamiliesmorethanthe

required30daygraceperiodbeforetheylosecoveragefornonpaymentofpremiums. CHIPRA

requiresstatestoprovideaminimum30daygraceperiodpriortocancellingachildscoverageundera

separateCHIPprogramformissingapremiumpayment. Fifteen(15)statesimposealockoutperiod

followingdisenrollmentfornonpaymentofpremiums,duringwhichtimethechildisbarredfromre

enrollingintheprogram. Twentyseven(27)statesrequirefamiliestoreapplyand22requirere

paymentofoutstandingpremiumsbeforeachildcanreenrollincoverage.

20


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Figure 17

States with Co-payments for Selected Servicesfor Children at 200% FPL, January 2011

2926

22

18

13

States ChargingAny Co-payments

PrescriptionDrugs

Physician Visits(non-preventive)

EmergencyRoom

InpatientHospital

Number of States:

Note: Based on the number of states charging co-payments for children in families with income at 200% of the federal poverty level.SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and theGeorgetown University Center for Children and Families, 2011.

During2010,3states(CT,NH,andNC)

increasedoraddedcopaymentstotheir

childhealthprograms.AsofJanuary1,

2011,26statesnowrequirecopayments

forprescriptiondrugs,22require

copaymentsfornonpreventivedoctor

visits,18requirecopaymentsfor

emergencyroomcare,and13requireco

paymentsforinpatienthospitalcarein

theirchildrenshealthprograms(Figure

17).

PremiumsandCostSharingforAdults

Four(4)states(CT,IA,NJ,andPA)madechangesinpremiumpoliciesforadultsin2010. Ingeneral,

fewstateschargepremiumstoadultsinMedicaidsinceeligibilityforadultsisoftenlimitedtolow

incomelevelsandstatesareonlyallowedtochargepremiumsforadultsinMedicaidbeginningat150

percentofthefederalpovertylevel.20AsofJanuary1,2011,3states(IL,RI,andWI)chargepremiumsto

parentsenrolledinMedicaidwithincomesabove150percentofthefederalpovertylevel. However,

premiumsandenrollmentfeesarecommonlyincludedinwaiverorstatefundedcoverageforadults

21ofthe29statesthathavewaiverorstatefundedcoverageforparentsand/orotheradultscharge

premiums. During2010,Iowaraisedtheincomelevelatwhichpremiumsbegintobechargedinits

IowaCarewaiverprogramfrom100to150percentofthefederalpovertylevel,protectingmore

adultsfromcharges.21Ontheotherhand,Connecticutstoppedsubsidizingpremiumcostsfornew

enrolleesinitsstatefundedCharterOakprogramandNewJerseyandPennsylvaniaincreased

premiumsintheiradultwaiverandstatefundedcoverageprogramsin2010.

Delaware

eliminated

a

copayment

for

transportation

services

while

4

states

(AZ,

IN,

MA,

and

PA)

increasedcopaymentsintheiradultcoveragein2010.Overall,40statesrequirecopaymentsfor

selectedservicesfromparentsenrolledinMedicaid. Further,allbutoneofthe29statesthathave

expandedwaiverorstatefundedcoverageforparentsand/orotheradultschargecopaymentsfor

selectedservices.

V. Discussion

Thistenthannualsurveyofeligibilityrulesandenrollmentproceduresshowsstrikingstabilityin

MedicaidandCHIPcoveragein2010. Nearlyallstates(49,includingDC)heldsteadyormadetargeted

improvementsintheirMedicaidandCHIPeligibilityrulesandenrollmentproceduresin2010. Bydoing

so,theymaintainedtheimportantroleofpublicprogramsinprovidingaffordablecoverageoptionsto

childrenand,toalesserextent,theirparentsandotheradults,manyofwhomlostjobsandtheiraccess

toemployerbasedcoverageintheongoingdownturn. Thisstabilitycanbedirectlyattributedtothe

MOErequirementsandtheenhancedfederalMedicaidmatchingrateprovidedtostatesthroughout

2010andnowextendedthroughJuneof2011. Withoutthem,statesalmostcertainlywouldhavemade

morecutbacksincoveragein2010duetobudgetpressures.


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Despitethedifficulteconomicsituation,statescontinuedtomaketargetedexpansionsand

improvementstonotonlyincreasecoveragebutalsodrawdownadditionalfederalfundsandachieve

programefficiencies.Thirteen(13)statescontinuedeffortstoexpandeligibility,particularlyfor

children. Anumberoftheseexpansionsfocusedonprovidingcoveragetomoreuninsuredindividuals,

butmanyalsohadtheaddedbenefitofproducingsomestatesavingsbyallowingthestatetodraw

downfederalmatchingfundsforpreviouslyfullystatefundedcoverage. Statesalsocontinuedto

simplifyandimproveenrollmentandrenewalprocedures,benefitingfamiliesbyreducingburdensand

creatingadministrativeefficienciesbyeliminatingunnecessarypaperworkandincreasingtheuseof

technology.

Althoughstateshaveachievedsignificantprogresscoveringlowincomechildren,thereisstillalarge

coveragegapforlowincomeadults.Whilealmostallstatesnowcoverchildrenabove200percentof

thefederalpovertylevel,inmoststates,parentMedicaideligibilitylevelsremainwellbelowpoverty

andmostothernondisabledadultsremainineligibleforMedicaidregardlessoftheirincome. Under

reform,Medicaidwillexpandtoanationaleligibilityfloorof133percentofthefederalpovertylevel,

helpingtofillthegapincoverageforadultsandprovidingmillionsofcurrentlyuninsuredadultsan

importantnewcoverageoption. However,untiltheexpansionisimplemented,manylowincomeadults

willcontinuetolackaccesstoanyaffordablecoverageoptions.

Continuedsimplificationofenrollmentandrenewalproceduresandincreaseduseoftechnologywill

beimportantforpreparingforreform. WithpassageoftheACA,stateeffortstosimplifyand

streamlineenrollmentprocedurestakeonaddedimportance. Notonlywillthelawexpandcoverageto

millionsofpeople,necessitatingalargeenrollmenteffortinmanystates,italsoenvisionsanintegrated,

webbased,technologydrivenenrollmentprocessforMedicaid,CHIP,andExchangecoverage. State

experiencetodatehasestablishedtheimportanceofsimpleapplication,enrollment,andrenewal

proceduresforgettingandkeepingeligibleindividualsenrolled. Assuch,tosuccessfullyenrollnewly

eligibleindividualsundertheexpansioninatimelymanner,itwillbeimportantforprocedurestobeas

simpleaspossible. Further,increaseduseoftechnologywillbekeyforenablingstatestostreamline

processes

and

coordinate

enrollment

across

coverage

programs.

Early

state

adopters

of

technology

are

showingthatitcanincreaseefficiencyandcosteffectivenesswhilesimplifyingtheapplicationand

renewalprocessforfamilies,andimprovingtheaccuracyofeligibilitydecisions. Moreover,the

popularityandsuccessoftheelectronicdataexchangewiththeSSAtoverifycitizenshipillustratesthe

powerfulimpactthattechnologycanhaveontheadministrationofMedicaidandCHIP.

Despiterecentimprovements,stateshaveasubstantialamountofworktodotoprepareforreform.

Assignificantasincrementaleffortstoincreaseeligibilityandimproveenrollmentandrenewal

processeshavebeeninMedicaidandCHIP,thechangesnowrequiredtoexpandcoverageandmake

enrollmentsystemsworkasenvisionedunderreformwillbefarmoresweepingandtransformative.

Moststateswillneedtomakelargescaleupgradesandimprovementstotheireligibilitysystemsand

processestofulfillthepromiseofreformandtheyhavelimitedtimeinwhichtodoso. Withthe

issuanceofitsproposedruletoprovidea90percentfederalmatchingrateformodernizingMedicaid

eligibilitysystemsandearlyInnovatorgrantsinuptofivestates,thefederalgovernmenthasoffered

someimportantfinancialhelpandtakenstepstofosterthesharingofinformationandtechnology

acrossstates.

22


28/88

VI. Conclusion

Asimplementationofbroaderhealthreformmovesforward,thefindingsofthissurveydescribethe

foundationforcoverageoflowincomefamiliesandindividualsthroughMedicaidandCHIP. These

programswillplayanevenmoresubstantialroleintheyearstocome,particularlywiththeexpansionin

coverageforlowincomeadultsincludedinACA. Valuablelessonscanbelearnedfromhowstateshave

streamlinedandsimplifiedtheirenrollmentandrenewalproceduresintheseprograms,andwhile

additionalimprovementsarenecessarytofurthertransformMedicaidandCHIPinordertofulfillthe

promiseofreform,theyprovideasoundplatformonwhichtobegin.

Lookingahead,statesfacethechallengeofimplementingreformwhileatthesametimedealingwith

significantbudgetpressuresduetothenationscontinuingeconomicproblemsandthecorresponding

increasedneedforcoverage. Tocontinueprogressforwardonreformandkeepthefoundationsolid,it

willbeimportanttofocusonsustainingthecoveragegainsmadetodateeveninthefaceofthese

challenges.Healthreformhasthepotentialtomarkedlyreducethenumberofuninsuredandprovides

statesnewopportunitiestomodernize,streamline,andcontinuetoimproveMedicaidandCHIP. While

someofthemostsignificantchangesinhealthreformdonotgointoeffectuntil2014,itisimportantfor

statestolaythegroundworknow. In2010,therewereinitialsignsofstateMedicaidagenciespreparing

forhealthreformimplementation,butmoreactivitycanbeexpectedin2011.


29/88

Endnotes 1E.McNichol,P.Oliff,&N.Johnson,StatesContinuetoFeelRecessionsImpact,CenteronBudgetandPolicyPriorities

(UpdatedDecember16,2010).2J.Holahan,The200709RecessionAndHealthInsuranceCoverage,HealthAffairs(December6,2010).3KaiserCommissiononMedicaidandtheUninsured,MedicaidEnrollment:December2009DataSnapshot(September30,

2010).

4OriginallyavailabletostatesfromDecember2008throughDecember2010,thetemporaryincreaseintheMedicaidmatching

ratewasextendedatareducedlevelthroughJune30,2011byPublicLaw111226,signedbyPresidentObamaonAugust10,

2010. UndertheoriginalARRAprovisions,statesreceiveanextra6.2percentagepointsinthefederalmatchingratefortheir

Medicaidprograms,plusanadditionalincreasebasedonthestate'sunemploymentrate. Undertheextension,thesizeofthe

enhancementdeclinesto3.2percentagepointsinJanuary2011and1.2percentagepointsinApril,againwithanadditional

increasebasedonthestatesunemploymentrate.Thesamemaintenanceofeffortrequirementsthatappliedtostatesunder

ARRAwerecontinuedbytheextension.CenterforMedicaid,CHIP,andSurvey&Certification,CentersforMedicareand

MedicaidServices,CMCSInformationalBulletin:FMAPExtensionGuidance(August18,2010).5LetterfromCindyMann,DirectorofCenterforMedicaidandStateOperations,CentersforMedicareandMedicaidServices,

toStateMedicaidDirectors(SMD#09003)(June17,2009).6V.Smith,etal.,HopingforEconomicRecovery,PreparingforHealthReform:ALookatMedicaidSpending,Coverage,andPolicyTrends,KaiserCommissiononMedicaidandtheUninsured(September30,2010).7G.Kenny,etal.,WhoandWhereAretheChildrenYettoEnrollinMedicaidandtheChildrensHealthInsuranceProgram?,HealthAffairs(September3,2010).8Formoreontheseefforts,visithttp://www.insurekidsnow.gov/professionals/campaigns/index.html. 9C.DeNavasWalt,B.Proctor,&J.Smith,Income,Poverty,andHealthInsuranceCoverageintheUnitedStates:2009,U.S.

CensusBureau(September16,2010).10Childrenwithfamilyincomebetween185and200percentofthefederalpovertylevelcanqualifyforpremiumassistance,

butonlyiftheirparentsqualifyforInsureOklahoma,aprogramthatprovideshelpbuyingcoveragetoindividualswhowork

forsmallbusinesses(under99workers)offeringaqualifiedhealthplananddirectcoverageforotherswhoareunemployed,

selfemployedorcannotaccesscoveragethroughtheiremployer.11

D.Horner,etal.,TheChildrensHealthInsuranceProgramReauthorizationActof2009,GeorgetownCenterforChildrenandFamilies(March2009).12

Foradetaileddescriptionoftheperformancebonusprovision,seeGeorgetownUniversityCenterforChildrenandFamilies

andtheKaiserCommissiononMedicaidandtheUninsured, CHIPTips:PerformanceBonusandCHIPTips:Performance

Bonus5of8Requirements(June4,2009) 13

ForadetaileddescriptionofthecitizenshipdocumentationrequirementandtheSSAverificationoption,seeGeorgetown

UniversityCenterforChildrenandFamiliesandtheKaiserCommissiononMedicaidandtheUninsured,CHIPTips:CitizenshipDocumentationChanges(May8,2009).14

CMShasnotyetissuedguidanceonthemaintenanceofeffortrequirementsintheACA. Itseemsclearthatstateswillnotbe

abletoestablishnewCHIPenrollmentcapsorfreezesnotpreviouslycontemplatedunlesstheyrunoutoffederalCHIP

matchingfunds. It,however,islesscertainhowCMSwilltreatstatesthathaveapprovedlanguageintheirCHIPstateplans

authorizingsuchenrollmentrestrictions,but,onthedateofenactmentoftheACAdidnotactuallyhavethemineffect. 15

Intheabsenceofawaiver,statescannotmakeuninsuredchildrenwaitforcoverageinMedicaid,includinginCHIPfinanced

Medicaidexpansions.16

Moststateswillreceivefullfederalfinancingfor20142016andthen90percentfederalfinancingby2020;alimitednumber

ofspecifiedexpansionstateswillreceiveanenhancedmatchrateforcoverageofcertainchildlessadultsthatisphasedinto

equal90percentin2020. Overall,itisestimatedthatthefederalgovernmentwillpayfor95percentofthenewMedicaid

coveragecostsforadults. 17

D.CohenRoss,NewCitizenshipDocumentationOptionforMedicaidandCHIPIsUpandRunning,CenteronBudgetand

PolicyPriorities(April20,2010).18

Whilethestatutoryoptiontoprovide12monthcontinuouseligibilityinMedicaidappliesonlytochildren,itispossiblethat

statescouldachieveasimilarresultforadultsthroughawaiverfromCMSorpossiblythroughuseoflessrestrictiveincome

methodologies(e.g.,astatecoulddisregardchangesinincomethatoccurduringthecourseofa12monthrenewalperiod). 19

CMShasissuedguidanceindicatingthatitconsiderspremiumincreasestobeaviolationoftheMedicaidMOEincludedin

ARRA,whichremainsineffectuntilJune2011. Todate,CMShasnotissuedguidanceonwhetherastatecanincreaseitsCHIP

premiumswithoutviolatingtheCHIPMOEincludedintheAffordableCareAct. 20

J.GuyerandJ.Paradise,ExplainingHealthReform:BenefitsandCostSharingforAdultMedicaidBeneficiaries,KaiserFamily

Foundation(August2010).21

IowaCareisalimitedhealthcareprogramthatcoversadultsages1964whowouldnotnormallybecoveredbyMedicaidup

to200percentofthefederalpovertylevel.

24


30/88

VII.TrendandStatebyStateTables

TableA: ExpandingEligibilityandSimplifyingEnrollment:TrendsinChildrensHealthCoveragePrograms,July1997toJanuary2011

Table

B: ExpandingEligibilityandSimplifyingEnrollment:TrendsinHealthCoverageforParents,

January2002toJanuary2011

Table1: UpperIncomeEligibilityLimitforChildren'sCoverageandProgramTypeTable1A: IncomeEligibilityLimitsandOtherEligibilityFeaturesofChildren'sHealthCoverageTable2: KeyFeaturesofBuyInProgramsforChildrenTable3: LengthofTimeaChildisRequiredtobeUninsuredPriortoEnrollmentinCHIPTable4: AdultIncomeEligibilityLimitsatApplicationasaPercentoftheFederalPovertyLevelby

CoverageAuthority

Table5: IncomeEligibilityLimitsforWorkingAdultsatApplicationasaPercentoftheFederalPovertyLevelbyScopeofBenefitPackage

Table6: IncomeEligibilityLimitsandOtherFeaturesofHealthCoverageforPregnantWomenTable7: StreamlinedApplicationRequirementsforChildren'sHealthCoverageTable8: StreamlinedEnrollmentProcessesforChildren'sHealthCoverageTable9: UseofOnlineApplicationFormsinMedicaidandCHIPTable10: IntegrationofMedicaidandCHIPEligibilitySystems Table11: RenewalPeriodsandStreamlinedRenewalRequirementsforChildren'sHealthCoverageTable12: RenewalMethodsAvailableforChildren'sHealthCoverageTable13: StreamlinedApplicationProcessesforParentsinMedicaidTable14: RenewalPeriodsandStreamlinedRenewalProcessesforParentsinMedicaidTable15: Premium,EnrollmentFee,andCopaymentRequirementsforChildrenTable16: PremiumsandEnrollmentFeesforChildrenatSelectedIncomeLevelsTable17: DisenrollmentPoliciesforNonPaymentofPremiumsinChildren'sCoverageTable18: CopaymentAmountsforSelectedServicesforChildrenatSelectedIncomeLevelsTable19: CopaymentAmountsforPrescriptionDrugsforChildrenatSelectedIncomeLevelsTable20: Premium,EnrollmentFee,andCopaymentRequirementsforAdultsTable21: PremiumsandEnrollmentFeesforAdultsatSelectedIncomeLevelsTable22: CostSharingAmountsforSelectedServicesforAdultsatSelectedIncomesTable23: PrescriptionDrugCopaymentsforAdultsatSelectedIncomes


31/88

TableA

ExpandingEligibilityandSimplifyingEnrollment:

TrendsinChildrensHealthCoveragePrograms

July1997toJanuary2011

July

1997 Nov.

1998 July

2000 Jan.

2002 April

2003 July

2004 July

2005 July

2006 Ja20

Numberofchildrens

healthcoverage

programs

51MCD

51MCD

19CHIP

51MCD

32CHIP

51MCD

35CHIP

51MCD

35CHIP

51MCD

36CHIP

51MCD

36CHIP

51MCD

36CHIP

51M

37C

Coveredchildrenator

above200%FPL61 22 36 40 39 39 41 41 4

Lawfullyresiding

immigrantchildren

coveredwithout5

yearwait(ICHIA)

option

not

available

option

not

available

option

not

available

option

not

available

option

not

available

option

not

available

option

not

available

option

not

available

opt

n

avai

JointMedicaid/CHIP

application N/A

not

collected28 33 34 34 34 33 3

Applicationcanbe

submittedonline

not

collected

not

collected

not

collected

not

collected

not

collected

not

collected

not

collected

not

collected

n

colle

Eliminatedassettest 36

40(M)

17(C)

42(M)

31(C)

45(M)

34(C)

45(M)

34(C)

46(M)

33(C)

47(M)

33(C)

47(M)

34(C)

47

35

Adoptedpresumptive

eligibilityforchildren

option

not

available

6(M)8(M)

4(C)

9(M)

5(C)

7(M)

4(C)

8(M)

6(C)

9(M)

6(C)

9(M)

6(C)

14

9(

Eliminatedfaceto

faceinterviewat

enrollment22

2

333(M)

not

collected

(C)

40(M)

31(C)

47(M)

34(C)

46(M)

33(C)

45(M)

33(C)

45(M)

33(C)

46(M)

33(C)

46

34

Income

documentationnot

requestedat

enrollment6

not

collectednot

collected10(M)

7(C)13(M)

11(C)12(M)

11(C)10(M)

10(C)9(M)

9(C)9(M)

9(C)10

8

AdoptedSSAmatch

forcitizenship

verification

option

not

available

option

not

available

option

not

available

option

not

available

option

not

available

option

not

available

option

not

available

option

not

available

opt

n

avai

26


32/88


33/88

TableB

ExpandingEligibilityandSimplifyingEnrollment:

TrendsinHealthCoverageforParents

January2002toJanuary2011

SOURCE: BasedonanationalsurveyconductedbytheKaiserCommissiononMedicaidandtheUninsuredwiththeCenteron

BudgetandPolicyPriorities,2009;andwiththeGeorgetownUniversityCenterforChildrenandFamilies,2011.

Thenumbersinthetablereflectthenetchangeinactionstakenbystatesfromyeartoyear. Specificstrategiesmaybe

adoptedandretractedbyseveralstatesduringagivenyear.

1.Wdenotesafreezeinawaiverprogram;SFdenotesafreezeinastatefundedprogram.

Jan

2002April

2003July

2004July

2005July

2006Jan

2008Jan

2009Dec

2009Jan

2011

Totalnumberof

healthcoverage

programsforparents

51 51 51 51 51 51 51 51 51

Coveredworking

parentswithincome

atorabove100%

20 16 17 17 16 18 18 17 18

Familyapplication 23 25 27 27 27 28 31 27 29

Eliminatedassettest 19 21 22 22 21 22 23 24 24

Eliminatedfaceto

faceinterviewat

enrollment

35 36 36 36 39 40 41 41 44

12montheligibility

period

38

38

36 36 39 40 40 43 45

Eliminatedfaceto

faceinterviewat

renewal

35

42

42 43 45 46 46 46 46

Implemented

enrollmentfreeze1

not

collected

1(W)

2(SF)

3(W)

2(SF)

2(W)

2(SF)

2(W)

2(SF)

2(W)

2(SF)

4(W)

2(SF)

3(W)

2(SF)

1(W)

28


34/88

TotalMedicaidExpansion 13Tot

Documents

Kaiser - Holding Steady, Looking Ahead Medicaid and CHIP Report