Georgetown University Health Policy Institute The Future of Children’s Health Coverage Next Steps Introduction and Background for the The Children’s Health Insurance Program (CHIP) serves a vital role in America’s health care system. First enacted in 1997, Children’s today CHIP provides health coverage to 6.8 million people each month—mostly children.1 Under the program, states are provided funding through a complex formula to cover children Health and pregnant individuals whose family incomes are over eligibility levels for Medicaid but may otherwise be uninsured.2 Insurance At present, the median income eligibility level for CHIP is 255 percent of the federal poverty line.3 Program Under the program, states can choose whether to accept funding and provide coverage to children through their Medicaid program or by establishing a separate CHIP program, or a combination of both. Most states operate by Joan Alker and Anne Dwyer combination programs with some individuals enrolled through the state’s Medicaid program and some enrolled in a separate CHIP program, or full Medicaid expansion CHIP programs (see map).4 As a result, the majority of children are now enrolled Eleventh in a series of papers from the in CHIP-funded Medicaid programs. Only two states operate Georgetown University Center for fully separate CHIP programs. In all states, CHIP sits on the Children and Families on the future of shoulders of Medicaid—which covers a much larger number children’s health coverage. of children, nearly 32 million.5 Over the past several decades, Medicaid and CHIP together have contributed to a dramatic August 2021 decline in the share of uninsured children of more than 60 percent6—though the number of uninsured children began to increase from 2017 onward.7 As part of its financing structure, CHIP provides enhanced federal funding under which states receive federal matching funds for all children eligible for CHIP (even if they are covered through their Medicaid program) based on Medicaid’s formula, but with a higher level of federal participation than for Medicaid.8 Federal matching funds for CHIP were also further temporarily increased in response to the COVID-19 public health emergency as a result of the increase to the base Medicaid matching rate.9 See Appendix 1. However, unlike Medicaid, federal CHIP funding is capped and not permanent. As a consequence, Congress has had to act to reappropriate funds periodically. CCF.GEORGETOWN.EDU next steps for CHIP 2 Currently, CHIP funding is available until September 30, September 30, 2017 until January 22, 2018—forcing states 2027 (i.e., through federal fiscal year 2027), and states to rely on carryover funding and, in some cases, to notify are also required to keep current income eligibility levels families that they were planning to close enrollment.10 for children in place up to 300 percent of the federal This financial uncertainty does not work well for states poverty line through fiscal year 2027. While there is or families, and deters states from making program considerable bipartisan support for CHIP, its extension improvements when they are uncertain about future federal has not always been a smooth process in Congress. Most funding. recently Congress let annual funding for CHIP lapse from States can choose whether to accept funding and provide coverage to children through their Medicaid program or by establishing a separate CHIP program, or a combination of both. Combination (33 states) Medicaid expansion CHIP (17 states including DC) Separate CHIP (2 states) * Wyoming received approval from CMS to convert its combination CHIP program to a CHIP Medicaid expansion program in May 2021 ** This map employs the Medicaid-expansion CHIP designation from the 2021 Kaiser survey; some CHIP Medicaid-expansion states may have a separate CHIP program for individuals covered under the unborn child option Source: Brooks, T. et al., “Medicaid and CHIP Eligibility and Enrollment Policies as of January 2021: Findings from a 50-State Survey” (Washington DC: Georgetown University Center for Children and Families and Kaiser Family Foundation, March 2021), available at https://www.kff.org/ medicaid/report/ medicaid-and-chip-eligibility-and-enrollment-policies- as-of-january-2021-findings-from-a-50-state-survey/ (Table 3); and “Child Enrollment in CHIP and Medicaid by State, FY 2019 (thousands),” Medicaid and CHIP Payment and Access Commission, and “Child Enrollment in CHIP and Medicaid by State, FY 2019 (thousands),” Medicaid and CHIP Payment and Access Commission, https://www.macpac.gov/wp-content/uploads/2015/01/EXHIBIT-32.-Child- Enrollment-in-CHIP-and-Medicaid-by-State-FY-2019-thousands.pdf. CCF.GEORGETOWN.EDU next steps for chip 3 As Congress considers major health legislation, what should become of CHIP? CHIP funding should be made permanent CHIP has established itself as a critical piece of the federal/ announcements on their websites or sent notices to families state response to children’s health care needs. In addition alerting them that their CHIP coverage could end—with to covering over 6 million children directly, CHIP has Connecticut even going as far as to implement an enrollment spurred outreach and enrollment simplification efforts that freeze on new applications during the Christmas and New have resulted in more eligible children receiving Medicaid. Year holidays in 2017.13 Though children enrolled in separate CHIP programs Such lapses are unacceptable for children, particularly in do not have a coverage guarantee such as children in a post Affordable Care Act (ACA) world, where everyone Medicaid, the coverage provided to children under CHIP should have a path to affordable coverage. This long- is more comprehensive and responsive to their needs than standing bipartisan program has demonstrated time and benefits provided through federal and state marketplaces.11 time again that it works to provide comprehensive, affordable Accordingly, CHIP should be made permanent to ensure health coverage to millions of children across the nation. that children and families do not have to withstand future As policymakers consider what is next for America’s health lapses in Congressional commitment, and states have care system and contemplate improvements to the existing the certainty from the federal government to maintain and system, making funding for CHIP and its supporting financing improve their programs. structures permanent (including the redistribution fund, the Prior to 2009, Congress had to take action on a number of Child Enrollment Contingency Fund and qualifying state occasions to avert funding shortfalls under the program.12 option) should be included in any major health legislation. The Children’s Health Insurance Program Reauthorization Act (CHIPRA) of 2009 made a number of critical Various bills have been introduced in Congress to improvements to CHIP’s underlying financing structure make CHIP funding permanent. The Patient Protection to help ensure that states did not face such shortfalls, and Affordable Care Enhancement Act, which was however, annual CHIP funding remained temporary in passed by the House of Representatives in July of nature. As a result, Congress has had to act multiple times 2020, included permanent funding for CHIP. Earlier this since CHIPRA to appropriate funding for the program. year, the CARING for Kids Act (H.R. 66) and the CHIPP During the most recent funding extension negotiations, Act (H.R. 1791) were introduced in the House—both Congress missed its deadline altogether and failed to bills would permanently fund CHIP and extend other appropriate new funding for CHIP at the beginning of CHIP financing structures such as the Child Enrollment federal fiscal year 2018 (see Figure 1). While Congress Contingency Fund.14 ultimately acted to extend funding, in the intervening weeks and months of uncertainty, a number of states posted Figure 1. Fiscal Year 2018 CHIP Funding Uncertainty FY 2018 CHIP Funding October 1, 2017 December 8, 2017 December 22, 2017 January 22, 2018 February 9, 2018 September 30, 2027 Fiscal year 2018 Congress reallocates Congress provides Congress finally Congress further Current CHIP starts without a unspent redistribution temporary CHIP extends annual extends funding appropriation new CHIP funds to fill state funds through funding for CHIP for CHIP through ends appropriation funding gaps March 2018 through FY 2023 FY 2027 Source: Mitchell, A., “Federal Financing for the State Children’s Health Insurance Program (CHIP)” (Washington, DC: Congressional Research Service, May 2018), available at https://fas.org/crs/misc/R43949.pdf. CCF.GEORGETOWN.EDU next steps for CHIP 4 Maintain children’s income eligibility Increase and permanently extend standards and protections outreach and enrollment funding In addition to guaranteeing funding for CHIP, permanently In 2009, CHIPRA established grants to eligible entities such extending the children’s “maintenance of effort” (MOE) as community-based organizations to conduct outreach requirements will be critical to ensuring stability of coverage and enrollment efforts to reduce the number of children for children in Medicaid and CHIP. eligible but not enrolled in Medicaid and CHIP. Funding for these grants was extended as part of subsequent CHIP Originally included in the ACA and subsequently extended, extensions including most recently under the HEALTHY the MOE ensures that children maintain stable health KIDS Act and the ACCESS Act in 2018.20 Unfortunately, the coverage by requiring states to maintain Medicaid and ACCESS Act, which extended funding for CHIP for fiscal CHIP income eligibility standards and preventing them years 2024 through 2027, reduced outreach and enrollment from adding new barriers to enrollment such as increased funding during this timeframe relative to previous funding premiums. This requirement remains in place through fiscal levels.21 year 2027 though it was modified under the HEALTHY KIDS Act in 2018 to apply only to families with incomes less than 300 percent of the federal poverty level.15 Outreach and As discussed in our 2017 brief, this requirement—along enrollment grants with coverage expansions for parents and other adults in serve an important role Medicaid and the state and federal marketplaces—helped in helping to ensure bring the uninsured rate for children down to historic children can access and lows.16 While this positive trend reversed over the past few maintain Medicaid years, the MOE has undoubtedly prevented even more and CHIP coverage. children from losing coverage. In fact, the recent increases in the rate of uninsured children make the continuation of the MOE more important than ever. It is clear that CHIP Outreach and enrollment grants serve an important role in funding and the MOE go hand in hand to ensure children in helping to ensure otherwise eligible children can access Medicaid and CHIP can depend on stable health coverage. and maintain Medicaid and CHIP coverage and have been Accordingly, permanent continuation of the MOE must be targeted to organizations working with children that are part of any future CHIP legislation. more likely to be uninsured—such as American Indian and Alaska Native children, adolescents, and children living in rural areas.22 Nearly 6 in 10 uninsured children CHIP Enrollment Caps and Freezes are eligible for Medicaid and CHIP but are not currently Over the 24-year history of CHIP, 12 states have put an enrolled.23 Outreach and enrollment assistance with trusted enrollment cap or freeze in place. While most lasted for messengers is important especially for communities where less than a year,17 the longest and most significant freeze there has been a chilling effect as a consequence of anti- was initiated in 2010, when the state of Arizona froze immigrant policies.24 enrollment in response to state budget cuts just before the ACA’s MOE went into effect leading to waiting list Accordingly, funding for outreach and enrollment should for Arizona’s KidsCare program of more than 100,000 be part of any CHIP legislation. In addition, outreach and children.18 While Arizona later lifted the enrollment enrollment funding for fiscal years 2024 and onward should freeze,19 such state actions demonstrate the need to be provided at least at the HEALTHY KIDS Act levels to ensure children are fully protected from harmful freezes support these essential activities. or caps. Accordingly, any extension of the CHIP MOE should include a statutory change to ensure that states cannot restrict enrollment through freezes or caps so that children living in states like Arizona are protected. CCF.GEORGETOWN.EDU next steps for chip 5 What other improvements can be made to CHIP? There are a number of other policy changes that could be addition, states that operate separate CHIP programs made to modernize and strengthen CHIP. may also impose higher cost-sharing requirements including co-insurance and deductibles (i.e., UT) that 1. Eliminate the option for states to have “waiting could diminish access to care.30 periods” Originally conceived of as a measure to prevent In recognition of the challenges premiums and cost- dropping of employer-sponsored coverage, states are sharing pose, many states waived or lowered premiums currently permitted to establish waiting periods of up and cost-sharing, eliminated premium lockouts, and/ to 90 days before children can be enrolled in CHIP or waived outstanding premiums for the period of coverage.25 Many states have dropped their waiting the public health emergency as part of temporary periods over the years, but 12 states still have waiting disaster relief state plan amendments.31 Such actions periods—10 of which are for the maximum permissible demonstrate that states recognize that premiums and length of 90 days.26 This provision amounts to a forced cost-sharing present burdensome barriers to necessary period of uninsurance for children during which they coverage. Moreover, such premium and cost-sharing may miss needed preventive or acute care and families policies should be revisited at the federal level in light may incur large medical bills.27 There is no evidence of the Affordable Care Act and subsequent changes that these policies are preventing dropping of employer- focused on improving access to and affordability of sponsored coverage and they should be prohibited. coverage such as the increase to premium subsidies included under the American Rescue Plan.32 2. Allow states to increase children’s income eligibility through a state plan amendment rather Federal policymakers should take a number of steps than through a waiver to ease the burdens of premiums, cost-sharing and lockouts on families and better align CHIP policies with As a result of changes made by the ACA, states can that of Medicaid: no longer expand income eligibility for children above a certain threshold via a state plan amendment. zz States should not be permitted to impose lockouts Therefore, most states must seek permission to on families for nonpayment of premiums or expand eligibility through Section 1115 demonstration enrollment fees. authority. This creates a complicated path for a state zz States should not be permitted to charge that wishes to cover more children. A simple technical premiums to children in families with incomes fix would clarify that states have the flexibility to raise below 150 percent of the federal poverty line (FPL). their income eligibility threshold for children in CHIP. This would bring CHIP premium rules in line with Medicaid policies.33 It would also align with current 3. End “lockouts” and better align CHIP premium eligibility for Advance Premium Tax Credits (APTCs) and cost-sharing rules with Medicaid allowing for coverage with zero premiums for States that operate separate state CHIP program are people with incomes below 150 percent of FPL in permitted to charge premiums, deny coverage to those the ACA marketplace.34 families who cannot pay them, and even “lockout” zz States should be required to align CHIP cost- children for a period of up to 90 days for nonpayment— sharing protections with those in Medicaid.35 even after a family resumes paying the premiums. For low- and moderate-income families, premiums and zz States should be encouraged to maintain the lockouts pose a barrier to coverage and contribute to policies that were adopted during the public health periods of uninsurance for children.28 Twenty-six states emergency to minimize the burden of premiums charge premiums; with five states charging premiums and cost-sharing on families. to children in families with incomes below 150 percent of the federal poverty line (AZ, FL, GA, NV, UT).29 In CCF.GEORGETOWN.EDU next steps for CHIP 6 4. Create a permanent Pediatric Quality Measures 6. Ensure that children in separate CHIP programs Program are eligible for the Vaccines for Children CHIPRA launched the Child Core Set of Health program Care Quality Measures in Medicaid and CHIP, which As the COVID-19 pandemic has made painfully clear, states must report beginning in 2024. To support vaccinations are a critical part of children’s preventive pediatric quality measurement, CHIPRA initiated care. The Vaccines for Children (VFC) program the development of the Pediatric Quality Measures provides vaccines at no or de minimus charge to Program (PQMP), which funds Centers of Excellence children who would otherwise not have access due intended to improve and strengthen the initial core to cost. However, Congress has not acted to update set of child health quality measures and to increase the VFC program for decades and it does not reflect the portfolio of evidence-based, consensus-driven the existence of CHIP or advancements in vaccine pediatric quality measures available to both public and science.36 As a consequence, children enrolled in CHIP private payers. In the annual review of the child core through a state’s Medicaid program are eligible for VFC set, quality experts have continued to point out gaps vaccines, but children enrolled in a state’s separate in quality measures in key areas including adverse CHIP program are not—unless they are American childhood experiences, the social determinants Indian or Alaska Native children. To simplify vaccine of health, and continuity of coverage. Federal administration, the VFC program should be expanded policymakers should continue to fund and support the to include all CHIP enrollees. development and testing of new measures through the PQMP and to incentivize states to demonstrate 7. Extend Medicaid rebates to separate state CHIP improvement in the quality of care children receive in programs Medicaid and CHIP. As we recommended in our 2019 report on how to strengthen the Medicaid Drug Rebate Program (MDRP) 5. Make Express Lane Eligibility a permanent state and address rising Medicaid prescription drug costs, option and extend it to adults Medicaid rebates should be extended to separate CHIP Express Lane Eligibility (ELE) is a state option that programs.37 Under current law, the MDPR does not allows states to use the eligibility findings from other apply to separate CHIP programs. As a result, separate public programs to streamline enrollment and renewal state CHIP programs are not benefiting from rebates for children in Medicaid and CHIP. States like Alabama available under the MDRP that would help lower CHIP and Louisiana have successfully used Supplemental prescription drug costs. Moreover, it is very likely that Nutrition Assistance Program (SNAP) enrollment data separate state CHIP programs, and the managed to ensure that children receiving SNAP benefits are also care plans that contract with them, are obtaining enrolled in Medicaid, an effort that also helps address considerably smaller rebates than what is now required the social determinants of health and is administratively under Medicaid. Extending Medicaid rebates to efficient. However, the fact that prior CHIP funding separate state CHIP programs would provide additional extensions have always established a sunset date for financial assistance to states and also help to better the policy discourages states from implementing it as it ensure children in separate CHIP programs receive requires an upfront investment of time and technology access to needed prescription drugs. to maximize its efficiency and effectiveness. Congress should make ELE a permanent state option and extend the policy to adults so that states can enroll all eligible members of a family. CCF.GEORGETOWN.EDU next steps for chip 7 Conclusion The nation has made enormous progress in reducing the at a minimum—so that other challenges they face can be number of uninsured children thanks to Medicaid and addressed. CHIP plays a critical role in providing such CHIP; however recent trends have moved the number in coverage and improving the health of the nation’s children. the wrong direction. Having access to public coverage Therefore, CHIP funding should be made permanent provides children and society with long-term benefits as alongside other improvements as described above to health and educational gains provide a strong return on better support this vital program and the children and investment.38 Children who face additional barriers to good families that rely on it to meet their health care needs. health as a consequence of income, geography, race, or all of the above, must have continuous affordable coverage Acknowledgments This brief was written by Joan Alker and Anne Dwyer of Georgetown Center for Children and Families. The authors would like to thank Tricia Brooks, Edwin Park, Kelly Whitener, and Aubrianna Osorio for their contributions to the report. Design and layout provided by Nancy Magill. The Georgetown University Center for Children and Families (CCF) is an independent, nonpartisan policy and research center founded in 2005 with a mission to expand and improve high-quality, affordable health coverage for America’s children and families. CCF is based in the McCourt School of Public Policy’s Health Policy Institute. CCF.GEORGETOWN.EDU next steps for CHIP 8 Appendix Table 1. State E-FMAPs FY 2021 (with Families First Coronavirus State FY 2021 Response Act FMAP increase) Alabama 80.81% 85.15% Alaska 65.00% 69.34% Arizona 79.01% 83.35% Arkansas 79.86% 84.20% California 65.00% 69.34% Colorado 65.00% 69.34% Connecticut 65.00% 69.34% Delaware 70.42% 74.76% District of Columbia 79.00% 83.34% Florida 73.37% 77.71% Georgia 76.92% 81.26% Hawaii 67.11% 71.45% Idaho 79.29% 83.63% Illinois 65.67% 70.01% Indiana 76.08% 80.42% Iowa 73.23% 77.57% Kansas 71.78% 76.12% Kentucky 80.44% 84.78% Louisiana 77.19% 81.53% Maine 74.58% 78.92% Maryland 65.00% 69.34% Massachusetts 65.00% 69.34% Michigan 74.86% 79.20% Minnesota 65.00% 69.34% Mississippi 84.43% 88.77% Missouri 75.47% 79.81% Montana 75.92% 80.26% Nebraska 69.53% 73.87% Nevada 74.31% 78.65% New Hampshire 65.00% 69.34% New Jersey 65.00% 69.34% New Mexico 81.42% 85.76% New York 65.00% 69.34% North Carolina 77.18% 81.52% North Dakota 66.68% 71.02% Ohio 74.54% 78.88% Oklahoma 77.59% 81.93% Oregon 72.59% 76.93% Pennsylvania 66.54% 70.88% Rhode Island 67.86% 72.20% South Carolina 79.44% 83.78% South Dakota 70.80% 75.14% Tennessee 76.27% 80.61% Texas 73.27% 77.61% Utah 77.26% 81.60% Vermont 68.20% 72.54% Virginia 65.00% 69.34% Washington 65.00% 69.34% West Virginia 82.49% 86.83% Wisconsin 71.56% 75.90% Wyoming 65.00% 69.34% Source: Medicaid and CHIP Payment and Access Commission analysis of U.S. Department of Health and Human Services, Federal Register notices for FYs 2019–2022, available at https://www.macpac.gov/wp-content/uploads/2018/04/EXHIBIT-6.-Federal-Medical-Assistance- Percentages-and-Enhanced-FMAPs-by-State-FYs-2019%E2%80%932022.pdf. CCF.GEORGETOWN.EDU next steps for chip 9 About this Series This issue brief is eleventh in a series of papers from Georgetown University Center for Children and Families on the future of children’s health coverage. Other briefs in the series include: Continuous Eligibility in Medicaid and CHIP. An update on the current policy landscape and the benefits of continuous eligibility. (July 2021) Covering All Kids. Focuses on the remaining 4 million uninsured children and makes recommendations for policy changes to reach them as well as to simplify and improve children’s coverage overall. (February 2020) Promoting Health Coverage of American Indian and Alaska Native Children. Focuses on improving access to health care for American Indian and Alaska Native children. (September 2019) How Medicaid and CHIP Can Support Student Success through Schools. Examines how Medicaid can help schools better serve children and families and how schools can help students get the health care they need. (April 2019) The Questions to Ask When Assessing the Impact of Coverage Expansion Proposals on Children. Focuses on a number of key questions to help assess the relative merits of coverage expansion proposals from the perspective of children. (February 2019) How to Strengthen the Medicaid Drug Rebate Program to Address Rising Medicaid Prescription Drug Costs. Focuses on the effectiveness of the Medicaid Drug Rebate program and how to improve it. (January 2019) Promoting Young Children’s Healthy Development in Medicaid and the Children’s Health Insurance Program (CHIP). Focuses on ways that state and federal policymakers can use Medicaid and CHIP to more effectively put young children on the best path for success in school and in life. (October 2018) How Medicaid and CHIP Shield Children from the Rising Costs of Prescription Drugs. Focuses on how Medicaid and CHIP protect most children from the rising costs of prescription drugs. (July 2017) Fulfilling the Promise of Children’s Dental Coverage. Focuses on pediatric dental coverage and ways to improve children’s oral health. (August 2016) The Future of Children’s Coverage: Children in the Marketplace. Focuses on ways to improve marketplace coverage and the associated financial assistance for children. (June 2016) CCF.GEORGETOWN.EDU next steps for CHIP 10 Endnotes 1 “March 2021 Medicaid & CHIP Enrollment Data Highlights,” Centers 12 Herz, E. J., Peterson, C. L., and Baumrucker, E. P. “State Children’s for Medicare & Medicaid Services, https://www.medicaid.gov/medicaid/ Health Insurance Program (CHIP) Legislative History,” Congressional program-information/medicaid-and-chip-enrollment-data/report- Research Service, February 2009, available at https://www. highlights/index.html. everycrsreport.com/files/20090218_R40229_571e29ed7e49db35b74d1 3c194c58c1a18d217dc.pdf. 2 There are a few exceptions to this like the unborn child option. 13 Brooks, T., “CHIP Funding Has Been Extended, What’s Next 3 Brooks, T. et al., “Medicaid and CHIP Eligibility and Enrollment Policies For Children’s Health Coverage?” Health Affairs Blog, January as of January 2021: Findings from a 50-State Survey” (Washington DC: 2018, available at https://www.healthaffairs.org/do/10.1377/ Georgetown University Center for Children and Families and Kaiser hblog20180130.116879/full/. Family Foundation, March 2021), available at https://www.kff.org/ medicaid/report/medicaid-and-chip-eligibility-and-enrollment-policies- 14 Patient Protection and Affordable Care Enhancement Act, H.R. 1425, as-of-january-2021-findings-from-a-50-state-survey/. 116th U.S. Congress, 2nd Session (June 29, 2020), available at https:// www.congress.gov/bill/116th-congress/house-bill/1425/text; CARING 4 Medicaid and CHIP Payment and Access Commission analysis of FY for Kids Act, H.R. 66, 117th U.S. Congress, 1st Session (January 4, 2019 CHIP Statistical Enrollment Data System (SEDS) data, available at 2021) available at https://www.congress.gov/bill/117th-congress/house- https://www.macpac.gov/wp-content/uploads/2015/01/EXHIBIT-32.- bill/66?s=1&r=5; and CHIPP Act, H.R. 1791, 117th U.S. Congress, Child-Enrollment-in-CHIP-and-Medicaid-by-State-FY-2019-thousands. 1st Session (March 11, 2021), available at https://www.congress.gov/ pdf; and Brooks, T. et al., op. cit. bill/117th-congress/house-bill/1791?q=%7B%22search%22%3A%5B 5 Centers for Medicare & Medicaid Services, op. cit. %22H.R.+1791%22%5D%7D&r=1&s=3. 6 Dubay, L. C., and Kenney, G. M., “When the CHIPs Are Down — 15 See Helping Ensure Access for Little Ones, Toddlers, and Hopeful Health Coverage and Care at Risk for U.S. Children,” New England Youth by Keeping Insurance Delivery Stable Act (referred to as the Journal of Medicine 378, no. 7 (February 2018): 597-599. HEALTHY KIDS Act), Pub.L. 115-120, section 3001 et seq. and the Advancing Chronic Care, Extenders and Social Services Act (referred to 7 Alker, J. and Corcoran, A., “Children’s Uninsured Rate Rises by Largest as the ACCESS Act), Pub.L. 115-123, section 50100 et seq; Whitener, Annual Jump in More than a Decade” (Washington DC: Georgetown K. op. cit.; and Brooks, T., Roygardner, L., and Artiga, S., “Medicaid University Center for Children and Families, October 2020), available at and CHIP Eligibility, Enrollment, and Cost Sharing Policies as of https://ccf.georgetown.edu/2020/10/08/childrens-uninsured-rate-rises- January 2019: Findings from a 50-State Survey” (Washington DC: by-largest-annual-jump-in-more-than-a-decade-2/. Georgetown University Center for Children and Families and Kaiser 8 The regular Medicaid Federal Medical Assistance percentage (FMAP) Family Foundation, March 2019), available at https://www.kff.org/report- is on average 56 percent, while the CHIP enhanced matching rate section/medicaid-and-chip-eligibility-enrollment-and-cost-sharing- (E-FMAP) is on average almost 70 percent. “Federal Medical Assistance policies-as-of-january-2019-findings-from-a-50-state-survey-tables/. Percentage (FMAP) for Medicaid and Multiplier,” Kaiser Family 16 Georgetown University Center for Children and Families, “The Foundation, https://www.kff.org/medicaid/state-indicator/federal- Maintenance of Effort (MOE) Provision in the Affordable Care Act,” matching-rate-and-multiplier/?currentTimeframe=0&sortModel=%7 Georgetown University Center for Children and Families, May 2017, B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D; available at https://ccf.georgetown.edu/wp-content/uploads/2017/05/ “Enhanced Federal Medical Assistance Percentage (FMAP) for CHIP,” MOE-fact-sheet-FINAL.pdf. Kaiser Family Foundation, https://www.kff.org/other/state-indicator/ enhanced-federal-matching-rate-chip/?currentTimeframe=0&sortMode 17 Georgetown University Center for Children and Families analysis of l=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22% the annual 50-state survey on eligibility and enrollment procedures 7D. published by the Kaiser Commission on Medicaid and the Uninsured and other reports on CHIP enrollment freezes and caps. North Carolina 9 “Families First Coronavirus Response Act,” Pub. L. 116-127, 177 Stat had a freeze in place from January to July 2001. Between 2001 until 134 (2020), amended by the “Coronavirus Aid, Relief, and Economic 2007, Utah processed CHIP enrollment only during specific open Security (CARES) Act,” Pub. L. 116-136, 280 Stat 134 (2020). enrollment periods. During the 2003-2004 recession, 7 states (AL, CO, 10 Whitener, K., “Healthy Kids and ACCESS Acts: Summary of Key GA, FL, ID MD, MT) implemented caps or freezes for less than one Provisions Impacting Children” (Washington DC: Georgetown University year. California implemented a freeze from July until September 2009. Center for Children and Families, March 2018), available at https://ccf. Tennessee has two CHIP-funded programs, both of which have been georgetown.edu/wp-content/uploads/2020/04/March-2018-Healthy- closed and re-opened at various times; both are currently open. Note: Kids-Access-Act.pdf. Maryland had a separate CHIP program during its enrollment freeze but merged the program into Medicaid in 2007. 11 Medicaid and CHIP Payment and Access Commission, “Comparing CHIP Benefits to Medicaid, Exchange Plans, and Employer Sponsored 18 Burak, E. W., “Children’s Health Coverage in Arizona: A Cautionary Insurance” (Washington DC: Medicaid and CHIP Payment and Access Tale for the Future of the Children’s Health Insurance Program (CHIP)” Commission, March 2015), available at https://www.macpac.gov/ (Washington DC: Georgetown University Center for Children and wp-content/uploads/2015/03/Comparing-CHIP-Benefits-to-Medicaid- Families, January 2015), available at https://ccf.georgetown.edu/wp- Exchange-Plans-and-Employer-Sponsored-Insurance.pdf. content/uploads/2015/01/Childrens-Coverage-in-Arizona-A-Cautionary- Tale-for-the-Future-of-Childrens-Health-Insurance-Program.pdf. CCF.GEORGETOWN.EDU next steps for chip 11 19 For more background on Arizona’s KidsCare and KidsCare II programs 29 Brooks, T., Roygardner, L., and Artiga, S., op. cit. (Table 14). and enrollment freeze, see Brooks, T., Heberlein, M., and Fu, J., 30 Centers for Medicare & Medicaid Services, Approval of Utah State “Dismantling CHIP in Arizona: How Losing KidsCare Impacts a Child’s Plan Amendment (SPA) UT-19-0021, November 2019, available at Health Care Costs” (Washington DC: Georgetown University Center https://www.medicaid.gov/CHIP/Downloads/UT/UT-19-0021.pdf. for Children and Families and Children’s Action Alliance, May 2014), available at https://ccf.georgetown.edu/wp-content/uploads/2014/05/ 31 See, e.g., CHIP disaster relief SPA approvals for AZ, DE, GA, IA, ID, Dismantling-CHIP-in-Arizona.pdf.  IL, IN, KS, LA, ME, MA, MO, MT, NV, NJ, PA, UT, WA, WV, WI (states eliminating premiums and/or premium locks under CHIP disaster relief 20 See endnote 15. state plan amendments) and CT, GA, ID, IN, IA, IL, MT, NJ, VA, WA, WV 21 HEALTHY KIDS Act and ACCESS Act, op. cit. Outreach and (states eliminating copayments or cost-sharing under CHIP disaster enrollment grants have been funded at approximately $20 million per SPAs) at “Approved 1135 Waivers and State Plan Amendments for year from fiscal year 2009 through 2023 including under the HEALTHY COVID-19,” Georgetown University Center for Children and Families, KIDS Act. However, the ACCESS Act reduced total funding for outreach https://ccf.georgetown.edu/2020/03/24/approved-1135-waivers/. and enrollment to $48 million over the 2024 through 2027 fiscal year 32 Pollitz, K., “How the American Rescue Plan Will Improve Affordability period bringing funding levels down to $12 million a year. of Private Health Coverage,” Kaiser Family Foundation, March 2021, 22 See, e.g., “Outreach & Enrollment Grants,” InsureKidsNow.gov, available at https://www.kff.org/health-reform/issue-brief/how-the- https://www.insurekidsnow.gov/campaign-information/outreach- american-rescue-plan-will-improve-affordability-of-private-health- enrollment-grants/index.html.  coverage/. 23 Haley, J. M et al., “Uninsurance Rose among Children and Parents in 33 “MACPAC Recommendations,” Medicaid and CHIP Payment and 2019,” (Washington DC: Urban Institute, July 2021), available at https:// Access Commission, (CHIP, March 2014 and January 2017), https:// www.urban.org/sites/default/files/publication/104547/uninsurance-rose- www.macpac.gov/recommendations-of-the-medicaid-and-chip- among-children-and-parents-in-2019.pdf. payment-and-access-commission/. 24 Whitener, K., Snider, M., and Corcoran, A., “Expanding Medicaid 34 People up to 150 percent FPL can now get silver plans for zero Would Help Close Coverage Gap for Latino Children and Parents” premium for the 2021 and 2022 plan year under the American Rescue (Washington DC: Georgetown University Center for Children and Plan; see Pollitz, K., op. cit. Families and Unidos US, June 2021), available at https://ccf. 35 “Premiums, Enrollment Fees, and Cost-Sharing Requirements for georgetown.edu/2021/06/29/expanding-medicaid-would-help-close- Children,” Kaiser Family Foundation, https://www.kff.org/medicaid/state- coverage-gap-for-latino-children-and-parents/. indicator/premiums-enrollment-fees-and-cost-sharing-requirements-for- 25 Originally, CHIP waiting periods could extend up to a year in some children/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Loc cases. Under the ACA, waiting periods were limited to three months. ation%22,%22sort%22:%22asc%22%7D. See “Waiting Periods in CHIP,” Centers for Medicare & Medicaid 36 Georgetown University Center for Children and Families, “Urgent Services, https://www.medicaid.gov/chip/eligibility-standards/waiting- Action Needed to Catch Up on Routine Childhood Vaccinations” periods-chip/index.html. (Washington DC: Georgetown University Center for Children and 26 Brooks, T. et al., “Medicaid and CHIP Eligibility, Enrollment, and Cost Families, July 2021), available at https://ccf.georgetown.edu/wp- Sharing Policies as of January 2020: Findings from a 50-State Survey” content/uploads/2021/07/Kids-and-Vaccines-v4.pdf. (Washington DC: Georgetown University Center for Children and 37 Park, E. “How to Strengthen the Medicaid Drug Rebate Program to Families and Kaiser Family Foundation, March 2020), available at https:// Address Rising Medicaid Prescription Drug Costs” (Washington DC: files.kff.org/attachment/Table-2-Medicaid-and-CHIP-Eligibility-as-of- Georgetown University Center for Children and Families, January 2019), Jan-2020.pdf (Table 2); and Centers for Medicare & Medicaid Services, available at https://ccf.georgetown.edu/wp-content/uploads/2019/01/ Approval of Wyoming State Plan Amendment (SPA) WY-21-0018, May Medicaid-Rx-Policy-Options-v4.pdf.  2021, available at https://www.medicaid.gov/CHIP/Downloads/WY-21- 0018.pdf. 38 Park, E., Alker J., and Corcoran, A. “Jeopardizing a Sound Investment: Why Short-Term Cuts to Medicaid Coverage During Pregnancy and 27 Brooks, T., “Now is the Time to Remove CHIP Waiting Periods and Childhood Could Result in Long-Term Harm,” The Commonwealth Welcome Kids into Coverage,” Say Ahhh!, Georgetown University Fund, December 2020, available at https://www.commonwealthfund. Center for Children and Families, April 17, 2020, available at https://ccf. org/publications/issue-briefs/2020/dec/short-term-cuts-medicaid-long- georgetown.edu/2020/04/17/now-is-the-time-to-remove-chip-waiting- term-harm. periods-and-welcome-kids-into-coverage/. 28 Artiga, S., Ubri, P., and Zur, J., “The Effects of Premiums and Cost Sharing on Low-Income Populations: Updated Review of Research Findings” (Washington DC: Kaiser Family Foundation, June 2017), available at https://www.kff.org/medicaid/issue-brief/the-effects-of- premiums-and-cost-sharing-on-low-income-populations-updated- review-of-research-findings/.