Georgetown University Health Policy Institute The Future of Children’s Health Coverage Continuous Executive Summary Coverage in Continuous health insurance coverage produces a broad array of benefits across the health care sector for individuals, states, health plans, and providers. In particular, Medicaid Medicaid continuous eligibility promotes health equity by limiting gaps in coverage for low-income children and adults who experience disproportionate rates of health disparities. Consistent access to health care, including management of chronic conditions and CHIP and care coordination, improves health status and well-being and drives more efficient health care spending. Importantly, continuous eligibility mitigates the negative effects of income by Tricia Brooks and Allexa Gardner volatility that disproportionately impact low-income families and essential workers. By reducing the administrative costs associated with enrollees cycling on and off of Medicaid due to temporary fluctuations in income, states can dedicate Tenth in a series of papers from the more of the Medicaid dollar to pay for health care. Moreover, Georgetown University Center for continuous eligibility is necessary to fully measure the quality Children and Families on the future of of health care in Medicaid and the Children’s Health Insurance children’s health coverage. Program (CHIP), which also opens the door to improved accountability and oversight of insurers including Medicaid July 2021 managed care plans. Currently, all Medicaid enrollees are continuously enrolled until after the end of the COVID public health emergency (PHE), which is widely expected to continue through the entirety of 2021, if not longer.1 But as states resume normal operations post-PHE, many beneficiaries will lose the benefit of this continuous coverage. Under current law, states have limited continuous coverage requirements and state plan options in Medicaid and CHIP. Pregnant individuals in Medicaid must be continually covered through pregnancy until 60-days postpartum, and their infants must be continuously covered for one year. States may also opt to cover children for up to a full year, regardless of income fluctuations, through a straightforward state plan amendment (SPA). However, in order to extend continuous coverage to other eligibility groups, states must seek section 1115 demonstration authority from the federal government, an uncertain process that can be administratively complex, time-consuming, costly, and by no means assured. (For more information on SPAs vs. waivers, see page 5). CCF.GEORGETOWN.EDU continuous coverge in medicaid and chip 2 Medicaid primarily serves low-income individuals There will likely be important lessons learned by and families, who are more likely to experience examining enrollment patterns before, during, income volatility. As a result, Medicaid enrollees and after the PHE. As states develop their plans often encounter gaps in coverage due to “churn” for resuming normal eligibility and enrollment where they cycle on and off coverage due to operations post-pandemic, it is critically important temporary changes in income. Even short gaps to take appropriate steps to maintain ongoing in coverage can undermine their access to care, coverage for all eligible individuals. Moreover, the management of chronic conditions, and overall end of the PHE is an ideal time to take stock of health. Research shows that individuals with opportunities in Medicaid and CHIP to expand continuous coverage experience fewer unmet health continuous eligibility policies and implement care needs and are in better health than those who administrative processes that have proven to cycle on and off coverage.2 Providing continuous promote continuity of coverage. coverage can help avoid higher health care costs that can result when care is delayed or sought in hospital emergency rooms due to gaps in coverage. Benefits of Continuous Eligibility Recognizing the many benefits of continuous zz Drives more efficient health care spending eligibility, there has been growing interest in zz Improves health status and wellbeing in extending the policy to other eligibility groups in the short and longer term Medicaid, and in providing multi-year coverage for young children during their formative developmental zz Mitigates the impact of income volatility years. on families This brief provides an update on the current policy zz Promotes health equity landscape and benefits of continuous eligibility. zz Reduces administrative burden and costs It describes administrative actions that promote continuity of coverage at renewal, and during the zz Enhances the ability to fully measure the year between renewals. It also recommends policy quality of care strategies to advance continuous coverage in zz Provides states with better tools to hold Medicaid such as: health plans accountable for quality and zz guaranteeing full-year coverage for all children; improved health outcomes zz allowing states to provide multi-year continuous eligibility for children without a section 1115 waiver; zz extending federal continuous eligibility requirements following pregnancy from 60 days to 12 months; and zz creating a new state option to extend 12-month continuous eligibility to adults. CCF.GEORGETOWN.EDU continuous coverage in medicaid and chip 3 Current State Options to Provide 12-Month Continuous Eligibility with Federal Funding Continuous eligibility for a full year is often confused with 12-month renewal periods. To promote coverage stability, the Affordable Care Act (ACA) effectuated annual renewal periods for non-disabled, non-elderly enrollees in Medicaid and CHIP.3 States must redetermine eligibility once every 12 months, but not more frequently.4 However, unless a state chooses to implement continuous eligibility, it must act on changes in circumstances that may impact eligibility between renewals even when such changes are temporary. Children However, five states (Arkansas, Delaware, Nevada, Tennessee, Continuous eligibility for children is a long-standing policy and Texas) offer 12-month continuous coverage only in their option in Medicaid and CHIP that allows states to cover separate CHIP program, leaving lower-income children in children for up to a full year unless the child ages out, moves Medicaid more vulnerable to additional administrative burdens out of state, is disenrolled for nonpayment of premium, or that can result in coverage gaps.9 requests voluntary disenrollment.5 States may limit the policy to a specific age group and apply a continuous eligibility period Adults of less than one year. However, most states adopting the policy In general, federal law does not provide an easy option for cover all children for a full year. As of January 2020, 32 states states to extend continuous coverage in Medicaid to non- provide 12-month continuous eligibility to children in Medicaid pregnant adults. In May 2013, the Center for Medicare & and/or CHIP (see Appendix Table 1).6 Medicaid Services (CMS) provided guidance to states seeking to extend continuous eligibility to adults.10 Citing all of the Of the 32 states, 24 states guarantee full year coverage benefits of stable coverage for children, CMS noted that for children of all ages in both Medicaid and CHIP. Three allowing states to extend 12-month continuous coverage will states (Florida, Pennsylvania, and Utah) that provide full-year provide adults with the same advantages derived by children coverage for all CHIP children have taken steps to extend and result in better coordination for the entire family. This coverage to subsets of younger children in Medicaid. Florida approach is not a state plan option under current law; section and Pennsylvania provide 12 months of coverage in Medicaid 1115 demonstration authority is required. Currently, two for children under ages five and four, respectively.7 Utah states—Montana and New York—have approved section 1115 approved 12-month continuous Medicaid eligibility for waivers providing continuous coverage to adults.11 However, children under age six in 2020 but the COVID-19 pandemic recent efforts in Montana to discontinue 12-month continuous has stalled the effort. Indiana also provides full-year Medicaid eligibility for adults appear to be moving forward.12 and CHIP coverage to children under the age of three.8 State Take-Up of 12-Month Continuous Eligibility for Children 12-month continuous eligibility for all children under 19 in Medicaid and CHIP (24 states) 12-month continuous eligibility for all children under 19 in CHIP only (6 states) 12-month continuous eligibility for some children in Medicaid and/or CHIP (3 states) No 12-month continuous eligibility for any children in Medicaid or CHIP (17 states and D.C.) Source: Based on a national survey conducted by Kaiser Family Foundation with the Georgetown University Center for Children on Families, 2020. Data on South Carolina is based on the 2019 survey. CCF.GEORGETOWN.EDU continuous coverge in medicaid and chip 4 Post Pregnancy To adopt the new ARPA state option, states must provide full benefits to pregnant people in both Medicaid and Under current law, pregnant enrollees must be continuously CHIP for 12 months. It applies to all pregnant citizens, covered in Medicaid and CHIP during their pregnancy but regardless of their eligibility category, and to lawfully continuous eligibility extends only 60 days after the end residing pregnant people in the 25 states that have adopted of the pregnancy unless the individual is eligible under the option. It does not apply to pregnant people eligible for a different eligibility pathway.13 Prior to and during the coverage through emergency Medicaid or the CHIP unborn COVID-19 continuous eligibility requirement, a number of child option. In the meantime, all individuals enrolled in states were actively exploring or pursuing longer periods of Medicaid must be continuously covered through the end postpartum coverage through section 1115 demonstration of the COVID-19 public health emergency (PHE), which is authority. However, the American Rescue Plan Act (ARPA) expected to be in place at least for the entirety of 2021.16 of 2021 now provides a new state plan option to extend This allows time for CMS to promulgate rules and provide postpartum coverage for a full year following the end of the additional implementation support to states. If the PHE pregnancy, but not until April 2022. At least a dozen states ends prior to April 2022, CMS guidance on resuming have shown interest in extending postpartum coverage normal operations gives states flexibility to phase in beyond 60 days. CMS has recently approved waivers in delayed renewals and actions on changes in circumstances several states that extend postpartum coverage for less in a way that could bridge any gap between the end of the than a full year or to only a subset of individuals (e.g., PHE and when the new state option becomes effective.17 individuals with substance use disorder or mental health Current law sunsets this option in five years unless issues).14 With the new ARPA state plan option, CMS Congress extends it in the future. should no longer approve section 1115 waivers unless they are as expansive as the new ARPA state plan option.15 Status of State Postpartum Coverage Extensions Approved section 1115 waiver Proposed or pending section 1115 waiver Enacted legislation to seek federal * approval for a SPA or section 1115 wavier * * Pending legislation to seek federal approval for a SPA or section 1115 wavier Implemented state-funded coverage * Planning to submit a SPA or section * 1115 waiver No action on postpartum coverage extension * State limits the eligible population, provides a limited benefit package, and/or limits the coverage period to less than 12 months Source: Kaiser Family Foundation, Medicaid Postpartum Extension Tracker, as of July 1, 2021. CCF.GEORGETOWN.EDU continuous coverage in medicaid and chip 5 State Plan Option vs. Waiver State Plan Amendments Waivers Federal law sets broad requirements for the States seeking additional flexibility may apply to Medicaid program, mandating coverage of some the Secretary of the U.S. Department of Health populations and benefits while providing a variety and Human Services (HHS) for formal waivers of state options, such as 12-month continuous of certain statutory requirements if such actions eligibility for children. Each state specifies the promote the objectives of the Medicaid program. nature and scope of its Medicaid program through Section 1115 Medicaid waivers are granted at the the state plan, which serves as a formal, written discretion of the Secretary to test or demonstrate agreement between a state and the federal new concepts. Although not in federal statute, government. As federal requirements and state CMS requires section 1115 waivers to be budget policies change over time, updates are made via neutral to the federal government, meaning that state plan amendments (SPAs). Generally, SPA federal spending under the waiver cannot exceed templates (a checkbox/fill-in-the blank form) are what it would have been in absence of the waiver. available to facilitate state adoption of allowable Section 1115 waivers are subject to special options. terms and conditions, including reporting and evaluation. Typically, they are granted for a limited Once a SPA is submitted, CMS has 90 days period of time and then must be renewed if the to make a decision. Otherwise, the proposed state wishes to continue the demonstration. change automatically goes into effect, although the agency can “stop the clock” by requesting Unlike most SPAs, waivers require lengthy additional information. Upon approval, changes application and public comment processes at can take effect retroactively to the first day of the both the state and federal level, which promote quarter in which the SPA was submitted. Unlike consideration of stakeholder input. To assist with waivers, most SPAs are not subject to federal this lengthy process, CMS may develop templates notice requirements that provide an opportunity to renew existing section 1115 demonstrations for stakeholder comment on proposed changes, and to expedite approval of targeted actions, although states may have their own requirements. such as waivers to address the COVID-19 Also, SPA approvals are not contingent on pandemic. meeting any budgetary target or budget neutrality The extensive use of waivers (almost every as required in waivers. state now has at least one section 1115 waiver agreement in place) has contributed to wide variations in program design, covered services, and eligible populations among states and even within states.18 CCF.GEORGETOWN.EDU continuous coverge in medicaid and chip 6 The Benefits of Continuous Coverage The primary and most obvious impact of continuous XXPromotes Health Equity eligibility is that it limits the cycling of children and adults Continuous eligibility policies are one way to address on and off Medicaid and CHIP due to fluctuations in the health disparities and inequities that exist for income, but the implications are far broader. Changes in people of color and low-income or rural communities income eligibility are often temporary, and a large share of as a result of gaps in health coverage. Black, Hispanic, individuals who lose coverage re-enroll within a matter of and Indigenous individuals and families are more likely weeks or months.19 This pattern of short-term enrollment, to live in poverty and therefore have higher rates of disenrollment, and re-enrollment—known as churning— income volatility than Whites (see figure 1).21 More drives up administrative costs and diminishes access to than half (54 percent) of families living in poverty and timely and appropriate health care services. a third of low-income families (under 200 percent of the Federal Poverty Level (FPL)) experience volatility in XXImproves Health Status and Well-Being monthly household income.22 Losing coverage, even Individuals with continuous coverage experience fewer temporarily, compounds other challenges these families unmet health care needs and are in better health. A encounter as a result of structural racism in the health study by the Government Accountability Office (GAO) care system. It also puts individuals in the untenable found that beneficiaries covered by Medicaid for a full situation of choosing health care over other basic needs year reported fewer difficulties in obtaining necessary such as providing adequate food and safe, stable medical care and prescription medicine, similar to those housing for their families. with private insurance for a full year. Individuals with partial year health insurance—coverage for between one and 11 months—were more likely to report problems obtaining needed care, whether covered by Medicaid or private health insurance.20 Figure 1. Share of Individuals Living on Poverty or Near Poverty, by Race and Ethnicity 43.8% 41.5% 41.0% 39.3% 24.8% 22.4% 21.9% 20.3% 16.6% 16.8% 10.1% 9.6% American Black Other White Asian/Native Hispanic/ Indian/Alaska Hawaiian/ Latino Native Pacific Islander Below 100% of poverty Below 200% of poverty Source: Georgetown University Center for Children and Families analysis of U.S. Census Bureau 2019 American Community Survey (ACS) data using Public Use Microdata Sample (PUMS). “Other” includes individuals who indicated that they were of “Some other race” or “Two or more races.” The Census Bureau distinquishes between race and Hispanic origin/Latino ethnicity. Individuals of Hispanic/Latino origin can be of any race and individuals of any race can be Hispanic/Latino. CCF.GEORGETOWN.EDU continuous coverage in medicaid and chip 7 XXMitigates the Impact of Income Volatility on Medicaid to be between $400 and $600.28 Churning- Families related administrative costs, multiplied by the number Seasonal employment, variable work hours, or of people who churn in a year, can add up quickly occasional overtime pay can easily drive temporary leaving a smaller share of the Medicaid dollar to pay for changes in eligibility even if annual income remains health care.29 below the Medicaid threshold.23 The U.S. Financial The administrative burden extends to managed Diaries project determined that low- and moderate- care organizations (MCOs) which cover 82 percent income households experience 2.6 months a year in of Medicaid enrollees.30 MCOs must take steps to which their income was more than 25 percent above disenroll individuals, including sending notices of their average monthly income. Families with variable disenrollment, only to re-enroll and replace insurance income are more likely to experience churn in Medicaid cards when eligibility is reinstated. Frequently moving eligibility, and they also encounter other adverse in and out of eligibility makes it difficult for MCOs to consequences such as food insecurity, unstable coordinate care for enrollees with chronic conditions housing, greater parental stress, and reduced child or children with special health care needs. It also adds academic attainment.24 Consistent access to health to other administration burdens such as researching care can help mitigate these negative effects while and reconciling billing issues or delivering duplicative ensuring that medical debt, the most common cause of new member services when individuals are auto- bankruptcy, does not compound the difficulties these enrolled in a different health plan. In turn, different plan families face.25 assignments can disrupt access to usual sources of XXDrives More Efficient Health Care Spending care and preferred providers.31 Enrollment churn also creates confusion, adding to administrative workloads Ongoing health insurance coverage is effective at with an increased need for member and provider achieving better health outcomes and lower costs support services. when it promotes appropriate preventive, primary, and condition-specific care. Continuous coverage can help XXEnhances the Ability to Measure the Quality avoid higher health care costs that can result when care of Care is delayed or sought in hospital emergency rooms due Measuring the quality of health care accurately is to gaps in coverage.26 Consistent access to prescription essential to improving health outcomes, addressing drugs helps to manage multiple chronic conditions health equity concerns, and ensuring that public funds and lower the cost of treating acute episodes of care. are being spent responsibly. Continuous enrollment Continuous coverage minimizes disruptions in care with no more than a one-month gap in coverage is a coordination or care management services, which are prerequisite for most health care quality measures such critical to the health and well-being of children with as preventive care, immunization rates, and appropriate special health care needs and adults with chronic health medication management.32 Individuals with gaps in conditions. As a result, research has shown that monthly coverage are excluded from the data used to assess health care expenditures for continuously covered the quality of care, thus providing an inadequate picture individuals are lower than for those who experience of how well our public health insurance programs disruptions in coverage.27 are performing on key quality indicators. Beginning XXReduces Administrative Burden and Costs in 2024, states will be required to report on the Child Core Set of Health Care Quality Measures in Medicaid Continuous coverage reduces the administrative cost and CHIP and the behavioral health measures in of handling changes in circumstances, processing the Adult Core Set. Without continuous enrollment, terminations, and mailing disenrollment notices, only assessing the quality of care in Medicaid will be to have individuals reapply for coverage. Churning incomplete and may misrepresent how well Medicaid creates substantial administrative costs for the Medicaid and CHIP are performing. (See text box on page 8 for program in general and Medicaid managed care plans more information about the Child Core Set of Quality in particular. A 2015 study estimated the administrative Measures.) cost of one person churning off and back on to CCF.GEORGETOWN.EDU continuous coverge in medicaid and chip 8 XXSupports Accountability in Managed Care About the Child and Adult Core Set of Health Health care quality measures are also tools for Care Quality Measures in Medicaid and CHIP holding managed care plans accountable for providing the services they are contracted to The CHIP Reauthorization Act of 2009 called for the deliver. However, churning in Medicaid excludes development and maintenance of a set of health care plan members from the accountability system for quality measures for children in Medicaid and CHIP, managed care when they do not meet continuous known as the Child Core Sets of Health Care Quality enrollment criteria for measuring the quality of care.33 Measures. The following year, the ACA initiated a Accurate and complete quality measurement in companion set of quality measures for adults. Currently Medicaid and CHIP is indispensable in pinpointing reporting on quality measures for all Medicaid and CHIP specific areas in need of quality improvement, beneficiaries is voluntary for states but, beginning in prioritizing performance improvement goals, and 2024, states will be required to report all Child Core establishing performance targets for health plans and Set measures and the behavioral health measures in providers. Quality data is also essential in fairly and the Adult Core Set. Improving the completeness and effectively administering incentive-based payment accuracy of Medicaid and CHIP quality measurement arrangements for health plans and providers and in data is important in advance of mandatory reporting.34 assessing and monitoring overall MCO performance. Cost Considerations in Extending Continuous Eligibility Short Term Cost of Continuous Eligibility occurred at renewal or another time. Cost estimates should Adopting 12-month continuous eligibility does come with be based on only paying for the gaps in coverage for full a cost in additional coverage months, as well as one-time benefit enrollees who cycle off and back on within the implementation costs such as changes to a state’s eligibility 12-month renewal period. Moreover, some determination and claims payment systems. However, the reduction in should be made as to the impact of continuous coverage health care costs over time, coupled with administrative on overall health care costs over time, which decline with savings in processing temporary changes, can help offset longer periods of continuous coverage. However, there must these costs. Estimating the fiscal impact of continuous be a mechanism to reconcile declining monthly costs with coverage requires detailed knowledge of Medicaid eligibility contractual capitated payments to managed care plans. and enrollment policies, as well as access to the available enrollment data. It is important to exclude any additional Return on Investment costs for the share of enrollees who move out of state, age Gaps in coverage lead to the delay or avoidance of preventive, out of coverage, or request voluntary disenrollment. routine, and acute care, and disrupt efforts to effectively manage costly chronic conditions. Gaps in Medicaid Twelve-month continuous eligibility does not extend coverage have been associated with increased hospitalization coverage for individuals who lose coverage at renewal due for heart failure, diabetes, chronic obstructive pulmonary to ineligibility or procedural reasons. It also does not apply disease, and other ambulatory sensitive conditions.35 Studies to individuals enrolled for limited time periods such as have shown that skipped or delayed health care can lead presumptive eligibility, or those who are covered for limited to unnecessary illness or death, and can result in inefficient benefits such as emergency services for immigrants. In and expensive use of emergency room or hospital care for order to project the cost of extending continuous coverage, preventable conditions like asthma or diabetes.36 enrollment data must include reasonable assumptions about disenrollment patterns including whether a disenrollment CCF.GEORGETOWN.EDU continuous coverage in medicaid and chip 9 Notably, early life Medicaid coverage is associated with fewer chronic conditions in adulthood such Factors to Consider in Estimating the as high blood pressure, heart disease, obesity, Cost of Continuous Eligibility and diabetes.37 A number of studies find that Cost estimates should exclude cost for the share of Medicaid eligibility for children is associated with a enrollees, on average, who: greater likelihood of on-time graduation from high zz move out of state school and a decrease in the high school dropout rate, particularly among children of color. In turn, zz age out of coverage educational attainment improves health status in zz request voluntary disenrollment adults and can be a ticket out of poverty.38 Children’s zz are disenrolled for nonpayment of premiums health status can impact spending on special zz lose coverage at renewal education, child welfare, and juvenile justice, among zz are not subject to continuous eligibility provisions, other social issues. Accounting for Medicaid’s including individuals effects over the life course changes the cost-benefit zz enrolled on a temporary basis through calculation. Research shows that Medicaid can have presumptive eligibility positive long-run effects on health, human capital, zz receiving limited benefits such as emergency earnings, and tax payments.39 These longer-term and services for immigrants cross-sector impacts make continuous eligibility a sound public policy investment. Cost estimates should: zz include only the gaps in coverage for people cycle off To this end, a handful of states have recently taken and back on within the continuous eligibility period initial steps toward multi-year continuous coverage zz be offset by: for some children. California recently budgeted $1.8 zz the cost of coverage for enrollees would otherwise million annually to provide continuous eligibility move to different eligibility pathways with different for children from birth to age five. Legislators federal matching rates (e.g., Medicaid to CHIP, or in Washington state have directed the state’s pregnancy coverage to adult expansion) Health Care Authority to assess the feasibility and zz savings in administrative costs associated with fiscal impacts of a section 1115 waiver to extend reduction in churn continuous eligibility for children through age five. Oregon is considering five-year continuous eligibility zz declining monthly health care costs over time for children and adolescents in its proposed section zz savings in financial assistance to purchase higher 1115 waiver renewal. cost Marketplace plans Children Enrolled in Medicaid 1040 $$ $ Miss fewer Do better Graduate and Become Earn higher Pay more school days in school attend college healthier adults wages in taxes CCF.GEORGETOWN.EDU continuous coverge in medicaid and chip 10 Recommendations State Federal These recommendations range from actions that can be taken by a state, the Center for Medicaid and CHIP Services (CMCS), and/or Congress. See detailed recommendations on pages 15 and 16 on steps each governing unit can take to promote continuity of coverage and reduce administratively-costly churn. Expand Continuous Eligibility Policies Guarantee 12-months of continuous eligibility for all children in Medicaid and CHIP. Children in the lowest-income families remain eligible for much of their childhood. Despite frequent but temporary income fluctuations, the lowest income families whose children rely on Medicaid have significantly less income mobility than higher income families. Between 1975 and 2011, when overall family income increased by an average of 37 percent, family income actually declined for the poorest one-third of children.40 Of all children currently covered by Medicaid or CHIP, nearly 80 percent have a median income of less than 149 percent FPL ($38,144 for a family of four)—well below the median upper income limit of 255 percent FPL ($67,575 for a family of four) for both programs. 41, 42 These data suggest that very few children in Medicaid are likely to become income-ineligible. Permit multi-year coverage for young children via a state plan option. The science is strikingly clear—early childhood is the most critical developmental period in a child’s life, building a lifelong foundation for learning, behavior, and health. Continuous coverage for young children promotes consistent access to health care and the preventive services needed to identify and address physical, behavioral, and developmental concerns before they impede a child’s performance in school. Thus, health and school readiness are inextricably linked, which is why Head Start Program performance standards require that each enrolled child has a source of continuous health care and health insurance coverage.43 As the primary source of health coverage for young children—serving four out of every five children under age six living in poverty—Medicaid has a key role to play in assuring school readiness, which is a predictor of success in school and beyond.44 Create a state plan option to provide 12-month continuous eligibility to adults. Ideally, all individuals in Medicaid and CHIP should receive continuous coverage no matter where they live. As an incremental approach, states should be given the option to cover adults for a full year through a state plan option. Allowing states to provide 12-month continuous eligibility for adults will also reduce administrative burden by aligning enrollment policies between children and parents. Extend continuous coverage requirements for pregnant enrollees in Medicaid and CHIP from 60 days to one year post pregnancy. Maternal mortality and morbidity are shockingly far worse in the United States (U.S.) than all other developed countries, and wide racial and ethnic disparities exist.45 Women face considerable risks to their health and life during the postpartum period with one-third of pregnancy-related deaths occurring postpartum.46 Extended postpartum coverage allows mothers to better manage their own health and build strong relationships with their infants, which is critical for their child’s healthy social and emotional development.47 ARPA is a good start allowing states the flexibility extend postpartum coverage for a full year. However, as seen with other state options, it may not be enough to ensure uniform adoption across the states. To assure access to services across all states without imposing an unfunded mandate, the Medicaid and CHIP Payment and Access Commission (MACPAC), in its March 2021 report, urged Congress to require all states to extend the postpartum period 12 months with 100 percent federal financing.48 CCF.GEORGETOWN.EDU continuous coverage in medicaid and chip 11 Align Medicaid and CHIP Policy. The CHIP statute does not allow states to establish eligibility standards or premium and cost-sharing structures that favor children in higher income families.49 But unlike Medicaid, CHIP programs are not required to direct families to report changes between renewals, which contributes to churn.50 Current law also allows states to provide more favorable treatment of higher income children by permitting CHIP to provide 12-month continuous eligibility without adopting similar policies for lower income children in Medicaid. As noted above, ARPA recognizes the importance of aligning extended postpartum coverage in both Medicaid and CHIP, a concept that should be applied to continuous eligibility for children. If states want to adopt policies that promote continuity of coverage for children in CHIP, they should be required to do so for children in Medicaid. Families will also obtain the full benefit of ongoing and coordinated access to health care if enrollment policies are aligned between children and parents. Improve Retention of Coverage at Renewal Continuous eligibility for a full year does not protect eligible individuals from a loss of coverage at renewal. To ensure ongoing coverage for enrollees who remain eligible, states should take steps to minimize the loss of coverage at renewal due to procedural (“red-tape”) reasons. Increase the share of enrollees who are successfully redetermined at renewal using ex parte and other data driven processes without requiring families to take action. Some states report they are able to renew coverage automatically for a majority of enrollees, while other states report that only a small share of renewals are successfully determined via ex parte processes. Best practices include expanding data sources and exploring eligibility system changes that will increase the share of beneficiaries renewed automatically.51 Additionally, states have the option to use Express Lane Eligibility (ELE) to renew Medicaid and CHIP for children based on the data obtained through other public benefits such as the Supplemental Nutrition Assistance Program (SNAP). Coordinating Medicaid with other benefits reduces the administrative burden on state agencies and families, and assures that eligible families continue to receive the public benefits that support healthy families. Congress could also take steps to incentivize states to achieve specific performance standards on renewal related data, such as a specified threshold of ex parte and data-driven renewals, through an enhanced administration Federal Medicaid Assistance Percentage (FMAP) or performance payment. Improve beneficiary communications and follow-up to promote retention. There are numerous strategies states can deploy to improve retention of coverage for eligible individuals when ex parte processes are unsuccessful. Encouraging enrollees to use online accounts, maximizing the use of cost-effective electronic communications, following up with people when action is needed to maintain coverage, allowing adequate time to provide information or proof of eligibility, and improving the readability of notices are among the many steps that can be taken to improve retention. Boost consumer assistance at the state and community-level. States are required to provide consumer assistance in person and over the phone at application and renewal.52 Too often, especially during peak workloads, state call centers lack the capacity to provide timely assistance and enrollees encounter long wait times resulting in high call abandonment rates. States are also required to outstation eligibility workers to assist with applications, but not renewals, at all or most disproportionate share hospitals and federally qualified health centers, and have the flexibility to establish other outstation locations where potentially eligible pregnant women or children receive services.53 Outstationing could be expanded to include assistance with renewals. Additionally, states could pick up the option to establish certified application counselor programs to provide consumer assistance at community-based organizations, an approach that is more likely to be successful in reaching targeted populations. Lastly, Congress should permanently fund and expand the CHIPRA outreach and enrollment grants that are intended to provide critical support for the effective and targeted strategies needed to enroll and retain eligible children.54   CCF.GEORGETOWN.EDU continuous coverge in medicaid and chip 12 Take proactive steps to update mailing addresses. Low-income individuals and families are more likely to experience housing instability and face barriers in keeping their mailing addresses up-to-date. With current issues facing the U.S. Postal Service, mail is often delayed, particularly if the individual has filed a change of address form to have mail forwarded to a new address. This is acutely problematic when states limit the response time for individuals to update their mailing address to 10 days. Some states go so far as to interpret current regulations to allow the disenrollment of an individual when a single piece of mail is returned and make no further attempt to locate the individual. States should be required to take steps to keep mailing addresses up- to-date and to the locate the individual through other means (e.g., electronic communications or phone call) when mail is returned. While most states offer online accounts that allow enrollees to report changes electronically, other options also exist. These include giving enrollees 30 days to verify their new address, providing online forms or interactive voice response systems to simplify reporting of address changes, engaging MCOs in keeping addresses current, and identifying changes through the U.S. Postal Service Change of Address Database (USPS NCOA). Adopt Administrative Actions that Promote Continuity of Coverage between Renewals The ACA was intended to improve continuity of coverage by adopting annual renewal periods and eliminating unnecessary paperwork for states and enrollees, and by using technology to verify eligibility electronically. But without continuous eligibility, states must process changes in circumstances that may impact eligibility, even if they are temporary. Moreover, states are not restricted from aggressively trying to identify data discrepancies through electronic data searches that are known to accelerate churn. Adopt policies to smooth out income fluctuations. States have the option to take into consideration reasonably predictable income variability such as seasonal employment for both new applicants and current enrollees. As a starting point, states need to prompt applicants and enrollees to report anticipated income changes so they can be dealt with appropriately. States also have the option to keep beneficiaries enrolled until the end of the calendar year following a change in income if annual projected income remains under the Medicaid limit. In addition to smoothing out temporary fluctuations in income, extending coverage to the end of the calendar year can provide time for individuals to obtain other coverage. This is particularly important for enrollees who may have to meet a waiting period before becoming newly eligible for employer-based health insurance. Eliminate or disallow periodic data checks. Although states cannot conduct full renewals more than once a year, they may take actions to identify changes or discrepancies in eligibility data between renewals. This approach was encouraged by the Trump Administration at a time when child enrollment in Medicaid and CHIP declined and the uninsured rate for children began to rise after more than a decade of progress.55 Conservative interests also have been pushing model state legislation that creates duplicative eligibility data collection systems to identify data discrepancies that inevitably increase administrative costs and escalate churn.56 Such actions are specifically intended to erect administrative burdens, and often limit response times to 10 days, making it difficult for low-income families to maintain continuity of coverage and access to health care.57 Promote continuity of coverage when processing changes in circumstances. When processing a change in circumstances, states have the option to push out renewal dates if other eligibility criteria is not subject to change (e.g., citizenship or date of birth) or can be reverified without requesting information from the enrollee. States also have the flexibility to extend a 90-day reconsideration period when an individual does not respond to a request for information when the state has identified such a change. This allows the individual to provide proof of eligibility or other required information without having to submit a new application. CCF.GEORGETOWN.EDU continuous coverage in medicaid and chip 13 Improve Retention-Related Data Collection and Transparency Develop a standardized methodology for estimating the cost of 12-month continuous eligibility. State-level data is often inadequate to take into consideration all of the factors needed to project the cost of continuous eligibility. Even with dependable data, eligibility and enrollment expertise is essential to accurately analyzing the data to estimate the cost of continuous eligibility. Fiscal notes associated with proposed state-level legislation to adopt continuous eligibility have often over-estimated the cost, thereby discouraging adoption of the policy. Addressing data deficiencies and developing a standardized methodology would ensure that estimates of the cost of continuous eligibility are reliable. Develop and standardize measures of churn and retention rates. Currently, there are no standardized measures of retention, churn, or continuity of coverage in Medicaid. Researchers must conduct extremely complex analyses of enrollment data on a month-to-month basis in order to identify gaps in continuous enrollment. Standardized measures are needed to assess the extent to which churn drives up administrative costs and undermines access to timely and appropriate health care for eligible beneficiaries. Improve and report retention-related performance indicators. As a condition of enhanced federal funding to support Medicaid IT systems, states are required to have the ability to produce specific data or performance indicators that are necessary for oversight, administration, evaluation, integrity, and transparency.58 Currently, the performance indicators differentiate disenrollment data when ineligibility is established versus when ongoing eligibility could not be established (i.e., procedural reasons). States are also expected to report specific eligibility change reasons through the federal Transformed Medicaid Statistical Information System (T-MSIS); however, these data are not currently included in the T-MSIS analytic files that are available to researchers. A starting point is public reporting of disenrollment reason codes that can be used to monitor trends and pinpoint ways to improve retention.59 Tracking reasons of ineligibility such as aged out or moved out of state is fairly straightforward if states take care to accurately record the reason. These data are important to understanding retention and estimating the cost of continuous eligibility. To address churn, however, it is important to identify the underlying reasons why procedural disenrollments occur. According to the T-MSIS data dictionary, states report three eligibility change reasons associated with non-eligibility related procedural disenrollments: missing verification, nonpayment of premium, and lack of response. If a large share of disenrollments is due to missing verifications, the state should explore ways to improve data sources and ex parte processes. If a large share of individuals did not respond to a request for information, the state should examine whether or not notices are easy to understand and test different strategies to see if reminder notices, enrollee outreach, or more time to respond will improve the response rate. Surveys of recently disenrolled people can help identify actions the state can take to remove barriers, reduce churn, and improve retention. Additionally, the T-MSIS eligibility reason codes should be expanded to assess the extent that returned mail has led to the disenrollment. Expand the definition of an eligibility error to include state disenrollment of eligible individuals. The Payment Error Rate Measurement program (PERM) is the federal process for auditing eligibility and improper payments in Medicaid. Currently PERM identifies payment errors when an ineligible individual is enrolled or there is insufficient documentation to confirm how eligibility was determined. However, disenrolling an eligible individual (as well as denying new applicants erroneously) should also be an administrative error. States are more likely to take additional steps to make sure an eligible individual is not denied or disenrolled from coverage if such actions would increase the state’s eligibility error rate. While inaccurate eligibility denials or disenrollments do not result in improper payments, they do call into question the reliability of the eligibility process and whether states are providing the coverage that Medicaid guarantees to eligible individuals. CCF.GEORGETOWN.EDU continuous coverge in medicaid and chip 14 Conclusion Continuous coverage drives more efficient health care spending and improves health status and well-being. Gaps in coverage are associated with financial exposure for the family, and disrupt access to needed care for children and adults. A majority of states have adopted at least one of the limited options to provide 12-month continuous eligibility but guaranteeing full-year coverage for all children in Medicaid and CHIP and full-year post-pregnancy coverage would extend these benefits to children and pregnant women regardless of where they live.60 Allowing states to offer continuous coverage to adults and extend multi-year continuous coverage to young children through a simple SPA process would encourage states that are interested in improving continuity of coverage to move forward. As the state Medicaid agencies prepare for resuming normal operations in advance of the end of the COVID public health emergency, it is an ideal time for states to strengthen continuity of coverage by taking up available opportunities to adopt continuous eligibility. It is also a good time for Congress to consider how it can strengthen continuity of coverage and for CMS to consider how best to use its rulemaking or waiver authority to further support state efforts to promote continuous coverage. Acknowledgments The authors would like to thank Jennifer Wagner, Center for Budget and Policy Priorities, and Kristen Golden-Testa, The Children’s Partnership, for their review and feedback on this brief. We also want to acknowledge our colleagues, Joan Alker, Ema Bargeron, Alexandra Cochran, Maggie Clarke, Anne Dwyer, and Kelly Whitener for their contributions. 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 continuous coverage in medicaid and chip 15 Recommendations to Promote Medicaid Continuity of Coverage Expand Continuous Eligibility Policies Policy State CMS/Administration Congress 12-month continuous • Adopt state option • Enact a federal requirement for 12-month eligibility for children continuous eligibility for children Multi-year continuous • Apply for section 1115 waiver • Provide expedited section 1115 • Enact a state option eligibility for children • Adopt state option, if enacted by Congress waiver template 12-month continuous • Adopt new state option • Provide guidance on using CHIP • Enact a requirement for 12-month postpartum eligibility post-pregnancy Health Services or section 1115 coverage for all pregnancies covered by Medicaid authority to extend postpartum and CHIP (adults, emergency Medicaid, CHIP coverage under emergency Medicaid unborn child) and unborn child eligibility pathways • Provide a higher match for mandatory postpartum • Approve section 1115 waivers to coverage extend postpartum coverage only if • Remove the five-year sunset on new state plan they are as expansive as state option option that becomes effective April 2022 Requirement or state • Apply for section 1115 waiver • Expedite approval of state section • Require states to provide 12-month continuous option for 12-month • Adopt state option, if enacted by Congress 1115 waivers, if state requirement or eligibility for everyone continuous eligibility for option is not enacted • Alternatively, enact a state option allowing states to adults provide 12-month continuous eligibility for adults Align Medicaid and CHIP • Align continuous eligibility and procedures • Require states to adopt 12-month continuous policies in Medicaid and CHIP eligibility for children in Medicaid if adopted in CHIP Improve Retention of Coverage at Renewal Improvement State CMS/Administration Congress Increase share of data- • Work with IT vendors to expand data • Share best practices for achieving • Require states to adopt express lane eligibility and/ driven and ex parte sources and increase share of renewals high rates of ex parte renewals or other streamlined eligibility procedures which are renewals successfully processed via ex parte • Add the share of ex parte renewals currently a state option • Adopt express lane eligibility to facilitate to state performance indicators and • Provide states that use the express lane option renewals for children using SNAP or other report publicly in Medicaid and CHIP with an enhanced public program data • Provide guidance to states on ways administrative FMAP to incentivize use to align renewal dates for all members • Require the use of express lane eligibility in Medicaid of the family if used in CHIP • Provide states that meet a certain threshold of total ex parte renewals or increase their ex parte renewals by a certain threshold with an enhanced administrative FMAP Beneficiary • Send follow-up reminders via different • Work with states to provide model • Establish statutory minimums for beneficiary follow communications and modes (text, email, phone) when notices up for disenrollments (and denials) related to follow-up information is required at renewal • Ensure that state notices meet procedural issues • Offer robust and encourage use of requirements for plain language and • Require state notices to meet certain minimums online accounts and mobile applications translations to ensure they are sufficiently tailored and for beneficiaries to help manage their individualized as appropriate information • Provide states with an enhanced administrative • Take steps to increase the number of FMAP if they reduce procedural denials by a certain enrollees actively using their account threshold • Work with stakeholders to improve notices • Comply with federal rules regarding use of plain language • Provide notices in required languages • Ensure access to translation services in call centers Consumer Assistance • Ensure that call center and eligibility staff • Report state call center performance • Require a Government Accountability Office report have been trained on cultural competency indicators on call volume wait times, on state compliance with outstationed eligibility • Establish and fund certification application and abandonment rates workers requirements. counselor programs • Issue guidance on best practices • Add a statutory requirement to add assistance at • Expand outstationed eligibility sites and in following up with enrollees when renewal to outstationing requirements. incorporate assistance at renewal renewal information is needed • Expand and permanently fund outreach and enrollment grant funding CCF.GEORGETOWN.EDU continuous coverge in medicaid and chip 16 Recommendations to Promote Medicaid Continuity of Coverage (cont’d) Improve Retention of Coverage at Renewal (cont’d) Improvement State CMS/Administration Congress Update mailing address • Use the USPS National Change of Address • Issue guidance to states on best • Require a Government Accountability Office report (NCOA) database to identify address practices in keeping addresses current on the impact of returned and delayed mail on changes • Issue guidance on acceptable sources continuity of coverage • Work with MCOs and providers to keep of verifying updated addresses (e.g., mailing addresses up to date MCOs, USPS NCOA, providers, • Provide simple tools for easy reporting of navigators, etc.) address changes through online forms or • Issue guidance on sources of interactive voice response system address changes that do not require • Take steps to connect beneficiaries via verification text, email or phone when mail is returned Adopt Administrative Actions that Promote Continuity of Coverage between Renewals Action State CMS/Administration Congress Income Fluctuations • Ensure that applications and eligibility • Provide technical assistance to states processes can capture anticipated in smoothing out the income of changes in income temporary income fluctuations • Adopt option to use annual income through calendar year-end when processing changes Periodic data checks • Reduce churn by eliminating or limiting • Update rulemaking to align response periodic data checks times for all requests for information • Align response times for all requests for with the 30-day response requirement information with the 30-day response for renewals requirement for renewals • Send follow-up notices if periodic data checks are conducted Promote continuity • Push out renewal dates if all eligibility • Require states to extend out renewal of coverage when criteria can be verified without requesting dates when processing a change processing changes in additional information in circumstances, if other eligibility circumstances • Offer a 90-day reconsideration period if criteria can be confirmed or is not individual does not respond to a request subject to change for information following a change in • Update rules to require a 90-day circumstances reconsideration period for processing requests for information following a change in circumstances Improve Retention-Related Data Collection and Transparency Improvement State CMS/Administration Congress Estimating the cost of • Consider all relevant factors when • Work with researchers to develop continuous eligibility estimating the cost of continuous eligibility a standardized methodology for policies estimating the cost of continuous eligibility Standardized measures • Quantify and report churn in between • Work with measure developers and • Require states to report churn and retention rates of churn and retention renewals stewards to create standardized and the Secretary of HHS to publicly release state- • Quantify and report retention rate at measures by-state statistics (on a quarterly and annual basis) renewal • Incorporate churn and retention measures into performance indicators Enrollment and retention- • Collect, report, and make publicly available • Add returned mail/unable to locate as • Require state T-MSIS report and for the Secretary related performance all performance indicator data a T-MSIS eligibility change reason to issue regular enrollment and eligibility T-MSIS indicators • Include eligibility change reasons in data reports published T-MSIS research files • Report all state Medicaid performance indicator data on a monthly basis Define inaccurate • Revise PERM regulations to treat disenrollments as inaccurate disenrollments (and eligibility errors denials) as an eligibility error CCF.GEORGETOWN.EDU continuous coverage in medicaid and chip 17 Appendix Table 1. States With 12-Month Continuous Eligibility in Medicaid and/or CHIP 12-Month Continuous 12-Month Continuous 12-Month Continuous State in Medicaid in CHIP in Medicaid or CHIP TOTAL 24 25 32 Alabama X X X Alaska X N/A (M-CHIP) X Arizona Arkansas X X California X N/A (M-CHIP) X Colorado X X X Connecticut Delaware X X District of Columbia (N/A M-CHIP) Florida Under age 5 X X Georgia Hawaii (N/A M-CHIP) Idaho X X X Illinois X X X Indiana Under age 3 Under age 3 Iowa X X X Kansas X X X Kentucky Louisiana X X X Maine X X X Maryland (N/A M-CHIP) Massachusetts Michigan X N/A (M-CHIP) X Minnesota (N/A M-CHIP) Mississippi X X X Missouri Montana X X X Nebraska (N/A M-CHIP) Nevada X X New Hampshire (N/A M-CHIP) New Jersey X X X New Mexico X N/A (M-CHIP) X New York X X X North Carolina X X X North Dakota X N/A (M-CHIP) X Ohio X N/A (M-CHIP) X Oklahoma (N/A M-CHIP) Oregon X X X Pennsylvania Under age 4 X X Rhode Island (N/A M-CHIP) South Carolina X N/A (M-CHIP) X South Dakota Tennessee X X Texas X X Utah X X Vermont (N/A M-CHIP) Virginia Washington X X X West Virginia X X X Wisconsin Wyoming X X X Source: Based on a national survey conducted by Kaiser Family Foundation with the Georgetown University Center for Children on Families, 2020. Data on South Carolina is based on the 2019 survey. CCF.GEORGETOWN.EDU continuous coverge in medicaid and chip 18 About this Series This issue brief is tenth 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: 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 continuous coverage in medicaid and chip 19 Endnotes 13 Centers for Medicare and Medicaid Services, State Health Official Letter no. 09-006 (May 11, 2009), available at https://downloads.cms.gov/cmsgov/ 1 Brooks, T., “Families First Coronavirus Response Act Freezes Disenrollment archived-downloads/SMDL/downloads/SHO051109.pdf. States have the in Medicaid,” Georgetown University Center for Children and Families, June option of considering an unborn child to be a targeted low-income child 24, 2020, available at https://ccf.georgetown.edu/2020/03/23/families-first- and therefore eligible for coverage under CHIP, if other applicable eligibility coronavirus-response-act-freezes-disenrollment-in-medicaid/. criteria are met. This permits States to provide health care services to 2 Government Accountability Office, “States Made Multiple Program promote healthy pregnancies, regardless of the mother’s eligibility status. Changes, and Beneficiaries Generally Reported Access Comparable States may continue to pay for pregnancy and delivery services through a to Private Insurance,” Report 13-55 (Washington DC: Government bundled payment or global fee method, under which a single payment is Accountability Office, November 2012), available at https://www.gao.gov/ made for prenatal care, labor, delivery, and postpartum care. assets/gao-13-55.pdf. 14 “Medicaid Postpartum Coverage Extension Tracker,” Kaiser Family 3 These include children, pregnant women, parents, and expansion adults— Foundation, available at https://www.kff.org/medicaid/issue-brief/medicaid- the groups with income eligibility based on Modified Adjusted Gross Income postpartum-coverage-extension-tracker/. (MAGI) standards. 15 Gardner, A. and Alker, J., “Georgia and Missouri Postpartum Medicaid 4 42 C.F.R. 435.916(a) (2012). Waiver Approvals Promote Limited Coverage,” Say Ahhh!, Georgetown University Center for Children and Families, May 10, 2021, available at 5 Twelve-month continuous eligibility was authorized in the 1997 Balanced https://ccf.georgetown.edu/2021/05/10/georgia-and-missouri-postpartum- Budget Act. “Balanced Budget Act of 1997,” Public Law 105-33, United medicaid-waiver-approvals-promote-limited-coverage/. States Statutes at Large 111: 251-787. CHIP eligibility ends when a child turns 19, while states have the option to extend Medicaid to 19 and 20 16 Office of the Secretary of Health and Human Services, “U.S. Department year-olds. Children also may be disenrolled for nonpayment of premiums of Health and Human Services Letter,” (January 22, 2021), available at following the grace period, which can be as short as 30 days. 42 C.F.R. https://ccf.georgetown.edu/wp-content/uploads/2021/01/Public-Health- 457.342 (2016); 42 C.F.R. 457.570 (2013); Title XXI of the Social Security Act Emergency-Message-to-Governors.pdf. §2103(e)(3)(C) (2018). 17 Centers for Medicare and Medicaid Services, “Planning for the 6 Brooks, T. et al., “Medicaid and CHIP Eligibility, Enrollment, and Cost Resumption of Normal State Medicaid, Children’s Health Insurance Program Sharing Policies as of January 2020: Findings from a 50-State Survey” (CHIP), and Basic Health Insurance Program (BHP) Operations Upon (Washington DC: Georgetown Center for Children and Families and Conclusion of the COVID-19 Public Health Emergency,” State Health Official Kaiser Family Foundation, March 2020), available at https://www.kff.org/ Letter no. 20-004 (December 22, 2020), available at https://www.medicaid. coronavirus-covid-19/report/medicaid-and-chip-eligibility-enrollment-and- gov/federal-policy-guidance/downloads/sho20004.pdf. cost-sharing-policies-as-of-january-2020-findings-from-a-50-state-survey/. 18 See “Medicaid Waiver Tracker: Approved and Pending Section 1115 7 Ibid. Waivers by State,” Kaiser Family Foundation, available at https://www.kff. org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending- 8 Ibid. section-1115-waivers-by-state/. 9 Ibid. 19 Sugar, S. et al., “Medicaid Churning and Continuity of Care: Evidence and Policy Considerations Before and After the COVID-19 Pandemic” 10 With no state plan option available, CMS created an expedited section (Washington DC: Office of Health Policy, Assistant Secretary for Planning 1115 waiver path for states to provide full year continuous eligibility to and Evaluation, the U.S. Department of Health and Human Services, April adults. Given that section 1115 authority requires budget neutrality— 2021), available at https://aspe.hhs.gov/system/files/pdf/265366/medicaid- meaning that federal spending under the waiver cannot exceed what it churning-ib.pdf. would have been in absence of the waiver—the guidance requires a modest adjustment to the 90 percent Federal Medical Assistance Percentage 20 Government Accountability Office, “States Made Multiple Program (FMAP) applicable to the Medicaid adult expansion group. In 2014, the Changes, and Beneficiaries Generally Reported Access Comparable agency announced that 97.4 percent of the member months for expansion to Private Insurance,” Report 13-55 (Washington DC: Government adults could be matched at the 90 percent enhanced match rate with the Accountability Office, November 2012), available at https://www.gao.gov/ remaining 2.6 percent of member months matched at the state’s regular assets/gao-13-55.pdf. FMAP. This accounts for the estimated number of member months that beneficiaries would have been disenrolled due to excess income in the 21 Ibid. absence of continuous eligibility. 22 Hannagan, A. and Morduch, J., “Income Gains and Month-to-Month Centers for Medicare and Medicaid Services, “Facilitating Medicaid and Income Volatility: Household Evidence from the U.S. Financial Diaries,” CHIP Enrollment and Renewal in 2014,” State Health Official Letter no. Wagner School of Public Service, New York University and Center for 13-003 (May 17, 2013), available at https://www.medicaid.gov/sites/default/ Financial Services Innovation, (U.S. Financial Diaries Project Paper 1, March files/Federal-Policy-Guidance/downloads/SHO-13-003.pdf. 2015), available at http:// www.usfinancialdiaries.org/paper-1/. 11 “Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers 23 Smith-Ramani, J., Lucas McKay, K., and Mitchell, D., “Income Volatility: by State,” Kaiser Family Foundation, available at https://www.kff.org/ Why It Destabilizes Working Families and How Philanthropy Can Make a medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending- Difference” (New York: The Aspen Institute, December 11, 2017), available at section-1115-waivers-by-state/. https://www.aspeninstitute.org/publications/income-volatility-destabilizes- families-philanthropy-can-make-difference/; Hannagan, A. and Morduch, 12 Meier, Adam (Director, Montana Department of Public Health and Human J., op. cit.; Board of Governors of the Federal Reserve System, “Report on Services), letter to Centers for Medicare and Medicaid Services (letter, the Economic Well-Being of U.S. Households” (Washington, DC: Board of March 17, 2021). Governors of the Federal Reserve System, July 2014), available at https:// www.federalreserve.gov/econresdata/2013-report-economic-well-being-us- households-201407.pdf. CCF.GEORGETOWN.EDU continuous coverge in medicaid and chip 20 24 Andersen, V. et al., “Addressing Income Volatility of Low Income 35 Ku, L. et al., “Improving Medicaid’s Continuity of Coverage and Quality Populations,” University of Madison Wisconsin LaFollette School of Public of Care” (Association for Community Affiliated Plans and The George Affairs (working paper for The Financial Clinic Workshop in Public Affairs, Washington University Department of Health Policy, July 2009), available at Madison, Spring 2015), available at https://lafollette.wisc.edu/images/ http://casesjournal.org/files/departments/healthpolicy/DHP_Publications/ publications/workshops/2015-income.pdf. pub_uploads/dhpPublication_66898AB4-5056-9D20-3D5FC0235271FE99. pdf; Bindman, A., Chattopadhyay, A., and Auerback, G., op cit. 25 Himmelstein, D. et al., “Medical Bankruptcy: Still Common Despite the Affordable Care Act,” American Journal of Public Health 109, no. 3 (March 1, 36 Ku, L. et al., “Improving Medicaid’s Continuity of Coverage,” op cit.; 2019): 431-433, available at https://ajph.aphapublications.org/doi/10.2105/ Institute of Medicine (US) Committee on the Consequences of Uninsurance, AJPH.2018.304901?eType=EmailBlastContent&eId=a5697b7e-8ffc- “Care Without Coverage: Too Little, Too Late” (Washington DC: National 4373-b9d2-3eb745d9debb&=&. Academies Press (U.S.), 2002), available at https://pubmed.ncbi.nlm.nih. gov/25057604/. 26 Bindman, A. et al., “Medicaid Reenrollment Policies and Children’s Risk of Hospitalizations for Ambulatory Care Sensitive Conditions,” Medical 37 Miller, S. and Wherry, L.R., “The Long-Term Effects of Early Life Medicaid Care 46, no. 10 (October 2008): 1049-54, available at https://pubmed.ncbi. Coverage,” Journal of Human Resources 54, no. 3 (Summer 2019): 785–824, nlm.nih.gov/18815526/; Bindman, A., Chattopadhyay, A., and Auerback, available at https://muse.jhu.edu/article/729939. G., “Interruptions in Medicaid Coverage and Risk for Hospitalization for 38 Greenstone, M., “Thirteen Economic Facts about Social Mobility and the Ambulatory Care-Sensitive Conditions,” Annals of Internal Medicine 149, Role of Education” (The Hamilton Project at The Brookings Institution, June no. 12 (December 2008): 854-60, available at https://pubmed.ncbi.nlm.nih. 2013), available at https://www.brookings.edu/wp-content/uploads/2016/06/ gov/19075204/; Fairbrother, G., Presentation of Research Conducted by the thp_13econfacts_final.pdf. University of Cincinnati and Cincinnati Children’s Hospital, “Review of Ohio Medicaid Enrollment and Retention Trends,” 2010. 39 Goodman-Bacon, A., “The Long-Run Effects of Childhood Insurance Coverage: Medicaid Implementation, Adult Health, and Labor Market 27 Ku, L., Steinmetz, E., and Bysshe, T., “Continuity of Medicaid Coverage Outcomes” (Opportunity and Inclusive Growth Institute Federal Reserve in an Era of Transition,” Association for Community Affiliated Plans (Working Bank of Minneapolis, October 2020), available at http://goodman-bacon. Paper, November 2015), available at http://www.communityplans.net/ com/pdfs/medicaid_longrun_ajgb.pdf; Hendren, N. and Sprung-Keyser, B., Portals/0/Policy/Medicaid/GW_ContinuityInAnEraOfTransition_11-01-15.pdf. “A Unified Welfare Analysis of Government Policies,” The Quarterly Journal 28 Swartz, K. et al., “Reducing Medicaid Churning: Extending Eligibility For of Economics 135, No. 3 (August 2020): 1209–1318, https://doi.org/10.1093/ Twelve Months Or To End Of Calendar Year is Most Effective,” Health Affairs qje/qjaa006. 34, no. 7 (July 2015): 1180-1187, available at https://www.ncbi.nlm.nih.gov/ 40 Greenstone, M., op cit. pmc/articles/PMC4664196/pdf/nihms708512.pdf. 41 Median income eligibility for Medicaid is slightly higher for infants up 29 Ibid. to age 1 at 195 percent FPL. The median Medicaid eligibility level is 149 30 According to CMS, 82 percent of Medicaid beneficiaries were enrolled percent FPL for children ages 1-5, and 142 percent FPL for children ages in some type of managed care, with 70 percent enrolled in comprehensive 6-18. Brooks, T., et al., op cit. managed care in 2018. Centers for Medicare and Medicaid Services, 42 Centers for Medicaid and CHIP Services, “December 2020 and January “Managed Care Enrollment and Program Characteristics, 2018” (Baltimore 2021 Medicaid and CHIP Enrollment Trends Snapshot” (Baltimore: Centers and Washington, DC: Centers for Medicare and Medicaid Services and for Medicare and Medicaid Services, June 2021), available at https://www. Mathematica, Winter 2020), available at https://www.medicaid.gov/ medicaid.gov/medicaid/program-information/medicaid-chip-enrollment- medicaid/managed-care/downloads/2018-medicaid-managed-care- data/medicaid-and-chip-enrollment-trend-snapshot/index.html. enrollment-report.pdf. 43 “Access to Health Insurance,” Administration for Children and Families, 31 Summer, L. and Mann, C., “Instability of Public Health Insurance Coverage U.S. Department of Health and Human Services, available at https://eclkc. for Children and Their Families: Causes, Consequences, and Remedies” ohs.acf.hhs.gov/family-support-well-being/article/access-health-insurance. (Washington DC: Georgetown University Health Policy Institute, June 2006), available at https://www.commonwealthfund.org/sites/default/files/ 44 Wright Burak, E., “Promoting Young Children’s Health Development in documents/___media_files_publications_fund_report_2006_jun_instability_ Medicaid and the Children’s Health Insurance Program (CHIP)” (Washington of_public_health_insurance_coverage_for_children_and_their_families__ DC: Georgetown Center for Children and Families, October 2018), available causes__consequence_summer_instabilitypubhltinschildren_935_pdf.pdf. at https://ccf.georgetown.edu/wp-content/uploads/2018/10/Promoting- Healthy-Development-v5-1.pdf. 32 Centers for Medicaid and CHIP Services, “Core Set of Children’s Health Care Quality Measures for Medicaid and CHIP (Child Core Set): Technical 45 “Maternal Mortality,” National Center for Health Statistics, U.S. Centers Specifications and Resource Manual for Federal Fiscal Year 2021 Reporting” for Disease Control and Prevention, available at https://www.cdc.gov/nchs/ (Baltimore: Centers for Medicare and Medicaid Services, March 2021), maternal-mortality/index.htm. available at https://www.medicaid.gov/medicaid/quality-of-care/downloads/ medicaid-and-chip-child-core-set-manual.pdf?t=1624632277. 46 “Pregnancy-Related Deaths: Saving Women’s Lives Before, During and After Delivery,” Centers for Disease Control and Prevention, U.S. 33 Fairbrother, G. et al., “Churning in Medicaid Managed Care and Its Effect Department of Health and Human Services, available at https://www.cdc. on Accountability,” Journal of Health Care for the Poor and Underserved gov/vitalsigns/maternal-deaths/index.html. 15, no. 1 (February 2004): 30-41, available at https://pubmed.ncbi.nlm.nih. gov/15359972/. 47 “Young Children Develop in an Environment of Relationships,” National Scientific Council on the Developing Child (Working Paper, October 2009), 34 The Bipartisan Budget Act of 2018 made state reporting on the Child Core available at https://46y5eh11fhgw3ve3ytpwxt9r-wpengine.netdna-ssl.com/ Set mandatory (see §50102 “Bipartisan Budget Act of 2018,” Public Law wp- content/uploads/2004/04/Young-Children-Develop-in-an-Environment- 115-123, United States Statutes at Large 132: 64-132 (2018)), followed by the of- Relationships.pdf. requirement for reporting behavioral health measures in the Adult Core Set in the Support Act of 2018 (see §5001 “Substance Use-Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities Act,” Public Law 115-271, United States Statutes at Large 132: 3893-4143 (2018)). CCF.GEORGETOWN.EDU continuous coverage in medicaid and chip 21 48 Medicaid and CHIP Payment and Access Commission, “Report to 59 Harrington, M., Trenholm, C., and Snyder, A., “Using Data to Drive State Congress on Medicaid and CHIP” (Washington DC: Medicaid and CHIP Improvement in Enrollment and Retention Performance” (Mathematica Payment and Access Commission, March 2020), available at https:// Policy Research, National Academy for State Health Policy, and the www.macpac.gov/wp-content/uploads/2020/03/March-2020-Report-to- Robert Wood Johnson Foundation, November 2011), available at https:// Congress-on-Medicaid-and-CHIP.pdf. www.rwjf.org/en/library/research/2011/11/using-data-to-drive-state- improvement-in-enrollment-and-retentio.html; Harrington, M., Trenholm, 49 “Prohibited eligibility standards. In establishing eligibility standards and C., and Snyder, A., “New Denial and Disenrollment Coding Strategies methodologies, a State may not—cover children with a higher household to Drive State Enrollment Performance” (Mathematica Policy Research, income without covering children with a lower household income within National Academy for State Health Policy, and the Robert Wood Johnson any defined group of covered targeted low-income children.” See 42 Foundation, October 2012), available at https://www.mathematica.org/ C.F.R. 457.320(b)(1) (2016); “General cost-sharing protection for lower download-media?MediaItemId=%7BD0A20EFB-CF70-4A89-9D2C- income children. The State may vary premiums, deductibles, coinsurance, E2AC4D533217%7D. copayments or any other cost sharing based on household income only in a manner that does not favor children from families with higher income over 60 Brooks, T. et al., op cit. children from families with lower income.” See 42 C.F.R. 457.530. 50 “If the State requires reporting of changes in circumstances that may affect the enrollee’s eligibility for child health assistance, the State must: (a) Establish procedures to ensure that enrollees make timely and accurate reports of any such change; and (b) Promptly redetermine eligibility when the State has information about these changes.” See 42 C.F.R. 457.960. 51 Wagner, J., “Streamlining Medicaid Renewals Through the Ex Parte Process” (Washington DC: Center on Budget and Policy Priorities, March 2021), available at https://www.cbpp.org/research/health/streamlining- medicaid-renewals-through-the-ex-parte-process. 52 42 C.F.R. 435.908 (2013) 53 42 C.F.R. 435.904 (1994) 54 For more information on CHIPRA outreach and enrollment grants, see https://www.insurekidsnow.gov/campaign-information/outreach-enrollment- grants/index.html. 55 Brooks, T., Park, E., and Roygardner, L., “Medicaid and CHIP Enrollment Decline Suggests the Child Uninsured Rate May Rise Again” (Washington DC: Georgetown University Center for Children and Families, May 2019), available at https://ccf.georgetown.edu/2019/05/28/medicaid-andchip- enrollment-decline/; Alker, J. and Corcoran, A., “Children’s Uninsured Rate Rises by Largest Annual Jump in More than a Decade” (Washington DC: Georgetown University Center for Children and Families, October 2020), available at https://ccf.georgetown.edu/wp-content/uploads/2020/10/ACS- Uninsured-Kids-2020_10-06-edit-3.pdf. 56 The Foundation for Government Accountability has been pushing model legislation that requires states to contract with third party vendors to establish duplicative eligibility verification systems and conduct frequent searches for data to identify discrepancies in eligibility data. For more information, see https://www.vox.com/policy-and- politics/2019/9/4/20835692/conservative-think-tank-foundation-for- government-accountability-food-stamps-snap-poverty-welfare. Herd, P. and Moynihan, D., “Administrative Burden: Policymaking by Other 57 Means” (New York: Russell Sage Foundation, 2018). 58 “Overview of the Medicaid and CHIP Eligibility and Enrollment Performance Indicators,” Centers for Medicaid and CHIP Services Medicaid and CHIP Learning Collaborative, September 2015, available at https:// www.medicaid.gov/medicaid/downloads/overview-of-performance- indicator-project.pdf.