Performing Under Pressure: Annual Findings of a 50-State Survey of Eligibility, Enrollment, Renewal and Cost-Sharing Policies in Medicaid and CHIP, Martha Heberlein, Tricia Brooks and Jocelyn Guyer Georgetown University Center for Children and Families Samantha Artiga and Jessica Stephens Kaiser Commission on Medicaid and the Uninsured Kaiser Family Foundation January 18, 2012

FIGURE 1 50-State Survey of Eligibility, Enrollment, Renewal, and Cost Sharing Polices, th annual survey covering trends in 50 states and D.C. –Based on telephone interviews with Medicaid and CHIP program administrators Covers Medicaid and CHIP eligibility, enrollment, renewal, and cost-sharing policies –Policies for children, pregnant women, parents and non-disabled adults –Adoption of state options provided in CHIPRA and early steps related to health reform implementation Data on policies in effect on January 1, 2012 and changes during 2011

FIGURE 2 Key Factors Affecting State Policies in 2011 Lingering economic pressures –Ongoing high level of need for coverage among low-income families –Continuing revenue challenges for states –Expiration of enhanced federal Medicaid matching funds from ARRA –Diminishing resources for administrative functions and eligibility staff ACA requirement to maintain coverage CHIPRA options and incentives New, time-limited opportunity to secure enhanced federal funding for major Medicaid eligibility system changes Nearing 2014 ACA coverage expansion implementation date

FIGURE 3 State Medicaid and CHIP Eligibility, Enrollment, and Cost Sharing Policy Actions, January 2011 – January 2012 SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, Number of States that Expanded/Simplified Number of States that Restricted 0 Premiums/ Cost-Sharing Enrollment/Renewal Procedures TotalEligibility

FIGURE 4 Number of States Taking Action Affecting Medicaid/CHIP Eligibility, by Population, January January 2012 SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, States that Expanded Eligibility States that Restricted Eligibility 0

FIGURE 5 Children's Eligibility for Medicaid/CHIP by Income, January % FPL (21 states) < 200% FPL (4 states) 250% or higher FPL (26 states, including DC) NOTE: The federal poverty line (FPL) for a family of three in 2011 is $18,530 per year. OK has a premium assistance program for select children up to 200% of the FPL. AZ’s CHIP program is currently closed to new enrollment. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, WY WI WV WA VA VT UT TX TN SD SC RI PA OR OK OH ND NC NY NM NJ NH NV NE MT MO MS MN MI MA MD ME LA KY KS IA IN IL ID HI GA FL DC DE CT CO CA AR AZ (CHIP closed) AK AL

FIGURE 6 Median Medicaid/CHIP Eligibility Thresholds, January 2012 Minimum Medicaid Eligibility under Health Reform - 133% FPL ($24,645 for a family of 3 in 2011) SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012.

FIGURE 7 NOTE: The federal poverty line (FPL) for a family of three in 2011 is $18,530 per year. Several states also offer coverage with a benefit package that is more limited than Medicaid to parents at higher income levels through waiver or state-funded coverage. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, Medicaid Eligibility for Working Parents by Income, January 2012 WY WI WV WA VA VT UT TX TN SD SC RI PA OR OK OH ND NC NY NM NJ NH NV NE MT MO MS MN MI MA MD ME LA KY KS IA IN IL ID HI GA FL DC DE CT CO CA AR AZ AK AL 50% - 99% FPL (16 states) < 50% FPL (17 states) 100% FPL or Greater (18 states, including DC)

FIGURE 8 NOTE: Map identifies the broadest scope of coverage in the state. CT, DC, HI, & VT also offer more limited coverage. OR and UT also offer premium assistance with open enrollment. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, Coverage of Low-Income Adults by Scope of Coverage, January 2012 More Limited than Medicaid (13 states) Premium Assistance Only (4 states) Medicaid Comparable (8 states, including DC) No Coverage (26 states) “Closed” denotes enrollment closed to new applicants WY WI (closed) WV WA VA VT* UT* (closed) TX TN ( closed ) SD SC RI PA OR* (closed) OK OH ND NC NY NM (closed) NJ NH NV NE MT MO MS MN MI (closed) MA MD ME LA KY KS IA IN (closed) IL ID HI* (closed) GA FL DC* DE CT* CO CA AR AZ (closed) AK AL

FIGURE 9 Actions Taken to Simplify Medicaid/CHIP Enrollment and/or Renewal Procedures, January January 2012 NOTE: Simplified renewal options include phone, online, and administrative renewals. A state is classified as providing administrative renewal if it sends a pre-populated form or renewal letter to the family in advance of the renewal date and, if there have been no changes in circumstances the family is not required to take any action or, at most, must sign and return the form to continue coverage. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, Number of States:

FIGURE 10 State Adoption of CHIPRA Options in Medicaid or CHIP, February 2009-January 2012 Represents total number of states adopting option. Some states may have only picked up the option in either Medicaid or CHIP. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, Coverage of Lawfully-Residing Immigrants without 5-Year Wait

FIGURE 11 Simplified Renewal Methods for Children in Medicaid and CHIP, January 2012 NOTE: A state is classified as providing administrative renewal if it sends a pre-populated form or renewal letter to the family in advance of the renewal date and, if there have been no changes in circumstances the family is not required to take any action or, at most, must sign and return the form to continue coverage. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012.

FIGURE 12 Consistency of Simplification Measures for Children and Parents in Medicaid, January 2012 Note: A state is classified as providing administrative verification of income at application and/or renewal if it seeks to verify income through available data sources or collateral contacts with third parties prior to requesting income documentation from the family or if the family is unable to provide documentation. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012.

FIGURE 13 Features of Online Applications and Accounts for Medicaid and CHIP, January 2012 NOTE: In some states the online application is only available to children applying for coverage. “Enhanced functionality” denotes online accounts that allow families to review the application status, report changes in circumstances, view notices, pay premiums and/or renew coverage. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012.

FIGURE 14 NOTE: “APD” refers to an Expedited Advanced Planning Document. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, Status of Major Medicaid Eligibility System Upgrades, January 2012 Submitted APD (11 states) Approved APD (18 states) Plan to submit APD next year (19 states) WY WI WV WA VA VT UT TX TN SD SC RI PA OR OK OH ND NC NY NM NJ NH NV NE MT MO MS MN MI MA MD ME LA KY KS IA IN IL ID HI GA FL DC DE CT CO CA AR AZ AK AL Not considering at this time (3 states)

FIGURE 15 Key Themes of Survey Findings Reflecting the ACA requirement to maintain coverage, Medicaid and CHIP eligibility held steady in 2011, and 29 states made improvements in coverage Coverage for low-income parents and adults continues to lag far behind that of children Although states had flexibility to change copayment requirements for families, a small number of states made increases Half of states improved enrollment or renewal procedures, often utilizing technology to streamline and automate processes New enhanced federal funding spurred many states to begin major systems development work These actions helped states deal with current pressures, and also lay the groundwork for 2014

FIGURE 16 Secrets to Success: Four States’ Experience as Leaders in Covering Kids Source: J. Guyer, T. Brooks and S. Artiga, “Secrets to Success: An Analysis of Four States at the Forefront of the Nation’s Gains in Children’s Health Coverage,” Kaiser Commission on Medicaid and the Uninsured, January Examined factors of success for a leading state in each region: Alabama, Iowa, Massachusetts, and Oregon – MA has achieved the highest coverage rate for children in the nation at 99.5% – AL, IA, and OR have all significantly improved coverage for children in recent years – All have adopted a variety of enrollment simplifications Common Elements of Success – Political leadership prioritizing children’s coverage – Expansive eligibility levels and adoption of a broad range of simplifications – Engagement of providers and community partners – Strong coordination between Medicaid and CHIP Remaining Challenges and Next Steps – Diminished administrative resources – Improving retention – Updating eligibility and enrollment systems – Administrative and cultural changes to strengthen coverage and prepare for reform