1. 1 Recent Texas Medicaid and CHIP Trends: What Can We Learn? Texas Health Care Access Conference Texas Association of Community Health Centers/Covering Kids and Families/Texas CHIP Coalition February 28, 2006 Anne Dunkelberg, Assistant Director (dunkelberg@cppp.org) 900 Lydia Street - Austin, Texas 78702 Phone (512) 320-0222 – fax (512) 320-0227 - www.cppp.org

2. 2 Texas Child Medicaid Enrollment (January 2001-December 2005) Source: All figures from Texas Health and Human Services Commission Center for Public Policy Prioritieswww.cppp.org Simplified Enrollment begins

3. 3 Texas CHIP Enrollment (May 2000-January 2006) Source: All figures from Texas Health and Human Services Commission; Compares most recent month with September 2003 Center for Public Policy Prioritieswww.cppp.org Highest, 5/02: 529,271 9/03: 507,259 1/06: 316,679

4. 4 Texas Child Medicaid and CHIP Combined Enrollment (January 2002-December 2005) Source: All figures from Texas Health and Human Services Commission; Compares most recent month with September 2003 Center for Public Policy Prioritieswww.cppp.org

5. 5 Texas CHIP Asset Test, 8/2004-10/2005 Source: THHSC 9,446 children 6,205 4,791

6. 6 CHIP Asset Test: Lessons & Questions Lessons Cash savings alone more likely to disqualify a child than vehicle alone. Vehicle values contribute to 60% of total denials, but only 17% are due to vehicles ALONE Asset test accounted for about 7% of all denials at renewal during this period. Questions Does the “hassle factor” related to documenting assets add to these numbers? –(E.g., make, model, and year not enough: must also provide the “style code”.) –Are more parents failing to complete applications because of these requirements? Cases like that would NOT be reflected in these statistics. What share of denied applications were due to assets? (HHSC has never reported stats on numbers of CHIP applications received.)

7. 7 CHIP Renewal Statistics Monthly Averages New Enrollees Renewals % Ineligible @ Renewal Total Disenrolled % Did Not Renew Before 2003 Changes 5/00-8/03* 28,64720,016 70.2% 3,01615,647 3.3% 8,776 After 9/03, Before Asset Test 9/03-7/04 19,00135,254 73.1% 5,82032,220 7.9% 13,385 After Asset Test, 8/04- 12/05 19,57634,930 81.1% 6,22821,824 6.6% 8,313 Fully Implemented Benchmark FY 2003 25,60322,900 68.5% 3,80926,313 5.2% 10,581 *New Enrollees, Total Disenrolled: 6/0-8/03; Renewals, Inelig. @ Renewal, Non- Renewal: 6/01 to 8/03;

8. 8 CHIP Renewal Statistics: Lessons and Questions Lessons: New Enrollment each month since 9/2003 is dramatically LOWER than in start-up period, OR in the stable-enrollment year, FY 2003. –Suggests that APPLICATION rates may have dropped, thus OUTREACH needed. –To really understand what has happened to CHIP caseloads, we need to know more about current and historical APPLICATION rates. Ineligible at renewal each month since 9/2003 is dramatically HIGHER than in start-up period, OR in the stable-enrollment year, FY 2003. This is a logical result of having twice as many children renew every month (i.e., under the 6-month coverage policy) than was the case before 9/2003. Ineligible at renewal each month as a percentage of total enrollment has more than DOUBLED from 0.75% in FY 2003 to 1.88%. Total Disenrolled each month as a percentage of total enrollment has more than DOUBLED compared to FY 2003 (from 0.61%  1.71% since 9/2003).

9. 9 CHIP Renewal Statistics: Lessons and Questions Lessons: BUT! “attempted renewal” rates have actually INCREASED since 9/2003: that’s the % of kids due for renewal who actually get a renewal thru the process (includes those renewed, and those denied) –Suggests that the percentage of parents who try to renew has not gotten worse; so it is possible that renewed outreach and marketing could increase the attempted renewal rate and thus improve enrollment rates. Questions: Every month, the “total disenrolled” number I reported by HHSC is MUCH LARGER than the sum of (renewed) + (denied @ renewal) + (non-renewals). The number of kids losing coverage who are not reflected in the HHSC report is, on average, about 41% of the “total disenrolled” figure. –To really understand what is happening to CHIP caseloads and how we can increase participation and enrollment, we need to get better information from HHSC as to the reasons for these children losing coverage.

10. 10 Ask, and Ye Shall Receive Example: December 2005, “Total Disenrolled” = 19,048 –7,428 Did Not Renew –6,297 Ineligible at Renewal –39 Child or Family Moved –911 Child Turns 19 or Deceased –170 Eligibility change DURING 6-month period: Gains other health insurance; Ineligible due to immigration status; Provisional Eligibility Terminated; Eligible for ERS; Pregnant; “Ineligible for Other Reason” –1,803 Already Enrolled in Medicaid –2,333 Early Medicaid Enrollment –24 Duplicate Account –43 Disenrolled for Other reasons

11. 11 CHIP Renewal Statistics: Signs of Transition Challenges, 1/06 New Enrollees Renewals % Ineligible @ Renewal Total Disenrolled % Did Not Renew 8/04-12/05, Monthly Averages 19,57634,930 81.1% 6,22821,824 6.6% 8,313 December 2005 20,38537,964 83.6%6,297 19,048 5.9% 7,428 January 2006 14,08618,880 52.2% 1,22720,303 6.4% 17,290 November 2005, CHIP eligibility & enrollment transitioned from original contractor (ACS) to new contractor (Accenture, AKA “TAA”). January 2006 TAA begins processing new applications for children’s health insurance; HHSC also imposes new enrollment fee and renewal documentation policies.

12. 12 CHIP Renewal Statistics: More Signs of Transition Challenges Preliminary Information (HHSC has not posted February Stats yet): Feb. and March enrollment expected to drop further (around 311,000 and 295,000) Renewal rates in Feb. continued to be very low, with high numbers terminated for failure to reply to renewal, missing information, and failure to pay the enrollment fee. Feb. New Enrollment may reflect a partial “catch up” after January’s large deficit. WHAT STEPS SHOULD THE TEXAS CHIP COALITION AND OTHER STAKEHOLDERS RECOMMEND HHSC TAKE TO STOP THIS DECLINE?

13. 13 Snapshot: CHIP Vision Care Use FY 2003 Use of CHIP vision care not dependent on where child’s family fell in the income range: 71% of all CHIP children were at/below 150% FPL, and 71% of kids using vision care were in that income range. About 15% of CHIP children got some kind of vision-related exam in FY 2003 (73,720 children). –Since HHSC did not include actual eyeglasses in this count, the real percentage using vision care is likely a bit higher (though MOST eyeglass or contact purchases for children will be accompanied by an exam). Not surprisingly, about 90% of the vision care went to school-aged children (6-18). Vision check-ups were #7 most common billed CHIP visit in FY 2003. Though need for/use of vision care is not universal like dental care, outreach to educate parents about the restored CHIP vision benefit should be an important component of CHIP outreach.

14. 14 Age Distribution Of Children in CHIP (FY 2003 vs. January 2006) In FY 2003, children aged 1-5 made up 22.6% of enrollment; as of 1/1/2006 they had dropped to 16.5%. What does this suggest for OUTREACH?

15. 15 CSA11 EPO North 1X EPO East 1X EPO Central 1X EPO South 1X CHIP Service Areas

16. 16 CHIP Enrollment by CSA, Plan, and Age Group, Change in Share of Total State Enrollment (9/03 to 12/05) CSASept. 2003 % of total state Dec. 2005% of total state 1 Amarillo/Lubbock13,5412.7%7,2202.2% 2 Dallas-Fort Worth100,65419.8%69,84921.6% 5 Austin25,0384.9%16,5775.1% 6 Houston137,63927.1%93,76629.0% 7 San Antonio38,0607.5%25,2917.8% 8 Corpus Christi18,3323.6%10,4153.2% 10 Laredo10,0802.0%5,8861.8% 11 El Paso22,2164.4%13,6844.2% 12 EPO Central17,0563.4%9,4682.9% 13 EPO East48,5639.6%28,0608.7% 14 EPO North20,9824.1%10,9743.4% 15 EPO South55,09810.9%31,7089.8% Statewide Total507,259100.0%322,898100.0% Blue= Lost Share

17. 17 Regional CHIP Enrollment Declines: Lessons and Questions First table: Share of Total State Enrollment There have not been massive shifts in the share of total CHIP enrollment statewide; but Who gained share? Largest urban areas: D-FW; Houston, Austin, San Antonio Who lost share? Everywhere else. Hypothesis: Is this because community-based outreach efforts continued in the big cities, while Legislature/HHSC’s discontinuation of outreach and marketing left the rest of the state at a relative disadvantage?

18. 18 CHIP Enrollment by CSA, Plan, and Age Group, Regional Decline Compared to State Average (9/03 v. 12/05) CSASept. 2003 Dec. 2005Decline% Decline 1 Amarillo/Lubbock13,5417,220-6,321-46.7% 2 Dallas-Fort Worth100,65469,849-30,805-30.6% 5 Austin25,03816,577-8,461-33.8% 6 Houston137,63993,766-43,873-31.9% 7 San Antonio38,06025,291-12,769-33.5% 8 Corpus Christi18,33210,415-7,917-43.2% 10 Laredo10,0805,886-4,194-41.6% 11 El Paso22,21613,684-8,532-38.4% 12 EPO Central17,0569,468-7,588-44.5% 13 EPO East48,56328,060-20,503-42.2% 14 EPO North20,98210,974-10,008-47.7% 15 EPO South55,09831,708-23,390-42.5% Statewide Total507,259322,898-184,361-36.3% Blue = Decline Greater than State Average

19. 19 Regional CHIP Enrollment Declines: Lessons and Questions Second table: Regional Enrollment Decline Compared to Statewide Average Statewide decline more than one-third (36.3%); BUT largest urban areas: D-FW; Houston, Austin, San Antonio experienced lower rates of decline, AND rates of decline everywhere else dramatically higher; –Northwest Texas looks especially bad –But all of rural, south, and border areas have had a disproportionate loss in coverage Repeat Hypothesis: Is this related to continued community-based outreach efforts in the big cities, while Legislature/HHSC’s discontinuation of outreach and marketing left the rest of the state at a relative disadvantage?

20. 20 CHIP Enrollment by Income Group: Did Policy Changes Affect Lowest Income Groups Most? Number by FPLPercent by FPL <100%100%- 150% 151%- 185% 186- 200% <100 % 100%- 150% 151%- 185% 186- 200% 12/0520,638173,778105,17523,307322,8986.4%53.8%32.6%7.2% 11/0394,341211,849117,92534,051458,16620.6%46.2%25.7%7.4% 9/03107,211258,780112,88728,381507,25921.1%51.0%22.3%5.6% 9/02108,845260,670112,38628,856510,75721.3%51.0%22.0%5.6% 9/01106,303204,26792,19726,299429,06624.8%47.6%21.5%6.1% 9/0022,82339,38316,9284,40483,53827.3%47.1%20.3%5.3%

21. 21 CHIP Enrollment by Income Group: Did Policy Changes Affect Lowest Income Groups Most? The elimination of income disregards in CHIP was applied to all enrollees effective November 2003. This had the effect of “shifting” many children from one category, up to the next higher category (and “shifted” about 17,000 children out of CHIP that month). To take the shift into account, we use November 2003 as a benchmark for comparing how the income distribution continued to change AFTER that shift. The change from 11/2003 to the present is “real”, that is, it is due to other factors than the income disregard change. –Increased cost sharing and decreased benefits –No offsetting outreach message from the state As the next slide shows, All groups have declined since 11/2003: –below-poverty group saw the largest decline (73,703  ; 78% drop) –185-200% FPL group dropped 32%, probably due to asset test –100-150% FPL group dropped 18%; but number is large (38,071  ) because this is where enrollment was, and still is, concentrated.

22. 22 Change in Texas CHIP Enrollment, by Income November 2003* – December 2005 Source: CPPP analysis of Texas Health and Human Services Commission data Percent Change in Enrollment: Total Enrollment * Enrollment dropped by 49,093 from 9/2003- 11/2003; thus totals shown here understate full decline number and percent. -73,703 -135,268 -10,744 -38,071 -12,750

23. 23 Did the Children Leaving CHIP All Go to Medicaid? Well, No…… Tracking movement between CHIP and Medicaid has never been easy, because the programs used very different data systems HHSC did special analysis back In 12/2004 (but not released until 2/2005) of the movement between programs in 2000-2004. The report looked at children who left Medicaid or CHIP, and checked to see if they had either shifted to the other program, or re-enrolled in the original program, during the following 12 months –FY 2004 report findings on “migration” were not 100% complete, because a full 12 months had not passed since many children had left the programs.

24. 24 Kids Leaving CHIP Children Leaving Back to CHIPTo Medicaid Neither FY 00 1,698 57834.0% 1,21871.7%16.4%, 279 FY 01 53,524 13,92326.0% 24,36245.5%37.1%, 19,881 FY 02 269,091 76,54328.4% 114,27242.5%36.2% 97,358 FY 03 303,337 82,12427.1% 138,67945.7%35.4%, 107,242 FY 04 379,009 73,98019.5% 158,37841.8%44.6% 169,223 Migration during the 12 months after leaving CHIP Source: HHSC Center for Strategic Decision Support, 12/2004

25. 25 Kids Leaving Medicaid Children Leaving Back to Medicaid To CHIP Neither FY 00 743,422 318,93242.9% 48,2076.5% 385,109 (51.8%) FY 01 750,862 349,14446.5% 105,24514.0% 321,867 (42.9%) FY 02 667,514 341,06151.1% 82,70812.4% 267,022 (40.8%) FY 03 771,901 404,09352.4% 75,3859.8% 315,240 (40.8%) FY 04 887,224 364,52641.1% 91,09010.3% 451,188 (50.9%) Migration during the 12 months after leaving CHIP Source: HHSC Center for Strategic Decision Support, 12/2004

26. 26 Did the Children Leaving CHIP All Go to Medicaid? Well, No…… Key Findings: There was NO increase in the rate of transfer to Medicaid in FY 2004 to offset CHIP decline. In fact, the transfer late is much LOWER, though an updated final report might show a higher %. –This is also evidenced by the greatly-REDUCED growth rate in children’s Medicaid; Medicaid growth would have INCREASED if CHIP children were shifting there in greater proportions. Also shows a higher percentage of children NOT returning to either program in FY 2004; –the independent ICHP disenrollment report (12/2004) found 52% of kids leaving CHIP remained uninsured. –And found that of the 47% who got coverage later, 31% went to Medicaid and only 11% got employer-sponsored insurance (ESI)

27. 27 Average Monthly Enrollment Growth for Texas Children in Medicaid, FY 2001 – FY 2005* Source: CPPP analysis of Texas Health and Human Services Commission data 97,836 Change in Enrollment: 317,756251,692135,319 Rolled back some simplification measures Simplification of application and renewals 41,499 *FY 2006 YTD: -0.1%; Avg. annual TX child pop. growth rate 2001-2004 1.2%

28. 28 Texas Child Medicaid Enrollment (January 2001-December 2005) Source: All figures from Texas Health and Human Services Commission Center for Public Policy Prioritieswww.cppp.org Simplified Enrollment begins

29. 29 How Have Children’s Medicaid Enrollment and Renewal Rates Fared? Application Approval rate Renewal Approval Rate Denied Missing Info Auto Closure* (as % of denials) Denied Assets (as % of denials) Denied Income (as % of denials) 9/00- 12/01 58%73%13%n/aNot avail. 1/02- 9/02 70%78%11.7%81.7%0.7%15% 10/02- 1/04 78%64%2.6%83.6%0.2%6.9% 2/04- 3/05 78%61.4%8.4%73%0.5%12% *Implemented June 2002

30. 30 How Have Children’s Medicaid Enrollment and Renewal Rates Fared? Goal of 2001 Legislation: Make sure children eligible for Medicaid are not left uninsured due to “rationing by inconvenience” (Lt. Gov. Ratliff). Implemented January 2002. Approval rates for initial applications have improved Renewal Approval rates have declined since early stages of simplification “Red-Tape” denials for Missing Information at renewal have crept back up, though still lower than before January 2002. Auto Closure (implemented June 2002) is a proxy for failing to return renewal in a timely manner. –Rate has improved since early stages of implementation, both as % of renewals denied and as % of total renewals processed. –There is no way to distinguish parental failure to respond, from HHSC failure to process timely, but no recent documented reports of problems (HHSC made prompt renewal processing a priority after first round of problems in 2002) Questions: What kinds of missing information are driving the increase in denials? What kind of outreach would improve renewal rates?

31. 31 Texas Health Insurance Stats: What They Tell Us About the Need for Outreach? Texas Children who are Uninsured – U.S. Census All incomes, under age 19 (0-18*; 3-year average 02-04 Census CPS) 21% 1.39 million < 200% FPL; under age 19 (0-18; raw Census CPS for 2004) 30% of <200%; 14.4% of all kids 948,000 In other words, 2/3 of uninsured Texas children are below 200% FPL, despite Medicaid and CHIP. Texas is home to an estimated 230,000 undocumented kids, and another 160,000 legal immigrant (LPR) children under age 18 (Pew Hispanic Center). But, the LPR kids can participate in CHIP. Clearly, undocumented children are just a small part of our uninsured problem At least 700,000 (half) of our uninsured kids could enroll in Medicaid or CHIP! (Texas children: Kids Count 3-year average: 6.49 million aged 0-18)

32. 32 Next Steps? Outreach: Need renewed focus on rural, lowest-income and pre- school Need to publicize vision and dental Need special outreach on new Enrollment Fees!! Other: Need ICHP to study both child Medicaid and CHIP population non-renewal populations for reasons, investigate missing information issues Revitalize collaboration and communication between CBOs & stakeholders, and HHSC and its contractors What Specific Steps do YOU think should be given top priority?