More contact with families stops the loss of benefits

Michelle Mickey Rork, program director for PeachCare for Kids, Georgia's State Children's Health Insurance Program (SCHIP), says that one of the state's most successful initiatives for increasing enrollment and retention of eligible children has been through the work of its Right from the Start Medicaid Outreach Project.

The project was established July 2003 to expand Medicaid eligibility services at the local level for low-income pregnant women and children. Workers are housed at community locations and work after regular business hours to help families with application and enrollment. "Nontraditional sites include day care centers, outpatient clinics, community recreation centers and other community locales that serve the potentially eligible population," she reports.

In addition, a video was produced explaining the Medicaid eligibility process. This can be viewed online, and also is played in provider offices and community centers. "We also partner with the school system to send outreach materials to all school children in the state," says Ms. Rork.

Geoff Wool, a communications specialist with the Texas Health and Human Services Commission, says that the state's outreach campaign emphasizes the importance of renewing coverage as well as trying to reach families not already enrolled.

CHIP and Children's Medicaid are marketed together in Texas, and parents fill out one application to be considered for both programs. Families may move without notifying the state of their new address, forget to send in the renewal application, or may send in renewal applications that are not completely filled out or missing some of the documents of proof required for income and expenses.

"The message reminding parents to renew their children's CHIP or Children's Medicaid coverage is a standard part of our outreach effort," says Mr. Wool. "Above and beyond that, we take a proactive approach to making sure families have the opportunity to renew their children's coverage."

Orientation helps families

Once a family enrolls in Medicaid, the family goes through an orientation session on the benefits they will receive, including a segment that emphasizes the importance of renewing coverage.

In the months before the child's CHIP or Medicaid coverage is due to end, a renewal packet is sent to the family. A letter reminds the parents that their children's coverage is due to expire and that it is time to renew the coverage. The mailing also includes a renewal application.

"If a month goes by and the parents still have not sent us the renewal application, we send them a final reminder notice reminding the parents to renew their children's coverage," says Mr. Wool. These mailings tell parents where they can call to get an application or help filling out the brochure.

"We also contract with 28 community organizations in Texas that help us get share information about these programs with families that may be eligible," says Mr. Wool. Staff with those organizations are trained to answer questions and provide people with help filling out the CHIP/Children's Medicaid application. "One project soon to come is a web portal where parents can renew their children's CHIP coverage online," says Wool.

55% are recertified

Mike Fogarty , CEO of the Oklahoma Health Care Authority, says the primary reason for failure to re-enroll in his state is the citizenship and identity documentation requirements imposed by the Deficit Reduction Act.

In any given month in Oklahoma, about 400,000 children are enrolled in SoonerCare, the state's Medicaid program. That number has grown consistently since November 1997, when eligibility was increased up to 185% of the federal poverty level (FPL). At that time, about 20% of children had no insurance. "In Oklahoma, that's 200,000 kids, which is an incredible number," he says. "Now we are closer to 12%, which is still way too high, but it's a heck of a lot better than 20%."

In the last 10 months, since the first terminations due to failure to document citizenship, more than 35,000 children have lost their eligibility at renewal time. "That is a very scary number to us. It represents a huge step backward," says Mr. Fogarty. "We have done a very aggressive follow-up with that population, and we are satisfied that all of these kids are citizens. It's just that their families have not successfully navigated the process to get documented."

The state now is verifying and documenting citizenship electronically. "We use our own pay claims data to show that they were born here, along with a very aggressive follow-up with telephone calls, written notices and personal follow-up," says Mr. Fogarty. "We managed to get about 55% of them recertified. So, of the 35,000 that were terminated, we managed to get about 20,000 back on."

Other obstacles exist

Another obstacle to re-enrollment that Oklahoma is struggling with is the "welfare stigma." "When we expanded eligibility to 185% of FPL for a family of three, that's about the median family income in Oklahoma," says Mr. Fogarty. "These are not folks who are accustomed to looking to the welfare system. We think there is some real hesitation initially, and at renewal time as well, to have to communicate with the traditional welfare department for purposes of renewal."

For this reason, the program is referred to as SoonerCare, not Medicaid, and terms such as "recipients" or "eligible" are avoided.

Also, an electronic enrollment process was just implemented which enrolls newborns before they leave the hospital. "It aligns them with one of our primary care providers, and avoids them having to rely on a parent to deal with the welfare system in order to get that accomplished," he says. By next October, an online enrollment process will be in place for all Medicaid recipients. "So, access to the program will be at any point where they have access to the Internet whether at home, school, or at a provider's office," says Mr. Fogarty.

'Income cliff' a problem

Another barrier is the "income cliff," which Mr. Fogarty says means that if a single working parent with a $15-an-hour job gets a $2 raise, he or she will lose Medicaid benefits. "That's not unique to Oklahoma; but in the 10 years I've been talking about this, health care insurance has doubled. So if someone's wages increased by as little as 10%, chances are good that they will lose their medical benefits," he says.

The legislature authorized expansion of coverage up to 300% of the FPL two years ago. However, the Aug. 17, 2007, guidance from the Centers for Medicare & Medicaid Services came out shortly afterward, which placed new requirements on states covering uninsured children in families with income over 250% of the FPL. "We submitted our waiver application to do this but have been unable to get approval," reports Mr. Fogarty. "We are now in our 15th month of trying to negotiate an approvable waiver."

Enrollment, retention challenges

Mr. Fogarty explains that if the number of children covered by commercial insurance in the state has dropped more than 2% in five years, then states are precluded from extending coverage to children with a gross income of over 250%. "So the very statistic that demonstrates you have a problem, because families no longer have coverage, is the same statistic that bars the state from trying to reach out to those families," he says. "That was the criteria that stopped us cold."

Kentucky Gov. Steve Beshear recently announced a statewide outreach effort for the state's KCHIP program, effective Nov. 1, 2008, to break down some of the challenges and obstacles to enrolling and retaining children.

The program amended the denial process to provide a new 30-day grace period to offer additional information regarding denied application. "Local staff will follow up by phone or mail with applicants who fail to supply requested information," says Kentucky Medicaid Commissioner Elizabeth A. Johnson.

As part of the program's outreach efforts, families participating in other agency programs will be identified to determine potential eligibility for KCHIP. "Providers and advocates will be trained about the application process, so that they can assist in having the application completed and mailed in for processing," she says.

Contact Mr. Fogarty at (405) 522-7300 or mike.fogarty@okhca.org, Ms. Johnson at (502) 564-4321, Ms. Rork at (404) 657-9506 or mmickey@dch.ga.gov, and Mr. Wool at (512) 424-6500 or Geoffrey.Wool@hhsc.state.tx.us.