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CHIPRA is "platform" for enrollment changes
Beginning in 2014, individuals must be able to apply for and renew coverage for Medicaid, the Children's Health Insurance Program (CHIP), and tax credits for exchange coverage using a single application and to do this online. States will utilize existing state and federal government databases to establish, verify, and update eligibility.
However, due to many of the options available in the Children's Health Insurance Program Reauthorization Act (CHIPRA), some states have already begun making those changes.
"Many of the strategies promoted by CHIPRA fall right in line with the administrative simplification and data-driven eligibility processes laid out as part of health reform," says Beth Morrow, a Brooklyn, NY-based staff attorney for The Children's Partnership, a child advocacy organization.
"CHIPRA helps states to build those practices for Medicaid and CHIP programs right now," says Ms. Morrow. "And they can do so in a manner that creates a platform for health reform enrollment systems."
Specifically, the Express Lane Eligibility provision in CHIPRA allows state Medicaid and CHIP agencies to base an eligibility or renewal determination on information provided in state tax returns or on the specific findings of other need-based programs.
Under section 2002 of the Patient Protection and Affordable Care Act, states are authorized to continue to use Express Lane Eligibility.
"CHIPRA also encourages states to construct administrative, paperless renewal processes, using available data to perform renewal without contacting the family," says Ms. Morrow. "Furthermore, CHIPRA helps states make these systems improvements by providing performance bonuses for a few more years."
Many states taking advantage
Although states are continuing to experience budget shortfalls, many continue to move forward with the simplifications and expansions made possible by CHIPRA.
"Somewhat surprisingly, given the economy and state budgets, many states are taking advantage of these options and are actively working to increase Medicaid enrollment," says Jenny Sullivan, a senior health policy analyst at Families USA in Washington, DC. "This is setting the stage for successful health reform implementation."
Because CHIP and Medicaid are so closely intertwined, many of the opportunities CHIPRA created are available in both programs. The Centers for Medicare & Medicaid Services (CMS) awarded $40 million in CHIPRA outreach and enrollment grants to agencies and organizations in 42 states and Washington, DC, in September 2009. Options include:
States can simplify the citizenship documentation requirement by conducting data matching with the Social Security Administration.
"As of April 2010, nearly half of all states had begun or were in the testing stages of implementing the option to match Medicaid and CHIP applicant information with Social Security Administration databases to confirm citizenship," says Ms. Sullivan.
By implementing at least five of eight enrollment simplifications in both Medicaid (for children) and CHIP, states can qualify for performance bonuses.
Nine states have implemented at least five enrollment simplifications in Medicaid and CHIP and met enrollment targets for children's Medicaid enrollment, qualifying these states for performance bonuses totaling $72.6 million.
Express lane eligibility can be used to streamline enrollment in both Medicaid and CHIP.
"Three states have already implemented versions of express lane eligibility Alabama, Louisiana, and New Jersey. Three others are actively pursuing the option," says Sullivan.
States have the opportunity to expand Medicaid and CHIP to legally residing immigrants previously prohibited from enrollment because of the five-year bar.
As of March 2010, 20 states have taken steps to cover legally residing immigrant children or pregnant women in the country for fewer than five years. "This includes two states that never covered this group prior to CHIPRA's enactment," says Ms. Sullivan.
Health reform makes simplifying and streamlining enrollment in Medicaid, CHIP, and tax credits for the health information exchanges (HIEs) "an imperative," says Ms. Sullivan. States' experiences with Medicaid and CHIP enrollment simplifications provide "rich information" on successful ways to improve enrollment and retention in the health reform context, she adds.
"It is critical that in the years between now and 2014, national, state, and local collaboration take place to encourage creation of the best possible enrollment systems," says Ms. Sullivan.
In order to redesign eligibility systems, states will need specific types of help, according to Catherine Hess, senior program director at Maximizing Enrollment for Kids in Washington, DC. "States are asking for this kind of support, so that each state does not have to invent its own wheels," she explains.
The hope is that CMS will work with states quickly to establish the parameters for new systems and assist with procurement and financing. "States have been clear that in order to have their systems ready for 2014, they need to start planning for them now," says Ms. Hess.
States also will need to examine how their Medicaid and welfare eligibility determinations interface. Another issue is whether county-based eligibility systems can meet the challenges and demands of efficiently enrolling millions more people.
"States have learned a lot about streamlining eligibility and enrollment, particularly through efforts to enroll children in CHIP, and Medicaid," says Ms. Hess. "We need to take the lessons further now, applying them systemwide."
The Robert Wood Johnson Foundation program Maximizing Enrollment for Kids is building on these lessons to make progress in improving state systems. "Health care reform now gives us a new set of tools to accelerate what we can do to simplify and modernize our policies and systems," says Ms. Hess.
In order for states to implement these changes, though, they need technical assistance and mechanisms to work with each other to problem-solve.
"The biggest challenge states face by far is that most of their eligibility systems are very old legacy systems that can barely handle the challenges of the current caseload, let alone the significant change coming in a reformed system," says Ms. Hess. "States lack the resources, dedicated staff, and time needed to update their systems properly."
The National Academy for State Health Policy has joined with the National Governors Association, the National Association of State Medicaid Directors, and the National Association of Insurance Commissioners to form a consortium to coordinate and develop assistance for states and work with federal agencies to support states in implementation.
Even with sufficient resources, staffing, and time to implement changes, states still need guidance on system requirements, which systems to select, and how to ensure that the systems will be able to communicate with other eligibility systems. "Although other challenges are significant, none surpasses the magnitude or importance of this one," says Ms. Hess.
Lan Nguyen, health policy coordinator for the Children's Alliance in Seattle, says that there are new opportunities for Washington state through CHIPRA. Prior to CHIPRA, state dollars funded coverage for children who did not meet the five-year bar requirement. However, Washington now receives federal matching funds to provide coverage for many of these children.
The federal performance bonus encourages states to implement procedures that are geared toward growing enrollment. "This is needed at a time like this when families have fewer options for affordable, comprehensive health coverage for kids," says Ms. Nguyen. "Washington received a federal performance bonus of $7.5 million in 2009 that has been vital in preserving our state's Apple Health for Kids program."
Federal health care reform represents a "sustained commitment" by the federal government for fiscal support of CHIP, as well as Maintenance of Effort requirements that eligibility not be reduced or additional barriers placed before families, says Ms. Nguyen.
To maximize the benefits under health care reform, Ms. Nguyen says these approaches are key for Washington state:
Focus on activities that continue to enroll all children currently eligible for Apple Health for Kids.
Develop strategies that maximize the use of data the state already holds to identify, enroll and renew coverage for eligible children, including Express Lane Eligibility.
Identify ways to connect to children in other settings, such as those participating in free- and reduced-price meals in school.
Streamline renewal processes, so that kids do not unnecessarily fall off of coverage at renewal time when there has been no change in eligibility level.
Support outreach activities to identify currently eligible but unenrolled children.
In Washington, the upper-income limit for Apple Health for Kids, the state Medicaid and CHIP program, is 300% FPL. "There will be more opportunities for other members of the family, including parents and caregivers, to obtain health coverage as a result of federal health care reform," says Ms. Nguyen. "This is vital, because we know that children are more likely to receive the care they need when their parents are insured."
Contact Ms. Morrow at (718) 832-6061 or firstname.lastname@example.org, Ms. Nguyen at (206) 324-0340, ext. 15 or Lan@childrensalliance.org, and Ms. Sullivan at (202) 628-3030 or email@example.com.