the urban institute 1 innovative strategies to enroll eligible people into medicaid and chip sci...

THE URBAN INSTITUTE 1

Innovative strategies to enroll eligible people into Medicaid and CHIP

SCI National MeetingAlbuquerque, NM

Stan Dorn The Urban [email protected]

July 30, 2009


Topics to discuss

I. Express Lane Eligibility (ELE) under CHIPRAII. Eligibility determination and enrollment in

Massachusetts


Preliminary comment: CHIPRA’s new incentives to enroll eligible children•If CHIP enrollment this year is low, future CHIP

allocations shrink•If child Medicaid enrollment grows, the state wins

performance bonuses


Part I. Express Lane Eligibility under CHIPRA


Key ELE principles•Basic idea:

Been there, done that

•Don’t sweat the small stuff: ELE overlooks different eligibility methodologies•Multiple uses –

enrollment and renewal


Key limits and requirements •May not use ELE to establish citizenship

Immigration status OK

•The “Express Lane Agency,” or ELA, must give the family an opt-out notice

•May not use ELE to deny eligibility•Reasonable time period

State choice

•New options for “Screen and enroll”Threshold approach, 30 FPL percentage points

above standard Medicaid eligibility Temporary coverage, based on the child’s likely

eligibility


No CMS interpretation as yet

•But – no sanctions if the state reasonably interprets CHIPRA •Key questions for CMS

include:1115 waivers to use ELE for

parentsDefinition of “error rate” Access to enhanced FMAP

for IT improvements


First example of ELE: state income tax forms

CHIPRA specifically authorizes ELE based on gross income or adjusted gross income on state income tax returns and records


Uninsured children who qualify for Medicaid or CHIP, by legal requirement to file federal income taxes and eligibility for federal EITC: 2004

Legally required to file federal income

tax returns79%

Not legally required to file, but eligible

for EITC12%

Neither legally required to file nor

eligible for EITC9%

Source: Dorn, et al., Feb. 2009.


Among various groups of uninsured children, the estimated percentage whose families filed federal income tax returns: 2004

90.7% 87.2% 94.5% 89.4%

9.3% 12.8% 5.5% 10.6%

0%

25%

50%

75%

100%

All Eligible forMedicaid

Eligible forSCHIP

Eligible forEither Program

Families filed returns Families did not file

Sources: Dorn, et al., Feb. 2009.


What about state income taxes?

•Very high percentage of eligible, uninsured children.IA, MD and NJ - hundreds of

thousands of children identified

•Consider:Minimum income threshold for

required tax filing? Any refundable state income tax

credits?Money withheld from paychecks?


How state income tax ELE could work1. On tax form, parent taxpayers:

Identify their uninsured children Can request disclosure of their tax data to the health

agency Very important step.

2. Grant income-eligibility based on gross income (or AGI) and household size as shown on the income tax return

3. Qualify children as citizens based on SSA data4. Determine immigration status for non-citizens

Intensive application assistance to obtain immigration evidence Enrollment phase Presumptive eligibility (PE)

Possible ELE based on SSA and SSN


How it could work, continued5. If child is partially but not fully eligible

based on ELE, use standard methods to figure out the rest.

6. Collecting any remaining paperwork CBOs, facilitated enrollers In a managed care state, can

collect documents during enrollment, using managed-care organizations (MCOs)

o Key: no MCO contact with family until a plan is chosen


Possible adjustments•Prior-year tax data

CHIPRA allows – not a legal problem

Ample federal precedent: Medicare Part B premium subsidies, 2008 stimulus payments, federally-subsidized college student aid

For policy reasons, a state might: adjust prior-year tax information based

on more recent quarterly earnings data (via IEVS or National Directory of New Hires)

limit ELE if a new hire is reported or if the prior-year tax return shows significant non-W-2 income

•Self-employment income


Second example of ELE: food stamps


Background information on food stamps• Income-eligibility: Household must be at or below:

100 percent FPL in net income (using food stamp disregards); and

130 percent FPL in gross income• Impact. 12.4 percent of eligible, uninsured children

received food stamps in 2004. Dorn, et al., April 2009.•Administrative ease. Most Medicaid agencies already

have access to food stamp eligibility files.•Huge efficiency gains. Almost no value is added by

requiring a separate health application. < 1 percent are ineligible for Medicaid and CHIP, under

standard rules for health coverage. Dorn, et al., April 2009.


How food stamp ELE could work1. Identify uninsured children, by matching eligibility

records2. Send opt-out notice3. Determine eligibility

Automatically find, via ELE, that All food stamp children are income-eligible for Medicaid; All immigrant food stamp children are legally residing in

the U.S., for purposes of Medicaido Maybe not in a state with a 5-year bar for newly

arrived immigrants Establish citizenship via SSA data-match See if have private coverage

4. Parents must consent before enrollment 5. Use ELE at renewal

If child receives food stamps, automatically continue income-eligibility for Medicaid


Third example of ELE: the National School Lunch Program (NSLP)


Background information on NSLP• Practical issues

Matchable, centralized eligibility data in your state’s NSLP?Can you implement statewide? Or must you go district-by-district?What incentives apply to schools?

• Broad reach—Dorn and Kenney, 2006, found that NSLP families include:

59% of all uninsured children under 200% FPL56% of uninsured citizen children under 200% FPL

• NSLP eligibilityFree lunch: 130% FPL, gross incomeReduced-price lunch: 185% FPL, gross incomeNo immigration status restrictions


How ELE could work with NSLP1. On NSLP application form, parents can:

Identify any uninsured children; and Consent to disclose data to establish eligibility for

health coverage2. If children receive free lunches, use ELE to

automatically qualify them as income-eligible for Medicaid

3. If children receive reduced-price lunches, either ELE or PE, then intensive assistance to establish ongoing

eligibility4. For anything beyond PE, need standard

Medicaid/CHIP procedures to establish citizenship or legally resident status

5. Collection of remaining paperwork Can follow income tax approach


NSLP-recipient children, by type of NSLP benefit and income-eligibility under standard Medicaid and CHIP rules (based on audited family income)

Children receiving free school lunches

Children receiving reduced-price school lunches

Income-eligible for Medicaid

81% 49%

Income-eligible for CHIP

14% 38%

Income too high for both programs

4% 13%

Total: 100% 100%

Source: Dorn, April 2009.


Part II. Eligibility determination and enrollment in Massachusetts

Preliminary findings from a SHARE grant funded by the Robert Wood Johnson Foundation


Coverage expansion in Massachusetts • Extraordinary results.

Only 2.6 percent of state residents were uninsured in 2008

• Well-known policy changes Subsidies up to 300% FPL, through

Medicaid and a new program, called Commonwealth Care (CommCare)

All adults mandated to purchase coverage

Exception for those unable to afford coverage

Health insurance exchange (the “Connector”) offers multiple private plans


Net increase in the number of Massachusetts residents with health insurance, by coverage type: 6/30/06 to 9/30/08

Private group, 148,000

Private nongroup,

39,000Medicaid,

76,000

CommCare, 169,000

Source: Massachusetts Division of Health Care Finance and Policy, February 2009.


How did Medicaid and CommCare enroll so many people?• Generous subsidies, comprehensive

benefits • Massive PR campaign

The mandate was important in getting people’s attention. Not enforced:

73% of CommCare enrollees All Medicaid adults

Behavioral economics research - “avoiding a problem” motivates more than “gaining a benefit”

• Community-based organizations (CBOs) received $2.5-$3.5 million in annual outreach and enrollment mini-grants

Long before 2006 legislation


Eligibility determination • A single application form for multiple

programs:Medicaid/CHIP/CommCareUncompensated care payments to

safety net hospitals and community health centers

KDE instrument• A single agency - Medicaid - determines

eligibility for all of those programsOne statewide office Logic-driven and computerized, not

worker-drivenCommon eligibility methodologies for all

programs• Integrated eligibility determination

prevents consumers from falling through the cracks between programs


Eligibility determination (continued)• On-line application form (“virtual gateway”)

Trained staff + computer routines=cheaper applications to process

• The application form must be properly completed for a hospital or clinic to get paid DSH dollars go fartherState does not pay providers for this work

• Provider or CBO becomes the applicant’s authorized representative, copied on all eligibility-related state notices murder mystery

• Major efficiency gains – roughly doubled caseload while increasing state administrative staff less than 10%.But there were up-front transition costs,

both financial and cultural • Timing: Long before recent legislation


Data-driven eligibility

•Auto-conversion, based on free-care pool data•Enrollment into MCOs:

Notice of eligibility, encouraged to pick MCOAuto-assignment to MCOs, if eligible for premium-

free coverage Under 100% FPL, 48,000 auto-assigned in late 2006100-150% FPL, approximately 15,000 auto-assigned in late

2007*• If an eligible consumer neither chooses nor is auto-

assigned to an MCO, what happens when the consumer seeks care?


The effects of data-driven eligibility• Huge initial impact

> 80% of all CommCare enrollment by the sixth month • Leverage to lower MCO premium bids• Simplified enrollment by eliminating the need to complete and

process application forms100-300% FPL – 62,000 were auto-converted to

CommCare. Not yet known how many chose an MCO and enrolled.

Total auto-conversion: 110,000Compared to requiring standard application forms, less

costly for providers, CBOs, and state• Consumers were more likely to enroll without the need to

complete application forms. • Fits with other state policies that encourage trained private

entities to complete applications on behalf of consumers, via “virtual gateway”

Rough estimate: >50% of Medicaid and CommCare enrollment comes via virtual gateway


Massachusetts is not paradise•Government costs rose, because the formerly

uninsured received subsidies.•A few administrative glitches remain. For example:

ChurningMovement from Medicaid to CommCare.

CommCare does not begin until the first of the month, but Medicaid begins and ends at any time.

The state’s integrated eligibility system leaves out one program, which covers the recently unemployed. As a result, uninsured consumers eligible for subsidies sometimes go months without coverage as they move between programs.

Confusion when notices come from Medicaid.


Conclusion• Behavioral economics: many people won’t fill out

forms.Not just low-income people. The classic studies

involve middle-income people & 401(k) plans.• ELE uses existing data to establish eligibility,

eliminating the need for consumers to complete largely redundant application forms.

• Massachusetts:Used existing data to establish eligibility without

new application forms, in many casesSafety net providers and CBOs filled out forms

for consumers A single, integrated eligibility system for multiple

programs simplified enrollment, often making it seamless

• Potential results:Increase participationLower state administrative costs Cut red tapePrevent errors


Sources•Express Lane Eligibility

•Massachusetts

Stan Dorn, Express Lane Eligibility and Beyond: How Automated Enrollment Can Help Eligible Children Receive Medicaid and CHIP, prepared by the Urban Institute for the Robert Wood Johnson Foundation and the National Academy for State Healthy Policy, April 2009.

Stan Dorn, Bowen Garrett, Cynthia Perry, Lisa Clemans-Cope, and Aaron Lucas, Nine in Ten: Using the Tax System to Enroll Eligible, Uninsured Children into Medicaid and SCHIP, prepared by the Urban Institute for First Focus, February 2009.

Stan Dorn and Genevieve Kenney, Automatically Enrolling Eligible Children and Families Into Medicaid and CHIP: Opportunities, Obstacles, and Options For Federal Policymakers, prepared by the Economic and Social Research Institute and the Urban Institute for The Commonwealth Fund, June 2006.

Massachusetts Division of Health Care Finance and Policy, Health Care in Massachusetts: Key Indicators, February 2009.

Stephanie Anthony, Robert W. Seifert, Jean C. Sullivan, The MassHealth Waiver: 2009-2011…and Beyond, prepared by the Center for Health Law and Economics, University of Massachusetts Medical School, for the Massachusetts Medicaid Policy Institute and the Massachusetts Health Policy Forum, February 2009.

The Massachusetts Health Insurance Connector Authority, Report to the Massachusetts Legislature: Implementation of the Health Care Reform Law, Chapter 58, 2006-2008, October 2008.

Note: much of the presentation’s discussion of Massachusetts reforms is based on a site visit to Massachusetts, which was part of Urban Institute research conducted through a grant under the State Health Access Reform Evaluation program (SHARE). SHARE is funded by the Robert Wood Johnson Foundation, with the State Health Access Data Assistance Center serving as the national program office. Together with state administrative data, findings from the site visit will be published shortly.

the urban institute 1 innovative strategies to enroll eligible people into medicaid and chip sci...

Documents

state income tax ele

state income tax returns

state income tax formschipra

state income taxes

gross income

grant incomeeligibility

federal income tax returns

federal income taxes