Closing the Gap: What the Data Say About Keeping Eligible Children Enrolled

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Closing the Gap What the Data Say About Keeping
Eligible Children Enrolled

• Gerry Fairbrother, Ph.D.
• Cincinnati Childrens Hospital Medical Center
• Presented at
• Covering Kids and Families Conference
• Voices For Children
• November 28, 2006

This research was supported by The Commonwealth
Fund, the California Endowment, the Jewish
Healthcare Foundation and Blue Cross/Blue Shield
of Michigan. I thank Medicaid officials in the
participating states for their assistance.
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Why do we want to close the gaps?

• Gaps are bad for quality
• Children delay and even forego care during gaps
• Chronic conditions may worsen
• Managed care plans ability to MANAGE CARE is
  diminished
• Gaps make for inefficiencies in care and
  administration
• Processing and re-processing the same eligible
  beneficiaries in wasteful
• Managed care plans may need to re-acquaint
  themselves with the same child
• Gaps affect cost
• Cost of care after the gap may be higher due to
  pent-up demand
• Unnecessary processing costs

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If we want to understand how to close the gap, we
need to know

• Reasons for Gaps
• Number and Length of Gaps (and level of
  stability)
• Effectiveness of Policies to address Gaps
• Costs associated with gaps

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We examined these questions

• Using Medicaid eligibility files in five states
• California, Michigan, Ohio, Oregon, Pennsylvania
• We took children 5-18 enrolled in Medicaid as of
  December 2003
• We described enrollment patterns for these
  children during the three prior years (January
  2001 December 2003), including
• Proportion of children enrolled continuously for
  1, 2, and 3 years
• Proportion of children with breaks in enrollment
• Length of the breaks in enrollment

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Medicaid is a Stable Source of Coverage for Many
Children almost 2 out of 3 children were
enrolled for gt2 years in PA, CA, and OH
Percent of Children Enrolled for Specific Number
of Years
Years Continuously Enrolled
Data Source State Medicaid Enrollment Files, CY
2001-2003. Note Continuous enrollment over the
three prior years for children enrolled in
Medicaid in December 2003. Data includes children
ages 3-17 (PA data includes children 5-17).
Percentages may not add to 100 due to rounding.
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And a Revolving Door for Others From 18 to 44
of Children Have Gaps in Coverage
Data Source State Medicaid Enrollment Files, CY
2001-2003. Data includes children ages 3-17.
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Most Gaps in Coverage Last Only a Few Months
from 2 to 4
Includes only those who were in Medicaid in Dec
03 and had at least 1 break during the 3 years.
Data Source State Medicaid Enrollment Files.
Data includes children ages 3-17 (PA data
includes children 5-17).
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Most children get back on coverage, but not soon
enough
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Gaps are Associated With

• Changes in zip codes before and after gap
• Changes in eligibility codes before and after
• Higher incomes within Medicaid
• Hispanic children (in California)
• Data on this slide from analysis of California
  Medicaid eligibility files, 2003-2005

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Features of the Medicaid Program that may Affect
Enrollment/Renewal
Donna Cohen Ross and Laura Cox. Beneath the
Surface Barriers threaten to slow progress on
expanding health coverage of children and
families. Kaiser Family Foundation. October 2004.
(Based on data as of July 2004)
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What does this say about Closing the Gap?

• It says that
• High proportion of the 100,000 eligible uninsured
  children in Ohio are CHILDREN IN A GAP
• Exact percentage is an estimate, but could be
  60,000 to 70,000 of the eligible uninsured
• Need a 2-pronged strategy
• Once on the rolls, keeping children there
• Reaching children new to Medicaid

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Also has Implications for Costto Close the Gap

• Cost to insure the 100,000 eligible, uninsured
  children is NOT
• full year costs for the 100,000 children
• Rather, cost is more like
• 3 or 4 months premium for 60,000 to 70,000
  children
• Full year cost for 30,000 to 40,000 children

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How do Gaps in Medicaid Affect Managed Care Plans?
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GAP BETWEEN THE TIME MEDICAID COVERAGE BEGINS
AND WHEN ENROLLMENT IN A PLAN BEGINS
Enrollment in Medicaid
Enrollment in Health Plan
BEST
WORST
Eligibility Determination
RECERTIFICATION
Plan Enrollment
Retroactive
Auto-assignment
APPLICATION to Medicaid
Free-Look Period
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Children are Enrolled in Medicaid Longer than in
MMC
Data Source State Medicaid Enrollment
Files. Data includes children ages 5-18.
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Proportion of Children Enrolled in a Medicaid
Managed Care Plan for 1 or More Years
N1,272,212
N224,337
N159,895
N330,424
N67,442
Data Source State Medicaid Enrollment
Files. Data includes children ages 5-18.
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Cost to Enroll
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Total costs are nearly doubled after a gap in
coverage of at least 3 months(but follow similar
trend of decrease w/ continued enrollment)
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Fee-for-service pays for Costs in Months
Immediately After a Gap Managed Care Assumes
Cost by Month 4
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Recommendationsto Close the Gap

• Focus on keeping eligible children in Medicaid,
  once enrolled
• Shorten time to enroll (re-enroll) in managed
  care
• MAKE CHURNING VISIBLE
• EMPHASIZE EFFICIENCY IN RENEWAL

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Focus on Keeping Children Enrolled

• Enrollment Assistance
• 12 month renewal
• Involve managed care plans in renewal (with
  checks to ensure equitable emphasis on renewing
  all children)
• Self-declaration of income (with audit checks)
• Presumptive eligibility

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Shortening time to Enroll in Managed Care

• Assistance in plan selection at time Medicaid
  application is filled out
• Incentives to enrollment broker to help with plan
  and PCP selection
• Automatic re-enrollment in same managed care plan
  if break in enrollment is 6 months or less

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MAKE CHURNING VISIBLE

• State Medicaid report routinely on level
  churning, number of gaps and length of gaps
• State Medicaid report on costs of inefficiencies
• Managed care plans report on proportion of
  children included in the HEDIS measure
• Now care plans report performance on children who
  fulfill the continuous enrollment, but do not
  report on what that proportion is