What Can Consumer Health Assistance Programs
and States DO To Improve Medicaid and SCHIP Enrollment and Retention

Notes from Health Assistance Partnership call, October 28, 2004

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Speakers: Laura Cox, Center on Budget and Policy Priorities; Jodi Ray, Florida Covering Kids and Families Project; and Kate Lawler, Children’s Aid Society, New York City.

Introduction
This call focused on two areas (1) outreach to get children enrolled in SCHIP and (2) procedures to ensure that once enrolled in Medicaid or SCHIP, people renew their benefits and remain enrolled in the programs.

A number of states returned unspent federal SCHIP money to the federal treasury this year (Alaska, Arkansas, Kentucky, Maine, Massachusetts, New York, North Carolina, South Carolina, Tennessee). Particularly in those states, their may be a need to increase outreach about SCHIP. Some other states had insufficient SCHIP funds and actually closed enrollment. Consumer health assistance programs then faced questions about whether to continue publicizing the SCHIP program so that people would be aware of its availability when it again became available.

In virtually all states, many people lose Medicaid and SCHIP when it is time to renew or recertify for benefits.  In some cases, families lose access to their regular treating physicians when they re-enroll first in Medicaid and then in a managed care plan after a break in enrollment. Consumer health assistance programs can help people overcome recertification problems and can advocate that their states adopt simpler procedures for enrollment in and renewal of Medicaid and SCHIP.

Consumer Health Assistance Programs: What Can They Do?

Provide outreach to beneficiaries and potential beneficiaries about eligibility for Medicaid and SCHIP, enrollment, and the process for renewal (also called recertification).

REPETITION is key!

Work with your state to improve its outreach about enrollment and renewal.
For example, Project Pathfinder is an initiative of the Florida Healthy Kids Program that provides 16 methods to find and help families through the Florida SCHIP renewal process. Some of these methods include the following:

• Establish a call center in which the family is reminded of their SCHIP renewal time and can call for information.
• Write Letters reminding families to renew SCHIP.
• Go door-to-door to help families in the renewal process. In Florida, Blue Cross/Blue Shield provided the funding for this door-to-door outreach.

Give families materials about renewal in multiple languages. For example, KidCare Organizer is a step-by-step tool, available in English, Spanish, and Creole to assist families through Florida’s renewal process.

The Covering Kids and Families Project in Florida advocated for the above outreach initiatives by working with Florida KidCare partners to develop a series of community regional meetings around the state. These meetings provided an overview of changes in Florida SCHIP enrollment, what was to remain the same, and the interim process for the changes. Participants were asked to brainstorm on the best way to address the changes and how to convey the information to KidCare families.

Develop a “Tickler” System of consumers that come into contact with your f assistance program, and the dates they will need to renew benefits. Design a database/log of beneficiary information and send a letter or call the individual or family to remind them to renew their benefits. Consumers may respond to a consumer health assistance program that has helped them when they would otherwise overlook government paperwork.

Develop reports from your consumer health assistance program’s data and anecdotes about any problems consumers encounter in the enrollment and renewal process, or about the benefits of various enrollment and renewal procedures. Provide these reports to state officials. For example, New York Children’s Aid Society published A Reality Check: A View from the Front Lines of Public Health Insurance Enrollment in March 2004. This report discusses the real-life difficulties faced by families in gathering documentation to prove their Medicaid eligibility. It urges New York to ease documentation requirements and points out that federal law allows New York to do so.

Continue outreach if your state develops a waiting list for SCHIP or for a Medicaid waiver program. This ensures that once the program opens again, people can quickly be enrolled. In Florida, the length of a waiting list convinced state legislators to allocate funds to re-open a program.

If your state cuts back one category of Medicaid or SCHIP eligibility, help consumers determine if they might still be eligible for a different category of benefits. Remember that family situations are always changing. A family that was once eligible for SCHIP but not for Medicaid might become Medicaid-eligible when a new child is born; an adult may become Medicaid-eligible when he or she grows older or becomes disabled. Thus, it is important to continually screen for Medicaid eligibility and remind consumers of the many pathways through which they may qualify for benefits.

States Can Help: Consumer-Friendly Enrollment and Simplified Recertification

Enrollment

• Eliminate requirements for consumers to provide written documentation of their eligibility, to the extent allowed by federal law. Federal law generally requires state Medicaid programs to verify applicants’ social security numbers. However, federal law does not require states to obtain written documentation of income, assets, or age directly from Medicaid and SCHIP applicants—states can instead verify this information through information exchanges with IRS, Social Security, the state unemployment agency, or other agencies. While some states have thus simplified application procedures for Medicaid and SCHIP by allowing applicants to “self-declare” their income, many states continue to require consumers to submit burdensome documentation of eligibility.
• If your state will not eliminate requirements for consumers to produce written documentation of income requirements, it can still reduce income documentation requirements. States can, for example, require consumers to submit just one pay stub to verify income instead of pay stubs from a full month.
• Eliminate asset tests for not only children, but their parents as well. Studies have shown that most low-income families have few assets. Eliminating asset tests for families in Medicaid and SCHIP saves states administrative costs, reduces paperwork, and eases the Medicaid and SCHIP application process for families.
• Use presumptive eligibility for children and pregnant women. This temporarily enrolls children and pregnant women in SCHIP and Medicaid as soon as they apply for benefits, pending a final eligibility determination.
• Contract with community-based organizations to facilitate enrollment and renewal. For example, in New York State, the state contracts with a number of community-based organizations to ensure that consumers receive help with enrollment and renewal processes in their own languages, during non-traditional hours, and through organizations that they know and trust.

Renewal or Recertification

• Use a 12-month recertification period to ensure that people in need of health care remain covered under Medicaid for a full year, instead of for just six months.
• Time Medicaid eligibility periods to coincide with managed care enrollment periods. This helps avoid situations in which people may be enrolled in Medicaid fee-for-service on renewal while awaiting entr`into a managed care plan.
• Coincide Renewal Times for Medicaid and SCHIP. In states with separate Medicaid and SCHIP programs, eliminate confusion for a single family by making the renewal times of family members who are Medicaid coincide with the renewal times for family members in SCHIP. 
• Conduct ex parte renewals, using information from food stamp case files. This procedure allows caseworkers to use information from a family’s food stamp case to extend their Medicaid without asking them to do anything else. The family is sent a letter informing them that their Medicaid is extended an additional 12 months.
• Allow “passive renewal,” in which families may maintain their coverage without providing another form or more income documentation as long as no family member’s income has changed.
• Allow a grace period for renewals (or simplified re-application period). If simplified renewal processes exist (that is, a simpler renewal form or fewer documentation requirements at renewal than on initial application), allow applicants to re-apply through this simplified process if they re-apply within a grace period of one to three months after a missed renewal.
• Conduct renewal by telephone. The family receives information that it is time to renew their Medicaid. They can either submit the renewal forms or call the number given to renew their coverage. A signature is not always required.
• Mail-in renewal Send a pre-printed form to families, allowing them to simply check-off information that has not changed, and mail back any corrections. For state examples of simplified renewal forms, contact Laura Cox, Center on Budget and Policy Priorities, cox@cbpp.org.

For more information about these options and states that have used them, see Beneath the Surface: Barriers Threaten to Slow Progress on Expanding Health Coverage of Children and Families, prepared by Donna Cohen Ross and Laura Cox (Center on Budget and Policy Priorities, 10/04).

For links to other materials on enrollment and retention.