Making CHIPRA Work: Enrolling Eligible Children In Health Coverage

1. Making CHIPRA Work:Enrolling Eligible Children In Health Coverage New England Alliance for Children’s Health April 24, 2009 Donna Cohen Ross, CBPP Tricia Brooks, Georgetown CCF

2. Coverage Provisions • Allows CHIP coverage for pregnant women • Removes 5-year waiting period for covering legally residing immigrant children and pregnant women (Medicaid or CHIP) • Gives explicit option to cover CHIP kids to 300% FPL • over 300% reverts to Medicaid match • Phases out adults, no new parent waivers

3. Benefit Provisions • Mental health parity in CHIP; but no mandate • Dental mandate and must meet equivalency test • Dental coverage only for privately-insured kids otherwise eligible for CHIP

4. Financing Provisions • New, higher national funding levels • Change in allotment formula to send money to states that use it • Multiple “safety valves” to avoid shortfalls • Performance bonuses • Outreach grants • Enhanced translation match

5. Why is there a performance bonus? • Help states meet the cost of enrolling eligible but not enrolled, particularly low-income children • Bonus is calculated on number of children enrolled above specific enrollment targets which are beyond expected increases • Driven by economy • Due to growth in child population

6. Enrollment Targets

7. Who counts? • Medicaid kids • CHIP funded Medicaid expansions & 1115 waivers • Expansions after July 1, 2008 not counted for three years, with a base year reset • ICHIA expansions specifically excluded

8. Performance Bonus Calculation • Two bonus levels… • On enrollment above the target (tier 1) Bonus = 15% of state Medicaid share • On enrollment that is 10% above target (tier 2) Bonus = 62.5% of state Medicaid share • Calculated only on enrollment above the target • Paid in lump sum (not from allotment) in first quarter after fiscal year end

9. $100 Million Outreach Fund • Broad discretion by HHS Secretary • $10 million national campaign • Partnerships with other agencies • National hotline ensuring all states participation • $10 million for Native American outreach • $80 million in grants to states and CBO’s • Areas with high rates of eligible but not enrolled, including rural areas • Minorities and health disparities

10. What entities are eligible? • State, county or local government • National, state, local community-based public or nonprofit organizations • Faith-based organizations • Federal safety net providers • Elementary or secondary schools • Community health workers • Federally-funded programs like Head Start

11. How does the funding work? • No match required • MOE on prior year outreach funding for states receiving grants • Related enhanced match for translation & interpretation • 75% or CHIP match + 5%, if higher • Outreach, enrollment, retention, access services

12. What must grantees do? • Have access to and credibility with target population • Demonstrate ability to address enrollment barriers • Develop outcome measures • Conduct an assessment of effectiveness • Cooperate in data collection/reporting

13. Questions • When will CMS announce when and how entities can apply? • What are the expected range of grant awards? • What is the expected length of grants? • How will CMS enforce the outreach MOE?

14. It’s No Secret Outreach matters! But enrollment and retention simplification measures are still needed!

15. How does CHIPRA change citizenship documentation requirements? • Effective immediately • Three amendments to DRA • Effective January 1, 2010 • Applies to separate CHIP programs but exempt from 10% admin cap • New option to confirm US citizenship through match with SSA records • Opportunity for CMS to reissue current regulations remains

16. CIT-DOC Changes Already in Effect • Reasonable opportunity to provide documents • If applicant has otherwise proven eligibility, states CANNOT delay benefits • States get federal match regardless • Infants born to Medicaid moms exempt, including at 12 mo renewal • Tribal documents satisfy both citizenship and identity • Retroactivity to DRA could be important

17. How does the new option work?

18. What else about the SSA match? • SSA agreement is the “heavy lift” • Opportunity to build on current data exchanges • Enhanced federal match • 90% - systems development and implementation • 75% - ongoing operational cost • “Real-time basis” exempts state from tracking and reporting % of mismatches

19. Simplify Current Regulations • CMS could issue new regulations easing complexity of current requirements • Not original documents • Affidavit of identity embedded in application • Simplify hierarchy of documents

20. Express Lane Eligibility • Allows use of information from public programs to verify eligibility; enroll & renew • Regardless of differences in methodology • Can’t find child ineligible • Verifies immigration status but NOT citizenship • Screen & enroll options • Use of information from tax returns allowed

21. What else about ELE? • Federal match - 90% systems development/75% operational costs • Addresses data sharing/confidentiality • Evaluation of effectiveness and administrative cost/savings • Sunset in September 2013 • Additional federal guidance expected

22. The Performance Bonus “Price of Admission” • States must implement at least 5 out of 8 “enrollment and retention provisions” • Must be in place throughout the entire fiscal year • Must be applied to both Medicaid and CHIP (except premium assistance)

23. Questions • For 2009 only, can the 5 of 8 provisions be counted if not in place for full year • If state legislation is required? • What criteria will CMS use to determine if a provision is met? • Meaningful yet realistic ? • Shows progress over time ?

24. The Eight Enrollment and Retention Provisions (1, 2, 3) • 12-month continuous eligibility • Required for children of all ages? • “Liberalization” of asset test • No asset test, or • Administration verification of assets • No in-person interview (face-to-face) required

25. The Eight Enrollment and Retention Provisions (4, 5) • Use of common forms and uniform processes for Medicaid and CHIP • Joint application, renewal, supplemental forms, and • Same “information verification process” • Automatic renewal (administrative renewal) • State sends pre-printed form, eligibility is renewed unless changes reported by applicant (required) • Ex parte satisfies requirement

26. The Eight Enrollment and Renewal Provisions (6,7,8) • Presumptive eligibility for children • Express lane eligibility • Premium assistance subsidies

27. Does Your State Have Five of Eight? BIN GO!

28. For more information • Contact information: • Donna Cohen Ross • cohenross@cbpp.org • 202-408-1080 • Tricia Brooks • pab62@georgetown.edu • 202-365-9148