Transcript Slide 1

900 Lydia Street - Austin, Texas 78702
Phone (512) 320-0222 – fax (512) 320-0227 www.cppp.org
Recent Texas Medicaid and CHIP
Trends: What Can We Learn?
Texas Health Care Access Conference
Texas Association of Community Health Centers/Covering Kids and
Families/Texas CHIP Coalition
February 28, 2006
Anne Dunkelberg, Assistant Director ([email protected])
1
Texas Child Medicaid Enrollment
(January 2001-December 2005)
Simplified Enrollment
begins
1,900,000
1,800,000
1,700,000
1,809,164
1,600,000
1,500,000
1,400,000
1,300,000
1,200,000
1,100,000
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1,000,000
Source: All figures from Texas Health and Human Services Commission
2
Center for Public Policy Priorities
www.cppp.org
Texas CHIP Enrollment
(May 2000-January 2006)
Highest, 5/02:
529,271
600,000
9/03:
507,259
500,000
1/06:
316,679
400,000
300,000
200,000
100,000
Nov-05
5-Aug
May-05
Feb-05
Nov-05
Aug-04
May-04
Feb-04
Nov-03
Aug-03
May-03
Feb-03
Nov-02
Aug-02
May-02
Feb-02
Nov-01
Aug-01
May-01
Feb-01
Nov-00
Aug-00
May-00
0
Source: All figures from Texas Health and Human Services Commission;
Compares most recent month with September 2003
Center for Public Policy Priorities
3
www.cppp.org
Texas Child Medicaid and CHIP
Combined Enrollment (January 2002-December 2005)
2,200,000
2,149,352
2,100,000
2,132,062
2,000,000
1,900,000
1,800,000
1,700,000
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1,600,000
Source: All figures from Texas Health and Human Services Commission;
Compares most recent month with September 2003
Center for Public Policy Priorities
4
www.cppp.org
Texas CHIP Asset Test, 8/2004-10/2005
9,446 children
10,000
9,000
8,000
7,000
3,993
6,205
6,000
5,000
2,637
4,000
4,791
3,000
2,000
1,000
Combined Assets
Cash Only
Vehicles Only
2,500
1,356
1,343
1,068
0
Disenrolled at
Renewal
Source: THHSC
3,843
1,610
542
Application
Denied
Total Children
Affected
5
CHIP Asset Test: Lessons & Questions
Lessons
• Cash savings alone more likely to disqualify a child than vehicle
alone.
• Vehicle values contribute to 60% of total denials, but only 17% are
due to vehicles ALONE
• Asset test accounted for about 7% of all denials at renewal during
this period.
Questions
• Does the “hassle factor” related to documenting assets add to these
numbers?
– (E.g., make, model, and year not enough: must also provide the
“style code”.)
– Are more parents failing to complete applications because of
these requirements? Cases like that would NOT be reflected in
these statistics.
• What share of denied applications were due to assets? (HHSC has
never reported stats on numbers of CHIP applications received.)
6
CHIP Renewal Statistics
Monthly
Averages
New
Enrollees
Renewals
%
Ineligible
@
Renewal
Total
Disenrolled
%
Did Not
Renew
Before 2003
Changes
5/00-8/03*
28,647
20,016
70.2%
3,016
15,647
3.3%
8,776
After 9/03,
Before Asset
Test 9/03-7/04
19,001
35,254
73.1%
5,820
32,220
7.9% 13,385
After Asset
Test, 8/0412/05
19,576
34,930
81.1%
6,228
21,824
6.6%
Fully
Implemented
Benchmark
FY 2003
25,603
22,900
68.5%
3,809
26,313
5.2% 10,581
8,313
*New Enrollees, Total Disenrolled: 6/0-8/03; Renewals, Inelig. @ Renewal, NonRenewal: 6/01 to 8/03;
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CHIP Renewal Statistics: Lessons and Questions
Lessons:
• New Enrollment each month since 9/2003 is dramatically LOWER
than in start-up period, OR in the stable-enrollment year, FY 2003.
– Suggests that APPLICATION rates may have dropped, thus
OUTREACH needed.
– To really understand what has happened to CHIP caseloads, we need
to know more about current and historical APPLICATION rates.
• Ineligible at renewal each month since 9/2003 is dramatically
HIGHER than in start-up period, OR in the stable-enrollment year,
FY 2003. This is a logical result of having twice as many children
renew every month (i.e., under the 6-month coverage policy) than
was the case before 9/2003.
• Ineligible at renewal each month as a percentage of total enrollment
has more than DOUBLED from 0.75% in FY 2003 to 1.88%.
• Total Disenrolled each month as a percentage of total enrollment
has more than DOUBLED compared to FY 2003 (from 0.61% 
1.71% since 9/2003).
8
CHIP Renewal Statistics: Lessons and Questions
Lessons:
• BUT! “attempted renewal” rates have actually INCREASED since
9/2003: that’s the % of kids due for renewal who actually get a
renewal thru the process (includes those renewed, and those
denied)
– Suggests that the percentage of parents who try to renew has
not gotten worse; so it is possible that renewed outreach and
marketing could increase the attempted renewal rate and thus
improve enrollment rates.
Questions:
• Every month, the “total disenrolled” number I reported by HHSC is
MUCH LARGER than the sum of (renewed) + (denied @ renewal) +
(non-renewals). The number of kids losing coverage who are not
reflected in the HHSC report is, on average, about 41% of the “total
disenrolled” figure.
– To really understand what is happening to CHIP caseloads and
how we can increase participation and enrollment, we need to
get better information from HHSC as to the reasons for these
children losing coverage.
9
Ask, and Ye Shall Receive
• Example: December 2005, “Total Disenrolled” = 19,048
– 7,428 Did Not Renew
– 6,297 Ineligible at Renewal
– 39 Child or Family Moved
– 911 Child Turns 19 or Deceased
– 170 Eligibility change DURING 6-month period: Gains other
health insurance; Ineligible due to immigration status; Provisional
Eligibility Terminated; Eligible for ERS; Pregnant; “Ineligible for
Other Reason”
– 1,803 Already Enrolled in Medicaid
– 2,333 Early Medicaid Enrollment
– 24 Duplicate Account
– 43 Disenrolled for Other reasons
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CHIP Renewal Statistics:
Signs of Transition Challenges, 1/06
New
Enrollees
Renewals
%
Ineligible
@
Renewal
Total
Disenrolled
%
Did Not
Renew
8/04-12/05,
Monthly
Averages
19,576
34,930
81.1%
6,228
21,824
6.6%
8,313
December
2005
20,385
37,964
83.6%
6,297
19,048
5.9%
7,428
January 2006
14,086
18,880
52.2%
1,227
20,303
6.4% 17,290
November 2005, CHIP eligibility & enrollment transitioned from original
contractor (ACS) to new contractor (Accenture, AKA “TAA”).
January 2006 TAA begins processing new applications for children’s health
insurance; HHSC also imposes new enrollment fee and renewal
documentation policies.
11
CHIP Renewal Statistics:
More Signs of Transition Challenges
Preliminary Information (HHSC has not posted February
Stats yet):
• Feb. and March enrollment expected to drop further
(around 311,000 and 295,000)
• Renewal rates in Feb. continued to be very low, with high
numbers terminated for failure to reply to renewal,
missing information, and failure to pay the enrollment
fee.
• Feb. New Enrollment may reflect a partial “catch up”
after January’s large deficit.
• WHAT STEPS SHOULD THE TEXAS CHIP
COALITION AND OTHER STAKEHOLDERS
RECOMMEND HHSC TAKE TO STOP THIS DECLINE?
12
Snapshot: CHIP Vision Care Use
FY 2003
• Use of CHIP vision care not dependent on where child’s family fell in
the income range: 71% of all CHIP children were at/below 150%
FPL, and 71% of kids using vision care were in that income range.
• About 15% of CHIP children got some kind of vision-related exam in
FY 2003 (73,720 children).
– Since HHSC did not include actual eyeglasses in this count, the
real percentage using vision care is likely a bit higher (though
MOST eyeglass or contact purchases for children will be
accompanied by an exam).
• Not surprisingly, about 90% of the vision care went to school-aged
children (6-18).
• Vision check-ups were #7 most common billed CHIP visit in FY
2003.
• Though need for/use of vision care is not universal like dental care,
outreach to educate parents about the restored CHIP vision benefit
should be an important component of CHIP outreach.
13
Age Distribution Of Children in CHIP
(FY 2003 vs. January 2006)
300,000
250,000
200,000
FY 2003
6-Jan
150,000
100,000
50,000
0
<1 Yrs
1-5 Yrs
6-14 Yrs
15-18 Yrs
In FY 2003, children aged 1-5 made up 22.6% of enrollment; as of 1/1/2006
they had dropped to 16.5%. What does this suggest for OUTREACH?
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CHIP Service Areas
EPO
North
1X
EPO
East 1X
CSA11
EPO Central
1X
EPO South 1X
15
CHIP Enrollment by CSA, Plan, and Age Group, Change
in Share of Total State Enrollment (9/03 to 12/05)
CSA
Sept.
2003
% of total
state
Dec. 2005
% of total
state
1 Amarillo/Lubbock
13,541
2.7%
7,220
2.2%
2 Dallas-Fort Worth
100,654
19.8%
69,849
21.6%
5 Austin
25,038
4.9%
16,577
5.1%
6 Houston
137,639
27.1%
93,766
29.0%
7 San Antonio
38,060
7.5%
25,291
7.8%
8 Corpus Christi
18,332
3.6%
10,415
3.2%
10 Laredo
10,080
2.0%
5,886
1.8%
11 El Paso
22,216
4.4%
13,684
4.2%
12 EPO Central
17,056
3.4%
9,468
2.9%
13 EPO East
48,563
9.6%
28,060
8.7%
14 EPO North
20,982
4.1%
10,974
3.4%
15 EPO South
55,098
10.9%
31,708
9.8%
Statewide Total
507,259
100.0%
322,898
100.0%
Blue= Lost Share
16
Regional CHIP Enrollment Declines:
Lessons and Questions
First table: Share of Total State Enrollment
• There have not been massive shifts in the share of total
CHIP enrollment statewide; but
• Who gained share? Largest urban areas: D-FW;
Houston, Austin, San Antonio
• Who lost share? Everywhere else.
• Hypothesis: Is this because community-based outreach
efforts continued in the big cities, while
Legislature/HHSC’s discontinuation of outreach and
marketing left the rest of the state at a relative
disadvantage?
17
CHIP Enrollment by CSA, Plan, and Age Group, Regional
Decline Compared to State Average (9/03 v. 12/05)
CSA
Sept.
2003
Dec. 2005
Decline
% Decline
1 Amarillo/Lubbock
13,541
7,220
-6,321
-46.7%
2 Dallas-Fort Worth
100,654
69,849
-30,805
-30.6%
5 Austin
25,038
16,577
-8,461
-33.8%
6 Houston
137,639
93,766
-43,873
-31.9%
7 San Antonio
38,060
25,291
-12,769
-33.5%
8 Corpus Christi
18,332
10,415
-7,917
-43.2%
10 Laredo
10,080
5,886
-4,194
-41.6%
11 El Paso
22,216
13,684
-8,532
-38.4%
12 EPO Central
17,056
9,468
-7,588
-44.5%
13 EPO East
48,563
28,060
-20,503
-42.2%
14 EPO North
20,982
10,974
-10,008
-47.7%
15 EPO South
55,098
31,708
-23,390
-42.5%
Statewide Total
507,259
322,898
-184,361
-36.3%
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Blue = Decline Greater than State Average
Regional CHIP Enrollment Declines:
Lessons and Questions
Second table: Regional Enrollment Decline Compared to Statewide
Average
• Statewide decline more than one-third (36.3%);
• BUT largest urban areas: D-FW; Houston, Austin, San Antonio
experienced lower rates of decline,
• AND rates of decline everywhere else dramatically higher;
– Northwest Texas looks especially bad
– But all of rural, south, and border areas have had a disproportionate
loss in coverage
• Repeat Hypothesis: Is this related to continued community-based
outreach efforts in the big cities, while Legislature/HHSC’s
discontinuation of outreach and marketing left the rest of the state at
a relative disadvantage?
19
CHIP Enrollment by Income Group:
Did Policy Changes Affect Lowest Income Groups Most?
Number by FPL
<100%
100%150%
151%185%
Percent by FPL
186200%
<100
%
100%150%
151%185%
186200%
12/05
20,638
173,778
105,175 23,307
322,898
6.4%
53.8%
32.6%
7.2%
11/03
94,341
211,849
117,925
34,051
458,166
20.6%
46.2%
25.7%
7.4%
9/03
107,211
258,780
112,887
28,381
507,259
21.1%
51.0%
22.3%
5.6%
9/02
108,845 260,670
112,386
28,856
510,757
21.3%
51.0%
22.0%
5.6%
9/01
106,303 204,267
92,197
26,299
429,066
24.8%
47.6%
21.5%
6.1%
9/00
22,823
16,928
4,404
83,538
27.3%
47.1%
20.3%
5.3%
39,383
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CHIP Enrollment by Income Group:
Did Policy Changes Affect Lowest Income Groups Most?
• The elimination of income disregards in CHIP was applied to all
enrollees effective November 2003. This had the effect of “shifting”
many children from one category, up to the next higher category (and
“shifted” about 17,000 children out of CHIP that month).
• To take the shift into account, we use November 2003 as a benchmark
for comparing how the income distribution continued to change
AFTER that shift.
• The change from 11/2003 to the present is “real”, that is, it is due to
other factors than the income disregard change.
– Increased cost sharing and decreased benefits
– No offsetting outreach message from the state
• As the next slide shows, All groups have declined since 11/2003:
– below-poverty group saw the largest decline (73,703; 78% drop)
– 185-200% FPL group dropped 32%, probably due to asset test
– 100-150% FPL group dropped 18%; but number is large (38,071  )
because this is where enrollment was, and still is, concentrated.
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Change in Texas CHIP Enrollment, by Income
November 2003* – December 2005
Percent Change
in Enrollment:
<100%
-73,703
Total
Enrollment
101-150%
151-185%
-10.8%
186-200%
-18.0%
-12,750
-10,744
-135,268
-31.6%
-29.5%
-38,071
* Enrollment dropped by 49,093 from 9/200311/2003; thus totals shown here understate full
decline number and percent.
-78.1%
Source: CPPP analysis of Texas Health and Human Services Commission data
22
Did the Children Leaving CHIP All Go to
Medicaid? Well, No……
• Tracking movement between CHIP and Medicaid has
never been easy, because the programs used very
different data systems
• HHSC did special analysis back In 12/2004 (but not
released until 2/2005) of the movement between programs
in 2000-2004.
• The report looked at children who left Medicaid or CHIP,
and checked to see if they had either shifted to the other
program, or re-enrolled in the original program, during the
following 12 months
– FY 2004 report findings on “migration” were not 100%
complete, because a full 12 months had not passed
since many children had left the programs.
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Kids Leaving CHIP
Migration during the 12 months after leaving CHIP
Children
Leaving
Back to CHIP
To Medicaid
Neither
FY 00
1,698
578
34.0%
1,218
71.7%
16.4%,
279
FY 01
53,524
13,923
26.0%
24,362
45.5%
37.1%,
19,881
FY 02
269,091
76,543
28.4%
114,272 42.5%
36.2%
97,358
FY 03
303,337
82,124
27.1%
138,679 45.7%
35.4%,
107,242
FY 04
379,009
73,980
19.5%
158,378 41.8%
44.6%
169,223
Source: HHSC Center for Strategic Decision Support, 12/2004
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Kids Leaving Medicaid
Migration during the 12 months after leaving CHIP
Children
Leaving
Back to
Medicaid
To CHIP
Neither
FY 00
743,422
318,932
42.9%
48,207
6.5%
385,109
(51.8%)
FY 01
750,862
349,144
46.5%
105,245 14.0%
321,867
(42.9%)
FY 02
667,514
341,061
51.1%
82,708
12.4%
267,022
(40.8%)
FY 03
771,901
404,093
52.4%
75,385
9.8%
315,240
(40.8%)
FY 04
887,224
364,526
41.1%
91,090
10.3%
451,188
(50.9%)
Source: HHSC Center for Strategic Decision Support, 12/2004
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Did the Children Leaving CHIP All Go to
Medicaid? Well, No……
Key Findings:
• There was NO increase in the rate of transfer to Medicaid
in FY 2004 to offset CHIP decline. In fact, the transfer late
is much LOWER, though an updated final report might
show a higher %.
– This is also evidenced by the greatly-REDUCED growth rate in
children’s Medicaid; Medicaid growth would have INCREASED if
CHIP children were shifting there in greater proportions.
• Also shows a higher percentage of children NOT returning
to either program in FY 2004;
– the independent ICHP disenrollment report (12/2004) found 52%
of kids leaving CHIP remained uninsured.
– And found that of the 47% who got coverage later, 31% went to
Medicaid and only 11% got employer-sponsored insurance (ESI)
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Average Monthly Enrollment Growth for Texas
Children in Medicaid, FY 2001 – FY 2005*
Simplification
of application
and renewals
2.2%
Rolled back some
simplification
measures
1.4%
0.8%
0.7%
0.2%
FY 2001
Change in
97,836
Enrollment:
FY 2002
FY 2003
FY 2004
FY 2005
317,756
251,692
135,319
41,499
*FY 2006 YTD: -0.1%; Avg. annual TX child pop.
growth rate 2001-2004 1.2%
Source: CPPP analysis of Texas Health and Human Services Commission data
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Texas Child Medicaid Enrollment
(January 2001-December 2005)
Simplified Enrollment
begins
1,900,000
1,800,000
1,700,000
1,809,164
1,600,000
1,500,000
1,400,000
1,300,000
1,200,000
1,100,000
Ja
n0
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-0
1
Ju
l-0
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-0
Ja 1
n0
A 2
pr
-0
2
Ju
l-0
O 2
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-0
Ja 2
n0
A 3
pr
-0
3
Ju
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-0
Ja 3
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A 4
pr
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4
Ju
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O 4
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-0
Ja 5
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-0
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1,000,000
Source: All figures from Texas Health and Human Services Commission
28
Center for Public Policy Priorities
www.cppp.org
How Have Children’s Medicaid
Enrollment and Renewal Rates Fared?
Application Renewal
Approval Approval
rate
Rate
Denied
Missing
Info
Auto
Closure*
(as % of
denials)
Denied
Assets
(as % of
denials)
Denied
Income
(as % of
denials)
9/0012/01
58%
73%
13%
n/a
Not
avail.
Not
avail.
1/029/02
70%
78%
11.7%
81.7%
0.7%
15%
10/021/04
78%
64%
2.6%
83.6%
0.2%
6.9%
2/043/05
78%
61.4%
8.4%
73%
0.5%
12%
29
*Implemented June 2002
How Have Children’s Medicaid
Enrollment and Renewal Rates Fared?
Goal of 2001 Legislation: Make sure children eligible for Medicaid are not
left uninsured due to “rationing by inconvenience” (Lt. Gov. Ratliff).
Implemented January 2002.
• Approval rates for initial applications have improved
• Renewal Approval rates have declined since early stages of
simplification
• “Red-Tape” denials for Missing Information at renewal have crept back
up, though still lower than before January 2002.
• Auto Closure (implemented June 2002) is a proxy for failing to return
renewal in a timely manner.
– Rate has improved since early stages of implementation, both as % of
renewals denied and as % of total renewals processed.
– There is no way to distinguish parental failure to respond, from HHSC
failure to process timely, but no recent documented reports of problems
(HHSC made prompt renewal processing a priority after first round of
problems in 2002)
• Questions: What kinds of missing information are driving the
increase in denials? What kind of outreach would improve
renewal rates?
30
Texas Health Insurance Stats:
What They Tell Us About the Need for Outreach?
Texas Children who are Uninsured – U.S. Census
All incomes, under age 19 (0-18*; 3-year
average 02-04 Census CPS)
< 200% FPL; under age 19 (0-18; raw
Census CPS for 2004)
21%
1.39 million
30% of
<200%;
14.4% of all
kids
948,000
•In other words, 2/3 of uninsured Texas children are below 200% FPL, despite
Medicaid and CHIP.
•Texas is home to an estimated 230,000 undocumented kids, and another
160,000 legal immigrant (LPR) children under age 18 (Pew Hispanic Center).
•But, the LPR kids can participate in CHIP.
•Clearly, undocumented children are just a small part of our uninsured
problem
•At least 700,000 (half) of our uninsured kids could enroll in Medicaid or
CHIP!
31
(Texas children: Kids Count 3-year average: 6.49 million aged 0-18)
Next Steps?
Outreach:
• Need renewed focus on rural, lowest-income and preschool
• Need to publicize vision and dental
• Need special outreach on new Enrollment Fees!!
Other:
• Need ICHP to study both child Medicaid and CHIP
population non-renewal populations for reasons,
investigate missing information issues
• Revitalize collaboration and communication between
CBOs & stakeholders, and HHSC and its contractors
What Specific Steps do YOU think should be given top
priority?
32