What we know about discontinuity in
children’s coverage
• NY: half lost coverage in a year despite most
remaining technically eligible (Lipson 2003)
• 12 states: less than half timely renewed (Hill
2003)
• 4 states: half lapsed at renewal but one-fourth
back in 2 months (Dick 2002)
• 7 states: two-thirds of disenrolled ineligible for
SCHIP (but Medicaid?) (Riley 2002)
• Kansas: procedural and computer problems
often at fault (Allison 2003)
Churning: Children’s Coverage
Discontinuity and Its
Consequences in Kentucky
Julia F. Costich and Svetla Slavova
College of Public Health
University of Kentucky
Kentucky Children’s Health Insurance
Program (KCHIP)
KCHIP Policy Changes
• Medicaid expansion to 150% FPL
• Look-alike to 200% FPL
• Administered by Dept. for Medicaid
Services
• Eligibility determination by same agency as
cash assistance, food stamps, etc.
• Enrollment stable at ~50,000 children
• Compare Medicaid at ~321,000
• 1998: Mail-in application, in-person renewal
• 7/1/2000: Mail-in renewal with pre-populated
form and self-declaration of income
• 6/1/2001: Return to in-person interview for
renewal
• 7/1/2002: Mailed renewal reinstated; return
to in-person interview for initial application
• Confusion among caseworkers and families
Percentage of All Children Enrolled in KCHIP or Medicaid, SFY 2003
Data source: Kentucky Dept. for Medicaid Services
Fig. 1: KCHIP Enrollment May 2001-March 2004
56000
Under 30%
Recertification policy changes
55000
30-39%
40-49%
54000
Campbell
Premiums
Boone
Kenton
53000
50-59%
Gallatin
Pendleton
Carrll
Over 60%
Bracken
Grant
Trimble
Mason
Owen
Robertson
Henry
Fleming
Nicholas
Shelby
Rowan
Bourbon
Anderson
Bath
Elliott
Montgomery
Menifee
Clark
Jessamine
Webster
Larue
Mclean
Ohio
Livingston
Ballard
Warren
Christian
Barren
Knox
45000
Mar-04
F eb-04
J an-04
Dec -03
Nov -03
O c t-03
Sep-03
Aug-03
J ul-03
J un-03
May-03
Apr-03
Mar-03
F eb-03
J an-03
Dec -02
Nov -02
O c t-02
Sep-02
Aug-02
J ul-02
J un-02
May-02
Apr-02
Mar-02
Bell
F eb-02
Whitley
J an-02
Mccreary
Dec -01
Clinton
Nov -01
Monroe
Calloway
Fulton
O c t-01
Allen
46000
Sep-01
Simpson
Harlan
Wayne
Aug-01
Cumberland
J ul-01
Logan
Letcher
J un-01
Todd
Leslie
Russell
May-01
Graves
47000
Clay
Laurel
Pulaski
Adair
Metcalfe
Trigg
Hickman
Knott
Perry
Caldwell
Lyon
Marshall
48000
Pike
Owsley
Casey
Green
Mccracken
Carlisle
Jackson
Rockcastle
Taylor
Hart
Edmonson
Floyd
Breathitt
Lincoln
Grayson
Butler
Muhlenberg
49000
Magoffin
Lee
Marion
Crittenden
Hopkins
Wolfe
Estill
Garrard
Boyle
Union
Johnson
Martin
Madison
Washington
Hardin
Morgan
Powell
Mercer
Nelson
Breckinridge
50000
Lawrence
Fayette
Woodford
Spencer
Bullitt
Meade
Hancock
Daviess
End of mail-in application
51000
Boyd
Carter
Scott
Franklin
Henderson
Greenup
Lewis
Harrison
Oldham
Jefferson
52000
Prepared by: Julia F. Costich, College of Public Health
1
Problems with added eligibility office
workload
Fig. 2: Combined KCHIP and Children's Medicaid Enrollment, May 2001-March 2004
Source: Family Resource & Youth Service Center Staff Survey
380000
•
•
•
•
•
•
•
370000
360000
350000
340000
330000
320000
310000
Long waits in understaffed urban offices
Refusal to provide scheduled appointments
Overloaded phone system; unanswered voice mails
Unexpected requests for additional documentation
Inappropriate denial based on confusion
Staff reporting suspect immigration status
Failure or inability to accommodate working
families’ schedules
M ar-04
F eb-04
J an-04
D ec -03
N ov -03
O c t-03
Sep-03
Aug-03
J ul-03
J un-03
M ay -03
Apr-03
M ar-03
F eb-03
J an-03
D ec -02
N ov -02
O c t-02
Sep-02
Aug-02
J ul-02
J un-02
M ay -02
Apr-02
M ar-02
F eb-02
J an-02
D ec -01
N ov -01
O c t-01
Sep-01
Aug-01
J ul-01
J un-01
M ay -01
Churning effect
•
•
•
•
•
•
•
46% did not renew on time
New applications were 52% of total enrollment
Yet total enrollment grew by only 4%
Millions of wasted state dollars
Risk of gaps in coverage
Wide variation across the state
Timely renewal highest in Medicaid expansion
Data sources
• Open records request to Medicaid for data by
county, month and program
– “Requires” staff to provide data
• Data limitations
– Not individual-level
– “New” applications may be internal to system when renewal
deadline is missed by staff
• 3 categories
– Number of children up for renewal
– Number timely renewed
– Number of new applications approved
Methodology
• Percentage of all children (Census data)
enrolled in KCHIP or Medicaid
– Critically important to include both because of
frequent movement between programs
– Failure to account for movement overstates
churning
• Percentage of children eligible for renewal in
either program who renewed on time
• New applications approved as percentage of
total enrollment
2
Percentage of Children Enrolled and
Percentage of Timely Renewals (R2 = .44)
New Approvals as Percentage of Total and
Percentage of Timely Renewals (R2 = .55)
Methodology and statistical findings
Discussion
• SAS univariate regression analysis
• F test found p < .0001 for relationships
between
– renewal and enrollment
– new applications and non-renewal
• R2 = .44 and .55 respectively
• Low rate of timely renewal similar to other studies’
findings
• Identified need for pre-termination contact,
follow-up
– Problem: hiring freezes, state budget deficit
• Next steps:
– Determine whether supportive environment of highrenewal counties can be replicated with outreach
workers, volunteers
– Advocate for more realistic federal budget allocations
Limitations
• Inability to track individual children
• Considerable migration among programs
• Eligibility determination office practice giving
rise to spurious new applications
• Possible delinking issues in information systems
• Antiquated eligibility determination system
may introduce errors
3