Instability of Public Health
Insurance Coverage for
Children and their Families:
Consequences, Causes,
and Remedies
Laura Summer, M.P.H and Cindy Mann, J.D.
Health Policy Institute, Georgetown University
With Support from The Commonwealth Fund
Academy Health Annual Research Meeting
June 2005
Approach
• Literature Review
• Roundtables with: states, plans, providers
• More intense work in four states
LA
Major effort to simplify renewal
RI
Family coverage; premiums; premium assist.
VA
Local retention efforts; premiums
WA
Changes in renewal policies
Consequences of
insurance instability
•
•
•
•
Higher administrative costs
Difficulties managing and monitoring care
Less access to care
Perhaps higher expenditures for health
care services
Administrative costs for plans
Dis-enrollment and reinstatement tasks:
–
–
–
–
–
paperwork,
system updates,
printing, mailing,
handling calls about enrollment status
researching denied claims
Tasks to reduce churning:
–
–
–
–
Reminder calls
Address change reports
Outreach activities
Data analysis
Extent of the Administrative
Burden
Status of Plan Members Added for Average Month, 2004
(Neighborhood Health Plan of Rhode Island)
Returning
Member
65%
New Member
(2500)
35%
(1300)
<90 days
70%
90+ days
30%
(N = 3800)
Source: Neighborhood Health Plan of Rhode Island, Health Plan Retention Data, 2004.
Difficulties managing and
monitoring care
• Confusion regarding reassignment for
plans or providers
• CHCs report that primary care continues,
but access to other services is not assured
• Participation in disease management
programs can be compromised
• “Small denominator” when measuring
quality of care
Less Access to Care
Access to Care for Children with
Continuous and Intermittent Coverage
(Rhode Island: RIte Care)
120
91 85
Percent
100
97 90
80
Continous
Intermittent
60
28
40
20
7
0
Difficulty
Getting
Medical Care
Have a
Personal
Doctor
Had a Checkup in Past
Year
Source: Do Gaps in Children’s Health Coverage Make a Difference? Results of Rite Care Family Health Survey prepared by Jane
Griffin, RI ACCESS Project, September 2004.
Reasons for Insurance Instability
Coverage not retained at renewal
–
–
–
–
Unaware of need to reapply
Language or cultural differences
Renewal process is too complex
Frequency of renewal
Nonpayment of premiums
Administrative difficulties
– Transitions among public programs
– Backlogs; address changes
Evidence that families are
unaware of the need to reapply
Proportion of Families Aware That They Must
Re-enroll Annually to Keep Coverage for Their
Children (Virginia: Medicaid and FAMIS)
100
Percent
80
85
72
60
40
20
0
Medicaid
FAMIS
Source: Study of Enrollment and Non-Renewal Among Families with Children Eligible for FAMIS or Medicaid, MATRIX Marketing
Research Group, 2005.
Evidence that renewal policies
affect stability
Trend in Prior Exit Reasons for Children Re-enrolling
Returning Cyclers: Trend in Prior Exit Reasons
(First Month Back on Children's Medical)
(Washington: Children’s Medical Program)
3,500
3,000
2,500
2,000
1,500
1,000
500
0
Ja
n02
Fe
b02
Ma
r02
Ap
r02
Ma
y02
Ju
n02
J
ul02
Au
g02
Se
p02
Oc
t02
No
v02
De
c02
Ja
n03
Fe
b03
Ma
r03
Income Verification/SSN
Ap
r03
Ma
y03
Ju
n03
J
ul03
Au
g03
Se
p03
Failure To Complete ER
Oc
t03
No
v03
De
c03
Ja
n04
Fe
b04
Ma
r04
Ap
r04
Ma
y04
Ju
n04
J
ul04
Au
g04
Se
p04
All Other
Source: The Children’s Medicaid Caseload: Why the Decline?, Washington State Department of Social and Health Services, 2005.
Evidence that premiums
can affect stability
Status in May 2003 of Families
Sanctioned for Nonpayment of Premiums
during 2002 (Rhode Island: Rite Care)
Not returned
Returned to to program
36%
program
60%
Continued
coverage
4%
Source: Rite Care Premium Collection Reports, Rhode Island Office of Health and Human Services, 2003.
Remedies for instability
Simplify renewal
–
–
–
–
Annual renewal; continuous coverage
Flexible eligibility periods; rolling certifications
Provide reminders and assistance
Passive renewals; telephone renewals; selfdeclaration; ex parte
Evidence that simpler renewals
promote stability
Proportion of Cases Renewed and Closed Before and After
Fall 2003 Renewal Simplification
(Louisiana: LaChip)
May 2003
April 2005
Closed
12%
Closed
32%
Renewed
65%
Renewed
88%
Source: Medicaid Re-enrollment Outcome Reports, Louisiana Department of Health and Hospitals, 2005.
More remedies for instability
Make administrative changes
–
–
–
–
Timing; grace periods
Smooth transitions among public programs
Rules regarding plan assignment
Address changes
Train on procedural and cultural changes
Measure for management
Evidence that training and
cultural change matter
Renewal Outcomes
Four Sites in Fairfax County, Virginia
April 2005
Site #2
Site #1
14%
Site #3
3%
2%
17%
Site #4
84%
2%
80%
1%
21%
23%
75%
78%
Total with
coverage
Total not
renewed
Excess income
Conclusion
 Report and Issue Brief available in the
fall
 Additional data on enrollment patterns
relative to policy changes
 Changes in policy and practice can
make a substantial difference in
promoting stability