1

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 (dunkelberg@cppp.org)

900 Lydia Street - Austin, Texas 78702Phone (512) 320-0222 – fax (512) 320-0227 - www.cppp.org

2

Texas Child Medicaid Enrollment (January 2001-December 2005)

1,809,164

1,000,000

1,100,000

1,200,000

1,300,000

1,400,000

1,500,000

1,600,000

1,700,000

1,800,000

1,900,000

Jan-01

Apr-01Jul-0

1

Oct-01

Jan-02

Apr-02Jul-0

2

Oct-02

Jan-03

Apr-03Jul-0

3

Oct-03

Jan-04

Apr-04Jul-0

4

Oct-05

Jan-05

Apr-05Jul-0

5

Oct-05

Source: All figures from Texas Health and Human Services Commission

Center for Public Policy Prioritieswww.cppp.org

Simplified Enrollment begins

3

Texas CHIP Enrollment(May 2000-January 2006)

0

100,000

200,000

300,000

400,000

500,000

600,000M

ay-0

0

Aug

-00

Nov

-00

Feb-

01

May

-01

Aug

-01

Nov

-01

Feb-

02

May

-02

Aug

-02

Nov

-02

Feb-

03

May

-03

Aug

-03

Nov

-03

Feb-

04

May

-04

Aug

-04

Nov

-05

Feb-

05

May

-05

5-A

ug

Nov

-05

Source: All figures from Texas Health and Human Services Commission;Compares most recent month with September 2003

Center for Public Policy Prioritieswww.cppp.org

Highest, 5/02: 529,271 9/03:

507,259

1/06: 316,679

4

Texas Child Medicaid and CHIP Combined Enrollment (January 2002-December 2005)

2,149,352

2,132,062

1,600,000

1,700,000

1,800,000

1,900,000

2,000,000

2,100,000

2,200,000

Jan-02

Apr-02

Jul-0

2

Oct-02

Jan-03

Apr-03

Jul-0

3

Oct-03

Jan-04

Apr-04

Jul-0

4

Oct-05

Jan-05

April-0

5

July-

05

Oct-05

Source: All figures from Texas Health and Human Services Commission;Compares most recent month with September 2003

Center for Public Policy Prioritieswww.cppp.org

5

1,068 5421,610

2,500

1,343

3,843

2,637

1,356

3,993

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

Disenrolled atRenewal

ApplicationDenied

Total ChildrenAffected

Combined Assets

Cash Only

Vehicles Only

Texas CHIP Asset Test, 8/2004-10/2005

Source: THHSC

9,446 children

6,205

4,791

6

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.)

7

CHIP Renewal StatisticsMonthly

AveragesNew

EnrolleesRenewals % 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, 8/04-12/05

19,576 34,930 81.1% 6,228 21,824 6.6% 8,313

Fully Implemented

Benchmark FY 2003

25,603 22,900 68.5% 3,809 26,313 5.2% 10,581

*New Enrollees, Total Disenrolled: 6/0-8/03; Renewals, Inelig. @ Renewal, Non-Renewal: 6/01 to 8/03;

8

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).

9

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.

10

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

11

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.

12

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?

13

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.

14

Age Distribution Of Children in CHIP

(FY 2003 vs. January 2006)

0

50,000

100,000

150,000

200,000

250,000

300,000

<1 Yrs 1-5 Yrs 6-14 Yrs 15-18 Yrs

FY 2003

6-Jan

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?

15

CSA11

EPO North 1X

EPO East 1X

EPO Central 1X

EPO South 1X

CHIP Service Areas

16

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

17

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?

18

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%

Blue = Decline Greater than State Average

19

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?

20

CHIP Enrollment by Income Group:Did Policy Changes Affect Lowest Income Groups Most?

Number by FPL Percent by FPL

<100% 100%-150%

151%-185%

186-200%

<100%

100%-150%

151%-185%

186-200%

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 39,383 16,928 4,404 83,538 27.3% 47.1% 20.3% 5.3%

21

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.

22-78.1%

-18.0%-10.8%

-31.6% -29.5%

<100% 101-150% 151-185% 186-200%

Change in Texas CHIP Enrollment, by Income

November 2003* – December 2005

Source: CPPP analysis of Texas Health and Human Services Commission data

Percent Change in Enrollment:

Total Enrollment

* Enrollment dropped by 49,093 from 9/2003-11/2003; thus totals shown here understate full decline number and percent.

-73,703-135,268-10,744

-38,071

-12,750

23

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.

24

Kids 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

Migration during the 12 months after leaving CHIP

Source: HHSC Center for Strategic Decision Support, 12/2004

25

Kids Leaving Medicaid

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%)

Migration during the 12 months after leaving CHIP

Source: HHSC Center for Strategic Decision Support, 12/2004

26

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)

27

0.8%

2.2%

1.4%

0.7%

0.2%

FY 2001 FY 2002 FY 2003 FY 2004 FY 2005

Average Monthly Enrollment Growth for Texas Children in Medicaid, FY 2001 – FY

2005*

Source: CPPP analysis of Texas Health and Human Services Commission data

97,836Change in Enrollment: 317,756 251,692 135,319

Rolled back some simplification measures

Simplification of application and renewals

41,499

*FY 2006 YTD: -0.1%; Avg. annual TX child pop. growth rate 2001-2004 1.2%

28

Texas Child Medicaid Enrollment (January 2001-December 2005)

1,809,164

1,000,000

1,100,000

1,200,000

1,300,000

1,400,000

1,500,000

1,600,000

1,700,000

1,800,000

1,900,000

Jan-01

Apr-01Jul-0

1

Oct-01

Jan-02

Apr-02Jul-0

2

Oct-02

Jan-03

Apr-03Jul-0

3

Oct-03

Jan-04

Apr-04Jul-0

4

Oct-05

Jan-05

Apr-05Jul-0

5

Oct-05

Source: All figures from Texas Health and Human Services Commission

Center for Public Policy Prioritieswww.cppp.org

Simplified Enrollment begins

29

How Have Children’s Medicaid Enrollment and Renewal Rates

Fared?Application

Approval rate

Renewal Approval

Rate

Denied Missing

Info

Auto Closure*(as % of denials)

Denied Assets

(as % of denials)

Denied Income (as % of denials)

9/00-12/01

58% 73% 13% n/a Not avail.

Not avail.

1/02-9/02

70% 78% 11.7% 81.7% 0.7% 15%

10/02-1/04

78% 64% 2.6% 83.6% 0.2% 6.9%

2/04-3/05

78% 61.4% 8.4% 73% 0.5% 12%

*Implemented June 2002

30

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?

31

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)

21% 1.39 million

< 200% FPL; under age 19 (0-18; raw Census CPS for 2004)

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!

(Texas children: Kids Count 3-year average: 6.49 million aged 0-18)

32

Next Steps?Outreach:• Need renewed focus on rural, lowest-income and pre-

school• 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?