THE ENROLLMENT PROCESS

Families with uninsured children access health care through various means. Some families apply for state- or federally-subsidized health insurance, i.e., Medicaid, while others rely on direct health care programs for their care such as community health centers and WIC. One of the biggest challenges states are facing is the creation of an enrollment system focused on channeling uninsured children into the most appropriate program without losing them in the process. To address this concern, states are beginning to channel uninsured children into appropriate programs by creating more coordinated enrollment processes among Medicaid, separate state insurance programs, and other existing state programs (e.g., Title V and welfare programs). None of the nine states opted to use enrollment brokers.

The following sections present strategies used by the nine study states to establish a seamless enrollment process.

Seven out of the nine children’s health insurance programs we examined receive referrals from their state Medicaid program, and all but one also refer Medicaid-eligible children to their state's Medicaid program.

The "spend-down" process is another dynamic that has resulted in an interaction between children’s health insurance programs and Medicaid. "Spend-down" refers to the process in which a family must spend its income on health care services until its resources are reduced to a level in which they become eligible for Medicaid. Spend-down is most often seen in the case of children with special health care needs who may require expensive inpatient care. Some children’s insurance programs, particularly those separate from Medicaid, often require families to spend-down and become Medicaid eligible.

A common difficulty in coordinating enrollment between Medicaid and other children’s health insurance programs is the incompatibility of computer systems and technology. Often state Medicaid programs will have a different enrollment system than the insurance program, prohibiting the two programs from screening applicants simultaneously or tracking the changing income levels of children.

In addition to computer systems and technology not being compatible between the two programs, the application process for Medicaid tends to be more complex than enrollment procedures for a separate children’s health insurance program. Families are often deterred from enrolling in Medicaid due to complex application procedures and requirements for face-to-face interviews. In contrast, many state children’s health insurance programs have much simpler application procedures.

State and Program	Referral of Applicants by Medicaid to the Children's Health Program	Medicaid-Eligible Applicants Referred by the Children's Health Program?	Requirement of Spend-down into Medicaid
CaliforniaKids	No-Medicaid does not currently refer to the program.	Yes-If an applicant is eligible for Medicaid, they are given information about who to contact for an application.	N/A-Current program covers only preventive and primary health care and does not include inpatient coverage. Children requiring inpatient care are usually referred to the Medi-Cal program on an individual case-by-case basis.
Colorado Children’s Health Plan (CCHP)	Yes.	Yes-If applicant is eligible for Medicaid, their $25 application fee is returned with a letter advising them to apply for Medicaid at the county Department of Social Services.	N/A-Current program covers only preventive and primary health care and does not include inpatient coverage. Children requiring inpatient care are usually referred to the Colorado Indigent Care Pool (CICP).
Florida Healthy Kids	No. This is something they are looking into for the future.	No- A study showed that only 0.42% of Healthy Kids enrollees were actually eligible for Medicaid. Healthy Kids decided that this did not justify the administrative cost of screening for Medicaid eligibility.	No.
Massachusetts Children’s Medical Security Plan (CMSP)	Yes-When a child is denied eligibility for Mass Health (Medicaid) they are sent an application for CMSP.	Yes-If a child applies to CMSP but is eligible for Mass Health, they are enrolled in CMSP under presumptive eligibility and given an application to apply for Medicaid. The Medicaid office is also notified and the family is included in outreach efforts.	Yes-A one-time spend-down process exists whereby an individual has a six month window to achieve spend-down in order to be eligible for a Medicaid benefit package.
MinnesotaCare	Yes-By year 2000.	Yes- Families who are eligible for both Medicaid and MinnesotaCare are given the choice between programs. The benefits packages are the same, but some families prefer to pay the premiums required by MinnesotaCare in order to avoid the "welfare" stigma associated with Medicaid.	No.
New York Child Health Plus	Yes-The New York Department of Social Services (DSS) refers children to the program and helps with the transition when children go off Child Health Plus and onto the Medicaid program.	Yes-Child Health Plus advises county DSS offices regarding referrals of Child Health Plus applicants who are Medicaid eligible.	No- Families are not required to participate in spend-down, although they are encouraged to apply for Medicaid if their family income situation changes and it appears that they might be eligible.
Pennsylvania Children’s Health Insurance Program (CHIP)	Yes-Medicaid applicants who are determined ineligible are automatically sent a CHIP application. The county Medicaid offices usually coordinate with the CHIP HMO operating in the region to facilitate this process.	Yes- CHIP plans are required to refer ineligible children to Medicaid.	Yes-Families are required to participate in spend-down whenever a child requires inpatient hospitalization. However, CHIP also gives these children priority re-entrance into CHIP when their health status improves and they once again become ineligible for Medicaid.

States have found the coordination among children’s health insurance programs and other social service and health programs to be more difficult. Programs in which uninsured children commonly access health services (i.e., WIC, Head Start, and community health centers) are often administered by an office other than Medicaid or the state children’s health insurance program. Other children access health care through private physicians or hospital emergency rooms. These variable points of access to the system have made it difficult for states to identify eligible children. Most of the children’s health insurance programs examined in this report suggested that other social service agencies in their state were fairly consistent in educating families about insurance programs and distributing applications. However, few states had established a formal referral process to ensure the application of children into the appropriate program through some type of follow-up provision.

Table 6:
Enrollment Coordination with Other State Programs and Private Providers Table

State and Program	Potential Applicants Referred by Other State Programs?	Common Enrollment Form Used in Conjunction with Other State Programs?	Applicants Can Be Enrolled by Private Providers?
CaliforniaKids	Yes. Program partners with school nurses, Head Start, Healthy Start and AIM programs.	No.	No. All applications must be processed by CaliforniaKids.
Colorado Children’s Health Plan (CCHP)	Yes. Children enrolled in HCP, WIC, the state prenatal program or one of three food programs can be automatically enrolled in CCHP.	Yes. Short enrollment form developed to screen families for eligibility into CCHP, HCP, WIC, Colorado Indigent Care Pool, and three food programs.	No. However, Colorado is exploring the potential implementation of an internet-based enrollment system as part of the new Children’s Basic Health Plan. This would allow private physicians and hospitals to actually process CBHP applications over the computer.
Florida Healthy Kids	Yes. Healthy Kids has had an informal arrangement with Florida’s MCH programs to coordinate care for children who require more extensive health care services. Healthy Kids is currently trying to formalize this process.	No.	No.
Children’s Medical Security Plan (CMSP)	Yes. WIC and school health nurses are trained to target uninsured children and refer them to program.	No.	When children come to the emergency room for care, they are asked if they have insurance. If not, they are referred to CMSP.
Massachusetts Children’s Medical Security Plan (CMSP)	Yes. WIC and school health nurses are trained to target unisured children and refer them to program.	No.	No.
MinnesotaCare	Yes. County health departments make referrals to MinnesotaCare on an informal basis.	No.	No.
New York Child Health Plus	Yes. Other state programs refer to program on an informal basis.	No.	No. Private providers distribute information with the names and numbers of the CHP plans in the child’s area. The family is responsible for contacting the plans for an application.
Pennsylvania Children’s Health Insurance Program (CHIP)	Yes. Department of Health screens for CHIP eligibility through its toll-free Healthy Babies hotline. BC/BS Caring Programs also make referrals to CHIP.	No.	No.
Tennessee TennCare	Yes. The state MCH Department is very active in making referrals to TennCare. All county clinic nurses attend a training class on TennCare.	No.	No.
Washington Basic Health Plus	Yes. The Washington Basic Health Plan refers eligible children to the Basic Health Plus Program. (About 40% of their applicants are referred this way.) WIC program also refers families.	Yes. Children and their parents enroll into the Basic Health Plan and Basic Health Plus (Medicaid program for children) with the same application form.	No.