CHIPRA Mandated Evaluation of the Children's Health Insurance Program: Final Findings. Churning and Transitions Between Medicaid and CHIP

08/01/2014

Program churning was more common among disenrollees from state Medicaid programs than among disenrollees from separate CHIP programs, with a median churn rate in Medicaid of over twice that of separate CHIP.

Overall, the proportion of disenrollees churning back onto coverage within seven months was more common among Medicaid (and Medicaid expansion CHIP) disenrollees than among children leaving separate CHIP programs.45 Over the 4-year period examined, approximately 21 percent of exits from Medicaid returned to Medicaid within seven months, whereas just 10 percent of separate CHIP disenrollees churn back onto coverage within seven months. This finding was consistent across the 10 study states, where, in all but New York, the Medicaid churn rate exceeded that of separate CHIP disenrollees. The rate of disenrollees returning to coverage within seven months was fairly constant over the 4-year period.

Despite little variation in overall program-specific churn rates, the cross-state variation in the rates was considerable, particularly in the Medicaid program. Depending on the state, anywhere from 8 to 36 percent of Medicaid disenrollees churned back onto the program within seven months, with the corresponding separate CHIP rates ranging between 2 and 19 percent (Figure VI.7). Alabama and Texas had markedly higher churn rates in their Medicaid programs: approximately one in three disenrollees returned to Medicaid coverage within seven months. In contrast, Louisiana had little churn in both its Medicaid and separate CHIP, with rates of 8 and 2 percent, respectively. Michigan and Virginia also experienced little churn in their separate CHIP programs, with rates of 6 and 4 percent, respectively.

Figure VI.7. Percentage of Disenrollees Who Re-enroll in the Same Program Within Seven Months, by State and Program Type (2008–2011)

Figure VI.7. Percentage of Disenrollees Who Re-enroll in the Same Program Within Seven Months, by State and Program Type (2008–2011)

Source: Mathematica analysis of state-provided Medicaid and CHIP enrollment data for children who disenrolled from Medicaid or CHIP during calendar years 2008 to 2011.


It was common for children to move between Medicaid and CHIP and to be enrolled in more than one public program during a one- or three-year time period.

A sizeable proportion of children enrolled in state CHIP programs were likely to have also had an enrollment period in state Medicaid programs over a one- or three-year time period. One in four children enrolled in separate CHIP and half of all children enrolled in Medicaid expansion CHIP had a spell of enrollment in Medicaid during the same year. Depending on the state, 29 percent (Louisiana) to 62 percent (Michigan) of children enrolled in Medicaid expansion CHIP were also enrolled in Medicaid during the same year, and between 12 percent (California) and 43 percent (Michigan) of separate CHIP enrollees were enrolled in Medicaid during the same year.

The likelihood of an enrollment period in both programs increased markedly as the period of observation extended from one to three years. The median percentage (across states) of Medicaid expansion CHIP enrollees ever enrolled in regular Medicaid increased from 50 to 74 percent between one and three years, and the median percentage of separate CHIP enrollees ever enrolled in Medicaid increased from 28 to 52 percent (Figure VI.8).

Movement between separate CHIP and Medicaid expansion CHIP was fairly limited. The median yearly percentage of Medicaid expansion CHIP enrollees ever enrolled in a separate CHIP program was 9 percent, and the reverse was 3 percent. In states running combination programs, the income eligibility band for one of the two CHIP programs is often narrow. Louisiana, which operates a small separate CHIP, accounts for the highest percentage of children enrolled in a separate CHIP who were ever enrolled in Medicaid expansion CHIP (38 percent), followed by Virginia (11 percent).

Figure VI.8. Percentage of Children Enrolled in More than One Program over a One- and Three-Year Period

Figure VI.8. Percentage of Children Enrolled in More than One Program over a One- and Three-Year Period

Source: Mathematica analysis of state-provided Medicaid and CHIP enrollment data for children enrolled in Medicaid or CHIP during the period from period January 1, 2008 to December 31, 2012.

Notes: Due to considerable variation across states, we found it useful to summarize the patterns of joint enrollment in Medicaid and CHIP based on the unweighted median averages across the states. For each state, we calculated the percentage of enrollees in multiple programs each year. We then averaged these values to determine the state-specific single-year average. We repeated this process with our three-year joint enrollment data.

S-CHIP = separate CHIP; M-CHIP= Medicaid expansion CHIP


Given that, in every state, Medicaid enrolls substantially more children than CHIP, the fraction of Medicaid enrollees also enrolled in one of the two CHIP programs during the same year (roughly 4 percent) was considerably smaller than the fraction of CHIP enrollees also enrolled in Medicaid during the year.

Transitions between separate CHIP and Medicaid often led to gaps in public coverage.

Transitions between Medicaid and Medicaid expansion CHIP tend to be seamless and largely administrative in nature. In contrast, children moving between Medicaid and a separate CHIP were more likely to lose coverage temporarily (two to six months without public coverage), with a sizable proportion of transitions resulting in a coverage gap. In terms of the median percentage across the states, 40 percent of transitions from Medicaid to a separate CHIP, and 16 percent of transitions in the reverse direction had a gap in public coverage.46 This finding is largely driven by results in four states – California, Florida, New York, and Texas – where transitions from Medicaid to separate CHIP are over five times as likely to follow a short gap in coverage as corresponding transitions from separate CHIP to Medicaid. In states with combination CHIP programs, transitions between CHIP programs largely mirrored this trend—33 percent of transitions from a Medicaid expansion CHIP to a separate CHIP program and 11 percent of transitions in the reverse direction had a gap in public coverage. These findings suggest that coordination of movement from Medicaid to separate CHIP programs remains an issue and suggest that efforts continue to improve transitions between programs and the adoption of policies that simplify these transitions. These challenges may be particularly acute for states whereby CHIP and Medicaid eligibility is administered by separate agencies; among the study states, only three – Louisiana, Ohio, and Utah – administer CHIP and Medicaid out of the same agency. Premium or enrollment fee requirements and waiting periods unique to separate programs may also be a factor for some transitions to separate CHIP programs.


45 Because Medicaid expansion CHIP is administered by state Medicaid agencies, we define both Medicaid and Medicaid expansion CHIP enrollees as Medicaid enrollees in this section.

46 Analysis excludes Ohio (which does not have a separate CHIP program), and Alabama (due to concerns about the quality of the Medicaid data received from the state).

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