CHIPRA Mandated Evaluation of the Children's Health Insurance Program: Final Findings. How the Affordable Care Act Had Influenced CHIP Programs as of Early 2013


The Affordable Care Act had already affected CHIP operations in early 2013 and was expected to have an even larger influence on future CHIP operations and enrollment.

In early 2013, administrators in 29 states reported that the Affordable Care Act had already affected CHIP in some way, particularly with respect to the time that program staff had spent preparing for eligibility and enrollment changes (Figure X.1). For example, state staff had devoted time to ensuring the alignment and compatibility of CHIP and Medicaid eligibility and enrollment policies, systems, and processes and to preparing for the implementation of new MAGI rules. Administrators in 7 states cited the Affordable Care Act’s MOE rules as significantly affecting their CHIP programs while administrators in 3 states cited CHIP’s expansion to dependents of state employees as an important effect of the act. In 10 states, administrators pointed to other changes, such as CHIP’s increased attention to care delivery approaches.

Figure X.1. Effects of the Affordable Care Act on CHIP Reported by States as of Early 2013 (N=47)

Figure X.1. Effects of the Affordable Care Act on CHIP Reported by States as of Early 2013 (N=47)

Source: Survey of State CHIP Program Administrators Conducted by Mathematica Policy Research in 2013.
Note: CHIP = Children’s Health Insurance Program; IT = Information Technology; MAGI = Modified Adjusted Gross Income.

When asked how the Affordable Care Act might affect CHIP in the future, the majority of administrators focused on potential operational and enrollment effects. For example, administrators in 10 states cited the switch to MAGI rules for income eligibility determination as an important influence of the Affordable Care Act on CHIP, along with the resulting movement of children from CHIP to Medicaid because of the new income eligibility rules. Administrators from 6 states talked about the streamlining of CHIP eligibility and enrollment processes to coordinate with the Marketplace as an important future effect on CHIP. Administrators in several states expressed concern about the way the new rules and regulations are making CHIP programs more like Medicaid, placing at risk some of the unique features of CHIP that contributed to the program’s success.

Given the uncertainty about continued federal funding for CHIP after 2015, CHIP administrators expressed concern for CHIP’s future, but most had not made contingency plans as of early 2013.

The 2013 survey of program administrators found widespread uncertainty about how CHIP would fit into states’ post-reform environments: administrators in more than three-quarters of states that participated in the survey were unsure about CHIP’s future. The relatively unprecedented nature of the pending expansions and programmatic changes made it difficult for states to forecast and plan. Further, the vast majority of state legislatures and state-based advocates had yet to initiate discussions about CHIP’s future. Most CHIP administrators were overwhelmed with the many tasks and efforts involved in understanding and preparing for compliance with the Affordable Care Act’s rules and timelines; they had been too busy to focus on contingency planning in the event that CHIP funding is not reauthorized in 2015. The states that had engaged in some contingency planning generally expected that, if CHIP were to expire, children would move to Medicaid or the Marketplace. However, families with access to affordable ESI coverage for the employee are not eligible for subsidies for dependent coverage in the Marketplace.

Most CHIP administrators expected there would be good continuity of care for families as they move from one program to another: overlap among Medicaid and CHIP plans and providers was generally high, and administrators expected that most Marketplace plans and providers will also overlap with Medicaid and CHIP.

Even though CHIP administrators expressed concern regarding coordination between plans and programs after the full implementation of the Affordable Care Act, the majority of states with separate CHIP programs noted that their CHIP and Medicaid plans currently overlap completely. As a result, only 2 states expected little overlap, and only one state expected no overlap among health plans that participate in Medicaid, CHIP, and the Marketplace. Likewise, many CHIP administrators reported that current provider networks between Medicaid and separate CHIP programs in their states are similar; in only 4 states do Medicaid and CHIP networks differ more than minimally. When asked about provider overlap once the Marketplaces are in place, administrators in 21 of 44 responding states said that they expect a high degree of overlap; in 10 states, administrators said that they expect some overlap. Administrators in 2 states expect complete overlap among providers participating in Medicaid, CHIP, and the Marketplace.

Some states are taking (or considering) steps to minimize coverage disruptions. For example, administrators in 9 states said that their states were encouraging plans to participate in Medicaid, CHIP, and the Marketplace; seven states were implementing enrollment and renewal simplification strategies that will help families remain enrolled in whatever programs they qualify for; and six states were using outreach efforts to encourage providers to participate in all three options.

Although details on benefits and costs in the Marketplace options were not known when we interviewed them, many administrators expected the benefits or costs between Medicaid, CHIP, and the Marketplace plans to differ.

Where differences in cost sharing arrangements were expected, cost sharing in Marketplace plans was expected to be higher than in Medicaid and CHIP, primarily because cost sharing in Medicaid and CHIP is kept to a minimum by federal rules. Most states were unsure about how Marketplace benefit packages would compare with Medicaid and CHIP but administrators in 5 states expected benefits in Marketplace plans to be less generous than in Medicaid and CHIP. Administrators from 6 states expected there would be some similarities between benefits or cost-sharing arrangements among the three programs. When asked about what Medicaid services might be excluded from Marketplace plans, administrators identified such services as non-emergency transportation; early and periodic screening, diagnostic and treatment (EPSDT) services; and long-term care, among others.

Most states are concerned that provider capacity may not be adequate for some services or geographic areas.

Administrators in 7 states (of 43 responding) expected their state’s health care system to be able to handle the additional volume of newly insured individuals because the state either already covered newly eligible people in some way or had added capacity in preparation for the increase. Administrators in 28 states said that the capacity of their health care system would be inadequate to deal with the influx; administrators in 8 states did not know if their state could handle the newly insured. With respect to provider capacity, respondents in 32 states (of 47 responding) expressed concern about the availability of at least one type of provider (22 expressed concern about two or more types of providers); the concern applied especially to dental and mental health providers but also to primary care and pediatric providers. CHIP administrators in 3 states were concerned about all types of providers in their states. Of those noting concerns, administrators in 16 states said that they were considering steps to mitigate potential problems, including, for example, the possibility of adopting alternative delivery mechanisms (such as providing more care in schools to relieve some demand on the system, or permitting nurses to take on an expanded role in primary care) and reforms as well as increases in provider rates.

Administrators in 30 of 35 responding states expressed concern about capacity in specific geographic areas. In 18 states, administrators mentioned rural areas; in 6 rural states (labeled as “rural states” by the CHIP administrators in those states), administrators were concerned about capacity statewide. Administrators in 7 other states mentioned specific regions of their states (for example, “the northern part of the state”), and one mentioned concern about capacity in inner-city areas. In 5 states, administrators noted that their states were looking into ways to address the shortages in the areas mentioned by, for example, increasing provider rates, implementing statewide managed care, and conducting outreach to providers.

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