CHIPRA Mandated Evaluation of the Children's Health Insurance Program: Final Findings. IX. Families’ Perceptions, Knowledge, and Experiences with the CHIP/MEDICAID Application and Renewal Process

08/01/2014

KEY FINDINGS:

  • While most lower-income families with uninsured children expressed interest in enrolling their children in CHIP or Medicaid, roughly half did not believe they were eligible and one-third did not know where to get more information about these programs and how to enroll in them.
  • Most new enrollees said that they had applied for CHIP coverage either because of its affordability (35 percent), a specific health care need for their child (33 percent), or to keep their child healthy (26 percent).
  • More than one-third of new CHIP enrollees applied for coverage online, and this was the most popular application option for new CHIP enrollees in half the study states. Online approaches were less common at renewal.
  • Among those who had newly enrolled in Medicaid or CHIP, 46 percent said the application process was very easy and 43 percent said it was somewhat easy. Roughly one-third of these families obtained assistance completing their application, and those receiving assistance reported overwhelmingly that it was helpful. However, these results contrast with the perception of families with uninsured children who may be eligible for these programs, only 43 percent of whom thought the application process would be easy.

In this chapter, we present findings on how low-income families perceive and experience the application and renewal processes for CHIP and Medicaid. The chapter begins with findings from an analysis of the 2011/2102 National Survey of Children’s Health (NSCH) focused on a subsample of families below 200 percent of the FPL with an uninsured child, most of whom are likely eligible for one of these two coverage programs.63 The findings presented in this chapter focus on families’ knowledge of the programs, interest in enrolling, beliefs about their child’s eligibility, and perceptions of the enrollment/re-enrollment processes. The chapter then presents findings from the CHIP 10-state survey on both the experiences of new enrollee families as they applied for CHIP (or Medicaid) coverage and the experiences of more established enrollee or recent disenrollee families with the renewal process for these programs.64

Nearly all low-income families with an uninsured child were familiar with Medicaid/CHIP and said they would like to enroll their child, but several barriers to enrollment remain.

On the 2011/2012 NSCH, nearly all families below 200 percent of the FPL with an uninsured child (95 percent) said that they had heard of CHIP or Medicaid; awareness of CHIP was lower than awareness of Medicaid (74 and 94 percent, respectively). Many low-income uninsured children had prior experience with the programs: 59 percent had been covered by at least one of these programs in the past, many within the past year.

Of those who had heard of Medicaid or CHIP, 91 percent said that they would enroll if told that their child was eligible (Figure IX.1). This includes 88 percent of those who had not been enrolled in one of these programs in the past and 94 percent of those with prior enrollment (data not shown). Interest in enrolling was high across a variety of subgroups, including different racial/ethnic and age groups. For example, among parents of black and Hispanic children, 96 percent said that they would be interested in enrolling in Medicaid or CHIP; and among parents of white children, 81 percent expressed similar interest.

Figure IX.1. Perceptions of Medicaid/CHIP Among Parents of Low-Income Uninsured Children, 2011–2012

Figure IX.1. Perceptions of Medicaid/CHIP Among Parents of Low-Income Uninsured Children, 2011–2012

Source: 2011/2012 National Survey of Children’s Health.

Note: Excludes those who have not heard of Medicaid or CHIP. Low income is below 200 percent of the FPL.


While most low-income parents with uninsured children were familiar with Medicaid and CHIP and said they want to enroll their child, barriers to enrollment remain.

Parents identified several reasons for their children remaining uninsured, including confusion about eligibility, lack of information, and negative perceptions of the enrollment/renewal processes. For example, the parents of just over half (53 percent) of low-income uninsured children believe their child is eligible (Figure IX.1); the remaining 47 percent reported either that they did not think their child was eligible or that they were uncertain whether their child was eligible. Since the vast majority of low-income uninsured children qualify for one of the programs, this indicates that some of these families may be confused about the eligibility requirements. Moreover, a third of these uninsured children have parents who either did not know where to get more information about Medicaid/CHIP coverage or did not know how to enroll their child (Figure IX.1).

Some parents of uninsured children had negative perceptions of the application and re-enrollment processes (Figure IX.1). Among those whose children have never been enrolled in Medicaid or CHIP, 43 percent believed applying for Medicaid/CHIP is easy. The rate was lower among those whose children had been enrolled before; only 35 percent of these parents believed enrolling is easy. In addition, the survey indicates differential patterns of awareness, knowledge, and perceptions across many demographic, socioeconomic, and geographic subgroups. Most notably, non-English-speaking Hispanic families—who have high levels of uninsurance—had less experience with and lower awareness of the programs, more confusion about the eligibility requirements, and less knowledge about how and where to enroll.

New CHIP enrollees learned about the program from numerous sources and usually applied because of affordability or a medical need.

When asked what source of information was most important in applying for coverage, new CHIP enrollees mentioned numerous different sources with some frequency (not shown). Close to a third (29 percent) answered that it was a friend or family member, making it the most common response. This was followed by a hospital or other health care provider (19 percent), a government agency (18 percent), various forms of media (10 percent), school (9 percent), and other types of programs, such as SNAP (9 percent). This distribution held fairly stable across the 10 states and demographic subgroups.

When asked why they applied for CHIP coverage for their child, roughly two-thirds of parents of new enrollees cited affordability (35 percent) and/or an immediate health care need (33 percent) as a main reason (Figure IX.2). Among the health needs most often cited by parents were a prescription (23 percent), a dental need (16 percent), or an urgent medical need (15 percent) (data not shown). Other common reasons parents applied for CHIP coverage were to keep their child healthy or a loss of other coverage. Parents with a new Medicaid enrollee cited similar reasons for applying for coverage, though a higher proportion cited health care needs (49 percent) and a smaller proportion cited loss of other coverage (13 percent).

Figure IX.2. Most Common Reasons for Enrolling in CHIP, New CHIP Enrollees

Figure IX.2. Most Common Reasons for Enrolling in CHIP, New CHIP Enrollees

Source: 2012 Congressionally Mandated Survey of CHIP and Medicaid Enrollees and Disenrollees; new enrollee sample (N = 4,140).

Note: Reasons related to health care need were largely given in response to three direct questions that asked whether the child had enrolled due to an urgent medical need (such as an illness), a dental need, or a need to fill a prescription, All other reasons were given in response to an open-ended question and, with the exception of those shown above, offered with low prevalence (6 percent or less of respondents).


More than one-third of new CHIP enrollees applied for coverage online, and this was the most popular application option for new CHIP enrollees in half the study states. Online approaches were less common at renewal.

As seen in Figure IX.3, the largest proportion of new CHIP enrollees still applied for coverage through the mail (41 percent), but the share using the internet was nearly as large (36 percent). In 5 of the 10 study states, a majority of the new CHIP enrollees applied for coverage through an online tool—Florida (77 percent), Michigan (67 percent), Utah (66 percent), Alabama (64 percent), and Louisiana (63 percent) (data not shown). The share using the internet is likely to grow, as it was still a relatively new option in most states at the time of the survey, and it is a required pathway under the Affordable Care Act in 2014.

Figure IX.3. Mode of Application, New CHIP Enrollees

Figure IX.3. Mode of Application, New CHIP Enrollees

Source: 2012 Congressionally Mandated Survey of CHIP and Medicaid Enrollees and Disenrollees; new enrollee sample (N = 4,140).


Most families that recently enrolled in CHIP found the application process at least somewhat easy.

The vast majority of the parents of recent CHIP enrollees surveyed reported little difficulty completing the application process. When asked about their overall experience with this process, 46 percent reported that it was very easy, and an additional 43 percent reported that it was somewhat easy (Figure IX.4). Just 11 percent reported that it was somewhat difficult. These findings were generally consistent across the 10 states and also among different demographic groups; they were also consistent with those for new Medicaid enrollees in three states (not shown).

Findings for CHIP enrollees contrast with the less-positive perceptions held by families with eligible-but-uninsured children reported above, including those who reported being covered by these programs in the past. This difference could arise for numerous reasons, making it difficult to interpret. For example, it could arise purely as a matter of perception, as those families who just successfully enrolled their children into CHIP or Medicaid might offer more favorable impressions of the application process than those whose children had enrolled in these programs in the past but were now without coverage. Conversely, it may reflect real differences in the experience of families, especially because the enrollment experiences of the uninsured population reported on the NSCH predated the experiences of families interviewed for this evaluation. Families of children newly enrolling in CHIP or Medicaid in 2012 may have encountered a different, likely easier, application process than families who applied earlier.

Figure IX.4. Ease/Difficulty of the Application Process, New CHIP Enrollees

Figure IX.4. Ease/Difficulty of the Application Process, New CHIP Enrollees

Source: 2012 Congressionally Mandated Survey of CHIP and Medicaid Enrollees and Disenrollees; new enrollee sample (N = 4,140).


About a quarter (26 percent) of new CHIP enrollees received assistance completing the application form, including 12 percent who received help with translation. Most (71 percent) received this assistance from a government agency, though some cited either a health care provider (13 percent) or a friend/family member (10 percent) as their source of assistance. When asked if this assistance was helpful, 90 percent reported that it was very helpful. Across states, assistance was most common for new CHIP enrollees in New York (48 percent) and California (34 percent), both states that have been relatively proactive in connecting families to assistance. Findings were similar across demographic groups and for new Medicaid enrollees in the three states surveyed.

New CHIP enrollees often waited weeks for coverage, and few understood the renewal requirement.

When asked for the length of time between submitting the application and receiving a notification of enrollment, 15 percent of new CHIP enrollees reported that it was less than two weeks, whereas 42 percent reported it was four weeks or more. This distribution was generally consistent across states. The only exception is Michigan, which had by far the shortest wait times; 38 percent of families reported waiting less than two weeks, while 24 percent waited four weeks or more. This result is likely due in part to Michigan’s online application process, which notifies families immediately of their eligibility status upon completion of their application. Consistent with this policy measure, 44 percent of new CHIP enrollees who applied online in Michigan reported enrolling within two weeks, far more than those applying through any mode in any other state.

When asked if they had heard of a renewal requirement for CHIP, 65 percent of new CHIP enrollees reported that they had heard of this requirement; of this group, 79 percent reported the correct time frame for the renewal. Taken together, this means that about half of new CHIP enrollees understood the renewal requirement for the program, a factor that could ultimately contribute to some eligible children eventually losing coverage. Findings were similar among new Medicaid enrollees and also largely consistent across different demographic groups.

Nearly all CHIP enrollees who tried to renew coverage found the process at least somewhat easy, even if they subsequently left the program.

Among families who had successfully renewed coverage for their child and remained enrolled, most (79 percent) said that they received a renewal form by mail and returned it for processing. Relatively few of these families reported receiving assistance in returning the form (18 percent), and nearly all found the process of doing so at least somewhat easy -- 52 percent reported it to be very easy and an additional 40 percent reported it to be somewhat easy. Among families whose child had been recently disenrolled, a smaller fraction (48 percent) reported receiving and returning a renewal form by mail. However, even among these families, nearly all found the process of returning the renewal form to be at least somewhat easy (92 percent) and only a small share reported receiving assistance (13 percent).

As seen in Figure IX.5, among CHIP disenrollees who did not return a renewal form, two-thirds (65 percent) said they believed their child was no longer eligible. When asked for the reason, more than half said that that they had obtained other insurance and about a quarter said that their family’s income had changed (see note to Figure IX.5). Another 16 percent showed a lack of interest by not returning the form, as indicated by reasons like forgetting, not needing the insurance, and not being interested in renewing. Just 6 percent of disenrollees cited difficulties with paperwork as a reason for not returning the form and only 4 percent cited affordability issues. Taken together, these findings suggest that barriers to completing the renewal process (such as paperwork burden and affordability) are a much less common reason for leaving CHIP coverage than changes in eligibility.

Figure IX.5. Reasons for Not Returning a Renewal Form, CHIP Disenrollees

Figure IX.5. Reasons for Not Returning a Renewal Form, CHIP Disenrollees

Source: Congressionally Mandated Survey of CHIP Enrollees and Disenrollees, disenrollee sample (N = 469).

Notes: The category "Child not eligible" includes one or more of the following: gained other insurance (35 percent), income too high or low (13 percent), child is too old (9 percent), moved out of states (3 percent), and other eligibility-related reasons (7 percent).


63 For further details on relevant findings from the analysis of data from the 2011/2012 National Survey of Children’s Health, see Haley et al. (2013), Kenney et al. (2013a), and Kenney et al. (2013b).

64 For further details on relevant findings from the analysis of data from the 2012 congressionally mandated survey of CHIP and Medicaid enrollees and disenrollees, see Trenholm et al. (2013), contained in Harrington and Kenney et al. (2014).

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