Children may be disenrolled from SCHIP for three types of reasons: (1) they do not fulfill administrative requirements, such as paying premiums or completing a renewal application, (2)they are no longer eligible (for example, because of the child's age or changes in the family's income), or (3) they obtain private insurance. In the six study states, all of which, as a practical matter, allow children to be enrolled for 12 months without their eligibility being redetermined, the only disenrollment that would be expected before 12 months would be for children who do not meet administrative requirements, such as paying premiums, or who obtain private health insurance. At the 12-month point, when eligibility is redetermined, it would be reasonable to expect more children to be disenrolled because they are no longer eligible. The states have focused on the rates of re-enrollment at 12 months as a marker of retention. In a preliminary analysis of retention rates during the first year in two study states, Moreno and Black (2001) found that up to 6 months after enrollment, very few children had been disenrolled in Louisiana and Texas (94 percent still enrolled) and there was little change in Texas 9 months after enrollment (92 percent still enrolled). 43 Thus the states' focus on factors leading to disenrollment at redetermination time seems appropriate.
According to the focus groups, most parents with SCHIP experience viewed the process of reenrollment in SCHIP as simple and straightforward (although these participants are the ones who re-enrolled successfully):
"Unless your address changes or your marital status, or if you have more kids. There are boxes and you mark yes or you mark no, it is simple." (Buffalo, New York)
"When your card is about to run out, they'll send you something in the mail and you fill it out, which is very convenient." (Salisbury, Maryland)
In some states, including Florida, the process was simple enough that parents of program participants were barely aware they had to reapply, while in other states they said the process required minimal effort.
The focus group study reported that parents whose children were reenrolled in Medicaid were more likely to have experienced difficulty with the reenrollment process than were parents whose children were reenrolled in SCHIP. For example:
"They mail [the forms] to you, so you fill them out and then take them back in. Once you get there then you have to go through the whole computer with her to ask the different questions. These questions are already on the papers, and then she asks all the questions in the computer, and then they ask stupid stuff like, 'Do you have farm equipment?'" (Atlanta, Georgia)
"I work 45 to 50 hours a week so I don't have much time to do anything. That's the reason he doesn't have coverage now, because I couldn't take time off work to go recertify." (Rochester, New York)
Challenges associated with SCHIP eligibility renewal and retention remain, however. In three of the study states--Colorado, Louisiana, and New York--SCHIP children's renewal rates had begun to attract the attention of state officials. State officials in Colorado reported disenrollment rates of approximately 40 percent. In Louisiana, state officials were equally concerned about lower-than-expected numbers of children renewing their coverage. In New York, state and local officials reported that they were "losing children at redetermination faster than we can sign them up." These observations are consistent with recent declines in total enrollment in New York (recall Figure 4) attributed by state officials to retention problems. Between 25 and 50 percent of children coming up for renewal in New York were disenrolled (it varies by health plan). Plans that had redeployed much of their marketing staffs to focus on eligibility redetermination and had made aggressive attempts to contact families were achieving renewal rates of 75 percent.
In two of the other study states, there is less information about renewal rates. In California, data systems cannot report routinely on the outcomes of eligibility renewals; thus, a precise retention figure was unavailable. 44 In Texas, officials had had little experience with eligibility renewal at the time of our visit, since TexCare's Phase 2 was only 14 months old. A preliminary analysis of enrollment records fount that, 12 months after enrolling, 65 percent of children remained enrolled in TexCare--yielding a disenrollment rate of 35 percent (Moreno and Black 2001).
State officials suggested reasons why children were disenrolled at redetermination, but had limited data. The limited data indicate that nearly as many children lose SCHIP eligibility at redetermination because they never complete the renewal process, as lose coverage because they are found to be no longer eligible for the program. For example, in Colorado, state officials estimated that roughly 40 percent of children who lose coverage at redetermination do so because their renewal applications are either never submitted or are submitted incomplete. In California, state data systems were unable to generate precise reasons for children being disenrolled, but officials estimated that two-thirds of children are disenrolled for "potentially avoidable reasons," including the state never receiving renewal applications from families and nonpayment of premiums. In Texas, the one state with findings (from a preliminary analysis of state enrollment records for which 12 months of information for each enrollee was analyzed), failure to pay premiums or to meet other administrative requirements related to eligibility renewal at 12 months represents a more common reason for exits than ineligibility does (Moreno and Black 2001). The parents of some children who are disenrolled do not renew SCHIP because they have gained access to private coverage--a positive outcome--but case study respondents in several states believed that this was not a major reason for children being disenrolled.
Again, findings from the focus group study provide insights into why children were disenrolled from Medicaid or SCHIP when they were still eligible for coverage. In most cases, parents had not made a deliberate decision to stop participating as a result of dissatisfaction with the programs or because they decided they did not need insurance. In fact, much of the disenrollment discussed by focus group participants represents what is referred to as "churning," the temporary exit of children from a program. The three main reasons for disenrollment that focus group participants noted are: (1) lack of knowledge about the reenrollment process and the consequences of not reapplying; (2) (for Medicaid eligible children) the time, cost, and stigma associated with visiting social services offices and providing the documentation required to re-apply; and (3) problems resulting from different program requirements for Medicaid and SCHIP. Less frequently cited reasons included failure to pay premiums.
Preliminary analyses of SCHIP retention and reenrollment patterns using program data, including the reasons for exiting the program, revealed important differences across a number of key sociodemographic characteristics of children and their families. For instance, in Louisiana, African American children are less likely to remain enrolled in LaCHIP than Hispanic or White children, even after controlling for income (Moreno and Black 2001). These findings suggest that reenrollment and retention policies might need to be targeted to specific groups of children. For instance, state efforts to follow up children who do not return their reapplication forms may need to take into account language and other cultural differences across racial and ethnic groups.
Survey data will be available to clarify the reasons why children are disenrolled. The survey of children who were disenrolled that took place during 2002 and 2003 asked the reasons why the children were disenrolled. The analysis of these reasons for disenrollment will provide the first really detailed information coded uniformly across a large number of states.
43. Nine months of data were not available for Louisiana.
44. State officials recently analyzed their data and found that for every 100 children who enroll in Healthy Families, 76 remain on the program one year later--an apparent retention rate of 76 percent.