Lack of coordination between separate SCHIP programs and Medicaid programs affected families most seriously in the program areas of enrollment and retention. As discussed in Chapter VIII, the study states, like those across the nation, have introduced simple eligibility rules and enrollment procedures under SCHIP. Consistently, the study states employ joint SCHIP/Medicaid application forms; permit applications to be submitted by mail; apply no assets test in the SCHIP eligibility process; extend 12 months of continuous eligibility to children; and, to varying extents, require little documentation from parents submitting applications for their children. However, the study states had done much less to simplify their Medicaid rules and procedures or their SCHIP eligibility redetermination rules. The lack of alignment in eligibility and enrollment procedures was described as very confusing for families, sometimes resulting in inappropriate interruptions or losses of coverage, and was observed as presenting the most challenging administrative and coordination problems for states.
At enrollment, differing program rules sometimes resulted in joint application forms that were longer than necessary for SCHIP, since they had to reflect the rules and requirements for both SCHIP and Medicaid. During the federally required "screen-and-enroll" process, differing rules essentially required families to apply for coverage twice. Reportedly, families were often confused when, after they submitted applications for SCHIP, they were later contacted and told that their children were being considered for Medicaid and that they needed either to submit more information and verification to the state or county, or appear for a face-to-face interview.
One of the more prominent coordination problems concerns the logistics of information sharing between "single point of entry" vendors (under contract to determine SCHIP eligibility) and county social services departments (which maintain responsibility for Medicaid eligibility determination). Many case study respondents noted problems related to the "deeming" of applications, back and forth, between SCHIP vendors (who had received applications for children who appeared Medicaid-eligible) and county social services agencies (who had screened applicants who appeared SCHIP-eligible), and that the two entities interpreted program eligibility rules differently. Moreover, these entities often had severe problems tracking the status of applications moving between them. Ultimately, these problems had serious implications for families: in one state applications were described as falling into "a black hole" once they were submitted to the single point of entry; and, in several states, advocates feared that many families were falling through the cracks.
"After I got pregnant with my son, I enrolled in Healthy Start a second time. They covered us through my pregnancy and then they did one of these switcheroos to the Medicaid and needed multiple types of paperwork--car titles and bills and some back paychecks that I was unable to receive from the companies. So they discontinued my coverage and since that point in time my children either have health insurance through their father when he is employed, or they have no insurance when he is unemployed." (Suburban Cleveland, Ohio)
Coordination problems at redetermination were analogous to those that occurred during initial enrollment. For example, SCHIP and Medicaid programs often use different forms for redetermining eligibility, and impose different requirements on families concerning the submission of information and documentation. Families experienced the problems that can arise when two sets of rules apply when screen-and-enroll procedures at renewal time resulted in their applications being referred from SCHIP to Medicaid, or vice versa. Once again, if a child enrolled in one program was found at redetermination to be eligible for the other program, it often meant that parents had to complete additional steps, submit additional information, and, sometimes, appear for a face-to-face interview. If parents failed to abide by any of these additional requirements, their child or children might be disenrolled from coverage. The focus group study indicated that states are more likely to refer to Medicaid children whose family income drops below the SCHIP minimum than they are to refer to SCHIP children whose family income rises above the Medicaid maximum. Even in states that make an effort to make transitions smooth, families may face difficulties:
"My son has been bounced around from Medicaid to Child Health Plus to Medicaid to Child Health Plus so many times, I didn't even know what he was on until I got the phone call [to participate in the focus group] and said, 'Oh. Okay.' I had no idea and to this day I'm still getting bills from when they dropped and changed and I don't know who to call. I don't know what he had at that time." (Buffalo, New York)
On a more positive note, it appeared that several states have improved coordination of SCHIP and Medicaid enrollment over time, and that many of the most egregious problems could be attributed to start-up confusion and administrative "glitches." In California, state officials were working with their vendor to design improved tracking mechanisms and, in Texas, the electronic transmission of applications and documentation between the vendor and county social services agencies appeared to smooth screen and enroll efforts. In addition, case study respondents noted that community-based application assistors played a key role in alleviating parents' stress and confusion by helping families negotiate the sometimes confusing procedures, and by supporting families when coordination problems arose between vendors and county agencies.