Issues in Developing Programs for Uninsured Children: A Resource Book for States. A. Coordination with Medicaid


Seven out of the nine children’s health insurance programs we examined receive referrals from their state Medicaid program, and all but one also refer Medicaid-eligible children to their state's Medicaid program.

  • In some instances, referral into the most appropriate programs is an informal process.
  • In Pennsylvania, children who have applied for CHIP and have been deemed Medicaid-eligible are notified (in written form) of their ineligibility for CHIP and are instructed to apply for Medicaid. In Philadelphia, there is also a 1-800 number, operated by the Pennsylvania Department of Health in cooperation with two local consumer groups, that "screens" callers to determine if they are eligible for Medicaid or for CHIP. Callers who appear to qualify are sent a simplified one-page application form. Those appearing to be eligible for Medicaid are referred to help lines where counselors take applications and explain procedures. No formal process is in place to ensure the enrollment of these children into Medicaid.
  • MinnesotaCare is establishing a coordinated enrollment process, going into effect in 2000, using the same employees to process applications for Medicaid and for MinnesotaCare. These employees will be trained to place applicants in the most appropriate program.
  1. Spend-down Requirements

The "spend-down" process is another dynamic that has resulted in an interaction between children’s health insurance programs and Medicaid. "Spend-down" refers to the process in which a family must spend its income on health care services until its resources are reduced to a level in which they become eligible for Medicaid. Spend-down is most often seen in the case of children with special health care needs who may require expensive inpatient care. Some children’s insurance programs, particularly those separate from Medicaid, often require families to spend-down and become Medicaid eligible.

  • The Pennsylvania CHIP program has a medically needy provision that directs children requiring inpatient care to spend-down. The spend-down process in Pennsylvania is most often initiated by the hospital on the first day the child is admitted. The hospital will provide the child’s family with a Medicaid application and an estimate of the expenses the child will incur during hospitalization. Within ninety days, the state's Medicaid program will recalculate the family’s Medicaid eligibility, and will take begin to pay the child's medical expenses from that point. During this period, CHIP coordinates with Medicaid to allow the child to remain with the CHIP physician, rather than requiring the child to switch to a new provider. If a child's health status improves and/or the income of the child's family rises and the child is no longer eligible for Medicaid, CHIP will permit the child to re-enter the program.
  1. Barriers to Coordination

A common difficulty in coordinating enrollment between Medicaid and other children’s health insurance programs is the incompatibility of computer systems and technology. Often state Medicaid programs will have a different enrollment system than the insurance program, prohibiting the two programs from screening applicants simultaneously or tracking the changing income levels of children.

  • Colorado is addressing this issue in the design of the Children’s Basic Health Plan (CBHP) by creating a system of ID numbers and family information that will be compatible with the system currently used by the Medicaid program. The state believes that this type of system will prevent the "fall out" of children eligible for one program or the other.

In addition to computer systems and technology not being compatible between the two programs, the application process for Medicaid tends to be more complex than enrollment procedures for a separate children’s health insurance program. Families are often deterred from enrolling in Medicaid due to complex application procedures and requirements for face-to-face interviews. In contrast, many state children’s health insurance programs have much simpler application procedures.

  • The application for the Colorado Children's Health Plan can be completed through the mail and is approximately four pages long if the child is not enrolled in any other state-subsidized programs. If the child is enrolled in another state program (e.g., WIC, Free and Reduced Price Meal Program), the family is only required to complete a one page enrollment form. However, the Colorado Medicaid application is twenty-five pages long and requires a face-to-face interview.

Table 5: Program Coordination with Medicaid

State and Program Referral of Applicants by Medicaid to the Children's Health Program Medicaid-Eligible Applicants Referred by the Children's Health Program? Requirement of Spend-down into Medicaid
CaliforniaKids No-Medicaid does not currently refer to the program. Yes-If an applicant is eligible for Medicaid, they are given information about who to contact for an application. N/A-Current program covers only preventive and primary health care and does not include inpatient coverage. Children requiring inpatient care are usually referred to the Medi-Cal program on an individual case-by-case basis.
Colorado Children’s Health Plan (CCHP) Yes. Yes-If applicant is eligible for Medicaid, their $25 application fee is returned with a letter advising them to apply for Medicaid at the county Department of Social Services. N/A-Current program covers only preventive and primary health care and does not include inpatient coverage. Children requiring inpatient care are usually referred to the Colorado Indigent Care Pool (CICP).
Florida Healthy Kids No. This is something they are looking into for the future. No- A study showed that only 0.42% of Healthy Kids enrollees were actually eligible for Medicaid. Healthy Kids decided that this did not justify the administrative cost of screening for Medicaid eligibility. No.
Massachusetts Children’s Medical Security Plan (CMSP) Yes-When a child is denied eligibility for Mass Health (Medicaid) they are sent an application for CMSP. Yes-If a child applies to CMSP but is eligible for Mass Health, they are enrolled in CMSP under presumptive eligibility and given an application to apply for Medicaid. The Medicaid office is also notified and the family is included in outreach efforts. Yes-A one-time spend-down process exists whereby an individual has a six month window to achieve spend-down in order to be eligible for a Medicaid benefit package.
MinnesotaCare Yes-By year 2000. Yes- Families who are eligible for both Medicaid and MinnesotaCare are given the choice between programs. The benefits packages are the same, but some families prefer to pay the premiums required by MinnesotaCare in order to avoid the "welfare" stigma associated with Medicaid. No.
New York Child Health Plus Yes-The New York Department of Social Services (DSS) refers children to the program and helps with the transition when children go off Child Health Plus and onto the Medicaid program. Yes-Child Health Plus advises county DSS offices regarding referrals of Child Health Plus applicants who are Medicaid eligible. No- Families are not required to participate in spend-down, although they are encouraged to apply for Medicaid if their family income situation changes and it appears that they might be eligible.
Pennsylvania Children’s Health Insurance Program (CHIP) Yes-Medicaid applicants who are determined ineligible are automatically sent a CHIP application. The county Medicaid offices usually coordinate with the CHIP HMO operating in the region to facilitate this process. Yes- CHIP plans are required to refer ineligible children to Medicaid. Yes-Families are required to participate in spend-down whenever a child requires inpatient hospitalization. However, CHIP also gives these children priority re-entrance into CHIP when their health status improves and they once again become ineligible for Medicaid.