One of the most significant challenges faced by children’s health insurance programs, particularly the stand-alone programs, is the creation of a "seamless" system. Insurance status of some children fluctuates as family income and coverage change within a given year. Such children may be eligible for a separate state insurance program one month, covered under private insurance the next, and eligible for Medicaid in the following month. This fragmentation of coverage and the discontinuity of care that may result is an important issue policy makers have grappled with over the past year. Changes in insurance status for children has become a major barrier to accessing appropriate care. First, families may not realize that once they become ineligible for one program that they have become eligible for another. Second, the provider networks that provide care within one program may not have an arrangement to provide care under the other. This becomes problematic when families must seek care from new physicians under different plans on a regular basis. As a result, many children in publicly funded programs have decreased access to and a lack of continuity with health care services.
Several state programs have attempted to create a "seamless" system of care for children focused on those children in situations with rapidly changing family income.
- The Colorado Children’s Health Plan is considering continuous eligibility for their program in which children enrolled in the program are enrolled for one full year, regardless of their Medicaid eligibility status throughout that year. Colorado plans to establish continuous eligibility under their Title XXI plan, but they have not determined the method by which they will track income and eligibility changes throughout the enrollment period. The process will most likely require the Colorado Medicaid program to provide a monthly report identifying current Medicaid beneficiaries. CCHP will then cross-reference this list with the list of their enrollees. If a child enrolled in CCHP is found to be enrolled in Medicaid, CCHP will discontinue the capitated payment to the CCHP physician for the period in which the child is enrolled in Medicaid. If the child then becomes ineligible for Medicaid and returns to CCHP, payment to that child's physician will be reinstated.
It is important to examine the issue of continuous enrollment and recertification as the eligibility status of a substantial number of children will inevitably fluctuate: families move to different states, incomes rise and fall, employment status changes, and children begin to "age out" of state-sponsored programs. Most of the nine children’s health insurance programs presented require enrollees to be recertified on an annual basis. Of the states examined, annual turnover rates have been identified to be as high as 40%. This is an important finding, and may be due to some extent to the difficulty some families have in dealing with the enrollment process.
Several states are attempting to create simple enrollment processes in order to prevent children in need of coverage from dropping out of the system.
- Florida automatically recertifies children enrolled in Healthy Kids unless they are notified by the parent of a change in insurance status (e.g., private insurance or public assistance).
- CaliforniaKids distributes a renewal form to all parents two months prior to the deadline for recertification.
Continuous Eligibility and the Recertification Process