Martha Heberlein, Tricia Brooks and Jocelyn Guyer

1. Performing Under Pressure: Annual Findings of a 50-State Survey of Eligibility, Enrollment, Renewal and Cost-Sharing Policies in Medicaid and CHIP, 2011-2012 Martha Heberlein, Tricia Brooks and Jocelyn Guyer Georgetown University Center for Children and Families Samantha Artiga and Jessica Stephens Kaiser Commission on Medicaid and the Uninsured Kaiser Family Foundation January 18, 2012

2. 50-State Survey of Eligibility, Enrollment, Renewal, and Cost Sharing Polices, 2011-2012 • 11th annual survey covering trends in 50 states and D.C. • Based on telephone interviews with Medicaid and CHIP program administrators • Covers Medicaid and CHIP eligibility, enrollment, renewal, and cost-sharing policies • Policies for children, pregnant women, parents and non-disabled adults • Adoption of state options provided in CHIPRA and early steps related to health reform implementation • Data on policies in effect on January 1, 2012 and changes during 2011

3. Key Factors Affecting State Policies in 2011 • Lingering economic pressures • Ongoing high level of need for coverage among low-income families • Continuing revenue challenges for states • Expiration of enhanced federal Medicaid matching funds from ARRA • Diminishing resources for administrative functions and eligibility staff • ACA requirement to maintain coverage • CHIPRA options and incentives • New, time-limited opportunity to secure enhanced federal funding for major Medicaid eligibility system changes • Nearing 2014 ACA coverage expansion implementation date

4. State Medicaid and CHIP Eligibility, Enrollment, and Cost Sharing Policy Actions, January 2011 – January 2012 Number of States that Expanded/Simplified Premiums/ Cost-Sharing Enrollment/Renewal Procedures Total Eligibility 0 Number of States that Restricted SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012.

5. Number of States Taking Action Affecting Medicaid/CHIP Eligibility, by Population, January 2011 - January 2012 States that Expanded Eligibility 0 States that Restricted Eligibility SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012.

6. Children's Eligibility for Medicaid/CHIP by Income, January 2012 ME VT WA NH MT ND MN OR MA NY WI SD ID MI RI CT WY PA NJ IA NE OH DE IN IL NV MD CO UT WV DC VA CA KS MO KY NC TN AZ (CHIP closed) SC OK AR NM GA AL MS LA TX FL AK HI < 200% FPL (4 states) 200-249% FPL (21 states) 250% or higher FPL (26 states, including DC) NOTE: The federal poverty line (FPL) for a family of three in 2011 is $18,530 per year. OK has a premium assistance program for select children up to 200% of the FPL. AZ’s CHIP program is currently closed to new enrollment. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012.

7. Median Medicaid/CHIP Eligibility Thresholds, January 2012 Minimum Medicaid Eligibility under Health Reform - 133% FPL ($24,645 for a family of 3 in 2011) SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012.

8. Medicaid Eligibility for Working Parents by Income, January 2012 ME VT WA NH MT ND MN OR MA NY WI SD ID MI RI CT WY PA NJ IA NE OH DE IN IL NV MD CO UT WV DC VA CA KS MO KY NC TN AZ SC OK AR NM GA AL MS LA TX FL AK HI < 50% FPL (17 states) 50% - 99% FPL (16 states) 100% FPL or Greater (18 states, including DC) NOTE: The federal poverty line (FPL) for a family of three in 2011 is $18,530 per year. Several states also offer coverage with a benefit package that is more limited than Medicaid to parents at higher income levels through waiver or state-funded coverage. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012.

9. Coverage of Low-Income Adults by Scope of Coverage, January 2012 ME VT* WA NH MT ND MN OR* (closed) MA WI (closed) NY ID SD MI (closed) RI CT* WY PA NJ IA NE OH DE IN (closed) IL NV MD UT* (closed) WV VA CO DC* CA KS MO KY NC TN (closed) AZ (closed) SC OK AR NM (closed) GA AL MS LA TX FL AK No Coverage (26 states) HI* (closed) Premium Assistance Only (4 states) More Limited than Medicaid (13 states) Medicaid Comparable (8 states, including DC) “Closed” denotes enrollment closed to new applicants NOTE: Map identifies the broadest scope of coverage in the state. CT, DC, HI, & VT also offer more limited coverage. OR and UT also offer premium assistance with open enrollment. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012.

10. Actions Taken to Simplify Medicaid/CHIP Enrollment and/or Renewal Procedures, January 2011 - January 2012 Number of States: NOTE: Simplified renewal options include phone, online, and administrative renewals. A state is classified as providing administrative renewal if it sends a pre-populated form or renewal letter to the family in advance of the renewal date and, if there have been no changes in circumstances the family is not required to take any action or, at most, must sign and return the form to continue coverage. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012.

11. State Adoption of CHIPRA Options in Medicaid or CHIP, February 2009-January 2012 Coverage of Lawfully-Residing Immigrants without 5-Year Wait Represents total number of states adopting option. Some states may have only picked up the option in either Medicaid or CHIP. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012.

12. Simplified Renewal Methods for Children in Medicaid and CHIP, January 2012 NOTE: A state is classified as providing administrative renewal if it sends a pre-populated form or renewal letter to the family in advance of the renewal date and, if there have been no changes in circumstances the family is not required to take any action or, at most, must sign and return the form to continue coverage. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012.

13. Consistency of Simplification Measures for Children and Parents in Medicaid, January 2012 Note: A state is classified as providing administrative verification of income at application and/or renewal if it seeks to verify income through available data sources or collateral contacts with third parties prior to requesting income documentation from the family or if the family is unable to provide documentation. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012.

14. Features of Online Applications and Accounts for Medicaid and CHIP, January 2012 NOTE: In some states the online application is only available to children applying for coverage. “Enhanced functionality” denotes online accounts that allow families to review the application status, report changes in circumstances, view notices, pay premiums and/or renew coverage. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012.

15. Status of Major Medicaid Eligibility System Upgrades, January 2012 ME VT WA NH MT ND MN OR MA NY WI SD ID MI RI CT WY PA NJ IA NE OH DE IN IL NV MD CO UT WV DC VA CA KS MO KY NC TN AZ SC OK AR NM GA AL MS LA TX FL AK HI Approved APD (18 states) Submitted APD (11 states) Plan to submit APD next year (19 states) Not considering at this time (3 states) NOTE: “APD” refers to an Expedited Advanced Planning Document. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012.

16. Key Themes of Survey Findings • Reflecting the ACA requirement to maintain coverage, Medicaid and CHIP eligibility held steady in 2011, and 29 states made improvements in coverage • Coverage for low-income parents and adults continues to lag far behind that of children • Although states had flexibility to change copayment requirements for families, a small number of states made increases • Half of states improved enrollment or renewal procedures, often utilizing technology to streamline and automate processes • New enhanced federal funding spurred many states to begin major systems development work • These actions helped states deal with current pressures, and also lay the groundwork for 2014

17. Secrets to Success: Four States’ Experience as Leaders in Covering Kids • Examined factors of success for a leading state in each region: Alabama, Iowa, Massachusetts, and Oregon • MA has achieved the highest coverage rate for children in the nation at 99.5% • AL, IA, and OR have all significantly improved coverage for children in recent years • All have adopted a variety of enrollment simplifications • Common Elements of Success • Political leadership prioritizing children’s coverage • Expansive eligibility levels and adoption of a broad range of simplifications • Engagement of providers and community partners • Strong coordination between Medicaid and CHIP • Remaining Challenges and Next Steps • Diminished administrative resources • Improving retention • Updating eligibility and enrollment systems • Administrative and cultural changes to strengthen coverage and prepare for reform Source: J. Guyer, T. Brooks and S. Artiga, “Secrets to Success: An Analysis of Four States at the Forefront of the Nation’s Gains in Children’s Health Coverage,” Kaiser Commission on Medicaid and the Uninsured, January 2012.