Access to Medicaid for Pregnant Women, Children and Families: Where do the states stand?

1. Access to Medicaid for Pregnant Women, Children and Families: Where do the states stand? Findings From a 50-state survey on Eligibility, Enrollment, Renewal and Cost-Sharing Practices in Medicaid and SCHIP Donna Cohen Ross Director of Outreach Center on Budget and Policy Priorities Washington, DC 202-408-1080; cohenross@cbpp.org Presentation at: AMCHP Annual Meeting February 22, 2005

2. Where We’ve Come From • A trio of effective strategies helped boost enrollment in Medicaid and SCHIP. • Expanding eligibility • Simplifying enrollment and renewal procedures • Outreach • States were making steady progress since late 1990s. • Medicaid and SCHIP have prevented millions of children from becoming uninsured during recent weak economic times.

3. Medicaid and SCHIP Have Prevented Millions of Children from Becoming UninsuredCoverage Trends for Children, Percentage Point Change from 2000-2003 2.4 Million Children 244,000 Children 1.5 Million Children 4.3 Million Children Note: 2000 data included implementation of a 28,000 household sample expansion. Source: Georgetown Health Policy Institute analysis based on March 2001-2004 Current Population Survey. Data for Medicaid include SCHIP.

4. Signals that the trends may be reversing began to emerge in 2003 • CBPP survey of 50 states and DC conducted for the Kaiser Commission on Medicaid and the Uninsured (third in series) identified new tensions in 2003: • State budget pressures led to retractions • Parent coverage scaled back • Some simplified procedures reversed • Federal fiscal relief prevented or mitigated cutbacks in some states.

5. Changes in Eligibility, Enrollment and Renewal Procedures and Cost-Sharing in Medicaid and SCHIP for Children and Parents April 2003 – July 2004 • On the surface: • Income-eligibility remained stable, for the most part. • Beneath the surface: • Nearly half the states (23) made it harder for eligible children and families to secure and retain coverage. • Imposed financial barriers (premiums) • Froze enrollment • Reinstated procedural barriers • Most of the changes were in SCHIP — Medicaid largely protected • States began to see adverse effects on enrollment.

6. Nearly Half the States Made it More Difficult to Secure and Retain Health Coverage for Children and Families, April 2003-July 2004 Number of States Imposing Enrollment Barriers in Medicaid or SCHIP 23 16 8 8 *Includes states that froze children’s enrollment for at least a portion of the time period April 2003-July 2004. In addition, three states froze enrollment for parents under their Medicaid waiver programs. SOURCE: Based on a national survey conducted by the Center on Budget and Policy Priorities for KCMU, 2004.

7. Figure 7 States with Premiums or Enrollment Fees in Children’s Health Coverage Programs, July 2004 Number of States Income level at which premium payment required *The Federal Poverty Line (FPL) for a family of three in 2004 is $15,670. SOURCE: Based on a national survey conducted by the Center on Budget and Policy Priorities for KCMU, 2004.

8. IL States with Children’s Enrollment Freezes, April 2003 to July 2004 NH VT WA ME MT ND MN MA OR NY ID SD WI RI MI CT WY PA NJ IA NE OH IN NV DE IL WV UT VA MD CO CA KS MO KY NC DC TN OK SC AR AZ NM AL GA MS TX LA AK FL HI Enrollment Freeze** (8 states) > 200% FPL* (AL, FL, MD, UT) < 200% FPL* (CO, ID, MT, TN) *The Federal Poverty Line (FPL) for a family of three in 2004 is $15,670. **Includes states that froze children’s enrollment for at least a portion of the time period April 2003-July 2004. SOURCE: Based on a national survey conducted by the Center on Budget and Policy Priorities for KCMU, 2004.

9. Ohio’s “Regular” Medicaid Enrollment for Children, Families, & Pregnant WomenJune 1997-June 2001 Monthly enrollment in thousands • During 2000, Ohio: • Expanded coverage modestly • Adopted a new family application • Reduced verification requirements • Addressed TANF issues Source: KCMU analysis of data reported to Health Management Associates by State Medicaid agencies

10. Washington State Medicaid Enrollment of Low-Income Children* Number of Children April 2003: Increased verification requirements July 2003: 12-mo. continuous eligibility eliminated; 6-mo. renewal instituted *Children under 200% of the Federal Poverty Line (FPL) who are not eligible for TANF or SSI. SOURCE: Data from Washington’s Caseload Forecast Council website

11. Figure 11 States Reversing Previously Adopted Procedural Simplifications, 2001-2004 Number of States 11 5 1 SOURCE: Based on a national survey conducted by the Center on Budget and Policy Priorities for KCMU, 2004.

12. Where are the states on income-eligibility?

13. IL Children’s Eligibility for Medicaid/SCHIP by Income, July 2004 NH VT WA ME MT ND MN MA OR NY ID SD WI RI MI CT WY PA NJ IA NE OH IN NV DE IL WV UT VA MD CO CA KS MO KY NC DC TN OK SC AR AZ NM AL GA MS TX LA AK FL HI > 200% FPL,* No Enrollment Freeze (35 states including DC) < 200% FPL, No Enrollment Freeze (8 states) *The Federal Poverty Line (FPL) for a family of three in 2004 is $15,670. **Includes states that froze children’s enrollment for at least a portion of the time period April 2003-July 2004. SOURCE: Based on a national survey conducted by the Center on Budget and Policy Priorities for KCMU, 2004. Enrollment Freeze** (8 states) > 200% FPL (AL, FL, MD, UT) < 200% FPL (CO, ID, MT, TN)

14. IL Medicaid Eligibility for Pregnant Women by Income, July 2004 NH VT WA ME MT ND MN MA OR NY ID SD WI RI MI CT WY PA NJ IA NE OH IN NV DE IL WV UT VA MD CO CA KS MO KY NC DC TN OK SC AR AZ NM AL GA MS TX LA AK FL HI > 185% FPL* (16 states including DC) 134% - 185% FPL (26 states) 133% FPL (9 states) *The Federal Poverty Line (FPL) for a family of three in 2004 is $15,670. SOURCE: Based on a national survey conducted by the Center on Budget and Policy Priorities for KCMU, 2004.

15. IL Medicaid Eligibility for Working Parents by Income, July 2004 NH VT WA ME MT ND MN MA OR NY ID SD WI RI MI CT WY PA NJ IA NE OH IN NV DE IL WV UT VA MD CO CA KS MO KY NC DC TN OK SC AR AZ NM AL GA MS TX LA AK FL HI > 100% FPL* (13 states including DC) 50% - 100% FPL (24 states) < 50% FPL (14 states) *The Federal Poverty Line (FPL) for a family of three in 2004 is $15,670. SOURCE: Based on a national survey conducted by the Center on Budget and Policy Priorities for KCMU, 2004.

16. Median Medicaid/SCHIP Income Eligibility Threshold for Children, Pregnant Women, and Parents, July 2004 Percent of Poverty Federal Poverty Line for a family of three ($15,670 in 2004) Note: Eligibility levels for parents based on the income threshold applied to a working parent in a family of three. SOURCE: Based on a national survey conducted by the Center on Budget and Policy Priorities for KCMU, 2004.

17. Some key simplifications still are underutilized

18. Asset Test Requirements for Children’s Medicaid/SCHIP by State, July 2004 NH VT WA ME MT ND MN MA OR NY ID SD WI RI MI CT WY PA NJ IA NE OH IN NV DE IL WV UT UT VA MD CO CA KS MO KY NC DC TN OK SC AR AZ NM AL GA MS TX LA AK FL HI No asset test in Medicaid or SCHIP (45 states including DC) Asset test in Medicaid and/or SCHIP (6 states) SOURCE: Based on a national survey conducted by the Center on Budget and Policy Priorities for KCMU, 2004.

19. IL Medicaid Asset Test Requirements for Pregnant Women by State, July 2004 NH VT WA ME MT ND MN MA OR NY ID SD WI RI MI CT WY PA NJ IA NE OH IN NV DE IL WV UT UT VA MD CO CA KS MO KY NC DC TN OK SC AR AZ NM AL GA MS TX LA AK FL HI No asset test in Medicaid for Pregnant Women (45 states including DC) Asset test in Medicaid for Pregnant Women (6 states) SOURCE: Based on a national survey conducted by the Center on Budget and Policy Priorities for KCMU, 2004.

20. IL Medicaid Presumptive Eligibility for Pregnant Women by State, July 2004 NH VT WA ME MT ND MN MA OR NY ID SD WI RI MI CT WY PA NJ IA NE OH IN NV DE IL WV UT UT VA MD CO CA KS MO KY NC DC TN OK SC AR AZ NM AL GA MS TX LA AK FL HI Presumptive Eligibility for Pregnant Women (29 states including DC) No Presumptive Eligibility for Pregnant Women (22 states) *CO dropped PE after July 2004 SOURCE: Based on a national survey conducted by the Center on Budget and Policy Priorities for KCMU, 2004.

21. Figure 21 States Have Not Simplified Health Coverage for Parents to the Extent They Have for Children, July 2004 Number of States SOURCE: Based on a national survey conducted by the Center on Budget and Policy Priorities for KCMU, 2004.

22. Illinois Continued to Advance on Eligibility, Simplification and Outreach • Expanded eligibility • Increased SCHIP from 185%FPL to 200%FPL • Increased parents coverage (in two stages) from 49%FPL to 133%FPL • Adopted new simplifications • Reduced income verification requirements • Adopted presumptive eligibility for children • Outreach • Continues to support and expand community-based enrollment assistance with payments to KidCare Application Agents (apps have 90% approval rate) • Enrollment increased between January 2003 and September 2004 • 104,000 children (Medicaid and SCHIP) • 72,000 parents

23. Conclusion • Medicaid and SCHIP played an essential role in preventing an increase in the number of uninsured children over the last three years. • Barriers to coverage — new and reinstituted — are surfacing at a time when there is a need for public programs to be more, not less, accessible. • For continued progress on reducing the number of uninsured, sufficient funding — state and federal — is needed to support current caseloads and additional enrollment of eligible people. • Proposals being debated in some states and at the federal level could result in cuts in eligibility and benefits for pregnant women and children.