1. Making CHIPRA Work: Enrolling Eligible Children In Health Coverage New England Alliance for Children’s Health April 24, 2009 Donna Cohen Ross, CBPP Tricia Brooks, Georgetown CCF

2. Coverage Provisions Allows CHIP coverage for pregnant women Removes 5-year waiting period for covering legally residing immigrant children and pregnant women (Medicaid or CHIP) Gives explicit option to cover CHIP kids to 300% FPL over 300% reverts to Medicaid match Phases out adults, no new parent waivers

3. Benefit Provisions Mental health parity in CHIP; but no mandate Dental mandate and must meet equivalency test Dental coverage only for privately-insured kids otherwise eligible for CHIP

4. Financing Provisions New, higher national funding levels Change in allotment formula to send money to states that use it Multiple “safety valves” to avoid shortfalls Performance bonuses Outreach grants Enhanced translation match

5. Why is there a performance bonus? Help states meet the cost of enrolling eligible but not enrolled, particularly low-income children Bonus is calculated on number of children enrolled above specific enrollment targets which are beyond expected increases Driven by economy Due to growth in child population

6. Enrollment Targets Base Year Mo. Ave Enrollment 2007 + Child Pop Growth % + 4% 2008 + Child Pop Growth % + 4% 2009 Child Pop Growth % + 3.5% per year 2010 - 2012 Child Pop Growth % + 3% per year 2013 - 2015 Child Pop Growth % + 2% per year 2016+

7. Who counts? Medicaid kids CHIP funded Medicaid expansions & 1115 waivers Expansions after July 1, 2008 not counted for three years, with a base year reset ICHIA expansions specifically excluded

8. Performance Bonus Calculation Two bonus levels… On enrollment above the target (tier 1) Bonus = 15% of state Medicaid share On enrollment that is 10% above target (tier 2) Bonus = 62.5% of state Medicaid share Calculated only on enrollment above the target Paid in lump sum (not from allotment) in first quarter after fiscal year end

9. $100 Million Outreach Fund Broad discretion by HHS Secretary $10 million national campaign Partnerships with other agencies National hotline ensuring all states participation $10 million for Native American outreach $80 million in grants to states and CBO’s Areas with high rates of eligible but not enrolled, including rural areas Minorities and health disparities

10. What entities are eligible? State, county or local government National, state, local community-based public or nonprofit organizations Faith-based organizations Federal safety net providers Elementary or secondary schools Community health workers Federally-funded programs like Head Start

11. How does the funding work? No match required MOE on prior year outreach funding for states receiving grants Related enhanced match for translation & interpretation 75% or CHIP match + 5%, if higher Outreach, enrollment, retention, access services

12. What must grantees do? Have access to and credibility with target population Demonstrate ability to address enrollment barriers Develop outcome measures Conduct an assessment of effectiveness Cooperate in data collection/reporting

13. Questions When will CMS announce when and how entities can apply? What are the expected range of grant awards? What is the expected length of grants? How will CMS enforce the outreach MOE?

14. It’s No Secret Outreach matters! But enrollment and retention simplification measures are still needed!

15. How does CHIPRA change citizenship documentation requirements? Effective immediately Three amendments to DRA Effective January 1, 2010 Applies to separate CHIP programs but exempt from 10% admin cap New option to confirm US citizenship through match with SSA records Opportunity for CMS to reissue current regulations remains

16. CIT-DOC Changes Already in Effect Reasonable opportunity to provide documents If applicant has otherwise proven eligibility, states CANNOT delay benefits States get federal match regardless Infants born to Medicaid moms exempt, including at 12 mo renewal Tribal documents satisfy both citizenship and identity Retroactivity to DRA could be important

17. How does the new option work? Applicants given 90 days Provide documentation or resolve inconsistency with SSA State attempts to resolve inconsistency Clerical errors, other data sources SSA responds Confirms citizenship; reports inconsistencies States submit applicant information to SSA Info includes SSN; frequency at least monthly States execute agreements Data sharing with SSA; technology match approval from CMS

18. What else about the SSA match? SSA agreement is the “heavy lift” Opportunity to build on current data exchanges Enhanced federal match 90% - systems development and implementation 75% - ongoing operational cost “Real-time basis” exempts state from tracking and reporting % of mismatches

19. Simplify Current Regulations CMS could issue new regulations easing complexity of current requirements Not original documents Affidavit of identity embedded in application Simplify hierarchy of documents

20. Express Lane Eligibility Allows use of information from public programs to verify eligibility; enroll & renew Regardless of differences in methodology Can’t find child ineligible Verifies immigration status but NOT citizenship Screen & enroll options Use of information from tax returns allowed

21. What else about ELE? Federal match - 90% systems development/75% operational costs Addresses data sharing/confidentiality Evaluation of effectiveness and administrative cost/savings Sunset in September 2013 Additional federal guidance expected

22. The Performance Bonus “Price of Admission” States must implement at least 5 out of 8 “enrollment and retention provisions” Must be in place throughout the entire fiscal year Must be applied to both Medicaid and CHIP (except premium assistance)

23. Questions For 2009 only, can the 5 of 8 provisions be counted if not in place for full year If state legislation is required? What criteria will CMS use to determine if a provision is met? Meaningful yet realistic ? Shows progress over time ?

24. The Eight Enrollment and Retention Provisions (1, 2, 3) 12-month continuous eligibility Required for children of all ages? “Liberalization” of asset test No asset test, or Administration verification of assets No in-person interview (face-to-face) required

25. The Eight Enrollment and Retention Provisions (4, 5) Use of common forms and uniform processes for Medicaid and CHIP Joint application, renewal, supplemental forms, and Same “information verification process” Automatic renewal (administrative renewal) State sends pre-printed form, eligibility is renewed unless changes reported by applicant (required) Ex parte satisfies requirement

26. The Eight Enrollment and Renewal Provisions (6,7,8) Presumptive eligibility for children Express lane eligibility Premium assistance subsidies

27. Does Your State Have Five of Eight? B I N G O!

28. For more information Contact information: Donna Cohen Ross cohenross@cbpp.org 202-408-1080 Tricia Brooks pab62@georgetown.edu 202-365-9148