1. Center for Public Policy Prioritieswww.cppp.org 1 Texas House Committee on Government Reform Texas House Committee on Government Reform Recent Trends in Texas Children’s Medicaid and CHIP Coverage July 26, 2006 Anne Dunkelberg, Assistant Director 900 Lydia Street - Austin, Texas 78702 Phone (512) 320-0222 – fax (512) 320-0227 - www.cppp.org

2. Center for Public Policy Prioritieswww.cppp.org 2 Texas Medicaid: Who it Helps June 2006, HHSC data. Total enrolled 6/1/2006: 2,644,167

3. Center for Public Policy Prioritieswww.cppp.org 3 Income Caps for Texas Medicaid and CHIP, 2006 $22,078/yr $30,710/yr 185% 133% $16,600 100% $2,256$3,696 13.6%22.3% 74% $7,476 222% $21,708 $33,200 200% Income Limit as Percentage of Federal Poverty Income Annual Income is for a family of 3, except Individual Incomes shown for SSI and Long Term Care

4. Center for Public Policy Prioritieswww.cppp.org 4 Texas Child Medicaid and CHIP Enrollment (January 2002-June 2006) Source: Enrollment from Texas Health and Human Services Commission; Texas State Demographer's 0-17 Population Estimates

5. Center for Public Policy Prioritieswww.cppp.org 5 Texas Child Medicaid Enrollment (February 2001-June 2006) Source: All figures from Texas Health and Human Services Commission Simplified Enrollment begins High: 1,838,239

6. Center for Public Policy Prioritieswww.cppp.org 6 Texas CHIP Enrollment (May 2000-July 2006) Source: All figures from Texas Health and Human Services Commission; Compares most recent month with September 2003 Highest, 5/02: 529,271 9/03: 507,259 7/06: 298,731

7. Center for Public Policy Prioritieswww.cppp.org 7 ReCap: CHIP Decisions in the 79 th 2005: 79 th Legislature appropriated funds for enrollment to grow to over 351,000 in 2007, and Rider 57 HHSC (SB 1) requires agency to request more $$ for CHIP from LBB if needed for enrollment and benefits. BUT, even before recent contractor problems, CHIP enrollment growth did not materialize. Missing: outreach, marketing. These 2003 Changes Remain: –Coverage period reduced from 12 months to six. Language in law now makes this permanent, rather than planning for a return to 12 month coverage at a future date. –New coverage delayed for 90 days. –Income deductions eliminated (gross income determines eligibility). –Asset test (limit) added for those above 150% of the poverty line (took effect August 2004). –Outreach and marketing were reduced in 04-05.

8. Center for Public Policy Prioritieswww.cppp.org 8 CHIP Caseloads: Now and Projected 20062007 September 2003 actual caseload507,259 July 2006 actual caseload 298,731 decline, 9/03 to 7/06 (-41%)(-208,528) HHSC 2/05 enrollment projection, if 12-month eligibility restored 386,110467,404 HHSC 2/05 enrollment projection (6 month renewal) 360,786388,920 SB 1 funded caseload, traditional CHIP (6 month renewal)* 344,750351,132 Additional caseload, perinatal coverage 17,42547,498 Total, SB 1 projected CHIP caseload, traditional & perinatal CHIP 362,175398,630 *Rider 57 HHSC (SB 1) requires agency to request more $$ for CHIP from LBB if needed for enrollment and benefits.

9. Center for Public Policy Prioritieswww.cppp.org 9 CHIP Renewal Statistics: Transition Woes Late November 2005, CHIP eligibility & enrollment transitioned from original contractor (ACS) to new contractor (Accenture, AKA “TAA”). December 2005 TAA begins processing new applications for children’s health insurance (combined children’s Medicaid and CHIP) ; January 2006 HHSC also imposes new enrollment fee and renewal documentation policies. Same renewal (“program integrity”) policies had been in effect for Children’s Medicaid since 2003. –HHSC ended a policy know as “EZ” renewal, –Second, HHSC had novice private contractor employees perform “third- party data broker” checks on income and resource information Theory that policy changes more to blame than TAA implausible: –Children’s Medicaid did not decline when identical program integrity policies were implemented in 2003 (tho state did need to allow more time and staff to accommodate new procedures), –Original CHIP contractor did NOT have the poor renewal rates seen since January 2006. From May 2000 to January 2004, when premium payments were a routine part of CHIP, renewal rates averaged over 70%.

10. Center for Public Policy Prioritieswww.cppp.org 10 CHIP Renewal Statistics: Transition Challenges Problems widely reported by the most conscientious motivated parents with the sickest kids - NOT just deadbeats who can’t or won’t do their paperwork. Enrollment dropped by 24,167 from December 1 to July 1; May enrollment would have been lower by 27,768 if not for HHSC decision to extend deadlines for payment and missing information for that many children. –This delay avoided cutting a record nearly 50,000 children in a single month, and a renewal rate of only 23.5% (compared to a fiscal year 2005 average of 80%). CHIP renewal rates plummeted from about 83% per month to 50- 57% from January thru May, with high numbers terminated for failure to reply to renewal, missing information, and failure to pay the enrollment fee. June & July: signs of improvement with 76.5%, 73.4% renewal rates. July enrollment up by 5,300, but overall still below March 2006.

11. Center for Public Policy Prioritieswww.cppp.org 11 Children on Medicaid Drop Even More than CHIP Since creation of CHIP, there have been two ways for children to enter Texas Medicaid: 1.through the HHSC state-operated eligibility system, or 2.through the CHIP contractor ’ s “ joint application ” process Children’s Medicaid applications and renewals are processed by both the old eligibility system and the new contractor –Many new applications for CHIP and children’s Medicaid (and all CHIP renewals) go through the new contractor, –Other new applications for children’s Medicaid go through state eligibility offices, –Medicaid renewals are still processed at state eligibility offices. –Problems with both systems are contributing to the decline, and the higher rate of decline in Travis and Hays counties suggests that multiple issues are affecting enrollment. Statewide, the number of children insured by Medicaid dropped for four consecutive months from December to April.

12. Center for Public Policy Prioritieswww.cppp.org 12 Children on Medicaid Drop Even More than CHIP The magnitude of the drop is also unprecedented, with nearly 99,000 fewer children enrolled in April 2006 than in December 2005; fortunately, May enrollment was higher and June level, for a net loss of 79,080. Children ’ s Medicaid enrollment had grown steadily since CHIP outreach first began in 2000.  This is the only decline of more than 2 months since May 2000.  The largest 2-month combined decline since 2000 was 22,500. In contrast, the decline for December 2005 alone was over 29,000. Enrollment of children dropped 4.3% statewide from December 2005 to May 2006, and is not limited to any one part of the state. –However, Travis county enrollment has dropped at more than 3 times the state average (13.5%) and Hays almost 5 times (23%).  With the current set-backs in coverage, as of June 2006 Texas is covering over 98,000 fewer children in Medicaid and CHIP combined, compared to September 2003 (July Medicaid numbers not yet available).

13. Center for Public Policy Prioritieswww.cppp.org 13 Recent Declines in Texas Children’s Medicaid Enrollment December 2005 June 2006 Decline, December to June State total1,838,2391,759,159-79,080-4.3% Bexar139,682132,871-6,811-4.9% Cameron64,33964,083-256-0.4% Dallas182,954177,402-5,552-3.0% El Paso98,31994,078-4,241-4.3% Harris316,896299,266-17,630-5.6% Hays4,9534,038-915-18.5% Tarrant97,90894,916-2,992-3.1% Travis52,66744,762-7,905-15.0% Webb36,47332,735-3,738-10.2% Source: Texas Health and Human Services Commission

14. Center for Public Policy Prioritieswww.cppp.org 14 Recent Declines in Texas CHIP Enrollment December 2005 June 2006 Decline, December to June State total 322,898 293,342-29,556-9.2% Bexar 20,915 18,550-2,365-11.3% Cameron 7,814 8,0832693.4% Dallas 33,325 29,588-3,737-11.2% El Paso 13,628 11,758-1,870-13.7% Harris 65,465 56,583-8,882-13.6% Hays 1,489 1,329-160-10.7% Tarrant 19,754 19,172-582-2.9% Travis 8,550 7,782-768-9.0% Webb 5,279 5,251-28-0.5% Source: Texas Health and Human Services Commission

15. Center for Public Policy Prioritieswww.cppp.org 15 Adult Medicaid Trends Dec-05Jun-06Dec 05 to June 06 Change Aged and Disabled 687,177701,36214,1852.06% Cash Assistance 31,87624,979-6,897-21.64% Maternity93,61797,1613,5443.79% Other Parents 64,65660,445-4,211-6.51% Total877,326883,9476,6210.75% CAVEAT: Travis and Hays Medicaid enrollment DECLINED for every category of adult, including aged and disabled and maternity (6.5% Travis; 13.4% Hays) from December 2005 to June 2006. Points to problems with the IE&E pilot and TIERS

16. Center for Public Policy Prioritieswww.cppp.org 16 Problems Identified, Progress Made 4/5/06 HHSC announces 30-day review of problems, suspension of roll-out timeline pending results; 5/4/06 further indefinite delay announced. HHSC 5/4/06 Review –Many details about problems in training, computers, staffing. –Problems are identified both in the IE&E operations and on the CHIP side –A number of STEPS to address problems are also detailed, including revised state staffing changes –A very helpful document.

17. Center for Public Policy Prioritieswww.cppp.org 17 Child Advocates Call for Comprehensive Plan to Reverse Children’s Medicaid and CHIP Enrollment Declines Texas CHIP Coalition letter to HHSC Commissioner Hawkins (May 25, 2006) detailing steps needed to reverse the decline in CHIP and Children’s Medicaid enrollment. 1) Continue to extend deadlines 2) Establish adequate contractor and state staffing levels (restore processing times, correct training) 3) Identify and resolve computer system issues 4) Restructure the new procedures for verifying family income and assets to eliminate or minimize requests for additional documentation

18. Center for Public Policy Prioritieswww.cppp.org 18 Child Advocates Call for Comprehensive Plan to Reverse Children’s Medicaid and CHIP Enrollment Declines 5) Adopt policies to help families above 133% FPL with the new enrollment fees. 6) Reinvest in outreach and application assistance by Community-Based Organizations. 7) Build on the steps HHSC has already taken to reinvigorate an active partnership with providers, health plans, advocates, community-based organizations, and businesses to get eligible children enrolled and keep them on the rolls.

19. Center for Public Policy Prioritieswww.cppp.org 19 Child Advocates Call for Comprehensive Plan to Reverse Children’s Medicaid and CHIP Enrollment Declines TAA’s CHIP performance has serious implications for the contractor’s take-over of major responsibilities for Medicaid and Food Stamps under IE&E, potentially affecting more than 4 million Texans (thirteen times the size of the CHIP program) including children, the aged, and Texans with disabilities. The Coalition urged HHSC to make successful reversal of the problems with CHIP a prerequisite for any further roll-out of the IE&E model.

20. Center for Public Policy Prioritieswww.cppp.org 20 HHSC 6/13/06 Response to Texas CHIP Coalition Similar actions to 5/4/06 memo, plus some new CHIP/child Medicaid specifics: –Improve enrollment file accuracy (to health plans, CBOs) –Income counting errors –Review of correspondence, stakeholder input –Use of third-party data to verify income –Extending CHIP coverage to prevent gaps in transitions to Medicaid –Accept asset info via phone (missing info) –Additional 30 days to submit enrollment fee –Pursuing credit and debit card option –STUDY cash payment option (e.g., grocery) –REJECTED installment plan option

21. Center for Public Policy Prioritieswww.cppp.org 21 More Steps HHSC has taken to Address Enrollment Outreach and Marketing In 2002-2003, CBO outreach was funded at 6.1 million for CBO outreach, and $3.8 million for marketing ($9.9 million total). After 2003, HHSC ’ s CBO contracts were altered to eliminate outreach, marketing was nearly eliminated, and total spending cut in half. HHSC announced new $3 million marketing campaign (4/11/06) RFP released 7/6/06 for expanded CBO services: –calls for application assistance across all the IE&E-related programs: CHIP, Medicaid (not just kids), Food Stamps, and TANF –Budgeted at $3.5 million per year, though FY 2008 contingent on appropriations — could also be increased by Lege.

22. Center for Public Policy Prioritieswww.cppp.org 22 Where Things Stand Enrollment Trends: not enough information to call: Children ’ s Medicaid uptick in May, then nearly unchanged for June, still no July numbers CHIP uptick in July (w/improved renewal rates), but still below March. Too early to call a trend, but hopeful.

23. Center for Public Policy Prioritieswww.cppp.org 23 Top Concerns at this Point Problems have slowed but not ended. New cases who have been trying to enroll for 6+ months still surfacing. Latest stats available to us show “call abandonment” rates for IE&E and CHIP/Children’s Medicaid high, hold times still long, and TAA staff turnover still high. Multiple computer systems problems, including questions about viability of TIERS system, but also with the various TAA systems Computer system issues may be resolved over time, but must also address: Adequate numbers of trained state staff, and of physical locations to help those who need (or are required to access) in-person help. TAA model relies on low-paid unskilled workers. This may not be workable. Must focus on both the number and the level of staff. With Leadership and political will to make enrollment and renewal competent, fair, and simple, enrollment will grow. Texas knows how to run accurate and family-friendly enrollment systems.

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