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Maintaining Coverage for Children: Retention Strategies


Strategies

When developing retention strategies, it is important to acknowledge that there is a decade of work in states that has yielded much information about how to improve retention rates. In fact, most successful retention practices are within a state's discretion and in use somewhere; some of these are detailed below.

To view renewal procedures by state see: Renewal Procedures in Medicaid & SCHIP for Children (PDF). Information on other state program procedures are available at Facts and Statistics.

Strategy 1. Establish a Routine and Standardized Measurement and Retention Goal
All states collect enrollment data, but not all collect data that provide a clear picture of enrollment dynamics. At a minimum, it is important to know how many people are entering and exiting a program each month. Other vital measures include renewal rates and the reasons for case closings at the point of renewal.

In addition, administrative data do not always capture families' perceptions of the reasons for the renewal failure. For example, a state may find a high number of children are disenrolled because on non-payment of premium. There are many reasons why a family may not pay a premium, including that the family found coverage someplace else and did not pay as a way of disenrolling from the program. However, nonpayment could also be due to a family not being able to afford the premium or not receiving a notice in time. Family surveys can help complete this picture.

Once the data are better understood, establishing a retention goal can help guide strategies. In fact, states that do not routinely measure and track their drop-off and renewal rates have greater instability in their coverage. 1 While some children lose coverage for unavoidable reasons, states can focus on preventing children from losing coverage for avoidable or procedural reasons. It is possible and realistic to set high standards; for example, through a number of simplification measures, Louisiana has been able to decrease its procedural closure rate to less than 2 percent among children in its Medicaid program. (See Louisiana Close-Up.)

Strategy 2. Make it Easier for Families to Enroll and Stay in the Program

Adopt 12-month continuous eligibility or lengthen the renewal period. To promote continuity of coverage and care, states have the option under Medicaid and SCHIP to enroll children for periods of up to 12 months. The continuous eligibility period allows a child to remain enrolled regardless of changes in income, which tend to be relatively inconsequential. Most importantly, it ensures a family need not submit unnecessary paperwork to retain coverage and guarantees a set period of coverage. This in turn ensures continuity of care and that children do not lose coverage due to small fluctuations in income. Continuous eligibility also limits costly "churning" and makes it easier to attract managed care plans to participate. If continuous eligibility is not possible in a state, another option is implementing a 12-month renewal period, in which a family renews yearly but if their income or circumstances change they must report that to the state.

Simplify the renewal process. There are a number of measures a state can take to ensure that the renewal process is fair, accurate, and family-friendly. As much as possible, the goal should be to minimize any unnecessary burden on families seeking to maintain their children's health insurance. This approach can include:
  • Complying with federal rules that require states to establish ex parte procedures at renewal. The most effective approach is for a state to conduct ex parte reviews of the information already available prior to sending the renewal form to families, limiting what must be requested from families.
  • If applicable, creating a simple and single renewal form for both Medicaid and a separate SCHIP program. The form should not require unnecessary or duplicative information. One way to simplify the form is to pre-populate it with information already on record for the family. That way a family only needs to update information that has changed since enrollment.
  • Eliminating unnecessary documentation. States have discretion in requiring families to provide documentation of income or other eligibility requirements if the state cannot verify the information through other means. Using this discretion at the point of renewal is a cost-effective and streamlined way to ensure eligible children remain enrolled. At a minimum, a state should eliminate the asset test for families, which requires extensive paperwork.
Make premiums easier to pay. A number of states have found that non-payment of premiums can be a primary reason families lose SCHIP coverage. Requiring families to submit premium payments every month puts them at risk for losing coverage. A state can rectify this by ensuring their premiums are affordable for families and implementing streamlined payment procedures. These payment procedures include allowing for premium grace periods and a range of payment options and/or mechanisms, like payroll deductions, to facilitate collections. 2

Conduct outreach and education to families. In addition to administrative simplifications, it is important to ensure that families have the assistance they need to renew coverage. Most outreach focuses on enrolling new participants. Yet misperceptions about on-going eligibility and how to renew are common. Participating families may need regular follow-up to stay enrolled. 3 It is also important to provide accessible, culturally appropriate renewal assistance in the community.

A simple increase in the number of follow-up calls to families can have a significant impact on retention. For example, California's SCHIP (Healthy Families) increased its reminder calls to families from three to five and ensured those calls where made at varying times of day and different days in the week, including Saturday. State officials report that these changes, in combination with simplifications to its forms and letters, increased the state's SCHIP retention rate by seven percent from 2003 to 2004, with the gains holding steady in subsequent years.

State Examples:
  • Ex parte review in Louisiana. In 2000, Louisiana Medicaid staff began to verify eligibility and renew coverage by using a range of external data sources. Beginning with citizenship, household, and residency data, the sources were expanded to include child support and age data, and then information from other public programs such as TANF, Food Stamps, and SSI. These ex parte renewals are now utilized for a majority of its Medicaid children, and procedural closures at renewal have dropped to less than 2 percent statewide. (See Louisiana Close-Up.)
  • Reminders and telephone renewal in Arkansas. To reduce drop-off from unreturned re-enrollment forms, Arkansas outreach workers call families. If they do not reach families directly, a special number is left for them to call. This designated call-back number is answered immediately, and renewal is completed with just five questions (changes in household, income, child care, insurance, and doctor). (See www.aradvocates.org.)
  • Community-based express renewal in Massachusetts. A pilot program in Massachusetts allowed families, whose circumstances had not changed since their last determination and were within 30 to 180 days of their next scheduled renewal, to renew coverage during appointments at community-based health clinics. Completion of a one-page form and a quick certification of family and income status led to renewal for a full 12 months. Initial results showed that 42 percent of the "Express Renewal" applications had coverage extended. Those that did not result in an extension lacked available information on renewal dates and/or did not fit the Express Renewal requirements. Ultimately the statewide implementation of the program could not be supported by the state's existing automated systems, which the state is currently revising. 4 (See www.hcfama.org.)

Strategy 3. Use Linkages and Technology to Streamline the Renewal Process

Implement rolling renewals. Some states coordinate the renewal for insurance programs with other public programs to increase the likelihood that families will successfully renew coverage, a one-stop-shopping approach. For example, a family renewing its food stamp benefits can be given the opportunity to simultaneously renew their health coverage even if it is not yet due for renewal. Once done, the family has secured health coverage for another year. These so-called "rolling" renewals are designed to give families a convenient way to renew their insurance even before their next regularly scheduled renewal period. This process has been used in Idaho, Illinois, South Dakota, New York, Washington, and Wisconsin.

Automatically enroll children transferring between Medicaid and a separate SCHIP program. A child no longer eligible for Medicaid or a separate SCHIP program because of income should have their case automatically reviewed for eligibility in the other program and automatically enrolled when eligible. This goes beyond providing simple referrals; instead the process should be seamless and automatic for families.

Use new technologies to speed-up renewal. Technology offers the ability for states to truly create simplified renewal systems. Technology systems will allow: online processing and e-signatures for renewal applications; sharing of data across agencies that are serving the same families; gathering of information from existing primary data records (e.g., social security); and automatic updates for public health coverage files. 5

State Examples
  • Rolling Renewals in Washington. Washington's data system automatically transmits new information given for food stamp and TANF recertifications into Medicaid files. Renewal periods for the programs are coordinated, so Medicaid can be automatically renewed. The system updates records, calculates eligibility, and sets a new 12-month continuous eligibility period without any labor by program staff. 6 (See www.whf.org.)
  • Automated Renewals in Pennsylvania. Pennsylvania's multi-program application, called COMPASS, allows families to renew coverage at any time of day, from anywhere. As part of a larger system that keeps client information records across programs, those reenrolling can simply confirm rather than reenter data and there is no need to re-obtain stable information like citizenship status. COMPASS users "e-sign" their renewal applications, a process federally approved for Medicaid and SCHIP. 7 (See Pennsylvania Close-Up.)

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Resources

Footnotes


1. L. Summer & C. Mann, "Instability of Public Health Insurance Coverage For Children And Their Families: Causes, Consequences, and Remedies," Georgetown University Health Policy Institute, (June 2006).; and Southern Institute on Children and Families, "Covering Kids And Families: Promising Practices From The Nation's Single Largest Effort To Insure Eligible Children And Adults Through Public Health Coverage," (April 2007). Back

2. See: L. Ku & V. Wachino, "The Effect of Increased Cost Sharing in Medicaid: A Summary of Research Findings," Center on Budget and Policy Priorities (July 7, 2005). Back

3. T. Riley, C. Pernice, M. Perry, & S. Kannel, "Why Eligible Children Lose or Leave SCHlP: Findings From A Comprehensive Study Of Retention And Disenrollment," National Academy for State Health Policy and Lake Snell Perry & Associates, (February 2002). Back

4. D. Cohen Ross, A. Horn, & C. Marks, "Health Coverage for Children and Families in Medicaid and SCHIP: State Efforts Face New Hurdles: A 50-State Update on Eligibility Rules, Enrollment and Renewal Procedures, and Cost-Sharing Practices in Medicaid and SCHIP in 2008," Kaiser Commission on Medicaid and the Uninsured, (January 2008). Back

5. B. Morrow & D. Horner, "Harnessing Technology to Improve Medicaid and SCHIP Enrollment and Retention Practices," The Children's Partnership and The Kaiser Commission on Medicaid and the Uninsured, (May 2007). Back

6. ibid. Back

7. Office of Management and Budget, Memorandum for the Heads of Departments and Agencies, M-00-10, "OMB Procedures and Guidance on Implementing the Government Paperwork Elimination Act," April 25, 2000. Back


Table of Contents

Summary

Background

Legislative Authority

Strategies

Resources


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