Nearly 42 million children — roughly half of all children in the United States — get their health care through Medicaid or the Children’s Health Insurance Program (CHIP). These programs have been vital sources of coverage for kids during the COVID-19 pandemic. With a provision of the Families First Coronavirus Response Act requiring states to keep Medicaid enrollees insured throughout the public health emergency, approximately 7.3 million more children gained Medicaid/CHIP coverage in the first three years of the pandemic. But with the provision ending on March 31, 2023, states are now in the process of redetermining the eligibility of their entire Medicaid populations.
Redeterminations put millions of children at significant risk of losing their Medicaid coverage despite remaining eligible. Early data from a handful of states show high rates of “procedural disenrollments,” occurring when beneficiaries don’t complete renewal paperwork by the due date. Completing paperwork on time can be challenging for many reasons: some beneficiaries don’t receive their forms because the state doesn’t have their current mailing address; some struggle to gather the required information by the due date; and others have difficulty navigating notices that are sometimes unclear or unavailable in their preferred language.
Children are at particularly high risk of being disenrolled for procedural reasons; without action, an estimated 5.3 million could lose access to much-needed coverage in the coming months. States can take several steps to protect them now and in the long term:
- Maximize the use of existing data sources to complete redeterminations. One of the most effective ways states can protect coverage is by trying to confirm eligibility through existing data sources, like state quarterly wage data, before requesting additional information from beneficiaries. While states are required to attempt this process, known as ex parte renewals, for all beneficiaries to qualify for enhanced federal funding, many don’t have the infrastructure to do so successfully. Recognizing these challenges, the Centers for Medicare and Medicaid Services is allowing states to adopt new waiver flexibilities that can improve ex parte renewal rates, such as using Supplemental Nutrition Assistance Program (SNAP) eligibility. States also can implement express lane eligibility, a similar but underutilized policy option that simplifies Medicaid/CHIP enrollment and renewal processes for children by using eligibility from other public programs like SNAP, Head Start, and the National School Lunch Program.
Example: Tennessee has adopted several 1902(e)(14)(A) waivers allowing them to renew all beneficiaries based on SNAP and TANF eligibility during the unwinding. - Invest in outreach and messaging tailored to families with children. Across all states, Medicaid income eligibility is higher for children than it is for adults, often by a significant amount. When states send renewal paperwork to families, it is critical they communicate that children might still qualify for Medicaid even if adults in the household are no longer eligible. Otherwise, parents and caregivers who know they are no longer eligible may assume the same applies to children in their household and fail to complete their renewal paperwork. States also can use renewal notices to highlight that adults and children no longer eligible for Medicaid may qualify for no- or low-premium coverage in the marketplace. States can partner with schools, Head Start programs, childcare centers, summer camps, and other community groups to ensure that families receive these messages.
Example: Ohio’s Department of Medicaid created a communications toolkit for partners that includes outreach materials with messaging about how children may still be eligible even if parents no longer qualify for coverage. - Allow more time to review the eligibility of families with children. States have flexibility over how they spread out the work of redetermining their Medicaid population’s eligibility. Some states are first redetermining eligibility for beneficiaries that have already been flagged as likely ineligible while delaying redeterminations for other population groups. To mitigate unnecessary coverage losses among kids, states can delay redetermining eligibility for households with children until later in the process, which gives states more time to communicate with and prepare families.
Example: Rhode Island is delaying redeterminations of families with children until December 2023. Oklahoma is categorizing certain beneficiaries as “high risk” and will deprioritize them for redeterminations so that their renewals are conducted later in the unwinding period. Families with children under 5 years of age (among other population groups) are included in the high-risk category. - Ensure families and providers know how to reinstate Medicaid coverage for children that are disenrolled but remain eligible. As a condition of enhanced federal funding, states must have a Medicaid “reconsideration period” of at least 90 days for parents and most children. This allows procedurally disenrolled beneficiaries to have their coverage reinstated without having to complete a new application if they submit missing paperwork to the state within 90 days. However, beneficiaries may not be aware of this. States can make sure people know how to reenroll by including plain language information about the reconsideration period in renewal paperwork and other communications. States also can take advantage of new waiver options to allow certain providers and community organizations, like pharmacists and pediatricians, to help reenroll kids who lose coverage but are likely still eligible.
Example: Washington, D.C., Medicaid includes messaging about the 90-day reconsideration period on their “How to Renew Your Medical Coverage” webpage. - Implement 12-month continuous coverage requirements for children as soon as possible and consider longer time frames. The 2023 Consolidated Appropriations Act requires all states to adopt 12 months of continuous eligibility for children with Medicaid/CHIP by January 1, 2024. This policy, which many states have already adopted, will ensure that kids with Medicaid/CHIP have stable access to coverage for a full year. However, as of January 2023, 17 states and the District of Columbia had not yet adopted continuous coverage, putting children in these states at higher risk of losing coverage. Implementing continuous coverage as soon as possible, rather than waiting until January 2024, is an easy way for these states to help children stay covered. As a longer-term strategy, states also can expand continuous coverage for longer than 12 months by applying for a Section 1115 waiver.
Example: Through a recently approved 1115 waiver, Oregon will implement continuous coverage for children in Medicaid/CHIP from birth through their sixth birthday. Beneficiaries ages six and older will have two years of continuous coverage.
Though early redetermination data should be interpreted with caution, stakeholders and policymakers can monitor state reports, where available, to get a picture of how redeterminations are impacting children’s access to care. Before the pandemic, children regularly experienced gaps in their Medicaid/CHIP coverage — known as “churn” — leading to negative health impacts and high out-of-pocket costs for families. Emergency provisions over the past three years worked to safeguard vulnerable children, but as Medicaid programs return to normal operations, policymakers may need to utilize the tools at their disposal to prevent the potential reversal of pandemic-era coverage gains.
