As states unwind the continuous coverage requirement that was in place during the COVID-19 public health emergency (PHE), there has been concern that children will lose Medicaid or Children’s Health Insurance Program (CHIP) coverage during the renewal process.1 Even in normal times, many children lose their Medicaid or CHIP coverage, despite remaining eligible, as a result of paperwork requirements, lost mail, and confusing notices and forms. After experiencing a gap in coverage, children often return to coverage months later. Before the PHE, about 8 percent of children on Medicaid and CHIP churned off and back on coverage within a given year. Rates of churn are higher for children than adults, and greatest for children of color. To address this issue, Congress has taken steps to promote continuous enrollment in Medicaid and CHIP; a growing number of states are adopting additional protections.
Why Consider Continuous Enrollment?
Continuous enrollment (CE) in Medicaid and CHIP ensures stable coverage for a prescribed period, without requiring additional paperwork and regardless of fluctuations in family circumstances, with the goal of promoting consistent access to needed care. This can help all Medicaid enrollees, but especially young children, given the importance of preventive services and timely interventions for children and throughout a person’s life. Research also shows that “churning” on and off insurance disproportionately affects people of color. During the PHE continuous enrollment period, Oregon found that its historically persistent coverage gap between Black and white residents narrowed substantially, from 3 percentage points to 1.6 percentage points.2
Federal law has long offered states the option to provide 12 months of CE for children in Medicaid and CHIP; about half the states have elected the option. Looking for more consistency in stabilizing coverage, Congress recently turned the state option into a federal requirement. Effective, January 1, 2024, 12-month CE will be in place for all children enrolled in Medicaid and CHIP. In April 2020, Congress provided states the option to provide continuous Medicaid coverage to birthing people for 12 months postpartum, as opposed to the standard policy of 60 days. To date, 41 states have adopted the 12-month policy.
As described below, several states are going beyond these statutory requirements and options by seeking Section 1115 waiver authority to provide additional continuous enrollment protections for Medicaid and CHIP enrollees, particularly for children. To date, the Biden administration has been receptive to these requests, which are aligned with its coverage, access, and equity goals.
State Initiatives to Advance Continuous Enrollment
State CE waiver policies and proposals vary in terms of the duration of coverage and the populations they protect. Some examples include:
- Oregon and Washington were the first states to gain approval from the Centers for Medicare and Medicaid Services (CMS) to provide continuous enrollment for children in Medicaid and CHIP until age 6. New Mexico and North Carolina currently have similar waiver proposals pending with CMS. Hawaii’s and Pennsylvania’s waivers are at an earlier stage, seeking public comments from state stakeholders. In states with these approvals, children will be assured of continuous coverage and uninterrupted health care throughout their preschool years.
- Legislation to implement multiyear CE for children up to age 6 (or younger, in some states) has been enacted in Colorado, Minnesota, and Ohio; California passed legislation, subject to appropriation, and legislation is pending in several other states, including Maryland and New York, as well as in Washington, D.C.
- States are also seeking to extend multiyear CE to older children and to targeted groups of children and adults. In addition to multiyear CE for preschoolers, Oregon’s approved waiver provides two years of CE to everyone older than age 6; Hawaii’s proposal includes two years of CE to older children. Arizona has an 1115 waiver pending with CMS to provide coverage to former foster youth ages 18 to 26, and Massachusetts has an approved waiver to provide 24 months of coverage to children and adults who are homeless.
Federal policy does not permit 1115 waivers to increase federal costs and requires states to offset costs through other waiver policies or by using savings banked from previous waivers. But CMS has determined that waiver-authorized CE does not require an offset or savings. This is because the policy largely protects individuals who are already eligible from losing coverage. CE does not expand eligibility; it ends the churn among eligible children and other individuals.3
What Comes Next
As states implement new CE policies for children and pregnant women pursuant to federal legislative changes, momentum for more expansive CE policies is building. Medicaid coverage for children has been shown to lead to better health, including a reduction in hospitalizations and emergency room visits, higher educational attainment, and higher earnings in adulthood. The impact of providing multiyear CE for young children — particularly if combined with other reforms in the delivery of children’s care — can be a game-changer for children, improving well-being, outcomes, and equity.
