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'Eligibility Equals Enrollment' the New Paradigm at Medicaid, CHIP, Mann Says

By John Reichard, CQ HealthBeat Editor

September 24, 2010 -- Federal officials are pushing now to increase Medicaid enrollment, rather than waiting for when eligibility sharply expands four years from now, the top Medicaid official told a new congressional advisory panel Friday.

Cindy Mann, director of the Center for Medicaid at the Centers for Medicare and Medicaid Services, said there has long been a mindset that there will always be a big "eligible but unenrolled" population for Medicaid and the Children's Health Insurance Program (CHIP). But the "new paradigm" at CMS is that "eligibility equals enrollment," she said.

Mann spoke at the second day of the inaugural public meeting of the new Medicaid and CHIP Payment and Access Commission, known as MACPAC.

The mantra among federal CMS officials is that "2014 is Now!" Mann said, referring to the date Medicaid eligibility expands under the health care overhaul law (PL 111-148, PL 111-152) to include uninsured people with yearly incomes up to 133 percent of the federal poverty level.

Even as federal workers prepare for that date, they are mounting an aggressive "Connecting Kids to Coverage" campaign targeting uninsured youngsters now eligible for Medicaid or CHIP but not actually enrolled, Mann said.

"Sometimes people think, 'They keep working on eligible but unenrolled, it must be that it can't be accomplished,' and in fact, it can be accomplished," she said. New census data shows a drop in the uninsured rate for low-income children because of Medicaid and CHIP, even though the rate rose in society as a whole, Mann said. "It is no accident that that's happened. . . . it shows we can and have made concerted progress."

Historically, one of the obstacles to enrolling low-income Americans in federal programs is that those who are eligible don't know it. For their part, government workers aren't sure how best to find them in order to let them know.

But Mann said "we know there are roughly 4.7 million of those eligible but unenrolled children, and we know more precisely than we have before where they are residing. . . . It's rare that everybody stands up and says, 'You know, if you're eligible, you have to be enrolled, you ought to be enrolled. It is our job to get you enrolled. That's really a new paradigm shift."

Mann said cost control and quality improvement goals for Medicaid and CHIP can't be met "unless we not only get everybody enrolled, but they are enrolled all year continuously in the right program without gaps in coverage, without churning. Only then can we really focus on making sure that access is there, that the quality of care is strong, and that our cost containment goals are able to be met."

Efficient enrollment in the programs also will require marrying the enrollment and renewal process with that of the state health insurance exchanges. Those exchanges will begin operating in 2014 as Americans seek coverage and subsidies to fulfill the legal mandate that everyone have insurance, Mann said.

Some people who come to the exchanges to find coverage options and see if they are eligible for subsidies may learn that they are qualified for Medicaid or their children for CHIP. That could become another way to enroll people in those programs.

Or, maybe in trying to sign up for Medicaid they will find they make too much money to qualify, but that they can get subsidies through the exchange. All of that suggests the need for close coordination between Medicaid, CHIP and the exchanges.

Mann also sees enrollment coming through the Web portal that opened up earlier this year,, which points Americans to coverage options. People can now get a general idea of whether they or their kids are eligible for Medicaid or CHIP in a state. Further refinements will be made to let them know for sure and ultimately to give them the ability to enroll in the programs, she said.

Mann touched on a variety of other issues in her presentation, including the need for research on problems with access to care in the programs, and the use of various measures to assure quality of care.

Commissioners listened with interest, but the enrollment issue can be a touchy one. Republicans under the George W. Bush administration tightened eligibility criteria for uninsured children in Medicaid and CHIP. And MACPAC itself may draw fire from the right depending on how it handles the issue.

Earlier this year, Senate GOP staffer Rodney Whitlock said MACPAC will be valuable if it pinpoints how payments can improve access — but not if it focuses primarily on better outreach to increase enrollment in a broken system that states can ill afford.

MACPAC's Vice Chairman David Sundwall told Mann at Friday's meeting that "it's all very interesting to me to see the energy and creativity that you have related to Medicaid." But, he said, "your enthusiasm is not shared by a lot of states. It is really difficult for us who are on the ground trying to balance budgets.

"I just hope you will factor in if you will the ambivalence that we might seem to be demonstrating or the challenges that we face whether they be budget or philosophical differences with the legislatures we work with," Sundwall said. "I see this mammoth energy and interest and intellect kind of churning to get this done, but I hope you also appreciate that there's some people and opposite forces at work making our lives difficult" at the state level.

"What we need to make sure we have the opportunity to do is have some thoughtful dialogue with people of different views or concerns, Mann responded. "For example, on the cost side there is no one more committed to reducing costs in our health care system and in Medicaid than Don Berwick," she said, referring to the new CMS administrator.

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