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TexasTexas House Committee on House Committee on Government ReformGovernment Reform

Recent Trends in Texas Children’s Medicaid and CHIP Coverage

July 26, 2006Anne Dunkelberg, Assistant Director

900 Lydia Street - Austin, Texas 78702Phone (512) 320-0222 – fax (512) 320-0227 - www.cppp.org


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Texas Medicaid: Who it Helps

Children, 1,759,159

Disabled, 340,388

Elderly, 360,974

Poor Parents, 60,445

TANF Parent, 24,979

Maternity, 97,161

June 2006, HHSC data.

Total enrolled 6/1/2006: 2,644,167


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Income Caps for Texas Medicaid and CHIP, 2006

0%

50%

100%

150%

200%

250%

PregnantWomen

Newborns Age 1-6 Age 6-18 TANFparent of

2, noincome

WorkingParent of

2

SSI (agedor

disabled)

LongTermCare

CHIP

Mandatory Optional

$22,078/yr

$30,710/yr $30,710/yr

185% 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 IncomeAnnual Income is for a family of 3,

except Individual Incomes shown for SSI and Long Term Care


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Texas Child Medicaid and CHIP Enrollment (January 2002-June 2006)

1,600,000

1,700,000

1,800,000

1,900,000

2,000,000

2,100,000

2,200,000

Jan-0

2

May

-02

Sep-0

2

Jan-0

3

May

-03

Sep-0

3

Jan-0

4

May

-04

Sep-0

4

Jan-0

5

May

-05

Sep-0

5

Jan-0

6

May

-06

Ch

ildre

n E

nro

lled

5,800,000

5,850,000

5,900,000

5,950,000

6,000,000

6,050,000

6,100,000

6,150,000

6,200,000

6,250,000

6,300,000

Ch

ild P

op

ula

tio

n

Source: Enrollment from Texas Health and Human Services Commission; Texas State Demographer's 0-17 Population

Estimates


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Texas Child Medicaid Enrollment(February 2001-June 2006)

now:

1,759,159

1,000,000

1,100,000

1,200,000

1,300,000

1,400,000

1,500,000

1,600,000

1,700,000

1,800,000

1,900,000

Feb-01

May

-01

Aug-01

Nov-01

Feb-02

May

-02

Aug-02

Nov-02

Feb-03

May

-03

Aug-03

Nov-03

Feb-04

May

-04

Aug-04

Nov-05

Feb-05

May

-05

Aug-05

Nov-05

Feb-06

May

-06

Source: All figures from Texas Health and Human Services Commission

Simplified Enrollment begins High:

1,838,239


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Texas CHIP Enrollment(May 2000-July 2006)

0

100,000

200,000

300,000

400,000

500,000

600,000

May

-00

Sep-00

Jan-01

May

-01

Sep-01

Jan-02

May

-02

Sep-02

Jan-03

May

-03

Sep-03

Jan-04

May

-04

Sep-04

Jan-05

May

-05

Sep-05

Jan-06

May

-06

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


7ReCap: CHIP Decisions in the 79th

• 2005: 79th 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.


8CHIP Caseloads: Now and Projected

2006 2007

September 2003 actual caseload

507,259

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

386,110 467,404

HHSC 2/05 enrollment projection (6 month renewal)

360,786 388,920

SB 1 funded caseload, traditional CHIP (6 month renewal)*

344,750 351,132

Additional caseload, perinatal coverage

17,425 47,498

Total, SB 1 projected CHIP caseload, traditional & perinatal CHIP

362,175 398,630

*Rider 57 HHSC (SB 1) requires agency to request more $$ for CHIP from LBB if needed for enrollment and benefits.


9CHIP 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%.


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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.


11Children 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.


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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).


13Recent Declines in Texas Children’s Medicaid Enrollment

December 2005

June 2006

Decline, December to June

State total 1,838,239

1,759,159 -79,080 -4.3%

Bexar 139,682 132,871 -6,811 -4.9%

Cameron 64,339 64,083 -256 -0.4%

Dallas 182,954 177,402 -5,552 -3.0%

El Paso 98,319 94,078 -4,241 -4.3%

Harris 316,896 299,266 -17,630 -5.6%

Hays 4,953 4,038 -915 -18.5%

Tarrant 97,908 94,916 -2,992 -3.1%

Travis 52,667 44,762 -7,905 -15.0%

Webb 36,473 32,735 -3,738 -10.2%

Source: Texas Health and Human Services Commission


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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 8,083 269 3.4%

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


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Adult Medicaid TrendsDec-05 Jun-06 Dec 05 to

June 06Change

Aged and Disabled

687,177 701,362 14,185 2.06%

Cash Assistance

31,876 24,979 -6,897 -21.64%

Maternity 93,617 97,161 3,544 3.79%

Other Parents

64,656 60,445 -4,211 -6.51%

Total 877,326 883,947 6,621 0.75%

•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


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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.


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Child Advocates Call for Comprehensive Plan to Reverse Children’s Medicaid and

CHIP Enrollment DeclinesTexas 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


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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.


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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.


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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


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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.


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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.


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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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for use in making public presentations.

If you reproduce these slides, please give appropriate credit to CPPP.

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