Partner Spotlight: How Continuous Eligibility Could Reduce Churn

By Guest Blogger

This blog was written by Meg Murray and Kathy Kuhmerker, CEO and VP for Medicaid Policy, respectively, at the Association for Community Affiliated Plans (ACAP). ACAP is a member of Enroll America’s Advisory Council.

In 2014, the Affordable Care Act will expand Medicaid eligibility and bring coverage to more than 15 million people who don’t have it today, which is a real step forward on many levels. But challenges await the newly eligible. The most elementary step is the first one: signing up. Enroll America and its partners will be actively engaged in a public education campaign to raise awareness so people can connect to coverage they are eligible to receive.

But staying covered is a bigger challenge than you might think. Every year, millions of people who are eligible for Medicaid fall off the rolls, but not because they move to another state or find a good-paying job. They fall off the rolls for purely administrative reasons. Some can’t take time off work to go to a local Medicaid office to re-verify their income—which some states require every three months. Others move to a different address, forget to provide the needed paperwork, and “get lost” in the system. They are then summarily removed from the Medicaid rolls despite their underlying eligibility. They will likely re-enroll in Medicaid when the time comes to receive medical services, creating unnecessary administrative costs. This is known as “churning.”

Churning has a pervasive negative impact on health for low-income Americans. It stymies the efforts of plans serving Medicaid populations to provide consistent, coordinated care and to measure the quality of care delivered by the physicians in their network. Worst of all, churning interrupts care for many people and forces them to go to an emergency department rather than their primary care doctor because they don’t have the coverage they thought they did.

People with private insurance don’t have this problem because private coverage is typically available for a whole year, and enrollees don’t need to do anything to keep their coverage. As we look to 2014, we see an opportunity to cut some of the red tape out of the Medicaid eligibility process so that people can enroll and stay enrolled for an entire year. This will help ensure that the newly enrolled can rely on their coverage being there when they need it.

We already know that conditions are ripe for churning to continue in 2014 among those who are newly eligible for coverage. Research shows that up to half of the 28 million adults with incomes less than twice the poverty level (an annual income of $22,340 for an individual or $38,180 for a family of three) will have income fluctuations that will require them to switch between Medicaid and coverage offered through health insurance exchanges in a given year. This shift in eligibility may trigger a sudden change in plans and provider networks, which can have serious repercussions for the enrollee’s financial and health status.

One effective way to avoid this bouncing back and forth is by guaranteeing 12 months of continuous eligibility to everyone with Medicaid. With continuous eligibility, once you are determined eligible, you are enrolled for a full 12 months, regardless of changes in income. At the end of those 12 months, your eligibility is re-evaluated. This is similar to how private insurance and Medicare work. Right now, states have the option to guarantee continuous eligibility for children, but only some states have acted; 23 states have taken up this option for Medicaid, and 30 have done so separately for their Children’s Health Insurance Programs (CHIP). More than 17 million children on Medicaid and 30 million adults remain unprotected. There is currently legislation in Congress that would require continuous eligibility for children in Medicaid and CHIP. And although continuous eligibility is limited to children’s coverage for now, the streamlined eligibility process in the Affordable Care Act calls for 12-month eligibility periods for adults in Medicaid, with the requirement to report any income changes throughout the year. This is at least an incremental improvement over many current policies, which require re-certifications (and sometimes in-person interviews) every few months.

Health reform will open the door to health coverage to tens of millions of Americans. Getting them in the door is crucial, but it’s only the first step. Ensuring uninterrupted access to high-quality care through 12 months of continuous eligibility is the best way to make sure that door doesn’t revolve and leave people out in the cold without coverage.


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