Churning: Children’s Coverage Discontinuity and

Its Consequences in Kentucky

Julia F. Costich and Svetla SlavovaCollege of Public HealthUniversity of Kentucky

What we know about discontinuity in children’s coverage

• NY: half lost coverage in a year despite most remaining technically eligible (Lipson 2003)

• 12 states: less than half timely renewed (Hill 2003)

• 4 states: half lapsed at renewal but one-fourth back in 2 months (Dick 2002)

• 7 states: two-thirds of disenrolled ineligible for SCHIP (but Medicaid?) (Riley 2002)

• Kansas: procedural and computer problems often at fault (Allison 2003)

Kentucky Children’s Health Insurance Program (KCHIP)

• Medicaid expansion to 150% FPL• Look-alike to 200% FPL• Administered by Dept. for Medicaid

Services• Eligibility determination by same

agency as cash assistance, food stamps, etc.

• Enrollment stable at ~50,000 children• Compare Medicaid at ~321,000

KCHIP Policy Changes

• 1998: Mail-in application, in-person renewal• 7/1/2000: Mail-in renewal with pre-populated

form and self-declaration of income• 6/1/2001: Return to in-person interview for

renewal• 7/1/2002: Mailed renewal reinstated; return

to in-person interview for initial application• Confusion among caseworkers and families

Percentage of All Children Enrolled in KCHIP or Medicaid, SFY 2003Data source: Kentucky Dept. for Medicaid Services

Adair

Allen

Anderson

Ballard

Barren

Bath

Bell

Boone

Bourbon

Boyd

Boyle

Bracken

Breathitt

Breckinridge

Bullitt

Butler

Caldwell

Calloway

Campbell

Carlisle

Carrll

Carter

Casey

Christian

Clark

Clay

Clinton

Crittenden

Cumberland

Daviess

Edmonson

Elliott

Estill

Fayette

Fleming

Floyd

Franklin

Fulton

Gallatin

Garrard

Grant

Graves

Grayson

Green

Greenup

Hancock

Hardin

Harlan

Harrison

Hart

Henderson

Henry

Hickman

Hopkins

Jackson

Jefferson

JessamineJohnson

Kenton

Knott

Knox

Larue

Laurel

Lawrence

Lee

Leslie Letcher

Lewis

Lincoln

Livingston

Logan

LyonMccracken

Mccreary

Mclean

MadisonMagoffin

Marion

Marshall

Martin

Mason

Meade Menifee

Mercer

Metcalfe

Monroe

Montgomery

Morgan

Muhlenberg

Nelson

Nicholas

Ohio

Oldham

Owen

Owsley

Pendleton

Perry

Pike

Powell

Pulaski

Robertson

Rockcastle

Rowan

Russell

Scott

Shelby

Simpson

Spencer

Taylor

ToddTrigg

Trimble

Union

Warren

Washington

Wayne

Webster

Whitley

Wolfe

Woodford

Prepared by: Julia F. Costich, College of Public Health

Under 30%

30-39%

40-49%

50-59%

Over 60%

Fig. 1: KCHIP Enrollment May 2001-March 2004

45000

46000

47000

48000

49000

50000

51000

52000

53000

54000

55000

56000

May-01

Jun-01

Jul-01

Aug-01

Sep-01

Oct-01

Nov-01

Dec-01

Jan-02

Feb-02

Mar-02

Apr-02

May-02

Jun-02

Jul-02

Aug-02

Sep-02

Oct-02

Nov-02

Dec-02

Jan-03

Feb-03

Mar-03

Apr-03

May-03

Jun-03

Jul-03

Aug-03

Sep-03

Oct-03

Nov-03

Dec-03

Jan-04

Feb-04

Mar-04

End of mail-in application

Premiums

Recertif ication policy changes

Fig. 2: Combined KCHIP and Children's Medicaid Enrollment, May 2001-March 2004

310000

320000

330000

340000

350000

360000

370000

380000

May-01

Jun-01

Jul-01

Aug-01

Sep-01

Oct-01

Nov-01

Dec-01

Jan-02

Feb-02

Mar-02

Apr-02

May-02

Jun-02

Jul-02

Aug-02

Sep-02

Oct-02

Nov-02

Dec-02

Jan-03

Feb-03

Mar-03

Apr-03

May-03

Jun-03

Jul-03

Aug-03

Sep-03

Oct-03

Nov-03

Dec-03

Jan-04

Feb-04

Mar-04

Problems with added eligibility office workload

Source: Family Resource & Youth Service Center Staff Survey

• Long waits in understaffed urban offices• Refusal to provide scheduled appointments• Overloaded phone system; unanswered voice mails• Unexpected requests for additional documentation• Inappropriate denial based on confusion• Staff reporting suspect immigration status• Failure or inability to accommodate working

families’ schedules

Churning effect

• 46% did not renew on time• New applications were 52% of total enrollment• Yet total enrollment grew by only 4%• Millions of wasted state dollars• Risk of gaps in coverage• Wide variation across the state• Timely renewal highest in Medicaid expansion

Data sources

• Open records request to Medicaid for data by county, month and program– “Requires” staff to provide data

• Data limitations– Not individual-level– “New” applications may be internal to system when renewal

deadline is missed by staff

• 3 categories– Number of children up for renewal– Number timely renewed– Number of new applications approved

Methodology• Percentage of all children (Census data)

enrolled in KCHIP or Medicaid– Critically important to include both because of

frequent movement between programs– Failure to account for movement overstates

churning

• Percentage of children eligible for renewal in either program who renewed on time

• New applications approved as percentage of total enrollment

Percentage of Children Enrolled and Percentage of Timely Renewals (R2

= .44)

New Approvals as Percentage of Total and Percentage of Timely Renewals (R2

= .55)

Methodology and statistical findings

• SAS univariate regression analysis• F test found p < .0001 for relationships

between – renewal and enrollment– new applications and non-renewal

• R2 = .44 and .55 respectively

Discussion

• Low rate of timely renewal similar to other studies’ findings

• Identified need for pre-termination contact, follow-up– Problem: hiring freezes, state budget deficit

• Next steps: – Determine whether supportive environment of

high-renewal counties can be replicated with outreach workers, volunteers

– Advocate for more realistic federal budget allocations

Limitations

• Inability to track individual children• Considerable migration among programs• Eligibility determination office practice

giving rise to spurious new applications• Possible delinking issues in information

systems• Antiquated eligibility determination system

may introduce errors