Key Implementation Issues: Retention and Churn

A significant challenge for states in 2014 and beyond is the projected movement of children and their families between being insured and uninsured, or across CHIP, Medicaid, and the marketplace. This movement or “churning” could cause disruptions in care that could be costly for children and their families, decrease the incentive for insurers to invest in an individual’s long-term health, and result in significant administrative burden for states. In addition, the risk of becoming uninsured is high—an Urban Institute analysis projects that 19.5 million people will churn between Medicaid and being ineligible for insurance. To minimize the harm and magnitude of churn, states may want to consider implementing strategies to improve coordination among programs and to streamline and simplify the renewal process for families. Some challenges and considerations for states include:

  • Using data from disenrollment and denial reason codes: This data can be used to identify reasons for procedural denials and to modify processes, materials, or policy to improve retention in one program or improve rates of seamless transfer to others.
  • Reducing the burden of renewal placed on Medicaid and CHIP families: States may choose to adopt options such as administrative or ex-parte renewal, express lane eligibility, or 12-month continuous eligibility, which may improve the consumer experience.
  • Aligning providers or plans across health coverage programs: States may choose to require or incentivize providers or plans to provide coverage across insurance affordability programs in order to promote continuity of care and coverage.
    • December 2012 FAQ from the Centers for Medicare and Medicaid Services gives states the option to offer a bridge plan—a Medicaid managed care plan certified as a QHP in the marketplace—to certain populations in order to promote continuity of coverage between Medicaid, CHIP, or the marketplace. Tennessee originally developed this option and in March 2013 California announced its intent to offer bridge plans in 2014.
    • Washington: To limit the impact of changes in a family’s income on continuity of care and coverage, the state’s Health Care Authority plans to allow QHPs in the marketplace to also participate in Medicaid managed care as a “limited Medicaid plan.” Medicaid and CHIP-eligible children would be able to enroll in this option and remain covered for the duration of their 12-month eligibility period, regardless of their parents’ coverage status.
    • How Exchanges Can Work with Medicaid Managed Care for Continuity of Coverage: This NASHP presentation discusses requirements for coordination between Medicaid, CHIP, and the marketplaces as well as options states have in the implementation of these requirements.
  • Using Medicaid premium assistance to minimize churning between Medicaid and being ineligible for all subsidized insurance options.
  • Implementing a Basic Health Plan (BHP) option: Although a BHP option would not directly impact children’s coverage, states that take up this option would be able to offer subsidized coverage to adults between 133 percent and 200 percent of the FPL, who otherwise would be eligible for the marketplace. Regulations pertaining to implementation of the BHP option will be released in 2013 and 2014, and the federal government expects that the first BHPs will be operational on January 1, 2015.

Additional State Resources

New: Washington Apple Health simplified renewal form: Washington’s Medicaid agency created a simplified, streamlined renewal form used by the state this past year (10/1/13 – 9/30/14) for MAGI Medicaid (family, children, pregnancy) households. The one-page form helped families understand and provide the information the state needed to continue their coverage. Other states may want to model their MAGI Medicaid renewal forms after this one.

New: The RIte Care Renewal Business Process Plan is a public health coverage renewal resource for stakeholders created by the Rhode Island Heath Coverage Project as part of their “Keep Families Covered” Campaign. The document outlines a plan that aims to engage health providers and human service agencies like WIC or Head Start to help keep children and families covered. The plan includes action steps and information to provide to families, including the RIte Care Renewal Flyer, which informs families about the different renewal pathways that are available to them and information about helplines.

New JerseyThis analysis examines how coordination and transitions between Medicaid, CHIP, employer-sponsored insurance, and the proposed marketplace could take shape in New Jersey while keeping a focus on continuity of care.

Washington: This brief examines churning in Washington State under three potential ACA implementation scenarios.

Other Resources

Beyond Enrollment: Ensuring Stable Coverage for Children in Medicaid and CHIP: This Community Catalyst report examines options for policymakers to reduce administrative requirements on families and help keep children and families from churning between programs.

Churning Under the ACA and State Policy Options for Mitigation: This Urban Institute analysis proposes state options for minimizing the harm caused by churning.