Policy Priorities

Policy Priorities image of kids

The System for Health Coverage Must Be Simple and Seamless

State bureaucratic barriers—like the requirement for frequent renewal of health coverage—prevent many eligible children from getting and keeping health coverage through Medicaid and the Children's Health Insurance Program (CHIP). Such barriers have been shown to actually increase costs by requiring major administrative procedures. In order for health reform not to be a hollow promise for millions of children, it must ensure they get enrolled and stay enrolled.

Automatic enrollment is one of the most effective ways to enroll eligible children in health coverage and has been extremely successful in other programs.(1)  In the Medicare Part B program, 96 percent of eligible seniors obtained coverage thanks to an auto-enrollment procedure, compared to only 33 percent of eligible seniors in Medicare Savings Programs, which require seniors to apply independently.(2)  Since nearly 86 percent of uninsured children are currently in other need-based programs like the National School Lunch program, the Women, Infants, and Children (WIC) program and Food Stamps, the majority of children eligible but not enrolled could be automatically enrolled in health coverage using data from these programs alone.(3)

Another barrier many states employ is frequent renewals. Failure to implement policies that allow children to be continuously eligible for coverage has contributed to “churning,” where children lose coverage and sometimes regain it over a short period. Some parents have a hard time maintaining coverage for their children because of misunderstandings about eligibility requirements, confusion about the annual recertification process, or because they were never informed of their child's disenrollment.(4) Churning increases administrative costs and leads to frequent, unnecessary, and harmful coverage gaps for children.(5)

Substantial evidence from states has shown that real health coverage for children requires the health system to be simple and seamless to the user, with a streamlined application and enrollment process to make it easy to get and stay enrolled. Currently, 36 states operate joint Medicaid/CHIP application processes,(6) however, some states have implemented strict enrollment procedures to limit the number of eligible children who apply for or obtain coverage, in an attempt to control program costs.(7)  Barriers to enrollment and retention must be eliminated by requiring states to institute:

  • Short, simple application forms.
  • Automatic enrollment in which, unless a parent/guardian declines enrollment, children who are identified as income eligible by their participation in other means-tested programs (including the National School Lunch Program, food stamps, WIC or the Earned Income Tax Credit (EITC)) are automatically enrolled for health coverage. Additionally, child health coverage status should be evaluated at critical life junctures, such as birth, school enrollment and health care visits so uninsured children can be enrolled.
  • Presumptive eligibility at the point of service for uninsured children until an application is processed, rather than delaying the start of coverage until eligibility is confirmed.
  • 12-month continuous enrollment with automatic renewal, regardless of temporary family income changes, like a parent receiving additional overtime pay or increasing their hours. Additionally, children's coverage at the end of 12 months should be automatically renewed unless changes in eligibility are reported.
  • Elimination of resource and asset tests.
  • Self-declaration of income allowing states to verify a family’s income electronically (when possible) rather than requiring the family to provide proof of income.
  • Culturally and linguistically competent outreach to inform families of benefits for which they are eligible and to promote their children’s enrollment.
  • Multiple methods for parents to submit applications (e.g., by mail, through the Internet).
  • Prohibition of waiting lists, enrollment caps or other measures to delay or limit enrollment.

States recognize the benefits of these simplifications. As of September 2009, 48 states do not require a face-to-face interview when children apply for coverage, 46 states do not require an asset test for enrollment, 20 states have adopted 12-month continuous eligibility, and 11 states have adopted presumptive eligibility.(8)

Despite facing severe state budget deficits this year, 23 states have worked to increase the number of children and families receiving coverage through Medicaid and CHIP.(9)  Specifically, 11 states (including six that also expanded eligibility levels) improved enrollment and renewal procedures, illustrating how creating a simple system to get and keep children enrolled is a high priority of states.(9)

Find out what your state is doing to make enrollment in health coverage simpler and more seamless for children.


1) Remler, D., Glied, S., “What Other Programs Can Teach Us: Increasing Participation in Health Insurance Programs,” American Journal of Public Health, 93(1), January 2003.

2) Dorn, S., Kenney, G., “Automatically Enrolling Eligible Children and Families into Medicaid and SCHIP: Opportunities, Obstacles, and Options for Federal Policymakers,” The Commonwealth Fund, June 2006.

3) The Lewin Group, "Analysis of Selected Amendments to the American Affordable Health Choices Act of 2009 (H.R. 3200)," August 2009.

4) Georgetown University Center for Children and Families, "Reducing Enrollee Churning in Medicaid, Child Health Plus, and Family Health Plus: Findings from Eight Focus Groups with Recently Disenrolled Individuals," February 2009.

5) Ross, DC., et al., “Health Coverage for Children and Families in Medicaid and SCHIP: State Efforts Face New Hurdles. A 50 State Update on Eligibility Rules, Enrollment, Renewal Procedures, and Cost-Sharing Practices in Medicaid and SCHIP in 2008,” Kaiser Commission on Medicaid and the Uninsured, January 2008.

6) Georgetown University Center for Children and Families, “Medicaid/CHIP Enrollment Procedures for Children,” July 2009.

7) For an example, see: Fairbrother, G., Schuchter, J., “Stability and Churning in Medi-Cal and Healthy Families,” Child Policy Research Center, Cincinnati Children’s Hospital Medical Center, March 2008.

8) Georgetown University Center for Children and Families, "Medicaid and CHIP Programs by State: A Snapshot," September 2009. 

9) Georgetown University Center for Children and Families, “Weathering the Storm: States Move Forward on Child and Family Health Coverage Despite Tough Economic Climate,” September 2009.