Policy Priorities

Policy Priorities image of kids

Glossary

Roughly 43.5 million children in lower-income families get health coverage through Medicaid and the Children’s Health Insurance Program (CHIP). Unfortunately, a family’s ability to obtain coverage and services for their children through these programs largely depends on where the family lives and what enrollment procedures are in place. The fact that approximately two-thirds of uninsured children are already eligible for Medicaid or CHIP but are not enrolled, indicates a serious failure to make it simple for families to both enroll in and retain coverage for their children.

Simplification Procedures:

12-month Continuous Eligibility — In states that have adopted this important procedure, children enrolled in CHIP and Medicaid are guaranteed coverage, without interruption, for 12 months, regardless of changes in their family’s financial circumstances. In other words, if one parent gets a cost of living increase that puts the family’s income just over the limit, the family has until the end of the year to find a new, affordable health plan for their children. Continuous coverage ensures that children are not suddenly dropped from coverage, thus preventing harmful disruptions.

Express-lane Eligibility – In states that have implemented this method of enrollment, Medicaid and SCHIP eligibility and renewal are determined based on data from other need-based programs, such as the National School Lunch Program (NSLP), Food Stamps, and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).   

Joint Application — In states with a joint application, parents fill out the same form whether their child is eligible for Medicaid or CHIP. This is important because often parents might not know which program their children qualify for. In fact, in one household, a child under age five could be eligible for Medicaid while an older sibling is only eligible for CHIP. So rather than completing an application for Medicaid, getting rejected, and having to reapply for CHIP coverage, with a joint application, it automatically goes to the appropriate office, reducing the burden on the parents and preventing children from slipping through the cracks created by two programs.

Medicaid Expansion — When CHIP was created in 1997, states had the option to create separate CHIP programs or expand their Medicaid program to include CHIP. In the Medicaid expansion programs, there is one income eligibility threshold, which reduces confusion, and all children are eligible for all medically necessary benefits, known as Early Periodic Screening, Diagnosis, and Treatment or EPSDT. Other states have substantial flexibility in designing their benefit packages in CHIP, and many of these do not include coverage for all medically necessary services. Consequently, some children with CHIP coverage may be underinsured.

Presumptive Eligibility — Presumptive eligibility is temporary coverage so that a child can receive medical care while the application is officially processed. Presumptive eligibility is granted by specific state-authorized groups, such as health care providers and schools. In other words, a sick child can be seen by a doctor and the fees will be the same as if the child had CHIP or Medicaid. Additionally, because parents are enrolling at health clinics or schools, they receive community assistance and support with the application forms and required documentation.

Administrative Verification of Income — In states with administrative verification, families do not have to provide verification of income to prove eligibility. These states typically verify income information by accessing data from other government agencies.

Barriers:

Asset Test — In states that require an asset test, a parent enrolling a child in Medicaid or CHIP has to provide proof of income and submit to an examination of their other resources, like cars and savings accounts. Most families applying for Medicaid and CHIP lack substantial assets, so the asset test is just one more unnecessary bureaucratic hurdle that discourages eligible families from applying or successfully enrolling their children.

Face-to-Face Interview — In three states, a family must go to the Medicaid office for an in-person interview to apply for coverage. Face-to-face interviews are often difficult for families to schedule without having to take time off work, putting working parents at a significant disadvantage and often jeopardizing successful enrollment of their child in the programs. In Mississippi, for example, two-thirds of counties do not have a Medicaid office, so families have to travel to another county for the interview.

Waiting Period — In some states, children are required to be uninsured for one, three, or six months before they can apply for Medicaid or CHIP coverage. States impose waiting periods to discourage parents from dropping private health care coverage for public coverage. For children, however, going without coverage for a few months can be an enormous disruption – preventing them from accessing timely care and receiving well-child check-ups on schedule.

Other Terms:

Blended states — States are able to use their CHIP funds to expand children’s health coverage by expanding their Medicaid program, covering children through a separate program, or using a combination of the two approaches. States that use a combination approach are called “blended states.” In some states that use a combination approach, children at the lower end of the income range of eligibility are enrolled under the expansion of Medicaid, while children at the upper end of the range are enrolled in the separate program under SCHIP. Using a different approach, other states cover children below a certain age under the Medicaid expansion and older children under the separate program.1

Medicaid expansion states — States are able to use their CHIP funds to expand children’s health coverage by expanding their Medicaid program, covering children through a separate program, or using a combination of the two approaches. States that use all their CHIP funds to expand Medicaid are called “Medicaid expansion states.” There are currently 13 Medicaid expansion states plus the District of Columbia.

Premium — The amount paid, often on a monthly basis, for health insurance. The cost of the premium may be shared between employers or government purchasers and individuals.

Co-payments — A fixed dollar amount paid by an individual at the time of receiving a covered health care service from a participating provider. The required fee varies by the service provided and by the health plan.

Out of pocket costs — Health care costs, such as deductibles, co-payments, or premiums that are not covered by insurance. Out-of-pocket costs do not include premium costs.

Last updated 2009


1. Congressional Budget Office. “The State Children’s Health Insurance Program.” May 2007. http://www.cbo.gov/ftpdocs/80xx/doc8092/05-10-SCHIP.pdf. Accessed November 5, 2009.