Child Health

Cover Letters: CDF-TX testifies on the importance of continuous coverage for kids on Medicaid

February 8, 2019 | Texas

By Vinit Shah

CDF – Texas Deputy Director, Dr. Laura Guerra-Cardus, testified before the Senate Finance Committee on Wednesday on the need to support children’s healthcare coverage. Ensuring that children in Medicaid have access to continued, guaranteed coverage for 12 months is critical for reducing the high rates of children who are uninsured in Texas.

Currently, Texas only provides 6 months of continued coverage for children enrolled in Medicaid. In the latter half of the year, families must undergo monthly income checks in months 5, 6, 7, and 8, and begin the process of renewing Medicaid for the next year. The hodgepodge of paperwork required to meet these income checks makes the current process confusing, costly, and time-consuming for families trying to provide basic health care for their children, and effectively causes children to fall on and off coverage. Texas’s monthly income checks particularly affect children in families with fluctuating incomes. In 2013, for example, roughly 1 in 3 children living in a state without 12 months of continuous coverage experienced a change in family income that affected their eligibility for Medicaid, CHIP, or premium tax credits under the Affordable Care Act. This lapse in coverage can create additional burdens for families who are already unable to afford health insurance. Children who go without coverage, for example, are more likely to delay seeking necessary medical care, and families that don’t have continuous coverage for their children generate higher medical costs in the long run than families that do.

Take the case of the Cantu family, referenced in Guerra-Cardus’s testimony below. Last year, the family was asked to submit income verifying information. The family complied, but two months later, found that their child no longer had health insurance. Apparently, the family had mistaken the income checks for the Medicaid renewal process -which asks for the same information – that takes place at the end of the year, and therefore did not submit information to renew their child’s Medicaid.

Having health care coverage in childhood has been linked to better academic, health, and economic outcomes in later life, yet Texas continues to neglect coverage for our children, as we are home to one-fifth of the nation’s uninsured children, a third of whom are eligible for Medicaid but are not enrolled. Texas must begin prioritizing the health and well-being of our children by reducing barriers to enrolling in Medicaid, and that starts with passing 12 months of continuous Medicaid coverage for children.

Fortunately, there are currently two bills in the Texas House that would solve this problem: HB 342, filed by Rep. Philip Cortez of San Antonio, and HB 829, filed by Rep. Toni Rose of Dallas. Contact your local representative and urge them to support either one of these two bills. You can also read our full testimony to the Senate Finance Committee below for information on Medicaid continuous coverage.




Children’s Defense Fund – Texas

Testimony to the Senate Finance Committee

February 6, 2019

Laura Guerra-Cardus, M.D., Deputy Director Children’s Defense Fund – Texas

In Texas, we believe that all children should have access to health care. That is why our state has made wise investments in Children’s Medicaid and CHIP, which together with employer-sponsored coverage and the ACA marketplace provide an affordable coverage option for nearly every child in our great state. However, due to flaws in implementation and ongoing accessibility issues, today Texas remains the state with the largest number and rate of uninsured children in the country. At an uninsured rate of 10.7%, Texas doubles the national average. More concerning, our already unacceptable numbers actually worsened in 2017, as our child uninsured rate increased for the first time in ten years. Today, one in five uninsured children in the country lives in Texas. (Of our 835,000 uninsured children, just over 460,000 of them are in families in the Medicaid and CHIP income range, and 350,000 of them are eligible, but not enrolled.[1] )

The good news is that we can take simple steps to help reverse this trend. Allowing children in Medicaid stay covered for a year at a time – just like most children in CHIP and like most of us here today, would be the single most effective step we can take to reduce the number of uninsured children.

Currently our state gives children one six month period of continuous coverage followed by an onerous series of monthly income checks. CDF-Texas helps families apply for children’s health coverage through Medicaid and CHIP in Houston, the Valley and in East Texas. Since these periodic income checks were instituted, we have seen significant confusion among families who have to navigate an overly complicated process. The result has been eligible children losing coverage, with an increased need for time-consuming one-on-one assistance to correct errors and help families get their children back into care.


Some of the top issues we have seen in the field include:

  • Confusion about renewals vs. periodic income checks (PICs).

The Cantu family got a letter asking them to verify their income. Ms. Cantu submitted all necessary pay stubs, only to be told by her pediatrician during a sick visit two month later that her child was no longer covered. Apparently Ms. Cantu had complied with HHSC’s request for information during her periodic income check but had failed to recognize that the request that came in shortly after – which asked for the same information – was a separate one regarding her child’s renewal.

  • Delayed receipt of letters and inadequate time to provide verifying information.

We frequently assist families who get letters days before (and even after) their deadline to submit verifying information. Even if received a few days before the deadline, families often have to get paperwork from employers, find a way to scan or fax information, all of which cannot always be done in a few days’ time. This results in eligible children falling on and off coverage and is expensive for HHSC as they have to process numerous applications for the same child.

  • Eligibility system error

Families have complicated lives, income verification databases have inherent flaws and our eligibility system is complicated. Despite the agencies best efforts, human error is inevitable. We have had a case where a family was asked to have documented proof that they no longer worked for a company that they had, in fact, never worked for.

  • Impossible situations for families with fluctuating incomes.

Many Texas families who have contract or seasonal jobs – for example fishing boats, tourism, oil rigs, etc. – have fluctuating incomes, which can create an impossible situation for children in real need of health care. We are currently working with a family whose son was diagnosed with a blood cancer. Depending on which month their income is being checked, the family has to make hard decisions about not taking a job, working fewer hours, or simply getting into medical debt because they cannot afford to lose even a month of healthcare coverage for their child.

The implementation of PIC in 2013 essentially increased the number of times children can fall through the cracks from once a year to up to five times a year – per child. As some of you may know, some families also do not have their children aligned for the same eligibility and renewal period, complicating the situation even further. Keeping children enrolled in Medicaid has become a full-time job for some parents and caretakers, simply because of the burdensome and ceaseless paperwork requirements.

Ensuring children on Medicaid can stay covered for a 12 month continuous period is not only a best practice in reducing our child uninsured rate, but it has cost benefits as well.

  • When children go without coverage, they seek care in more expensive emergency-room settings. When children are re-enrolled, Medicaid must retroactively pay for this more expensive care. Prior analysis of emergency services comparing continuously covered children and those with gaps in coverage shows that children with coverage gaps have both more ER visits per month and higher ER payments per month of enrollment.
  • When children stay on a single plan for a longer period of time, the cost of care is significantly reduced. Research has shown that average monthly Medicaid costs for children steadily decline over time; in 2010, by a child’s 10th month of coverage, costs were down 27 percent compared to the first month of coverage.
  • The primary way to achieve long term healthcare savings is by improving the quality of care. However, quality based payment initiatives are hindered when children are unable to maintain a stable medical home and relationship with a provider.
  • Children going on and off of the Medicaid rolls require additional unnecessary eligibility determinations. Continuous coverage would reduce administrative costs to the state, Medicaid Managed Care health plans, and physicians.
  • At a time when our state is most interested in assessing the quality of care in our Managed Care plans, our state is unable to fully measure the quality of healthcare without continuous coverage. In most circumstances, a minimum of 12 month continuous coverage is required to compute most health care performance indicators. This means that children who are enrolled for fewer than 12 months are excluded when performance measurement rates are calculated. When we look at quality data in Medicaid Managed Care we are not getting the full picture.

At the end of the day it’s really about how much we value children and their wellbeing. We believe that everyone in this rooms wants Texas children to be able to thrive and they can’t do that when they lack access to basic healthcare coverage. This is a simple streamlining process so that children can go see a doctor.

In closing, it is also important to remember that research shows that when parents have coverage, children also do better. We want to express our strong support for reducing our state’s uninsured by ensuring families at all income levels have access to affordable health care coverage. Texas is now one of only 14 states who has not brought home their federal tax dollars to create a coverage solution for their citizens. This becomes more important to everyone as our state faces a fiscal cliff in 2022 when our 1115 Medicaid waiver expires. We also strongly support HHSC’s ECI exceptional item request. Children have only one childhood and the lack of access to developmental supports has both human and financial repercussions throughout a child’s life.

[1] U.S. Census Bureau, 2008-2017 American Community Survey 1-year estimates, Texas children 0-17 by race and ethnicity.