Continuous eligibility (CE) guarantees at least one year of uninterrupted Medicaid or Children's Health Insurance Program (CHIP) coverage regardless of income changes.
Low-income children, including those with genetic disorders, who have complex or chronic medical needs have increased access to preventive and specialty care with CE.
CE reduces state administrative costs, increases access to preventative care, and reduces healthcare expenditures on emergency room visits and hospital stays.
What are the impacts of continuous eligibility for children with genetic disorders?
Continuous eligibility (CE) guarantees at least one year of uninterrupted health insurance coverage from the date of enrollment in a healthcare plan with disability or income eligibility requirements (Center for Medicare & Medicaid Services (CMS) 2023). Beginning in 2024, children under 19 years old who qualify for Medicaid or the Children’s Health Insurance Program (CHIP) are guaranteed a minimum one-year period of coverage each time they enroll (42 CFR 435.926). Under the Consolidated Appropriations Act of 2023, a state cannot terminate a child's coverage during each one-year CE period unless the eligibility was approved by mistake, the child turns 19, moves out of state, voluntarily disenrolls, or dies (CMS 2023).
Children are eligible for Medicaid and CHIP if their households are below a set income threshold, if they are disabled, and they do not have other health insurance (U.S. DHSS n.d.). Prior to 2024, if these circumstances changed and they became ineligible, or if caregivers missed administrative deadlines to renew coverage, children would be immediately unenrolled and would need to re-enroll if they became eligible again. Often, children lost coverage because of issues with paperwork, rather than actual ineligibility (Burak 2024, Riley et al. 2002). This process of unenrollment followed shortly by re-enrollment is known as churn (Corallo et al. 2021).
CE has reduced unenrollment and churn for children on Medicaid (Williams et al. 2022). However, churn rates increase in the period following the initial year of coverage, resulting in temporary coverage loss. To reduce the number of eligible but uninsured children, some states have implemented multi-year CE (Burak 2024, Williams et al. 2022, Figure 1). Multi-year CE provides continuous, uninterrupted insurance coverage from the point of enrollment up to age six (CMS 2023). In some states, multi-year CE also includes 2 years of continuous coverage from the time of each enrollment for children between 6-19 years of age. Rather than re-enrolling each year, eligible children can re-enroll once every two years.
Disruptions in health insurance coverage can delay access to care (Brooks & Gardner 2021). Children with CE have more consistent access to medical care an preventative services, fewer gaps in care especially during key developmental stages, and access to specialty services for complex or chronic conditions (Brantly & Ku 2022). Consistent access to healthcare also results in reduced hospitalizations, lower numbers of emergency room visits for preventable conditions, greater school readiness and on-time graduation rates, a reduction in chronic conditions, and overall improved health outcomes throughout adulthood (Boudreaux et al. 2016, Cohodes et al. 2016, Groves 2019, Miller & Wherry 2019).
Children with genetic disorders do not automatically qualify for Medicaid or CHIP (see Science Note MO HealthNet Coverage of Genetic Disorders). However, some children with genetic disorders who are low-income or high need may qualify. CE provides unbroken access to specialty care, which is particularly critical for children with chronic or complex medical needs, such as some genetic disorders (Brantly & Ku 2022).
Churn of insurance coverage increases administrative costs to the state and families (Brooks & Gardner 2021, Fairbrother et al. 2004). In 2015, Medicaid patient churn cost the program $400 to $600 per person, while average program expenditures per child were $3,141 (Swartz et al. 2015, U.S. HHS 2015). Prior to national CE, between 5%-15% of children on Medicaid or CHIP experienced churn in a given year (Corallo et al. 2021, MACPAC 2021, Williams et al. 2022). During this period, states with CE policies had lower churn rates (2%-13%). In MO, where an average of 71,000 children were eligible for CHIP or Medicaid in 2015, a churn rate of 10% would cost the state approximately $3.55 million in administrative expenditures, or 2% of its Medicaid and CHIP operating budget that year (MO Department of Social Services 2015).
Fewer emergency room visits and decreased hospitalizations also reduce overall healthcare costs (Bindman et al. 2008a, Bindman et al. 2008b). Continued coverage minimizes disruptions in care and provides consistent access to prescription medication. Particularly for children with chronic conditions, such as genetic disorders, these outcomes reduce the likelihood of emergency or hospital service use, and reduce costs for treating acute episodes (Ku et al. 2015).
Figure 1. States that have implemented multi-year continuous eligibility (CE). All states require one year of CE for children under the age of 19 who qualify for Medicare or CHIP. CO offers CE from birth until age three; MN, NM, NY, PA, and WA provide CE from birth until age six. Following those age limits, enrollees in these states are entitled to annual one-year CE until they turn 19. HI, NC and OR have CE from birth to age six, and provide two-year CE while children remain eligible. Figure made with Mapchart.
References
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