federal spending bill – Coverage continues for kids in Medicaid, CHIP

Missouri will be required to provide year-long, continuous coverage for anyone under age 19 enrolled in Medicaid or the Children's Health Insurance Program, as part of a $1.7 trillion spending package expected to be approved by Congress this week.

In a move advocates have long pushed for as a way to avoid unnecessarily forcing children off the rolls, all states will be required to continue public health insurance coverage for one year after a child is enrolled — regardless of whether their family's income fluctuates.

Missouri is one of 17 states that does not already offer any 12-month continuous eligibility for kids.

That means temporary changes in household monthly income, which are particularly common among people who work hourly jobs with unpredictable schedules, can result in the state stripping children of Medicaid or CHIP eligibility, according to Georgetown University's Center for Children and Families. States generally conduct Medicaid renewals annually, but in the meantime, can redetermine eligibility based on changes in circumstances.

Research has found disruptions in health coverage pose health and financial risks to families. Cost barriers can cause families to avoid routine care and incur medical debt if an emergency occurs. More years of childhood Medicaid coverage are associated with fewer hospitalizations in adulthood, and states with continuous coverage policies have fewer children who cycle on and off Medicaid within 12 months, a Kaiser Family Foundation study found this month.

"We couldn't be more thrilled," said Casey Hanson, director of outreach and engagement for Kids Win Missouri, a coalition of state organizations that advocate for child well-being, about the federal bill.

Kids Win has been pushing for state legislation to provide continuous coverage for children for the last several years. A bill introduced last year that included continuous coverage for kids, sponsored by Democratic state Sen. Lauren Arthur of Kansas City, was voted out of committee but did not proceed further.

Hanson said Kids Win planned to prioritize the issue again, but "it's great when it happens federally."

"When kids have continuous access to coverage," Hanson said, "they're better able to get access to preventative care, to maintain chronic conditions and other things like asthma that we know so many kids in Missouri are affected by."

With the passage of the federal bill, Kids Win will be able to "be even more laser-focused" on other policies, such as ensuring children maintain coverage through the unwinding of the federal public health emergency, which has prohibited states from removing Medicaid enrollees from their rolls over the course of the COVID-19 pandemic but is set to expire next year.

The federal continuous coverage requirement would take effect Jan. 1, 2024.

Procedural barriers to renewal

Roughly half of the 1.4 million Missourians enrolled in Medicaid are children, according to Washington University in St. Louis's Medicaid enrollment dashboard. In years past, the state has come under scrutiny for erroneously removing kids from their Medicaid rolls, which advocates hope the continuous coverage provision may mitigate.

In 2019, Missouri's social service department faced criticism for significant Medicaid enrollment declines, including among children, after they adopted a new renewal process and information system.

Research that year by the Missouri Budget Project, a liberal public policy think tank, found families were often kicked off Medicaid despite being eligible for coverage because of challenges with the renewal process, including not receiving the proper paperwork or submitting the paperwork only for it to be lost or not processed.

Over the course of federally-declared public health emergency, states have been barred from removing Medicaid recipients from their rolls in exchange for receiving enhanced federal funding.

Some worry that once the public health emergency ends, Missouri could return to a situation in which the renewal process strips eligible Medicaid recipients of coverage due to administrative barriers. The rate of uninsured children in Missouri declined from 2019 to 2021, a Georgetown study found earlier this month, in large part because the state was barred from making eligibility redeterminations.

In both years covered by the Georgetown study, Missouri had a higher prevalence of uninsured children than the national average.

Missouri was previously identified as one of six states where children are at the highest risk of losing coverage once assessments resume, in part because it lacks continuous coverage.

The federal continuous coverage policy for children would likely go into effect months after states begin redeterminations, wrote Joan Alker, executive director of Georgetown's Center for Children and Families, but will still "mitigate against red tape losses," in which children lose coverage due to procedural reasons.

The federal bill set a date, for the first time, of when states will be allowed to begin reassessing Medicaid eligibility, regardless of when the federal emergency ends: April 1, 2023.

Republican leaders, including Missouri Gov. Mike Parson, have long been pushing for a clear end date from the federal government. Parson signed a letter earlier this week urging President Joe Biden to allow the public health emergency to expire in April, citing swelling numbers of Medicaid recipients and rising costs.

The enhanced federal funds will be gradually phased down over the next calendar year, with several standards states must meet in the process of conducting eligibility redeterminations, according to provisions in the bill.

Heather Dolce, a spokeswoman for the Missouri Department of Social Services, said in an email to The Independent that the agency has been working with the federal Centers for Medicare & Medicaid Services "to develop and finalize a robust plan for resuming Medicaid eligibility renewals in preparation for the impending unwinding," and that Missouri "would be prepared to move forward with implementing this plan" if the unwind begins in April, as expected, based on the federal bill.

Unlike most states, Missouri has not yet publicly provided its plan for the public health emergency unwind or a plan summary, according to Georgetown's unwinding tracker.

Dolce said DSS is focused on ensuring they have the correct addresses for Medicaid recipients, and urged participants to report their updated information.