Churning remains a long-term issue

Interruptions in Medicaid coverage, widely known as “churn,” cause gaps in care for members as well as substantial administrative burdens for all stakeholders. And the Affordable Care Act (ACA) doesn’t solve the problem.

Medicaid health plans have been concerned about the issue of churning since the Medicaid program began, says Margaret A. Murray, CEO of the Association for Community Affiliated Plans (ACAP) and an editorial advisor for Managed Healthcare Executive. ACAP is a national association representing 58 not-for-profit safety-net health plans.

“It’s not a simple as it should be to keep people on Medicaid,” Murray says. “Sometimes people go to the pharmacy, and they think they’re covered, but they’re not. And then they can’t get their asthma medication and their maintenance drugs.”

Losing coverage

According to ACAP, enrollment in Medicaid-unlike private insurance or Medicare-is like a sieve: Every year millions of people enroll, only to subsequently lose their coverage for a variety of reasons. Those who lose coverage often find their way back into the system, and then churn out of it again.

Even with the exchange marketplaces directing individuals and families to Medicaid when they qualify:

• Administrative and technical problems can delay or halt the Medicaid enrollment process when a member does not have information or fails to complete the application correctly.

• Short-term enrollment periods require frequent re-enrollment that members might not be aware of.

• Temporary changes in income can cause individuals or families to lose eligibility for Medicaid and experience a gap in coverage while they seek new coverage or default to being uninsured.

Gaps in coverage can span from several months to years. The average person who qualifies for Medicaid is only covered and has use of benefits for 9.7 months of the year, Murray says. For a non-disabled adult, it’s only 8.7 months of the year.

“Texas is most egregious state in that way,” she says. “An eligible adult in Texas is only on Medicaid for half of the year-well below the national average.”

Children fare better, however. About half the country has state laws that guarantee 12-month continuous coverage for children, and they have an enrollment continuity of 82%, meaning the population has continuous enrollment for an average of 82% of a full year.

Murray says ACAP would like to see a requirement for all states to keep adults and children enrolled in Medicaid for a continuous 12 months at a time.

At the federal level, an April 2013 bipartisan bill sponsored by Reps. Gene Green and Joe Barton of Texas would require 12-month continuous enrollment guarantees for all Medicaid beneficiaries to reduce churn in the population. Murray says 19 representatives have sponsored the bill in the House and Senate introduction is expected soon.

Churning into exchanges

While ACA aims to drive healthcare coverage for all Americans through increased Medicaid eligibility and financial assistance in the commercial market for those who don’t qualify, churning still occurs between coverage situations.

“Now we’re concerned because people’s income might change, and they’ll no longer be eligible for Medicaid, so they’d go to the exchanges and be eligible for subsidies,” Murray says.

She says a significant number of individuals will be crossing the Medicaid/exchange line multiple times a year. A 2011 study in Health Affairs estimates that within a six-month period more than 35% of all adults with family incomes below 200% of the Federal Poverty Level will either lose Medicaid coverage and transition into the Marketplace, or vice versa.

Murray says having the same plans in Medicaid and in the exchanges could help ensure continuity of care for members. For example, members that stay with the same health plan, even though they might be moving from Medicaid coverage to commercial coverage, could maintain their preferred doctors and stay on their care regimens, she says.

“We did a study that showed of all the health plans that are in an exchange, 41% are also in Medicaid,” Murray says.

ACAP’s study found 117 of 287 Qualified Health Plans in the federal and state-based exchanges operate managed-care Medicaid plans in the same state. In fact, 16 of ACAP’s member plans are participating in the exchanges, she says.

While the benefits of such overlap need more exploration, the organization believes participation by managed care plans in Medicaid and the exchanges can reduce churn and it’s associated costs.

Cost savings

Research proves there are cost savings associated with continuous Medicaid enrollment.

A George Washington University report released by ACAP late last year, “The Continuity of Medicaid Coverage: An Update” used new data to calculate the average monthly costs for Medicaid enrollees. It found that the average monthly cost to the Medicaid program is $345 for adults enrolled in Medicaid for 12 months of the year, compared with $597 for those who are enrolled for just one month-a difference of more than 40%.

Researchers found significantly lower costs for children who are continuously enrolled, with an average monthly cost of $110 for children enrolled in Medicaid for 12 months of the year, versus monthly costs of $151 for those enrolled for just one month, a difference of more than 25%.

Additionally, there are long-term consequences to consider. Churn also interferes with efforts to measure outcomes. Most quality measures such as those used by the National Committee on Quality Assurance require continuous enrollment for 12 months for a patient’s data to count toward a specific quality measure. Full-year enrollment would provide for more stable measurement and help health plans, providers and policymakers leverage the data to improve the quality of care delivered to beneficiaries.

Better quality leads to reduced costs as well.

Smooth the transition

In the meantime, plans are launching unique programs to help smooth the transition for members who might experience churn. For example, AmeriHealth Caritas offers high-touch services to help its Medicaid members re-enroll as required.

“We have a couple of units that focus on those members whose eligibility period is coming to an end,” says Karen Michael, vice president of corporate medical management for AmeriHealth Caritas Family of Companies. “They help them go through the re-up process with the county assistance office or the state Medicaid entity.”

Michael says with the churn into exchanges, the AmeriHealth Caritas outreach teams will connect members with navigators that can help them enroll in a commercial plan. It’s especially critical that the members entering the exchange understand their eligibility for subsidies to make coverage affordable as they transition out of Medicaid.

During the transition, the plan also offers downloadable clinical summaries to reduce care gaps.

“Members can go online and see their medical history that’s gathered out of our claim data, and they can print that and take that with them if they experience a coverage change or a churn period where they’re starting over with a new physician or primary care provider,” Michael says.

Data includes office visits, hospital stays, pharmacy claims, diagnoses and high-level radiology information, she says. The program began just over a year ago and adoption is increasing across the 15 states AmeriHealth Caritas serves.

“What we’re working on now is a mobile platform because we know the internet and paper-based [data] is not necessarily the most accessed modality for our members anymore,” she says. “It’s not just in the Medicaid market; it’s in all the markets.”

More Online:

See ACAP’s state-by-state outline of enrollment continuity here.