Evidence Tools
MCH Best. NPM 15: Continuous and Adequate Insurance

Strategy. Expansion of Coverage Eligibility (Partnerships with Medicaid)

Approach. Promote expansion of Medicaid benefits; reduce barriers to Medicaid enrollments; leverage partnerships with Medicaid.

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Overview. Children who reside in states that expanded public health insurance programs to parents participate in Medicaid at a rate that is 20 percentage points higher than of those who live in states with no expansions.^1,2 Numerous, overarching approaches for this strategy include:

• Improving parents' health coverage, thus increasing coverage and access to care for entire family.*
• Removing red tape barriers that can keep eligible children from maintaining consistent Medicaid or CHIP coverage, boost outreach and enrollment efforts, 12-month continuous coverage, presumptive eligibility, consumer assistance/navigators.**
• Measuring and reporting data on child health quality (e.g., all Medicaid and CHIP Core Set measures, managed care plan performance). ***
• Establishing, nurturing, and leveraging partnerships with Medicaid to maximize the proportion of children who are covered by Medicaid as well as maximizing the benefits that are covered, especially in alternative payment models like managed care.  

Evidence. Moderate Evidence. Medicaid buy-in programs have shown to be effective. This strategy has been tested more than once and results trend positive overall. Access the peer-reviewed evidence through the MCH Digital Library. 

* Research on coverage expansions shows “welcome mat” effect, where unenrolled, eligible children get enrolled in Medicaid as adults gain coverage for the first time.³ At least one study⁴ shows that children whose parents gained Medicaid coverage under the Affordable Care Act (ACA) expansion were more likely to access primary care. (Read more about understanding evidence ratings).

** Strong policy/practice evidence based on state experience.⁵

*** Expert opinion.⁶

Target Audience. State/National.

Outcome. Percent of children ages 0-17 who are adequately insured. For detailed outcomes related to each study supporting this strategy, click on the peer-reviewed evidence link above and read the "Intervention Results" for each study.

Examples from the Field. Access descriptions of ESMs that use this strategy directly or intervention components that align with this strategy. You can use these ESMs to see how other Title V agencies are addressing the NPM.

The Family Opportunity Act (FOA) was passed as part of the Deficit Reduction Act of 2005 (PL No. 109-171, Section 6062). It includes a state option to create a Medicaid Buy-in program for children with disabilities whose family income is less than 300% of the Federal Poverty Level (FPL). As of 2017, five states have implemented an FOA Medicaid Buy-in program: Colorado,  Iowa, Louisiana, North Dakota, and Texas.

The Role of Title V. Title V agencies are required to have an interagency agreement/MOU with Medicaid. Title V Agencies can establish, nurture, and leverage their partnership with Medicaid to improve the health insurance coverage for CYSHCN. Title V provides valuable expertise to Medicaid on a variety of topics and engage with Medicaid in the following policies:

• Title V-Medicaid Interagency Agreement/MOU
• Medicaid Buy-In Programs
• Medicaid Managed Care Contracts
• Medical Necessity
• Express Lane Eligibility for Medicaid
• 1915 HCBS Waivers
• TERFA/Katie Beckett Waivers
• Other ways of Expanding Medicaid Eligibility

Sample ESMs. Using the approach “Promote expansion of Medicaid benefit eligibility through support of Medicaid buy-in policy,” here are sample ESMs you can use as a model for your own measures using the Results-Based Accountability framework (for suggestions on how to develop programs to support this strategy, see The Role of Title V in Adapting Strategies):

Note. ESMs become stronger as they move from measuring quantity to measuring quality (moving from Quadrants 1 and 3, respectively, to Quadrants 2 and 4) and from measuring effort to measuring effect (moving from Quadrants 1 and 2, respectively, to Quadrants 3 and 4):

Learn More. Read how to create stronger ESMs and how to measure ESM impact more meaningfully through Results-Based Accountability.

References:

¹Hudson, J. L., & Moriya, A. S. (2017). Medicaid expansion for adults had measurable ‘welcome mat’ effects on their children. Health Affairs, 36(9), 1643-1651.

² Dubay & Kenney. (2003). Expanding Public Health Insurance to Parents: Effects on Children’s Coverage Under Medicaid. Heath Services Research.

³ Burak, E.W. Parents’ and Caregivers’ Health Insurance Supports Children’s Healthy Development (Washington: Society for Research in Child Development, June 2019).

Hudson, J.L., & Moriya, A.S. (2017). Medicaid expansion for adults had measurable ‘welcome mat’ effects on their children. Health Affairs, 36, n.p.

⁴ Venkataramani, M., Pollack, C.E., and Roberts, E.T. (2017). Spillover effects of adult Medicaid expansions on children’s use of preventive services. Pediatrics, 140, n.p. Retrieved from https://pediatrics.aappublications.org/content/140/6/e20170953

⁵ See, for example, Brooks, Tricia (2020) Policy Options : How to Regain Momentum on Medicaid/CHIP Enrollment and Boosting Outreach and Consumer Assistance to Regain Enrollment Momentum.

⁶ Government Accountability Office (2019). Additional CMS Data and Oversight Needed to Help Ensure Children Receive Recommended Screenings, Georgetown CCF GAO to CMS: Set Goals, Measure Progress on EPSDT.