2.1. Describe the extent to which, and manner in which, children in the state including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in section 2110(c)(2)). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements).
Summary of District’s Children Population
Based upon adjusted Current Population Survey (CPS) data, there were an estimated 112,557 children under age 19 living in the District of Columbia. This number includes District residents and undocumented immigrants living in the District.
On an average monthly basis, 67,734 (60.2 percent) of the approximately 112,557 children under age 19 living in the District are covered under Medicaid; 30,074 (26.7 percent) are covered under an employer-sponsored plan or some other type of coverage; and about 14,749 children (13.1 percent) are uninsured.
Summary of Data on Uninsured Children Living in the District
Of the 14,749 uninsured children under age 19 living in the District, approximately 32.5 percent are under age 6; 52.7 percent are between the ages of 6 and 14; and 14.8 percent are between the ages of 15 and 18.
About 75.8 percent of the 14,749 uninsured children under age 19 living in the District are reported as African-Americans and 21.2 are reported as white. The remaining 3 percent are reported as "other."
Based upon estimates provided by the Bureau of the Census and the Immigration and Naturalization Service (INS), an estimated 20,00 undocumented immigrants living in the District of Columbia. Of the 20,000 undocumented immigrants living in the District, 4,407 are under age 19. Of the 4,407 undocumented immigrant children living in the District who are under age 19, about 833 would be CHIP-eligible "but for" their immigration status. Under federal law, these children are not eligible for either Medicaid or CHIP.
There is no reliable data on the number of legal immigrant children who have arrived in the District since the enactment of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (August 22, 1996). These children are statutorily ineligible for Medicaid for their first five years in the country. Thereafter, these children are eligible for Medicaid subject to (a) a state’s option, and (b) sponsor deeming rules.
Summary of Current Medicaid Enrollment
Under the District’s current Medicaid eligibility rules, infants are eligible up to 185 percent of poverty; children ages 1 through 5 are eligible up to 133 percent of poverty; children ages 6 through 14 are eligible up to 100 percent of poverty; and children ages 15 through 18 are eligible up to approximately 50 percent of poverty.
Of the 112,557 children under age 19 living in the District, approximately 73,835 were Medicaid eligible at some point during 1966. This includes all children who qualified for the program under one or more categories of eligibility including: AFDC recipients; medically needy; disabled children; or the federally mandated expansion in eligibility for poverty-related groups.
Of the 73,835 children who were Medicaid-eligible at some point during 1966, only 67,734 actually enrolled in the program. This represents an overall program enrollment rate of 91.7 percent.
The enrollment rate for children who were eligible for AFDC cash assistance (typically persons below 40 percent of the federal poverty level) was 97 percent while the enrollment rate for children in non-cash expansion groups (Medicaid only) was 74 percent.
There were approximately 6,101 children who were eligible for, but not enrolled in Medicaid. Of these, 3,272 (53.6 percent) were uninsured; 2,289 (37.5 percent) had employer-sponsored coverage; and the remaining 540 (8.9 percent) had individually purchased insurance coverage.
Approximate Number of CHIP Eligible Children Among the Total Number of Uninsured
Of the 14,749 uninsured children living in the District of Columbia, approximately 833 are undocumented immigrant children living in families with incomes less than 200 percent of the federal poverty level. Although these approximately 833 children meet the income eligibility criteria for CHIP, they are ineligible for CHIP because of their immigration status.
Of the 14,749 uninsured children living in the District of Columbia, 2,701 are in families with income above 200 percent of the federal poverty level and are therefore ineligible for CHIP.
Of the 14,749 uninsured children living in the District of Columbia, 3,272 are uninsured, Medicaid-eligible, and not currently enrolled in the Medicaid Program. These 3,272 children are ineligible for CHIP because they are eligible for Medicaid under eligibility rules in effect on March 31, 1997.
Where one subtracts from the total number of 14,749 uninsured children: (a) the number of children who are not eligible for CHIP because of their immigration status (833); (b) the number of uninsured children who are in families with incomes above 200 percent of the federal poverty level (2,701); and (c) the number of children who are currently eligible for but not currently enrolled in Medicaid (3,272), there are 7,943 children among those who are currently uninsured in the District who are eligible for CHIP.
Approximate Number of CHIP-Eligible Children Expected to Enroll in CHIP (Including Substitution)
The District proposes to increase the Medicaid income eligibility limit for the CHIP program to 200 percent of the federal poverty level (FPL) for all uninsured children living in the District who are under age 19. The benefits provided to these newly eligible children will be the same as those now provided to children currently enrolled in Medicaid.
There are approximately 7,943 uninsured children who are: (a) District residents; (b) live in families with income below 200 percent of the federal poverty level; and (c) are under age 19. Approximately 6,672 (84 percent) of these 7,943 uninsured children are expected to enroll in CHIP.
There are approximately 4,322 children living in the District of Columbia who are in families with access employer-sponsored dependent coverage. Approximately 1,729 (40 percent) are expected to drop such coverage and enroll in CHIP.
There are approximately 1,170 children in the District of Columbia who are in families with income up to 200 percent of the federal poverty level and who are either enrolled in CHAMPUS or Medicare. None of these children are expected to drop their coverage with either CHAMPUS or Medicare to enroll in CHIP.
The total number of children who are expected to enroll in CHIP is derived as follows: (a) approximately 6,672 (84 percent) of the7,943 uninsured children; plus (b) 1,729 (40 percent) of the 4,332 children with private insurance coverage who are expected to drop such coverage and enroll in CHIP; plus (c) none of the 1,170 children currently enrolled in CHAMPUS or Medicare; equals a total number of 8,401 children who are expected to enroll in CHIP.
Impact of CHIP Outreach and Education Efforts on Medicaid Enrollment (The Currently Eligible But Not Enrolled Population)
There are approximately 6,101 children living in the District who are eligible for but not enrolled in the Medicaid program under March 31,1997 eligibility criteria. All of these children are eligible to enroll in Medicaid even though a portion of them (46.4 percent) already have some sort of private insurance coverage.
The District’s implementation of CHIP will include an outreach effort designed to encourage enrollment among those who are CHIP-eligible.
Based upon results from prior outreach programs, we assume that about 20 percent of those who are eligible for but not enrolled in Medicaid will enroll in response to the intensified outreach efforts. We further assume that the entire 20 percent of persons in this category will come from that portion of the total population of 6,101 who are currently uninsured.
Thus, it is estimated that the outreach initiative will increase Medicaid enrollment by about 1,223 children per year.
Impact of CHIP Enrollment and Outreach on Total Program Numbers
The number of CHIP-eligible children who are likely to enroll in the program is 8,401. The number of currently Medicaid-eligible children who are likely to enroll in the program due to outreach activities is 1,223. Thus overall Medicaid program enrollment will increase from 67,734 to 77,358.
Impact on the Number of Uninsured Children in the District
There are currently an estimated 14,749 uninsured children living in the District of Columbia. The combined effect of CHIP and its associated outreach program will be to increase the number of children with Medicaid coverage by 9,624. This number includes the 8,401 children who will enroll in CHIP and the 1,223 children who will be added to the regular Medicaid program as a result of outreach. Total Medicaid program enrollment (including regular Medicaid and CHIP-Medicaid) will increase from 67,734 to 77,358.
Approximately 6,854 children are expected to remain uninsured despite the CHIP expansion and vigorous outreach activities. About 2,701 (39.4 percent) of the children who remain uninsured are in families with income in excess of 200 percent of the federal poverty level. Another 833 (12.2 percent) of these children who will remain uninsured, meet the income eligibility criteria under either Medicaid or CHIP, but are ineligible because they are undocumented aliens. About 2,049 of the children who will remain uninsured (29.9 percent) will be children who are eligible for Medicaid under the current program who will not enroll despite vigorous outreach efforts. This is equal to the number of eligible but not enrolled persons who are uninsured (3,272) less the number of eligible non-enrollees who would become covered due to outreach (1,223). All of the eligible but not enrolled children who enroll due to intensified outreach efforts are assumed to be persons who would be otherwise uninsured.
Finally, 1,271 of those who will remain uninsured are newly eligible CHIP children who, for a variety of possible reasons, will not enroll in the program. Thus, 6,854 children will remain uninsured in the District despite the CHIP expansion and vigorous outreach efforts. (See Appendix A Discussion Paper: Coverage and Costs under the Children’s Health Insurance Program, revised March 16, 1998, prepared by The Lewin Group, Inc.)
Summary of two Private Initiatives: Capital Community Kids Care and the Kaiser Kids Program
There are two privately funded initiatives currently underway in the District to provide health insurance coverage to uninsured children.
Both of the initiatives are funded by private foundations and sponsored by two local managed care organizations (Capital Community Health Plan and Kaiser Permanente).
Each plan has 500 slots into which uninsured children may be enrolled. Both plans have expressed that they intend to expand the number of available slots over time.
The Capital Community Kids Care Program covers children in families with income up to 275 percent of the federal poverty level.
The Kaiser Kids Program covers children in families with income up to 200 percent of the federal poverty level.
Both of the programs require children to be ineligible for Medicaid.
As of February 1998, there were 500 children enrolled in the Capital Community Kids Care Program and 500 children enrolled in the Kaiser Kids Program.
Enrollment criteria for both programs includes: (a) the child may not be eligible for Medicaid; (b) the child must be under age 18; and (c) the child must be a resident of the District of Columbia. (See Appendix B: Description of Capital Community Kids Care Program) (See Appendix C: Description of Kaiser Kids Program)
2.2. Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing ((Section 2102)(a)(2)).
2.2.1. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e. Medicaid and state-only child health insurance):
Summary of District Activities to Identify and Enroll Medicaid Eligible Children
The Medical Assistance Program: The Medical Assistance Program (Medicaid) is the only public health insurance program currently available to children who are residents of the District of Columbia.
Income Maintenance Administration: The Income Maintenance Administration (IMA) is the entity within the Department of Human Services responsible for eligibility determinations for the District’s Medicaid program as well as cash assistance, food stamps and other benefits. Individuals can walk into any of the eight (8) IMA service centers at any time and be processed for Medicaid eligibility.
Income Maintenance Administration Community Outreach: Representatives from IMA give talks to community groups upon request. The purpose of these presentations is to inform the public about: (a) general eligibility requirements for the District’s Medicaid program; (b) the requirements for Medicaid eligibility; and (c) the eligibility determination process. Examples of groups addressed include: The Children’s Health Coalition, area churches, DSH Hospitals and the District’s two federally qualified health centers. East of the River and Upper Cardoza.
Disproportionate Share Hospitals: All DSH Hospitals in the District conduct the following outreach and enrollment activities: (a) place signs up in their facilities that alert people about Medicaid; (b) provide assistance with completing the Medicaid application; and (c) collect completed applications and deliver them to IMA offices. DSH hospitals include: Children’s Hospital, Hospital for Sick Children, Providence Hospital, Hadley Hospital, Greater Southeast Hospital, DC General Hospital, and Howard University Hospital, and Saint Elizabeth’s Hospital. Saint Elizabeth’s Hospital and DC General Hospital have District government employed IMA workers on site who accept applications and make final determinations on-site; all other DSH hospitals have contracts with private firms to gather and collect application information and assist with the preparation of Medicaid applications. This information is then forwarded to the central IMA unit on H Street NE. within five days of client signing the application.
Public Benefits Corporation Clinics: The PBC clinics (13 clinics across the District) have their own employees who: (a) collect, gather, and assist with the completion of Medicaid applications and, (b) send the client with the completed application packet to the appropriate service center based on census tract information.
Non-DSH Hospitals: Non-DSH Hospitals in the District (George Washington University Hospital, Georgetown University Hospital, Washington Hospital Center, and Sibley Hospital) either have members of their own staffs or hire contracted staff to assist Medicaid applicants. This staff activity includes: (a) assisting clients with completing applications; (b) assembling completed application packets; and (c) forwarding completed application packets to the central IMA unit on H Street NE.
Mary’s Center for Maternal and Child Health: Mary’s Center is a non-profit community-based clinic that provides comprehensive health services to low-income women and children. The clinic primarily provides services to Latino, African and Middle Eastern immigrants. An employee of the District government is located at the Center. This individual assists Medicaid applicants with the following: (a) assisting clients with completing applications; (b) assembling completed application packets; and (c) forwarding completed application packets to the central IMA unit on H Street NE. Most of these applications are processed in IMA’s Multinational Unit.
Other Hospital-Related Activities: Many local hospitals hire staff to assist Medicaid-eligible individuals during every phase of the enrollment process. For example, Children’s Hospital has contracted with a private organization to: (a) assist self-pay customers with filling out the Medicaid application; (b) obtain the necessary supporting documentation; (c) submit the application to the Income Maintenance Administration; and (d) follow up with eligibility workers until the customer’s application is given a final determination.
Medical Care Advisory Committee: Through its Medical Care Advisory Committee, the District’s Medicaid program provides ongoing information to Committee members on key program changes and receives guidance on successful outreach strategies.
Medical Assistance Program Staff: Staff of the Medical Assistance Program (Medicaid) give frequent presentations and briefings to consumer and provider groups on Medicaid eligibility rules and other aspects of accessing the program.
Section 330 Federally Qualified Health Centers: The Federally Qualified Health Centers have their own staff to assist Medicaid applicants. Their activities include the following: (a) assisting clients with completing applications; (b) assembling completed application packets; and (c) forwarding completed application packets to the central IMA unit on H Street NE.
The Supplemental Food Program For Women, Infants and Children: The Supplemental Food Program for Women, Infants and Children (WIC) is located within the Department of Health. WIC employees distribute literature on Medicaid and Medicaid eligibility to all WIC applicants. Many WIC sites are located in clinic settings where clients have access to clinic personnel for assistance with applying for Medicaid. (See Appendix D: Medicaid Outreach Information Distributed by WIC Agencies)
Office of Maternal and Child Health: The District’s Office of Maternal and Child Health (OMCH) is located within the Department of Health. Established in 1982, the OMCH is charged with planning, promoting, and coordinating a state-based system of comprehensive health services for all mothers and children, including children with special health care needs, in both the public and private sectors of the District of Columbia. The OMCH integrates Medicaid-related outreach activities into many of their programs. Generally, individuals working in the various programs inform parents and providers about Medicaid eligibility and about Medicaid Managed Care. (See Appendix E: Description of OMCH Outreach Programs Description of HMO Oversight Program)
Other Activities: A number of community clinics, community-based groups, and other nonprofit associations throughout the District conduct the following activities: (a) provide information to consumers about the District’s Medicaid program; (b) assist consumers with completing the Medicaid application; (c) assist consumers with locating, assembling and photocopying necessary documentation; (d) provide translation services for non-English speaking or limited-English speaking consumers who are applying for Medicaid; and, (e) interface between eligibility workers and customers when necessary. Examples of some of these groups include:
The United Planning Organization (UPO)
The Non-Profit Clinic Consortium
The 10 Non-Profit Clinics
The DC Primary Care Association
DC Action for Children
Children’s Health Coalition of DC
Chartered Health Plan
China Town Community Center of the Chinese Community Church
Planned Parenthood
Whitman Walker Clinic, Inc.
Summary of District Activities to Assist Non-Medicaid Eligible Children in Enrolling in the Private Initiatives
Representatives from the District’s Department of Health including the District’s Medicaid Program serve on a task force created to identify effective outreach strategies for the District’s two privately funded health insurance initiatives. The District is currently exploring ways to incorporate information about these two initiatives into its outreach and education strategy for CHIP. The Medicaid Assistance Program (Medicaid) is the only publicly-funded health insurance program in the District of Columbia.
2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership:
There are no health insurance programs in the District of Columbia that involve a public-private partnership.
2.3. Describe how the new State Title XXI program(s) is(are) designed to be coordinated with such efforts to increase the number of children with creditable health coverage so that only eligible targeted low-income children are covered: (Section 2102)(a)(3)
Triage During the Enrollment Process: Enrollment activities for CHIP will be based on a strategy that is designed to direct families to an appropriate source of health insurance coverage. This means that during the enrollment process eligibility workers will be trained to do CHIP eligibility determinations and income based Medicaid eligibility determinations. As individuals come forward to enroll a child in CHIP, the child will first be screened for Medicaid-eligibility prior to being enrolled in CHIP. Individuals who are eligible for regular Medicaid (based solely on income) will be enrolled in the program as part of the same process as that used for CHIP enrollment.
Appropriate Referrals: Individuals who are eligible for Medicaid based upon other criteria (e.g. spend-down) will be referred to appropriate eligibility workers. These individuals will also be referred to appropriate application assistance programs if such assistance is required. In addition, eligibility workers will be trained to refer individuals to either of the two private initiatives (see above) when the individual would be an appropriate referral.
Comprehensive Outreach: Although the primary goals of Title XXI outreach efforts are to identify and enroll CHIP-eligible children (who will be separately tracked once enrolled,) the District is eager to identify and enroll all children who are eligible for but not enrolled in the Medicaid program as well as children who are not eligible for Medicaid but may be eligible for one of the two private initiatives. Thus, the District plans to mount a comprehensive outreach strategy designed to reach (a) children who are eligible for but not enrolled in Medicaid and (b) children who are eligible for CHIP. Appropriate referrals will be made for children who are ineligible for Medicaid and CHIP but may be eligible for either of the two private initiatives.
Provider Education: The District’s Medicaid Agency will undertake activities to educate providers about CHIP and changes in the enrollment and eligibility determination process. The Agency will work collaboratively with the DC Primary Care Association, the Medical Society of DC, the DC Chapter of the American Academy of Pediatrics, and the DC Hospital Association to ensure that a maximum number of providers are reached.
Coordination of Department Health Activities: There will be coordination among all Department of Health Programs (e.g. Maternal and Child Health, Title X Family Planning, Immunizations, etc.). to ensure that each program integrates Medicaid and CHIP outreach strategies and enrollment assistance into their ongoing activities.
Coordination with other City Programs: The Department of Health will work with the City’s School Lunch Program, the Head Start Program, and other City programs serving large numbers of low-income children to ensure that effective outreach occurs among their respective populations.
