CHIPRA-10 State Selection_ for OMB

MEMORANDUM

555 S. Forest Ave., Suite 3
Ann Arbor, MI 48104-2583
Telephone (734) 794-1120
Fax (734) 794-0241
www.mathematica-mpr.com

TO:

Elizabeth Pham

FROM:

CHIPRA 10-State Evaluation Team

SUBJECT:

CHIPRA 10-State Evaluation: Final State Selection Decisions for the 10-State Survey and
Case Studies

1/7/2011
CHIP10-008R
DATE:

This memo presents our final recommendations of states to be selected for the study. On
November 4, 2010, we submitted a memorandum to the Assistant Secretary for Planning and
Evaluation (ASPE) proposing a set of criteria for selecting the 10 states to be included in the
Children’s Health Insurance Program Reauthorization Act (CHIPRA) 10-state evaluation. In
response to comments from ASPE received on November 16, 2010, we updated the selection
criteria and decision rules for selecting states in a memo sent to ASPE on December 3, 2010.
Comments on that memo are incorporated into the selection results presented here. The selection
criteria and decision rules used to apply these criteria are presented in Table 1, organized into
three groups or stages that reflect the order in which they are applied. Criteria in Stage I are
considered primary and must be satisfied because they are either mandated in the legislation or
are essential to the evaluation. Criteria in Stage II are considered next and ensure that the
selected states collectively capture important programmatic and policy features. Stage III
includes two practical criteria that states must meet in order to be included in the study.
PROPOSED STATES
We applied the Stage I and Stage II selection criteria sequentially as described in the memo
of November 4, 2010. The selection process resulted in a primary list of 10 states along with 10
possible substitutes. The states recommended for the study are Texas, California, Florida, Ohio,
Alabama, Louisiana, New York, Michigan, Utah, and Virginia. 1 The last column of Table 1
shows how these 10 states line up against the various criteria. Table 2 provides more detail
about characteristics of each state so that a state’s relative merits can be more easily compared
with the other proposed states. In the remainder of this memo we describe the process we used
and discuss the rationale for selecting these states.

1

The backup states are Colorado, Nevada, Pennsylvania, Kentucky, Maryland, Oklahoma, North Carolina,
Oregon and Illinois.

An Affirmative Action/Equal Opportunity Employer

MEMO TO: Elizabeth Pham
FROM:
CHIPRA 10-State Evaluation Team
DATE:
1/7/2011
PAGE:
2
STATE SELECTION APPROACH
The process we used involved multiple steps. We applied the selection criteria in priority
order to arrive at a set of states that would collectively meet all of the Stage I criteria and as
many of the Stage II criteria as possible. Table 1 shows all of the criteria used in the selection
process; the discussion refers to the criteria numbering that is used in that table.
Step 1: Program Type and Size of the Uninsured Population
First we stratified the 50 states based on program type (M-CHIP, S-CHIP, or combination).
Next, we stratified states within each type based on the share of low-income uninsured children
(criteria 1 and 2 of Stage I). We focused on states with a larger share of the uninsured to meet
the criteria that selected states would represent at least 50 percent of the nation’s low-income
uninsured children. We determined that we must include Texas, California, and Florida in
order to meet the 50 percent threshold because, when combined, these states account for 40
percent of the uninsured children in the United States. If any of these three states is unable to
participate, we will not be able to meet the 50 percent threshold. Among the remaining states,
we focused on the 25 states with at least 1 percent of the nation’s uninsured low-income child
population. States with smaller uninsured child populations would be considered only if they
met other important Stage I criteria.
 Three states selected thus far: Texas, California, Florida
Step 2: Program Size
We then applied the third criterion from Stage I, size of the CHIP program, to ensure that the
pool of selected states would represent at least 40 percent of the nation’s CHIP population and
include some states with more moderately sized programs. The criteria specified we were to
include no more than 5 of the 10 states with the largest CHIP programs, and we already had three
of the largest programs (Texas, California and Florida). The other top-ten states are New York,
Georgia, Illinois, Pennsylvania, Ohio, New Jersey, and North Carolina. Because Ohio is the
only pure M-CHIP state among the top 10, we recommend it be added to the list of study states.
This would enable us to pick one more state from the list of largest programs if necessary.
 Four states selected thus far: Texas, California, Florida, and Ohio
Step 3: Program Participation and Retention
Next we applied criteria 4(a) from Stage I to select states with higher and lower CHIP and
Medicaid participation rates. Among states in the top quartile (of which we had to select at least
two), five stood out because they also had a larger share of the nation’s uninsured children or a
larger share of the nation’s CHIP enrollees: Michigan, New York, Louisiana, Illinois, and
Wisconsin. We ranked these five states highly for possible inclusion in the study and we

MEMO TO: Elizabeth Pham
FROM:
CHIPRA 10-State Evaluation Team
DATE:
1/7/2011
PAGE:
3
specified that in future steps we would select at least two of them to meet this Stage I threshold.
Among the bottom quartile states, Florida and Texas were already on our list, so we had already
satisfied that criterion. Other states of interest from the bottom quartile (because they had at
least a 1 percent share of the nation’s uninsured or a 1 percent share of the nation’s CHIP
enrollment) were Oregon, Colorado, Utah, and Nevada.
Next we applied the 4(b) criteria, looking for indications of the following enrollment and
retention best practices: CHIPRA bonus payments, express lane eligibility (ELE) programs, and
Social Security Administration (SSA) matching. Alabama stood apart with the only approved
ELE program for CHIP, the largest CHIPRA bonus payment, and an SSA matching program, so
we added it to the list of study states. We also selected Louisiana in this step because it has all
three best practices: its ELE is for Medicaid, it is in the top quartile for participation, and it has a
large share of the nation’s uninsured children. Michigan remains a consideration, having
received CHIPRA bonus payments in both 2009 and 2010. Texas and Florida will enable us to
meet the criteria that we include at least two states that do not have ELE, SSA matching, or
CHIPRA bonus payments. Other states that did not meet any of these criteria included
Wisconsin, Oregon, Virginia, Colorado, Kentucky, North Carolina, Utah, and Illinois.
Finally, we applied the 4(c) criterion to select at least two states that report their separate
CHIP program data in MSIS. Louisiana already met this criterion; other possibilities were
Wisconsin, Oregon, Virginia, Colorado, Kentucky, North Carolina, Utah, and Illinois.
 Six states selected thus far: Texas, California, Florida, Ohio, Alabama, and Louisiana
Step 4: Geographic and Population Characteristics
The final Stage I criteria are designed to ensure we select states from all the major Census
regions in the United States and select states that contain adequate numbers of important
subpopulations. First we applied criterion 5(a) to ensure we would have at least two states with
25 percent or more of their population in urban areas. All of the states picked thus far met that
criterion. Of the states already on the list, however, only Alabama and Ohio met the rural
standard. We reviewed other states flagged as possibilities in prior steps and found four
possibilities that met the rural criterion: Wisconsin, Oregon, Colorado, and Illinois.
Next, we focused on Census region, criterion 5(b), to ensure we had adequate geographic
representation. Among the six states already on the list, three of the four Census regions were
represented (South, West, and Midwest) but we had no state from the Northeast region. We
reviewed possibilities identified in earlier steps and New York was the only state recommended
more than once (in Steps 2 and 3) that was also in the Northeast region. Thus, New York was
recommended for inclusion as one of the 10 study states.

MEMO TO: Elizabeth Pham
FROM:
CHIPRA 10-State Evaluation Team
DATE:
1/7/2011
PAGE:
4
 Seven states selected thus far: Texas, California, Florida, Ohio, Alabama, Louisiana,
and New York
We then focused on ensuring adequate representation of important subpopulations, criteria
5(c). We needed seven states in the top half in percentage non-white, three in the top quartile in
percentage Hispanic, and three in the top quartile in percentage African American. After
considering the population make-up in states already selected, we had met these criteria with the
exception of needing one more state from the top half in percentage non-white. After reviewing
states identified in previous steps, Colorado, Nevada, and Virginia surfaced as the only
possibilities for meeting this criterion.
Final Step: Filling Remaining Gaps
We reviewed all the states that had been identified in earlier steps but had not yet been
selected: Pennsylvania (criterion 3); Michigan (criterion 4a and 4b); Kentucky (criterion 4b);
Nevada (criteria 4a and 5c); Utah (criteria 4a, 4b, and 4c); Virginia (criteria 4b, 4c, and 5c);
Wisconsin (criteria 4a, 4b, 4c, and 5a); Oregon (criteria 4a, 4b, 4c, and 5a); and Colorado
(criteria 4a, 4b, 4c, 5a, and 5c). From this shorter list of states, we focused on those that fulfilled
three or more Stage I criteria, which restricted us to Utah, Virginia, Wisconsin, Oregon, and
Colorado. We then reviewed these four states together with the seven already selected on both
the Stage I and Stage II criteria to try to determine which states to include or exclude. We
selected Wisconsin because it met the Step 4 rural criterion and would bring in a state from the
Midwest Census region (up to this point, we had only one state from the Midwest region—
Ohio). However, when approached, Wisconsin declined to participate in the study. As a
replacement, we selected Michigan because among the states on our short list, it represents the
Midwest region and fulfilled selection criteria 4a and 4b; it also is in the top third of states in
terms of African American residents.
Utah and Oregon both fulfilled at least three key Stage I criteria, but only Utah also met
two important Stage II criteria: potentially burdensome cost-sharing (Stage II criterion 2) and
receiving a CHIPRA quality demonstration grant (Stage II criterion 5.b). Thus we selected Utah
over Oregon. Between Virginia and Colorado, which are quite similar states in terms of the
Stage I and Stage II criteria, we chose Virginia because it provides a seventh state with a higher
percentage non-white population and it is a true combination CHIP program. In contrast,
Colorado has an S-CHIP program and we already had six such states on our list.
 Final 10 states selected: Texas, California, Florida, Ohio, Alabama, Louisiana, New
York, Michigan, Utah, and Virginia
As shown in Table 2, the 10 recommended states fulfill all of the Stage I and Stage II criteria
for inclusion in the study. We subsequently reviewed states that met some of the Stage I criteria
and included them as possible substitute states, also shown on Table 2. Substitutions would be
made based on comments from ASPE on this selection memo and subsequently if we find that a

MEMO TO: Elizabeth Pham
FROM:
CHIPRA 10-State Evaluation Team
DATE:
1/7/2011
PAGE:
5
state is unwilling or unable to participate in the evaluation when we apply Stage III of the
selection criteria.
Overlap with States in Prior CHIP Evaluation
Congress specified that this evaluation use similar methods as in the first Congressionallymandated CHIP evaluation. We employed similar methods for state selection: establishing a
prioritized list of relevant criteria, including those specified in the CHIPRA legislation, and
applying those criteria sequentially. The process of applying the criteria resulted in a set of 10
states that represent 54.3 percent of all uninsured children under 200 percent of the federal
poverty level, and 56.7 percent of CHIP enrolled children (data also shown in Table 2, found on
page 10, columns 2a and 3a). Because the states are dynamic, the resulting application of the
criteria in 2011 did not result in the identical list of states that were selected for the first study.
However, as noted on the second panel of Table 2 (found on page 11, column 5a), five of the
selected states—Texas, California, Florida, Louisiana, and New York—participated in the first
CHIP evaluation. For these states, we plan to conduct a limited set of comparative analyses. For
example, in the individual case study reports for each of these states, we anticipate including a
section on the changes that have taken place in CHIP over the past decade -- in program design,
policy context, and enrollment -- and how these changes may be affecting the experiences of
eligible children and families. Likewise, in the reports based on the household survey, we
anticipate including a brief presentation of how the composition and experiences of CHIP
children and families have changed since the prior study in these five states. Examples of
potential areas of interest for this presentation include changes in CHIP enrollees’ demographics,
their insurance coverage before and after CHIP coverage, and their access to and use of
preventive and other health care while covered by the program.

MEMO TO: Elizabeth Pham
FROM:
CHIPRA 10-State Evaluation Team
DATE:
1/7/2011
PAGE:
6

Table 1. Proposed Criteria for Selecting States for CHIPRA 10- State Evaluation
Criteria

Proposed Decision Rule(s) for
Meeting Criteria

Rationale

States

Stage I: Primary Selection Criteria (Must Be Satisfied)
1. Program type

2. Size of the
uninsured
population

3. Program size

Legislation specifies
importance of selecting
states with diverse
approaches to
providing coverage

Legislation specifies
that selected states
should contain a
significant portion of
uninsured children

Larger programs will
support generalizing
findings at the national
level; moderate-sized
programs will help
generalize findings to
more states

Selected states should approximate
the national distribution on program
type:
a)

2 or 3 states with only Medicaid
expansions (either pure M-CHIP
programs or combination
programs with more than 80%
of enrollees in their M-CHIP
program)
b) 5 or 6 states with separate
programs (either pure S-CHIP
programs or combination
programs with more than 80%
of enrollees in the S-CHIP
program)
c) 1 or 2 states with combination
programs with enrollment more
evenly divided between M-CHIP
and S-CHIP
Selected states include:
a)

b)

at least 50% of nation’s lowincome uninsured children
at least 2 states from among the
10 with highest rates of
uninsured children below 200%
FPL

Selected states include:
a)

b)

at least 40% of CHIP enrollees
nationally
at least 5 states outside the top
10 in terms of program size

a) OH, LA

b) TX, CA, FL, NY,
AL, UT

c) VA, MI
a) All 10 states
combine to
represent 54.28% of
the nation’s
uninsured children
b) TX, CA, FL, NY,
OH
a) All 10 states
combine to
represent 56.66% of
CHIP enrollees
nationally
b) LA, AL, MI, UT, VA

MEMO TO: Elizabeth Pham
FROM:
CHIPRA 10-State Evaluation Team
DATE:
1/7/2011
PAGE:
7

Criteria

4. Program
participation
and retention

5. Geographic
characteristics

Rationale

Programs with varied
success enrolling and
retaining eligible
children can improve
generalizing findings
and provide basis to
compare and contrast
state experiences

Legislation specifies the
need to represent
various geographic
areas (including mix of
more rural and more
urban states, variation
of races/ethnicities)

Proposed Decision Rule(s) for
Meeting Criteria

Selected states include:
a)

at least 2 in the top and bottom
quartiles in estimated
participation rate
b) those meeting at least one of
the four subcriteria for “best
practices” in
enrollment/retention (see II.1
below)
c) at least 2 states that report their
S-CHIP enrollment in MSIS
Selected states include:
a)

b)
c)

at least 2 states where at least
25% of the population live in an
urban area, and at least two
states where at least 20% of the
population live in a rural area
at least 1 state from every
Census region
at least 7 in top half in
percentage non-White; at least
3 in the top quartile in
percentage Hispanic; at least 3
in top quartile in percentage
African American

Stage II: Secondary Selection Criteria (Will Be Satisfied in Proposed Order of Priority)
1. Best practices
for enrollment
and retention

Inclusion of states with
different policies and
procedures for enrolling
and retaining eligible
children can help link
the impact of these
various approaches on
enrollment and
reductions in the
number of uninsured
children

Selected states include:
a)

b)
c)
d)

at least 2 with (separate)
program components that have
integrated their Medicaid and
CHIP eligibility systems
at least 2 that have received
CHIPRA bonus payments
at least 2 that have adopted ELE
and two that have adopted SSA
matching
at least 2 that do not satisfy (ac) above

States
a) Top: NY, LA, MI;
Bottom: TX, FL, UT
b) see II.1 below
c) LA, UT, VA

a) all 10 states have
at least 25% of
residents in urban
areas; AL & OH fulfill
the rural criteria
(28.6% in AL and
23.3% in OH)
b) all Census regions
are represented
c) 7 in top half
percentage nonwhite: TX, CA, FL,
AL, LA, NY, VA;
3 top quartile
Hispanic: TX, CA, FL,
NY;
3 top quartile
African American:
FL, LA, AL, VA
a) Data on integrated
Medicaid and CHIP
eligibility is
unavailable; will be
determined through
Stage III telephone
calls
b) LA, AL, MI
c) ELE: LA, AL
SSA: CA, OH, LA, AL,
VA
d) TX, FL, NY, UT

MEMO TO: Elizabeth Pham
FROM:
CHIPRA 10-State Evaluation Team
DATE:
1/7/2011
PAGE:
8

Criteria

2. Cost-sharing

3. Delivery
system

4. Program
Eligibility

5. Participation in
other key
research

Rationale

Inclusion of states with
different cost-sharing
approaches can help
inform about the
impact on access, use,
and other key health
care outcomes

Including states with
different approaches to
care delivery can help
inform their possible
links to access, use,
and other key health
care outcomes

Including states with
different income
eligibility limits, those
that use and do not use
buy-in programs, and
those that include and
exclude parents in their
CHIP programs can help
inform about the effects
on take-up of offers of
health insurance
Opportunities to
leverage findings from
other studies

Proposed Decision Rule(s) for
Meeting Criteria

Selected states include:

at least 2 states whose premium
and/or cost-sharing structure
would be considered
burdensome, with premiums
and/or co-insurance costs that
may discourage beneficiaries
from seeking care
b) at least 2 states with more
limited and predictable costsharing that would not be
expected to discourage careseeking behavior
Selected states should approximate
the national distribution on use of
capitation-based managed care
arrangements:

States

a) LA, UT

a)

a)

at least 2 states enrolling 90% or
more of the CHIP population in
managed care
b) 1 state with no managed care
enrollment
c) At least 4 states with a mix of
managed care, PCCM, and FFS
Selected states include:
a)

b)
c)

at least 2 with income eligibility
limits above 300% FPL and at
least 2 with income eligibility
limits below 200% FPLa
both those that have and do not
have buy-in programs
at least 1 state with an
adult/parent CHIP expansion

Selected states include:
a)

b)

c)

at least 4 that participated in
the prior CHIP evaluation
at least 2 that received CHIPRA
quality grants (and are the focus
of the evaluation of those
grants)
at least 2 that participate in the
Maximizing Enrollment for Kids
program and evaluation

Stage III: Screening Criteria (Must be Satisfied for Final Selection)

b TX, CA, FL, AL, VA

a) TX, NY, UT
b) LA, AL
c) CA, FL, OH, MI, VA
a) Above 300% FPL:
NY, AL.
Below 200% FPL: TX,
FL, OH, UT, VA, MI.
b) Have buy-in
programs: FL, NY,
OH. No buy-in
programs: TX, CA,
LA, AL, UT, VA, MI
c) VA
a) TX, CA, FL, NY, LA
b) FL, UT
c) NY, LA, AL, UT, VA

MEMO TO: Elizabeth Pham
FROM:
CHIPRA 10-State Evaluation Team
DATE:
1/7/2011
PAGE:
9

Criteria

1. Sufficient
capability of state
data systems

2. Willingness of
state to participate

Rationale

State data systems
must be able to
provide accurate,
complete, and timely
data for survey
sampling

State cooperation is
essential to ensuring
accurate, complete,
and timely data for
survey sampling

Proposed Decision Rule(s) for
Meeting Criteria

States

Qualitative assessment of study team
as to whether criterion is met (note
that ready access to Medicaid data
will be part of the assessment and
could affect whether criterion is met)

To be determined

Signed MOU with state that specifies
roles and responsibilities of both
state staff and evaluation team
members

To be determined

Previously this criteria specified selecting states in the top or bottom quintile of income eligibility limits.
However, upon review of the data, the states cannot be divided into quintiles or quartiles on this criterion
because many have the same income eligibility limits (for example, the highest income eligibility limits are
in New York, at 400 percent, followed by 13 states that all have an income eligibility limit of 300 percent
FPL).

a

CHIP = Children’s Health Insurance Program; CHIPRA = Children’s Health Insurance
Reauthorization Act; ELE = express lane eligibility; FFS = fee for service; FPL = federal poverty
CHIP = Medicaid expansion CHIP program; MOU = memorandum of understanding; MSIS =
Statistical Information System; PCCM = primary care case management; S-CHIP = Separate CHIP
SSA = Social Security Administration.

Program
level; MMedicaid
program;

MEMO TO: Elizabeth Pham
FROM:
CHIPRA 10-State Evaluation Team
DATE:
1/7/2011
PAGE:
10
Table 2. Application of Primary and Secondary State Selection Criteria, CHIPRA 10-State Evaluation

5.a.

5a.

5.b.

5.b

5.b.

•
•

S
W

•
•

•
•

•

•

S

•

•

•
•
•

MW
S
S

•
•

•
•

NE
MW

•
•

•
•

W
S

•

•

•
•
•

•

W
W
NE
S
S
S

•
•

•

•

•
•
•
•
•
•

•

At least 3 states, top
quartile, percentage African
American children

•

At least 3 states in top
quartile, percentage
Hispanic children

At least 7 states in top half,
percentage non-white
children

5.a.

At least one state from each
of the 4 Census Regions

4.c.

At least 3 states where at
least 25% of the population
live in an urban area

4.b.

At least 3 states where at
least 20% of the population
live in a rural area

4.b.

At least 2 states reporting SCHIP enrollment in MSIS

At least 2 states that
received CHIPRA bonus
payment

4.b.

At least 2 states that meet
none of the other 4.b.
criteria

4.b.

At least 2 states, SSA
matching

4.a.

At least 2 states with ELE

3.b.

At least 2 states each, top
and bottom quartile,
Medicaid and CHIP
participation rate

State

3.a.

At least 40% share of CHIP
enrollees nationally

2.b.

At least 2 of the top 10
states, highest rate of
uninsured children

2.a.

At least 50% share of
uninsured children under
200% FPL

Program type

1

At least 5 states outside top
10, CHIP program size

Stage I: Primary Selection Criteria (Must Be Satisfied)

Recommended 10 States
Texas
California
Florida
Ohio
Alabama
Louisiana
New York
Michigan
Utah
Virginia
Colorado
Nevada
Pennsylvania
Kentucky
Maryland
Oklahoma
North Carolina
Oregon
Illinois

S
C (S:
82%)
C (S:
99.6%)
M
S
C (M:
97%)
S
C (S:
78%)
S
C (mix)

16.64%
14.57%

•
•

10.97%
22.71%

• (Bottom)

9.74%

•

4.53%

• (Bottom)

2.66%
1.33%
1.06%

•

3.09%
1.39%
2.55%

•
•

• (Top)

•
•

3.15%
1.76%

•

7.71%
0.93%

•

• (Top)
• (Top)

•

0.84%
1.94%

•
•

• (Bottom)

S
S
S
C (Mix)
M
C (M:
97%)
C (S:
72%)
S
C (Mix)

2.48%
1.90%
2.27%
0.86%
0.92%
1.51%

•

1.30%
0.45%
3.86%
1.09%
2.01%
1.32%

•
•

• (Bottom)
• (Bottom)

•
•
•

• (Top)

3.03%

•

2.62%

1.51%
2.35%

•

0.96%
3.93%

1.51%
1.86%

•

•

•
•

•
•
•

•
•
•
•

•
•
Possible Substitute States

• (Bottom)
• (Top)

•
•

•
•

•

•

•
•
•

•
•
•

•

•

•

•

S

•

•
•

•

•

•
•

W
MW

•

•

•
•
•

•
•

MEMO TO: Elizabeth Pham
FROM:
CHIPRA 10-State Evaluation Team
DATE:
1/7/2011
PAGE:
11

Colorado
Nevada
Pennsylvania
Kentucky
Maryland
Oklahoma
North Carolina

•

Source:

•
•

•
•

•

•

•
•

•
•

•
•

At least 2 states
participating in the
Maximizing Enrollment for
Kids evaluation

At least 1 states with an
adult expansion program
in CHIP

5.c.

•
•
•

•

•
•
•

•

•
•
•
•

•
•
•

•
•
•

•
•

•
•

•

•

•
•

•
•

•
•
•

•

•
•

5.b.

•
•

•

Programs without buy-in
programs

Programs with buy-in
programs

At least 2 states with
income eligibility limit of
200% or lower

At least 2 states with
income eligibility limit of
300% or higher

•

5.a.

•
•

•

•
•
•
Possible Substitute States

•
•

•
•
•
•

•
•

•

•
•
•
•
•

•
•

•
•

•

•
•

Oregon
Illinois

•
•
•

•

Michigan

Utah
Virginia

Recommended 10 States
•

•

a

At least 2 states that
received CHIPRA quality
grants

•
•
•

Stage II: Secondary Selection Criteria (Will Be Satisfied in Proposed Order of Priority)
3.c.
4.a.
4.a.
4.b.
4.b.
4.c.

At least 4 states that
participated in the prior
CHIP evaluation

Texas
California
Florida
Ohio
Alabama
Louisiana
New York

3.b.

At least 4 states with a mix
of managed care, PCCM,
and FFS in CHIP

3.a.

At least 1 state with no
CHIP managed care
enrollmentb

2.

At least 2 states with
potentially burdensome
cost-sharing
At least 2 states with
more limited , predictable
cost-sharing
At least 2 states with 90%
of more of the CHIP
population in managed
care

2.

•
•
•

•
•
•

•

Program type data: CMS FY 2008 CHIP Annual Enrollment Report. Available at
https://www.cms.gov/NationalCHIPPolicy/downloads/FY2008StateTotalTable012309FINAL.pdf, accessed November 23, 2010.
Uninsured rate among low-income children: V. Lynch, S. Phong, G. Kenney, and J. Macri. “Uninsured Children: Who Are They and Where Do They Live?” August
2010. Available at http://www.rwjf.org/files/research/67668.pdf, accessed October 27, 2010.
CHIP enrollment as of June 2009: Kaiser Family Foundation. “Monthly CHIP Enrollment.” Available at
http://www.statehealthfacts.org/comparetable.jsp?ind=236&cat=4&sub=61&yr=1&typ=1, accessed October 27, 2010.
Medicaid and CHIP participation rate: Kenney, G., V. Lynch, A. Cook, and S. Phong. “Who and Where Are the Children Yet to Enroll in Medicaid and the Children’s
Health Insurance Program?” Health Affairs, vol. 29, no. 10, 2010, pp. 1920–1929. Available at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.2010.0747,
accessed October 27, 2010.
CHIPRA bonus payments: HHS News Release. “States Get Bonuses for Boosting Enrollment in Children’s Health Coverage.” December 17, 2009. Available at
http://www.hhs.gov/news/press/2009pres/12/20091217a.html, accessed November 23, 2010.

MEMO TO: Elizabeth Pham
FROM:
CHIPRA 10-State Evaluation Team
DATE:
1/7/2011
PAGE:
12

Express Lane Eligibility information: Families USA. “Express Lane Eligibility: What Is It and How Does It Work?” October 2010. Available at
http://www.familiesusa.org/assets/pdfs/Express-Lane-Eligibility.pdf, accessed October 27, 2010.
SSA Matching information: Donna Cohen-Ross. “New Citizenship Documentation Option for Medicaid and CHIP Is Up and Running.” April 20, 2010. Available at
http://www.cbpp.org/cms/index.cfm?fa=view&id=3159, accessed November 23, 2010.
Reporting of S-CHIP data in MSIS: Matthew Hodges, research analyst, Mathematica Policy Research, personal communication, November 16, 2010.
Geographic Data: available at http://www.census.gov/, accessed October 27, 2010.
Racial and ethnic data: Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau’s March 2008 and 2009 Current
Population Survey (CPS: Annual Social and Economic Supplements). Available at
http://www.statehealthfacts.kff.org/comparetable.jsp?ind=7&cat=1&sub=1&yr=199&typ=1, accessed November 23, 2010.
Premium, copayment, eligibility, and buy-in program information: Donna Cohen-Ross, Marian Jarlenski, Samantha Artiga, and Caryn Marks. “A Foundation for
Health Reform: Findings of a 50 State Survey of Eligibility Rules, Enrollment and Renewal Procedures, and Cost-Sharing Practices in Medicaid and CHIP for
Children and Parents During 2009. Data Tables.” December 2009. Available at http://www.kff.org/medicaid/upload/8028_T.pdf, accessed November 23, 2010.
Managed care and adult/parent expansion program information: Matthew Hodges, personal communication, October 26, 2010.
Prior CHIP and Maximizing Enrollment for Kids evaluations: Mathematica data.
CHIPRA quality grants: Insure Kids Now. “Summary, CHIPRA Quality Demonstration Grants.” Available at
http://www.insurekidsnow.gov/professionals/CHIPRA/grants_summary.html, accessed October 23, 2010.

Note:

Program types: C = Combination program; M = M-CHIP program; S = S-CHIP program.
Census regions: MW = Midwest; NE = Northeast; S = South; W = West.

a

Stage II, number 1 criteria are shown above as Stage I criteria 4.b.
This refers to enrollment in managed care organization (MCO) arrangements and does not include enrollment in primary care case management (PCCM) arrangements. In
Louisiana, most children enrolled in the M-CHIP program (which contains 97 percent of its CHIP enrollees) are in a PCCM program, with a small portion in fee-for-service
programs. Most of Louisiana’s S-CHIP enrollees are in fee-for-service programs but a few are in PCCM programs. In Alabama, it appears all the children are enrolled in fee-forservice programs. In North Carolina, it appears that all CHIP enrollees are in a fee-for-service program.
b

CHIP = Children’s Health Insurance Program; CHIPRA = Children’s Health Insurance Program Reauthorization Act; ELE = express lane eligibility; FPL = federal poverty level;
MSIS = Medicaid Statistical Information System; SSA = Social Security Administration.

MEMORANDUM

555 S. Forest Ave., Suite 3
Ann Arbor, MI 48104-2583
Telephone (734) 794-1120
Fax (734) 794-0241
www.mathematica-mpr.com

TO:

Elizabeth Pham

FROM:

CHIPRA 10-State Evaluation Team

SUBJECT:

CHIPRA 10-State Evaluation: Recommendation for
Selecting Three Medicaid States for the Survey of Enrollees
and Disenrollees

1/18/2011
CHIP10 – 011R
DATE:

This memo presents our recommendations for the three states to be selected for the survey of
Medicaid enrollees and disenrollees that will be conducted as part of the CHIPRA 10-state
evaluation. Final recommendations for the CHIP states were outlined in a memorandum to
ASPE dated January 7, 2011. The 10 states are: Alabama, California, Florida, Louisiana,
Michigan, New York, Ohio, Texas, Utah, and Virginia.
The inclusion of a Medicaid survey in three of the 10 CHIPRA study states will allow us to
contrast the enrollment and access experiences of CHIP and Medicaid enrollees and gain insight
into how different aspects of the programs may affect key outcomes. To distinguish outcomes
due to program design from outcomes due to underlying differences in the target populations, we
recommend selecting state with Medicaid programs that differ operationally from the CHIP
programs administered in the states.
To assess which states should be included in the Medicaid survey, we reviewed key
characteristics about the Medicaid and CHIP programs in the 10 states proposed for the study
(Table 1 summarizes these characteristics). This process allowed us to identify states with
differences between their Medicaid and CHIP programs, states that would represent a large
segment of the Medicaid population, as well as states that might prove advantageous for the
study in terms of obtaining their Medicaid data. Based on this review, we recommend selecting
Texas, California, and Florida as the three Medicaid survey states. Reasons for recommending
these three states, while excluding the others, include:
•

•

Program type. Texas, California, and Florida all administer separate CHIP (S-CHIP) or
S-CHIP dominant combination CHIP programs. We recommend excluding states that
operate only a Medicaid expansion (M-CHIP) component or M-CHIP dominant programs
because CHIP programs in M-CHIP states generally mimic Medicaid. Thus we excluded
Ohio and Louisiana from consideration. In addition, even states with S-CHIP and
combination programs sometimes operate ‘lookalike’ Medicaid and CHIP programs, so
that the programs appear the same to families. Because Virginia operates a ‘lookalike’
CHIP programs, we excluded it from consideration as well. Alabama, Michigan, New
York and Utah also operate S-CHIP or S-CHIP dominant programs.
Delivery systems. Ideally we would like to select states with different delivery systems
for Medicaid and CHIP. According to their CARTS data reports from 2008, Texas,
An Affirmative Action/Equal Opportunity Employer

MEMO TO: Elizabeth Pham
FROM:
CHIPRA 10-State Evaluation Team
DATE:
1/18/2011
PAGE:
2

•

•

California, and Florida all use different delivery systems for their Medicaid and CHIP
programs, as do Alabama and Utah (column 8). Half of the states—Michigan, New York,
Virginia, Ohio, and Louisiana—use the same delivery systems for children in both
programs.
Size. Texas, California, and Florida together represent over one quarter of the children
enrolled in Medicaid in the U.S. (column 4). Selecting larger programs will support
generalizing findings at the national level. (Only Michigan, New York and Ohio are also
in the top 10 in terms of Medicaid program size.)
Medicaid data. Including Texas, California, and Florida as the Medicaid survey states
will significantly enrich the data available for the study: we would then have access to
Medicaid data for all 10 of the states. Five of the other states are providing Medicaid
data to the Maximizing Enrollment for Kids evaluation (column 11) and would likely
agree to share these data; Ohio and Michigan report M-CHIP data in MSIS (column 10)
so their data should also be reasonably accessible. With Medicaid data for all 10 study
states, we will be able to understand more fully transitions between Medicaid and CHIP
and the retention of children in public coverage overall (that is, for the programs
combined) which in turn will enrich the study of enrollment trends, churning, transitions,
and crowd out.

Because Alabama and Utah share many of the same Medicaid and CHIP characteristics as
Texas, California, and Florida (for example, all five of these states use different eligibility
systems and different delivery systems for Medicaid and CHIP), we considered selecting them
for the Medicaid survey. However, the size of the Medicaid program in both states is small—
Alabama has 1.6 percent of the nation’s Medicaid-enrolled children, and Utah has 0.5 percent of
the nation’s Medicaid-enrolled children—so the programs in Texas, California, and Florida
seemed to be of higher priority for the study, as together they represent over one quarter of all
Medicaid enrolled children (27.7 percent, as shown on the last page of this memo in Table 1,
column 4). We recommend Alabama and Utah as the back-up states, should Texas, California,
or Florida be unwilling or unable to participate in the Medicaid survey.
It is important to note that even though we will have access to Medicaid administrative data
for all 10 states, we will still face significant limitations in generalizing findings from the 3 states
included in the Medicaid survey, because the administrative data cannot substitute for data
obtained through the survey.
We would be happy to discuss the relative merits of the proposed Medicaid survey states,
and the back-up states, with you and other key ASPE or Health and Human Services staff.

cc: File

MEMO TO: Elizabeth Pham
FROM:
CHIPRA 10-State Evaluation Team
DATE:
1/18/2011
PAGE:
3
Table 1: Selected Characteristics about State CHIP and Medicaid Programs, 10 States of Interest for CHIPRA 10-State Evaluation
1

2

3

CHIP
Program
type

Share of
Nation’s
Uninsured
Children

Number of
Children
Enrolled in
Medicaid as of
December
2009

Texas
California
Florida
Alabama
Utah
New York
Michigan
Virginia

S
C (S: 82%)
C (S: 99.6%)
S
S
S
C (S: 78%)
C (mix)

16.64%
14.57%
9.74%
1.33%
1.51%
3.15%
1.51
1.86%

2,186,336
3,412,916
1,414,747
422,415
127,739
1,712,343
1,040,776
426,876

Ohio
Louisiana

M
C (M: 97%)

2.66%
1.06%

932,569
617,329

4

5

6

7

State uses
Share of
National rank in
the same
Nation’s
Share of
eligibility
Joint
MedicaidNation’s
system for
Medicaid/
enrolled
MedicaidMedicaid
CHIP
Children
enrolled Children
and CHIP
application
S-CHIP and Combination Programs
8.5%
2
•
13.2%
1
•
5.5%
4
•
1.6%
20
•
0.5%
37
•
•
6.6%
3
•
4.0%
6
•
1.7%
19
•
M-CHIP and M-CHIP Dominant Combination Programs
3.6%
8
•
•
2.4%
13
•
•

8

9

10

11

Same
delivery
system for
Children in
Medicaid
and CHIP

Same name
for Medicaid
and CHIP
programs for
children

State
reports
CHIP
enrollment
in MSIS

State participates in
Maximizing
Enrollment for Kids
Evaluation

•

•
•
•
•
•a

•
•
•
•
•

•
•

•

•
•

•

a

Louisiana uses the same delivery system for Medicaid and the M-CHIP program for children under 200 percent of the poverty level. Children in the S-CHIP portion of the program are in a different delivery system.

Note:

Program types: C = Combination program; M = M-CHIP program; S = S-CHIP program

Source:

Program type data: CMS FY 2008 CHIP Annual Enrollment Report. Available at https://www.cms.gov/NationalCHIPPolicy/downloads/
FY2008StateTotalTable012309FINAL.pdf]. Accessed on December 23, 2010.
Uninsured rate among low-income children: Lynch, Victoria, Samantha Phong, Genevieve Kenney, and Juliana Macri. “Uninsured Children:
Who Are They and Where Do They Live? New National and State Estimates from the 2008 American Community Survey.” Washington, DC: the Urban Institute,
August 2010.
Medicaid data: Compiled by the Health Management Associates from state Medicaid enrollment reports, for the Kaiser Commission on Medicaid and the Uninsured,
2010. For more details on the December 2009 enrollment data, please see “Medicaid Enrollment: December 2009 Data Snapshot,” available at
http://www.kff.org/medicaid/enrollmentreports.cfm.Accessed January 11, 2011.
Eligibility systems, joint application data: Heberlein, M., Brooks, T., Guyer, J., Artiga, S. and J. Stephens. “Holding Steady, Looking Ahead: Annual Findings of a 50State Survey of Eligibility Rules, Enrollment and Renewal Procedures, and Cost-sharing practices in Medicaid and CHIP, 2010 – 2011.” Report produced for the
Kaiser Commission on Medicaid and the Uninsured. January 2011. Available: http://www.kff.org/medicaid/upload/8130.pdf.
Delivery system and program name: Centers for Medicare & Medicaid Services. “CMS FY 2008 CHIP Annual Enrollment Report.” Available at
[https://www.cms.gov/NationalCHIPPolicy/downloads/FY2008StateTotalTable012309FINAL.pdf]. Accessed on December 23, 2010.
Reporting of S-CHIP data in MSIS: Matthew Hodges, research analyst, Mathematica Policy Research, personal communication, November 16, 2010.
Maximizing Enrollment for Kids evaluations: Mathematica data.