Dataset Information

Effects of Medicaid Automatic Enrollment on Disparities in Insurance Coverage and Caregiver Burden for Children with Special Health Care Needs.

ABSTRACT: We analyze how Medicaid automatic enrollment policies for children with special health care needs (CSHCN) who are enrolled in Supplemental Security Income (SSI) reduce disparities in health insurance coverage and caregiving burden. Using the 2009-2010 National Survey of Children with Special Health Care Needs, we implement a difference-in-differences regression model comparing insurance enrollment rates between CSHCN receiving SSI and CSHCN not receiving SSI, in states with and without automatic enrollment policies. We find that Medicaid automatic enrollment has a meaningful impact on insurance enrollment for low-income CSHCN who participate in SSI and can be an effective method for mitigating disparities in insurance coverage (reducing uninsurance by 38%). Medicaid automatic enrollment also reduces caregiver burden among socioeconomically disadvantaged families with CSHCN. The effects of these policies are largest families who might be on the margin of eligibility or who face high administrative burden.

SUBMITTER: Rennane S

PROVIDER: S-EPMC10218366 | biostudies-literature | 2023 Feb

REPOSITORIES: biostudies-literature

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Effects of Medicaid Automatic Enrollment on Disparities in Insurance Coverage and Caregiver Burden for Children with Special Health Care Needs.

Rennane Stephanie S Dick Andrew A

Medical care research and review : MCRR 20220705 1

We analyze how Medicaid automatic enrollment policies for children with special health care needs (CSHCN) who are enrolled in Supplemental Security Income (SSI) reduce disparities in health insurance coverage and caregiving burden. Using the 2009-2010 National Survey of Children with Special Health Care Needs, we implement a difference-in-differences regression model comparing insurance enrollment rates between CSHCN receiving SSI and CSHCN not receiving SSI, in states with and without automatic ...[more]

PMID: 35788159

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Project description:ImportanceIn 2021, the Centers for Medicare & Medicaid Services designated a new category of dual-eligible special needs plans (D-SNPs) with exclusively aligned enrollment (receive Medicare and Medicaid benefits through the same plan or affiliated plans within the same organization).ObjectiveTo assess the availability of and enrollment in D-SNPs with exclusively aligned enrollment and to compare the characteristics of beneficiaries enrolled in D-SNPs with exclusively aligned enrollment available vs beneficiaries without such enrollment available.Design, setting, and participantsFull-benefit beneficiaries enrolled in D-SNPs for 6 months or longer in 2021 or 2022. Availability of and beneficiary enrollment in D-SNPs were assessed by year and county for D-SNPs with exclusively aligned enrollment available vs D-SNPs without exclusively aligned enrollment available. The D-SNP enrollees residing in counties with aligned plans available were compared based on demographic, social, health, and area characteristics vs D-SNP enrollees in counties without such plans available. Comparisons were also made based on beneficiaries who enrolled in the aligned D-SNPs vs those who did not enroll (were enrolled in unaligned D-SNPs). The data analyses were conducted from October 1, 2023, to August 2, 2024.Main outcomes and measuresAvailability of aligned D-SNPs and beneficiary residence by county; enrollment in exclusively aligned D-SNPs vs unaligned D-SNPs; and beneficiary demographic, social, health, and area characteristics.ResultsOf 2 197 732 beneficiaries enrolled in D-SNPs in 2021, 881 736 (40.1%) were living in counties with aligned enrollment available and 251 305 (11.4%) enrolled. Of 2 689 045 beneficiaries enrolled in D-SNPs in 2022, 1 047 223 (38.9%) were living in counties with aligned enrollment available and 318 906 (11.9%) enrolled. Beneficiaries enrolled in D-SNPs residing in counties without aligned enrollment available were more likely to live in rural or micropolitan areas (21.9%) vs beneficiaries in counties with aligned enrollment available (8.1%) (standardized mean difference [SMD], 0.38 [95% CI, 0.38-0.38]), be entitled to disability (44.4% vs 27.3%, respectively; SMD, 0.36 [95% CI, 0.36-0.36]), or be Black individuals (27.4% vs 21.4%; SMD, 0.14 [95% CI, 0.14-0.14]); were less likely to be Hispanic individuals (15.4% vs 33.7%; SMD, 0.45 [95% CI, 0.45-0.45]) or Asian or Pacific Islander individuals (6.1% vs 12.2%; SMD, 0.22 [95% CI, 0.22-0.22]); and lived in zip codes with a higher area deprivation index (mean, 66.8 [SD, 26.4] vs mean, 43.2 [SD, 29.0]; SMD, 0.86 [95% CI, 0.86-0.86]). Beneficiaries enrolled in aligned D-SNPs were more likely to be receiving long-term institutionalized care vs beneficiaries in nonaligned D-SNPs (4.3% vs 1.0%, respectively; SMD, 0.24 [95% CI, 0.24-0.25]) or have dementia or Alzheimer disease (9.2% vs 5.9%; SMD, 0.13 [95% CI, 0.13-0.13]).ConclusionsThis study found that availability of and enrollment in D-SNPs with exclusively aligned enrollment are increasing, but the overall proportion enrolled remains low. Further reforms are needed to promote aligned enrollment.

Project description:ImportanceThe Affordable Care Act created 2 new coverage options for uninsured adults: Medicaid expansion, which in most states provides comprehensive coverage without premiums and deductibles; and private marketplace coverage, which requires a premium contribution and cost-sharing, though with generous federal subsidies at lower incomes. How enrollment rates compare in the marketplace vs Medicaid is an important policy question as states continue to weigh alternative coverage options such as Medicaid buy-in programs, enrolling Medicaid-eligible populations into marketplace plans, or creating a public option.ObjectiveTo assess the association between income eligibility for Medicaid vs marketplace coverage and insurance enrollment among low-income adults in Colorado.Design setting and participantsUsing 2014 and 2015 all-payer claims data from Colorado and detailed income eligibility information, we used a regression discontinuity design to assess the difference in Medicaid and marketplace enrollment just below and just above 138% of the federal poverty level (FPL), the eligibility threshold between the 2 programs. The sample included nonpregnant adults aged 19 to 64 years with incomes between 75% to 400% FPL. We stratified our analysis by age, sex, chronic condition status, and urban vs rural residence. Analysis was conducted from January to October 2020.Main outcome and measuresThe main outcome was total enrollment in either Medicaid or marketplace coverage during marketplace's Open Enrollment period. Income-based health insurance eligibility was assessed as a percentage of FPL at the time of initial application for coverage.ResultsThe primary analytical sample included 32 091 enrollees in 2014 and 55 451 in 2015, with incomes ranging from 120% to 156% FPL. Most enrollees were women (59.26% in 2014, 59.20% in 2015), resided in urban areas (70.36% in 2014, 73.08% in 2015), and had no chronic conditions (74.66% in 2014, 76.11% in 2015). For age, in 2014 and 2015, respectively, 13.22% and 13.93% were aged 19 to 25 years, 27.85% and 28.54% were aged 26 to 34 years, 23.58% and 24.34% were aged 35 to 44 years, 18.35% and 17.75% were aged 45 to 54 years, and 17.00% and 15.44% were aged 55 to 64 years. Marketplace enrollment was 81.3% (95% CI, -86.0% to -75.0%) lower than Medicaid enrollment in 2014 and 88.6% (95% CI, -90.8% to -86.0%) lower in 2015 among those close to the 138% FPL eligibility threshold. The drop-off in marketplace enrollment was largest among younger adults, aged 26 to 34 and 35 to 44 years: relative drop off -88.7% (95% CI, -93.3% to -80.8%) and -87.8% (95% CI, -90.8% to -83.9%) in 2014, and relative drop off -91.9% (95% CI, -94.5% to -87.9%) and -93.0% (95% CI, -94.5% to -91.1%) in 2015, respectively.Conclusions and relevanceIn this cross-sectional study using a regression-discontinuity analysis, meaningful gaps in insurance enrollment may have existed for those with incomes just above the eligibility threshold for Medicaid expansion, especially among younger adults. Policies expanding Medicaid income eligibility or zero-dollar premium marketplace plans are likely to be more effective at inducing enrollment than subsidized private plans with premium requirements.

Project description:ImportanceMore than 4 million Medicare beneficiaries have enrolled in dual-eligible Special Needs Plans (D-SNPs), and coordination-only D-SNPs are common. Little is known about the impact of coordination-only D-SNPs on Medicaid-covered services and spending, including long-term services and supports, which are financed primarily by Medicaid.ObjectiveTo evaluate changes in Medicaid fee-for-service (FFS) spending before and after new enrollment in coordination-only D-SNPs vs new enrollment in non-D-SNP Medicare Advantage (MA) plans among community-living beneficiaries enrolled in both Medicare and North Carolina Medicaid.Design, setting, and participantsThis cohort study applied a new user, active comparator design to control for selection into MA and inverse probability of treatment weighting to improve the comparability between groups. The cohort included community-living dual-eligible Medicare and Medicaid beneficiaries in North Carolina with 365 days of Medicare FFS enrollment prior to new enrollment in D-SNP (treatment) or other MA plan (active comparator). Linked 100% Medicare and North Carolina Medicaid claims data (2014-2017) provided payments across both payers prior to MA enrollment; after MA enrollment, payments for Medicaid-funded services and supplemental Medicaid payments for Medicare-funded services were observed. Data were analyzed from August 2023 to November 2024.ExposureNew D-SNP enrollment.Main outcomes and measuresOutcomes included annualized 1-year Medicaid FFS spending overall and by claim type, including inpatient, outpatient, carrier, home health, personal care services, and behavioral health services.ResultsAmong 8869 participants in the D-SNP cohort, 4762 (53.7%) were younger than 65 years, 5833 (65.8%), were female, and 975 (11.0%) resided in rural areas. After inverse probability of treatment weighting, characteristics were similar among the comparison MA cohort of 4389 participants (4706 [53.2%] aged <65 years; 5739 [64.9%] female; 971 [11.0%] rural). There were no significant differences in Medicaid FFS spending per person-year (PPY) at baseline or differential change in the year following new enrollment (mean marginal effect, -$387 [95% CI, -$1274 to $501) between groups. There were significant differences between groups in the change in spending on long-term services and supports, with maintained spending on community-based personal care services following new enrollment in D-SNPs compared with reductions for other MA, resulting in a relative increase of $343 (95% CI, $147 to $539).Conclusions and relevanceThis cohort study found that coordination-only D-SNPs was associated with maintained North Carolina Medicaid FFS spending levels for long-term services and supports compared with other MA plans, despite limited integration requirements. However, to reduce or delay nursing home transitions, higher levels of integration may be necessary.

Dataset Information

Effects of Medicaid Automatic Enrollment on Disparities in Insurance Coverage and Caregiver Burden for Children with Special Health Care Needs.

Publications

Effects of Medicaid Automatic Enrollment on Disparities in Insurance Coverage and Caregiver Burden for Children with Special Health Care Needs.

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