Health Care Utilization Among Children Enrolled in Medicaid and CHIP Via Express Lane Eligibility

Background: Express Lane Eligibility (ELE) enables state Medicaid and/or Children’s Health Insurance Programs (CHIP) to use another agency’s eligibility findings to qualify children for public health insurance coverage, thus facilitating enrollment of eligible uninsured children. Lack of prior enrollment may reflect limited awareness about enrollment or lower demand for health care. Because ELE sometimes requires few affirmative enrollment steps from families, a related issue is whether enrollees understand their new coverage.

Objective: Examine utilization patterns among ELE enrollees to assess whether: (1) they understand how to access care and (2) their demand for care differs from children who enroll via standard routes.

Data: Enrollment, claims, and encounter data for non-disabled children ages 0-18 enrolled, either through ELE or standard routes, in Medicaid or CHIP in Alabama, Iowa, Louisiana, and New Jersey during 2009 - 2012. The analytic sample includes enrollees with no prior Medicaid/CHIP coverage or a gap in Medicaid/CHIP coverage of at least two months, and who were continuously enrolled for six months.

Methods: We compared first-year utilization among non-disabled children who enrolled through ELE and standard pathways. Two-step estimation was used, first examining the likelihood of utilization and then service volume and cost among users. We examined several types of services: inpatient, outpatient/physician, and emergency room visits; prescription drugs, vision care, dental care; and behavioral health. Outcomes included any service use, the number of uses, cost of care, and exclusive use of that service type without other claims. We also examined length of time until first service receipt. Regression-adjusted utilization rates account for demographic characteristics and enrollment month. Logistic models were used for binary outcomes, Poisson models for counts of services, and generalized estimating equations with a gamma distribution and log-link for cost outcomes. Separate models were run for each state, and all models account for clustering of standard errors at the person level.

Findings: Most ELE enrollees (65 to 94% across states) accessed services in their first year of enrollment; however, ELE enrollees were less likely than other children enrolled in Medicaid/CHIP to use services by significant, but small margins (3 to 8% points, p < 0.05). ELE and other enrollees tended to use a variety of services; exclusive emergency room use was rare. ELE enrollees were somewhat less likely to use each service type we studied, and users often accessed fewer services than other enrolled children in their state. For example, ELE enrollees who used services averaged 10 to 44% fewer outpatient/physician visits (p < 0.05). Regression-adjusted fee-for-service costs for the first year were 14 to 52% lower for ELE enrollees using services (p < 0.05).

Conclusions: Utilization patterns suggest that ELE enrollees are aware of their coverage.  Results are consistent with the theory that eligible children who do not enroll directly may have a lower demand for health care than their enrolled peers. States considering ELE—especially those that negotiate contracts with capitated managed care organizations to deliver services—may expect that eligible but uninsured children will be less expensive to cover than existing beneficiaries.