It took six months and a letter to the governor with a picture of their newborn for two Philadelphia graduate students to successfully enroll their son in CHIP -- and even then their premiums were miscalculated, based on a system reporting error that tripled their actual income.
During that time, starting the day their son Erik was born in April 2012, Ari Friedman and Tara Mendola made 86 calls to the Medicaid district office, the Pennsylvania office, Independence Blue Cross and the CHIP hotline, in many cases following up on applications submitted and resubmitted that program managers said were lost or incomplete.
The couple themselves are insured through their universities -- Friedman at Penn, where he's getting a doctorate in health economics (he also hopes to complete medical school), and Mendola through NYU, where she's getting a doctorate in medieval Arabic and French literature (while living in Philadelphia). They planned on insuring their son through the Children's Health Insurance Program, which covers children whose families don't qualify for Medicaid but can't afford private insurance, and expected to complete the application within six weeks.
[See also: CMS awards states bonuses for increasing CHIP enrollment]
But as Friedman and Mendola write in Health Affairs, what should have been a fairly straightforward application process ended up being a bureaucratic maze that may or may not be improved under the Affordable Care Act.
While many state eligibility rules stipulate at least six months of uninsurance for children prior to CHIP coverage, Pennsylvania waives the "go-bare" requirement for children under the age of two, so Friedman and Mendola applied for coverage as soon as their son Erik was born.
They started by calling Independence Blue Cross, one of several private insurers providing CHIP coverage for the state, and were referred to the state Medicaid program as first step, because children have to be rejected by Medicaid before qualifying for CHIP.
Friedman and Mendola applied for Medicaid through the state's online portal, COMPASS, and called several days later to check on the status. A program representative could not find the application, surmising it had been "lost," and told them to reapply.
They reapplied, and several weeks later as Erik was turning one month old, received a letter notifying them that he was not eligible for Medicaid, as expected -- but with no mention of options for CHIP coverage.
After several calls to the Medicaid office, Friedman and Mendola were told their documentation had been lost in the Medicaid system (for a second time) and did not reach Independence Blue Cross to go forward with the CHIP application. They had to send documentation, for a third time, with a request for reconsideration, which essentially meant starting the process again and waiting on a four to six week timeline.
"We never learned why the application hadn't been passed on originally, or why the only way to correct the problem was to start again," they wrote.
Meanwhile, they bought Erik $90-per-month catastrophic coverage, with a $2,500 deductible and a $5,000 out-of-pocket maximum, as medical expenses for him piled up -- $600 for the hospital delivery, $500 for well visits and vaccinations and $400 for a minor surgical procedure.
"These were all relatively routine expenses for a healthy, full-term baby; had Erik been premature or sick in any way, the cost would have been much higher. We were lucky," they wrote.
Trying to check in on the Medicaid re-application, they contacted a local Medicaid office caseworker, who by program rules has to respond within two days, and never heard back. Not long after that, in early July, they received the second Medicaid rejection later -- but, like the first letter, it did not say whether or not the file was forwarded to Independence Blue Cross to complete the CHIP application.
A state Medicaid representative told them their file was flagged with the rejection code "69" -- which puzzled her, because that code didn't exist in the program manual. The Medicaid rep contacted the Philadelphia office and assured Friedman and Mendola they would be contacted in three days.
A week passed, and the couple called the district office, but they received no response.
Frustrated, they thought they would take their case in-person to the Philadelphia county Medicaid office. "When we went to the address listed on the state website at the time, however, we found only a demolished building." They called, found the correct address (now at the city's Office of Community Services) and met a caseworker who promised to resolve the problems.
The next day, they learned the file was finally sent to Independence Blue Cross for CHIP consideration. "Nearly a month later an employee of Independence Blue Cross called to tell us that our application was stalled because the company didn't have a copy of Erik's Social Security card--although the district Medicaid office had insisted early on that a Social Security number wasn't necessary."
They faxed a copy of the child's Social Security Card, and as the Pennsylvania Insurance Department checked to verify the child's current coverage, the couple asked Independence Blue Cross if it'd be alright to continue the catastrophic coverage as they waited for the CHIP decision.
"We assumed that would not be a problem because Pennsylvania exempts infants from the go-bare requirement, but the representative believed that any insurance coverage would very likely jeopardize Erik's application. He told us that approval should take only a week longer and recommended that we let Erik be uninsured."
While awaiting that decision, the couple decided to send letters detailing their ordeal, with photos of Erik, to Philadelphia Mayor Michael Nutter, Pennsylvania Governor Tom Corbett and Congresswoman Allyson Schwartz, and within a week a representative from Corbett called, saying she would try to help.
Three days later, they received a letter from the state Medicaid office: "You recently contacted Governor Corbett's office regarding your struggle in obtaining health care for your newborn son...Eric was found eligible for Full-Cost CHIP" (note that the child's name was misspelled).
"Although we were grateful for (the Corbett representative's) kindness, the fact that we needed political intervention signaled that something in the system was profoundly broken," Friedman and Mendola wrote.
But the struggle wasn't over. Full-cost CHIP premiums would be $241 a month, which was quite a bit more than it should have been. The couple's income was erroneously recorded at triple their actual income, and they had to resubmit pay stubs and request reconsideration.
In late August, they were found eligible for a subsidized rate of $30 per month. By that time, CHIP enrollment for September was closed, so they had to wait until October to enroll their son, although later the Pennsylvania director of CHIP policy called to apologize for the problems and offered to backdate the insurance policy to August.
After navigating such an apparently broken bureaucracy, how do Friedman, who wants to become a doctor, and Mendola feel about the experience?
"Throughout our months of waiting, no one was uncaring. But the system's inefficiency and lack of transparency stymied everyone's efforts to get us the service we needed," they write. "To blame the failures of that system on the myth of the governmental employee as recalcitrant and incompetent is to take the easy way out of a greater problem."
They are somewhat optimistic that new administrative and application simplifications going into effect next year under the Affordable Care Act will help alleviate the systematic problems, with one federal data center sharing applicant and eligibility information digitally among the Internal Revenue Service, the Department of Health and Human Services, the Social Security Administration and relevant state agencies.
At the same time, they write, there is the possibility that voters will continue to "tolerate programs which only look good instead of being good. We must believe not only that the gross inefficiencies of entitlement bureaucracies should be reformed, but also that such reform is both possible and necessary."