TITLE Implementation of the State Children's Health Insurance Program: Synthesis of State Evaluations

DOCUMENT RESUME ED 475 969 PS 031 231 AUTHOR Rosenbach, Margo; Ellwood, Marilyn; Irvin, Carol; Young, Cheryl; Conroy, Wendy; Quinn, Brian; Kell, Megan TITLE Implementation of the State Children's Health Insurance Program: Synthesis of State Evaluations. Background for the Report to Congress. INSTITUTION Mathematica Policy Research, Inc., Cambridge, MA. REPORT NO MPR-8644-100 PUB DATE 2003-03-00 NOTE 313p.; Supported by Centers for Medicare & Medicaid Services, Office of Research, Development, and Information. CONTRACT 500-96-0016-03 AVAILABLE FROM For full text: http://www.mathematica-mpr.com/ PDFs/impchildhlth.pdf. PUB TYPE Reports Descriptive (141) EDRS PRICE- EDRS Price MF01/PC13 Plus Postage. DESCRIPTORS Access to Health Care; *Child Health; Children; Eligibility; Enrollment; *Health Insurance; Low Income; Program Implementation; State Federal Aid; *State Programs IDENTIFIERS *Childrens Health Insurance Program; *Program Characteristics; Uninsured. Persons ABSTRACT The State Children's Health Insurance Program (SCHIP) provides funds to states to expand health insurance coverage for low-income children who are uninsured. States have a great deal of flexibility to design and implement SCHIP, resulting in considerable diversity across states. Enrollment reached 3.4 million in federal fiscal year 2000 and continued to climb to 4.6 million in 2001. This report describes the early implementation and progress of SCHIP programs in reaching and enrolling eligible children and reducing the number of low-income children who are uninsured. The report presents a snapshot of states' early experiences with their SCHIP programs based on information from state evaluations submitted in March, 2000, prior to modifications made to take advantage of the flexibility offered under the Social Security Act Title XXI statutes governing the Children's Health Insurance Program. Following a discussion of the background and rationale for the report, the report details the following:(1) factors affecting the provision of health insurance to low-income children;(2) SCHIP eligibility criteria and policies;(3) scope of benefits and cost-sharing requirements; (4) states' choice of delivery systems to serve SCHIP enrollees; (5) coordination between SCHIP and other public programs;(6) states' reflections on the effectiveness of their SCHIP outreach efforts;(7) how states are avoiding crowd-out of private insurance;(8) state progress toward reducing the number of uninsured low-income children; and (9) state recommendations for improving Title XXI. The report's three appendices include a profile of SCHIP programs in the U.S. territories, a summary of amendments to Title XXI state plans as of March, 2001, and supplemental information on benefit design and cost-sharing structure of SCHIP programs. (Contains 34 references.)(HTH) Reproductions supplied by EDRS are the best that can be made from the original document. Contract No.: 500-96-0016(03) MPR Reference No.:8644-100 MATHEMATICA Policy Research, Inc. Implementation of the State Children's Health Insurance Program: Synthesis of State Evaluations Background for the Report to Congress March 2003 U.S. DEPARTMENT OF EDUCATION PERMISSION TO REPRODUCE AND Office of Educational Research and Improvement DISSEMINATE THIS MATERIAL HAS EDUCATIONAL RESOURCES INFORMATION Margo Rosenbach BEEN GRANTED BY CENTER (ERIC) This document has been reproduced as Marilyn Ellwood )1(received from the person or organization originating it. Carol Irvin Minor changes have been made to Cheryl Young improve reproduction quality. Wendy Conroy TO THE EDUCATIONAL RESOURCES Points of view or opinions stated in this Brian Quinn INFORMATION CENTER (ERIC) document do not necessarily represent 1 official OERI position or policy. Megan Kell Submitted to: Submitted by: Centers for Medicare & Medicaid Services Mathematica Policy Research, Inc. Office of Research, Development, 50 Church Street, 4th Floor and Information Cambridge, MA 02138 7500 Security Boulevard (617) 491-7900 Baltimore, MD 21244 Project Officer: Project Director: Rosemarie Hakim Margo Rosenbach 2 lign COPYAVAILABITE This report was prepared for the Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services, under CMS contract number 500-96-0016 (03). The contents of this publication do not necessarily reflect the views or policies of CMS or DHHS, nor does the mention of trade names, commercial products, or organizations imply endorsement by CMS, DHHS, or Mathematica Policy Research, Inc. The authors are solely responsible for the contents of this publication. CONTENTS Chapter Page EXECUTIVE SUMMARY xiii INTRODUCTION 1 A. OVERVIEW OF SCHIP AS OF MARCH 31, 2001 1 B. RATIONALE FOR THIS REPORT 7 C. ORGANIZATION OF THIS REPORT 9 II FACTORS AFFECTING THE PROVISION OF HEALTH INSURANCE TO LOW-INCOME CHILDREN 11 A. THE ROLE OF PREEXISTING STATE PROGRAMS 11 B. OTHER CHANGES AND TRENDS AFFECTING THE PROVISION OF HEALTH INSURANCE TO LOW-INCOME CHILDREN 18 1. Changes in the Public Sector 21 2. Changes in the Private Sector 24 3. Changes in Delivery Systems 26 4. Changes in Socioeconomic Characteristics 26 C. CONCLUSION 27 III SCHIP ELIGIBILITY CRITERIA AND COVERAGE POLICIES 29 A. OVERVIEW OF SCHIP INCOME THRESHOLDS 30 B. THE EXTENT OF SCHIP EXPANSIONS BEYOND MEDICAID 34 C. USE OF NET INCOME TESTS TO ADJUST INCOME 39 D. OTHER CRITERIA USED TO DETERMINE ELIGIBILITY FOR SCHIP 42 iii CONTENTS (continued) Chapter Page 1. Use of Asset Tests 42 2. Service Area and Residency Requirements 43 E. OTHER POLICIES THAT AFFECT TIME LIMITS FOR COVERAGE 43 1. Retroactive Eligibility 44 2. Presumptive Eligibility 47 3. Frequency of Redeterminations and Continuous Eligibility 48 F. CONCLUSION 49 IV SCOPE OF BENEFITS AND COST-SHARING REQUIREMENTS. 51 A. STATE COST-SHARING STRUCTURES 53 B. SCOPE OF BENEFITS COVERED BY SCHIP PROGRAMS 62 C. STATE MONITORING OF FAMILY COST SHARING 78 D. CONCLUSION 81 V STATES' CHOICE OF DELIVERY SYSTEMS TO SERVE SCHIP ENROLLEES 83 A. OVERVIEW OF SCHIP DELIVERY SYSTEMS 84 B. USE OF CARVE-OUTS BY SCHIP PROGRAMS 88 C. CHALLENGES IN ESTABLISHING AND MAINTAINING PROVIDER NETWORKS 92 D. CONCLUSION 98 VI COORDINATION BETWEEN SCHIP AND OTHER PUBLIC PROGRAMS 101 iv 5 CONTENTS (continued) Chapter Page A. COORDINATION WITH MEDICAID 102 1. Joint Applications 103 2. Coordination of Outreach Activities 105 3. Coordination of Administration 106 4. Data Collection and Quality Assurance 106 5. Service Delivery, Procurement, and Contracting 107 B. COORDINATION WITH OTHER PROGRAMS 108 1. Coordination with Maternal and Child Health and Other Public Health Programs 109 2. Coordination with Schools and the National School Lunch Program 111 3. Coordination with the Special Supplemental Food Program for Women, Infants, and Children 113 C. CONCLUSION 115 VII STATES' REFLECTIONS ON THE EFFECTIVENESS OF THEIR SCHIP OUTREACH EFFORTS 117 A. METHODS USED BY STATES TO ASSESS THEIR OUTREACH EFFORTS 117 B. STATE ASSESSMENTS OF OUTREACH EFFECTIVENESS 123 1. Types of Outreach Activities Performed by States 123 2. Types of Outreach Settings Used by States 131 C. LESSONS LEARNED IN BUILDING THE OUTREACH INFRASTRUCTURE 137 1. Building Capacity for Outreach Activities 137 2. Coordinating Outreach Activities 138 3. Training State and Local Partners 140 4. Financing Outreach Activities 141 D. LESSONS LEARNED ABOUT OUTREACH TO SPECIAL POPULATIONS 142 E. CONCLUSION 145 v CONTENTS (continued) Chapter Page VIII HOW STATES ARE AVOIDING CROWD-OUT OF PRIVATE INSURANCE 147 A. OVERVIEW OF PROGRAM FEATURES TO PREVENT CROWD-OUT 148 B. USE OF WAITING PERIODS WITHOUT INSURANCE COVERAGE 150 C. HOW STATES PREVENT CROWD-OUT THROUGH THE ELIGIBILITY DETERMINATION PROCESS 154 D. STATE APPROACHES TO MONITORING AND MEASURING CROWD-OUT 157 E.EARLY FINDINGS ON THE EXTENT OF CROWD-OUT UNDER SCHIP 159 F.CONCLUSION 162 IX STATE PROGRESS TOWARD REDUCING THE NUMBER OF UNINSURED LOW-INCOME CHILDREN 165 A. STATE BASELINE ESTIMATES OF UNINSURED CHILDREN 166 B.STATE ESTIMATES OF THEIR PROGRESS TOWARD REDUCING THE NUMBER OF UNINSURED CHILDREN 169 1. State Approaches to Measuring Progress 180 2. Effect of SCHIP Outreach on Traditional Medicaid Enrollment 183 C. CONCLUSION 186 X STATE RECOMMENDATIONS FOR IMPROVING TITLE XXI 189 A. RECOMMENDATIONS TO IMPROVE COVERAGE 190 1. Expand Coverage for Children of Public Employees 190 2. Allow Coverage of Uninsured Parents 190 3. Allow Coverage of Other Populations 191 4. Remove Barriers to Coordinating with Employer-Sponsored Insurance 191 5. Ease Provisions Related to Crowd-Out 193 vi CONTENTS (continued) Chapter Page B. RECOMMENDATIONS TO IMPROVE FINANCING AND ADMINISTRATION 194 1. Eliminate or Modify the 10 Percent Administrative Cap 194 2. Extend the Deadline for Spending the SCHIP Allotment 196 3. Improve Technical Assistance and Coordination Among Federal Programs 197 C. RECOMMENDATIONS TO MAINTAIN OR INCREASE FLEXIBILITY 199 1. Reduce Requirements for SCHIP Programs 199 2. Increase Flexibility Regarding Cost-Sharing 201 3. Increase Flexibility in the Definition of Creditable Coverage 202 D. CONCLUSION 202 REFERENCES 205 APPENDIX A:PROFILE OF SCHIP PROGRAMS IN THE U.S. TERRITORIES APPENDIX B:SUMMARY OF AMENDMENTS TO TITLE XXI STATE PLANS, AS OF MARCH 7, 2001 APPENDIX C:SUPPLEMENTAL INFORMATION ON BENEFIT DESIGN AND COST-SHARING STRUCTURE OF SCHIP PROGRAMS vii TABLES Table Page I.1 PROGRAMS FUNDED THROUGH TITLE XXI, AS OF MARCH 31, 2001 2 1.2 CROSSWALK OF TITLE XXI STATUTES TO THIS REPORT 10 II.1 STATUS OF PREEXISTING STATE CHILD HEALTH PROGRAMS 13 11.2 CHANGES AND TRENDS IN THE

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