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Implementation of the State Children's Health Insurance

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Implementation of the State Children's Health Insurance Contract No.: 500-96-0016(03) MPR Reference No.: 8644-100 Implementation of the State Children’s Health Insurance Program: Synthesis of State Evaluations Background for the Report to Congress March 2003 Margo Rosenbach Marilyn Ellwood Carol Irvin Cheryl Young Wendy Conroy Brian Quinn 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 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 I 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 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)
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