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Benefits and Service Delivery Issues Under CHIP

Shelly Gehshan

Forum for State Health Policy Leadership, NCSL

September, 1998

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THIS PRESENTATION WILL REVIEW...

What benefits children need

What benefits CHIP plans will provide

CHIP service delivery issues

Implications for service delivery of using Medicaid versus a private plan

Concerns about key populations and services

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CHILDREN ARE NOT LITTLE ADULTS

4% have a developmental problem

7% have a learning disability

20% have an emotional or behavioral problem (1 in 4 is severe)

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CHILDREN WITH SPECIAL NEEDS

Estimates of CSHCN vary most on how many have mild to moderate disabilities

6 to 9% have some activity limitation

15 to 20% have some chronic condition that causes activity limitations or medical needs

23% have some targeted diagnosis

3 to 5% have severe complex conditions

NHIS data, Newacheck and Taylor, 1992

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HOW MANY CSHCN IN CHIP?

Of Low Income Uninsured Children...

6 to 7% (or 460,000) have some level of disability

18% (or 1,210,000) have some special health care need

12 to 15% of special needs kids are enrolled in Medicaid. NHIS, 1994/Newacheck

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ADOLESCENTS...

Will be the biggest group added under CHIP

Seek confidential care, sometimes independent of parents, impulse-driven

Need reproductive health care

Need mental health and substance abuse treatment.

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RANGE OF SERVICES NEEDED INCLUDES...

Preventive care, routine screenings

Primary and acute care, emergency

Specialty services (OT, PT, ST etc)

Ancillary and support services (translation, transportation)

Behavioral health

Reproductive health

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CHIP BENEFITS STRUCTURE

Of the 49 states and territories with submitted or approved plans…

25 will use Medicaid benefits

6 will use Medicaid benefits through an 1115 waiver program

2 will use “Medicaid look-alike” packages (but no obligation to do EPSDT)

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CHIP BENEFITS STRUCTURE (cont.)

11 will use state employee coverage

3 will use other benchmark plans

3 will use benchmark equivalent plans

(FEHBP, largest HMO)

3 packages are grandfathered (FL, NY, PA)

1 will use secretary-approved coverage (MCD look-alike)

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CHIP BENEFITS ISSUES

Equity issues for kids in states with private and combination plans

Benchmark packages were designed for adults--for episodic illnesses and accidents rather than routine preventive care

Benchmark plans will offer fewer benefits than Medicaid

CSHCN will face service limitations

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CHIP SERVICE DELIVERY ISSUES

Are not unique to CHIP

Depend on the approach the state is taking (Medicaid or private program)

Will build on the state’s experience with Medicaid managed care

Have been neglected in the design phase

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MANAGED CARE ISSUES TO WATCH

Capacity, impact on safety net providers

Inexperience with low income groups, cultural and language barriers

Financial incentives for underservice

Adverse selection, pent up need

Inadequate networks (links to FQHCs, specialists)

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MEDICAID PLANS, PROS AND CONS

More bargaining power with managed care plans +

Removes need for tracking cost-sharing +

One benefit package, one set of providers or plans +

Networks, data systems and contract mechanisms are already in place +

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MORE PROS AND CONS

CHIP adds more demand to the system -

Medicaid delivery systems still in transition to managed care +/-

Medicaid managed care systems have problems (low rates, service incentives) -

Traditional problems under fee for service system still not solved -

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MEDICAID FFS ISSUES WILL PERTAIN TO CHIP

Reimbursement rates too low

Administrative burden high, payment slow

Fear of too many Medicaid/CHIP patients

Stigma of caring for low income people

Mal-distribution, particularly in rural areas

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CHIP PRIVATE PLANS PROS AND CONS

New data systems, networks, contracts needed -

Start-up can be bumpy, slow, confusing -

Flexibility to set reimbursement rates +

Stigma lower w/ higher income groups, new name for program +

Coordination issues with Medicaid +/-

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SERVICE-SPECIFIC ISSUES

Dental care--largest unmet need; Medicaid a failure, start over

Family planning--Title X a success, build on it

Mental health/substance abuse--great unmet need; separate system of community providers

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POPULATION-SPECIFIC ISSUES

Adolescents--Hard to reach, school-based centers, many newly insured

Native Americans--Undercount due to I.H.S., serious outreach problems

Immigrants--where will they go now? outreach to legal children

CSHCN--ill suited to managed care, diverse needs

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OF THE 30 APPROVED PLANS...

26 use the Medicaid system or providers

11 will use FFS

6 will use PCCM model managed care

23 will use HMO managed care

21 will use some combination

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CONCLUSIONS

Significant differences exist between/in states on what benefits children can receive

Not all packages adequate for kids

New funding source creates shifts in service delivery system, winners and losers

There will be problems with some services, populations, and areas of states