GehshanView Graph # 0 Benefits and Service Delivery Issues Under CHIP Shelly Gehshan Forum for State Health Policy Leadership, NCSL September, 1998

GehshanView Graph # 1 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

GehshanView Graph # 2 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)

GehshanView Graph # 3 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

GehshanView Graph # 4 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

GehshanView Graph # 5 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.

GehshanView Graph # 6 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

GehshanView Graph # 7 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)

GehshanView Graph # 8 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)

GehshanView Graph # 9 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

GehshanView Graph # 10 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

GehshanView Graph # 11 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)

GehshanView Graph # 12 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 +

GehshanView Graph # 13 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 -

GehshanView Graph # 14 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

GehshanView Graph # 15 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 +/-

GehshanView Graph # 16 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

GehshanView Graph # 17 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

GehshanView Graph # 18 OF THE 30 APPROVED PLANS 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

GehshanView Graph # 19 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