Health Insurance for Children: State and Private Programs Create New
Strategies to Insure Children (Letter Report, 01/16/96, GAO/HEHS-96-35).
Pursuant to a congressional request, GAO reviewed state and private
efforts to insure children who are not eligible for Medicaid and whose
parents cannot purchase private insurance, focusing on: (1) enrollment,
costs, funding sources, and annual budgets of these state and private
programs; (2) state strategies to manage costs while providing children
access to health care; and (3) program design elements that have
facilitated program implementation.
GAO found that: (1) by 1995, 14 states and at least 24 private-sector
entities had programs to increase health care access for uninsured
children; (2) the number of children enrolled in the state programs
reviewed ranged from 5,000 to over 100,000 children and state budgets
ranged from $1.7 million to $55 million; (3) private-sector programs
enrolled up to 6,000 children and had budgets of $100,000 to $4.3
million; (4) state program funding sources included state general
revenues, donations, and small insurance premiums and copayments; (5)
budget limitations have reduced the number of Medicaid-eligible children
served and have forced these programs to cap enrollment and place
eligible children on waiting lists; (6) the programs' per-child costs
ranged from $20 to $70.60 per-month; (7) state programs have attempted
to reduce costs by limiting eligibility and covered services, relying on
Medicaid to provide inpatient care, and using patient cost-sharing,
managed care, and competitive bidding among insurers; (8) state efforts
to attract providers included using insurers' existing payment systems
and physician networks and paying near-market reimbursement rates, while
their efforts to attract families included guaranteeing patient access
to providers, having simple enrollment procedures, and avoiding the
appearance of a welfare program; and (9) surveys showed that families
were generally satisfied with state insurance programs, since the
programs increased childrens' access to appropriate health care
services.
--------------------------- Indexing Terms -----------------------------
REPORTNUM: HEHS-96-35
TITLE: Health Insurance for Children: State and Private Programs
Create New Strategies to Insure Children
DATE: 01/16/96
SUBJECT: Managed health care
Health insurance
Children
State programs
Eligibility criteria
Health care programs
Medical services rates
Disadvantaged persons
Health care cost control
Insurance premiums
IDENTIFIER: Medicaid Program
Alabama Caring Program for Children
Western Pennsylvania Caring Program for Children
Florida Healthy Kids Program
MinnesotaCare Program
New York Child Health Plus Program
Pennsylvania Children's Health Insurance Program
Alabama
Pennsylvania
Minnesota
New York
Florida
Census Bureau Current Population Survey
National School Lunch Program
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Cover
================================================================ COVER
Report to the Ranking Minority Member, Subcommittee on Children and
Families, Committee on Labor and Human Resources, U.S. Senate
January 1996
HEALTH INSURANCE FOR CHILDREN -
STATE AND PRIVATE PROGRAMS CREATE
NEW STRATEGIES TO INSURE CHILDREN
GAO/HEHS-96-35
New Strategies to Insure Children
(108220)
Abbreviations
=============================================================== ABBREV
AFDC - Aid to Families With Dependent Children
ER - emergency room
FPL - federal poverty level
FHKC - Florida Healthy Kids Corporation
HCFA - Health Care Financing Administration
HMO - health maintenance organization
Letter
=============================================================== LETTER
B-259618
January 18, 1996
The Honorable Christopher J. Dodd
Ranking Minority Member
Subcommittee on Children and Families
Committee on Labor and Human Resources
United States Senate
Dear Senator Dodd:
Since 1987, the number of children covered by employment-based health
insurance has decreased, and, by 1993, more than 9.3 million children
lacked health insurance. Studies have shown that uninsured children
are less likely than insured children to get needed health and
preventive care. Lack of such care can adversely affect their health
status throughout their lives.
In the mid-1980s, several states began using state and other
nonfederal funds to develop health insurance programs for children
who were caught in the uninsured gap between private insurance and
Medicaid, the federal/state program that insures some low-income
people. In addition to state efforts, Blue Cross/Blue Shield
organizations throughout the United States developed privately funded
programs to insure children. At the same time, the federal
government and many states expanded eligibility for Medicaid, the
primary source of insurance for poor children.\1
The 104th Congress is considering legislation making the Medicaid
program into a block grant, limiting the growth of program
expenditures, and removing most guarantees of eligibility for
coverage and requirements for states to cover services. Such
restructuring could give states significantly more flexibility in how
they provide insurance to children.
In light of these developments, you asked us to examine emerging
state and private efforts to insure children who are not eligible for
Medicaid and whose families are not able to purchase private
coverage. Specifically, you asked us to provide information on (1)
enrollment, costs, funding sources, and annual budgets of these state
and private programs; (2) the strategies these programs have used to
manage costs while providing children access to health care; and (3)
program design elements that have facilitated program implementation.
To answer these questions, we visited six programs in five states:
two privately funded programs--the Alabama Caring Program for
Children and the Western Pennsylvania Caring Program for
Children--and four state-funded programs--the Florida Healthy Kids
Program, MinnesotaCare,\2 New York's Child Health Plus Program, and
Pennsylvania's Children's Health Insurance Program.\3 We selected
programs that had at least 2 years' operational experience at the
time of our visit and that represented a variety of approaches in
diverse geographic areas. (See app. II for more detail on specific
programs.)
For each program, we reviewed relevant program documents and
interviewed program officials, participating insurers or managed care
organizations, and physicians. We also interviewed officials from
the Department of Health and Human Services' Health Care Financing
Administration (HFCA), which administers the Medicaid program, and
representatives from children's advocate organizations in program
states. We analyzed other information, including information
collected by the National Governor's Association, on programs to
insure children. We performed our work between November 1994 and
October 1995 in accordance with generally accepted government
auditing standards.
--------------------
\1 Health Insurance for Children: Many Remain Uninsured Despite
Medicaid Expansion (GAO/HEHS-95-175, July 19, 1995).
\2 MinnesotaCare began as a state-funded program and is classified as
such in this report. However, the children participating in the
program were transferred to Medicaid on July 1, 1995, as part of
Minnesota's Medicaid 1115 waiver.
\3 We also visited Maine's Medicaid program, which now covers
children of similar ages and family incomes as did the Maine Health
Program, a state-funded program that is no longer in existence.
However, this report focuses solely on programs that were state- or
privately funded at the time of our visit.
RESULTS IN BRIEF
------------------------------------------------------------ Letter :1
In the mid-1980s, states and private organizations began developing
health insurance programs to increase health care access for
children. By 1995, 14 states and at least 24 private-sector
organizations had such programs. The number of children enrolled in
the six programs we visited ranged from more than 5,000 to more than
100,000. Unlike state Medicaid programs, which operate as open-ended
entitlements funded in part by the federal government, these programs
operated within fixed and often limited budgets and were funded by
various nonfederal sources, such as dedicated state taxes and private
donations. To better target their resources, the state- and
privately funded programs restricted eligibility for subsidized
services to low-income, uninsured, or underinsured children.
Regardless, limited budgets compelled five of the six programs to cap
enrollment at times and to place eligible children on waiting lists.
To manage their costs, the programs used several strategies. Some
limited services covered, but all covered basic preventive and
outpatient services. Some of the programs that did not provide
inpatient care relied on Medicaid to provide this service. Other
cost-management strategies included patient cost-sharing through
premiums and copayments, enrolling children in managed care, and
using competitive bidding to select insurers.
The six programs were designed to attract both providers and
families. Most operated, at least partially, through nonprofit or
private insurers, which enabled the programs to use existing provider
payment systems and physician networks and to offer near-market
reimbursement rates--features that appealed to insurers and
providers. For patients, the programs guaranteed access to a
provider network, had simple enrollment procedures, and took specific
steps to avoid the appearance of a welfare program. Moreover,
initial surveys suggested that children in these programs increased
their access to and appropriate use of health care.
BACKGROUND
------------------------------------------------------------ Letter :2
Health insurance helps children obtain health care. Children without
health insurance are less likely to have routine doctor visits, seek
care for injuries, and have a regular source of medical care. Their
families are more likely to take them to a clinic or emergency room
(ER) rather than a private physician or health maintenance
organization (HMO).\4 \5 \6 Children without health insurance are
also less likely to be appropriately immunized--an important step in
preventing childhood illnesses.\7 \8
During the 1980s, employment-based health insurance--the most common
source of health coverage for Americans--decreased. By 1993, more
than 39 million Americans lacked any type of health insurance.
Almost one-quarter of these people were children, despite the
relative affordability of providing insurance for children.\9
Uninsured children are generally children of lower-income workers.
Lower-income workers are less likely than higher-income workers to
have health insurance for their families because they are less likely
to work for a firm that offers insurance for their families. Even if
such insurance is offered, it may be too costly for lower-income
workers to purchase.\10 In 1993, 61 percent of uninsured children
were in families with at least one parent who worked full time for
the entire year the child was uninsured. About 57 percent of
uninsured children had family income at or below 150 percent of the
federal poverty level.
Recognizing the need to provide insurance for children, the federal
government and the states expanded children's eligibility for
Medicaid, a jointly funded federal/state entitlement program.
Beginning in 1986, the Congress passed a series of Medicaid-expansion
laws that required states to provide coverage to certain children and
pregnant women and gave states the option to expand eligibility
further.\11 Many states opted to use this approach instead of funding
their own programs, because expanding Medicaid allowed them to get
matching federal funds. As of April 1995, 37 states and the District
of Columbia had expanded coverage for infants or children beyond
federal requirements. In addition to these expansions, between 1991
and August 1995, five states implemented Medicaid demonstration
waivers, some of which included coverage expansions to some uninsured
children. Between 1989 and 1993, Medicaid expanded from covering 14
percent of U.S. children (8.9 million) to 20 percent (13.7 million).
Nevertheless, many uninsured children remain ineligible for Medicaid.
--------------------
\4 Barbara Bloom, Health Insurance and Medical Care: Health of Our
Nation's Children, United States (Hyattsville, Md.: Advance Data
from Vital and Health Statistics, National Center for Health
Statistics, No. 188, 1990).
\5 David L. Wood and others, "Access to Medical Care for Children
and Adolescents in the U.S.," Pediatrics, Vol. 86, No. 5 (1990),
pp. 666-673.
\6 Mary D. Overpeck and Jonathan B. Kotch, "The Effect of U.S.
Children's Access to Care on Medical Attention for Injuries,"
American Journal of Public Health, Vol. 85, No. 3 (1995), pp.
402-404.
\7 Charles N. Oberg, "Medically Uninsured Children in the United
States: A Challenge to Public Policy," Pediatrics, Vol. 85, No. 5
(1990), pp. 824-833.
\8 David U. Himmelstein and Steffie Woolhandler, "Care Denied: U.S.
Residents Who Are Unable to Obtain Needed Medical Services," American
Journal of Public Health, Vol. 85, No. 3 (1995), pp. 341-344.
\9 Personal health care expenditures per capita for children were
$737 in 1987 (the most recent national data available)--one-sixth
those of the elderly. VHI-Lewin, a health care consulting firm,
estimated that the United States could implement a Medicare-type
system of coverage for children using existing public and private
coverage plus an increase of $5.7 billion--an increase of 0.4 percent
over current national health spending. See Robert G. Hughes, Tania
L. Davis, and Richard C. Reynolds, "Assuring Children's Health As
the Basis for Health Care Reform," Health Affairs, Vol. 14, No. 2
(1995), pp. 158-167.
\10 GAO/HEHS-95-175, July 19, 1995.
\11 The Omnibus Budget Reconciliation Acts of 1986 (P.L. 99-509),
1987 (P.L. 100-203), 1989 (P.L. 101-239), and 1990 (P.L. 101-508)
and the Medicare Catastrophic Care Amendments of 1988 (P.L.
100-360).
STATE- AND PRIVATELY FUNDED
PROGRAMS IMPROVED CHILDREN'S
COVERAGE
------------------------------------------------------------ Letter :3
Beginning in 1985, states and private entities began to fund programs
that provided insurance for children who were ineligible for or not
enrolled in Medicaid and did not have private or comparable insurance
coverage.\12 The programs we visited varied in several respects, but
all were limited in how many children they could cover by the size of
their budgets, which depended on their funding sources. Every state
had substantially more uninsured children than children enrolled in
one of these programs. Almost all of these programs have had to
restrict enrollment and develop waiting lists of children who could
not enroll because of insufficient funding. To target their funding,
most programs restricted enrollment to low-income, uninsured children
not enrolled in Medicaid.
--------------------
\12 For other discussions of these programs, see Ian T. Hill,
Lawrence Bartlett, and Molly B. Brostrom, "State Initiatives to
Cover Uninsured Children," The Future of Children, The Center for the
Future of Children, Vol. 3, No. 2 (Los Altos, Calif: 1993);
Patricia Butler, Robert L. Mollica, and Trish Riley, Children's
Health Plans, National Academy for State Health Policy (Portland,
Maine: 1993); Christopher DeGraw, M. Jane Park, and Julie A.
Hudman, "State Initiatives to Provide Medical Coverage for Uninsured
Children," The Future of Children, The Center for the Future of
Children, Vol. 5, No. 1 (Los Altos, Calif: 1995).
PROGRAMS VARIED IN SEVERAL
RESPECTS, BUT ALL PROVIDED
COVERAGE THROUGH SET BUDGETS
---------------------------------------------------------- Letter :3.1
In 1995, 31 states had either a publicly or privately funded program
that provided health insurance coverage for children.\13 (See app. I
for a list of these states.) Fourteen states had publicly funded
programs that provided insurance for children, which generally relied
heavily on state funding. In 1994, these programs enrolled from 39
to 98,538 children and had budgets ranging from about $240,000 to
about $71.5 million.
In addition to state-level efforts, the private sector developed
voluntary insurance programs supported through philanthropic funding.
The best known of these are the Caring Programs, sponsored by 24 Blue
Cross/Blue Shield organizations in 22 states. The Caring Programs,
which served more than 41,000 children in 1994, ranged in size from
400 to almost 6,000 enrolled children and had budgets from $100,000
to $4.3 million.
The four state- and two privately funded programs that we visited
varied in enrollments and funding sources. They provided insurance
coverage to between 5,532 and 104,248 children under set yearly
budgets. Much of the state programs' funding came from state general
revenues, cigarette or tobacco taxes, or health care provider taxes;
counties; and foundations and other private-sector entities. The
private programs each received funding from Blue Cross/Blue Shield
and from private individuals and organizations.
The programs' costs, covered services, and premium subsidies also
varied. Moreover, four of the programs operated statewide, but
Florida Healthy Kids and the Western Pennsylvania Caring Program for
Children operated only in certain counties. (See table 1.)
Table 1
Characteristics of the Six Programs
Annual
Program name, budget, Premium,
type, and Cost per 1994 (in copayment,
implementatio Enrollmen child per Funding millions Covered and
n date t, 7/95 month sources ) services deductible
------------- --------- ---------- -------------- -------- ----------- ------------
Alabama 5,922 $20.00 Private $1.7 Outpatient No premium,
Caring donations, only some
Program for Blue Cross/ copayments,
Children Blue Shield no
(private, deductibles
1988)
Western 5,532 70.60 Private 4.3 Outpatient; No premium,
Pennsylvania donations, limited some
Caring Blue Cross/ inpatient copayments,
Program Blue Shield no
for Children deductibles
(private,
1985)
Pennsylvania' 49,634 62.60 State 21 Outpatient; Sliding
s Children's cigarette tax, limited scale
Health premium inpatient premium,
Insurance payments, some
Program insurer copayments,
(state, 1993) donations no
deductibles
New York's 104,248 54.71 State Bad Debt 55 Outpatient Sliding
Child Health and Charity only scale
Plus Program pool raised premium,
(state, 1991) through some
hospital copayments,
assessments no
and premium deductibles
payments
Florida 15,254 46.50\a State general 8.8 Outpatient Sliding
Healthy Kids revenue funds, and scale
Program several types inpatient premium,
(state, 1992) of county some
funds, school copayments,
board funds, no
premium deductibles
payments
MinnesotaCare 44,689 53.00 State and 36.6\b Outpatient Sliding
(state, 1992) federal and scale
Medicaid inpatient premium, no
funds, premium copayments,
payments no
deductibles
-----------------------------------------------------------------------------------------
\a For Volusia County.
\b MinnesotaCare's budget included services for child and adult
participants.
Unlike state Medicaid programs, which operate as open-ended
federal/state entitlements, all the programs we reviewed operated
within limited and fixed budgets. These budgets did not allow them
to cover most of the uninsured children in their states. The private
program budgets were limited by the amount that could be raised by
corporate donors, such as Blue Cross/Blue Shield, and individual
donors. The state-funded programs had larger budgets, but they, too,
were limited by the amount of funding states were willing to devote
to insuring children.
All the states in which these programs operated had more uninsured
children than children enrolled in the programs.\14 For example, New
York's Child Health Plus Program represented a substantial investment
for the state in children's health coverage--$55 million--and it had
the largest enrollment: 104,248. But in 1993, New York State had
almost half a million uninsured children. Other programs could only
cover a small fraction of their uninsured. For example, Alabama had
156,000 uninsured children in 1993, and its Caring Program covered
5,922 in 1995--only about 3 percent. MinnesotaCare had the highest
ratio of enrolled children in 1995 to uninsured children in 1993:
44,689 to 76,517, or 58 percent.
Lack of funding forced all the programs we visited (except
Minnesota's) to restrict enrollment at times and to relegate children
who applied for the program to waiting lists. According to child
advocates and officials of these programs, restricting enrollment and
developing waiting lists undermine program credibility. In addition,
Florida has been unable to start its Healthy Kids Program in many
interested counties because the program has lacked funding.
--------------------
\13 Much of this information comes from Deborah F. Perry,
"Innovative State Health Initiatives for Children," Stateline,
National Governor's Association (Washington, D.C.: 1995).
\14 The numbers of uninsured children by state are 1993 numbers that
we derived from the Bureau of the Census' March 1994 Current
Population Survey, which was the most recent Census data on uninsured
children available.
SOME PROGRAMS LIMITED
ELIGIBILITY TO TARGET
RESOURCES TO CHILDREN MOST
IN NEED
---------------------------------------------------------- Letter :3.2
The programs we visited limited program eligibility to cover children
most in need of insurance. Generally, they tried to cover
low-income, uninsured children not enrolled in Medicaid in order not
to duplicate existing public coverage.
Four programs limited eligibility to families on the basis of their
income, although each program's income eligibility differed. All six
were designed to complement Medicaid coverage for children, since
none enrolled children who had Medicaid coverage and most tried to
steer possibly eligible children to Medicaid first. Four programs
required children to be uninsured, although two allowed children with
limited and noncomparable coverage to enroll. (See fig. 1.)
Figure 1: Program Eligibility
Requirements
(See figure in printed
edition.)
\a All eligible children in a family must be enrolled.
\b Enrollment in other health insurance is allowed as long as the
coverage is not equivalent to the coverage offered under Florida
Healthy Kids Program or New York's Child Health Plus Program.
\c Children must also be enrolled in the National School Lunch
Program.
\d Federal poverty level.
\e Children whose family incomes are between 150 and 275 percent of
FPL cannot have had insurance for the 4 months before applying for
MinnesotaCare and cannot have had access to employer-paid insurance
for the 18 months before applying for MinnesotaCare.
\f The maximum eligible age will increase by 1 year each year on
October 1, until the maximum age of 17 is reached in 1996.
Two programs--New York's Child Health Plus and Florida's Healthy
Kids--covered uninsured children at any income level as long as their
families paid the full premium costs. These two programs also
extended coverage to insured children if their health insurance was
not comparable to what the programs offered.\15
In western Pennsylvania, state- and privately funded programs
developed eligibility criteria to minimize duplication of coverage.
The three children's health insurance programs in western
Pennsylvania--Medicaid, the state-funded Children's Health Insurance
Program, and the privately funded Western Pennsylvania Caring Program
for Children--in combination provided coverage to children under 6
with family income at or below 235 percent of FPL\16
and to children from 6 to 19 with family income below 185 percent of
FPL. The Western Pennsylvania Caring Program for Children changed
its eligibility criteria after the Children's Health Insurance
Program was developed to complement its coverage and provide coverage
for children that it did not cover. (See fig. 2.)
Figure 2: Health Insurance
Eligibility for Children in
Western Pennsylvania
(See figure in printed
edition.)
Note: To be eligible for any of these programs, other applicable
program eligibility requirements, such as state residency, must be
met.
\a The law increases the eligible age for this program every year on
October 1; the maximum eligible age of 17 will be reached in 1996.
\b In this chart, Medicaid coverage includes expansions based on age,
poverty level, and eligibility related to receipt of Aid to Families
with Dependent Children (AFDC). Medicaid expansions require states
to provide Medicaid coverage to children up to age 6 with family
income at or below 133 percent of FPL and to poor children aged 6 or
over born after September 30, 1983, until all children living in
poverty up to age 19 are covered in October 2002. States could
expand eligibility further, which Pennsylvania did for infants. For
children older than 13, this figure shows Pennsylvania's Medicaid
income eligibility for a family of three in 1994 who received AFDC,
according to the Maternal and Child Health Update, National
Governors' Association, March 1995. Eligibility for AFDC ends at age
18 or, at state option, at age 19 if the child is a full-time
student. Other children, such as disabled children or children with
very high medical expenses, may be eligible for Medicaid coverage but
are not included in this simplified chart.
--------------------
\15 Insurance with benefits consistent with New York's Child Health
Plus benefit package and with payments and/or deductibles consistent
with insurance industry standards is considered equivalent. However,
policies that omit certain of the Child Health Plus benefits or that
impose greater cost-sharing requirements on enrollees than does Child
Health Plus can be deemed equivalent.
\16 The Caring Program, which predated the Children's Health
Insurance Program, provided insurance to children up to age 19 who
were at 150 percent of FPL and who were not covered by Medicaid.
When the Children's Health Insurance Program was created, the Caring
Program changed its eligibility criteria to insure children aged 6 to
19 at 185 percent of FPL. When the Children's Health Insurance
Program eligibility expanded in 1994, the Caring Program changed
eligibility criteria again, insuring children aged 15 to 19 at 185
percent of FPL who were not covered by the Children's Health
Insurance Program or the Medicaid program.
PROGRAMS MANAGED THEIR COSTS BY
LIMITING BENEFITS AND USING
OTHER STRATEGIES
------------------------------------------------------------ Letter :4
Health insurance costs for individuals were partially dependent on
the costs of covered medical services, but other factors influenced
costs as well.\17 Some programs covered inpatient care and other
expensive services, while others chose to limit or exclude expensive
services. Moreover, the premium costs per child were similar in some
of the programs that covered inpatient care and other expensive
services and in some that limited such services or did not cover
them.
In addition to limiting services, state and private programs used
other strategies to manage costs, such as sharing costs with patients
and using competitive bidding and managed care. One factor that did
not significantly increase costs as had been expected by program
administrators was excessive use of health services. On the
contrary, program children's use of services was similar to that of
privately insured children.
--------------------
\17 Variations in cost may reflect factors other than the services
covered, which could include the regional cost of care, amount of
provider payment, competition among providers, age of children
covered, and the use of managed versus fee-for-service care. In
addition, reported average costs per child were not always the full
cost per child, since some programs did not include all of their
administrative costs.
PROGRAM COSTS PER CHILD
VARIED BASED PARTIALLY ON
SERVICES COVERED
---------------------------------------------------------- Letter :4.1
The state and private programs' benefit packages varied from
providing only primary and preventive care and emergency and accident
services to providing a comprehensive range of benefits, including
inpatient services. Costs to provide coverage for children varied
from $20 to $70.60 per month, partly because of the kinds of services
covered and the limitations on those services.
All programs provided a core set of services that program officials
cited as most important for most children. These services included
primary and preventive services--such as well-child visits,
immunization, outpatient surgery, outpatient physician services, and
diagnostic testing--and outpatient emergency services. In addition,
most programs offered other benefits, such as mental health services,
vision and hearing care, and prescription drugs. Three of the state-
and privately financed programs also provided some dental services.
Officials from several state and private programs noted that they
would like to provide more benefits--such as dental care, which some
cited as a critical preventive service--but did not want to increase
the cost of their program. (See fig. 3.)
Figure 3: Average Cost Per
Child Per Month for Services
Covered by Programs
(See figure in printed
edition.)
\a Average cost reflects the total premium cost, regardless of the
funding source, but excludes program administrative costs.
\b Primary and preventive care services include well-child visits,
immunizations, diagnostic testing, outpatient physician services, and
outpatient surgery.
\c These services have specific limitations. See app. II.
\d These programs cover other services. See app. II.
The Alabama Caring Program for Children, which covered outpatient
care only, provided the fewest services and was the least expensive
per child--$20 per month. The other programs reported average
per-child costs ranging from $46.50 to $70.60 per month, and some
provided more benefits than others. Florida ($46.50) and Minnesota
($53) covered many services, including inpatient and outpatient
treatment, prescription drugs, and physical therapy. Minnesota also
covered dental care and inpatient and outpatient substance abuse
treatment. In contrast, New York's Child Health Plus Program
($54.71), Pennsylvania's Children's Health Insurance Program
($62.60), and the Western Pennsylvania Caring Program ($70.60) were
more expensive, yet they provided either limited or no inpatient
care.
The programs that did not provide inpatient services or provided only
limited inpatient services often relied on Medicaid to meet enrolled
children's needs. According to officials from two of these programs,
the families of children who needed hospitalization could qualify for
Medicaid services through medically needy spenddown provisions
because of the cost of the care. Under spenddown, the cost of
expensive services, such as hospitalization, is deducted from family
income to determine the child's Medicaid eligibility.\18
Pennsylvania's Children's Health Insurance Program was planned to
shift the costs of inpatient care to Medicaid when possible. The
program covers 3 days of hospitalization, after which families are
required to apply for Medicaid. For families whose children cannot
qualify for Medicaid through spenddown, the Children's Health
Insurance Program covers up to 90 inpatient days per year.
--------------------
\18 In 1994, the District of Columbia and 31 states, including
Florida, Maine, Minnesota, New York, and Pennsylvania, provided
coverage to some medically needy persons. Alabama did not.
PATIENT COST-SHARING ADDED
TO MOST PROGRAMS
---------------------------------------------------------- Letter :4.2
In addition to limiting benefits, most programs added some patient
cost-sharing provisions. However, they generally kept premiums and
copayments minimal, especially for families in the lowest income
ranges. None of the programs required deductibles. Because most
children enrolled were from the lowest income brackets, families did
not generally have to contribute much for their children's care.
(See table 2.)
Table 2
Comparison of Family Cost-Sharing
Provisions
Family
Income premium
range, as contribution
a per month Percent Service and
percentage per child by enrolled by amount of
Program of FPL income range income range Copayments copayment
----------------- ---------- ------------ ------------ ------------ ----------------
Alabama Caring $0- $0 100 Yes\b Outpatient
Program for 9,500\a services-$5
Children
Florida Healthy 0-130 5-20\c 73 Yes Prescription
Kids Program 131-185 13-27\c 14 drugs-$3,
over 185 43-49\c 13 eyeglass lenses-
$10,
refractions-
$3,
nonauthorized
emergency room
visits-$10
MinnesotaCare 0-150 4 66\e No None
151-275 4-138\d 34\e
\
New York's Child 0-159 0 87 Yes Prescription
Health Plus 160-222 2.08 13 drugs-$1-3,
Program over 222 54.71 <1 inappropriate
emergency room
use-$35
Pennsylvania's 0-184 0 95 Yes Prescription
Children's Health 185-235 39.75- 5 drugs-$5
Insurance Program 52.64\c
Western 0-185 0 100 Yes Prescription
Pennsylvania's drugs-$5
Caring Program
for Children
-----------------------------------------------------------------------------------------
\a Alabama uses absolute dollar amounts for income eligibility
determination.
\b Preferred doctors may require a $5 copayment for some services;
however, most doctors waive the copayment.
\c Premium contribution varies by locale or insurer.
\d Premium contribution varies by income level within specified
range.
\e Estimated by program officials.
Cost-sharing provisions varied by program. Family premium payments
priced on a sliding scale based on family income as a percent of FPL
were required by the four state-funded programs. Copayments for some
services were required by three of the four state-funded programs and
the two Caring programs. However, two state-funded programs did not
require families in the lowest income range to pay any portion of the
premium.
All of the state-funded programs expected families with income that
exceeded the lowest income level to pay a portion of their child's
premium. However, the size of the premium varied for families with
similar incomes. For example, a family with an income at 200 percent
of FPL would pay at least $43 per month in Florida to enroll one
child and at least $39.75 in Pennsylvania, but only $2.08 in New
York.
Some advocates expressed concern that premium contributions were too
high for lower-income families in Pennsylvania and Minnesota and that
high premium contributions discouraged these families from enrolling
their children. Florida's Healthy Kids executive director also
commented that the price of insurance affects enrollment. When the
Healthy Kids premium dropped below $50, she reported, the number of
enrollees who paid the full premium increased.
Two state-funded programs, those in Florida and New York, covered
children at any income level as long as families with income over a
specified level paid the full premium cost. Although this approach
enabled those programs to help any uninsured child, relatively few
children were enrolled when families had to pay all of the premium.
New York targeted its outreach to lower-income families, which might
explain why so few full-premium children enrolled, according to one
New York program official. Florida marketed its program to all
children attending public schools and still had low enrollment of
children paying the full premium.
COPAYMENTS ADDED FOR SOME
SERVICES
-------------------------------------------------------- Letter :4.2.1
Most programs did not require program participants to contribute a
copayment for most services. When programs did require copayments,
they were generally $10 or less and applied to those services listed
in table 2, such as prescription drugs and vision care. None of the
programs allowed providers to charge copayments for primary and
preventive services, except Alabama's Caring Program for Children,
which asked, but could not require, physicians to waive the
copayments they normally charged Blue Cross/Blue Shield patients.
MANAGED CARE STRATEGIES
BECOMING MORE COMMONLY USED
---------------------------------------------------------- Letter :4.3
Most of the state and privately funded programs we visited were
increasing their use of managed care, which is a strategy widely
followed by private companies to constrain health care costs.\19 Many
of the programs enrolled some of their children in HMOs, and most
were trying to increase their use of HMOs. In addition, three of the
state-funded programs paid insurers fixed, lump-sum payments to cover
needed health services, which placed risk with the insurer rather
than the program. Of these three state-funded programs, two used
competitive bidding to choose their insurers. (See fig. 4.)
Figure 4: Programs' Use of
Managed Care Strategies
(See figure in printed
edition.)
Minnesota paid Medicaid-certified providers on a fee-for-service
basis, but the program plans to transition to managed care in 1996.
The other programs covered children using private provider
networks,\20 HMOs, gatekeeper/case managers, or some combination of
these. Alabama's Caring Program for Children was the only program
using network providers exclusively, and Florida's program was the
only one using HMOs exclusively. Pennsylvania's Children's Health
Insurance Program and the Western Pennsylvania Caring Program for
Children enrolled children in HMOs whenever available. At least 80
percent of the enrollees in New York's Child Health Plus Program,
Pennsylvania's Children's Health Insurance Program, and the Western
Pennsylvania Caring Program for Children were in HMOs. These three
programs expect to increase their use of HMOs for program children's
care.
All of the state programs except Minnesota paid insurers a fixed, per
child, per month payment, which shifted risk from the public payers
to the insurers. The insurers or managed care organizations were
then responsible for providing or contracting for all covered health
services. Florida and Pennsylvania used a competitive process to
select insurers and set rates; New York had a selection process that
was not competitive. In Florida, Healthy Kids contracted with one
HMO organization selected through competitive bidding for each county
or group of counties. In Pennsylvania's Children's Health Insurance
Program, if more than one insurer bid, the contract was awarded to
the lowest qualified bidder, but other qualified bidders could
provide services in the same area at the lowest bidder's price. In
New York, all insurers who met specified program qualifications
during the selection process were permitted to participate, but the
state had approval rights over the premiums they charged.
--------------------
\19 Whether managed care actually reduces payer cost is unclear.
Managed care is a continuum of different types of care arrangements,
from least to most restrictive. HMOs, the most restrictive type of
care, seem to have the greatest potential to actually reduce costs,
since they can reduce utilization of expensive services. But whether
HMOs reduce costs for those paying the premiums depends not only on
reducing use of expensive services but also on passing these savings
on to payers. See Managed Health Care: Effect on Employers' Costs
Difficult to Measure (GAO/HRD-94-3, Oct. 19, 1993).
\20 Families with children enrolled in provider networks are either
prohibited from using nonnetwork providers or required to pay more
for care if they use them.
PROGRAMS DID NOT ATTRACT
HIGH-RISK, HIGH-COST
CHILDREN
---------------------------------------------------------- Letter :4.4
The insurers and developers of most of the programs we visited had
expected that children enrolling would be less healthy than children
with private insurance and would, therefore, use services more
frequently. In addition, since all the programs covered preexisting
health conditions, the programs were expected to attract families
with ill children who could not get other insurance coverage.
Programs like Pennsylvania's Children's Health Insurance Program and
the Florida Healthy Kids Program negotiated prices for their premiums
assuming that the programs would attract children who would be more
costly to serve than privately insured children. In addition,
Alabama required families to enroll all of their eligible children in
its program, which kept families from enrolling only sick children
and assisted in health promotion.
However, according to managers from all the programs, the children
served were not significantly sicker and did not use services more
than privately insured children. New York's Child Health Plus
Program officials found through a survey that most of the children
enrolled in the program did so after they lost private insurance
coverage. Alabama and Florida reported a slight increase in the use
of services due to initial demand, but that soon stabilized. The
lower-than-anticipated use of services led to cost-savings for
Pennsylvania's Children's Health Insurance Program and the Florida
Healthy Kids Program: a rebate of $1.3 million for the Pennsylvania
program and a 21-percent decrease in premiums for Healthy Kids in
Volusia County.\21
--------------------
\21 Pennsylvania's Children's Health Insurance Program included a
"rate margin" provision in some of its insurers' contracts to protect
them if the program attracted too many sick children. It guaranteed
the insurers that if their actual costs exceeded the costs on which
they based their premiums, the program would make up the difference,
up to a limit of 5 percent of the anticipated costs. But the rate
margin provision also guaranteed that if the insurers' costs were
below expectations, they would have to return the excess (again,
subject to the 5-percent limit). Since the insurers' costs were
below expectations, the state became entitled to a $1.3-million
rebate. In the second year, because the state and insurers had
information from the program's first year to help price the premiums,
the rate margin provision was dropped. Similarly, the Florida
Healthy Kids Program renegotiated premium rates with the Volusia
County HMO several times during the program's first year because
service utilization and costs were lower than expected. Overall, the
HMO cut the premium rate 21 percent--from $58.98 to $46.50 per month.
PROGRAM DESIGNS SIMPLIFIED
ADMINISTRATION AND FACILITATED
PARTICIPATION OF PROVIDERS AND
PATIENTS
------------------------------------------------------------ Letter :5
All the programs were designed to facilitate implementation and
provider and patient participation. Most state- and privately funded
programs relied on private insurers or nonprofits for many
administrative functions and used their physician networks. The
programs used existing billing systems and generally had
reimbursement levels that approximated market rates--factors that
were attractive to providers. The programs guaranteed access to a
provider network, used simple enrollment procedures, and in many ways
appeared similar to private insurance, which helped the programs
avoid the stigma of welfare. Families surveyed by their programs
were satisfied with the programs and with the health care their
children received.
PROGRAMS USED EXISTING
ADMINISTRATIVE SYSTEMS
---------------------------------------------------------- Letter :5.1
To some degree, all the programs we visited used administrative
systems already in place when designing and implementing their
programs. While Minnesota employed state Medicaid structures for
administrative functions, the other programs employed nonprofit
corporations or private insurers to perform key administrative
functions. (For more detail on specific programs, see app. II.)
For example, in both the state-funded New York Child Health Plus and
the Pennsylvania Children's Health Insurance programs, the state
agencies exercised general program oversight, but most administrative
functions were performed by private insurance plans under contract to
the state. In addition to assuming responsibility for paying
providers (and assuming risk for the costs involved), the insurers
processed applications and determined eligibility. Each enrollee
signed up with one of the insurers, which used its existing network
of providers or HMOs to serve program patients.
The nonprofit Florida Healthy Kids Corporation (FHKC) managed the
Healthy Kids program using schools, HMOs, and contractors to provide
some administrative services. It contracted with an HMO in each
county to provide program services to enrollees in that county and
with other entities to provide application processing, eligibility
determination, premium billing and collection, technical assistance,
and program evaluation. The schools also provided some
administrative services, such as distributing enrollment applications
and forwarding computerized data for eligibility determination.
IN-PLACE BILLING SYSTEMS AND
PROVIDER NETWORKS ENCOURAGED
PHYSICIAN PARTICIPATION
---------------------------------------------------------- Letter :5.2
All the programs we visited used existing billing systems and
provider networks, generally through private or nonprofit insurers.
Contracting with an existing network of providers facilitated program
implementation, since enrollees could be served as soon as a contract
was signed. New York's Child Health Plus Program required contracted
insurers to have an existing network of providers in place to enable
them to reach program children in every part of the state. Program
officials said that this requirement made the program "just another
line of business" for the insurers.
In addition, physicians did not have to adapt to new, or to
significantly change existing, operating processes to serve program
children, which increased their willingness to participate in these
programs. In Alabama, for example, all Caring Program providers
filed claims electronically through Blue Cross/Blue Shield's existing
claims system. According to a program official, most providers will
accept lower payment rates and new patients if their routine billing
and payment processes are not disrupted. One Alabama physician noted
that quick reimbursement and lack of "red tape" contributed to her
willingness to serve program children. Similarly, two providers
cited use of Minnesota's Medical Assistance program billing structure
as contributing to MinnesotaCare's success, because the physicians
did not have to adjust to new operating procedures and hospitals
could more easily participate in the program.
STATE AND PRIVATE PROGRAMS
GENERALLY SET ACCEPTABLE
RATES AND USED OTHER MEANS
TO ENSURE PROVIDER COVERAGE
---------------------------------------------------------- Letter :5.3
State and private programs have developed various methods for
ensuring provider and insurer participation. Most of the programs
chose to reimburse providers at close to market rates to ensure
provider participation. In addition, some of the programs required
physicians to accept the set rates as a condition of caring for
other, more lucrative patients.
The state and private programs we visited, with the exception of
MinnesotaCare, chose a strategy other than Medicaid for paying
providers' rates. Because many state Medicaid programs have paid
below market rates for services, these programs have had difficulty
maintaining an adequate provider network. Some studies have
indicated that Medicaid patients have more difficulty accessing
health care than non-Medicaid patients. MinnesotaCare paid Medicaid
rates, and some providers complained that MinnesotaCare's
reimbursement was about 50 to 60 percent of their normal billing
rates.
The other programs paid premiums intended to approximate market
rates. The Alabama and Western Pennsylvania Caring Programs
reimbursed physicians according to the rate schedules used by their
respective Blue Cross/Blue Shield organizations, although for Alabama
the rates paid for treating program participants were some of Blue
Cross/Blue Shield's lowest.
As an additional incentive, physicians in several programs were
required to treat program patients if they wished to treat other,
sometimes more lucrative patients. For example, physicians
participating in the Blue Cross/Blue Shield provider networks of
Alabama and Western Pennsylvania could not refuse to serve Caring
Program patients unless they withdrew from the Blue Cross/Blue Shield
provider network entirely. Similarly, insurers in New York's Child
Health Plus Program required their participating physicians to treat
program patients as a condition of treating the insurers' private
patients. And in Minnesota, physicians could not participate in the
more lucrative state and local government employee health benefit
program unless they also participated in the state's health
assistance programs, which included MinnesotaCare.
USING EXISTING PROVIDER
NETWORKS GAVE PROGRAM
PATIENTS GUARANTEED ACCESS
TO CARE
---------------------------------------------------------- Letter :5.4
All six programs gave children access to a network of providers. In
two programs, more than one insurer covered some parts of the state,
so families had a choice of networks. Patients in Minnesota's
program had access to providers that participated in Medicaid.
Through state mandate, MinnesotaCare is ensured a large network; in
1995, the program had 24,000 primary care providers for 48,000
enrolled children.
Patients enrolled in all the programs except Minnesota's had
guaranteed access to at least one and sometimes two established
provider networks or HMOs through private insurers. New York's Child
Health Plus Program had 15 insurers that together covered the entire
state. A few areas in the state were covered by more than one
insurer, and patients were allowed to select between insurers. Three
of the four regions covered by Pennsylvania's Children's Health
Insurance Program were served by at least two insurers, which
increased families' choices. The Alabama Caring Program for Children
used the existing Blue Cross/Blue Shield network, which covered most
physicians in the state. The Western Pennsylvania Caring Program for
Children used either the Blue Cross/Blue Shield HMO or the Blue
Cross/Blue Shield network, which included more than 12,000
physicians. Florida's Healthy Kids Program enrollees were limited to
providers in a single HMO per county, but the program required that
children be no more than a 20-minute car ride from a provider, except
in the most rural areas.
SIMPLE ENROLLMENT PROCEDURES
FACILITATED ACCESS TO
PROGRAMS
---------------------------------------------------------- Letter :5.5
The enrollment procedures for the state- and privately funded
programs were relatively simple. Some programs were flexible about
documenting information for eligibility and proceeding on the basis
of trust. Simplified enrollment procedures and flexible eligibility
documentation requirements minimized enrollment barriers and thus
encouraged program participation.
All the state and private programs used a simple mail-in enrollment
form (often one page long) and did not require face-to-face
interviews. In addition, New York's Child Health Plus Program
directed applicants to program insurers who provided telephone
assistance in completing the forms. MinnesotaCare, which also used a
mail-in application, asked follow-up questions by phone. Florida's
Healthy Kids Program allowed parents to obtain and submit one-page
applications through the schools.
Some programs were more flexible than others about documenting
enrollment information, such as income. For example, the Alabama
Caring Program for Children allowed an "honor system," on the theory
that applicants were truthful about their incomes, and New York's
Child Health Plus Program allowed a self-declaration of income if
applicants were unable to produce any other verification.
Pennsylvania's two programs required applicants to verify income, and
the Florida Healthy Kids Program relied on the National School Lunch
Program to verify applicants' income. Most of the programs did not
apply resource tests, which also simplified eligibility
determination. Minnesota and Alabama staff reported finding that
families generally reported information honestly and accurately when
applying for their programs.
PROGRAMS OFFERED AN IDENTITY
SEPARATE FROM MEDICAID TO
AVOID WELFARE STIGMA
---------------------------------------------------------- Letter :5.6
Program officials generally agreed that for families to use the
program, they must not feel stigmatized, a problem that often exists
with welfare recipients. Program staff stressed that it was
important to preserve the families' dignity at all times.
To avoid the stigma of welfare, the state and private programs tried
to resemble private insurance as much as possible. In addition to
generally using private insurers' networks and simplified
administrative processes that did not require face-to-face interviews
at welfare offices for eligibility determinations, the programs used
other strategies to preserve families' dignity. Some of these were
modest. For example, all programs using private insurers issued
enrollees insurance membership cards that were similar to cards
issued for the insurers' commercial programs.
FAMILIES SATISFIED WITH CARE
---------------------------------------------------------- Letter :5.7
Families generally reported being very satisfied in the five programs
that assessed patient satisfaction.\22 For example, 97 percent of
respondents in a 1993-94 survey of Florida's Healthy Kids families
were either "very satisfied" or "satisfied" with the care provided
for their children. More families with children in the Healthy Kids
Program were satisfied with their care than families of children in
any of the four comparison groups--Medicaid, private insurance, other
insurance, or uninsured. A separate study of Healthy Kids families
found that higher percentages of program families than of nonprogram
families were "very satisfied" with the benefits available to their
children, their doctor's availability, waiting times in the doctor's
office, and the amount they had to pay at the time of an office
visit. As another example, a 1989 survey of participants in
Minnesota's Children's Health Plan, predecessor to MinnesotaCare,
found that over 80 percent rated the program either a 9 or a 10 on a
scale of 1 to 10, with 10 being excellent.
--------------------
\22 Pennsylvania's Children's Health Insurance Program was the only
program that had not assessed patient satisfaction. The Western
Pennsylvania Caring Program for Children included its Children's
Health Insurance Program families in its satisfaction survey.
PROGRAMS IMPROVED CHILDREN'S
USE OF HEALTH CARE SERVICES
---------------------------------------------------------- Letter :5.8
All the programs we visited sought to reduce unmet medical needs and
to encourage the appropriate use of primary and preventive care
services. Several of the programs have begun to evaluate whether
their programs are achieving these goals. Although some programs are
finding that access and appropriate use of medical services have
increased, several have found that use of preventive services is
still below desired levels. Program staff have increased their
efforts to educate parents about the importance of preventive care
for children. (See app. III.)
CONCLUSIONS
------------------------------------------------------------ Letter :6
If enacted, legislation to change the Medicaid program to a block
grant would give states greater flexibility to redesign their
Medicaid programs, but it would also limit federal funding. To
accommodate these changes, states would need to make difficult
choices when structuring their Medicaid programs. While the programs
we visited differed from Medicaid, they exemplified the choices
states and private-sector organizations have made when using their
own resources to provide health coverage to uninsured children.
Most notably, the state- and privately funded programs we visited
covered some children who would not otherwise have been covered;
complemented existing Medicaid coverage;
kept per child costs to a minimum;
provided preventive and primary care services--the services
children are most likely to need;
offered a wide network of providers;
required families to share part of the cost;
used HMOs frequently to manage children's health care; and
used existing administrative systems of state, nonprofit, and
private organizations.
Despite these state and private efforts, many children remained
uninsured. In addition, eligible children sometimes had to wait to
enroll. Further, programs did not always cover services routinely
available to children insured through private insurance or Medicaid.
In the future, the responsibility for ensuring health care coverage
for children may fall more directly on the states; their local
communities, including private-sector providers and nonprofit
organizations; and children's families. The programs we visited
appear to have succeeded in bringing together these groups and
individuals to expand children's access to health care. Their
program experience could prove instructive for other states and the
Congress.
Although this report does not focus on agency activities, we
discussed its contents with responsible officials at HCFA, who had no
comments. We also discussed its contents with officials in the
programs we visited. Program officials' comments were generally
limited to specific technical corrections, which we incorporated in
this report.
---------------------------------------------------------- Letter :6.1
As agreed with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days
from the date of this letter. At that time, we will send copies to
interested parties and make copies available to others on request.
Please contact me at (202) 512-6806 if you or your staff have any
questions. This report was prepared under the direction of Sally
Jaggar, Mark Nadel, and Rose Marie Martinez by Sheila Avruch and
others. Other staff who contributed to this report are named in
appendix IV.
Sincerely yours,
Janet L. Shikles
Assistant Comptroller General
Health, Education, and
Human Services Division
MOST STATES HAVE EXPANDED MEDICAID
OR DEVELOPED OTHER HEALTH
INSURANCE PROGRAMS FOR CHILDREN
=========================================================== Appendix I
Forty-five states and the District of Columbia have expanded Medicaid
beyond federal requirements to cover infants or children, have
implemented a Medicaid waiver, or have developed privately funded or
state programs to insure children. Some states have more than one
type of program to add coverage for children. (See fig. I.1.)
Figure I.1: States' Health
Insurance Programs for Children
(See figure in printed
edition.)
Note: Some of these programs insure adults and children.
\a State Medicaid expansions as of April 1995.
\b State funded programs include those classified by the National
Governors' Association as both public and public/private, except
Rhode Island and Tennessee, which have Medicaid 1115 waivers. The
primary source of funding for most of these programs was state
financing.
\c The 1115 Medicaid waiver transferred children up to age 21 and
pregnant women from MinnesotaCare to Medicaid. The other adult
MinnesotaCare participants remained in the state-funded MinnesotaCare
program.
\d Medicaid funds the children's services for Washington's Basic
Health Plan.
Sources: "Innovative State Health Initiatives for Children,"
Stateline, July 21, 1995, National Governors' Association,
Washington, D.C., Center on Budget and Policy Priorities; Health
Insurance for Children: Many Remain Uninsured Despite Medicaid
Expansion (GAO/HEHS-95-175, July 19, 1995); Western Pennsylvania
Caring Program for Children, personal communication with executive
director; MinnesotaCare Program, personal communication with
director; and Washington Basic Health Plan Plus, personal
communication with program manager.
State- and privately funded programs vary in size: some cover fewer
than 100 children, and others cover up to 99,000. (See table I.1.)
Table I.1
1994 Enrollments and Budgets of State-
and Privately Funded Programs to Insure
Children
Budget (in
State Enrollment millions)
-------------------------- -------------- --------------
State-funded\a
----------------------------------------------------------
Arizona 2,300 $7.3
California 13,784 71.5
Colorado 1,712 .7
Delaware 8,473 NA\b
Florida 15,500 8.8
Maryland 3,500 .9
Massachusetts 22,021 12.0
Michigan 3,105 1.4
Minnesota 42,891 36.6
Nebraska 245 5.0
New Hampshire 39 .2
New York 98,538 55.0
Pennsylvania 28,923 21.0
Utah 99 2.0
Washington 16,944 20.0
Privately funded
----------------------------------------------------------
Alabama 5,400 1.3
California 5,000 1.2
Georgia 409 NA\b
Idaho 400 NA\b
Iowa 2,117 .4
Kansas 3,474 .7
Louisiana 412 .1
Mississippi 1,027 .2
Missouri (2 programs) 2,275 .9
North Carolina 3,498 1.4
Ohio 5,717 1.6
Pennsylvania (western) 5,877 4.3
Pennsylvania 3,434 2.2
(southeastern)
South Dakota 385 .2
Utah 1,615 .6
Wisconsin 800 NA\b
----------------------------------------------------------
Note: Budget and enrollment data were not identified for Caring
Programs in Maryland, Massachusetts, Montana, North Dakota, Oklahoma,
Texas, and Wyoming.
\a State-funded programs include programs classified by the National
Governors' Association as both public and public/private, except for
Rhode Island and Tennessee, which have Medicaid 1115 waivers.
\b Did not provide budget information.
Sources: "Innovative State Health Initiatives for Children,"
Stateline, July 21, 1995, National Governors' Association,
Washington, D.C., and Western and Southeastern Pennsylvania Caring
Programs for Children, personal communication with executive
directors.
DESCRIPTIONS OF THE SIX STATE- AND
PRIVATELY FUNDED PROGRAMS
========================================================== Appendix II
This appendix provides programmatic and administrative details about
the six programs we visited, presented alphabetically by state. Each
description includes
a background section, which highlights the history of the program
and its goals, and
a section on program structure and operations, which includes
information on administration; funding; eligibility; enrollment;
covered services and costs; insurer payment and provider
networks used; and publicity, outreach, and marketing.
THE ALABAMA CARING PROGRAM FOR
CHILDREN
-------------------------------------------------------- Appendix II:1
BACKGROUND
------------------------------------------------------ Appendix II:1.1
The Alabama Caring Program for Children is a statewide, privately
funded program that was created in 1988 by Blue Cross/Blue Shield of
Alabama. It provides primary care services to enrolled children
using Blue Cross/Blue Shield providers. Enrollees are children from
low-income, working families who do not have insurance through an
employer, yet whose income is not low enough to qualify them for
Medicaid.
PROGRAM STRUCTURE AND
OPERATIONS
------------------------------------------------------ Appendix II:1.2
The nonprofit Alabama Child Caring Foundation administers the
program, including determining eligibility, enrolling children,
publicizing the program, collecting donations, and fundraising. Blue
Cross/Blue Shield staff process claims and pay providers. All
administrative services, including Foundation staff salaries, are
donated by Blue Cross/Blue Shield. The program does not underwrite
insurance--instead it contracts with Blue Cross/Blue Shield for
claims and payment services. The program also uses Blue Cross/Blue
Shield's provider network to deliver health care services.
FUNDING
---------------------------------------------------- Appendix II:1.2.1
The Caring Program is funded entirely through the philanthropic
donations of businesses, churches, foundations, civic/service
organizations, and individuals. Blue Cross/Blue Shield matches all
contributions dollar for dollar. The program's budget for 1994 was
approximately $1.7 million, and the estimated budget for 1995 is
approximately $2 million.
ELIGIBILITY
---------------------------------------------------- Appendix II:1.2.2
Children may enroll if they (1) are under age 19, unmarried, and have
an annual family income under $9,500; (2) are full-time students
(unless they are under school age or have completed grade 12); (3)
are Alabama residents, and (4) are ineligible for Medicaid or other
insurance. Additionally, families must enroll all of their eligible
children in the program. Foundation staff refer children potentially
eligible for Medicaid to the Medicaid bureau before they can enroll
in the Caring Program.
ENROLLMENT
---------------------------------------------------- Appendix II:1.2.3
As of July 31, 1995, 5,922 children were enrolled in the program.
Since the available funding was not sufficient to provide coverage
for all eligible applicants, 1,766 eligible children were on a
waiting list. The Foundation generally responds to an application
within one day of receipt, but the average waiting time for
enrollment is 18 to 24 months, because the program does not have the
funding to enroll children as soon as they are determined eligible.
While the program is statewide, donors can designate their funding
for particular counties, so children in some counties spend less time
waiting to enroll.
The Alabama Child Caring Foundation determines eligibility and
enrolls children using a simple, one-page, 12-question form that can
be mailed to the Foundation. There are no income verification
requirements. Once a child is admitted, the Foundation staff send
the child a benefits handbook, a Blue Cross/Blue Shield
identification card, and a list of participating providers.
COVERED SERVICES, COSTS,
AND COST-SHARING
---------------------------------------------------- Appendix II:1.2.4
The program covers primary and preventive outpatient services
(well-child visits, immunizations, outpatient physician services,
outpatient surgery, and diagnostic tests). It also covers emergency
and accident care. It does not cover prescription drugs or
inpatient, vision, hearing, or dental care (except in one county,
which has a specially funded pilot program for dental care). Program
officials told us that benefits have not been expanded further
because funding is limited and many children are currently waiting to
join the program. The program does not have any pre-existing
condition exclusions.
The average monthly cost per child is $20, which does not include any
administrative expenses. Program participants pay no premiums or
deductibles. They may be required to pay a $5 copayment for some
outpatient services. However, program and Blue Cross/Blue Shield
officials have asked providers to waive the copayment in order not to
discourage program participants from obtaining care, and most
providers have complied.
INSURER PAYMENT AND
PROVIDER NETWORKS
---------------------------------------------------- Appendix II:1.2.5
The Foundation pays for covered services provided by physicians in
the Blue Cross/Blue Shield of Alabama provider network, to which most
physicians in the state belong, according to the program's executive
director. Physicians cannot refuse to treat Alabama Caring Program
patients without dropping out of the network. Providers are
reimbursed based on the existing Blue Cross/Blue Shield
fee-for-service rate schedule, and claims are processed through the
Blue Cross/Blue Shield billing system. Claims are paid within 5
days.
PUBLICITY, OUTREACH, AND
MARKETING
---------------------------------------------------- Appendix II:1.2.6
Program officials use a variety of methods for publicizing the
program, including public service announcements on TV and radio, free
advertising in newspapers, distribution of brochures and flyers, and
contacts with providers, advocacy organizations, churches, schools,
and corporate donors. Blue Cross/Blue Shield developed radio and TV
public service announcements using some of Alabama's college football
coaches. These announcements have been very successful at
publicizing the program. Since the program is currently wait-listing
applicants because it lacks the resources to enroll them, it has
focused the past year's efforts principally on fund-raising rather
than on outreach.
FLORIDA HEALTHY KIDS PROGRAM
-------------------------------------------------------- Appendix II:2
BACKGROUND
------------------------------------------------------ Appendix II:2.1
The Florida Healthy Kids Program is a school enrollment-based program
created through the July 1990 Healthy Kids Corporation Act. Its goal
is to provide every child access to quality health care by uniting
children with accessible, local, comprehensive health care providers.
The program was initially funded in Volusia County as a HCFA
demonstration project that also received state, county, and private
funds. It is currently available in seven Florida counties, with 13
other counties waiting to join. Uninsured children of any income
level attending school in a participating county can join, but only
children with family income at or below 185 percent of FPL will have
their premiums partially subsidized.
PROGRAM STRUCTURE AND
OPERATIONS
------------------------------------------------------ Appendix II:2.2
The nonprofit Florida Healthy Kids Corporation (FHKC) has overall
administrative responsibility for the program. FHKC contracts with
others for processing applications, determining eligibility, billing
and collecting premiums, providing technical assistance, and
evaluating the program. County schools and their boards help inform
parents about the program, disseminate enrollment applications, and
provide monthly computerized data, which are used for eligibility
redeterminations. In addition to the board that oversees FHKC, each
county has its own board to direct Healthy Kids activities.
FUNDING
---------------------------------------------------- Appendix II:2.2.1
The program was initially funded by federal and state funding,
including a HCFA demonstration grant, which ended in February 1995,
and family premium payments. The program is currently funded by
state general revenue funds, a county ad valorem tax for children's
services, other county funds, health district tax funds, county
school board funds, and premium payments by parents. The program's
total funding for 1994 was approximately $8.8 million, and the amount
budgeted for 1995 was $13.1 million.
ELIGIBILITY
---------------------------------------------------- Appendix II:2.2.2
A child may enroll in Healthy Kids if he or she is (1) 5 through 19
years of age or a 3- to 4-year-old sibling of an enrollee, (2)
actively attending school, (3) uninsured, and (4) not enrolled in the
Medicaid program. In some counties, children must prove they are not
eligible for Medicaid before being enrolled in Healthy Kids; in
others, not being enrolled in Medicaid is enough. Children must
participate in the National School Lunch Program to get their
premiums subsidized, since income eligibility for subsidized premiums
is determined through the School Lunch Program eligibility process.
FHKC redetermines eligibility monthly by having a contractor compare
computerized records for the Healthy Kids, School Lunch, and Medicaid
programs.
ENROLLMENT
---------------------------------------------------- Appendix II:2.2.3
The Healthy Kids Program provides school enrollment-based health
insurance. The children obtain health coverage in the form of group
insurance policies provided through the school districts, rather than
through employers. By using school districts, the program can tap
into existing communication systems with parents to market the
program and enroll children. School officials distribute and collect
applications during the open enrollment period at the beginning of
the school year. Additional enrollment periods are available to
children who transfer to other schools. An FHKC contractor
determines eligibility and then FHKC sends a list of eligible
children to the responsible HMO. The HMO sends the family new member
information and a membership card and requests that the family select
a primary care provider. If the family does not respond within 90
days, the HMO will send a follow-up letter and call the family to
encourage them to use well-child services.
As of July 1, 1995, 6,602 children were enrolled in Volusia County,
and 15,254 children were enrolled in the Healthy Kids Program
statewide. Statewide, 87 percent of enrolled children had family
income at or below 185 percent FPL and thus had their premiums
partially or fully subsidized; in Volusia County, 93 percent were in
that category.
COVERED SERVICES, COSTS,
AND COST-SHARING
---------------------------------------------------- Appendix II:2.2.4
The Volusia County program offers a wide range of services including
primary and preventive outpatient services (well-child visits,
immunizations, outpatient physician services, outpatient surgery, and
diagnostic tests), emergency and accident care, hospitalization, and
related inpatient physician services. It also includes physical,
speech, and occupational therapy (limited to 15 inpatient days per
contract year and 24 outpatient treatment sessions within a 60-day
period per episode of illness or injury). In addition, it covers
prescription drugs, vision care (corrective lenses limited to one
pair every 2 years unless prescription or head size changes), hearing
care, home health care, ambulance services, durable medical equipment
and prosthetic devices, family planning, chiropractic care (limited
to six visits in 6 months), and podiatric care (limited to 2 visits
per month). Mental health services are included, but limited to 15
inpatient days per contract year and 20 outpatient visits per
contract year, with a lifetime maximum expenditure of $20,000.
Substance abuse services are provided for pregnant teens only.
Healthy Kids covers newborn care, skilled nursing facility services
limited to 100 days per contract year, and transplant services.
Covered services and limitations may vary by county. For example,
dental care is available in some counties. There are no preexisting
condition exclusions.
The average cost per month to provide health services to children in
Volusia County was $46.50, which reflects the total premium payment
to the HMO. Program officials estimated that, in addition, the
program averages administrative costs of about $1.50 per month per
child.
The amount that parents pay toward premiums differs by county and
income category. Since September 1, 1995, all counties have required
parents to pay some share of their children's premium. Before that
time, Volusia County did not require poor parents to pay any share of
their children's premiums, while other counties required parents to
pay $5 per month for children in the lowest income group (at or below
130 percent of FPL.) Starting in September 1995 in Volusia County,
families with income at or below 100 percent of FPL paid $15 per
child per month; those with income between 101 and 130 percent of FPL
paid $20; those with income between 131 and 185 percent of FPL paid
$27; and those with income above 185 percent of FPL paid $48.
Families pay no deductibles.
Some services require a small copayment. Prescription drugs and
optometrist refractions both have $3 copayments, mental health
outpatient visits have a $5 copayment, and prescription eyeglass
lenses and nonauthorized ER visits have $10 copayments.
INSURER PAYMENT AND
PROVIDER NETWORKS
---------------------------------------------------- Appendix II:2.2.5
The program pays a capitated monthly fee to HMOs to cover enrolled
children's health care services. To choose HMOs, FHKC sends out
requests for proposals and then contracts with one HMO per county.
The HMOs are required to provide hospitalization and specialist
services as needed and ensure that children live no more than 20
minutes by car from a provider except in the most rural areas. To
meet these requirements, the HMO in Volusia County contracted with
some private doctors in the western, more rural, part of the county.
The HMO contracts with FHKC allow FHKC to pay for services that
patients need and then bill the HMO for the services if the HMO is
not providing adequate service. FHKC monitors waiting time and
patient complaints to measure access.
PUBLICITY, OUTREACH, AND
MARKETING
---------------------------------------------------- Appendix II:2.2.6
The Florida Healthy Kids Program uses numerous methods to reach its
target audience, including paid and public service radio and
television ads, brochures and flyers, a video, and presentations by
FHKC and HMO staff. In 1994, FHKC spent less than $5,000 on
advertising. However, most advertising is donated by HMOs, school
districts, county boards, and others. For example, in Volusia
County, one large fast-food restaurant used tray liners publicizing
the program. According to program officials, the school district and
the county board have been creative and effective at developing
advertising strategies tailored to their community.
The program has specifically targeted teens, and African-American and
migrant children, who were not joining the program at expected rates.
The program used high school coaches and shop teachers to speak for
the program and school dial-up message systems and direct mail to
reach teens' parents. The program has also worked through churches
to reach African Americans and through migrant crew chiefs to reach
migrant families.
MINNESOTA'S MINNESOTACARE
PROGRAM
-------------------------------------------------------- Appendix II:3
BACKGROUND
------------------------------------------------------ Appendix II:3.1
MinnesotaCare was established by the state legislature in 1992 to
both expand and replace Minnesota's Children's Health Plan. The
Children's Health Plan, the first statewide, state-funded program
providing health insurance coverage for uninsured children of
low-income families, began in July 1988. When MinnesotaCare was
implemented in October 1992, it broadened the Children's Health
Plan's eligibility criteria by allowing parents and siblings living
in the same households as qualifying children to enroll, and it
subsequently expanded to include adults without children. In April
1995, Minnesota received HCFA approval of a Section 1115 Medicaid
waiver that integrated a segment of the MinnesotaCare
population--children and pregnant women--into the state's Medicaid
program effective July 1, 1995. The waiver allows the state to
receive federal Medicaid funding for children and pregnant women in
MinnesotaCare, but leaves children and pregnant women subject to
MinnesotaCare rules regarding eligibility, enrollment, and
cost-sharing. The state hopes to develop uniform eligibility,
enrollment, and other criteria for MinnesotaCare, Medicaid, and the
state's General Assistance Medical Care program.
PROGRAM STRUCTURE AND
OPERATIONS
------------------------------------------------------ Appendix II:3.2
The program is administered by the state's Department of Human
Services, the same agency that administers the state's Medicaid
program. However, MinnesotaCare has a separate office within that
agency, as well as its own director and 89 dedicated staff. Other
Department of Human Services staff perform some duties related to the
program as well.
FUNDING
---------------------------------------------------- Appendix II:3.2.1
The portion of MinnesotaCare that covers children and pregnant women
is financed by a combination of federal Medicaid funding, state
funds, and enrollee premium contributions. The remainder of
MinnesotaCare is financed entirely by state funds and enrollee
premiums, which is how the whole program was financed before the
waiver. The state finances its share of the program through a
2-percent provider tax. Previous state funding sources have included
the state's general funds and a 1-percent cigarette tax. Program
costs (including administrative costs and program expenditures) were
$36.6 million in fiscal year 1994, and are budgeted at $93.9 million
for fiscal year 1995.
ELIGIBILITY
---------------------------------------------------- Appendix II:3.2.2
Children under age 21, as well as their parents and dependent
siblings if they reside in the same household, may enroll in
MinnesotaCare if (1) their family income does not exceed 275 percent
of the FPL, (2) they are permanent Minnesota residents, (3) they have
had no other health insurance for the preceding 4 months, and (4)
they could not get employer-subsidized insurance for the preceding 18
months. (The last two requirements do not apply to children in
families with incomes that do not exceed 150 percent of FPL.) Single
adults and families without children may enroll if their household
incomes do not exceed 125 percent of FPL and they satisfy the other
requirements. If funding is available, the state may increase the
upper income limit for single adults and families without children to
135 percent of FPL in October 1995 and to 150 percent of FPL in
October 1996.
The current eligibility criteria for MinnesotaCare are much broader
than the criteria used when the program that preceded it, the
Children's Health Program, was first implemented in 1988. At that
time, the only eligible group was children aged 1 through 8 with
family incomes up to 185 percent of FPL.
ENROLLMENT
---------------------------------------------------- Appendix II:3.2.3
As of July 1995, MinnesotaCare had 88,123 enrollees. Of this total,
50.7 percent were children, 43.2 percent were adults in households
with children, and 6.1 percent were adults in households without
children. MinnesotaCare has a mail-in enrollment and recertification
process. A staff of 44 eligibility representatives reviews the
applications and follows up with applicants by telephone or mail on
an as-needed basis to verify residency status, income, and
availability of other health insurance. Since May 1994, enrollees
have received a generic identification card that the state uses for
all its state-supported health care programs.\23
--------------------
\23 Previously, MinnesotaCare participants received an identification
card that specifically indicated that they were MinnesotaCare
enrollees.
COVERED SERVICES, COSTS,
AND COST-SHARING
---------------------------------------------------- Appendix II:3.2.4
MinnesotaCare provides children with a comprehensive benefit package
that includes primary and preventive outpatient care (including
well-child visits, immunizations, diagnostic testing, outpatient
physician services, and outpatient surgery); emergency and accident
care; physical, occupational, and speech therapy; prescription drugs;
inpatient hospital and psychiatric care; mental health and chemical
dependency services; vision, hearing, and dental care; home health
care; durable medical equipment and prosthetic devices; podiatry;
chiropractic services; family planning; case management; Christian
Science sanitoriums; daycare/school examinations; day treatment;
hospice care; intermediate care facilities for the mentally retarded;
nurse anesthetists, private duty nursing, nursing facility services,
and in-home nursing services; orthodontia; personal care; public
health clinic visits; speech, hearing, and language disorders
treatment; and medical transportation. Adults receive a similar
benefit package, but a few services (such as nonpreventive dental
care) are not covered, and some others are subject to service
limitations or copayments. The benefit package has expanded
considerably since the inception of the Children's Health Program in
1988, when only children's outpatient services were covered.
The average monthly cost per child for MinnesotaCare is $53,
excluding administrative costs. Enrollees pay a monthly premium that
is determined using a sliding scale linked to income level and
household size and that ranges from 1.5 to 8.8 percent of gross
family income. However, a reduced premium of $48 per year is payable
for children in families with incomes that do not exceed 150 percent
of FPL. According to state officials, about two-thirds of all
children in the program fall into this category. The program has no
deductibles or copayments for children's services, but adults are
required to contribute copayments for certain services.
PROVIDER NETWORK AND
REIMBURSEMENT
---------------------------------------------------- Appendix II:3.2.5
MinnesotaCare gives enrollees access to the same providers who
participate in the state's Medicaid program. It pays providers on a
fee-for-service basis using the Medicaid fee structure. Minnesota
requires providers to either take part in the state's health
assistance programs or forgo participating in the more lucrative
state and local government employee health benefit programs.
Under the terms of the Medicaid waiver, most of the children in
Medicaid, including those transferred into Medicaid from
MinnesotaCare, will eventually be enrolled in HMOs. Program
participants who live in areas where there is a scarcity of HMOs will
continue to be served by fee-for-service providers. The state plans
to award the first HMO contracts in 1996.
PUBLICITY, OUTREACH, AND
MARKETING
---------------------------------------------------- Appendix II:3.2.6
Program officials use a variety of methods to publicize the program,
including paid radio advertisements, radio and television public
service announcements, listings in community-based service agency
publications, and brochures and flyers. Officials also rely on
contacts with hospitals, doctors' offices, advocacy organizations,
public clinics, and schools, among others.
NEW YORK'S CHILD HEALTH PLUS
PROGRAM
-------------------------------------------------------- Appendix II:4
BACKGROUND
------------------------------------------------------ Appendix II:4.1
Child Health Plus is a statewide, state-funded program created by the
New York State legislature in 1990 to insure children. The program's
goals are to provide low-income children with comprehensive
outpatient health care services, increase children's access to
primary and preventive health care, and improve participating
children's health status. The program is open to children at all
income levels, but only children in families with gross income below
222 percent of FPL receive a subsidy.
PROGRAM STRUCTURE AND
OPERATIONS
------------------------------------------------------ Appendix II:4.2
The New York State Department of Health has overall responsibility
for administering the program, while the State Insurance Department
approves participating insurance companies' premiums and reviews
subscriber contracts. The State Insurance Department works with the
Department of Health to define "equivalent health insurance" to
determine which children can join the program. The program uses
private insurers to perform many administrative functions, including
processing applications, determining eligibility, collecting
premiums, paying providers, engaging in marketing and outreach, and
monitoring quality assurance. The program also contracts out
marketing and outreach activities to two nonprofit organizations.
FUNDING
---------------------------------------------------- Appendix II:4.2.1
The program is funded by enrollee premiums and New York's Bad Debt
and Charity Care pool, which is raised by an assessment on hospitals.
The amount appropriated to Child Health Plus limits the number of
children who may be enrolled. Child Health Plus received $55 million
from the Bad Debt and Charity Care pool during 1994 and has been
budgeted $76.5 million for 1995.
ELIGIBILITY
---------------------------------------------------- Appendix II:4.2.2
Children may enroll in Child Health Plus if they (1) are under age 15
and born on or after June 1, 1980; (2) do not have "equivalent
insurance";\24 (3) are New York State residents (even if they are not
legally in the United States); and (4) are not enrolled in Medicaid.
The maximum eligible age has been increased since the start of the
program from under 13 to under 15.
--------------------
\24 The "equivalent insurance" provision is intended to exclude
children with insurance coverage "consistent with the Child Health
Plus benefit package" and whose copayments and/or deductibles are
consistent with insurance industry standards.
ENROLLMENT
---------------------------------------------------- Appendix II:4.2.3
Child Health Plus is targeted primarily at low-income children.
According to a survey of program applicants completed in 1993, most
children joined after losing private insurance coverage or Medicaid.
Their average family income was $16,000. As of July 1995, the
program had 104,248 enrollees, of whom 99.6 percent were subsidized
(under 222 percent of FPL).
Insurers process enrollment using a simple one-page application,
which can be submitted by mail, without a face-to-face interview.
The program is flexible about the documents needed to prove
eligibility. For example, income can be proved by means of employer
attestations or, as a last resort, a self-declaration form. Under
the "presumptive eligibility" procedure, families lacking needed
documentation but whose children appear eligible can have their
children covered for up to 60 days while they complete the
application process. Unlike Medicaid, which counts net income and
also uses a resource test, the Child Health Plus Program counts gross
income and omits a resource test, which expedites eligibility
determination.
COVERED SERVICES, COSTS,
AND COST-SHARING
---------------------------------------------------- Appendix II:4.2.4
The program covers primary and preventive care (including well-child
care, in accordance with American Academy of Pediatrics guidelines,
immunizations, outpatient treatment of illness and injury, diagnostic
tests, and outpatient surgery); emergency care; prescription drugs;
outpatient treatment for alcoholism and substance abuse; short-term
physical and occupational therapy; radiation therapy; chemotherapy;
and dialysis. It does not cover inpatient care, including inpatient
mental health care; dental care (except when necessary to treat a
medical condition); or speech therapy.
In 1994, the average monthly per patient cost was $54.71. The
monthly per child premiums paid to insurers ranged from $36 to
$66.50, reflecting geographical and other differences among the
insurers. In addition, the Department of Health incurred $0.80 per
patient per month in administrative costs.
Most children's families pay little for coverage and services.
Families with gross incomes below 160 percent of FPL pay no premium
(almost 87 percent of enrolled children). Families with incomes
between 160 and 222 percent of FPL pay $25 per child per year up to a
maximum of $100 for the entire family (13 percent of enrolled
children) toward the premium cost. Families with incomes above 222
percent of FPL pay the entire premium (0.4 percent of enrolled
children). Families pay no deductibles. Families may have
copayments of $35 for inappropriate ER use (or may have these claims
denied) and may have copayments of up to $3 for each pharmacy
prescription, depending on the insurer.
INSURER PAYMENT AND
PROVIDER NETWORKS
---------------------------------------------------- Appendix II:4.2.5
The program pays a capitated monthly fee per child to insurers to
cover enrolled children's health care services. The participating 15
nonprofit insurers joined by submitting bids in response to a 1990
request for proposal. To join the program, insurers had to have an
existing network of providers in place, with a sufficient number of
board-certified physicians. Child Health Plus Program enrollees are
given access to the same physicians as plan members with private
insurance.
The 15 insurers together cover the entire state. Children must
enroll with an insurer responsible for the area in which they live.
Certain areas fall within more than one insurer's service area, so
enrollees residing in those areas have a choice of insurer. Of the
15 insurers, 12 are managed care plans and 3 are indemnity plans. As
of December 1993, 80 percent of the enrollees were enrolled in
managed care plans.
PUBLICITY, OUTREACH, AND
MARKETING
---------------------------------------------------- Appendix II:4.2.6
The state contracted with two nonprofit organizations to provide
marketing and outreach services to the program; insurers also provide
such services.\25 Both the contractors and insurers work through
community-based organizations that serve low-income populations, such
as churches, clinics, and schools. Both make presentations and
distribute brochures and posters. One of the contractors also
arranges "enrollment events" and operates a hotline for New York
City. The other contractor operates a statewide hotline for the
program. In addition, the Department of Health supports outreach.
For example, the staff worked with the State Education Department to
send an informational letter about the Child Health Plus Program to
every school district superintendent. The Department of Health also
provides a toll-free referral hotline that is used to publicize the
program and refer callers to participating insurers.
--------------------
\25 The state's total estimated expenditures to the two contractors
from the program's inception through the end of 1995 are
approximately $1,602,000, including $815,420 for January 1, 1994,
through December 31, 1995. The amount paid to the insurers for
marketing and outreach is included in their premiums.
PENNSYLVANIA'S CHILDREN'S
HEALTH INSURANCE PROGRAM
-------------------------------------------------------- Appendix II:5
BACKGROUND
------------------------------------------------------ Appendix II:5.1
Pennsylvania's Children's Health Insurance Program is a statewide,
state-funded program established by the Children's Health Care Act of
1992 to provide free or subsidized health care coverage to uninsured,
nonMedicaid-eligible children. It is modeled on Western
Pennsylvania's Caring Program for Children.
PROGRAM STRUCTURE AND
OPERATIONS
------------------------------------------------------ Appendix II:5.2
The Children's Health Insurance Management Team\26 has overall
responsibility for the program. They prepare budgets, execute
contracts with insurers, approve rates, and coordinate enrollment
outreach activities. They contract with insurers or their designates
to handle many other administrative functions, including processing
applications, determining eligibility, collecting premiums, paying
providers, and engaging in outreach.
--------------------
\26 The team consists of Pennsylvania's Secretary of the Budget,
Secretary of Health, and Insurance Commissioner.
FUNDING
---------------------------------------------------- Appendix II:5.2.1
The state funds the Children's Health Insurance Program through a
2-cent per pack cigarette tax, and through parental premium
contributions. Some insurers pay the parents' portion of the
premium. The state expended approximately $9.4 million on the
program during the fiscal year July 1993 through June 1994, and
approximately $28 million is budgeted for fiscal year 1995.
ELIGIBILITY
---------------------------------------------------- Appendix II:5.2.2
Children may enroll in the Children's Health Insurance Program if
they are (1) under age 6 with family income at or below 235 percent
of FPL, or age 6 through 15 with family income at or below 185
percent of FPL; (2) Pennsylvania residents for at least 30 days
(except for newborns); and (3) not eligible for Medicaid or other
insurance. Children who might be eligible for Medicaid must apply to
Medicaid before they can be enrolled in the Children's Health
Insurance Program. Children's Health Insurance Program participants
are annually reassessed for eligibility. If during annual
eligibility reassessment an enrolled child appears Medicaid-eligible,
the Children's Health Insurance Program will continue to cover the
child for up to 60 days while the Medicaid bureau determines the
child's eligibility.
ENROLLMENT
---------------------------------------------------- Appendix II:5.2.3
As of July 1, 1995, 49,634 children were enrolled in the Children's
Health Insurance Program. Ninety-seven percent of these children
have income at or below 185 percent of FPL and have their premium
fully subsidized. In May 1995, approximately 1,504 children were on
waiting lists across the state. Children on the waiting lists may
participate in the program by paying an at-cost premium.
Insurers determine eligibility and process enrollment, which can be
completed entirely by mail. Enrollment procedures vary somewhat
among insurers. Families who pay part of the premium must remit the
first payment before enrollment.
COVERED SERVICES, COSTS,
AND COST-SHARING
---------------------------------------------------- Appendix II:5.2.4
The Children's Health Insurance Program covers primary and preventive
health care (including well-child visits, immunizations, diagnostic
testing, outpatient physician services, and outpatient surgery);
emergency and accident care; physical, speech, and occupational
therapy; vision care (limited to one pair of corrective lenses every
6 months and one pair of frames every 12 months); and hearing,
dental, home health,and prescription drug services. An enrolled
child who cannot qualify for benefits under the Medical Assistance
spenddown provisions is eligible for a maximum of 90 days of
inpatient services for each calendar year, which includes inpatient
mental health services. Also covered are transplant services,
ultrasound and nuclear medicine, and allergy testing.
The original benefit package was established legislatively, but some
benefits have been added, such as inpatient and outpatient mental
health services in 1994. The program does not exclude coverage for
any preexisting condition.
The average monthly cost per child is approximately $63, which
includes both premiums and some administrative costs. The program
limits insurers' administrative cost reimbursement to no more than
7.5 percent of submitted invoices. Premium rates vary by insurer and
region--from $57.77 to $64.25 per child per month for fully
subsidized children, and from $67.30 to $83.52 per child per month
for partially subsidized children.
Most children's families pay nothing for coverage, and the remainder
are partially subsidized. Families with income at or below 185
percent of FPL (97 percent of enrolled children in July 1995) do not
pay any share of their children's premiums. The state pays half the
premium for children with family income between 185 percent and 235
percent of FPL. Some insurers subsidize the remaining half;
otherwise parents must pay that share of the premium. The program
requires no deductibles, and the only copayment ($5) is for
prescription drugs.
INSURER PAYMENT AND
PROVIDER NETWORK
---------------------------------------------------- Appendix II:5.2.5
The Children's Health Insurance Program pays a capitated monthly fee
per child to insurers to cover enrolled children's health care
services. Insurers were selected through a competitive bid process,
but the nonprofit insurers were legislatively required to bid.
Insurers who did not have the lowest winning bid for a premium rate
could participate if they were willing to match that rate.
Currently, four nonprofit insurers and one for-profit insurer give
families a choice of insurers in three of the four regions.
About 80 percent of program children are enrolled in HMOs, and the
rest are in preferred provider networks.\27 Children are
automatically enrolled in HMOs, where available. If a county changes
to HMO service, children may remain in the preferred provider network
plan until their recertification, but then they are automatically
transferred to the HMO.
--------------------
\27 We have previously described preferred provider networks as
arrangements that retain many elements of indemnity plans but provide
enrollees a financial incentive to receive care from providers
selected by the insurer (Managed Health Care: Effect on Employers'
Costs Difficult to Measure, GAO/HRD-94-3, Oct. 19, 1993, pp.7-8).
Although Children's Health Insurance Program officials did not
characterize its non-HMO plans as preferred provider networks, we
believe they are, because children in those plans who visit providers
who are outside the insurer's provider network may be required to pay
the difference between what the insurer pays its network providers
and what the nonnetwork providers charge.
PUBLICITY, OUTREACH, AND
MARKETING
---------------------------------------------------- Appendix II:5.2.6
Each of the insurers is responsible for program publicity and
outreach. The insurers use a variety of publicity and outreach
approaches, including paid radio, TV, and newspaper ads; distribution
of brochures and flyers; and contacts with hospitals, doctors,
advocacy organizations, churches, and schools. Insurers must develop
an outreach plan and are required to contribute at least 2.5 percent
of the total amount they bill the program as an in-kind outreach
contribution. The Department of Health and the Insurance Department
also conduct some outreach.
WESTERN PENNSYLVANIA CARING
PROGRAM FOR CHILDREN
-------------------------------------------------------- Appendix II:6
BACKGROUND
------------------------------------------------------ Appendix II:6.1
The Western Pennsylvania Caring Program for Children was the nation's
first private-sector initiative to provide primary care health
coverage to uninsured, low-income children who could not qualify for
Medicaid. In 1984, a group of Presbyterian ministers from a local
Pittsburgh church became concerned that many children were losing
employment-based health care coverage as the local steel mills
closed. The group approached Blue Cross of Western Pennsylvania and
Pennsylvania Blue Shield, which agreed to help provide health
coverage for the children. Together they developed the Caring
Program, which enrolled its first child in June 1985. The Caring
Program has changed its eligibility standards and its benefits since
then to complement changes in Medicaid eligibility and the
introduction of the Pennsylvania Children's Health Insurance Program,
a state-financed children's health insurance program that was
partially modeled on the Caring Program and introduced in 1993.
PROGRAM STRUCTURE AND
OPERATIONS
------------------------------------------------------ Appendix II:6.2
The Western Pennsylvania Caring Foundation, Inc., a nonprofit
organization set up by Blue Cross/Blue Shield, administers the Caring
Program. The Foundation conducts enrollment and eligibility
determination, care coordination for children with special health
care needs, and outreach. Blue Cross/Blue Shield provides claims
processing, retrieval, and legal services to the program.
FUNDING
---------------------------------------------------- Appendix II:6.2.1
The Caring Program is financed by tax-deductible donations made by
local foundations, religious organizations, civic groups, labor
unions, corporations, schools, and individuals. Community
contributions provide significant financial support for the
program--for example, for fiscal year 1994, Pittsburgh area
communities donated $870,000. However, the Caring Program's major
donor is Blue Cross/Blue Shield, which donates $2 for every $1
contributed by other donors as well as all administrative costs,
including Foundation staffs' salaries. In fiscal year 1994, Blue
Cross/Blue Shield contributed about $4 million.
ELIGIBILITY
---------------------------------------------------- Appendix II:6.2.2
When the program began, it enrolled uninsured children not eligible
for Medicaid from birth to 19 years of age with total family income
no greater than 100 percent of FPL. But as more public coverage
options became available for some of the younger children through
Medicaid and the Children's Health Insurance Program, the Caring
Program changed its eligibility rules to provide services to older
children and to complement rather than compete with the Children's
Health Insurance Program and Medicaid coverage.
Children may enroll in the Caring Program if they (1) are age 16 to
19 with total family income no greater than 185 percent of FPL, (2)
are attending school, (3) have resided in Pennsylvania for the past
30 days, and (4) are uninsured and ineligible for Medicaid.
Applicants who appear eligible for but are not receiving Medicaid
must apply for Medicaid and be denied before being enrolled in the
Caring Program. On average, the Caring Foundation refers about 300
to 400 applicants each month to Medicaid. The Foundation recertifies
eligibility annually on the family's enrollment date. At that time,
if a child appears to have become Medicaid-eligible, the Caring
Program provides temporary coverage while the child's Medicaid
eligibility is determined.
ENROLLMENT
---------------------------------------------------- Appendix II:6.2.3
As of July 1, 1995, 5,532 children were enrolled in the program. To
enroll, families fill out a simple, one-page application, which is
processed by the Foundation. If approved, the family is mailed an
acceptance letter and a provider directory. Children covered by a
fee-for-service system get active coverage as of the beginning of the
month, but those covered by an HMO must choose a provider to activate
their coverage. All participants receive an enrollment card that is
practically identical to that used by any other Blue Cross/Blue
Shield plan member. Enrollees must enroll in HMOs if Blue Cross/Blue
Shield is operating an HMO in their county.
COVERED SERVICES, COSTS,
AND COST-SHARING
---------------------------------------------------- Appendix II:6.2.4
The Caring Program's initial benefit package was very limited,
including only doctor office visits, immunizations, diagnostic
testing, emergency care, and outpatient surgery. The program
developers would have preferred to provide a more comprehensive
package at that time, but since the program's funding depended
entirely on charitable donations, limiting benefits allowed the
program to serve more children.
When the Children's Health Insurance Program began, the Caring
Program wanted to provide the same set of covered services. In 1993
and again in 1994, the Caring Program expanded its services, adding
dental, hearing, and vision care; prescription drugs; limited
hospitalization; and mental health services. As under the Children's
Health Insurance Program, families of children who are hospitalized
must apply for Medicaid coverage after 3 days. For families who do
not qualify for Medicaid, the Caring Program will pay for up to 90
days per year.
Currently, the program covers primary and preventive health care
(including well-child visits, immunizations, diagnostic testing,
outpatient physician services, and outpatient surgery); emergency and
accident care; physical, speech, and occupational therapy; vision
care (limited to one pair of corrective lenses every 6 months and one
pair of frames every 12 months); hearing, dental, and home health
care; and prescription drug services. An enrolled child who cannot
qualify for benefits under the Medical Assistance spenddown
provisions is eligible for a maximum of 90 days of inpatient services
for each calendar year, which includes inpatient mental health
services. Also covered are transplant services, ultrasound and
nuclear medicine, and allergy testing. The program does not exclude
coverage for any preexisting medical conditions.
The average cost for services is now $70.60 per child per month.
This does not include any administrative expenses, which are donated
by Blue Cross/Blue Shield. In 1985, the more limited benefit package
cost about $13 per child. The program requires little cost-sharing
from families: Families do not have to pay any share of their
children's premiums. The program requires no deductibles, but does
have a $5 copayment for prescription drugs.
INSURER PAYMENT AND
PROVIDER NETWORKS
---------------------------------------------------- Appendix II:6.2.5
The Foundation pays providers through Blue Cross/Blue Shield.
Children are enrolled in HMOs in 16 counties and in indemnity plans
in 13 counties. HMOs are paid on a capitated basis, while network
and other physicians are paid on a fee-for-service basis. Children
may go to doctors outside the Blue Cross/Blue Shield network, but if
they do the families are responsible for any charges beyond the rate
Blue Cross/Blue Shield would normally pay for services. Few children
use doctors who are not Blue Cross/Blue Shield providers.
PUBLICITY, OUTREACH, AND
MARKETING
---------------------------------------------------- Appendix II:6.2.6
The Caring Program publicizes itself in various ways, from Mister
Rogers television spots to bus billboards to grassroots efforts in
every county. In addition, its fundraising efforts help make it
known to churches and other community groups who can help outreach to
families. Three outreach specialists work in 29 counties to locate
sponsors for the children, make presentations, distribute
applications, and help families enroll. In 1993, more than 100
schools and several major corporations helped the program raise funds
and publicize its services. Currently, several chain stores have
distributed flyers and hung posters to inform shoppers about the
Caring Program. In addition, members of the Pittsburgh Steelers
football team have made speeches to community groups, donated prizes
to fundraisers, and hosted kick-off luncheons and victory parties as
incentives for schools raising funds for the program. The Western
Pennsylvania Caring Foundation spent about $370,000 in fiscal year
1994 for outreach and publicity for both the Caring Program and the
Children's Health Insurance Program.
LIMITED EVALUATIONS SHOW PROGRAMS
IMPROVED CHILDREN'S USE OF HEALTH
CARE SERVICES
========================================================= Appendix III
Limited available evaluations show that the six programs we visited
have improved children's access to and use of health care. The
programs increased the likelihood that children would get the care
that they needed, reduced inappropriate ER use in some cases, and
increased children's use of preventive services. Some evaluations
suggest children enrolled in the programs may still not be getting as
many preventive services as recommended by health authorities.
INCIDENCE OF UNMET MEDICAL
NEEDS HAS BEEN REDUCED
----------------------------------------------------- Appendix III:0.1
Three programs' evaluations have found evidence that they have
reduced their enrollees' level of unmet need for medical treatment.
A 1991 survey of participants in the Western Pennsylvania Caring
Program for Children found that, before enrolling their children in
the program, 33 percent of parents postponed taking them to a
physician when they thought it was necessary, but after enrollment
only 2 percent did so. HCFA's evaluation of the Florida Healthy Kids
Program found that more enrolled children had their medical needs met
than did uninsured children in those states. A separate study of the
Florida program found that only 1 percent of Healthy Kids
respondents, compared with 17 percent of non-Healthy Kids
respondents, failed to seek medical care for their children because
the cost of a doctor's visit deterred them.
INAPPROPRIATE USE OF
EMERGENCY ROOM WAS REDUCED
IN CERTAIN PROGRAMS
----------------------------------------------------- Appendix III:0.2
Low-income families sometimes use hospital ERs when treatment by a
primary care provider would be more appropriate and less costly. The
programs' effect on ER use was mixed: ER use by program children
declined in one program, but not in two others. In fact, the two
programs that used copayments to discourage inappropriate ER use had
different results.
Evaluation of the Healthy Kids Program found that participating
children were significantly less likely to use the ER than a
comparison group of nonparticipants. In addition, a hospital used by
program children in Volusia County studied its ER usage and found
that uninsured pediatric ER visits declined by about 15 percent
during the 2-year period after the program began, without an increase
in ER visits by children enrolled in the HMO used by the program.
Florida uses a copayment to discourage inappropriate ER use.
However, ER use by program families in the Western Pennsylvania
Caring Program and New York's Child Health Plus Program did not
decrease. According to a 1991 University of Pittsburgh survey,
participants in the Western Pennsylvania Caring Program used the ER
slightly more often following enrollment in the program. Preliminary
results of the University of Rochester's survey of participants in a
limited geographic area in New York's Child Health Plus Program
showed no significant changes in ER use following enrollment in the
program, even though Child Health Plus authorizes a copayment for
inappropriate ER use. Statewide data are not yet available to fully
evaluate the program's impact on ER use.
PREVENTIVE SERVICES USED BUT
PERHAPS NOT ENOUGH
----------------------------------------------------- Appendix III:0.3
A number of programs have been successful at encouraging use of
primary and preventive care services. However, evidence from three
programs suggests that preventive services may still be underused by
program participants.
Four programs found that enrolled children were more likely than
uninsured children to get preventive and primary care. For example,
a 1991 survey of participants in the Western Pennsylvania Caring
Program found that the likelihood of a child's having had at least
one well-child visit during the year and being up-to-date with
immunizations increased after the child enrolled in the program.
Evaluations of the Florida program found that enrolled children were
more likely to have had a doctor's visit or a preventive checkup in
the previous 3 months than a comparison group of uninsured children.
An Alabama Caring Program evaluation found that 81 percent of the
enrolled children had developed an ongoing relationship with a
pediatrician or family doctor, whereas before enrolling in the
program only 17 percent of these children had ever visited a private
doctor.
Despite these increases in children's use of primary and preventive
care, some children may still not be using preventive services at
recommended levels. Several programs evaluated their enrolled
children's care use and found that many children were not using their
insurance to get an initial checkup or to get immunized. For
example, the Institute for Child Health Policy in Florida analyzed
Healthy Kids children's use of health care services. They found that
32 percent of program children studied had never had a doctor's
examination, and that the poorest enrolled children and
African-American and Hispanic enrollees were more likely to have
never used program services--results similar to those found from
evaluating another health program serving a similar population. The
Institute for Child Health Policy concluded that various
sociopolitical and cultural factors may discourage African-American
and Hispanic families from getting preventive services for their
children.
New York and Minnesota also found that children were not using
preventive services sufficiently. An early quality assurance study
of New York's Child Health Plus Program found that enrolled children
averaged 2.5 immunizations by their first birthday, even though
American Academy of Pediatrics guidelines call for a minimum of 8
immunizations. The University of Minnesota found in a study of
Minnesota's Children's Health Program (the precursor to
MinnesotaCare) that more than 30 percent of enrolled children did not
receive well-child care in 1990. According to several program
officials or analysts, many families thought they were supposed to
use their children's coverage only when their children were sick.
Program officials or insurers in Florida, Minnesota, and New York
attempted to increase the use of preventive care through sending
newsletters and other written materials to families.
GAO CONTACTS AND STAFF
ACKNOWLEDGMENTS
========================================================== Appendix IV
GAO CONTACTS
Sally Jaggar, Director, (202) 512-7119
Sheila Avruch, Project Manager, (202) 512-7277
STAFF ACKNOWLEDGMENTS
In addition to those named above, the following individuals made
important contributions to this report: Cassandra Gudaitis and Marie
Cushing led the team in Los Angeles and, with Jay Goldberg, drafted
major sections of this report and helped conduct case studies in
Alabama, Florida, Maine, New York, and Pennsylvania; Tim Fairbanks,
Shawnalynn Smith, and Howard Cott helped conduct case studies in
Minnesota and Maine; Richard Jensen and Michael Gutowski advised the
team, with assistance from Deborah Perry of the National Governors'
Association; Karen Sloan helped write and revise the draft report;
Susan Lawes assisted in developing the case study design and
protocols; and Paula Bonin analyzed the March 1994 Current Population
Survey for information on uninsured children in states.
RELATED GAO PRODUCTS
============================================================ Chapter 0
Medicaid and Children's Insurance (GAO/HEHS-96-50R, Oct. 20, 1995).
Health Insurance for Children: Many Remain Uninsured Despite
Medicaid Expansion (GAO/HEHS-95-175, July 19, 1995.)
Medicaid: Spending Pressures Drive States Toward Program Reinvention
(GAO/HEHS-95-122, Apr. 4, 1995).
Medicaid: Restructuring Approaches Leave Many Questions
(GAO/HEHS-95-103, Apr. 4, 1995).
Medicaid: Experience With State Waivers to Promote Cost Control and
Access Care (GAO/HEHS-95-115, Mar. 23, 1995).
Uninsured and Children on Medicaid (GAO/HEHS-95-83R, Feb. 14, 1995).
Block Grants: Characteristics, Experience, and Lessons Learned
(GAO/HEHS-95-74, Feb. 9, 1995.)
Health Care Reform: Potential Difficulties in Determining
Eligibility for Low-Income People (GAO/HEHS-94-176, July 11, 1994).
Medicaid Prenatal Care: States Improve Access and Enhance Services,
but Face New Challenges (GAO/HEHS-94-152BR, May 10, 1994).
Managed Health Care: Effect on Employers' Costs Difficult to Measure
(GAO/HRD-94-3, Oct. 19, 1993).
Employer-Based Health Insurance: High Costs, Wide Variation Threaten
System (GAO/HRD-92-125, Sept. 22, 1992).
Access to Health Insurance: State Efforts to Assist Small Businesses
(GAO/HRD-92-90, May 14, 1992).
Mother-Only Families: Low Earnings Will Keep Many Children in
Poverty (GAO/HRD-91-62, Apr. 2, 1991).
Health Insurance Coverage: A Profile of the Uninsured in Selected
States (GAO/HRD-91-31FS, Feb. 8, 1991).
Health Insurance: An Overview of the Working Uninsured
(GAO/HRD-89-45, Feb. 24, 1989).
*** End of document. ***