The State Child Health Insurance Plan (SCHIP) Western State Schip Implementation Update for the Fifth Annual Western Summit on Indian Health Care 1998

Table of Contents
Preface and Acknowledgements
Alaska Page
Arizona KidsCare
California Healthy Families Program
Colorado Children Health Plan Plus (CHP+)
Hawaii
Idaho Children's Health Insurance Program
Kansas Children's Health Plan (HealthWave)
Montana Children's Health Insurance Plan
Nebraska
Nevada Check Up
SALUD!, New Mexico's Children's Health Insurance Program (Medicaid)
North Dakota
Oklahoma's Children's Health Insurance Program
Oregon Children's Health Insurance Program
South Dakota Child Health Insurance Plan (Medicaid)
Texas CHIP
Utah Children's Health Insurance Program (CHIP)
Washington
Wyoming

Preface and Acknowledgments

In December 1996, the Western Governors' Association (WGA) adopted Resolution 96-024, entitled "Indian Health Care", sponsored by Utah Governor Michael Leavitt. As directed by the resolution, WGA created a Task Force comprised of state public health officials, representatives of American Indian and Alaska Native tribes, federal Indian Health Service officials, federal Health Care Financing officials, and other interested parties. The resolution called on the Task Force to identify key health problems that could be effectively targeted to improve the health of Indian children. Under the leadership of the Utah Department of Health, the Task Force met twice in Salt Lake City and held several teleconference work sessions.

As a result of this work, the WGA Task Force produced a document entitled, "The State Child Health Insurance Plan (SCHIP) and American Indian and Alaska Native Children." It is available on the WGA Web site at www.westgov.org. It makes a number of recommendations to the governors on how to implement SCHIP with respect to Indian children. The governors adopted the report and its recommendation at their winter meeting in Seattle, Washington on December 5, 1997. Furthermore, the report was endorsed through resolution by the National Congress of American Indians and the National Indian Health Board.

This document is the WGA's effort to update attendees at the Fifth Annual Summit on Indian Health Care on the status of SCHIP implementation in each of the western states. It was prepared by Paul Orbuch of the WGA, with the assistance of Sharon Dawn.

The Western Governors' Association would like to thank the following organizations for most of the material contained in this report.

National Conference of State Legislatures -- (Legislative Policy Issues link to the State Children's Health Insurance Program)

State Children's Health Insurance Program

The information on these Web sites on SCHIP implementation is frequently updated. It is recommended that the timeliness of the information contained in this report be verified before you rely upon it.

Alaska

Date Submitted to HCFA: Plan should be submitted by August 31, 1998

Date Approved by HCFA: --

Legislation: H 369, signed by the governor on July 1, 1998

Targeted Number of Enrollees:

• 1999 40 percent of eligible but not enrolled children
• 2000 +15 percent of eligible but not enrolled children
• 2001 +10 percent of eligible but not enrolled children
• 2002 +10 percent of eligible but not enrolled children
• 2003 +5 percent of eligible but not enrolled children
• 80 percent of eligible but not enrolled children

Number of Uninsured Children:

Estimated from March Current Population Survey data:

• 2400 >100 percent - <133 percent
• 3700 >133 percent - <150 percent
• 5500 >150 percent - <200 percent
• 11600 under 200 percent of poverty
• 11900 over 200 percent of poverty
• 23500 uninsured children

Description of the Plan: Expansion of Medicaid to cover children to 200 percent of poverty; children in families with incomes from 150-200 percent that have private insurance will not be eligible; continuous eligibility for six months; no presumptive eligibility at this time; 12 month waiting period after willingly giving up private health insurance; pregnant women will be added up to 200 percent of poverty under a XIX expansion (approximately 800 women in Alaska).

Source of State Match: Primarily state general fund match appropriated by legislature.

Eligibility Standards and Methodology: See above.

Benefits: Same as current Medicaid program.

Medicaid Eligibility Levels: See above.

Cost Sharing and Payment: Premiums will be instituted for pregnant women from 150-200 percent of poverty.

Co-payments: None.

Service Delivery: Unchanged at this point.

Outreach and Coordination: Statewide Coalition formed to guide and provide feedback on outreach efforts designed; outreach approach that combines multi-media social marketing methods with person-to-person and person-to-community techniques, utilizing a Public Health model. Significant coordination with other statewide agencies, community organizations and providers, as well as with native health corporations funded through the Indian Health Service to coordinate services and access for Alaska Natives and others who are eligible.

Crowd Out Provisions: Children in families with incomes from 150-200 percent that have private insurance will not be eligible; 12 month waiting period after willingly giving up private health insurance.

Quality Assurance Mechanisms: Same as the existing Medicaid program.

Performance Measures:

• Market the Medicaid child heath insurance program:

- Number of enrollment forms distributed through outreach efforts.

- Number of collaborative efforts with community entities serving children and families.

- Extent of public information campaign media exposure.

• Enroll targeted low-income children in Medicaid:

- Measure the number of children enrolled in Medicaid in the baseline year and compare growth in future years.

• De-link Medicaid eligibility determination from public assistance programs:

- Create separate Medicaid eligibility determination units (Stand Alone Medicaid {SAM}).

• Simplify eligibility process:

- Create mail-in application process and shorten application.

- Implement policy for continuous eligibility for children and eliminate asset test.

• Deliver EPSDT services to new children enrolled at the same rate as age-comparable groups of other children enrolled in Medicaid:

- Compare percentages of newly enrolled CHIP children receiving EPSDT screenings to other Medicaid-enrolled children by measuring data from EPSDT subset of MMIS.

Background and Description of State Approach to Coverage: Expansion of Medicaid was chosen as the option due to lower cost for administration and the possibility of serving more eligible children due to a lower per child cost than a separate program.

Contact Person:

Deborah Smith

CHIP Coordinator

Department of Health & Social Services

PO Box 110601

Juneau, AK 99811-0601

(907) 465-1696

E-mail: Deborah_Smith@health.state.ak.us

Arizona KidsCare

Date Submitted to HCFA: June 25, 1998

Date Approved by HCFA: Pending

Legislation: PL AZ S-1008 d

Targeted Number of Enrollees: Arizona plans to provide health coverage under KidsCare to 70,000 low-income children once the program is fully established.

Number of Uninsured Children: 287,000 (CPS data, three year average)

Description of the Plan: The Arizona plan is a separate state child health insurance plan.

Eligibility Standards and Methodology: KidsCare is available to children under 19 years of age whose family income does not exceed:

• 150 percent of the FPL for state FY'99.
• 175 percent of the FPL for state FY'00.
• 200 percent of the FPL for state FY'01 through FY'07.

Benefits: Arizona will use the least expensive state employees' HMO benefit package as the benchmark, with the addition of dental and vision services.

Provisions for Special Needs Kids: Funded by a Title V block grant, the Arizona Department of Health Services (ADHS)/Children's Rehabilitative Services (CRS) provides health care services to children with special health needs. Additionally, Medicaid eligible children receive services through CRS and AHCCCS reimburses ADHS with Medicaid funds for covered services provided by the program.

Medicaid Eligibility Levels: Prior to implementation of KidsCare, Arizona Medicaid eligibility levels were:

• Children under age 1 covered to 140 percent FPL.
• Children age 1 through 5 covered to 133 percent FPL.
• Children age 6 through 14 covered to 100 percent FPL.

Cost Sharing and Payment:

Premiums: The state will impose monthly premiums for members with incomes above 150 percent of the FPL beginning July 1, 1999.

Co-payments: AHCCCS will use the same co-payments and procedures that have been approved for the Medicaid program. The following co-payments will be assessed for all members who are eligible for KidsCare:

• $1 for each physician visit, laboratory and x-ray.
• $5 for non-emergency surgery.
• $5 for non-emergency use of the emergency room.

Service Delivery:

• Arizona will provide KidsCare services through established AHCCCS health plans and the state employee HMOs who elect to participate in the program. In the second year of the program, the state will use Title XXI funding for direct services provided by participating community health care clinics and hospitals which serve predominately low-income children.
• All children will have a choice of available contractors and primary care providers in service geographic areas. Additionally, Native Americans can elect to receive services through the Indian Health Center (IHS), 638 tribal facilities, or one of the contractors.

Outreach and Coordination:

• Prior to the implementation of the KidsCare Program, the Governor will designate an Arizona KidsCare day. This announcement will be the kick-off for the KidsCare campaign.
• The Governor's Office and AHCCCS are working collaboratively with tribal entities to inform Native American families about the availability of KidsCare and to assist in enrolling children in KidsCare.
• AHCCCS has established an Outreach Coordinator position to assume major responsibility for KidsCare outreach activities.
• AHCCCS, and other interested parties, will develop outreach strategies and materials in English and Spanish. The state will use numerous methods to reach families of children likely to be eligible for KidsCare, including: radio, television, brochures, flyers, video, toll-free hotline numbers, mailings, and presentations throughout the state.
• Outreach efforts and the distribution of applications will be targeted to those agencies, organizations, and other entities that currently serve targeted low-income children.
• To specifically target low-income children of migrant workers, the Arizona Interagency Farmworkers Coalition has agreed to include information about KidsCare in their newsletters and will have a KidsCare presentation at an executive board meeting.

Crowd Out Provisions: The application process will request information about group health plan coverage within the past six months. If a child is covered by group health insurance or was covered and the coverage was voluntarily discontinued in the past six months, the child will not be eligible for KidsCare. An eligibility worker will review the application and ask the parent to make a declaration about whether the family member or an employer has discontinued employer-sponsored dependent insurance coverage in order to allow a child to participate in the KidsCare Program.

Quality Assurance Mechanisms: Quality assurance mechanisms will include:

• Quality standards defined in policy and contract.
• Annual on-site operational and financial reviews.
• Annual performance indicator and utilization measurement studies.
• Compliance with national quality measures.
• Member surveys.

Performance Measures: Arizona has established the following strategic objectives for the KidsCare Program:

• Decrease the percentage of children in Arizona who are uninsured.
• Improve the number of KidsCare eligible children who receive preventive and primary care by meeting the goals below:

- 1. 80 percent of children under 2 will receive age appropriate immunizations.

- 2. 60 percent of children under 15 months will receive the recommended number of well child visits.

- 3. 60 percent of 3, 4, 5 and 6 year olds will have at least one well child visit during the year.

- 4. 50 percent of children will have at least one dental visit during the year.

• Ensure that KidsCare enrolled children receive access to a regular source of care:

- 100 percent of enrolled children will be assigned a Primary Care Physician (PCP).

- 70 percent of KidsCare children will see a PCP at least once during the first 12 months of enrollment.

• Screen 100 percent of applications to determine if the child was covered by employer sponsored insurance within the last six months.
• Coordinate with other health care programs providing services to children to ensure a seamless system of coverage.

Background and Description of State Approach to Coverage:

• Arizona currently has a managed care Medicaid program (AHCCCS), four state-funded medical programs for low income persons, and numerous public health programs which provide health care services to children. These programs are:

- Medically Indigent/Medically needy program.

- Eligible Assistance Children program.

- Eligible Low Income Children program.

- State Emergency Services program.

• Through 12 contracted health plans, AHCCCS covers all mandatory and several optional Medicaid groups.
• There are 27 community health centers that offer a wide range of health care services based on a sliding fee schedule.

Contact Person:

Cheri Tomlinson

Federal and State Policy Administrator

Division of Policy, Analysis, and Coordination

Arizona Health Care Cost Containment System (AHCCCS)

801 East Jefferson Street

Phoenix, AZ 85002-5520

(602) 417-4534

California Healthy Families Program

Date Submitted to HCFA: November 20, 1997 (response to HCFA February 6, 1998, March 4, 1998, March 19, 1998)

Date Approved by HCFA: March 24, 1998

Legislation: A1126, S903

Targeted Number of Enrollees: 580,000

Number of Uninsured Children: 1,676,000 (CPS data, three year average)

Description of Plan: California's Healthy Families Program is a combination of a private plan and a Medicaid expansion.

Source of State Match: State funds will be used for the plan except for county mental health which will be matched by local funds, and California's Children's Services and Child Health and Disability Prevention (CHDP) program which will be matched by General and local funds.

Eligibility Standards and Methodology:

• Healthy Families is available statewide for resident children ages 1-19 with family incomes 100-200 percent FPL.
• Infants ages 0-1 with family incomes 200-250 percent FPL will be served by Access for Infants and Mothers (AIM).
• Children 14-19 with family incomes 85-100 percent FPL will be eligible for Medi-Cal through the Title XXI expansion.
• Children cannot be eligible for other insurance, Medi-Cal or Medicare and cannot have been covered by employer sponsored coverage within the last three months.
• Eligibility will be determined annually for Healthy Families. Medi-Cal will extend one month of continued eligibility for children whose family income increases beyond Medi-Cal's eligibility threshold for no-cost Medi-Cal.
• Parents must enroll all of their children into Healthy Families, pay the first month contribution and agree to remain in the purchasing pool for six months, if applicable.

Benefits: The state will use the CalPERS state employee benefit package as the benchmark coverage for health. Further, it will include dental and vision coverage, screening and initial treatment services through the CHDP program and treatment services for severely ill children in a non-managed care delivery system.

Provisions for Special Needs Kids:

• California Children's Services (CCS) case management, through its authorization and standards for providers, can insure that children with serious physically handicapping conditions are receiving health care services from the appropriate type and level of provider.
• Children with serious emotional disturbances receiving Mental Health Plan services under Title XXI will be included in the CCS requirements for provider selection.
• The Managed Risk Medical Insurance Board (MRMIB) will track the number of children with special health care needs who participate in the program and will track subscriber complaints and health plans' compliance with referral requirements.

Medicaid Eligibility Levels:

• Infants up to age 1 with family incomes at or below 200 percent FPL (the income between 185-200 percent and the parents' resources are disregarded).
• Children age 1 and under 6 with family incomes at or below 133 percent FPL.
• Children age 6 to 19 with family incomes at or below 100 percent FPL.
• Resources will be disregarded, making families eligible based on income alone.

Cost Sharing and Payment:

Service Delivery:

• Healthy Families will provide health care through a managed care system to be delivered through a health insurance purchasing pool and an insurance purchasing credit for children whose families have access to (but do not have) employer-sponsored coverage.
• The managed care program will be administered by MRMIB which will also administer the purchasing pool, the purchasing credit and the AIM program.

Outreach and Coordination:

• California will contract with a private firm which will conduct a media campaign and subcontract with community-based organizations and other entities to directly identify and assist potential Medi-Cal and Healthy Families enrollees.
• The state will use a pre-enrollment process and a one-time $25 application assistance fee to enroll eligible children in both Healthy Families and Medi-Cal.
• The state will reduce barriers, such as the complicated enrollment form, and target education and outreach to low-income women with materials and messages that are culturally and linguistically sensitive.
• Medi-Cal and Healthy Families will have a joint, simplified mail-in application form.
• A toll free number will be created to provide more information about the program.
• Business coalitions and employers will be targeted in order to ensure that employees are aware of the program. Details of sanctions for dropping employees' coverage will also be sent to employers.
• These efforts will be coordinated as often as possible with other public health programs such as maternal and child health programs, WIC and CHDP.

Crowd Out Provisions:

• Children previously covered by employer-sponsored insurance must be uninsured for at least three months (this may be changed to six months if it is determined that Healthy Families is causing crowd-out).
• The plan will provide funds to families to purchase coverage for their dependents through their employer's plan using a purchasing credit mechanism.
• Insurance agents, insurers and employers are prohibited from referring employees and dependents to the program when dependents are already covered by employer-sponsored insurance.
• Employers cannot change coverage or the employee share of cost for coverage to get employees to enroll in the program.

Quality Assurance Mechanisms:

• MRMIB will monitor quality standards in the purchasing pool through analysis and trending of reports from health, dental, and vision plans. These reports will include benefit grievances, regulatory entity reports, and enrollment and disenrollment reports.
• Inclusion of risk-adjusted premium payments.
• Monitoring the accreditation status of participating plans by entities such as NCQA.
• The specific quality indicators to be tracked will focus on child or adolescent specific outcomes. MRMIB intends to use the audited HEDIS measures generated by the California Cooperative HEDIS Reporting Initiative.
• Each of the contacts between MRMIB and participating health, dental, and vision plans will contain specific performance objectives. The standards will be based on testimony provided during the program development process and advice from the Healthy Families Advisory Panel.
• The Healthy Families gateway program, CHDP, reimburses for periodic health assessment of children under 21 years of age who are eligible for Medi-Cal, and for those under 19 whose families are below 200 percent FPL. The standards of the American Academy of Pediatrics serve as a basis for preventive service standards.
• The CCS program develops standards for provider participation under the Health and Safety Code. CCS program staff authorize approved providers to deliver services to eligible children.
• MRMIB will measure performance of purchasing pool plans through collaboration with other large purchasers, requiring all participating health plans to submit yearly HEDIS results, and requiring participating plans to submit results of standardized subscriber satisfaction surveys.

Performance Measures:

• Use Current Population Survey longitudinal data as well as Medi-Cal and emergency room data to measure increases in enrollment of Medi-Cal eligible children.
• Conduct a quantitative evaluation of the number of health plan choices provided to Medi-Cal and Healthy Families enrollees and analyze the demographic distribution of members by health plan in order to ensure enrollment choices.
• In order reach target audiences and develop an application that can be completed without an in-person meeting, MRMIB will ensure that all enrollment materials are available in languages identified by DHS, and at an eighth grade reading level.
• In order to ensure that participation cost will not exceed two percent of a family's annual income, CA will survey uninsured persons to determine if finances prevent enrollment.
• CA will use HEDIS to measure improvements in the percentage of targeted children receiving well-child visits and immunizations.
• DHS will require the outreach/education contractor to allocate a percentage of resources to fund community-based organizations' participation in outreach efforts.
• MRMIB will achieve increases in the number of children who have access to a provider located in their zip code or to traditional and safety net providers by requiring participating plans to report annually on the number subscribers selecting traditional or safety net providers.
• CA will assess changes in the insurance status of low-income children and ask questions relating to past employer-based insurance coverage in order to maintain the proportion of children under 200 FPL who are covered under an employer-based plan.

Background and Description of State Approach to Coverage:

• Before Title XXI, 53 percent of California's children were covered by employer-based insurance, 25 percent Medi-Cal, 3 percent by private insurance, 1 percent by Medicare/CHAMPUS and 17 percent were uninsured.
• With Title XXI, California will remove the Medi-Cal resource standard (leaving only the income standard) which will make it easier for providers and others assisting families to determine whether children are qualified for Medi-Cal or Healthy Families.
• Families who are no longer qualified for Medi-Cal but are instead qualified for Healthy Families will have one month of continued Medi-Cal eligibility to make the transition.
• The CHDP program, which provides preventive health services to children under 200 percent FPL, will act as a gateway for the new program, directing children into either Medi-Cal or Healthy Families.

Contact Person:

Lesley Cummings

Associate Director for Health Policy

Department of Health Services

714 P. Street, Room 1253

Sacramento, CA 95814

(916) 653-2223

Colorado Children Health Plan Plus (CHP+)

Date Submitted to HCFA: October 14, 1997 (responses to HCFA December 30, 1997, January 27, 1998)

Date Approved by HCFA: February 18, 1998

Legislation: HB97 1304, HB98 1325

Targeted Number of Enrollees: FY '98, 8,600; FY '99, 23,000; FY '00, 33,000

Number of Uninsured Children: 152,000 (CPS data, three year average)

Description of the Plan: CHP+ is a private plan. It expands upon the benefits of the existing Colorado Child Health Plan (CCHP), which provides basic medical services.

Source of State Match: CHP+ will be funded from the state General Fund, CHP cash reserves and donations.

Eligibility Standards and Methodology:

• The plan is offered statewide to resident children 0-18 years old with family income at or below 185 percent FPL.
• Families may apply for one full year's coverage up to the day before the child's 19th birthday. The child will then receive coverage for one additional year.
• Children cannot be eligible for Medicaid or any other insurance.

Benefits:

• Hospital and emergency room transport, inpatient/outpatient/ambulatory surgery, medical office visits, laboratory and x-ray services, preventive care, maternity care (prenatal, delivery, inpatient, well-baby care), neurobiologically-based mental illness, home health care, hospice care, outpatient prescription drugs, skilled nursing facility care, intractable pain, and autism.
• Limited coverage on mental health institutional care and outpatient care, alcohol and substance abuse, physical, occupational and speech therapy; durable medical equipment, organ transplants, vision and audiological services; and nutrition services.

Provisions for Special Needs Kids:

• Contracts with managed care plans will require that the plans have a process in place to permit special needs children to obtain a standing referral for specialty care.
• CHP+ will build on a five-year collaborative relationship with the HealthCare Program for Special Needs, which targets high-cost services and routine case management for children with special needs.

Current Medicaid Eligibility Levels:

• Prior to the Title XXI expansion, Medicaid eligibility was as follows:

- If the age of the child is less than 6, and the family's total income is less than 133 percent FPL, or if the child is younger than 15 (born after 9/30/83), and the family's total income is less than 100 percent FPL, the child may be Medicaid eligible.

- If the sum of the total personal assets less deductions is greater than $1,000 or if the sum of the vehicle equity and the personal assets less deductions is greater than $2,500, the family is ineligible for Medicaid.

Cost Sharing and Payment:

• For children with family income up to 100 percent FPL, there is no cost sharing.
• For families with incomes 101-185 percent FPL, the annual out-of-pocket maximum is 5 percent of annual family income adjusted for family size.
• For families with income 101-185 percent FPL, hospital and emergency room transport is $10 and waived with appropriate use.
• For families with income between 101-150 percent FPL, there is a $2 co-payment for medical office visits, for neurobiologically-based mental illness, mental health outpatient visits, for alcohol and substance abuse, physical, occupational and speech therapy, and referral and refraction benefits only (vision services); for families with income between 151-185 percent FPL, the co-payment for these services is $5.
• For families with income between 101-150 percent FPL, there is a $1 co-pay for outpatient prescription drugs; for families with income between 151-185 percent FPL, the co-payment is $3 (generic) and $5 (brand name).

Service Delivery:

• Delivery of CHP+ services will be primarily through health maintenance organizations (HMOs). The seven HMOs contracting with Medicaid will be allowed to serve CHP+ recipients.
• The CCHP statewide provider network of physicians, hospitals, and ancillary service providers will be expanded for children eligible for CHP+ who do not have access to HMOs.

Outreach and Coordination:

• Various state agencies are trying to make available to low-income families one-stop access to public assistance including CHP+ information and enrollment.
• Children currently enrolled in CCHP will offered to be enrolled in CHP+ and informed of this option through mailings.
• Outreach and application assistance will occur at Medicaid outstation and eligibility/presumptive eligibility sites; family resource centers; locations of contracted providers; Medicaid and TANF eligibility sites; job training and employment offices; eligibility verification agreements with other state programs such as free/reduced-price lunch programs and WIC; country public health and nursing departments; CHP Satellite Eligibility Determination sites; and public schools.
• Assistance will target migrant workers, homeless children and children in rural/frontier areas.
• Applications and information can be downloaded from the CHP+ Web site.
• All material will be available in English and Spanish.

Crowd Out Provisions:

• Children cannot be covered by any other type of insurance.
• CHP+ applicants who appear Medicaid-eligible will only be enrolled in the program after they have received a denial letter for Medicaid from a county office.
• Children covered under an employer health benefits plan with at least a 50 percent employer contribution during the three months prior to application are ineligible for CHP+.

Quality Assurance Mechanisms:

• The Blue Cross/Blue Shield of Colorado Foundation funds the University of Colorado's annual evaluation of the Program which examines quality, appropriateness, and access to preventive and acute health services to children.
• A Quality Assurance and Utilization Review Committee is responsible for all aspects of quality assurance and utilization review for the CCHP provider network. This includes evaluation and management of clinical quality and utilization, evaluation of access and service issues, patient/provider grievance process, and overall program evaluation.
• Health plans will collect and report HEDIS, CAHPS, and grievance data, which will be evaluated and used to assist enrollees in choosing a plan.
• The CHP+ HMOs will report their grievance data to the Division of Insurance.
• Consumer education tools will be developed to ensure that CHP+ enrollees can negotiate managed care enrollment.
• During open enrollment, a report card of the results of key performance measures will be provided to every member.

Performance Measures:

• In order to evaluate plans' performance, health plans will collect and report HEDIS data on immunizations, well-child visits, adolescent well care, availability of language interpretation services, and pediatric and mental health specialists.
• CAHPS data will be collected on: ease of identifying a provider, waiting time for appointments, phone waiting time for medical advice, access to assessment tests, treatment and specialists, emergency room use, ease of referral to specialists, and follow-up reminders.

Background and Description of State Approach to Coverage:

• Colorado's public programs which identify and enroll children include:

- Medicaid.

- Health Care Program for Children with Special Needs which pays medical bills and provides follow-up for children age 20 and under diagnosed with a clinically qualifying handicapping condition.

- Colorado Indigent Care Program which is a state/federally funded provider reimbursement program that discounts the cost of medical care at participating centers for adults and children.

- Colorado Uninsurable Health Insurance Plan which provides health insurance to adults and children who are denied health insurance because of pre-existing conditions.

- Direct health services delivered by community health centers, Title V, school-based health centers, voluntary practitioner programs, WIC, and the Commodity Supplemental Food Program.

• Colorado's public-private partnerships which are used to identify and enroll children include:

- Kaiser Permanente's School Connections program which offers full comprehensive health care services in collaboration with school-based health centers.

- Voluntary practitioner programs such as the Children's Clinic, the Monfort Clinic, Doctors Care, Rocky Mountain Youth, and the Marillac Clinic.

Contact Person:

Sarah Schulte

Senior Health Policy Analyst

Department of Health Care Policy and Financing

1575 Sherman Street, Fourth Floor

Denver, CO 80203-1714

(303) 866-3144

Hawaii

Date Submitted to HCFA: Scheduled to submit in September 1998

Date Approved by HCFA:

Legislation: HCR 121 urges the children's health insurance program planning committee to develop universal health coverage for all children.

Plans are unclear as the state's Medicaid program is undergoing changes as a result of a lawsuit. The state may reduce Medicaid eligibility from 300 percent for 6 to 18 year olds to 100 percent, and to 133 percent for children 1-6 years old, and finally to 185 percent for newborns to 1 year olds.

Idaho Children's Health Insurance Program

Date Submitted to HCFA: February 11, 1998

Date Approved by HCFA: June 15, 1998

Legislation: H799

Targeted Number of Enrollees: 7,538 children residing in households with incomes between 100 and 160 percent of the FPL will be eligible for coverage under Medicaid expansion.

Number of Uninsured Children: 43,000 (CPS data, three year average.)

Description of the Plan: Idaho is providing expanded benefits under the State's Medicaid plan.

Source of State Match: Non-Federal share of funds may be obtained from the Idaho State Legislature General Fund through a legislative appropriation.

Eligibility Standards and Methodology: All children found eligible for Medicaid will be enrolled in Medicaid, regardless of whether the children were eligible under the previous income level or the new expanded income level.

Benefits: Medicaid eligibility increased to 160 percent of the FPL.

Provisions for Special Needs Kids:

• The Child Find Program identifies, through the help of physicians, speech therapists, early intervention specialists, and physical therapists, children who have developmental disabilities or are at risk of developmental disabilities. Immediate contact is made with families that have a child born with disabilities, or that are identified as being at high risk for developmental disabilities, so that they may be referred to the program for eligibility determination.
• The Children's Special Health Program, a program of the Division of Health, provides health care for children with significant health problems or chronic illnesses/conditions requiring long-term medical treatment and rehabilitative measures. The program treats children 0-18 years old.

Medicaid Eligibility Levels:

• Children residing in households with incomes between 100 and 160 percent of the FPL.
• Children residing in households with incomes below 100 percent of the FPL are eligible for the Medicaid program under previous criteria.
• Pregnant women and infants living within 133 percent FPL.
• Children under six living within 133 percent FPL.
• Children 7-14 living within 100 percent of the poverty level.

Cost Sharing and Payment: The funds provided under Title XXI will be used only to provide expanded eligibility under the state's Medicaid plan.

Service Delivery:

• As an umbrella organization, the Idaho Department of Health and Welfare is directly responsible for child protection, child abuse prevention, family cash and other subsidy income supports, developmental services, and mental health and substance abuse services.
• The state of Idaho's current efforts to provide out-stationed eligibility services at Federally Qualified Health Centers and disproportionate share hospitals consist of enabling staff to complete Medicaid eligibility forms for patients who may qualify for Medicaid.
• The Medicaid expansion will be coordinated with the Division of Welfare to be sure that the additionally eligible children are identified through child support activities.
• Healthy Connections, a managed care 1915(b) waiver program for Medicaid clients will provide counseling and education services to the expanded population of children who choose to participate in Healthy Connections under the Medicaid expansion.
• The child services network includes program such as WIC and Head Start, as well as immunization clinics, the Child Find program, and the Children's Special Health program.

Outreach and Coordination:

• Funding from the administrative portion of Title XXI funds will be used to develop and implement a promotional campaign that will enhance public and private organizations' efforts to provide outreach and education services to the target population. The campaign will be coordinated by the DHW Office of Public Participation (OPP).
• The first phase of the outreach campaign will focus on developing a theme and logo for CHIP which are clear and easily understood by the target population.
• The second phase will consist of distributing the materials. Primary distribution points will include known organizations that are currently in regular contact with the target population. Special efforts will be made to employ innovative methods of identifying children who are traditionally difficult to reach.
• In the third phase, OPP will analyze the demographic characteristics of the newly enrolled population to ascertain which children are not being reached.
• In the fourth phase, the promotional campaign will be revised to reach families that did not respond to initial outreach efforts.
• The enrollment process will be facilitated by Self-reliance Specialists, who are located at sites where the targeted population receives health and welfare enrollment assistance.

Crowd Out Provisions: The funds provided under Title XXI will be used only to provide expanded eligibility under the state's Medicaid plan.

Quality Assurance Mechanisms: The funds provided under Title XXI will be used only to provide expanded eligibility under the state's Medicaid plan.

Performance Measures:

• The percentage of eligible beneficiaries enrolled in a health insurance program as of September 30, 1998 compared to eligible beneficiaries enrolled as of September 30, 1997.
• The number of outreach, education, and enrollment sites in place in counties on September 30, 1977 compared to the number of sites in operation on September 30, 1988.
• Provider-to-beneficiary ratios measured for each region and county on September 30, 1998; ratio should be 1:1253 or less.
• Average travel time between beneficiaries and providers in urban and rural areas at year end 1988 measured by recipient surveys of GIS analysis.
• Rate of office visits for child health program enrollees compared to rate for regular Medicaid enrollees as of September 30, 1998.
• Percentage of children in child health plan who have received age-appropriate vaccinations.
• Percentage of children who have completed age-appropriate well-child visits by September 30, 1998.
• Percentage of children with claims submitted by referral providers.
• Rate of emergency room visits compared to the control group.
• Hospitalization rates for asthma measured and compared to national norms.

Background and Description of State Approach to Coverage:

• Idaho is distinguished by its frontier counties - defined in Idaho as a county with fewer than six people per square mile.
• Although racially homogeneous for the most part, there are culturally diverse populations in several counties.
• For 1997, there are approximately 418,000 children under the age of 19 living in Idaho. Of these, approximately 202,500 reside in households earning incomes at or below 200 percent of the FPL. Most of these children are covered by some form of insurance; however approximately 17.9 percent of those living below 200 percent of the FPL do not have health insurance.
• Of those who had health insurance, 70.5 percent were privately insured, 19.8 percent were enrolled in Medicaid, .5 percent were enrolled in Medicare, and 3.2 percent were covered by military health care programs.

Contact Person:

Juanita Strolberg

Grants and Contracts Specialist

Division of Medicaid Administration Department of Health and Welfare

P.O. Box 83720, Third floor

Boise, ID 83720-0036

(208) 334-5552

Kansas Children's Health Plan (HealthWave)

Date Submitted to HCFA: July 15, 1998

Date Approved by HCFA: Pending

Legislation: PL KS S-424

Targeted Number of Enrollees: By December 31, 1999, at least 30,000 children will be enrolled in the CHIP program. Another 10,000 children per year will be enrolled in 2000 and 2001.

Number of Uninsured Children: 71,000 (CPS data, three year average)

Description of the Plan: The Kansas State Children's Health Plan (HealthWave) is a new insurance program that meets the requirements for a State Children's Health Insurance Plan.

Eligibility Standards and Methodology:

• Children from birth to age 19 will be covered in families with incomes up to 200 percent FPL.
• To be eligible for CHIP coverage, families above 150 percent of the poverty level must pay a monthly premium.

Benefits: Kansas State employee coverage will be the benchmark for the benefit plan.

Medicaid Eligibility Levels:

• Prior to Title XXI expansion, Medicaid eligibility was the following:

- Children age 0-1 covered to 150 percent FPL.

- Children age 1-6 covered to 133 percent FPL.

- Children age 6-17 covered to 100 percent FPL.

Cost Sharing and Payment:

• Premiums:

- $10 per month per family for 151-175 percent of FPL.

- $15 per month per family for 176-200 percent of FPL.

• There are no deductibles and no co-payments.

Service Delivery:

• Through the purchase of insurance, the Secretary of the Kansas Department of Social and Rehabilitative Services will contract with entities deemed appropriate to implement the health coverage plan, providing for several plan options to enrollees which are coordinated with federal and state child health care programs. Examples of these entities are: insurance companies, HMOs, non-profit dental service corporations, or non-profit hospital, and medical insurance corporations authorized to transact health insurance business in Kansas.

Outreach and Coordination:

• CHIP materials will be developed and distributed.
• The public school setting will be the main focus of outreach to families.
• Outreach sites and enabling services will include:

- implementation of a toll-free number for enrollment information.

- community outreach workers.

- public service announcements and inserts in utility bills.

- Indian Health Services.

- Head Start and early childhood intervention sites.

- local and rural health departments, WIC clinics, hospital emergency rooms and pediatric units.

- physician offices.

Crowd Out Provisions:

• The application/enrollment form will be used to evaluate current health insurance coverage as well as access to state employee coverage. Children found to have current health coverage will be denied eligibility for CHIP coverage.
• Access to state employee coverage will result in denial of benefits under CHIP.
• Children who had health coverage within six months prior to application for the CHIP program will be denied benefits unless such coverage was ended based on good cause. Good cause reasons include such things as non-voluntary loss of employment, discontinuation of health benefits to all employees of the individual's employer, and termination of a health insurance plan the child was covered under by the insurer.

Quality Assurance Mechanisms: The state will evaluate the quality and appropriateness of care through external and internal monitoring standards, which include:

• External monitoring

- Peer education.

- Drug Utilization Review (DUR).

- External Quality Review Organization (EQRO).

- EQRO Advisory Committee.

• Internal Monitoring

- Contract Compliance Review.

- Complaint and Grievance Review.

- Policy Evaluation.

- Utilization and Review Studies.

Performance Measures: The strategic objectives and performance goals of HealthWave include:

• Reducing the number of uninsured non-Medicaid eligible children under 19 years of age and below 200 percent FPL in the State of Kansas.

- By December 31, 1999, at least 30,000 previously uninsured non-Medicaid eligible children will be enrolled in the CHIP program. Another 10,000 children per year will be enrolled in years 2000 and 2001.

• Preventing crowd-out of employer-based health insurance for employees with CHIP-eligible children.

- Maintain the proportion of children under 200 percent of the FPL who are covered by employer-based insurance.

• Assuring that the enrolled children with significant health needs have access to appropriate care.

- Reduce the number of cases of hospitalization due to asthma among the enrolled children.

• Assuring that the enrolled children receive high quality health care services.

- By December 31, 2000, at least 90 percent of CHIP enrollees will report overall satisfaction with their health care.

• Increasing the percentage of enrolled children with regular preventive care.

- By December 31, 1999, at least 75 percent of enrolled children through two years of age will receive one or more age-appropriate immunizations.

- By December 31, 1999, at least 80 percent of enrolled children will receive one or more EPSDT services.

Background and Description of State Approach to Coverage:

• Outreach and enrollment activities for Medicaid programs are administered through the Department of Social and Rehabilitative Services (SRS). Education regarding the Medicaid program is provided to advocacy groups, schools, health care professionals, social service agencies, and other community organizations that may have contact with children requiring health insurance. There is also staff located in the field offices and in the central office who conduct public awareness and education activities for the Medicaid program.
• Outreach activities for Maternal and Child Health and Title V programs are conducted through the Kansas Department of Health and Environment (KDHE). Through an inter-agency agreement, SRS staff refers consumers potentially eligible for these programs to the appropriate agency for eligibility determination. KDHE staff also refers potential Medicaid eligibles to SRS.
• The state works cooperatively with the CARING Program for Children in providing education to SRS staff regarding the availability and program requirements for the program. Applicants for Medicaid who are found to be ineligible for benefits are referred to the CARING Program for potential eligibility determination. CARING Program staff are also educated regarding eligibility criteria for Medicaid and refer potential eligibles to SRS.

Contact Person:

Laura Howard

Public Affairs

Kansas Department of Social and Rehabilitation Services

915 SW Harrison Street

Topeka, KS 66612

(785) 296-6218

Montana Children's Health Insurance Plan

Date Submitted to HCFA: April 10, 1998

Date Approved by HCFA: Pending

Legislation: Not filed yet

Targeted Number of Enrollees: 20,000

Number of Uninsured Children: 25,000 (CPS data, three year average)

Description of the Plan: CHIP is a private program.

Source of State Match: For the first year, CHIP will be funded by an intergovernmental transfer from the Commissioner of Insurance. After that, CHIP will be funded by the general fund and private donations.

Eligibility Standards and Methodology:

• The plan is available statewide to children who are Montana residents up to the age of eighteen in families with incomes up to 150 percent FPL. The coverage for children who are eighteen years of age will continue until the child's 19th birthday.
• Eligibility is guaranteed for one year unless the child moves from the state, enrolls in Medicaid, is found to have other coverage, or becomes financially ineligible.
• Children cannot have had health insurance coverage within the past three months. Children of state employees are ineligible.
• The three month waiting period does not apply if the parent providing the primary coverage is fired, laid off, disabled, or has a lapse in coverage due to new employment. Children who are not U.S. citizens or Qualified Aliens are ineligible.
• No child will be denied eligibility based on disability status. Children receiving SSI and eligible for Medicaid will be referred to Medicaid.

Benefits: The state will use the basic plan offered to state employees as the benchmark.

Provisions for Special Needs Kids: CHIP will be coordinated to ensure that children with needs beyond what CHIP covers will be referred to existing programs such as Children with Special Health Care Needs, the Mental Health Access Program, and visiting nurses.

Medicaid Eligibility Levels:

• Infants born to Medicaid-enrolled women remain eligible for twelve months.
• Children 1-5 are covered up to 133 percent FPL.
• Children 6-14 are covered up to 100 percent FPL.
• Children 15-18 are covered up to 40.5 percent FPL.

Cost Sharing and Payment:

• For families with incomes up to 100 percent FPL, there will be an annual fee of $25 per child up to a maximum of $100 per family.
• For families with incomes between 101-150 percent FPL, there will be an annual fee of $40 per child up to a maximum of $200 per family.
• There is a $3.00 co-pay per emergency room visit. There are no other cost sharing mechanisms.

Service Delivery: The state will contract with indemnity plans and HMOs. The indemnity insurance plans and HMOs will perform the primary utilization management functions.

Outreach and Coordination:

• In phase I, CHIP will target its outreach efforts to children enrolled in the Caring Program for Children (a primary and preventive care program that is not an insurance product), Indian Health Service users who are not covered by Medicaid or other insurance, families who receive subsidized child care through DPPHS, families who have left the TANF program, those in the Children with Special Health Care Needs program, and children participating in the Mental Health Access Plan.
• In phase II, the program will be marketed statewide through the following four primary strategies:

• -Direct appeal to eligible families through press releases, public service announcements, and video. A toll free number will be set up to for callers to hear recorded information on the plan, speak to a customer service representative, or to request an application.

- Collaboration with school districts to conduct back-to school enrollment campaigns statewide.

- Conduct outreach and training sessions on CHIP eligibility for the staff of local agencies, grass roots organizations, and providers active in providing Medicaid outreach in the past such as health departments, social services, WIC coordinators, public assistance officers, family resource centers, churches, the program for Children with Special Health Care Needs, community-centered boards of grass roots organizations, Child Care Resource and Referral agencies, tribal health and social service staff, Head Start, and Child Find.

- Outreach collaboration with statewide maternal child health organizations.

• CHIP outreach efforts will be coordinated as often as possible with Medicaid and other children's health coverage or direct services.

Crowd Out Provisions:

• Children previously covered by a group health plan or health insurance coverage must wait three months. The three month waiting period is waived if the parent who is providing the primary insurance is fired, laid off, becomes disabled, or has a lapse in insurance coverage after starting a new job.
• Children appearing eligible for Medicaid when applying for CHIP will be offered assistance in filling out the Medicaid form.
• CHIP applicants who appear Medicaid-eligible will only be enrolled in the program after the eligibility broker receives a Medicaid denial letter.

Quality Assurance Mechanisms:

• The HMOs and indemnity insurance plans are required to collect and report HEDIS measures on childhood and adolescent immunization, children's access to primary care providers, well-child visits, and adolescent well care visits.
• CHIP staff will monitor consumer and provider complaints to the Commissioner of Insurance.
• CHIP staff will monitor access through the contractor's access plan of its provider network, access-related complaints, and HEDIS access to primary care physicians.
• CHIP staff will monitor access to emergency care through emergency-related complaint data.

Performance Measures:

• Improve the health status of children covered by the CHIP program with a focus on preventive and early treatment as measured by percent receiving immunizations, well-child visits, and well-care visits.
• Decrease the proportion of children <= 150 percent FPL who are uninsured and reduce the financial barriers to affordable health care coverage.
• Prevent crowd out of employer coverage by maintaining the proportion of children who are covered by employer-based plan adjusting for increasing health care costs and economic downturns.
• Coordinate and consolidate with other health care programs providing services to children to create a seamless health care delivery system for low-income children. This goal will be achieved by:

- Enrolling into CHIP a minimum of 50 percent of children currently receiving benefits through the Caring Program for Children December 1, 1999.

- Ensuring that 50 percent of children referred from CHIP to Medicaid enroll in Medicaid.

- Enrolling into CHIP 10 percent of the children served by Children with Special Health Care Needs program.

- Enrolling into CHIP 90 percent of the children in the Mental Health Access Plan who are also eligible for CHIP.

- Increase the enrollment of currently eligible, but not participating children in the Medicaid program.

Background and Description of State Approach to Coverage:

• Montana does not currently have a state health insurance program for low income children. Health services are provided to uninsured and Medicaid enrolled children through six community health centers, five urban IHS clinics, one migrant health clinic, 23 rural health clinics, and 12 National Health Service Corps providers. Public health referral systems include WIC, public health home visiting, and family planning programs.
• Children's Special Health Services (CSHS) provides coverage for a limited number of children who are not covered by Medicaid or other health care insurance. The CSHS program activities are funded under Title V resources.
• Montana's Mental Health Access Plan (MHAP) provides mental health services through a 1915(b) Medicaid waiver and a state only portion for people of all ages under 200 percent FPL.
• Part C of the Individuals with Disabilities Act provides statewide early intervention services for infants and toddlers diagnosed with disabilities or developmental delays.

The Caring Program for Children which is administered by Blue Cross/Blue Shield of Montana provides preventive and primary care to children who are not covered under federal, state or private health insurance program.

Contact Person:

Mary Dalton

CHIP Coordinator

Health Policy and Services Division

Department of Public Health and Human Services

Cogswell Building, 1400 Broadway

P.O. Box 202951

Helena, MT

(406) 444-4144

Nebraska Kids Connection

Date Submitted to HCFA: May 13, 1998

Date Approved by HCFA: Pending

Legislation: LB 1063, 1998

Targeted Number of Enrollees: 950 in FY '98

Number of Uninsured Children: 43,000 (CPS data, three year average)

Description of the Plan: Kids Connection is a Medicaid expansion.

Source of State Match: The source is from the state General Funds.

Eligibility Standards and Methodology: Nebraska will expand Medicaid to include resident children age 15-18 with family income up to or below 185 percent FPL. There is no resource test.

Benefits: Nebraska will use the same benefit package provided under Medicaid.

Medicaid Eligibility Levels: Prior to Title XXI, Medicaid eligibility was as follows:

• Children 0-1 with family income up to 150 percent FPL.
• Children 1-6 with family income up to 133 percent FPL.
• Children 6-14 with family income up to 100 percent FPL.

Cost Sharing and Payment: Cost sharing will be the same as in the state's Medicaid plan.

Service Delivery: Service will be through the same system as the state's Medicaid plan.

Outreach and Coordination: Phase I outreach efforts include:

• The Health and Human Services System (HHSS) uses a one-page simplified Medicaid application form that can be mailed in.
• HHSS runs a web site on the program and an 800 number staffed by a full-time advocate.
• HHSS is working with advocacy agencies in disseminating information on Medicaid eligibility and the application process to the low-income community.
• HHSS staff are meeting with tribal representatives and the Director of the Indian Affairs Commission to develop appropriate outreach plans to Native Americans.
• HHSS utilizes out stationed eligibility sites in a number of hospitals.
• HHSS distributes a number of educational and promotional materials for enrollees, providers, and local office trainings.

Performance Measures:

• Reduce the number of uninsured children by providing health care coverage through Medicaid/Kids Connection Program.
• Create the HHSS infrastructure for determining and tracking children eligible under Medicaid/Kids Connection.
• Enroll 70 percent of children identified as mandatory into Medicaid managed care within 90 days of eligibility date.
• Increase children's access to primary care providers.
• Improve children's health outcomes through proxy measures of well-child visits, dental care, and visual care.
• Expand to Phase II by September 1, 1998.

Background and Description of State Approach to Coverage:

• An estimated 45,689 children in Nebraska were covered by Medicaid and 43,397 have no health insurance. The Census Bureau estimates 7 percent of Nebraska's children had no private or public coverage from 1994-96. Between 1989-1993, the percent of uninsured children remained constant.
• Created in 1985, the Nebraska Comprehensive Health Insurance Pool (CHIP) program is a state-only insurance program for children who are ineligible for Medicaid and other insurance. The Insurance Commissioner sets the rate based on the average rate of the state's five highest volume plans.

Contact Person:

Nancy Staley

Regulatory Analyst

Health and Human Services System

Department of Regulation and Licensure

P.O. Box, 95007

Lincoln, NE 68509-5007

(402) 471-9171

Nevada Check Up

Date Submitted to HCFA: March 6, 1998

Date Approved by HCFA: pending

Legislation: SB 470

Targeted Number of Enrollees: 10,000 by 1999

Number of Uninsured Children: 77,000 (CPS data, three year average)

Description of the Plan: Nevada Check Up is a private plan.

Source of State Match: The source of funds is a dedicated account in the state's general fund.

Eligibility Standards and Methodology: The plan is available statewide for resident children up to age 18 in families at or below 200 percent FPL. A family can apply for up to one full year's coverage until the month before the child's 18th birthday. The child can then receive coverage through the month before the child's 19th birthday. Eligibility is guaranteed until the annual eligibility determination date of July 1st.

Benefits: A health benefit package available to the commercial population of Nevada's largest HMO. The plan also covers dental, prescription drugs, vision and audiological services.

Medicaid Eligibility Levels:

• Family assets cannot exceed $4,200.
• Children up to age 6 with family incomes at or below 133 percent FPL.
• Children 6-18 born on or after October 1, 1983 with family incomes at or below 100 percent FPL.

Cost Sharing and Payment: There is an initial enrollment fee and quarterly premium based on family size and income. The state will adjust the enrollment fees and quarterly payments to assure that the families sharing costs are below the levels included under Section 1916(b)(1), calculated on an annual basis.

• Families with income at or below 150 percent of FPL have no co-payments.
• For families above 150 percent of FPL, there is a $5 co-payment for each drug prescription and dental visit and a $10 co-payment for eye glasses and hearing aids.

Service Delivery:

• Services will be delivered through state-licensed managed care organizations. If no MCOs will provide coverage in remote areas of the state through a fee for service plan.
• The MCOs are primarily responsible for utilization management staff and procedures to assure that services provided to enrollees are medically necessary and appropriate.

Outreach and Coordination:

• The Division of Health Care Financing and Policy (DHCFP) will print 400,000 copies of the application packet in Spanish.
• The application packet will be distributed to every child in the seventeen Nevada school districts.
• In addition, the packet will be distributed through the Head Start program, Tribal Councils, child care facilities, Family Resource Centers, State welfare offices, the WIC program, employment centers, county social services agencies, county health districts, the State Health Division's Community Health Nursing and Special Children's Clinic programs, the Family to Family program, public libraries, Boys and Girls Clubs, and other program/facilities where parents of potentially eligible children may be reached.
• Applications will also be provided to other organizations that want to assist in outreach such as public hospitals, FQHCs, and other community-based organizations.
• An 800 number will provide assistance with applications and answer questions about the program.
• The simple application form will enable most parents to fill out the form without direct help.
• After the initial enrollment phase, demographic information on enrollees will be reviewed and compared with information from the survey on the uninsured to identify areas and populations where more targeted outreach efforts are necessary.
• Nevada Check Up will be closely coordinated with the Medicaid program. On a monthly basis, eligibility rolls will be reviewed to ensure that children who enroll in Medicaid are disenrolled from the program. Additionally, children disenrolling from Medicaid will be given an opportunity to enroll in Nevada Check Up without a waiting period.

Crowd Out Provisions: In order to apply for Nevada Check Up, children have to be uninsured for at least six months. The waiting period is waived for children losing Medicaid and for those in families losing insurance due to circumstances beyond their control. DHCPF will closely monitor overall insurance coverage for children and determine additions steps to be taken, if necessary.

Quality Assurance Mechanisms: DHCFP will monitor the contractors through the following actions:

• An annual quality and operational review of each contractor.
• Contractors reporting of the same encounter data as required under the Medicaid Voluntary Managed Care program.
• An External Quality Review Organization (EQRO) review of the contractors and their data.
• Contractors producing HEDIS data as required under the Medicaid Voluntary Managed Care program.
• Performing on-site reviews, if problems of a material nature arise.
• Yearly member satisfaction survey and State review, analysis and follow up of the results.
• Contractors will report grievances on a quarterly basis. DHCFP will track the number and type of grievance. DHCFP will use the information to identify plan performance needing improvement and to form future performance standards.
• Supplement information with other available data on health plan performance from the state's two health insurance regulatory entities.

Performance Measures: The contractor's performance will be measured by the following:

• Periodic screening measures:

- 80 percent of children enrolled for 12 months have an age-appropriate periodic screening.

- Chart review of critical areas such as age-appropriate developmental, dental, vision, and hearing screening with follow up.

• Immunization measures:

- 90 percent of children 0-2 are appropriately immunized.

- 95 percent of children 3-18 are appropriately immunized.

• Family planning measure: 80 percent of enrollees of child bearing age (enrolled for at least six months) will receive age-appropriate family planning education and services.
• Dental service measures:

- 20 percent of children ages 3-5 enrolled at least 12 months have at least one oral heath screening, referral, and follow-up for necessary diagnostic and preventive services.

- 50 percent of children age 5-18 who have been enrolled for 12 months have at least one dental visit.

• Plans will have procedures in place to ensure primary care, specialty appointments, and dental appointment standards set by the State are met.
• Medical records measure: 90 percent of records must contain medical record keeping and patient visit date items indicated as critical by the State.

Overall program monitoring will be performed on an ongoing basis by the following activities:

• Review and analysis of encounter and financial data.
• Review of client and provider complaints and grievances filed with the State Insurance and/or Health Division.
• Reviews and investigations, when warranted or based on consumer satisfaction data.
• Review quality performance measures for well baby care, well child care, and immunization.

Background and Description of State Approach to Coverage:

• As of January 1, 1998, the total TANF/Children's Health Assurance Program (CHAP) enrollment is 53,194. There are no other public or private programs providing coverage for low-income children.
• Several public programs identify and enroll children in Medicaid including WIC centers, FQHCs, Special Children Clinics, the Baby Your Baby program, Family Resource Centers, and the Family to Family Program. In addition, Medicaid eligibility workers are stationed at some public hospitals and FQHCs.

Contact Person:

Christopher Thompson, Administrator

Division of Health Care Financing and Policy

2527 North Carson Street

Carson City, NV 89710

(702) 687-4176 Ext. 247

SALUD!, New Mexico's Children's Health Insurance Program (Medicaid)

Date Submitted to HCFA: May 19, 1998

Date Approved by HCFA: Pending

Legislation: S132

Number of Uninsured Children: 128,000 (CPS data, three year average)

Description of the Plan: The plan is an expansion of the state's Medicaid program.

Source of State Match: The state's General Fund funds the plan.

Eligibility Standards and Methodology: The New Mexico Title XXI program will involve expanding Medicaid for children from birth to 18 years of age from the current ceiling of 185 percent FPL to 235 percent FPL.

Benefits: The expansion will offer the same benefits as Medicaid.

Medicaid Eligibility Levels: Effective October 1997 and prior to Title XXI expansion, Medicaid eligibility was the following:

• Children age 0-19 covered at or below 185 percent FPL.

Cost Sharing and Payment: Premiums: $15.00 per month/per family regardless of household size or income level for the population between 186 percent and 235 percent FPL.

Service Delivery: Children eligible for Medicaid via CHIP will be enrolled in SALUD! Most services are provided through SALUD!, while some specialized services are on a fee-for-service basis.

Outreach and Coordination:

• New Mexico is implementing presumptive eligibility.
• A private contractor will conduct a publicity campaign. The Human Service Department (HSD) will also coordinate outreach with other public health agencies and organizations.
• HSD will distribute the SALUD! Newsletter which will address CHIP implementation.
• HSD will target outreach to Native Americans, including:

- Implement presumptive eligibility at Indian Health Service (IHS) facilities.

- train IHS facilities in the Medicaid On Site Application Assistance program.

- participate in meetings of the Albuquerque Area Indian Health Board.

- assist in the design and implementation of a Native American HMO.

• HSD and several other public and private organizations have applied for a Robert Wood Johnson Foundation Grant to conduct outreach and coordination.
• HSD has simplified the application and is implementing a twelve-month continuous eligibility option regardless of family income changes.

Crowd Out Provisions: Children will be ineligible for 12 months from the date on which creditable health coverage was dropped. Exceptions would be an involuntary loss of insurance, including the dropping of coverage by the employer; a catastrophic illness in a family possessing limited coverage; underinsurance for children with special needs; and a change in marital status or any other change in circumstances which may inadvertently effect coverage.

Quality Assurance Mechanisms:

• Evaluation of services will be conducted by quality assurance mechanisms with oversight by the Medical Assistance Division.
• Data collected and analysis required under the Title XIX program will apply to children brought into Medicaid by Title XXI.

Performance Measures:

• By April 1999, 75 percent of all permissible designated agencies and providers who have applied for presumptive eligibility provider status will be trained and in place to perform outreach, presumptive eligibility and Medicaid On Site Application Assistance (MOSAA) activities.
• As of September 30, 1999, 25 percent of children through 18 years of age who are enrolled in Medicaid will have received their EPSDT screens on schedule.
• By September 30, 1999, 45 percent of children eligible for Medicaid and currently not enrolled, will be enrolled in Medicaid.

Background and Description of State Approach to Coverage:

• In April 1995, New Mexico began an expansion of Medicaid eligibility to cover more than 38,000 children with family income up to 185 percent FPL. An estimated 164,000 children are on Medicaid and 266,000 are covered by private insurance.
• Children's Medical Services (CMS) is New Mexico's program for children with special health care needs and is funded through Title V. Case Management is provided for these children and referrals are made to necessary services and to Medicaid when appropriate.
• CMS also administers the Healthier Kids Fund which covers primary care for children without health insurance or that have insurance with a very high deductible. The state funds this program.
• The Families First Program at the Department of Health provides case management to help pregnant women and infants access all available health care resources, including referral to Medicaid when appropriate.

Contact Person:

Robert Beardsley

Planning and Program Operation

Medical Assistance Division

Human Services Department

P.O. Box 2348

Santa Fe, NM 87504-2348

(505) 476-7818

North Dakota

Date Submitted to HCFA:

Date Approved by HCFA:

Legislation: Legislature did not meet in 1998, and the state is considering waiting until the legislature is back in session address SCHIP.

Governor proposes expansion for children up to 18 below 100 percent. He also supports a private health insurance program for children under age 19 from 101 to 150 percent.

Oklahoma's Children's Health Insurance Program*

Date Submitted to HCFA: January 20, 1998

Date Approved by HCFA: May 26, 1998

Legislation: S478 (1997), S1228, S1018

Targeted Number of Enrollees: The Oklahoma Health Care Authority (OHCA) expects to enroll between 94,000 and 108,000 additional children and between 2,000 and 6,000 newly eligible pregnant women during Phase I.

Number of Uninsured Children: 183,000 (CPS data, three year average)

Description of the Plan: Oklahoma will be providing expanded benefits under the State's Medicaid plan.

Eligibility Standards and Methodology: The state will use funds provided under Title XXI only to provide expanded eligibility under the state's Medicaid plan.

Benefits: The state will use funds provided under Title XXI only to provide expanded eligibility under the state's Medicaid plan.

Medicaid Eligibility Levels: Medicaid eligibility for pregnant women and for children under age 18 will be expanded up to 185 percent of the FPL. The expansion will begin December 1, 1997 and will continue over a three year period. Children ages 15-17 will be added by age cohort in each subsequent year.

Service Delivery:

• In areas of the State not served by HMOs, a system of Primary Care Physicians/Case Management was implemented. HMO services were expanded into rural counties bordering the metropolitan areas not previously served by health plans. Both initiatives were the result of 1115 Waivers. The program created as a result of these two initiatives is called SoonerCare.
• SoonerCare includes an urban model (SoonerCare Plus) and rural model (SoonerCare Choice).
• The OHCA currently contracts with five HMOs to serve AFDC beneficiaries and 500 PCP/CMs to deliver a defined set of primary care services to rural beneficiaries. Most other services delivered to rural beneficiaries are reimbursed to providers on a fee-for-service basis.
• The OHCA will use these programs to enroll targeted low-income children in the SoonerCare Program.

Outreach and Coordination:

• The OHCA has developed a generic press release targeting statewide DHS offices. The press release allows for individual adaptation by providing blank sections to be completed by each County Administrator.

• The OHCA has a contract with the OK Association of Broadcasters to coordinate the statewide broadcasts of 30-second TV and radio announcements.

[* The State of Oklahoma is not presently a member of the Western Governors' Association.]

• The OHCA designed and produced postcards and posters to mail or "hand-out."
• In an effort to reach the Hispanic community , the OHCA contracted with the Variety Health Center for the translation of all outreach materials.
• A toll-free number is available for prospective enrollees to ask questions or request applications.
• A program fact sheet was developed for distribution at community-level meetings.
• Information will be distributed through local DHS offices.
• Local coalitions will become actively involved in outreach.

Governor supports and intends to introduce legislation during the next session that would be a conservative expansion of health insurance coverage to low income children not being served by Medicaid. The proposal will be privately-based and employer-based, wherever possible, and will not seek to expand the state's Medicaid program. It is very important that incentives are in place to keep individuals that are privately insured in that market and not move them into a government program. The proposal will aim to improve access and will offer a basic benefits package.

Page last updated 10/10/1999