Anne Markus | PubMed Health

PubMed2006

From SCHIP benefit design to individual coverage decisions.

The majority of states have implemented separate SCHIP (S-SCHIP) programs that significantly depart from Medicaid and resemble less comprehensive commercial products. This difference in program design may result in S-SCHIP potentially being less responsive to children with special needs (CSHCNs). This study explores how responsive insurers are to these higher than average needs. We found that, with one exception, insurers did not agree on the coverage of any specific service, but overall they provided coverage beyond state limits and exclusions. Second, the less acute the childhood condition, the more frequently insurers imposed exclusions. Finally, in the majority of states, some insurers excluded services that arguably should have been covered according to the plan/contract language. We conclude that SCHIP coverage at current levels may not be sufficient to care for CSHCNs, making external reviews of insurers' coverage decisions and coordination with other sources of care important components of SCHIP program design.

Child↗

PubMed2002

State eligibility rules under separate state SCHIP programs--implications for children's access to health care.

This Policy Brief is the fourth in a series of reports issued by the George Washington University Center for Health Services Research and Policy that examine the design of separately-administered State Children's Health Insurance Programs (SCHIP) that is, programs that operate directly under the authority of the federal SCHIP statute rather than expansions of state Medicaid programs. These Policy Briefs also consider the implications of states' design choices for children's access to health care. The first three briefs in this series focused on three aspects of separate SCHIP programs: children's legal right to assistance under separate programs; benefit and coverage design choices under SCHIP plans; and the design and structure of freestanding managed care contracts negotiated by SCHIP agencies. This issue brief focuses on how financial eligibility for SCHIP actually is calculated, that is, the formulas that states have developed to count children's family income for purposes of measuring eligibility. This topic is of central importance to overall program administration because of the federal legal prohibition against assistance to targeted low-income children who are in fact Medicaid-eligible. This prohibition on duplication of assistance was a crucial assumption in the enactment of SCHIP. It is also key to the conservation of limited SCHIP funding for targeted low-income children who are ineligible for either Medicaid or any other form of health insurance, particularly as unemployment rises and the number of lower income children without health insurance may be poised to increase.

Child↗