V. COORDINATION AND LINKAGES OF SERVICES AND PROGRAMS

To increase the capacity of children's health insurance programs, the nine states have developed strategies to coordinate services with other health programs in the state.These linkages involve efforts to coordinate enrollment, outreach, computer networks, administration, referral, the care of children with special health care needs, and efforts to provide continuous eligibility to children in families with fluctuating income.

This section addresses the following topics:

• referring eligibles to Medicaid; coordinating electronic and administrative structures between programs;
• referring individuals to Medicaid or other programs for inpatient care or other benefits not provided by separate state programs;
• coordinating with Medicaid eligibility status of children in families with fluctuating incomes;
• coordinating state programs for insured adults and children;
• utilizing the same provider network for various state programs;
• coordinating care for children with special health care needs with the State Maternal and Child Health Bureaus;
• establishing joint outreach efforts to identify potential enrollees; and
• coordinating efforts with other programs to enroll children in children's health insurance programs.

1. Referral to Medicaid When Applying to the Children's Health Insurance Program

Four of the nine states reported the establishment of a systematic referral for children eligible for Medicaid to the Medicaid program by separate children's health insurance programs.

• In Colorado, families are referred to the county social services office for Medicaid enrollment. If they are applying to the CCHP program by mail, they receive a letter explaining why they are ineligible for the CCHP, notified of their potential eligibility for Medicaid, and referred to Medicaid.
• In Massachusetts, applications for the state program are screened for Medicaid eligibility and eligibles are then sent Medicaid applications.
• In New York, the State Department of Social Services (DSS) coordinates with Child Health Plus to refer children between Medicaid and other children's programs. County DSS offices also refer children and families to Child Health Plus and provide guidance to families regarding Medicaid and Child Health Plus eligibility. In addition, DSS explains procedures for terminating Child Health Plus when Medicaid eligibility is established.
• In Pennsylvania, the five CHIP health plans are required to refer ineligible families to other sources of health care for which they may be eligible. Generally, families are referred to Medicaid programs. Last year over 8,000 referrals were made to the Pennsylvania Medicaid program.

2. Electronic/Administrative Coordination of Enrollees' Eligibility With Medicaid

Two of the states have integrated the administrative procedures and computer systems between their separate children's health insurance and Medicaid programs.

• The Florida Healthy Kids Corporation interfaces electronically with Medicaid's third party administrator to verify that enrollees are not currently enrolled in Medicaid. However, the Healthy Kids program does not check a child's eligibility for Medicaid, but only their enrollment status.
• In Minnesota, the same employees will process the applications for both Medicaid and future MinnesotaCare, beginning June 1, 2000. If a family mistakenly applies to either MinnesotaCare or the Medicaid program, they are referred to the correct program.

3. Referral to Medicaid or Other Programs for Inpatient Care or Other Benefits Not Provided by the Program

Some children's health insurance plans offer a more limited benefit package with the intent of keeping costs low and insuring as many children as possible. In these cases, plans may find it helpful to coordinate services with the state Medicaid program so that children who become severely ill and in need of comprehensive benefits (perhaps not offered by the separate children's health insurance program) have access to Medicaid.

• CaliforniaKids does not offer inpatient care so they established a coordinated effort between CaliforniaKids and the Medicaid agency (MediCal) for inpatient care. Although the relationship is not formal, coordination with Medicaid is conducted on a case-by-case basis. When a child requires inpatient care, CaliforniaKids contacts and coordinates with MediCal to assist families in obtaining necessary services. However, CaliforniaKids has needed to coordinate the care of children with MediCal in only seven cases since the establishment of the program.
• In Pennsylvania, Caring Programs provide coverage to "wrap-around" the CHIP program. [The Children's Health Insurance Program provides coverage to children up to age 16 whose families are below 185% of the poverty level. These children receive free coverage. Children under age 6 up to 235% of the poverty level are eligible for subsidized coverage. Applicants must be residents of Pennsylvania for at least 30 days (except newborns) and cannot have access to any other private insurance or the Medicaid program.] The Caring Programs subsidize coverage for children ages 6-18 between 185-235% of poverty and offer free coverage for 17- and 18-year-olds under 185% FPL who are too old to be eligible for the CHIP program. In addition, Blue Cross/Blue Shield allows families on the CHIP waiting list to "buy-in" to the program while they wait for an open spot. The Caring Foundation will often subsidize their coverage until a spot in CHIP is available.

4. Coordination with Medicaid as Families' Income Changes

The actual income of low-income families tends to fluctuate a great deal, causing children's eligibility for various state programs to change from year to year. In an effort to provide continuity of care for this population, three of the six states with stand-alone programs examined in this study have instituted protocols for referring children between Medicaid and separate children's health insurance programs.

• In Colorado, the new Colorado Basic Health Plan (to be established in July 1998) will assign the same enrollee number to their enrollees as was assigned to them by the Medicaid program. Therefore, both agencies will have a list of recipients with identical identification numbers. The goal is to create a seamless system and to prevent children from "falling out" of that system.
• In Massachusetts, there is two-way communication regarding applications and denial of eligibility between the Children’s Medical Security Plan (CMSP) and Medicaid. If a child applies to CMSP, but is eligible for Mass Health (Medicaid), the child is enrolled in CMSP under presumptive eligibility and given an application to apply for Medicaid. The Medicaid office is informed of the enrollees eligibility for Mass Health so that they might be included in any outreach and enrollment efforts. This has been the established protocol as the CMSP application is much easier to complete than the Mass Health application, thus reducing the period of uninsurance of children waiting for enrollment in Mass Health. In addition, children denied eligibility for Mass Health are referred to CMSP.
• In New York, the State Department of Social Services (DSS) coordinates with Child Health Plus on referrals between Medicaid and other children's programs. County DSS offices refer children and families to Child Health Plus. In addition, DSS provides guidance regarding assessment of Medicaid and/or Child Health Plus eligibility and procedures for terminating Child Health Plus when Medicaid eligibility is established.

5. Coordination of Adult and Child Services

Washington State has worked to integrate its program for uninsured adults and children as much as possible in order to provide a simple method for families to obtain insurance. The state-supported program for adults, the Basic Health Plan, provides insurance coverage to adults up to 200% of poverty. This program enrolled children and adults until the advent of the Basic Health Plus program, a Medicaid expansion for children up to 200% of poverty. In order to prevent confusion within families qualifying for assistance, income eligibility was set at the same level for both programs. To simplify the effort further, there is a single enrollment form for both programs. In addition, there has been a tremendous effort focused upon synchronizing provider networks between the two programs. This year marked a significant event, when the two agencies administering the two programs sent out a joint RFP soliciting health plans to contract with the programs. There have also been consistent efforts to integrate the programs' computer systems.

6. Coordination of Provider Network With Other Children's Programs

In order to maintain and increase the continuity of care, state children's health insurance programs may coordinate with other state programs to develop a common provider network.

• CaliforniaKids contracts with the same providers as several other state programs: Assistance for Infants and Mothers (AIM), MediCal, and the Child Health, Disability and Prevention Program (CHDP).
• In Florida, the Healthy Kids program has included county public health clinics as providers in an effort to allow children to continue to obtain care from their historical providers.
• MinnesotaCare originally used the same providers as the FFS Medicaid program. In 1996, all MinnesotaCare recipients were enrolled in health plans and health plan providers that participate with a Medicaid program, as also required, participate in MinnesotaCare.

7. Coordination of Care for Children With Special Health Care Needs With the Maternal and Child Health Bureau

Three of the nine states reported comprehensive efforts to coordinate the care of children with special health care needs with the state health departments’ Maternal and Child Health (MCH) programs. Since state Maternal and Child Health programs have traditionally been responsible for the care of special needs children, there has been concern about the enrollment of these children into programs that may contract with managed care plans. To ensure access to comprehensive care, the state MCH programs have interacted with families and managed care plans to provide "wrap around" services, coordinate care, and provide transportation. MCH programs have also focused on continuing the provision of other services not generally covered by managed care but provided through Title V programs. For example, children who become severely ill may require services covered under the MCH program for children with chronic illnesses. Therefore, MCH may coordinate with the separate state program to ensure such children receive the appropriate care. In two instances, Healthy Kids has utilized the Maternal and Child Health program as a reinsurer for children with chronic conditions not covered by Healthy Kids.

• In Tennessee, ninety percent of children with special health care needs are enrolled in TennCare. There are currently eleven managed care organizations participating in TennCare. Therefore, the Maternal and Child Health program has focused a substantial amount of effort on negotiating the appropriate care for children with special needs with the contracted plans. In cases where children are denied services, families of those children appeal to the health plan, and if denied again, the Maternal and Child Health program will often provide the services through the Children’s Special Services (CSS) program. This most often occurs with the provision of medical devices.
• In Washington, the State is beginning to enroll SSI-eligible children in managed care through the Basic Health Plus program. There is a substantial amount of coordination occurring between the Children with Special Needs Department and Medicaid as they seek to determine the best way to provide care for this population.

8. Coordination With Other Programs to Enroll Children in the Children's Health Insurance Programs

Seven of the nine states reported coordination between their children's health insurance program and other state programs with respect to enrolling children.

• Other state programs in California have enrollment information for the CaliforniaKids program and can assist families in filling out the application.
• In Colorado, children enrolled in the free meal program, Health Care Program (HCP), WIC, the state prenatal program, or either of the two food programs, can automatically enroll in CCHP if they are not enrolled in Medicaid. If children enter the CCHP program through any of these programs, CCHP requires the "enrolling program" to verify assets. A shorter application form was developed for this purpose, and is available through each of the aforementioned programs and schools.
• In Massachusetts, WIC clinics and activity centers have on-site registration into the Children's Medical Security Plan (CMSP). In addition, any health or human services agency can assist in the enrollment of applicants to CMSP. Individuals in each department have been trained to assist with mail-in or phone-assisted enrollment for the CMSP or Mass Health (Medicaid) programs. Providers at community health clinics and outpatient clinics, school nurses and advocates have also been trained to enroll children into the program. Assisting this effort is a 45-day presumptive eligibility provision for the Children's Medical Security Plan allowing providers to fax an application to CMSP and treat children immediately.
• Minnesota has developed a common enrollment form for MinnesotaCare and the state Medicaid program. This will assist with the enrollment process while reducing administrative efforts.
• TennCare distributes applications at county health department offices, permitting families to enroll on site. The process requires approximately fifteen minutes, and applicant are interviewed face-to-face to ensure their understanding of the forms and the way in which TennCare operates. In addition, families may examine the provider networks for each plan before they make any choices. Health department staff are also trained to assist families through grievance and appeals processes if a claim is denied. Since working with local health departments, community acceptance of TennCare has increased dramatically in Tennessee.
• In Washington, the Health Care Authority (which administers the Basic Health Plan for adults) coordinates with the Department of Social and Health Services (which administers Basic Health Plus for children) to provide a uniform application for parents and children applying to the two programs. In order to reduce confusion, children and parents may enroll into the two separate programs with the same application form. The Department of Social and Health Services is responsible for verifying eligibility for applicants to both programs. The Department of Social and Health Services then enrolls the children, then forwards the list of eligible adults to the Health Care Authority for enrollment.

Table 17: Summary of Linkages Between Children's Health Insurance Programs and Other State Programs