INTRODUCTION

1. Purpose of the Resource Book

This resource book has been developed for states planning to implement new or expand existing children's health insurance programs in response to the availability of funding provided under Title XXI of the Social Security Act. The resource book contains reference information on nine states that established children's health insurance expansions prior to enactment of Title XXI. It is intended to provide relevant information for states as they design their own children's health insurance programs. The experiences of the state programs documented in this resource book have been identified as a result of a project funded by The U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Health Policy. The project focused on existing state children's health insurance programs in nine states: California, Colorado, Florida, Massachusetts, Minnesota, New York, Pennsylvania, Tennessee, and Washington.

The resource book includes information on the nine programs, the benefits offered, cost sharing arrangements, eligibility criteria and enrollment processes, outreach efforts, provider issues, and coordination with other types of programs. Examples of state programs and approaches are provided, however, they are not intended to be an identification or description of best practices.

2. The Enactment of Title XXI of the Social Security Act and States' Need for Information

Enabled under Title XXI of the Social Security Act, the State Children’s Health Insurance Program (CHIP) is providing $24 billion in funding to states over a five-year period to provide health insurance to uninsured children. The purpose of the law is to assist states in initiating and expanding children’s health assistance programs to uninsured, low-income children. The primary objective of Title XXI, to expand coverage for uninsured children, allows states to expand coverage beyond current Medicaid eligibility limits. This assistance can be provided through one of three methods: (a) a program to initiate and expand the provision of health care assistance via a separate State Insurance Program; (b) a Medicaid expansion; or (c) a combination of these methods. Coverage includes children under age 19 not eligible for Medicaid with family incomes below 200% of the federal poverty level or 50% above the current state Medicaid limit. State expansions could begin as early as October 1, 1997. Each state is eligible to receive a portion of the total amount, and allotments remain available for up to three years.

As a result of the enactment of Title XXI, states are faced with the challenge of designing and implementing programs that will increase the enrollment of eligible children without encouraging the substitution of employer-sponsored insurance. The complexity of family decisions, state policy objectives, and program design may impact the ability of a program to meet its intended goals. For example, states must consider the complexity of family dynamics as decisions to enroll in health insurance programs are based on the affordability of plans, the comprehensiveness of benefit packages, and the health status of their children, among other factors. Likewise, decisions regarding how and to what extent to expand coverage for uninsured children will be made in the context of broader state policy objectives and existing state programs. Existing and potential policies regarding insurance reform, efforts to assist employers in providing coverage, potential substitution of private coverage, and state social and economic policies are likely to be examined in the broader context of planning for expanded children's coverage. Additionally, the overall design of a state program will impact its ability to conduct outreach and enroll eligible children. The experiences presented in this resource book provide information and an historical context for states developing programs under Title XXI.

3. Methodology

Information provided in this resource book is based on information collected from program representatives of the nine study states. The criteria used to select the programs included: type of program (e.g., Medicaid expansion, state-sponsored, or foundation-sponsored), geographic location, age and size of program, and scope of the program. State representatives, including program directors, Maternal and Child Health directors, and Medicaid staff from all nine states were interviewed on their experiences in designing and implementing children's health insurance programs. Information collected through the interview process has been organized in a database created for the purpose of collecting children’s health insurance program, administrative, and legislative information.

4. Structure of the Resource Book

This resource book is specifically focused on six issue areas. As many children's health insurance programs have been in existence for only a short period of time, a number of these issues have only recently been identified and have not yet been fully evaluated. In general, there is little data to reflect best practices and overall efficacy of programs.

This resource book has been organized into issue areas related to the design and structure of children's health insurance programs. There may be some overlap across selected areas discussed in this resource book as some of the issues and state activities are closely related. Each chapter provides the following: an overview of the issue; a brief description of the approach the study states has taken within their program; and tables that exemplify or summarize the efforts of each state program.

• Section I discusses issues related to eligibility and recertification; Section II outlines the enrollment processes for each of the nine states; Section III focuses on the outreach and marketing efforts of the state programs; Section IV provides a description of issues related to the provider networks employed by state programs; Section V describes the role and collection of premiums and copayments; Section VI explains the coordination of children's health insurance programs with other programs and services;
• Appendix A provides an overview of the nine state children's health insurance programs;
• Appendix B lists the nine state programs, their administrators, and contact names and addresses; and
• Appendix C includes outreach and marketing materials and enrollment forms from the selected states.

5. Programs Included in this Review

The following programs are included in this Resource Book.