Examining Substitution: State Strategies to Limit "Crowd Out" in the Era of Children's Health Insurance Expansions. California Kids

12/09/1997

HISTORY:

California Kids is a non-profit organization sponsored by private donations that was founded July 30, 1992. The program was initially based in Los Angeles, and has since expanded to 33 counties. CaliforniaKids offers children a limited health insurance product that focuses on preventive care. The program coordinates with MediCal, the state Medicaid program, to obtain care for children who need inpatient treatment or other serious care that CaliforniaKids does not provide. CaliforniaKids partners with community organizations to identify and enroll eligible children. Children enrolled in CaliforniaKids pay no monthly premiums, but are responsible for small co-payments for their care. CaliforniaKids has provided coverage for 17,000 children since its inception in 1992.

TARGET POPULATION:

Uninsured children ages 2-18 who are unmarried, ineligible for coverage under any federal or state health benefit program, not currently enrolled under a private health care contract, and enrolled and attending school (if school-age) are eligible for CaliforniaKids if their family income is below 200% of the poverty level. In August 1997, a pilot program was initiated in San Diego that will expand income eligibility up to 300% of the poverty level in that county.

BENEFIT PACKAGE:

Benefits covered by CaliforniaKids include primary and preventive care, immunizations, prescriptions, a 24-hour nurse hotline, hearing screening and aids without co-payment, emergency treatment with a $25 co-payment, outpatient care and doctor visits with a $5 co-payment each, and dental and vision with a $10 co-payment each.

PROVIDER NETWORKS AND REIMBURSEMENTS:

CaliforniaKids utilizes a managed care, capitated system to maintain cost-effectiveness, minimize risk and unnecessary administrative expense due to excessive claims processing, and provide a "medical home" for the child. The network, administered by Health Affairs International, maintains choice and is sensitive to access, culture, language, gender, and age of child. Over 15,000 health care providers are contracted to provide services throughout the State and a 24-hour nurse hotline is available to all members to provide health care information and re-direct care from the emergency room to a lower cost, appropriate alternative. Plans donate their direct administrative expenses. CaliforniaKids partners with medical groups and IPAs, which offer wellness education to its members. Services are administered by Blue Cross of California, Delta Dental, Vision Service Plan, Wellpoint Pharmacy, and Access Health.

FINANCING:

CaliforniaKids is financed through private donations. CaliforniaKids does not collect premiums, but charges nominal co-payments for care. Costs are kept low by offering a limited benefit package and minimizing administrative costs.