Interim Evaluation Report: Congressionally Mandated Evaluation of the State Children’s Health Insurance Program. B. Program and Policy Characteristics


All four states with separate programs enhanced the benchmarks they used as models for SCHIP. In California and Texas, the benchmark consisted of the state employee health benefits plans. Colorado has a benchmark-equivalent package based on the Colorado Standard and Basic Health Benefit Plans for small employers 47 and New York started with the package used in its preexisting, state-only Child Health Plusprogram. New York made the greatest number of enhancements to its plan. Features of the benefit packages adopted by the four separate state programs are summarized in Tables 13 through 15. The most common enhancements (made by three states) were the addition of vision and substance-abuse treatment services. Two states added coverage for mental health and durable medical equipment, while individual states added coverage for dental, hearing, orthodontia, and therapy services, as well as over-the-counter drugs. California added retroactive coverage for screening EPSDT services provided to children whose doctors refer them to SCHIP and who are found eligible for SCHIP.

Medicaid, in essence, provides children with coverage for any service considered medically necessary, whereas coverage in the four separate state programs is not as extensive. Nevertheless, a review of the benefits packages in these four study states reveals that they are quite comprehensive. As shown in Table 14, the few services excluded were also often excluded from private insurance packages. The most common exclusions from the SCHIP package are coverage for care in intermediate-care facilities for the mentally retarded, and residential substance-abuse treatment services (each one not covered by three states). Other services excluded by more than one state are orthodontia, care in nursing facilities, over-the-counter medications, personal care services, and non-emergency transportation. In addition, New York excludes hospice care and emergency transportation, while Texas excludes family planning services. 48 Colorado is one of only two states in the nation that excluded preventive dental services from its SCHIP package; but the state added these services in 2002.

Separate SCHIP programs limit the amount of coverage provided for some services. All four of the separate programs in the study placed limits on restorative dental care, durable medical equipment and medical supplies, and mental health services; three of the four placed limits on preventive dental, therapy, and outpatient substance abuse services (Table 15). 49 While some service limits affect a wide range of children, most of the limitations have a much greater potential to affect children with special health care needs. Colorado's child health program, for example, limits coverage for durable medical equipment to $2,000 per year, which is less than half the cost of the typical power wheelchair covered by Medicare. With its Title V program, Colorado's children's health insurance program is developing a strategy to address the needs of children with special health care needs.

  Services Added
State (benchmark plan) Vision Dental Hearing OT, PT, ST Substance Abuse Treatment Mental Health Treatment Over-the-Counter Medication Durable Medical Equipment/ Medical Supplies Other
California (SEHBP) c+ c c c c c c c EPSDTa 
CSHCN servicesb
Colorado (Standard plan for small employer market) c+ nc c c c+ c nc c+  
New York (GrandfatheredChild Health Plus program) c+ c+ c+ c c+ c+ c+ c+  
Texas (SEHBP) c c c c+ c+ c+ nc c  

Notes: SEHBP = State Employee Health Benefit Plan; OT = Occupational therapy; PT = physical therapy; ST = speech therapy; CSHCN = children with special health care needs; EPSDT = Early Periodic Screening, Diagnosis, and Treatment.

aCalifornia's SCHIP program provides retroactive coverage of EPSDT screening services provided to children referred to and found eligible for SCHIP. 
bAdditional services for children with special health care needs are provided through the Title V/California Children's Services (CCS) program, as they are under the state's Medicaid program. 
c+ = Service added beyond benchmark coverage 
c = Covered under benchmark 
nc = Not covered

TABLE 14: 
  Services Excluded
State Preventive Dental Orthodontia Family Planning Contraceptive Services Long-Term Care Over-the-Counter Medication Personal Care Substance Abuse Treatment Transportation Case Management
CA c nc c ICF/MR c nc Residential c c
CO nc c c ICF/MR nc nc Residential Non-emergency c
NY c nc c ICF/MR 
Nursing facility 
Hospice care
c c c Emergency 
TX c c nc Nursing facility nc c Residential Inpatient c c

Notes: ICF/MR = Intermediate care facility for the mentally retarded. 
c = Covered 
nc = Not covered

  Service Limits
State Prescription Drugs Preventive Dental Restorative Dental Medical Supplies/ DME OT, PT, ST Substance-Abuse Treatment Mental Health Treatment
CA Varying limits Varying limits Varying limits Covers diabetic supplies; no coverage for therapeutic footwear 60 days Detoxification services and 20 visits for outpatient 30 days for inpatient; 20 visits for outpatient
CO Unlimited Not covereda Not covered $2,000 limit; diabetic supplies not covered 30 visits Unlimited for inpatient; 20 visits for outpatient 45 days for inpatient; 20 visits for outpatient
NY Varying limits Varying limits Varying limits Covers only commodes, walkers, diabetic supplies, and wheelchairs Short-term PT and OT 30 days for inpatient; 60 visits for outpatient 30 days for inpatient; 60 visits for outpatient
TX Unlimited Varying limits $300 limit $20,000 limit; diabetic supplies not counted against cap Unlimited 14 days for detoxification and crisis stabilization; 60 days for partial hospitalization; 12- week limit for rehabilitation 45 days for inpatient; 60 visits for outpatient

Notes: Information on limits for some services was taken from Hill, Lutzky, and Schwalberg, "Are We Responding to Their Needs? States' Early Experiences Serving Children with Special Health Care Needs Under SCHIP," Washington DC: The Urban Institute, May 2001. 
DME = Durable Medical Equipment; OT = Occupational therapy; PT = physical therapy; ST = speech therapy. 
aColorado has since added a dental benefit to its SCHIP program.

47. As implemented, the Colorado plan exceeds the actuarial value of all Title XXI benchmarks in the state.

48. Study informants described the omission of emergency transportation services in New York as an oversight; efforts were underway at the time of our site visit to add this service to the SCHIP benefit package.

49. As noted, Colorado excluded preventive dental care entirely at the time of the site visit, but has since added such a benefit.

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