The third program area where coordination between SCHIP and Medicaid is crucial for children is service delivery. The extent to which SCHIP and Medicaid delivery systems are aligned is a significant aspect of coordination between the two programs, that largely determines whether children receive seamless and integrated health care. In cases where SCHIP and Medicaid programs in a given state share the same (or at least similar) provider networks, children are more likely to receive continuous care from the same provider regardless of which program is paying the bills. If the opposite is true and SCHIP and Medicaid programs use significantly different networks, then children and families may be much more likely to experience disruptions in their relationships with caregivers and their continuity of care. This issue is especially important for "mixed coverage" families (that is, those with children covered by each of the programs), who might face the prospect of having different children enrolled in different health plans, receiving care from different providers.
As discussed in Chapter XI, most of the study states set out to make managed care the foundation of their SCHIP delivery systems. 76 Among the four states with separate programs, state officials explicitly sought to align SCHIP and Medicaid delivery systems to the greatest extent possible, while also expanding the use of managed care arrangements to a larger number of counties, including rural ones. Yet, in only half of these states did these efforts result in closely aligned systems of care for beneficiaries of the two programs, as described below. In two of the four states with separate programs, SCHIP and Medicaid systems were quite well coordinated; the vast majority of managed care health plans participated in both programs, and delivery arrangements in urban areas, in particular, were quite consistent. In Colorado, the state's authorizing legislation required that plans participating in SCHIP must also participate in Medicaid. In New York, the only difference between the two programs is that one large New York City plan participates in SCHIP but not Medicaid. In California and Texas, however, differences in plan participation across the two programs were more pronounced. Both states operate managed care arrangements in considerably more counties under SCHIP than Medicaid, and in Texas, only half of the health plans that participate in Medicaid also participate in SCHIP.
In all four states, there were more distinct differences between SCHIP and Medicaid service delivery in rural areas. SCHIP programs in California, Colorado, and Texas each operate some form of exclusive provider organization (EPO) with an organized network of participating physicians in their rural regions, while Medicaid programs operate traditional fee-for-service systems.
Despite the remaining differences between SCHIP and Medicaid service delivery networks, it appears that state efforts to achieve SCHIP and Medicaid alignment have fostered relatively coordinated service delivery in most areas of the study states, according to state and local officials, providers, and advocates. When the same plans participate in both programs, case study respondents informed us that families have a much easier time making the transition from one program to the other as family income or circumstances change. We also heard from advocates and local application assistors that families care most about being able to retain their relationships with particular physicians when they switch programs, rather than with particular health plans. On this score, it was reported that close alignment between SCHIP and Medicaid plans, and the provider networks in those plans, had led to consistent access and continued relationships with providers for most families. In Texas, the state with the most distinct SCHIP and Medicaid systems, the fact that SCHIP health plans are dominated by traditional safety net providers, and that Medicaid enrollment is concentrated in these plans as well, meant that families moving from one program to the other most often have had the same choices of plans and providers.
In the rural areas of the six states, however, more coordination problems related to service delivery were reported. As discussed in Chapter XI, the SCHIP programs in California, Colorado, and Texas use EPOs in rural areas, as a strategy to increase the numbers of physicians available to SCHIP enrollees and, in turn, improved children's access to primary care providers. However, continued reliance on traditional fee-for-service systems in Medicaid in these states has resulted in limited numbers of providers who are willing to participate in the program. Thus, when families switch programs in these regions, they face a greater likelihood of confronting disruptions in service delivery.
76. Louisiana is the only state of the first six we visited whose SCHIP program relies primarily on fee-for-service delivery and payment arrangements.