Children with Special Healthcare Needs

Shaping SCHIP Programs

This session highlighted approaches to serving children with special health care needs (CSHCN) through the State Children's Health Insurance Program (SCHIP) and explored how States have addressed a wide range of operational challenges within the context of the program.

Renee Schwalberg opened the session with a brief overview of key SCHIP/CSHCN design issues. Ms. Schwalberg addressed the important obstacles that exist for the CSHCN population in the context of SCHIP and highlighted program design strategies that seek to address them. Particularly when States choose to develop separate State programs under SCHIP, these programs pose a number of challenges for CSHCN:

• Potential gaps in benefits, including limits on therapies and equipment, lack of care coordination and support services, and restrictive definitions of medical necessity.
• Inaccessibility of SCHIP to underinsured CSHCN, due to waiting periods.
• Incomplete provider networks.
• Co-payments for services, which may impose a burden on families.

Harriette Fox then reviewed the findings of a national survey of SCHIPs on the key features in these programs affecting CSHCN. Some of these features include:

• Eligibility policies.
• Cost-sharing protections for CSHCN.
• Benefits policies.
• Managed care arrangements, including carve-outs and specialty plans.
• Provider requirements for CSHCN.
• Quality requirements for CSHCN.

Eligibility policies, cost-sharing protections, co-payment policies, benefits packages, and managed care arrangements vary for SCHIPs throughout the country. Ms. Fox pointed out that no States have set higher income-eligibility limits for CSHCN than for typical children. However, special provisions for CSHCN do exist in some States: Several States offer enhanced benefits for qualifying children, and three require no cost-sharing for CSHCN.

Jayne Parker of the Florida Department of Health then spoke about the system in place to serve CSHCN under KidCare, Florida's SCHIP program. Under the umbrella of KidCare, children identified as having special healthcare needs are enrolled in the Children's Medical Services Network (CMS), rather than in a mainstream managed care plan.

Ms. Parker discussed some critical features of CMS, including:

• The program's definition of CSHCN and the eligibility criteria for enrollment in CMS.
• The development of credentialed provider networks.
• The provision of care coordination and support services.
• The financing of care through a CMS-specific capitation rate.
• The development of a companion Behavior Health Specialty Care Network.

Ms. Parker also discussed plans for the future of the CMS program. The next phase of the CMS program will see care delivered through integrated care systems, which will be risk-bearing contracted arrangements in each region, selected through an "invitation to negotiate" process and overseen with service delivery criteria and standards. These systems will receive age- and risk-adjusted capitation rates for the children they serve, and the CMS offices will continue to be involved in determining the level of care and coordinating care for each child.

Ms. Parker reported that the key benefits of this approach are:

• A formally designed system of care.
• A solid structure for quality monitoring.
• Strong opportunities for partnerships.

The challenges associated with this approach include the development of risk-adjusted capitation rates and the State agency's transition to a role focused on management rather than provision of services.

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