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From SCHIP benefit design to individual coverage decisions
Anne Markus1, Sara Rosenbaum, Ruth E K Stein
1Center for Health Services Research and Policy, Department of Health Policy, George Washington University School of Public Health and Health Services, Washington, D. C., USA.
Policy Brief (George Washington University. Center for Health Services Research and Policy)
|February 10, 2006
Summary
Separate Children's Health Insurance Programs (S-SCHIP) may not adequately cover children with special needs (CSHCNs). Insurers often impose exclusions, potentially leaving CSHCNs without necessary services, highlighting a need for better oversight.
Area of Science:
- Pediatric Health Services Research
- Health Insurance Policy
- Public Health
Background:
- Most states operate separate State Children's Health Insurance Programs (S-SCHIP) that differ from Medicaid.
- S-SCHIP program designs often resemble commercial insurance, potentially impacting responsiveness to children with special needs (CSHCNs).
Purpose of the Study:
- To investigate the responsiveness of S-SCHIP insurers to the higher healthcare needs of CSHCNs.
- To identify patterns in service coverage, exclusions, and adherence to plan language by S-SCHIP insurers.
Main Methods:
- Comparative analysis of S-SCHIP program designs across states.
- Examination of insurer coverage decisions and exclusions for various childhood conditions.
- Review of adherence to stated plan/contract language regarding service coverage.
Main Results:
- Insurers rarely agreed on specific service coverage but generally exceeded state limits.
- Less acute childhood conditions were more frequently associated with insurer exclusions.
- In many states, insurers excluded services that appeared to be covered by plan language.
Conclusions:
- Current S-SCHIP coverage levels may be insufficient for CSHCNs.
- External review of insurer decisions and care coordination are crucial for effective S-SCHIP program design for CSHCNs.
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