From SCHIP benefit design to individual coverage decisions

The majority of states have implemented separate SCHIP (S-SCHIP) programs that significantly depart from Medicaid and resemble less comprehensive commercial products. This difference in program design may result in S-SCHIP potentially being less responsive to children with special needs (CSHCNs). This study explores how responsive insurers are to these higher than average needs. We found that, with one exception, insurers did not agree on the coverage of any specific service, but overall they provided coverage beyond state limits and exclusions. Second, the less acute the childhood condition, the more frequently insurers imposed exclusions. Finally, in the majority of states, some insurers excluded services that arguably should have been covered according to the plan/contract language. We conclude that SCHIP coverage at current levels may not be sufficient to care for CSHCNs, making external reviews of insurers' coverage decisions and coordination with other sources of care important components of SCHIP program design.