House Insurance Committee Hearing Children s Health Insurance Program (CHIP)

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1 House Insurance Committee Hearing Children s Health Insurance Program (CHIP) Thursday, September 11, 2003 Patricia Stromberg, Deputy Insurance Commissioner Pennsylvania Insurance Department Commonwealth of Pennsylvania

2 CHIP Informational Hearing Before the House Insurance Committee September 11, 2003 Good morning Mr. Chairman and members of the Committee. It is a pleasure to be here today to talk about my very favorite subject, the Pennsylvania s Children s Health Insurance Program- CHIP. CHIP, I am very proud to say, is 10 years old and still growing. Health Insurance Coverage In Pennsylvania Before I begin, I would like to share with you some facts about health insurance coverage in Pennsylvaniaboth private and public- that provide a frame of reference for this very special program. Ninety three percent (93%) of all Pennsylvanian s have some form of either private or publicly funded health care coverage Over ninety-two percent (92%) of all Pennsylvania children have health care coverage Pennsylvania ranks first among the most populous states in the percentage of children that have health care coverage The number of children covered by CHIP has increased from approximately 50,000 in January 1998 to 133,472 in August 2003 The number of children covered monthly by either CHIP or Medicaid has increased from 757,300 in December 1998 to almost 925,000 in July 2003, representing an increase in monthly enrollment of over 167,000 children Almost 1.7 million Pennsylvanians have some form of health care coverage through a public program such as Medicaid, CHIP or adultbasic I think that we can agree that these statistics are pretty impressive. They speak to the community value placed on health care coverage. More importantly, the statistics speak to the commitment that government, employers, and the citizenry have made. Historical Context Putting that commitment into an historical context is also interesting when you consider that: In 1966, Pennsylvania was one of only six states to implement the new federal Medical assistance program (Medicaid). In addition, the state provided coverage for adults and children who did not qualify for federally reimbursed categories of benefits. By the end of 1967, 120,000 persons were receiving coverage and annual expenditures exceeded $115,000. (Compare that to the billions of dollars expended today!) In 1989, Pennsylvania implemented Healthy Beginnings, a major expansion of Medicaid. This program targeted pregnant women and children. In 1992, legislation creating Pennsylvania s Children s Health Insurance Program (CHIP) was enacted. The program was one of the first of its kind in the nation. Thursday, September 11, Page 1

3 Later, in 1997, the U. S. Congress passed landmark legislation creating the State Children s Health Insurance Program. It used the Pennsylvania CHIP as its model. This was followed in 1998 with approval of Pennsylvania s State Plan for implementing the federally supported program. Substantial funding came to Pennsylvania as a result of this approval (approximately 68 cents reimbursed for every dollar expended on a child). This additional funding provided the resources to: Expand the age group of children being covered (up to the age of nineteen) Expand the benefit package to include such services as durable medical equipment, substance abuse treatment and rehabilitation therapies Implement a net income test that credits families with a deduction for work-related expenses and day care Program Implementation I know that all of you in this room today are very familiar, at least conceptually, with CHIP. You know that: There are eligibility limits. For example, the income limits for a family of four is $42,535. The benefit package is comprehensive. The package provides coverage for doctor and specialist visits, inpatient hospitalization, prescriptions, dental care, and durable medical equipment, to name a few. Coverage is provided through seven regular insurance companies. These companies include the Blues, Aetna, Americhoice and Three Rivers Health Plan. I think you also know that we have been aggressively promoting the program since Has anyone not seen a child with a CHIP hat on TV? Recent market research that we completed indicates that the CHIP hat and our toll-free number, KIDS, are very well known throughout the Commonwealth. We know that those advertisements have had a direct and significant impact on enrollment. When the ads play on TV, the phones ring at the Help Line and a substantial number of callers follow through with an application for either CHIP or Medicaid benefits. But, let me also talk to you about a few things of which you might not be aware, such as A pledge made by three state agencies to provide access to health-related services to all eligible children and their families Our participation in the Robert Wood Johnson sponsored Covering Kids initiative at both the state and national level The use of technology to increase access to CHIP, Medicaid, and a variety of other services What families have to say about CHIP The level of service being received by enrolled children Thursday, September 11, Page 2

4 Interagency Activities In 1998, a unique interagency consortium came together dedicated to increasing public- awareness of, and enrollment in, both CHIP and Medicaid; and to increasing access to the myriad of other health-related services offered through or by the Commonwealth. Senior staff and others from the Departments of Insurance, Public Welfare and Health were the first members of the group. The group later expanded to include other Commonwealth agencies, such as the Department of Education and the Governor s Commission on Latino Affairs, and other interested partners like the Pennsylvania Partnerships for Children and the Hospital Association. This unique consortium has been cited by the federal Department of Health and Human Services as a best practice to be emulated by other states. The agenda for increasing awareness and enrollment has included: Establishing a single toll-free number to provide a one-stop center for information for a variety of healthcare and human services ( KIDS) Jointly funding a multi-year contract with a media and advertising consultant Jointly funding community outreach grants Increasing access to coverage by improving eligibility and enrollment practices Measuring the impact of efforts by gathering and analyzing available data The results of these efforts have proven successful over and over again. The most obvious evidence is steadily increasing enrollment in both CHIP and children s Medicaid. We have also experienced increases in the number of callers to the Help Line. Prior to CHIP promotion, we experienced an average of fewer than 700 per month; now, we see sometimes as much as 20,000 per month. A recent study by KPMG Consulting revealed that over 70 percent of callers to the Help Line receive an application for health care coverage. Over 80 percent of the callers who file applications are determined to be eligible for coverage. Covering Kids Initiative Valuable lessons about community outreach also continue to be learned through pilot projects overseen by the Pennsylvania Partnerships for Children in the Covering Kids and Families Initiative funded by the Robert Wood Johnson Foundation. The five projects shepherded by the Partnership have taught us about potential barriers that keep parents from enrolling their children and what can be done to overcome them. From these projects we have learned that: Parents need good information about potential eligibility for coverage Some parents need assistance in applying (e.g. filling out application forms, etc.) Stigma or negative perception about involvement with a government program prevents some parents from applying for their children Some parents do not have a full appreciation or understanding of the value of having health care coverage for their children. (e.g. My children are healthy, why do I need insurance? ) Over the past five years we have been addressing these barriers and will continue to do so. It has also been my pleasure to serve on the Partnership s Covering Kids Steering Committee and have recently been appointed to the National Policy Committee of the Covering Kids and Families Initiative. Thursday, September 11, Page 3

5 Use of TechnologylCOMPASS Having already addressed the need for improving the paper application process to facilitate application for both CHIP and Medicaid, the Department of Public Welfare and the Insurance Department began to think about the possibility of yet another tool for improving access to benefits. The next logical step to take was an on-line, web based application. What came to be known as COMPASS (Commonwealth of Pennsylvania Application for Social Services), began as a Department of Public Welfare initiative to develop a multiple service on-line application. The first services selected for development were children s Medicaid and CHIP. The web site, became available for use in October Since that time, DPW has added Food Stamps, TANF benefits, adultbasic and adult Medicaid to the roster of services that can be applied for on-line with one application. It truly has streamlined the application process. It is important to note that COMPASS augments, but does not replace the paper application process. It is simply an alternative means of applying for program benefits. Applying via COMPASS can be done filed by individuals from their own homes or offices; from legislative offices; and by community organizations on behalf of clients. COMPASS has been sited by the National Academy for State Health Care Policy as one of the most aggressive and comprehensive on-line social service access sites in the nation. Another first for Pennsylvania! What Families Say about CHIP As I mentioned, the Department recently engaged a research firm to conduct focus groups around the State to learn more about what families know and think about CHIP. We were interested in what motivates parents to apply for coverage for their children, what obstacles might remain in the application process and how they might have learned about the program. The focus groups affirmed that CHIP provides peace of mind. Parents are motivated to provide health insurance for their children as a measure of responsibility and caring, and as a means of providing physical and economic security. Parents came to know about CHIP not only through advertisements but also through important and trusted sources. Friends, family, church and school topped the list of those sources. Of course, we also learned from the study that there is more to be done. For example, higher-income families sometime self-select themselves out of applying because they think they do not qualify. Strategies need to be developed to reduce this phenomenon and to increase the participation of families in the upper income ranges. We also learned that families with no prior experience with CHIP are not aware of the scope of coverage provided, the number of providers participating and the fact that it really is regular insurance. What Services Are Being Utilized While promotion of the program and increasing enrollment has been a major effort, let me assure you that it has not been our only focus. We are also very interested in the level of service utilization by enrolled children and whether we are meeting the primary goal of the program- to provide preventative care. Over the last two years, we have initiated a strategy that will help us to better understand whether or not we are meeting that goal. On an annual basis, the insurers are required to provide the Department with HEDIS data that compares services used by CHIP enrollees with those used by children in the commercial products offered by the insurer. HEDIS is a standard data set created by the National Committee for Quality Assurance (NCQA) and is used to measure utilization of services by HMO s throughout the country. Thirteen measures relating to child-specific services were selected to make the comparison. Thursday, September 11, Page 4

6 For the two years of data gathered thus far, we are pleased to report that CHIP enrollees are accessing services at least to the same extent as privately insured children. In addition, for most measures, utilization met or exceeded both regional and national norms. However, there are some measures for which we do have some concern and need to know more about. One example is the use of emergency room care. Some families continue to use the emergency room as a source of regular or non-emergency care. We will be probing into this issue in an attempt to determine the cause(s) and to set a course for amelioration. How Are We Doing With Funding? As I indicated previously, funding for CHIP is now a partnership with the Federal government. I would point out, however, that we presently receive reimbursement only for the free portion of the program. The lowcost portion continues to be paid for from state funds and from premiums paid by participating families. Congress established funding for SCHIP for ten years and states receive a grant allocation each federal fiscal year. The allocation is based upon a rather complex formula that considers, among other factors, the estimates of uninsured children and Medicaid participation. Further complicating matters is the fact that a state may take up to three years to spend any particular year s allocation. For example, the grant for FFY 1998 had to be spent by September 2000 and the grant for FFY 1999 by September Monies remaining unclaimed by a state at the end of the three-year period returned to a common pot for bonuses to some states and reallocation to others. What I can tell you more broadly is that there has been, and is expected to be, sufficient money to continue growth in the program. The Administration and the Legislature have been generous in appropriating both cigarette tax and general funds for use in matching the federal grant. I must say that this has not been the experience for some of my colleagues in other states, where significant budget shortfalls have taken their toll on state funding for both Medicaid and SCHIP programs. Are there issues to be addressed? As with any program, there are issues that have identified for administrative improvement. During this fiscal year, we will be focusing on issues such as improving outreach to underserved populations (e.g. Hispanic and Asian) and increasing the rate of children re-enrolling in the program at the time of their annual renewal. We will also continue to build a more focused school-based outreach strategy and improve our web site as a tool for conveying information to families. During this year, we will also have for the first time a fully centralized eligibility and enrollment system and an associated data warehouse. This will assure standardization of eligibility throughout the Commonwealth and give us substantial analytical capacity for both program and budget planning. With regard to the program design, there are some who advocate the addition of orthodontics to the benefit package (at least medically necessary orthodontia) and changes to the low-cost program to make it more affordable for families. Both of these initiatives would require legislative change. Thursday, September 11, Page 5

7 Closing Remarks There is much to be celebrated in the long-term commitment and progress that Pennsylvania has made in the area of health care generally and specifically with CHIP. It has been my great privilege to have been associated with the program over the past five years and to see it grow and mature. Again, I thank you for the opportunity to be with you today. I would be pleased to entertain any questions that you might have. Thursday, September 11, Page 6

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