Carol Tobias, Catalyst Center, Boston University School of Public Health

Transcription

1 Access to care and coverage for children with birth defects and developmental disabilities Carol Tobias, Catalyst Center, Boston University School of Public Health

2 The Catalyst Center: Financing Care for Children and Youth with Special Health Care Needs (CYSHCN) Cooperative agreement with Maternal and Child Health Bureau of HRSA 4 Domains of coverage and financing Insurance coverage of any kind Adequate coverage with no serious benefit gaps Services that may not be covered by any insurance e.g. care coordination Building capacity to provide care

3 Health Insurance Coverage for CYSHCN Both 8% None 4% Public 29% Private 59% From National Survey of Children with Special Health Care Needs, 2005 data

4 Who are the uninsured children? 1. Children in working families where the employer does not offer health insurance or does not provide family coverage; 2. Children in lower income working families where the cost of coverage is prohibitive; 3. Children in families where the parent experiences a gap in health insurance coverage; and 4. Children of immigrants

5 Why are children underinsured? Expensive co-pays High deductibles Limited benefits Therapies Medical equipment Supplies Strict prior approval guidelines Lifetime benefit caps

6 Start with the Basics: Any Kind of Coverage Medicaid SCHIP Private Insurance Legislative role Setting income ceilings for public programs Establishing premium assistance programs for low-income workers

7 Special Medicaid coverage for kids with serious disabilities TEFRA (Katie Beckett) Home and Community Based Waiver Programs Family Opportunity Act

8 Adequate Insurance Coverage Public Sector EPSDT Enhanced SCHIP benefits Family Opportunity Act Private Sector Mandated benefits Maximizing private coverage

9 EPDST - Early Periodic Screening, Diagnosis, and Treatment Identifying problems early, starting at birth Periodic Checking children's health at periodic, age-appropriate intervals Doing physical, mental,developmental, dental, hearing, vision, and other screening tests to detect potential problems Performing diagnostic tests to follow up when a risk is identified, and Treating the problems found.

10 EPSDT and SCHIP In combined Medicaid/SCHIP programs, EPSDT is included In stand-alone programs it does not have to be included Legislative role SCHIP wrap-around for CSHCN Connecticut Alabama

11 Family Opportunity Act Part of the Deficit Reduction Act Families up to 300% of the FPL SSI functional criteria for children more inclusive than Katie Beckett waivers, TEFRA or HCBS Premiums charged on sliding fee scale Premium assistance is an option for states

12 Buy-in vs. Waivers Waiver Buy-In Level of care Institutional SSI disability Income level None/300% FPL 300% FPL Benefits Medicaid + case mgmt, respite, home mods Medicaid Authority Waiver State plan Premiums Optional/none Yes Cost test Yes No

13 Pre-Existing Programs VT PA MA Income limit (FPL) 300% None None Disability criteria None SSI SSI Privately insured children Yes Yes Yes eligible Uninsured children eligible Yes Yes Yes Premiums charged Yes No Yes

14 New Programs Louisiana and North Dakota, started up this past year Iowa and Illinois have passed legislation

15 Title V Federal block grant and state dollars Ensure the health of mothers, infants, children, adolescents and CSHCN Gap filler for CSHCN, varies widely Strengths flexibility to respond to particular needs Weaknesses inconsistent and perennially underfunded

16 Private Sector Role in Early Intervention Mandated Benefit in 8 states, at last count - MA, RI, NY, PA, MO, TX, VA, NH Caps on private sector liability: MA, VA, RI benefit cap of $5,000- $5200/child/yr NH, CT benefit cap of $3,200/child/yr Exempt payments from the lifetime benefit cap State funds used for insured children or those who exceed private benefit cap

17 Maximize Access to Coverage Legislative role Outreach and identification services at CHCs Hospital linkage to coverage (SSI and/or Title V) for newborns

18 Maximize Private Coverage: Benefits Advocacy: IL Title V employs people from health insurance industry to advise staff and care coordinators VT Title V staff works with families to advocate with insurers

19 Resources Catalyst Center Chartbook Kaiser Family Foundation State Health Facts National Early Childhood Technical Assistance Center