Topic:
HEALTH INSURANCE; LEGISLATION; JUVENILES; CHILD HEALTH; POVERTY; MEDICAID; INCOME MAINTENANCE PROGRAMS;
Location:
INSURANCE - HEALTH;

OLR Research Report


February 16, 2007

 

2007-R-0185

SCHIP COVERAGE FOR CHILDREN WITH SPECIAL HEALTH CARE NEEDS

By: Robin K. Cohen, Principal Analyst

You asked if SCHIP money can be used to provide help to children with special health care needs and whether any states provide such coverage.

This report describes how Connecticut already serves these children using SCHIP funds. A separate report will address other states' programs. Information on the Department of Public Health's Children and Youth with Special Health Care Needs (Title V), a much older program also serving these children and which is coordinated with the SCHIP program, is available at www.dph.state.ct.us. Children with severe behavioral health care needs are served by the state's Behavioral Health Partnership and are not addressed by this report.

SUMMARY

Connecticut uses part of its SCHIP block grant to pay for services to children with physical health care needs through the HUSKY Plus program. Children enrolled in HUSKY B whose family income is less than 300% of the federal poverty level (FPL) and who meet certain diagnostic and acuity criteria can receive this supplemental coverage on top of regular HUSKY services.

Children in families who are ineligible for HUSKY B because their parents have employer sponsored coverage or incomes above 300% of the FPL have limited options. The state's Katie Beckett waiver currently has a waiting list. The state could use unspent SCHIP funds to cover more children but would likely need a federal waiver of SCHIP rules to cover the higher-income families. Alternatively, the state could take advantage of a new federal law that permits Medicaid coverage for children with special health care needs in families with incomes up to 300% of FPL. This latter provision could potentially help families with private insurance who lack catastrophic coverage. At least one 2007 proposed bill attempts to address the issue.

HUSKY COVERAGE FOR CHILDREN WITH PHYSICAL HEALTH CARE NEEDS

When the HUSKY B program was established in 1997, it included coverage for supplemental health insurance to children with intensive physical or behavioral health care needs that could not be met through the regular program's basic benefit package. The supplemental program, HUSKY Plus, is available to any child receiving HUSKY B coverage whose family income is less than 300% of the FPL. (When the original HUSKY law passed, this coverage was also available to people who bought-in to the HUSKY B program for unsubsidized coverage (income above 300% of FPL); PA 98-8 restricted the supplemental coverage to children receiving subsidized coverage.) (On January 1, 2006, DSS amended its SCHIP plan to pull the behavioral health services out of HUSKY Plus as part of the state's creation of the Behavioral Health Partnership.)

In addition to meeting the financial eligibility criteria, children applying for the HUSKY Plus Physical Program (HIP) must meet certain clinical criteria. These are based on diagnostic or acuity criteria and are the same as those used by the Department of Public Health in its Children and Youth with Special Health Care Needs Program (also called Title V). Eligibility for these services ends once the child turns age 19.

Table 1 lists the HPP services, including coverage limitations. This list can be revised from time to time as recommended by the HPP Steering Committee.

Table 1: HUSKY Plus Physical Services

Service

Limits

Adaptive Seating, specialized

One evaluation, fabrication and completion per year. Includes bi-weekly adjustment until family satisfied

Audiometry

Includes BAER, OAE—two per year

Cast Room

As necessary to maintain integrity of case or to implement treatment plan

Diagnostic imaging

 

Durable medical equipment

Exclusive of basic HUSKY B and includes items assisting with activities of daily living

EEG/telemetry

Two per year

EKG/Holter

Two per year

Emergency care

Exclusive of basic HUSKY B plan that is directly related to condition

Gait analysis

One per year

General dental, orthodontic

Only for children with malocclusive disorders or periodontal disease resulting from underlying qualifying condition or related treatment

Hearing aids

One (or one pair) analog hearing aid(s) as prescribed per year; one (or one pair) digital hearing aid(s) as prescribed every five years

Home health aide

10 hours per week

Laboratory

 

Medical and surgical supplies

 

Medical nutrition services

 

Medical 23 hours and day surgery

 

Occupational, physical, and speech therapy

 

Orthotics

No more than one per year or one pair per year per prescribed type, including all delivery fees, fittings, and adjustments

Pharmacy

Over the counter covered if medically necessary and directly related to condition; DSS prior authorization required

Physician fees for inpatient care

Visits must be requested as consultations by admitting physician and be specifically related to qualifying condition

Prosthetics/prosthetic devices

No more than one per year including all delivery fees, fittings, and adjustments and repairs. Excludes myoelectric devices

Pulmonary function testing

One per year

Radiology

 

Skilled Intermittent Nursing

One visit per day for evaluation, treatment, and education. Must be provided by a licensed home health agency

Sleep Study/polysomography

One per year

Special Nutritional Formulas or Supplements/PKU Foods

Nutritional habilitative or rehabilitative sustenance of a type or amount not usually required by children. Prescribed by an authorized professional within acceptable standards of American Dietetic Association

Transportation

Two round trips per year to any health care appointment by ambulance, chair-vans, or other licensed medical transportation for non-emergent visits

Wheelchairs

One new manual wheelchair no more than every three years. One new motorized wheelchair no more than every five years

Service Coordination and Utilization

The Connecticut Children's Medical Center (CCMC) in Hartford is the HPP coordinating organization, but services are provided by entities with which DPH contracts to provide services under the Title V program.

Services are provided only if they are medically necessary. The DSS SCHIP state plan defines this as “health care provided to correct or diminish the adverse effects of a medical condition; to assist an individual in attaining or maintaining an optimal level or health; to diagnose a condition; or prevent a medical condition from occurring.”

Each child enrolled in HPP is assigned a case manager, who coordinates with the child's HUSKY B case manager to ensure that regular HUSKY B is exhausted before HPP benefits are activated. The HPP Center must designate a lead case manager who is responsible for convening a case management and treatment team that develps an individualized global plan of care for each enrollee. The team can include the enrollee and enrollee's parent, treating clinicians, and case managers. In addition to ensuring that regular HUSKY B services are exhausted, the team ensures that the care plan does not replicate special education services authorized under an individualized education plan or individualized family service plan.

Quality

An external quality review organization reviews the HPP annually, in compliance with the state's SCHIP plan's goals. The DSS commissioner must report to the governor and legislature on HPP, which must include an evaluation of the special health outcome and access measures identified for HUSKY Plus enrollees. DSS must also review the HPP Center at least annually and recommend improvements, when appropriate.

Grievances

Federal SCHIP regulations require HUSKY Plus applicants to have the right to administrative hearings regarding decisions DSS makes on their applications. HPP attempts to resolve grievances informally, to the extent possible. But parents and providers are encouraged and supported in filing appeals, without fear of compromised services.

DSS ensures that all enrollees and applicants receive timely written notice of determinations that would prompt a grievance, such as failure to approve, furnish, or provide payment for services or settings. There are several levels of appeal and an expedited appeal.

OPTIONS FOR FAMILIES WITH PRIVATE INSURANCE OR INCOME TOO HIGH FOR HUSKY

Many families with children who have special health care needs have access to private insurance that does not offer “catastrophic” coverage, forcing them to pay out of pocket for these services. These families, including those with incomes under 300% of the FPL, are not eligible for HUSKY B unless they drop the private coverage and wait two months.

But higher income families cannot get HUSKY Plus (families with incomes above 300% of FPL can receive unsubsidized HUSKY B benefits for about $200 per month per child) at all, because state law creates what some have described as a “cliff effect.” Families with income just under the 300% limit have access to the full array of HPP services, while those with incomes just over the limit do not. The legislature could remedy this for uninsured families by removing the HUSKY Plus requirement that they be receiving subsidized HUSKY B coverage. (Since only a small number of families currently receive unsubsidized coverage (income above 300% of FPL), it is not known how many families with special needs children would benefit.)

The other option for families is the Katie Beckett program. This Medicaid waiver program offers the same type of coverage to families and essentially disregards the parents' income. But program enrollment is currently capped at 180 slots, all of which are filled, and has a growing waiting list.

Getting SCHIP To Pay for More Care

The state could use unspent SCHIP funds to provide some assistance to families with private insurance, which would be less costly than the regular HUSKY B program. Specifically, DSS could ask the federal government for an SCHIP waiver to allow it to provide wrap around coverage (coverage for services the private insurance will not pay for) for children in families with incomes up to 300% of the FPL. The state's share of the costs would be 35%, with SCHIP funds paying the balance.

Families with incomes above 300% of the FPL could buy into the wraparound program, again exhausting their private coverage (spending limits or service limitations) and paying premiums to get the supplemental coverage their children need.

Deficit Reduction Act

As an alternative to the SCHIP waiver, the state could create a Medicaid coverage group for children who meet the federal Social Security definition of disability. This alternative was authorized under the Family Opportunity Act provisions (Section 6062) of the federal Deficit Reduction Act (DRA) of 2005. Family income can be as high as 300% of the FPL, but states can go higher using only their own money with no federal funding.

The program will be phased in, with children up to age six covered first, beginning on January 1, 2007. States can amend their Medicaid state plans to include this new group without needing a federal waiver. Families must participate in employer-sponsored coverage in certain circumstances, as well as pay monthly premiums. The premium caps are higher than SCHIP's for families with incomes between 200% and 300% of the FPL (7.5% instead of 5%). States receive the regular 50% Medicaid match for their program expenditures.

PSB 246

Senator Harp has proposed a bill that directs the DSS commissioner to do four things to provide more health care access to families with special needs children:

1. amend the state Medicaid plan to implement the Family Opportunity Act provisions in the DRA;

2. develop a state-funded health coverage pilot program with cost sharing for families with incomes above 300% of the FPL;

3. amend the SCHIP state plan to use unspent SCHIP block grant funds to develop what appears to be a separate HUSKY Plus program (presumably for families with incomes over 300% of FPL); and

4. increase the number of funded Katie Beckett slots to 200.

The bill was heard on February 15, 2007.

RC:ro