Medicaid Enrollees and Disenrolles

ATTACHMENT C3
CASE STUDIES FOR CHIP 10—STATE EVALUATION PROTOCOL: HEALTH
CARE PROVIDERS

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Children’s Health Insurance Program (CHIP)
Case Studies of CHIPRA 10-State Evaluation
Health Care Providers

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3. Case Studies of CHIPRA 10 State Evaluation
Health Care Providers Topic Summary List
Topic
Background and
Overview

Subtopic
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Involvement with
CHIP Enrollment and
Outreach

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Benefits Coverage

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Service Delivery and
Payment
Arrangements

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Cost Sharing

Crowd Out
Family Coverage

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Employer Subsidy and
Buy In Programs

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CHIPRA and ACA

•
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Overall Lessons
Learned

Involvement with CHIP
Populations traditionally served
Whether practice represents a patient centered medical home
Baseline health of CHIP population
Service delivery system and major providers in your
community
Participation in CHIP and/or Medicaid outreach
Participation in CHIP and/or Medicaid enrollment
Participation in eligibility renewal process for Medicaid and/or
CHIP
Challenges enrolling and retaining children
Opinions on the adequacy of the CHIP benefit package
Gaps in coverage care
CHIP benefits package compared to Medicaid and private
insurance
Service delivery systems under CHIP and Medicaid
o Access to care
o Access problems for general or specific services
Ability of the managed care plans to serve the full range of
needs
Payment arrangements under CHIP and Medicaid
Payment rates
Collecting and monitoring cost sharing
Impact of cost sharing on utilization
Views on advantages and fairness of cost sharing
Experience with crowd out
Waiting periods as a barrier
Experiences and opinions on family coverage under CHIP
o Strengths and weaknesses of program
o If not offered, would expanded coverage of parents of
CHIP enrollees be welcomed
Experiences and opinions of such employer options
o Strengths and weaknesses of program
o If not offered, why/ why not should the state adopt this
option
Preparations for health reform
Views on health reform and its implications for CHIP
Impact of health insurance exchanges
Strengths and weaknesses of the program
Satisfaction with coordination between CHIP and Medicaid
Outstanding challenges
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3. Case Studies for CHIPRA 10 State Evaluation
Protocol for Health Care Providers
Key Informant Info:
Name:____________________
Title:_________
Agency: ___________________

Phone: ____________________
Fax: ____________________
E-mail:____________________

Thanks very much for agreeing to meet with us. We have been funded by the Office of the
Assistant Secretary for Planning and Evaluation of the Department of Health and Human
Services (DHHS) to conduct a national evaluation of the Children’s Health Insurance Program
(CHIP), as mandated by the U.S. Congress in the Children’s Health Insurance Program
Reauthorization Act of 2009.
DHHS previously conducted a congressionally-mandated evaluation of CHIP following its
enactment 1997; that evaluation ended in 2005. This current evaluation is patterned after our
previous work and comprises both quantitative and qualitative activities. We are here as part of
the qualitative/case study component of the project, for which we are visiting ten states to study
their recent experiences with CHIP and Medicaid and changes resulting from CHIPRA. We are
primarily interested in hearing from you today about CHIP and Medicaid in your state from
2006-onward, as our prior evaluation allowed us to track the program until then. We will be
conducting site visits to the following states—Texas, California, Florida, Ohio, Alabama,
Louisiana, New York, Michigan, Utah, and Virginia.
Information will be gathered from a broad range of key informants. At the state level, we are
meeting with officials responsible for Medicaid and CHIP administration; public health and Title
V/Maternal and Child Health; eligibility determination (enrollment brokers and/or social services
agencies); and statewide child advocacy groups. In addition, we will meet with individuals in
each state’s Governor’s office and the state Legislature to gather insights on the political debates
that have surrounded CHIP design and ongoing implementation. At the local level, we will meet
with such informants as: county social services administrators; front-line eligibility workers;
agencies and staff involved with outreach and enrollment; pediatric providers or clinics;
managed care plans; special providers serving children and adolescents with special health care
needs; and local child advocates. We will also be conducting a small number of focus groups
with parents of children enrolled in CHIP, among others.
During these interviews, we will discuss a broad range of issues, including the history and
development of CHIP in your state, benefits offered, program design, participation trends,
outreach and enrollment, access and utilization trends, cost sharing and premiums, and
anticipated impacts of health reform on CHIP.

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Information gathered during our site visit will be used in a series of state-specific case study
reports, as well as interim and final cross-cutting reports based on the findings across the study
states. Qualitative findings will also appear in our Reports to Congress. None of the information
you share with us today will be quoted without your permission, but we do generally list the
names of the people we’ve spoken with in an appendix to our final report. Would that be okay
with you?
Thanks very much for agreeing to meet with us. Do you have any questions about our project?
May we proceed with our questions?

I.

Background and Overview

1. First, please could you tell us what type of provider you are/you represent? How long have
you been involved with CHIP?
2. If you are a group or association, please give us an overview of your group’s system within
the state. (e.g. – If a local health department, how many local health departments are there
across the state? How are they distributed? What is their general role?)
3. What populations do you traditionally serve? Please tell us, if you can, the proportion of
each of the populations and how this has changed over time.
•
•
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•
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•

Medicaid?
CHIP?
Privately insured?
Children/families?
CSHCN?
Racial/ethnic groups?
Uninsured children and families?

4. What services do you traditionally provide?
5. Do you consider your practice to represent a patient-centered medical home? If yes:
•
•
•
•
•
•
•

For how long has your practice/group used this model?
Did you become a medical home as part of a larger effort?
What changes did adopting a patient-centered medical home model require for your
practice?
Are enrollees required to choose (or be assigned to) a primary care provider (PCP)?
What is your approach to care management? (For e.g., do you use a team-based
approach?)
Do you use HIT (such as electronic medical records or registries) to manage care
generally, or for populations with chronic conditions (such as diabetes)?
How are referrals managed?

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•
•

What strategies have you employed to expand access (for eg, expanded hours of
operation, open access appointments, etc.)?
Are you involved with a quality improvement demonstration project?

6. Now we would like to ask you about your CHIP population.
•

Have you an impression of the baseline health of these children? How does this compare
with children in private insurance and Medicaid?

7. Please also tell us a bit about the service delivery system in your community and the major
providers of care to families and children.

II. Involvement with CHIP Enrollment and Outreach
We would now like to discuss whether you participate in outreach, enrollment and
redetermination, and how you think the processes are working.
8. Do you participate in any way in CHIP and/or Medicaid outreach (defined as efforts to raise
public awareness of CHIP and of the importance of health insurance for children)? If so,
please describe your efforts.
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Have you taken part in the state’s outreach campaign? How?
Have you taken part in the community-based outreach efforts? How?
Do you distribute information to families about the programs?
Do you talk to families about the importance and availability of coverage, and about
the differences between CHIP and Medicaid?
Have you developed your own outreach materials? If so, what has been your central
message?
Where are these efforts focused? Do you make any special efforts to target particular
communities or populations (such as immigrants)?
How intensive is your outreach work?
How has your role in outreach been affected by funding uncertainties? CHIPRA?

9. Do you participate in any way in CHIP and/or Medicaid enrollment?
a) If so, please describe how you are involved with enrollment.
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Do you act as a CHIP enrollment site (i.e., do you have workers on site that are
trained to assist families with enrolling in CHIP/Medicaid)?
Do you make applications available to your patients?
Do you market your agency/plan to encourage enrollment?
Do you have county eligibility workers outstationed at your site?
Do you refer families to enrollment sites?
Are you permitted to grant presumptive eligibility?

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b) If you have workers trained to assist families in completing applications:
•
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Are you able to complete the applications on site, or do families have to come back to
you with documentation?
Do you have the capabilities for SSA data matching (to verify citizenship status)?
Are you able to help families by completing applications online? Or do you use
paper applications?
How long does this process take?
What do you do with the applications?
Does the state/county agency then follow up with you on the applications, or do they
follow up directly with families?
To your knowledge, do families need to meet face-to-face with the eligibility agency,
or can all follow-up steps be completed by mail and/or phone?
What kind of training did you receive to carry out this function?
How many applications are you handling each week?

10. Do you participate in any way in the eligibility renewal process for Medicaid and/or CHIP?
If so, how?
11. If applicable, how would you sum up your experience of involvement in outreach?
12. To your knowledge, how did most of your participating children hear about CHIP?
13. If applicable, how would you sum up your experience of involvement in enrollment?
a) Would you say that your actions have worked well?
•
•
•

Assistance given to families?
Outstationed / community-based enrollment?
Numbers of children enrolled?

b) In your experience, is the program effectively drawing on you as a provider to maximize
enrollment under Medicaid and CHIP?
14. To your knowledge, what have the major challenges been in enrolling children in this area?
In your opinion, what more could be done to improve enrollment rates?
15. In your experience, is the “screen and enroll” process is operating effectively (i.e., screening
children for eligibility in Medicaid and CHIP when they apply for either program)?
16. To your knowledge, what have been the major challenges in retaining children? Do you think
more attention should be paid to retaining children?

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III. Benefits Coverage
17. Let’s focus now on the benefits covered under CHIP. We would like to discuss with you your
opinions on the adequacy of the CHIP benefit package in meeting the needs of children.
a) How would you assess the adequacy of CHIP’s coverage for:
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Well-child care
Specialty medical care
Behavioral health care
Family planning for adolescents
Dental care
Case management
Ancillary therapies, DME, and other services often needed by CSHCN
Non-medical support services, such as health education, nutritional counseling and
support, social work counseling, parenting education, home visiting

b) Are there any services that, in your opinion, are not adequately covered under CHIP? If
so, how important do you think these gaps in coverage are?
c) How does the CHIP benefits package compare with that of Medicaid? Private insurance?
d) Is there anything that you would like to see changed about the package?

IV. Service Delivery and Payment Arrangements
Let’s turn to the service delivery system in your community. We would like to discuss the ability
of your service delivery systems to provide sufficient access to care for the children in your state.
18. Please tell us more about how your service delivery systems are working under both CHIP
and Medicaid. From your experiences to date, does it appear that children enjoy good access
to care under CHIP? How does this access compare to that afforded by Medicaid?
19. What are some of the leading health conditions among children that you most commonly
treat? What sorts of services do you most commonly provide?
20. Are you aware of any access problems either in general or for specific services (dental,
behavioral health, specialty)?

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a) If so, what is the source of these access problems?
•
•
•
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Too few providers?
Too few providers willing to participate in Medicaid and/or CHIP?
Geographic maldistribution (too few in rural or certain areas of the state)?
Problems associated with managed care referrals, prior authorizations, approvals,
etc.?

21. Are you satisfied that you are providing an adequate “medical home” for CHIP participants?
Are there obstacles that make it difficult for you to do this? (please describe)
22. If you participate in a CHIP managed care plan, how would you rate the ability of the
managed care plans to serve the full range of needs of children?
•
•
•
•

Do networks contract with traditional safety-net providers, like Federally Qualified
Health Centers and local health departments?
Are some subgroups of children less well served by managed care than others? (e.g.,
children with special health care needs, adolescents, non-English speaking children?)
Are networks experienced in serving low-income families?
Do MCOs tend to have stringent prior approval practices and/or limited
interpretations of medical necessity? Do you hear about, or experience many denials
of referrals for specialty care?

23. Is there anything about the arrangements for service delivery that you would like to see
changed?
24. Now let’s turn to payment arrangements. How are you paid under Medicaid and CHIP (feefor-service/capitation/combination)? Are there any incentives (such as pay for performance)
to improve the quality of care you provide? If so, how are these arrangements working, from
your perspective?
25. Are payment rates adequate to support the level of service you provide? Are there any
services in particular for which payment rates fall significantly short of what’s needed?
Generally, compare for us the rate you receive under Medicaid, CHIP, and private insurance.
Which payers pay better?
Have payment rates for CHIP or Medicaid changed at all recently? If so, have these changes
affected the services you provide?
28. Overall, how happy are you with the payment arrangements? Are there any changes you
would like to see?

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V. Cost Sharing
29. Do you collect cost sharing from CHIP participants? If so, what types and for which
services?
30. Are you responsible, in any way, for monitoring the accumulated total cost sharing that your
clients pay?
31. What is your impression of the impact of cost sharing on utilization?
•
•
•

How has this changed over time since start of program (or changed from earlier
program)?
How has this varied with particular services?
Are parents foregoing care for their children because they can’t afford/don’t want to
pay copayments?

32. Have you had any problems collecting copayments? Do you ever “forgive” coypayments
rather than collect them?
33. Overall, do you think that cost sharing is fair both to you and CHIP participants? Do you see
any advantages to cost sharing for participants?

VI. Crowd Out
34. Over the years, there has been much discussion of whether the program would displace either
private insurance or Medicaid, and not lead to an overall increase in the number of children
with insurance.
a) After more than 10 years of implementation experience, do you think that any form of
“crowd out” has occurred? If so, why? What evidence do you see that CHIP has
substituted for private insurance?
•
•
•

Families dropping private coverage to pick up CHIP coverage?
Families avoiding Medicaid and trying to enroll in CHIP instead?
Employers discontinuing their offers of dependent coverage to their employees?

b) If you know that families are switching coverage, do you feel that such switching of
coverage is justified, given either the quality of the new CHIP coverage or the
inadequacy of the private insurance a family might posses?
c) Have you heard parents discuss the waiting period for enrollment into CHIP as a barrier
to their switching coverage?

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VII.

Family Coverage

We would like to ask you about your experiences and opinions on family coverage under CHIP.
35. If there is family coverage under CHIP in this state: What, in your opinion, are the strengths
and weaknesses of covering parents, along with their children, under CHIP?
36. If there is no family coverage under CHIP in this state: Would you welcome expansion of
coverage to parents of children enrolled in CHIP? Do you think it would encourage more
widespread enrollment by families and/or better health care for low-income families overall?

IX. Employer Subsidy and Buy In Programs
There is an option under CHIP whereby states can subsidize the insurance already being offered
by employers to families that are CHIP eligible. There is another option that allows employers
to purchase CHIP coverage on behalf of their employees (the so-called “buy in” option). We
would like to ask you about your experiences and opinions of such an employer options.
37. If there are employer subsidy or “buy in” options under CHIP in this state: What, in your
opinion, are the strengths and weaknesses of these programs?
38. If there are no employer subsidy or “buy in” options under CHIP in this state: Would you
like to see the state adopt these options? If so, why?

X. CHIPRA and ACA
39. How is your state preparing for health care reform? What kinds of activities are state leaders
and provider associations engaged in?
40. What are your views of impending health reform, and what do you believe will be some of its
implications for CHIP, and for you as a provider?
41. With CHIPRA, federal CHIP allotments were extended only through September 2015. After
that, if Congress does not extend further CHIP funding, children enrolled in [CHIP program
name] will be moved to health insurance exchanges for their coverage. How do you think this
might impact children’s coverage in the coming years?

X. Overall Lessons Learned
42. In your opinion, how well does the CHIP program operate? What are the key strengths and
weaknesses of the program?
43. Are you satisfied with the coordination between CHIP and Medicaid? From the provider
perspective, are there any particular problems or disconnects between the two programs?

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44. What, if any, are the outstanding challenges that you face with CHIP?
45. Is there anything that you feel very strongly should be changed about the program?

Thanks very much for your time.

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