Medicaid Enrollees and Disenrolles

ATTACHMENT C4
CASE STUDIES FOR CHIP 10—STATE EVALUATION PROTOCOL: MANAGED
CARE PLANS/HEALTH PLAN ASSOCIATIONS

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Children’s Health Insurance Program (CHIP)
Case Studies of CHIPRA 10-State Evaluation
Managed Care Plans/Health Care Associations

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4. Case Studies of CHIPRA 10 State Evaluation
Managed Care Plans/Health Plan Associations Topic Summary List
Topic
Background and
Overview

Involvement with CHIP
Enrollment and
Outreach

Primary Care Provider
Selection

Benefits Coverage

Network and System
Capacity/Access

Payment

Subtopic
•
•
•
•
•

Background information on plan
Number of enrollees
Where plan operates
Baseline health of the children enrolled
Participation in CHIP/ Medicaid outreach
o Description of efforts
o Advantages and disadvantages of involving
health plans in outreach
• Participation in CHIP/ Medicaid enrollment
o Description of involvement
o Advantages and disadvantages of involving
health plans in enrollment
• Participation in CHIP/ Medicaid eligibility renewal
o Major challenges in retaining children
o Changes to enrollment/disenrollment policies as a
result of the new CHIPRA managed care
requirements
• Process immediately after a child is determined eligible
for coverage
o Assistance to help a family choose a primary care
provider
o Routine screens or assessments at intake
o Auto-assignment
• Opinions on the adequacy of the CHIP benefit package
in meeting the needs of children
• Services that are “carved out” of plans’ responsibility
• Design, scope, and breadth of your plan’s network(s) of
providers
• Requirements set forth in your CHIP contracts with
regard to the make-up of provider networks
• Definition of “medical necessity” and determination
process
• Primary care medical home efforts
• Access issues
• Information shared with families that describes how the
system works
• Capitated payments
• Risk
• Satisfaction with payment arrangements for CHIP and
Medicaid
• Future plans for MCO(s) and their involvement with
CHIP and Medicaid
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Topic
Cost Sharing

Crowd Out
Family Coverage

Subtopic
•
•
•
•
•
•
•

Employer Subsidy and
Buy-In Programs

•

Quality Monitoring

•
•
•

PPACA

Overall Lessons Learned

•
•
•
•
•
•

Collecting and monitoring cost sharing
Process to disenroll children/families for failure to pay
premiums
Impact of premiums on enrollment and retention
Affect of copayments on utilization
Evidence that any form of crowd out has occurred
Waiting periods as a barrier to enrollment
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
Data collected on Medicaid and CHIP
Participation in Quality Demonstration Projects as a
result of CHIPRA
Financial incentives to improve the quality of care
provided
Preparation of health reform
Views on health reform and implications for CHIP
Impact of health insurance exchanges
Strengths and weaknesses of the CHIP program
Satisfaction with coordination between Medicaid and
CHIP
Challenges of implementing CHIP in a managed care
environment

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4. Case Studies for CHIPRA 10-State Evaluation
Protocol for Managed Care Plans/Health Plan Associations
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, it would be helpful to get some background information about your plan. (Or, the
health plans you represent.)
a) What type of plan is it (staff-model HMO, IPO, etc.)?
b) For-profit or not-for-profit?
c) How long has your plan been involved in CHIP and Medicaid managed care? (Do you
serve both Medicaid and CHIP, or just one of the programs?)
2. We are also interested in the number of enrollees in your plan(s) in [state name].
a) How many enrollees do you have are insured by CHIP? Medicaid? Private insurance?
b) Do you know approximately what proportion of CHIP and Medicaid eligibles in your
state choose your plan? (i.e., What’s your share of the market?)
c) Has this number and proportion of enrollees been relatively stable in recent years?
3. Now could you tell us about where you operate.
a) Do you operate statewide under CHIP? Medicaid? Or do you serve only certain regions
of the state?
b) If you only serve certain regions of the state, what are the other provider networks
available to CHIP/Medicaid beneficiaries?
c) Has this changed over time? Are you hoping to expand in the future?
4. What you know about the baseline health of the children you enroll into CHIP and Medicaid.
How does this compare with your children enrolled in private insurance? What kind of
assessments or data do you use to understand their baseline health status?

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II. Involvement with CHIP Enrollment and Outreach
Now we would like to discuss whether you participate in outreach and enrollment, and how well
you feel the processes are working.
5. Do you/your plans 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.
•
•
•
•
•
•
•
•

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 at enrollment events,
such as health fairs?
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 for CHIP? 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)? What methods do you use for your
own outreach—TV or radio ads? Participating at health fairs? Others?
How intensive is your outreach work?
Has your role in outreach changed in recent years? Why did you make these changes?

6. If applicable, how would you sum up your experience of involvement in outreach? What do
you see as the advantages, and disadvantages, of involving health plans in outreach?
7. Do you/your plans participate in any way in Medicaid and/or CHIP enrollment?
a) If so, please describe how you are involved with enrollment.
•
•
•
•
•
•

Do you act as a CHIP enrollment site (i.e., do you have marketing and enrollment
staff on site (and/or in the field) that are trained to assist families with enrolling in
CHIP/Medicaid)?
Do you make applications available to your patients (for example, on your website)?
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?

b) If you have workers trained to assist families in completing applications:
•
•
•
•

Are you able to complete the applications in one sitting, or do families have to come
back to you with documentation?
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?
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•
•
•

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?

8. If applicable, how would you sum up your experience of involvement in enrollment? What
do you see as the advantages, and disadvantages, of involving health plans in enrollment?
a) In your experience, is the program effectively drawing on you as a plan to maximize
enrollment under Medicaid and CHIP?
b) Is your involvement in enrollment paying off?
•
•

Are you getting paid to do this? How much does the state pay you?
Are you getting paid enough to cover your overhead costs?

c) How does the state monitor/oversee your outreach, marketing and enrollment activities?
Are there specific rules surrounding this role to limit the potential for inappropriate
marketing activities?
9. In your experience, what have the major challenges been in enrolling children in this area? In
your opinion, what more could be done to improve enrollment rates?
10. Do you/your plans participate in any way in the eligibility renewal process for Medicaid
and/or CHIP? If so, how?
11. To your knowledge, what have been the major challenges in retaining children? Do you think
more attention should be paid to retaining children? Do you have any data on the reasons for
disenrollment? If so, what do they tell you about the major reasons why kids do not re-enroll
or are voluntarily disenrolled?
12. What changes have you had to make your enrollment/disenrollment policies as a result of the
new CHIPRA managed care requirements? (i.e., providing literature about enrollment and
disenrollment information; coverage/benefit changes; quality assurance reviews).

III. Primary Care Provider Selection
13. Please describe for us what happens immediately after a child is determined eligible for
coverage under CHIP or Medicaid.
a) What kind of assistance is provided to help a family choose a primary care provider for
their child(ren)?
b) At intake, do you conduct any routine screens or assessments to identify children and
adolescents who might have special needs? Such as a child with a chronic illness or
disability, or an adolescent with emotional problems?
c) What happens if a parent does not select a PCP? How does auto-assignment work?
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IV. Benefits Coverage
14. Let’s focus for now on the benefits covered under CHIP and Medicaid. 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:
•
•
•
•
•
•
•
•

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 Medicaid and private insurance?
d) Is there anything that you would like to see changed about the package?
15. Are any services that are “carved out” of your/your plans’ responsibility?
a)
b)
c)
d)

Which ones? (Dental? Behavioral health? Pharmacy?) Why were these carved out?
What providers/systems are responsible for delivering these services?
How are they reimbursed?
What mechanisms are in place to coordinate the services you deliver with those provided
through the carve out?
e) How is this arrangement working? Is service delivery well integrated, across the
systems, or have you experienced coordination, boundary, or other problems?

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V. Network and System Capacity/Access
16. Let’s now discuss the design, scope, and breadth of your plan’s network(s) of providers. Can
you generally describe the network you’ve assembled for CHIP?
•
•
•
•
•
•
•

How many primary care providers are in the network?
Of these, how many are FQHCs vs. private physicians?
How many hospitals are in your network?
Specialists?
Dentists?
Mental health providers?
Others?

17. How does this network compare to your Medicaid network?
18. Please describe and compare the requirements set forth in your CHIP contracts with regard to
the make-up of provider networks.
•
•
•
•
•
•

Are provisions in the two types of contracts the same?
Are you required to demonstrate arrangements with pediatric subspecialists,
children’s hospitals, Title V/CSHCN program providers?
Are you required or encouraged to have arrangements with adolescent health
providers, like school-based health centers?
Are you required or encouraged to have arrangements with community-based “safety
net” providers like FQHCs and local health departments?
Are you required or encouraged to have arrangements with developmental service
systems like Part H/Early Intervention or Special Education?
Are these requirements the same, or different, for Medicaid?

19. Now let’s turn to the issue of “medical necessity”.
a) What definition of “medical necessity” do you use under your Medicaid and CHIP
contracts? Does it include services that may prevent a condition from worsening, or that
help maintain function (as opposed to restore function)?
b) Please describe the medical necessity determination process.
20. In response to CHIPRA (or pre-dating CHIPRA), has your health plan engaged in any
primary care medical home efforts to improve access, quality, or coordination? If so, please
describe these efforts. For example:
•
•
•

For how long has your plan promoted the medical home model?
What changes did adopting a patient-centered medical home model require for your
plan?
What is your approach to care management? (For e.g., do you use a team-based
approach?)

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•
•

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?

21. Are you aware of any access problems, either in general or for specific services (e.g.
CSHCN, access to specialists)?
a) If so, what are the problems, and why do they arise?
•
•
•
•
•
•
•
•

Inadequate sources for referrals?
Services denied owing to “prior authorization” rules?
Strict interpretations of “medical necessity?”
Too few providers in certain regions?
Too few providers willing to get involved in CHIP and/or Medicaid
Too many providers on your panel that limit the numbers of CHIP/Medicaid patients
they will see?
Insufficient language skills amongst providers for immigrant groups?
Wait-lists?

22. Does access to care vary for various types of services:
a)
b)
c)
d)

Between CHIP and Medicaid?
Between managed care and fee-for-service regions?
Between urban and rural areas?
Between racial / ethnic groups?

23. Tell me how your “medical home” efforts are going. Do they seem to be achieving the
results you desired? Why? Why not?
24. Now we’d like to ask you about the information you share with families that describes how
the system is supposed to work (e.g., how families are supposed to select a PCP, obtain
referrals to services from specialists, and receive authorization for some services?)
a) Is it your impression that sufficient information is made available to families?
b) What kinds of resources do you give families that provides this type of information?
c) If your rules change, what actions do you take to ensure that families understand the
changes?
d) Are you aware of any access issues related to the amount of information available to
families?

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VI. Payment
25. First, we would like to know if you are paid on a capitated basis under CHIP?
26. If so, how are the capitated payments you/your plans receive structured?
a)
b)
c)
d)

How many different rates are you paid for children insured by Medicaid and CHIP?
Can you tell us what rates you are paid, or is that information proprietary?
Are rates the same between the two programs?
Are rates risk adjusted, in any way?

26. Now let’s turn to the issue of risk.
a) Do you/your plans pass risk on to your network providers? How is the risk sharing
structured (for example, via sub-capitation payments)?
b) Or are providers simply paid on a fee schedule, accepting no risk?
c) In your contracts with the state, are there risk corridors to protect against unanticipated
profits or losses?
27. Are plans required to purchase reinsurance? For how much?
28. Now we would like to ask you how satisfied you are with the payment arrangements for
CHIP and Medicaid?
a) Are payments adequate, or are you/your plans losing money?
b) How do CHIP payments compare with Medicaid and private insurance?
c) If there have been changes in the payment schedule in the past, how has this affected
you?
29. Financially, what might the future hold for MCO(s) and their involvement with CHIP and
Medicaid?

VII.

Cost Sharing

30. Do plans collect cost sharing from CHIP participants (e.g., premiums)? If so, what types and
for which services?
31. Are plans responsible, in any way, for monitoring the accumulated total cost sharing that
your clients pay? If so, what methods do you use to monitor this?
32. Are plans responsible for disenrolling children/families for failure to pay premiums? Can
you tell us how this works—are they notified by mail, do they have a certain timeframe
within which they can pay and remain enrolled, etc.?
33. Please tell us about your experiences collecting cost sharing amounts.

56

a) Have there been any problems in collecting cost sharing? Does this vary with different
populations?
b) Do you ever not collect cost sharing and then treat it as a “sunk cost?”
34. Please describe your impression on the impact of premiums on enrollment and retention?
a) Are families not enrolling into CHIP because they can’t afford the monthly premium? Or,
do you believe that premiums are in fact viewed as affordable by families, and if they are
not enrolling, it is for other reasons?
b) Do you have any evidence that the use of premiums has resulted in adverse selection
c) Do you have any experience regarding whether premium increases affect enrollment?
d) To what extent do you believe premiums lead to “churning,” that is, cycles of
disenrollment/re-enrollment among children whose parents do not keep up to date with
premium payments?
e) Some believe that nominal premiums actually encourage enrollment (by giving families a
sense that they are contributing to the cost of care and/or by dispelling the notion that
CHIP might be a government “hand out”). Do you believe this to be the case with your
families?
f) Has cost-sharing been a significant issue in disenrollment / retention? How so? Do you
have evidence of this from your data?
35. Have you a sense of whether copayments are affecting families’ utilization of care? (For
example, do your PCPs use an e-prescribing system where you are able to track whether
prescriptions written are filled (if there is cost-sharing for prescriptions)?)
36. Overall, do you think that cost sharing is fair both to you and CHIP participants?

VIII. Crowd Out
37. During the development of CHIP, there was 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 in your state? 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? (If so, is it because
Medicaid has a negative perception in the state, whereas CHIP does not?)
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 they may possess?
c) Have you heard parents discuss the waiting period for enrollment into CHIP as a barrier
to their switching coverage?
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IX. Family Coverage
We would like to ask you about your experiences and opinions on family coverage under CHIP.
38. If there is family coverage under CHIP in this state: What, in your opinion, are the strengths
and weaknesses of the program?
39. If there is no family coverage under CHIP in this state: Would you welcome expanded
coverage of parents of CHIP enrollees? Do you think it would encourage better health care
for low-income families overall?

X. 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, and another option where employers can buy
CHIP coverage on behalf of employees. We would like to ask you about your experiences and
opinions of such employer options.
40. If there is an employer subsidy option or an employer “buy in” option under CHIP in this
state: What, in your opinion, are the strengths and weaknesses of the program?
41. If there is no employer subsidy or buy in option under CHIP in this state: Would you like to
see the state adopt this option? If so, why?

XI. Quality Monitoring
42. Please describe the various quality monitoring efforts that your plan conducts.
a) What data on the Medicaid and CHIP programs to you collect?
•
•
•

Quality measures
Service denial
Family satisfaction surveys

b) What of these data do you routinely submit to the state? Do you submit the same data for
both programs?
c) Do you submit encounter data to the state?
d) What HEDIS measures do you report for children?
e) Are there any special quality initiatives or studies that you conduct for child populations?
43. Are there any patterns revealed by this data that you could tell us about?
44. Does your plan participate in any Quality Demonstration Projects that were created as a
result of CHIPRA? If so, please describe.

58

44a. Does the state offer any financial incentives to improve the quality of care provided? If
so, please describe these arrangements, how you have operationalized those to incentivize
providers to improve care quality, and how this is working to date.

XII. PPACA
45. How is your state preparing for health care reform? What kinds of activities are state leaders
and health plans engaged in?
46. 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 health plan?
47. 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?

XIII. Overall Lessons Learned
48. In your opinion, how successful has the CHIP program been? What are the key strengths and
weaknesses of the program?
49. Are you satisfied with the coordination between CHIP and Medicaid? From the health plan
perspective, are there any particular problems or disconnects between the two programs?
50. What, if any, do you see at the major challenges of implementing CHIP in a managed care
environment? How does this vary from Medicaid?
51. Is there anything that you feel very strongly should be changed about the program?
52. Would you welcome an expansion of the CHIP program?
Thanks very much for your time.

59

CHIPRA 10-State Evaluation Focus Group Moderator’s Guide:
Parents of Children Covered by Employer’s Sponsored Health Insurance
Introduction and Overview of Purpose
Hello and welcome to our focus group. I’d like to begin by thanking each of you for taking time
out of your day to be here. We appreciate it.
My name is ________, and I’m from the Urban Institute. My partner here is ________. We have
been hired to conduct this focus group to talk with you about your experiences obtaining health
care for your children through your employer sponsored health insurance policy.
Each of you has been invited here because one or more of your children is currently enrolled in
an employer sponsored health insurance policy. Over the next hour or so, we want to talk with
you about your experiences as a parent of a child who is covered and accessing health care
services through this policy. We are having two other focus groups like this one in [this state].
We are interested in learning about your experiences, including how you enrolled your children
in this policy, how well you can access health care services for your children with this policy,
how affordable it is, and how satisfied you are with the care you receive. This will allow us to
better understand how well people like you are able to access and afford health care services for
their children. Also, it will allow us to help policymakers and providers improve their programs
for health care consumers like you. So let’s get started.
Ground Rules
Before we go any further, let me go over a few “ground rules” for today’s discussion.
1) Have any of you ever been in a “focus group” before? Just so you know, a “focus group”
is an informal small group discussion, moderated by a facilitator (me) who will guide the
discussion through a series of questions, focused on a particular issue (in this case—health
insurance coverage). I’d like us to just imagine that we’re sitting around a kitchen table,
relaxed and casually chatting with some new friends. Sound good?
2) First, there are no “right” or “wrong” answers here today. Please feel free to share your
views, even if they are different from what others have said. Please also know that we
don’t work for your employer’s health plan or the government, so please tell us your
thoughts and opinions, whether they are positive or negative.
3) Second, your participation here is entirely voluntary. You are free to leave at any time.
Also, your confidentiality will be completely protected. When we summarize the findings
of the group, all responses will be “anonymous,” meaning nobody’s name will appear, and
nothing you say will be attributed to you, so please be as open as possible in sharing your
thoughts with us.
4) I would really like to encourage everyone to participate. Each of you does not have to
answer each and every question, though, nor do you need to raise your hand to speak. If,
however, some of you are shy or don’t get a chance to speak, I may call on you to give
you a turn, because I’d like to know what everyone here thinks.
5) It is important that only one person speak at a time. We want to be respectful of everyone
and give everyone their chance to speak. Also, you may have noticed that we are
60