Policy brief (George Washington University. Center for Health Services Research and Policy)最新文献

This policy brief examines Medicaid's assurance of medical transportation in the context of medically necessary but non-emergency health care. Reviewing the origins and evolution of the assurance and presenting the results of a 2009 survey of state Medicaid programs, the results of this analysis underscore Medicaid's unique capacity to not only finance medically necessary health care but also the services and supports that enable access to health care by low income persons since Medicaid covers non-emergency medical transportation. This ability to both finance health care and enable its use moves to the forefront as Congress considers whether to assist low income persons in health reform through Medicaid expansions or via subsidies for traditional health insurance, which typically does not provide comparable transportation coverage.

Poor vision health severely impacts school and work performance, quality of life, and life expectancy, and results in billions of dollars in medical expenditures each year. While eye and vision problems are often associated with age, low income and racial and ethnic minorities also have elevated risk of eye problems. Federally-funded community health centers, which are mandated to provide comprehensive primary care in underserved communities, are often the only option to improve vision health for low-income residents. With respect to certain chronic conditions, health centers are able to provide high quality care that meets or exceeds national benchmarks despite limited financial resources, a shortage of primary care providers, and greater health care demands. What is not well known, is the extent to which health centers are able to provide on-site professional vision care. Our analysis found that seven out of 10 health centers do not staff on-site eye care professionals to provide comprehensive eye exams. Rather, many health centers rely on referral arrangements with local optometrists and ophthalmologists for such services. Major barriers to providing on-site comprehensive eye care services include the inability to afford necessary space/equipment and the perceived lack of reimbursement or inadequate reimbursement from Medicaid, Medicare and private insurers. Health centers indicated also that they also need assistance in developing a business plan, designing space, and developing an inventory of eye care equipment. While the lack of health insurance coverage, differences in Medicaid coverage and benefits across states, and inadequate reimbursements are likely to limit capacity and access to vision care professionals, another challenge may be patient's general lack of understanding about the need for routine eye exams. Therefore, strategies to improve access to vision care must go beyond developing financial incentives and restoring eye care professionals for eligible placements in underserved communities, to include education about the importance of routine eye care exams.

The majority of states have implemented separate SCHIP (S-SCHIP) programs that significantly depart from Medicaid and resemble less comprehensive commercial products. This difference in program design may result in S-SCHIP potentially being less responsive to children with special needs (CSHCNs). This study explores how responsive insurers are to these higher than average needs. We found that, with one exception, insurers did not agree on the coverage of any specific service, but overall they provided coverage beyond state limits and exclusions. Second, the less acute the childhood condition, the more frequently insurers imposed exclusions. Finally, in the majority of states, some insurers excluded services that arguably should have been covered according to the plan/contract language. We conclude that SCHIP coverage at current levels may not be sufficient to care for CSHCNs, making external reviews of insurers' coverage decisions and coordination with other sources of care important components of SCHIP program design.

This Policy Brief is the fourth in a series of reports issued by the George Washington University Center for Health Services Research and Policy that examine the design of separately-administered State Children's Health Insurance Programs (SCHIP) that is, programs that operate directly under the authority of the federal SCHIP statute rather than expansions of state Medicaid programs. These Policy Briefs also consider the implications of states' design choices for children's access to health care. The first three briefs in this series focused on three aspects of separate SCHIP programs: children's legal right to assistance under separate programs; benefit and coverage design choices under SCHIP plans; and the design and structure of freestanding managed care contracts negotiated by SCHIP agencies. This issue brief focuses on how financial eligibility for SCHIP actually is calculated, that is, the formulas that states have developed to count children's family income for purposes of measuring eligibility. This topic is of central importance to overall program administration because of the federal legal prohibition against assistance to targeted low-income children who are in fact Medicaid-eligible. This prohibition on duplication of assistance was a crucial assumption in the enactment of SCHIP. It is also key to the conservation of limited SCHIP funding for targeted low-income children who are ineligible for either Medicaid or any other form of health insurance, particularly as unemployment rises and the number of lower income children without health insurance may be poised to increase.

This Policy Brief examines behavioral health managed care contracting under separately administered State Children's Health Insurance Programs (SCHIP), i.e., programs that operate under the direct authority of Title XXI of the Social Security Act rather than as expansions of Medicaid. Most separate SCHIP programs buy managed care style health insurance for some or most of their enrolled children. Because Title XXI provides states with far greater administrative flexibility than Medicaid with respect to coverage and benefit design, provision of services, and administration of managed care arrangements,studying separate SCHIP managed care products sheds important light on how states might approach insurance and managed care design generally in the area of behavioral health were Medicaid modified through section 1115 demonstration or federal statutory authority to permit greater latitude. To conduct this analysis, two nationwide databases maintained by the George Washington University Center for Health Services Research and Policy (CHSRP) were used: a database consisting of all Medicaid MCO-style managed care contracts in use in Calendar Year 2000; and a nationwide database consisting of contracts used by separate SCHIP programs for the same calendar year. As of the point of collection in 2000 there were 33 such separate programs; according to CMS' latest website information, that total has now reached 35. Both sets of contracts were analyzed and separated into their components by lawyers experienced in managed care contract analysis and interpretation. The data were entered into working tables that organize the contents of the contracts into a series of searchable domains.