Medicaid Enrollees and Disenrolles

ATTACHMENT C1
CASE STUDIES OF CHIP 10—STATE EVALUATION CORE PROTOCOL: STATE
OFFICIALS

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Children’s Health Insurance Program (CHIP)
Case Studies of CHIPRA 10-State Evaluation
Core Protocol: State Officials

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1. Case Studies of CHIPRA 10 State Evaluation
State Officials Protocol Topic Summary List
Topic
CHIP Program Design
and Management

Eligibility

Subtopic
•
•
•
•
•
•
•
•
•

Enrollment

•
•
•
•
•
•
•

Renewal

Data

•
•
•
•
•
•
•
•

Organizational structure
Changes to program administration as a result of CHIPRA
Changes to the design of the program and debates
surrounding these changes
Eligibility expansions since 2006
Additional coverage options through CHIPRA
Presumptive eligibility, express lane eligibility* , other
simplification efforts
Citizenship documentation process with SSA *
Key differences between the CHIP eligibility policies and
Medicaid eligibility policies.
“Screen and enroll” process, and walk-through of a
“typical” renewal case
CHIP application form* and walk-through of a “typical”
application process
Enrollment processes and changes as a result of CHIPRA*
CHIPRA “performance bonuses” simplification strategies
(which strategies were adopted, did state qualify for
“performance bonus”)*
How budget affects enrollment
Any enrollment freeze*
“Maintenance of effort” rules
Anticipated changes to maximize enrollment and retention
and streamline in anticipation of Health Reform
implementation
Differences between renewal policies and procedures for
Medicaid*
Changes in CHIP renewal policies as a result of CHIPRA*
Satisfaction with enrollment and renewal policies
Percent of applications successfully enrolled
Percent of applications denied
Reasons for denial
Application processing time
Retention rate

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Topic
Outreach efforts

Subtopic
•
•
•
•

Benefit Package Design

•
•
•
•
•

Service Delivery and
Payment Arrangements

•

•

•

Cost Sharing

•
•
•

Crowd-Out

•
•
•
•

Statewide and community-level outreach efforts*
Most effective outreach efforts and those that do not
work*
Outreach grants under CHIPRA*
New outreach campaigns as health care reform
implementation approaches
Budget pressures affecting funding of outreach
Data on how outreach has affected enrollment*
Benefit package under CHIP and changes overtime*
CHIP benefit package compared to Medicaid and
compared to private insurance
Additional coverage (Dental, Behavioral health, special
populations)
Current service delivery systems (managed care, fee-forservice, combination)*
o Behavioral health delivery systems
o Dental care delivery systems
o CHIP delivery system compared to Medicaid
o Payment rates and methods
o Changes made since CHIPRA
Providers
o “Provider participation” rate among private
physicians
o Access to providers
o Role of safety net providers in serving CHIPenrolled children
Capacity to serve special populations, including
adolescents and children with special health care needs
Quality of care*, quality improvement initiatives
Medical home models*
Cost sharing under your state’s CHIP program*
o Changes in policies since 2006*
o Providers/health plans experiences related to the
collection of cost sharing
o Greatest strengths and weaknesses of your cost
sharing approach
Impact of premiums on enrollment and retention
Impact of copayments on families’ decisions to utilize care
Strategies to prevent crowd out and most effective crowdout policies*
Changes since 2006? Changes since CHIPRA was
passed?* Planned changes for the future?
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Topic
Family Coverage
Employer Subsidy
Efforts and “Buy In”
Programs
Coverage of Special
Populations
Local Context
Financing

PPACA

Lessons Learned

Subtopic
•

Program requirements and experiences covering parents of
low-income children, or non-pregnant childless adults. *
• Efforts to provide employer-sponsored health insurance*
• Extended coverage to children of state employees
• “Wrap around” benefits to employer benefits when they
fall below minimum benchmark requirements
• Modified policies for children with special health care
needs related to outreach, enrollment, benefits, cost
sharing, crowd-out, or service delivery
• CHIP administration at the local level (variations county
to county, and in urban vs rural areas of the state)
• Size of your state’s federal CHIP allocation, views on its
adequacy, and current aggregate spending in the most
recent year.*
• Current budget environment
• Funding (primary sources, changes as a result of CHIPRA,
uncertainty after 2015)
• Preparation for implementation of national health care
reform
• Impacts so far (Federal “maintenance of effort” rules,
health insurance exchanges)
• Satisfaction with success
• Greatest challenges coordinating CHIP with Medicaid
• Future thoughts on CHIP

* indicates topics which will be only be verified during the site visit based on documentation
reviewed prior to the visit

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CHIPRA 10-State Evaluation Interview Question Summary Grid for State CHIP
Directors1
I.
− Has the organizational structure of your state’s CHIP/Medicaid agencies changed in recent
years? Did enactment of CHIPRA cause any changes to program administration?
− Have there been significant changes to the design of the CHIP program in your state since
2005? What were the various and most important debates that surrounded these changes in
your state’s CHIP program?
II.

Eligibility/Enrollment/Retention

− Have there been any significant eligibility expansions in your state since 2005? Were these
changes a result of the enactment of CHIPRA? What were the most important debates that
surrounded these changes?
− Did your state adopt any of the additional coverage options that CHIPRA allows? What was
the impetus for adopting these reforms? If these strategies were not adopted, what was the
reason?
− What have been your state’s primary efforts to simplify and streamline eligibility
determination under CHIP?
− Did your state change its enrollment processes as a result of CHIPRA? If so, what impacts
have you seen?
− For states that qualified for a “performance bonus” by virtue of having enrolled Medicaideligible children above target levels and adopting at least 5 of 8 strategies aimed at simplifying
enrollment, what were the strategies utilized to hit those targets, and why did you pursue these
strategies? For those who did not qualify for this bonus, can you discuss strategies you did
pursue and why you think the state was unable to meet the targets necessary to receive a
bonus?
− Did your state change its retention processes as a result of CHIPRA? If so, what impacts have
you seen?
− To what extent have simplification strategies adopted by CHIP “spilled over” to the Medicaid
program? What are the key differences between the two programs, with regard to enrollment
and retention processes?
− Since the passage of CHIPRA, how important have “maintenance of effort” rules been in
safeguarding your program?
− Overall, how satisfied are you with your state’s CHIP enrollment and renewal policies? What
are the system’s key strengths? What are its weaknesses?
− What changes, if any, do you think need to be made to maximize enrollment and retention?
Are those feasible to implement, given the current state fiscal and political environment?
III. Outreach
− Has your state conducted any statewide outreach campaigns promoting the availability of
CHIP since 2005? What were the key components of these campaigns? How were they
funded? What strategies have been most effective?
− Has your state received any outreach grants under CHIPRA? If so, can you describe what
efforts are being funded by these grants?
− How have budget pressures, over the years, affected your state’s funding of outreach?

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IV. Benefit Package Design
− Has the CHIP benefit package in your state changed at any point since 2005? If so, please
describe the key changes. Were these changes controversial?
− How does the CHIP benefit package in your state compare to Medicaid? To private
insurance?
− Overall, how well does the current CHIP benefit package in your state appear to be meeting
the needs of enrolled children?
V.

Service Delivery and Payment Arrangements

− What is the current dominant delivery system used for children enrolled in CHIP in your
state? What are this system’s strengths? What are this system’s weaknesses?
− How does this delivery system differ from that of Medicaid (e.g., plans, providers, rates)?
What have been the dynamics between the two programs?
− What changes, if any, were made to CHIP’s managed care contracts in response to CHIPRA?
− Is your state pursuing any quality improvement initiatives related to CHIP service delivery?
What is the scope and progress of this effort? What challenges have you confronted (or
anticipate confronting)?
− What care coordination or medical home features, if any, has your state implemented?
− Overall, how would you rate your CHIP program’s ability to extend primary care access to
children? Specialty care? Dental care? Behavioral health care?
− What do you see as the biggest challenges that your CHIP program faces in terms of
providing access to care? How do these compare to Medicaid?
VI. Cost Sharing
− Please highlight for us any changes your state has made to its cost sharing policies (i.e.,
premiums, copayments, coinsurance) since 2005? What were the debates surrounding these
changes?
− Have you determined whether these changes had any effects on enrollment, retention, or
utilization of care? What is your perception of the affordability of premiums and other costsharing amounts for low-income families?
− What are the greatest strengths of your cost sharing approach? Weaknesses?
VII. Crowd-Out
− Is fear of “crowd out” an issue in your state?
− Have any of your strategies to deter crowd-out changed since 2005, or since CHIPRA was
passed in early 2009?
− What do you believe are the most effective crowd-out policies and why? What are the least
effective?
− Are you planning any changes to your crowd out prevention policies? If so, what and why?
VIII. Family Coverage
− Has your state changed its policies regarding the extension of CHIP coverage to parents of
enrolled children? If so, when did this occur and what was the impetus for pursuing this
change?
− What have been your experiences of implementing family coverage? Do you believe
families are more attracted to programs that can cover the whole family?
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IX. Employer Subsidy Efforts and Premium Assistance Programs
− Does your state subsidize employer-based coverage under CHIP? If so, what have been your
experiences implementing the employer subsidy program?
− Has your state extend CHIP coverage to children of state employees?
− With the passage of CHIPRA, are you considering providing ‘wrap around’ benefits to
employer benefits when they fall below minimum benchmark requirements? Why or why
not?
− Has your state pursued the premium assistance option under CHIPRA to permit employers to
purchase coverage for their employees through CHIP? Why or why not?
− What do you see as the major strengths, weaknesses, and impact of incorporating employer
subsidy arrangements into CHIP?
X.

Coverage of Special Populations

− How do various features of your CHIP program affect children with special health care
needs?
− Have you modified any policies—such as those related to outreach, enrollment, benefits,
cost sharing, crowd-out, or service delivery—to make your program more responsive to
needs of children with special health care needs?
− How would you rate your CHIP program’s capacity to serve special populations, including
adolescents and children with special health care needs?
XI. Local Context
− Does CHIP administration and implementation vary at the local level? What are the
implications of this variation?
XII. Financing
− Please discuss the size of your state’s federal CHIP allocation, your views on its adequacy,
and current aggregate spending the most recent year.
− Please describe the current budget environment in your state. How has this impacted your
state’s CHIP program? What cuts were made, if any? Are any cuts being considered? What
have been your observations about the effects of these changes on access to care or quality of
care?
− What have been the primary sources of state funding for your CHIP program?
− How has the passage of CHIPRA – the new funding determinations and spending time
frames – changed the funding debate in your state?

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XIII. Preparing for Health Care Reform
− How, if at all, has the enactment of the ACA affected your state’s CHIP program?
− In what ways is your state preparing for implementation of national health care reform?
− Do you have plans for additional streamlining/simplification in anticipation of health reform
implementation?
− Do you anticipate needing to design new outreach campaigns as health care reform
implementation approaches? How do you see these taking shape?
− Have federal “maintenance of effort” rules safeguarded your state’s CHIP and Medicaid
eligibility policies during the recent economic downturn? Have state policymakers begun
talking about cuts, in spite of MOE requirements? Have these requirements had other
effects on CHIP or Medicaid?
− Do you anticipate increasing payments for primary care providers consistent with mandated
Medicaid increases? If so, how do you expect this to unfold?
− To what extent do you anticipate funding uncertainty after 2015 will impact your state’s
CHIP policies?
− Does your state anticipate including CHIP enrollees in health insurance exchanges? Why or
why not?
XIV. Lessons Learned
− Overall, how satisfied are you with the success of your CHIP program? Which aspects are
you most satisfied with, and which are you least satisfied with?
− Do you believe that your state has taken full advantage of new flexibility under CHIPRA?
Have there been any missed opportunities in your state?
− What have been the greatest challenges surrounding the coordination of CHIP with
Medicaid?
− To what degree have lessons learned through CHIP implementation and administration
“spilled over” to affect Medicaid policy?
− In the future, what would you like to see happen to CHIP? What new issues are likely to
arise for CHIP in light of new federal health care reform?
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This grid provides more detail on which of the core state official protocol questions will be
asked of CHIP and Medicaid directors.

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1. Case Studies of CHIPRA 10 State Evaluation
Core Protocol: State Officials

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?

Let’s begin by having you introduce yourself, tell us a bit about your agency and role within
that agency, and more broadly, your involvement with health policy in the state.
Could you say a few brief words about your background and your role?

I. Background: History/Evolution of CHIP Policy and Program Development
First we would like you to confirm some details about the design and characteristics of your
program.
1. From our background research, we have learned the following about the current status of
the program:
(Fill in the blanks…)

•
•
•
•

Name of program
Type of program (Medicaid, Separate, Combination)
Upper income eligibility thresholds, by age
Administrative structure/responsibility for CHIP and Medicaid

Could you please:
•
•
•

Confirm that these details are correct;
Fill in any gaps in our knowledge;
Explain any other changes in CHIP that have taken place since 2005?

2. It is also our understanding that your program emerged and evolved in the following
manner:

• History/politics surrounding CHIP policy development
• Key factors influencing original CHIP program design choices (separate CHIP,
Medicaid expansion; note states that have switched design over the past 10 years)

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Once again, could you please:

• Confirm that the details are correct
• Elaborate on any important aspects of program development
Now, we’d like to discuss the more recent history of the CHIP program in your state.
3. We reviewed current CHIP eligibility thresholds a moment ago; were these thresholds set
as a result of any significant eligibility expansions in your state since 2006?
•
•
•

If yes, please describe. Were they focused on children, or families (parents, childless
adults)?
Were any of these changes a result of the enactment of CHIPRA?
What were the most important debates (whether political, fiscal, or programmatic)
that surrounded this expansion under CHIP?

II. Eligibility/Enrollment/Retention
The first policy issue we would like to discuss with you today is eligibility determination and,
more specifically, the processes your state uses to enroll children into CHIP and renew their
coverage in those programs. A specific interest is the extent to which you have adopted
policies and procedures that simplify and streamline enrollment and retention.
4. From our background research, we have learned the following about your eligibility
policies and enrollment processes for CHIP.
With regard to the CHIP application form:

• Separate, or joint with Medicaid and/or other programs
• Length (with / without directions)
• Printed in x number of languages (list)
With regard to enrollment processes:

•
•
•
•
•
•
•
•
•
•

Application available online
Submit by mail / phone / internet/ online
Electronic signature allowed
Outstationed eligibility workers
Community-based application assistors
Hotline for assistance
Verification requirements (age, income, assets, residency, SSN)
Administrative verification of income (electronic data match)
Presumptive eligibility
Continuous eligibility (6- or 12-months)
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• Redetermination interval (6 or 12 months)
Please confirm that these details are correct.
Please could you tell us if and how these policies have changed since 2006? Why did
these changes occur?
5. CHIPRA allows states to adopt additional coverage options and enrollment simplification
strategies. From our background research, we’ve determined the following regarding
your state’s adoption of these strategies:
•
•
•
•
•

Coverage of legally resident immigrant children/pregnant women without imposing a
five-year waiting period
Citizenship documentation via Social Security Administration data match
Express Lane Eligibility
Federal matching rates in CHIP and Medicaid
CHIP coverage of children of public employees

Please confirm that these details are correct.
If applicable, what was the impetus behind adopting these reforms? Where did the
support come from—Governor’s office, legislature, advocates?
If CHIPRA expansions were not adopted, what was the reason? (e.g., Too expensive?
Politically unpopular?)
6. CHIPRA also made “performance bonuses” available to states that adopted at least five
of eight qualifying simplification strategies. Once again, from our analysis, it appears
that you that adopted the following strategies:
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)

12-month Continuous Coverage
Elimination of Asset Test or Liberalization of Asset Requirements
Elimination of In-Person Interviews
Joint Application and Shared Information Verification Process for Separate
Medicaid and CHIP Program
Automatic/Administrative Renewal
Presumptive Eligibility
Express Lane Eligibility
Premium Assistance

7. Did you adopt any of these strategies because of the CHIPRA incentive? If so, which
ones?
8. Did your state qualify for a “performance bonus” under CHIPRA, by not only adopting
qualifying simplification strategies, but by also meeting your enrollment target?
•

If so, when? How much was the bonus for, and how was the bonus used?
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9. We have reviewed many of the details of your CHIP program’s eligibility policies. I
would like to now turn to the application process, itself. Could you walk us through a
“typical” process that a parent might follow when applying for CHIP for their child?
a)
b)
c)
d)
e)
f)
g)
h)
i)

j)
k)

Where would a parent typically find an application?
How might that application be completed?
Would a parent likely receive help from someone in completing a form? By whom?
How much documentation would need to be submitted with the application, to verify
such things as income?
Would the parent need to meet, face to face, with an eligibility worker?
How would the application be submitted most typically? How many different ways
can an application be submitted—do you use a “no wrong door” policy?
Where would that application go for processing? (Does it go to a single statewide
processing center, or to county offices?)
Who reviews CHIP applications and determines eligibility?
How long does it take to process an application, on average? And does that rate
represent an improvement over the years, or is this rate typical for the past several
years? [if the state uses an outside vendor to determine eligibility: do they have
required turnaround times for processing?]
How would this parent be informed about whether (or not) their child has been
determined eligible?
What would be the next step in the process?

Let’s continue our discussion by talking about how various eligibility policies have been
implemented in your state.
10. How does Presumptive Eligibility work?
•
•
•
•
•

What kinds of providers are certified to grant PE? What kinds of providers typically
grant PE?
What forms do they use? (Are they different from the standard application?)
What are PE providers supposed to tell parents about establishing full eligibility for
their children?
What has been your state’s experience regarding rates of “successful” conversion of
children from presumptive to full eligibility?
Why do you think this rate is where it is?

11. How does Express Lane Eligibility work?
•
•
•

What is the reference program for which eligibility qualifies a child for CHIP?
How is that determination made, and in what ways are families involved?
How long have you used ELE procedures? Did you have to train/re-train workers on
this? How did that work, how long did it take? Was it a smooth process to
implement, or were there challenges? If so please describe those challenges.

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12. How has the data-driven citizenship documentation process with SSA worked? Has it
been a smooth process? Can you describe it for us?
Up to this point, we’ve been focused on CHIP eligibility and enrollment policies and
procedures. I’d like to shift gears now to Medicaid.
•
13. Please highlight for us any key difference between the CHIP eligibility policies and
Medicaid eligibility policies.
•
•
•

To what extent have eligibility simplification strategies adopted by CHIP “spilled
over” to Medicaid?
In what key ways do the two application processes differ?
What are the implications of those differences?

14. How does the “screen and enroll” process work? How do eligibility staff refer CHIP
applicants who appear Medicaid eligible to that program? And vice versa?
•

How do differences in CHIP and Medicaid rules and/or procedures complicate this
process?

15. Now let’s turn to eligibility redetermination, or renewal, under CHIP. From our research,
we have learned the following about your renewal process:
•
•
•
•
•

Form (pre-printed or blank)
Process (passive or active)
Verification (paperless, ex parte, or document submission required)
Face to face interview (or not)
Rolling renewal permitted (yes or no)

Please confirm these details and correct our efforts.
16. With regard to renewal, can you walk us through a “typical” case? In other words, how
would a parent typically renew CHIP coverage for her child?
a) How is a parent informed that they need to renew their child’s coverage?
b) How often does renewal occur (and are parents informed about renewal at application
so that they might anticipate needing to do something down the road?)
c) What form, if any, is required to be completed?
d) Does a parent need to meet with someone, face to face?
e) Can a renewal application be submitted by mail, or online?
f) What verification needs to be submitted, if any?
g) How long does it take for a renewal to be processed?
h) How is a parent informed of the outcome of the renewal application?
i) What’s the next step in the process?
j) If a child is being disenrolled from CHIP, is their eligibility for Medicaid assessed?
How does that process work? Is the process the same for children being disenrolled
for Medicaid – is their eligibility for CHIP assessed? Do you know what proportion
of children disenrolling from CHIP are referred to Medicaid, and vice versa?
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17. Are there any differences between renewal policies and procedures for Medicaid? Please
describe them for us.
18. To what extent have your CHIP renewal policies changed as a result of CHIPRA?
Let’s wrap up this portion of our interview by chatting about lessons learned, as well as
current and future budget and policy issues.
19. How has the state’s budget picture affected policy discussions surrounding CHIP
enrollment? Have there been pressures to trim eligibility, freeze enrollment, or do away
with simplification strategies?
20. In the past five years, has your state ever had to institute an enrollment freeze? Tell us
about that experience.
•
•
•
•
•

How long did the freeze last, and during what timespan was it in place?
Did you maintain a waiting list during the freeze?
How much disenrollment was experienced?
How quickly did enrollment bounce back after lifting the freeze?
What, if any, were the longer-term effects of having instituted an enrollment cap?

21. Since the passage of CHIPRA, how important have “maintenance of effort” rules been in
safeguarding your program?
a. What impact do you anticipate raising income eligibility standards will/would
have on enrollment in your state?
•
22. Overall, how satisfied are you with your state’s CHIP enrollment and renewal policies?
What works best in the system? What’s the worst aspect of the system?
•
23. What changes, if any, do you think need to be made to maximize enrollment and
retention?
•
24. Do you have plans for streamlining/simplification in anticipation of Health Reform
implementation?
25. Can you share with us any data on such measures as:
•
• Percent of applications successfully enrolled
• Percent of applications denied
• Reasons for denial
• Application processing time
• Retention rate
• Reasons for denial at renewal
• Other useful performance measures?
• How long have you been tracking these? And how does the state use this
information?
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III. Outreach
Let’s now turn to outreach, which we define as efforts to market CHIP and raise public
awareness of the availability of health insurance for children. We’ll divide our discussion
between statewide outreach efforts and those conducted at the community level.
26. Let’s begin by discussing any statewide outreach campaigns.
a) Has your state conducted any statewide, mass media campaigns promoting CHIP?
When were those conducted? Who conducted them (state itself or hiring of
firm/advocates)? Are they still being funded/conducted? Were there any periods
when no statewide outreach campaigns were going on?
b) What are the key components of your state-level campaign? Please tell us in more
detail about such components as television or radio ads, print materials (posters,
billboards, brochures), incentives, other strategies.
c) What are the basic messages of the campaign?
d) Does the campaign attempt to target specific populations (such as working families,
racial/ethnic groups, CSHCN)?
e) Please tell us the rationale and objective of your campaign.
27. Let’s continue by discussing community-level outreach efforts.
a) Has your state funded any community-level outreach efforts? When were those
conducted? Are they still being funded/conducted? Were there any time periods
when no local outreach was being funded/conducted?
b) What are the key components of your community-level efforts? Please tell us about
such strategies as:
•
•
•
•
•
•
•
•

grants to support outreach agencies;
fees to support community-based application assistance;
school-centered efforts;
provider-centered efforts;
health plan-centered efforts;
local and/or ethnic media;
faith-based efforts;
door-to-door canvassing; etc.

c) Does/how does the campaign target specific populations (working families,
immigrants, ethnic groups, former welfare recipients, CSHCN)?
d) To what extent (and how) do outreach efforts vary from community to community?
e) Have you made any efforts to publicize the fact that CHIP and Medicaid do not
constitute a “public charge” against an application for citizenship? If so, how has the
immigrant population in your state responded?
f) Please tell us the rationale and objective of your strategy.
28. Funding for outreach is often unstable. How have budget pressures, over the years,
affected your state’s funding of outreach?
15

29. Has your state received any outreach grants under CHIPRA? If so, can you please
describe what efforts are being funded by these grants?
30. Do you have any data (or evidence) regarding how outreach has affected enrollment?
What do these data tell you?
•
31. In your opinion, what have been your state’s most effective outreach efforts? Do you
have a sense of the relative effectiveness of statewide campaigns vs. community-based
outreach efforts?
•
32. What have you learned about what outreach strategies do not work?
•
33. Do you anticipate needing to design new outreach campaigns as health care reform
implementation approaches? Based on what you’ve learned under CHIP, how do you see
these taking shape?
•
IV. Benefit Package Design
Next, we’d like to discuss the benefits offered to enrollees under your state’s CHIP program.
34. From our background research, we understand the following regarding your benefit
package under CHIP:

• Medicaid vs. Benchmark (which benchmark / benchmark plus)
• Changes in the benefits package since start of CHIP
• Details on coverage (table)
Could you confirm that these details are correct?
35. Have there been any changes to your CHIP benefits since 2006? Please describe what
was cut or added.
36. What are the key differences between your CHIP package and that of Medicaid?
•
37. How would you compare your CHIP benefits to those typically covered by private
insurance policies? Is CHIP more, or less generous in its coverage?
•
38. Please describe your CHIP program’s coverage of dental services. Did CHIPRA rules
requiring dental coverage force changes in your state? Had dental coverage ever been
discontinued in your state, prior to CHIPRA?
•
39. Please describe your CHIP program’s coverage of behavioral health services
(content/nature/extent of coverage). Have new mental health parity requirements under
CHIPRA affected this coverage? How so?
•
16

40. Has your state adopted any special “wrap around” or enhanced benefits coverage for
special populations in CHIP? Tell us about the process and decision surrounding this
move. Was this a result of CHIPRA?
•
41. Overall, how well does the current CHIP benefit package in your state appear to be
meeting the needs of enrolled children?
•
• Does it fall short of meeting the needs of children in any way?

V. Service Delivery and Payment Arrangements
Now, we’d like to transition to discussing the service delivery and payment arrangements for
CHIP and Medicaid in your state.
42. Please describe the current service delivery systems used for children enrolled in CHIP in
your state.
•

Do you rely primarily on capitated managed care, fee-for-service systems, or some
combination of the two?

43. With regard to managed care arrangements, how many health plans currently participate
in CHIP?
•
•
•

What types of plans are these? Commercial? For profit? Nonprofit?
Do any particular plans dominate enrollment (e.g., BCBS)?
Has plan participation in CHIP been stable over time?

44. Now we’d like to focus on behavioral health. How are behavioral health services
delivered in your program? Through managed care or fee-for-service arrangements?
45. If you use managed care, are behavioral health services the responsibility of the health
plans, or are they “carved out”?
•
46. How many behavioral health organizations participate in CHIP?
47. Turning to dental care, how is dental care delivered in your program in CHIP (managed
care or fee for service)?
•
48. If you use managed care, is dental care delivery the responsibility of the health plans or
do you contract directly with managed dental networks?
•
49. How many dental managed care organizations participate in CHIP? What proportion of
dentists in the state participate in these plans?

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50. With regard to fee-for-service arrangements, let’s discuss these characteristics in more
detail.

•
•
•
•
•

How many primary care providers participate in CHIP?
How many pediatricians participate in CHIP?
How many dentists participate in CHIP?
How many specialists participate in CHIP?
Of these providers, do you have any data on the proportion that “actively” participate
(ie, accept new patients, bill the programs for a certain volume of business)?

51. Is your CHIP delivery system significantly different from Medicaid’s? What are the key
differences?
52. What have been the dynamics between the two programs, in terms of provider/plan
participation? (i.e., Does CHIP enjoy greater support from providers than Medicaid? If
so, why?)
53. What role do safety net providers (FQHCs, local health departments) play in serving
CHIP-enrolled children? Do they participate in CHIP health plan networks? What is the
current trend in this regard?
54. With regard to managed care arrangements, describe for us the process through which
CHIP enrollees select a health plan, as well as a primary care provider within the selected
health plan.

•
•
•
•
•
•
•
•

Do they need to select a plan before they are fully enrolled in CHIP?
What information is provided to families to assist in the selection?
Do you contract with an “enrollment broker” to assist families in this process?
How much time is a family given to select a plan before they are automatically
assigned to one?
What is your auto-assignment process?
What is your auto-assignment rate?
How are PCPs selected?
To what extent do these policies/procedures differ for Medicaid enrollees?

55. What changes, if any, were made to CHIP’s managed care contracts in response to
CHIPRA? Please describe.
56. With regard to fee-for-service arrangements, please describe for us the process through
which a CHIP enrollee selects a primary care physician. Does such a process exist?

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57. Let’s turn to payment rates and methods. Tell us more about the rates you are paying
under CHIP, and how they compare to Medicaid rates. With regard to managed care
providers:

• What are the capitation rates paid under CHIP and are the rates the same for all plans?
•

•
•
•
•
•

How many rate cells do you establish?
How are rates set?
Do you adjust your rates based on enrollees’ health status (or based on health plan’s
case mix)?
Have rates changed over time? In what direction?
How do health plans typically pay their participating providers? (FFS vs. subcaps?)
How do these rates/policies differ for Medicaid? Are Medicaid rates higher or lower?
Does your state use pay-for-performance incentives with health plans to promote
quality improvement?

58. With regard to fee-for-service providers, what are the rates you pay for key services, like
a well-child visit, a physician visit, a dental visit? (Others?)
59. How do these rates compare to those paid for similar services under Medicaid?
•
60. Have fee-for-service rates changed over time, for either program? How?
61. Can you estimate what the “provider participation” rate among private physicians is for
CHIP? How does it compare to Medicaid?
•
62. Do you believe there is an adequate supply of providers to serve CHIP enrollees?
Medicaid?
63. What factors most affect physicians’ decisions on whether or not to participate in these
programs?
•
• Fee levels?
• Administrative burden?
• Risk status of CHIP/Medicaid enrollees?
• Other factors?
64. Overall, how would you rate your program’s ability to extend primary care access to
children enrolled in CHIP?
•

How does this compare to Medicaid?

65. Have you heard of occasions where children have had access problems? Does this vary
with different subgroups of children, in different localities, or for particular types of
services?

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66. What do you see as the source of these access problems?
•
• Too few participating providers?
• Too few providers accepting new patients?
• Health plan networks insufficient?
• Problems with health plans’ determinations of “medical necessity” or extension of
prior authorization for referrals?
67. How well are children accessing dental care under CHIP? Under Medicaid? What
evidence do you have?
68. Overall, how would you rate your CHIP program’s capacity to serve special populations,
including adolescents and children with special health care needs?
69. Now let’s discuss the quality of care provided by your delivery system.
•

•
•
•
•
•

How are you monitoring quality of care? What measures are being monitored? What
data are being collected (e.g., HEDIS, EPSDT, immunizations)? Does the state
conduct surveys of consumers that explore access to care issues? What do the data
show? Can we get copies of any studies you have done?
What proportion of children enrolled in CHIP have a primary care “medical home?”
What proportion of families can identify a usual source of care for their children?
Do you have any evidence that children are receiving appropriate levels of preventive
care? Immunizations? Dental care?
Have you initiated any quality of care improvements since 2006 (e.g. care
coordination initiatives, EHRs, or other forms of HIT)?
Have you adopted any specific quality-of-care strategies since the passage of
CHIPRA, such as CHIP Quality Measures Reporting, or Medical Home?

70. Let’s talk specifically about medical home models in more detail. If applicable, tell us
about some of the key elements of your efforts, such as:
•
•
•
•
•
•
•

To what extent are enrollees expected to choose or be assigned to a particular medical
home?
How do medical homes manage care (for example, do you use team-based
approaches to care management)?
Are there any specific requirements related to how referrals for specialty and inpatient
care are handled?
Do you use HIT (such as electronic medical records or disease registries) to manage
care for people with chronic conditions?
How does information flow between PCPs and other providers? Again, do electronic
medical records facilitate information flow?
Do your state’s medical homes expand access through strategies such as expanded
hours/days, or open access appointment scheduling?
What incentive do you use to change the behavior or providers and/or enrollees?

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VI. Cost Sharing
And now, we’d like to discuss cost-sharing (i.e., premiums, copayments) for your state’s
CHIP program.
71. From our background research, we have learned the following about cost sharing under
your state’s CHIP program:

•
•
•
•

Premiums by income level
Enrollment fees by income level
Copayments by service
Changes over time

Can you confirm that these amounts are correct?
72. To what extent have these charges changed since 2005? Please describe.
a. Do you have any plans currently to increase premiums in the future?
73. Can you tell us about the decision to impose cost sharing? Were there contentious
debates around the decision to impose cost sharing? And have debates continued to be
contentious over the years, as cost sharing requirements were changed?
•
74. What methods are used for collecting premiums? Do you provide enrollees any
incentives for pre-paying premiums? Have premiums been difficult to collect?
•
75. What is the policy if premiums are not paid? Do you permit any exceptions for hardship,
or other causes? Do you allow a certain “grace period” before someone is disenrolled for
nonpayment of premiums? Is there a “blackout” period before allowing re-enrollment?
•
76. How does the state monitor families’ cost sharing burden against the 5 percent upper
limit? Does the state monitor aggregate cost sharing directly at the state level (and if so,
how)? Or, do you ask families to monitor this themselves (e.g., through the “shoebox”
method)? Do managed care plans play any role in monitoring aggregate cost sharing?
•
77. What is your policy for when a family reaches the 5 percent limit? How do you ensure
that such families are not subject to further cost sharing requirements? Have any families
reached the 5 percent threshold, to date?
•
78. Now we would like to ask you your opinions about the impact of premiums on
enrollment and retention.
•
•
•

Do you believe premiums are viewed as affordable by families with enrolled
children? Why do you think this is the case?
Do you believe premiums pose a barrier to enrollment?
Do you have any experience regarding whether premium increases affect enrollment?
If so, can you tell us what you have found?
21

•

•
•

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 families in your state?
Has cost-sharing been a significant issue in disenrollment/retention? How so? Do
you have evidence of this from your data?
Do you have any evidence that the use of premiums has resulted in adverse selection
(i.e., have you seen/heard of families disenrolling when their children are healthy and
re-enrolling when their children are sick)?

79. Do you believe that copayments have had an impact on families’ decisions to utilize
care? Has this impact been positive (i.e., discouraging inappropriate
utilization/encouraging appropriate utilization), or negative (i.e., discouraging families
from obtaining needed services)? Has this impact varied by type of service?
80. What have the providers/health plans experiences related to the collection of cost
sharing?
•

Are you aware of any instances where providers “forgive” copayments rather than
collect them and/or simply treat uncollected copayments as charity
care/uncompensated costs?

81. What are the greatest strengths of your cost sharing approach? Weaknesses?

VII. Crowd-Out
Now we’d like to discuss the issue of crowd out in your state (i.e., the concern that CHIP
coverage will substitute for available employer-sponsored coverage).
82. From our background research, we understand that you have implemented the following
strategies to prevent crowd out:

•
•
•
•
•

Ask about other insurance on application
Require a waiting period (of __ months)
Make exceptions to waiting periods
Monitor (as a strategy)
Others

Please confirm that these details are correct
83. Have these policies changed since 2006? Since CHIPRA was passed (early 2009)?
84. In most states, there was initially considerable concern surrounding the potential for
CHIP to crowd-out private insurance. With a decade of experience to reflect on, we
would like to know whether you think that this concern was warranted.
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•
•

•
•
•
•
•

To what extent is fear of crowd out still a concern of policymakers in your state?
Do you have any evidence of whether or not crowd out has occurred?
Do you know what percentage of applicants report that they have insurance (or had
insurance within the state’s waiting period)?
Are you satisfied with the effectiveness of your monitoring?
Has the behavior of employers changed since the passage of CHIP? (i.e., Have you
heard any reports of changes in the proportion of employers who offer their
employees dependent coverage?)
Do you have any evidence that people already enrolled in CHIP are refusing offers of
private coverage from their employers?
Have there been any issues with state employees?

85. Now let’s turn to how effective your crowd-out policies are.

• Do you have any evidence that speaks to whether your policies to prevent crowd-out
are working? What policies are working, and which ones are not?
86. Now let’s talk about some of the potential side effects of crowd out policy.

• Do you know if the waiting period has affected enrollment in this state? Has it
affected different populations differently?
• What is your impression of the impact of the state’s crowd out prevention policies on
families that purchased private coverage before CHIP and now are prohibited from
enrolling in CHIP (unless they drop their coverage and “go bare” for some period)?
• There are likely low-income families residing in your state who possess creditable
insurance that is either expensive or limited in scope—often referred to as “underinsured.” How do you think such families should be dealt with? Do you think there
are any circumstances under which they should be permitted to drop their current
insurance and sign up for CHIP? Have you considered changing your waiting period
exceptions policies to permit such families to enroll?
• Do you think CHIP could function effectively as “wrap around” coverage to private
insurance in cases where private insurance is deemed to be either too expensive or too
limited? (i.e., as Medicaid is currently permitted to “wrap around” private
insurance?)
87. Finally, are you planning any changes to your crowd out prevention policies? If so, what
and why?

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VIII. Family Coverage
There have been a lot of questions over time about whether CHIP funds should be used to
extend coverage to parents of children. We know that CHIPRA no longer permits states to
use CHIP to subsidize family coverage, except in cases where there is already a waiver in
place or a demonstration is not yet set to expire. As background, we would like to ask you
about any policies you have had that extend coverage to parents of low-income children, or
non-pregnant childless adults.
88. From our background research, we have learned that you have/have not pursued “family
coverage” under CHIP/Medicaid. Can you confirm whether this is correct?
89. If you do have family coverage, please describe your program in greater detail. For
example:
•
•
•
•
•
•

What are the eligibility requirements?
How does a family enroll in coverage?
What are the cost-sharing requirements?
How do you prevent crowd-out in family coverage?
Did you design any special outreach campaigns/messages to publicize the availability
of parental coverage?
How are you planning for the (financing) changes that are imminent as a result of
CHIPRA?

90. Please describe your experience formulating the family coverage plan under CHIP:
•
•

What were the major debates leading up to the adoption of family coverage?
What was your experience with the federal government pursuing and obtaining
approval of family coverage provisions?

91. What have been your experiences of implementing family coverage?
•
•
•
•
•
•

How many parents’ have been enrolled so far?
How many parents are you targeting for enrollment?
Has it changed the nature of CHIP? If so, how?
Has it improved rates of enrollment among children? Do you believe families are
more attracted to a program that can cover an entire family?
Has it affected overall access to care?
Tell us about any major problems or benefits with the program?

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IX. Employer Subsidy Efforts and “Buy In” Programs
And now we’d like to explore any efforts to provide employer-sponsored health insurance
subsidies provided through CHIP in your state.
92. Does your state subsidize employer-based coverage under CHIP?
•
•
•
•
•
•

If so, how is that program structured? Which employers are permitted to
participate?
How much must they contribute to the cost of premiums? (Did this contribution
change as a result of CHIPRA?)
How do you assess the cost effectiveness of the subsidy compared to straight
CHIP coverage?
What have been your experiences implementing employer-subsidy programs?
Is this a large portion of your CHIP program? What proportion of children
receives coverage this way?
What do you see as the major strengths, weaknesses, and impacts of incorporating
employer subsidy arrangements into CHIP?

93. With the passage of CHIPRA, are you considering providing “wrap around” benefits
to employer benefits when they fall below minimum benchmark requirements?
94. Has your state pursued the premium assistance option under CHIPRA to permit
employers to purchase coverage for their employees through CHIP?
•
•

If so, what have been your experiences implementing such a “buy in” program?
What do you see as the major strengths, weaknesses, and impacts of incorporating
employer “buy in” arrangements into CHIP?

X. Coverage of Special Populations
Now, we’d like to focus on how the CHIP program in your state specifically addresses
the care of children with special health care needs.
95. How do various features of your CHIP program affect children with special health
care needs? Specifically, to make your program more responsive to the needs of
these children, have you modified any policies related to:
•
• outreach,
• enrollment,
• benefits,
• cost sharing,
• crowd-out, or
• service delivery

25

XI. Local Context
96. How has CHIP administration operated at the local level?
97. Has the program’s implementation varied significantly, from county to county? If so,
what factors have contributed to this variation? (For example, do counties
autonomously administer eligibility and renewal systems, or do they operate under
state authority and consistent state rules?)
98. Has program implementation varied between urban and rural areas of the state? If so,
please describe variations in outreach and enrollment approaches, service delivery
approach, access to care, etc.

XII. Financing
Now, we’d like to turn to the financing of your CHIP program, including the current and
future funding outlook given the passage of CHIPRA.
99. Please discuss the size of your state’s federal CHIP allocation, your views on its
adequacy, and current aggregate spending in the most recent year.
100. Please describe the current budget environment in your state.
101. How did limited/uncertain funding over the past 5 years impact your state’s CHIP
program? What cuts, if any, were made to eligibility, benefits, provider
reimbursement, etc.? With the current budget environment, are any new cuts being
considered in these areas? If changes have been made in response to fiscal
constraints, what have been your observations about the effects of these changes on
access to care or quality of care?
102. What have been the primary sources of state funding for your CHIP program?
103. How has the passage of CHIPRA - the new funding determinations and spending time
frames - changed the funding debate in your state?

XIII. PPACA
Now, we’d like to hear your thoughts on how you anticipate the Affordable Care Act may
affect your state’s CHIP program.
104. In what ways is your state preparing for implementation of national health care reform?
105. How, if at all, has the enactment of the ACA affected your state’s CHIP program so
far?
•
26

106. Have federal “maintenance of effort” rules safeguarded your state’s CHIP and
Medicaid eligibility policies during the recent economic downturn? Have state
policymakers begun talking about cuts, in spite of MOE requirements?
107. Have these MOE rules had other effects on CHIP and/or Medicaid? (e.g., requiring cuts
in other aspects of the program not related to eligibility and enrollment, such as
provider reimbursements?)
108. Do you anticipate increasing payments for primary care providers consistent with
mandated Medicaid increases?
109. To what extent do you anticipate funding uncertainty after 2015 will impact your state’s
CHIP policies?
110. Does your state anticipate including CHIP enrollees in health insurance exchanges?

XIV. Lessons Learned
Finally, we’d like to wrap up our conversation today by discussing some of the lessons
learned by you and your agency/organization over the past decade.
111. Overall, how satisfied are you with the success of your CHIP program? Which aspect
of most satisfied with / which aspect least satisfied with? What do you rate as your
greatest success?
112. Overall, what have been the most important lessons you have learned to date in
developing and implementing your CHIP program? What are the greatest challenges
you have faced? In retrospect, are there any policies you would change?
•
113. In retrospect, what do you see as the major implications of the decision to adopt a
separate CHIP program/Medicaid expansion?
•
114. What have been the greatest challenges surrounding the coordination of CHIP with
Medicaid?
115. To what degree have lessons learned through CHIP implementation and administration
“spilled over” to affect Medicaid policy?
116. Overall, how well do you think your program is working? What aspects are
working particularly well, and what aspects could use some improvement?
117. In the future, what would you like to see happen to CHIP? What new issues are
likely to arise for CHIP in light of new federal health care reform?
•

27

Those are all the questions that we have for you today. Is there anything else that you think
might be helpful for us?

Thank you very much for your time and your thoughts.

28