The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) has the potential to support the transformation of children’s health care in the United States. The legislation emphasizes both coverage and quality of care, and provides funding to enroll millions of children who would otherwise be uninsured. Specifically, the legislation establishes mechanisms to finance and improve coverage; to boost participation rates among the lowest-income, Medicaid-eligible children; to develop consistent quality-of-care measures and encourage reporting on these measures; to promote health information technology; and to realign incentives to focus on quality and outcomes.
Much of the legislation's transformative potential lies in the details of implementation, both in the rulemaking at the Centers for Medicare and Medicaid Services (CMS), which will define the boundaries within which states work, and in further implementation decisions in the state capitols. Nearly every aspect of the new law depends on current and upcoming federal and state decisions.
This report explores two key areas of the implementation process—outreach and enrollment and quality of care—and makes recommendations for each. This report was developed based on three sources: legislative and policy analysis conducted by the authors over the past six months, key informant interviews with stakeholders and experts conducted between March and June 2009, and a meeting held in Washington, D.C. in June 2009.
Outreach and Enrollment Provisions in CHIPRA
Outreach Grants
CHIPRA includes a number of provisions to increase outreach funding and activities to enroll eligible but uninsured children in coverage, with an emphasis on those who are hardest to reach. The law allocates $100 million to support Medicaid and CHIP outreach and enrollment activities. It provides guidelines on how the funding will be allocated, but gives the Secretary of Health and Human Services (HHS) broad discretion in implementation.
Recommendation:
- HHS could give priority to states that will adopt or maintain key simplifications.
Express Lane Eligibility
Currently, many uninsured Medicaid- and CHIP-eligible children are enrolled in other public programs. The new law provides states with tools and flexibility for enrolling these children. In particular, it gives states the opportunity to use relevant findings from other public programs, like food stamps, school lunch, and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), when determining children’s eligibility for CHIP and Medicaid at enrollment or renewal.
Recommendations:
- Provide clarity on the relationship between express-lane procedures and error measurements.
- Align guidance from federal agencies on data sharing.
Citizenship Documentation
CHIPRA allows states to document citizenship by submitting names and Social Security numbers to the Social Security Administration for verification. Previously, citizenship for children, parents, and pregnant women was required to be documented in a highly prescriptive and paperwork-intensive manner, according to stipulations in the Deficit Reduction Act of 2005.
Recommendations:
- Monitor state adoption of new requirements.
- Convene all stakeholders to ensure timely adoption of Social Security number matching.
- Clarify the question of citizenship versus identity documentation.
- Update rules for states that do not adopt Social Security number matching.
Performance Bonus
Performance bonuses are designed to encourage states to enroll eligible, uninsured children. States that increase enrollment of eligible children above a target level receive a federal payment for each extra child enrolled to help defray the added costs of successful efforts. States must also adopt at least five of eight specified measures for simplifying enrollment and retention to qualify for the bonus.
Recommendations:
- Provide rapid guidance on how qualifying simplifications will be counted.
- Ratchet up qualifying simplification efforts.
- Make appropriate, allowable adjustments to enrollment targets.
Payment Error Rate Measurement Rules
CHIPRA requires that HHS adopt new rules for the measurement of payment errors and includes important clarifications for states. The new rules also provide an opportunity to modify the definition of errors to include those that result in eligible individuals being denied coverage—so-called "negative case errors."
Recommendation:
- Take into account negative case errors.
CHIP Enrollment Reporting
The law requires states to include data in their annual reports to help assess enrollment and retention efforts, including data on continuity of coverage, denials of eligibility at both the application and renewal stages, and children’s access to care. It also requires states to provide more timely Medicaid and CHIP enrollment data to the HHS Secretary and to include a description of state activities to reduce administrative barriers to enrollment and renewals in their CHIP state plans.
Recommendations:
- Convene stakeholders to determine how data should be collected to allow for meaningful comparisons across states and over time.
- Share data rapidly and publicly.
- Coordinate data collection with other CHIPRA provisions.
Medicaid and CHIP Payment and Access Commission (MACPAC)
The law creates a commission to report to Congress on payment policies, access issues, and the relationship of Medicaid and CHIP to the rest of the health care system.
Recommendations:
- Take advantage of previous efforts to study Medicaid.
- Measure access across all populations.
Strengthening Quality of Care and Health Outcomes
Develop an Initial Core Set of Health Care Quality Measures
By January 1, 2010, the Secretary of HHS will identify an initial recommended core set of child health quality measures for use by state programs. The measures include, but are not limited to, duration of children’s coverage over a 12-month period and a wide range of preventive services and treatments.
Recommendations:
- Extend the core set beyond the existing Healthcare Effectiveness Data and Information Set (HEDIS) measures for children, adolescents, and maternal care.
- Consider developing a CORE–PLUS set that identifies additional measures that address high-priority topics, but which some states may not be able to use immediately.
- Ensure that appropriate criteria are used in selecting the set.
A Pediatric Quality Measures Program
By January 1, 2011, the Secretary must establish an ongoing program that advances and improves pediatric quality measures for all children. This program will expand upon and increase existing pediatric measures and will award grants for developing and testing pediatric quality measures.
Recommendations:
- Build measures for the future.
- Focus measure development funding on outcomes and composites.
- Design improved specifications for measures at all levels of accountability.
Provisions Related to Measure Use and Reporting
By February 4, 2011, the Secretary of HHS will develop a standardized format for reporting information, procedures, and approaches that encourage states to use the initial core measurement set to voluntarily report information on quality of pediatric programs. The Secretary will also disseminate information to states on best practices for measuring and reporting on the quality of health care for children.
Recommendations:
- Ensure meaningful collaboration with states in the design and execution of each step of the reporting strategy.
- Make consistent quality reporting on the core set a goal for all states on all populations.
- The data that support the core measures should be made available nationally, not just aggregate data.
- Begin investing in a national and state infrastructure for ongoing, sustained quality improvement.
Demonstration Projects
CHIPRA includes $20 million annually for demonstration projects. HHS will provide grants to up to 10 states and child health providers to use and test child health quality measures and promote the use of health information technology for children. The law also includes a separate allocation of $25 million for a childhood obesity demonstration project.
Recommendations:
- Demonstrations should focus on improving quality of care generally, as well as demonstrating specific aspects targeted in the legislation (e.g., health information technology, provider-based models).
- Most of the demonstrations should focus on all children in Medicaid and CHIP, not just those in selected sites or plans.
- Demonstrations could be designed to answer questions across the priorities identified in the legislative language.
Development of Model Electronic Health Record (EHR)
CHIPRA includes $5 million for the development of a model EHR that addresses children's unique needs.
Recommendations:
- Ensure that the health information technology–related activities of CHIPRA are coordinated with those of the Office of the National Coordinator, which has oversight for the implementation of the American Recovery and Reinvestment Act investments.
- Build quality measurement and improvement capabilities into health information systems, including the model EHR.
Beyond the opportunities offered by the provisions themselves, CHIPRA offers an opportunity to enhance federal capacity to assist states in designing, implementing, evaluating, and improving care for children. CHIPRA is an opportunity to recalibrate the partnership between states and HHS, particularly CMS, and to move from a culture of audit and penalty, driven by concerns of fraud and abuse, to one that seeks to provide assistance, guidance, and expertise to the states. This will require an investment in staff and resources within the agencies, which has existed for the Medicare program for decades. In addition, this investment needs to be coupled with a commitment by HHS to have a coordinated approach across all agencies.
