History and Implementation
The Title XXI program expands access to an existing state Child Health Plus (CHPlus) program, a partnership between the state and private insurers with the state subsidizing private coverage for enrollees. The Title XXI program will also support expanded Medicaid eligibility in New York.

Pre-Title XXI
The Child Health Plus (CHPlus) Program was established in 1990, with a $20 million state appropriation, to provide primary, preventive care for low-income children under age 13. For six years, the program slowly expanded age eligibility as additional funding became available. By 1996, CHPlus covered children up to age 15 with a state annual appropriation of $73 million.

In 1996, Governor Pataki proposed to expand the program significantly by raising eligibility through age 18, adding inpatient care, and increasing annual funding. The Legislature approved authorizations to increase to $207 million by 1999, and also approved $1 million specifically for outreach activities. As a result of these changes, CHPlus grew to serve over 140,000 children under the age of 19 with family incomes up to 185 percent FPL, before Title XXI was enacted.

State Compliance with Title XXI
With the passage of Title XXI, additional funds were made available for children’s health insurance initiatives. New York’s State Plan, submitted to the Health Care Financing Administration(now known as Centers for Medicare and Medicaid Services(CMS)) (HCFA(now known as CMS)) in November 1997, became effective April 15, 1998. Legislation was enacted in 1998 which enhanced the program, and ensured that CHPlus was in compliance with the Federal requirements.

New York was one of three states in which existing children's health coverage benefit packages were "grandfathered" into the CHIP legislation, along with Florida and Pennsylvania.

Title XXI
In 1998, the Governor and both chambers of the State Legislature wanted to expand publicly funded children’s health insurance. A political compromise between the Governor, the Republican Senate and the Democratic Assembly resulted in new state legislation that significantly expanded eligibility for CHPlus and Medicaid, effective January 1999. Initially, these changes will:

• Allow children under age 19 with family incomes up to 230 percent FPL (rising to 250 percent in July 2000) to qualify for CHPlus;
• Allow all children under age 19 with family incomes up to 100 FPL to qualify for Medicaid; and
• provide 12 months of continuous Medicaid eligibility for all children under age 19.

• The state secures the necessary Federal approval to enroll children in a managed care program; or
• The Commissioner of Health certifies that at least 50 percent of the persons eligible to enroll under a managed care program through a Federal waiver are enrolled.

Federal/State Financing

• New York’s Title XXI allocation of Federal funds in its first year was up to $256 million.
• The state contribution is $205 million funded through the health care initiative pool approved in 1996 by the legislature in its Health Care Reform Act that expires in 1999.
• New York’s state match for Medicaid is 50 percent. The state normally imposes a local Medicaid matching requirement with 25 percent paid by the counties and the remaining paid by the state. There was unanimous agreement among state officials to pay the local share for children who qualify for Medicaid under the expansion (i.e., over six and under 19 up to 133 percent FPL). However, the state will not pay the local cost if the children were previously eligible, but not enrolled.

Current Enrollment
In 1997, 3,000 children a month were enrolled in CHPlus. Enrollment has been steadily increasing, with the monthly average now about 9,000 children. In New York State, there were 281,000 children receiving public health insurance as of February 1, 1999.

The state will soon establish a community-based infrastructure for applications for children’s health insurance programs (both Medicaid and CHPlus). Referred to as "facilitated enrollment", trained individuals will be stationed in community settings to help families apply for children’s health insurance; facilitate completion of the application; and forward the application to the appropriate program for eligibility determination. (The new enrollment process is described in more detail below.)

Key Factors in New York Implementation

• Phased expansion was helpful. By starting small with its state-funded program (CHPlus), New York could adapt its program as eligibility and funding expanded. State officials felt prepared to plan further modifications and expansions when the Federal Title XXI funds became available.

• Stakeholder support strengthened the foundation. CHPlus is very popular among all stakeholders. Families like it because they consider it a private insurance program that does not have the stigma of Medicaid. Insurance companies and the Business Council like it because they consider it an effective partnership between the public and private sectors benefiting low-income children and their families.

• Bipartisanship prevailed. Republicans and Democrats were prepared to allocate state funds to expand access to children’s health services, including the need to support outreach to locate potentially-eligible uninsured children.

• Policy discussions about how to expand CHPlus with the new Federal funds were bipartisan, and conducted independent of state budget negotiations.

State Approach
Various public and private agencies share responsibility for various outreach, marketing and enrollment activities. Their outreach activities are targeted to locate lower income children who are eligible for either Medicaid or CHPlus. The different agencies include:

• A community outreach contractor, selected through a competitive RFP process, who manages outreach and marketing.
• Participating private plans distribute marketing materials and enroll applicants.
• Local social services and health agencies help establish linkages with schools and community-based organizations.
• The Department of Health coordinates a statewide media campaign.

• The New York Health Plan Association is the community outreach contractor.
• There are 27 managed care organizations participating across the state although Empire Blue Cross/Blue Shield covers about one-half of all the children eligible for CHPlus.
• County social services and health agencies conduct final enrollment.
• State Department of Health provides overall administration.

State officials believe that the new outreach and enrollment infrastructure will help ensure that children are properly placed in CHPlus or Medicaid, depending on their eligibility. Another major goal is to locate multi-lingual community-based workers to interview potentially eligible families in the enormous range of ethnic populations in the state, especially in New York City. Specific language in the recent state legislation details how the facilitated enrollment process should operate.

The new approach was motivated, in part, by a desire to remove some of the stigma families report feeling when applying for Medicaid. For many years, because of a longstanding concern about possible fraud and abuse, state law has required face-to-face interviews of Medicaid applicants in local Department of Social Services (DSS) offices where families also apply for welfare. Under the new procedure, after the face-to-face interview in a community setting, the paperwork will be transmitted by mail or in person by the facilitated enroller to the local DSS office for the final eligibility decision. Federal law requires that eligibility determination be conducted by the Medicaid agency.

The initial phase of facilitated enrollment includes:

• The Department of Health recently issued a $10 million RFP to develop and implement the process.

• Two non-profit child advocacy groups have implemented "facilitated enrollment" programs and are testing the use of the single application for CHPlus, Medicaid and WIC. One project partners community-based organizations, community members and local students in an outreach and enrollment initiative in several neighborhoods in northern Manhattan. This group provides application assistance and developed an extensive booklet of information to use as a tool for this process. Another group obtained private foundation funding to train a network of child care workers in New York City to conduct family interviews. A model training curriculum was developed, including information to share with parents about establishing a schedule for well-child visits and learning about the developmental stages of childhood. It is anticipated that this group will obtain parent satisfaction information regarding the facilitated enrollment process

State Agencies

• The Unemployment Insurance Division in the Department of Labor distributed program information.

• The Office of Child Support Enforcement in the Department of Social Services distributed information.

• The Department of Education sent a mailing to all school superintendents informing them about CHPlus and the availability of promotional materials to distribute through their individual school systems. On an individual district basis, the outreach coordinator arranged for program materials to be distributed at various points in the school year such as information that accompanied student report cards. A statewide informational mailing was sent to school nurses regarding the program and the availability of outreach materials.

The initial funds for its $250,000 annual contract were provided through the health care initiative pool when the legislature approved expansions for CHPlus in 1996. Under its contract, which expires in December 1999, the coordinator:

• works with the State Perinatal Association to provide information at the regional level to providers and families;
• staffs the toll-free number that families call to discuss available programs and benefits and to request enrollment information; and
• conducts a wide array of outreach activities in local communities.

The community outreach coordinator attends local events across the state and organizes a variety of activities to educate the public about available children’s health insurance programs. Strategies include:

• Attending health fairs and community gatherings, sometimes with a van and a 20 foot tall blimp. At these events, bumper stickers, Frisbees, refrigerator magnets and sun visors are distributed to encourage interest in the program along with informational brochures.

• Making presentations at schools and through different faith communities;

• Arranging with McDonald’s to put CHPlus information on its tray placements; and

• Arranging with utility companies to include bill stuffers about CHPlus in its monthly statements mailed to households.

Media

• The Department of Health maintains responsibility for a major statewide media campaign that relies heavily on radio and television advertising. Agency officials believe that radio ads were most effective because they could be tailored for specific audiences. For example, the state developed public health messages about specific prevalent childhood conditions, such as asthma, and then followed it with an announcement about CHPlus to tell families how to call for more information.

• Highway billboards are placed prominently across the state to advertise CHPlus to state residents.

Creating a Seamless Health Care System for Eligible Children

Presumptive Eligibility

• Children have presumptive eligibility in CHPlus for 60 days while documentation is collected to establish whether they qualify for Medicaid or CHPlus. This provision was effective January 1, 1999.

• Starting January 1, 1999, children receive continued Medicaid eligibility for one year.

• The state requires an annual recertification of eligibility by the anniversary date of the child’s enrollment. Children who qualify for Medicaid are not eligible for CHPlus and their information is forwarded to Medicaid, if parental consent is obtained to do so. Previously, children could receive coverage through CHPlus even if they also qualified for Medicaid, but this is no longer possible under Federal law. Title XXI funds cannot be used to cover Medicaid-eligible children.

• There is one integrated application form that includes eligibility for Medicaid, CHPlus and the Special Supplemental Food Program for Women, Infants and Children (WIC) Program.

• The current outreach budget is $3.5 million.

• Using Title XXI funds, the state will significantly increase this budget by funding facilitated enrollment across the state. A $10 million RFP was recently issued for this process.

State officials acknowledge that groups require different marketing approaches. This is extremely challenging in New York State with its wide variety of populations.

Woodwork Effect
State officials recognize that a "woodwork" effect may result from its aggressive outreach efforts so they factored this into their fiscal projections for their Medicaid costs.

A larger concern among state officials is whether the state’s successful outreach efforts identify uninsured children whose families are reluctant to enroll in Medicaid. To help encourage eligible children to enroll in Medicaid, state officials want to reduce the program’s stigma and make the application process more convenient for the family. They hope that the facilitated enrollment process that uses trained workers to interview families in friendly community settings will help accomplish this. State officials are working to ensure that all children in CHPlus who are Medicaid eligible are moved to the Medicaid program as appropriate and that the continuity of health care is maintained.

Advice for Other States on Outreach

• Air public service announcements for children’s health insurance program after public health message about a specific condition (e.g., asthma) to capture more attention among television or radio audience.

• Families report radio announcements are their most frequent source of information.

• Convene monthly meetings with outreach coordinator to check enrollment data and to obtain feedback on different outreach strategies.

• Take a broad-based approach in the types of mass media used. Some types of media may be more effective in particular geographic regions or specific community environments.

• Disseminate informational materials in creative ways where people have easy access. For example, CHPlus brochures were displayed together with traveler information pamphlets in rest areas along the New York State Thruway.

• Educate other public agencies and local governments about the program. These entities can function as an important avenue of informal outreach their specific consumers.

Employer
State officials believe that a previous evaluation of the CHPlus program demonstrated that crowd-out did not occur — employers did not drop coverage for employees as the program expanded.

Employee
In New York, employers who offer insurance are statutorily required to meet minimum benefit standards defined by the State Insurance Commissioner for a particular type of insurance benefit. For example, Major Medical coverage has a minimum standard of benefits that must be included to be classified as Major Medical. Thus, officials believe there is little incentive for people to prefer the publicly-funded program benefits. On the other hand, there is some concern about families who cannot afford the cost of private insurance for their children. At a public hearing, a mother whose employer offered no premium assistance spoke about having to drop her child’s private insurance when the $200 monthly cost to cover both of them doubled. She enrolled her child in CHPlus and was able to keep her own coverage for the same $200.

State’s Response
To comply with Federal requirements to monitor crowd-out, state officials will continue to analyze its potential emergence through two mechanisms. They are evaluating:

• The proportion of children covered under an employer-based plan for evidence of possible employer or employee crowd-out, using the Current Population Survey as a base; and

• Responses to specific questions added to the single application formto ensure that families are not dropping employer-based coverage to enroll their children in CHPlus.

• Is the parent or responsible adult a public employee with access to family coverage by a state health benefits plan, and is the public agency paying all or part of the cost of the health care benefits coverage?
• Have your children been covered by health insurance, other than CHPlus, in the past six months?
• Was your prior insurance through an employer?
• Why was your prior insurance stopped? (Check only one)
• Employer discontinued offering this benefit or is no longer contributing toward premium for your children but continued the benefit for working parent.
• Premium was increased beyond what you could afford.
• Child Health Plus is a less expensive insurance.
• Child Health Plus insurance benefits are better.
• You are no longer working for employer who offered insurance.

Waiting Periods

• The state currently imposes no waiting period for children to become eligible for CHPlus. However, the Department of Health will assess quarterly the information submitted by MCOs from the application’s crowd-out questions. If evidence emerges that CHPlus is substituting for private health coverage in excess of eight percent, then the state will impose a six month waiting period.

• For CHPlus, children under age 19 with family incomes at or below 230 percent FPL rising to 250 percent by July 2000.

• For Medicaid, children under age 19 with family incomes below 100 percent FPL. This will later expand to cover children ages 6-19 whose net income is less than 133 percent FPL, after the state secures the necessary Federal Medicaid waiver or the Commissioner certifies that at least 50 percent of the population now eligible for Medicaid managed care is enrolled in that program.

• Families in CHPlus with incomes below 160 percent FPL make no premium contribution.

• Families with incomes between 160 percent-222 percent FPL pay $9 per month for each eligible child, capped at $27 per family.

• Families with income between 223 percent-230 percent FPL pay $15 per month for each eligible child, capped at $45 per family.

• Families of any income can purchase CHPlus for about $1,000 a year per child.

Co-payments

• Previous co-payment requirements for prescription drugs, physician office visits, and emergency room use were eliminated after January 1, 1999.

To be eligible, employees must work at least 20 hours per week. Employees may not pay any more than ten percent of the premiums, at the discretion of the employer.

Data for Program Design

• There are no current data about the number of uninsured children in the state below the statewide level projected in the CPS data. State officials and policy makers recognized that they disagreed about what methodology to use to establish the baseline data about uninsured children. To address this problem, the legislature mandated a study of uninsured individuals which will be conducted by either the Department of Health or contracted to an outside organization. There is no specific due date for the report.

• For CHPlus enrollment data, the Department of Health (DOH) reviews monthly reports from the community outreach coordinator. These reports also have demographic information about the children (e.g., age and family income) and how families learned about the program so DOH can evaluate the different outreach strategies.

• For Medicaid enrollment, the Department of Social Services district offices use the Medicaid Budget Logic system to make eligibility decisions.

• For performance data, participating private insurers must submit certain information annually to the Department of Health. If insurers do not submit these data, they are sanctioned. The information required from plans about the CHPlus population includes:
• Membership (by age, sex and payer; enrollment by county)
• Utilization (by condition and type of service; disenrollment rates)
• Quality (prenatal care; well child care visits in first year of life; adolescent well child care visits; HIV education; substance abuse counseling; immunizations; mental health follow-up)
• Access and member satisfaction (utilization of primary care providers; availability of scheduled service and emergency medical care).
• The Department of Health will monitor the facilitated enrollment process to identify and eliminate remaining barriers to enrollment.

Ten Percent Cap on Administrative Expenses
The Department of Health does not believe that the ten percent cap provides sufficient funding for outreach activities and for presumptive eligibility. The state is committed to enrolling eligible children, and these two activities are essential to successful enrollment.

Other Challenges
Officials pointed out several other challenges.

• Administration officials and the advocacy community anticipate a challenge to maintaining continuous coverage for children who must now switch from CHPlus into Medicaid. Part of the challenge is administrative, but some of it reflects the reluctance of families to enroll in Medicaid because of the required face-to-face interview at the welfare office. The facilitated enrollment program is designed to ease movement of children between the two public programs.

• Maintaining the "seamless" connection between CHPlus and Medicaid will be important for children moving back and forth between the two public health insurance programs when their employment status and family income fluctuates.

• The goal is to have the same local managed care organizations serve both Medicaid and CHPlus children, but when this is not possible, the continuity of health care may be disrupted for some children.

• Managed care organizations report some access to care problems, especially in rural areas, where they are unable to meet the needs of enrolled children, especially for mental health and dental problems.

• There is some concern about providing health insurance coverage to more higher income children through CHPlus than the number of lower income children who gain access to Medicaid.

• Management Information Systems specialists maintain that correcting all Y2K computer problems must take precedence over any requests to modify software or add data elements to evaluate CHPlus.