1. CHIP in California Child Health Policy Research Symposium Lesley Cummings Executive Director Managed Risk Medical Insurance Board March 2, 2009

2. SCHIP in California Covers Nearly 1.1 Million Children California’s SCHIP is the biggest in the country: greater than the next 3 largest states combined! What this means: California has done a fabulous job enrolling uninsured children–over 1.3 million (HFP and MC)!!!!!! California expenditures (and, to some degree, policy) drive the national budget.

3. SCHIP Reauthorization History Twice, bipartisan bills were sent to the President: – –Vetoed H.R. 976 on October 3, 2007: CHIPRA 1 – –Vetoed H.R. 3963 on December 12, 2007: CHIPRA 2 October 1, 2007 funds expired (Reauthorization fails!) December 29, 2007 SCHIP funding extension bill signed – Does not change policy – Flat-funds state allotments and adds supplemental funds for 21 shortfall states (including CA) thru March 31, 2009 February 4, 2009 President Obama signs CHIPRA 3, a 4 ½ year extension of SCHIP

4. CHIPRA Adequacy of Federal Funding Adequacy of Federal Funding

5. Funding California’s CHIP Coverage: What Will it Cost? Harbage Consulting February 17, 2009 Draft Release Prepared for the California HealthCare Foundation 2009

6. 4/10/2015Draft Copy Background: California’s Title XXI Programs ProgramEnrollment SFY 07-08 (Average Monthly) Total Spending SFY 07-08 In Millions State Spending FY 07-08 In Millions Healthy Families Program (HFP) 851,000Children$1,077$398 Access for Infants & Mothers (AIM) 1,035Mothers$131$57 Medi-Cal Associated Programs 331,000Children$726$260 6 Note: HFP includes legal immigrant children and AIM-linked infants. AIM enrolled a total of 12,415 women in SFY 07-08, with an average of 1,035 new mothers enrolling every month.

7. 4/10/2015Draft Copy 7 California’s Overall Estimate

8. California’s Overall Federal Need 8 4/10/2015Draft Copy $667 $760 $1,259 $2,193

9. HFP Projected Enrollment 9 4/10/2015Draft Copy

10. Access to Full Presentation Full presentation available at www.mrmib.ca.gov. Full presentation available at www.mrmib.ca.gov. www.mrmib.ca.gov One first screen, look to HFP/Federal Issues One first screen, look to HFP/Federal Issues

11. Conclusion Ample federal funding for FFY 2009 and 2010 Ample federal funding for FFY 2009 and 2010 Future federal allotments dependent on what states’ have spent (“rebasing”) Future federal allotments dependent on what states’ have spent (“rebasing”) It still takes a state dollar to get 2 federal dollars. The state of California has invested significantly in SCHIP, particularly during these difficult fiscal times. It is an incredible challenge to come up with the state match.

12. CHIPRA 3: Policy Issues In addition to providing sufficient federal funding for SCHIP, CHIPRA 3 enacted a number of policy and fiscal changes. In addition to providing sufficient federal funding for SCHIP, CHIPRA 3 enacted a number of policy and fiscal changes. A number of these require policy guidance from CMS. A number of these require policy guidance from CMS. The state will have to amend state law to implement some of them. The state will have to amend state law to implement some of them. Several are in the jurisdiction of Medi-Cal rather than HFP. Several are in the jurisdiction of Medi-Cal rather than HFP.

13. Mandates Requirement Requirement Date Applicable Application of DRA citizenship documentation and identification requirements to SCHIP. 1/1/10 Mental health and substance abuse parity. 10/1/09 unless state law change needed. If so, 1/ 1/11.

14. Mandates (continued) Requirement Requirement Date Applicable State cannot prevent FQHC from contracting with a private dentist. Applies to Medicaid and SCHIP. 4/1/09 Dental coverage required. State must select one of several specified benchmarks, one of which is state employee coverage. State must select one of several specified benchmarks, one of which is state employee coverage. Believe HFP will need to develop encounter/claims based system to meet reporting requirements. Believe HFP will need to develop encounter/claims based system to meet reporting requirements. 4/1/09 unless state law change needed. If so, 1/ 1/11.

15. Mandates (continued) Requirement Requirement Date Applicable FQHC’s and RHC’s must be paid as they are in Medicaid (prospective payments). 10/1/09 unless state law change needed. If so, 1/ 1/11. Medicaid Managed Care Standards applied to SCHIP. (enrollee protections, anti- discrimination, conflict of interest, sanctions, etc.) 7/1/09 unless state law change needed. If so, 1/ 1/11.

16. Mandates (continued) Requirement Requirement Date Applicable Quality Requirements. CMS to establish mandatory indicators. IOM and GAO to assess indicators for future modification. IOM and GAO to assess indicators for future modification. Promise of enhanced administrative funding for collecting and reporting child health measures. Promise of enhanced administrative funding for collecting and reporting child health measures. HHS will establish Quality Measurement Program by 1/10. CA must submit it’s Child Health Quality Report by 2/11.

17. Other Provisions Requirement Requirement Date Applicable Performance bonus for increased Medicaid enrollment of uninsured children. (Contingent on satisfying 5 “simplified” enrollment rules) 4/1/09 Outreach funding geared to rural areas and racial and ethnic populations. CMS to allocate funds. 4/1/09 Enhanced FMAP for translation and interpretation services for both Medicaid and SCHIP. 4/1/09

18. Other Provisions (cont.) Requirement Requirement Date Applicable GAO Report on Medicaid Managed Care Rates. 8/10 New commission on payment and access Medicaid and CHIP. Reports due March 2010 and June 2010. 2/ 4/09

19. Other Provisions (cont.) Requirement Requirement Date Applicable Small Employer Education and Outreach Task Force 4/1/09 PERM: CMS to issue final rule on PERM within 6 months. 8/1/09

20. State Options Option Date Applicable Expand coverage up to 300% at SCHIP funding ratios. Above 300% at Medicaid funding ratios. As of 4/09. If state expands coverage and needs additional funding (above allotment), SPA needs to be submitted by 8/31/09 for FFY 2010 Cover pregnant women with SCHIP funds. Unborn option left undisturbed with statement that no congressional intent expressed on legality or illegality of unborn option. As of 4/1/2009

21. State Options Option Date Applicable Draw down FFP for “recent legal immigrant” children and pregnant women in both Medicaid and SCHIP. In some cases, must obtain verification during eligibility re-determination that person is lawfully residing in U.S. As of 4/1/09 Express Lane option to use findings from school lunch, WIC and other “public agencies” when determining eligibility for MC or SCHIP. As of 2/4/09

22. State Options (continued) Option Option Date Applicable Dental Only Coverage. To use option, must cover children up to highest income eligibility standard as of January 1, 2009 not impose limitations or waiting lists and provide benefits to all eligible children. As of 4/1/09. Would require authorization in state statute. Use an SSN match to meet citizenship documentation requirements. As of 4/1/ 09

23. State Options (continued) Option Option Date Applicable Purchasing pool for employers with fewer than 250 employees. One employee must be pregnant or have an eligible child. Pool must offer two SCHIP benchmark products. No SCHIP funds can be spent on administration As of 4/1/09. Would require authorization in state statute.

24. State Options (continued) Option Option Date Applicable School Based Health Centers can provide funding for services. 4/1/09 unless state law change needed. Premium assistance in both SCHIP and Medicaid. Mandatory benefit wrap. Employer must contribute 40 percent of cost. April 1, 2009. Would require authorization in state statute.