Medicaid and SCHIP: States' Enrollment and Payment Policies Can Affect Children's Access to Care

States provide health care coverage to low-income uninsured children largely through two federal-state programs--Medicaid and the State Children's Health Insurance Program (SCHIP). Medicaid was established in 1965 to provide health care coverage to low-income adults and children. Medicaid expenditures for health services to 22.3 million children totaled $32.4 billion in 1998. Congress established SCHIP in 1997 to provide health care coverage to children living in poor families whose incomes exceed the eligibility requirements for Medicaid. SCHIP expenditures for health services to nearly 2 million children totaled $2 billion in 1999. In implementing SCHIP, states could opt to expand their Medicaid programs or establish a separate child health program distinct from Medicaid that uses specified public or private insurance plans offering a minimum benefit package. Thirty-five states have chosen SCHIP approaches that are, to varying degrees, separate from their Medicaid programs. Because eligibility for Medicaid and SCHIP can vary with a child's age, children may, at different ages, need to move from one program to the other. Access to care, therefore, is affected by the extent to which health plans and providers are available and participate in Medicaid and SCHIP. Differences in Medicaid and SCHIP enrollment requirements--particularly application requirements and eligibility determination practices--can affect beneficiaries' ability to obtain and keep coverage. To help simplify the process for applicants, eight of the 10 states GAO reviewed used joint applications that had similar--but not always identical--requirements for Medicaid and SCHIP applicants. When application requirements differed, Medicaid applicants had to provide additional information or documentation, such as proof of income or assets, or participate in interviews. Differences in the health plans and providers that participate in Medicaid and SCHIP, as well as differences in the payments they receive, have implications for beneficiaries' access to care. In the 10 states GAO reviewed, SCHIP often required enrollees to join a managed care plan and sometimes did not offer a choice of plans, while Medicaid offered families a choice of two or more plans or of care on a fee-for-service basis, including primary care case management. However, such choices did not necessarily give beneficiaries greater access to providers because plan choices may be limited to several smaller plans and may exclude larger plans with more extensive networks.