The Mental Health and Mental Retardation Authority of Harris County

In a few short months (May), the recently reconfigured Childrens Health Insurance Program (CHIP) is supposed to roll out across the state. A tremendous effort during the recently completed 76th Legislative Session resulted in an enriched and expanded benefit package for health and behavioral health conditions covered by CHIP. Children whose family (considering size and earnings) fall between 100% to 200% of poverty qualify for CHIP up through their 19th birthday. Truly, those working families with no health insurance will now, for the first time, have an option to provide an array of health care services covering their children in ways not seen before, if they sign up. A broader range of services and options will be available, broader than Medicaid and by far broader than provided under the current state benefit package.

There are certain requirements for CHIP that may make this a silver cloud with a dark lining. First and foremost, if a child is CHIP-eligible and currently receiving state-funded services, their family must sign up for CHIP in order to continue receiving those services. We are advised that the Health and Human Services Commission will be promulgating a policy for all state-supported agencies pertaining to this requirement. Because the legislative intent was for families to share in the cost of health care according to their means, CHIP has a premium to be paid either once a year or monthly, depending on where the family falls between 100% to 200% of poverty. The premium will cover all children in the family, regardless of the severity of the pre-existing condition. In addition, there is a required copay for each service, the amount and annual cap again established by the family income as a percent of poverty. One possible consequence of CHIP may be that unmotivated parents or those who are financially stressed where the children are not severely medically or psychiatrically impaired may not sign up, hoping to avoid or delay the financial outlay for the premium and copays. However, such action by the parents could, we are told, necessitate that the providers cease delivering the existing services. Such termination of services would thereby penalize the child, who cannot do anything to obtain the care, and, potentially, cause an increase in emergency services if and when the situation reaches crisis proportions. Or, if not in crisis, the child may suffer slowly – having his/her life changed in ways that might not have been necessary if care had been continued or provided. Furthermore, if families with very involved children sign up in disproportionate numbers, the financing for CHIP may be substantially inadequate.

Question – if this results in some children being withdrawn from care and, potentially, pushed into using more emergent care at state expense (requiring the most intensive and expensive interventions that might otherwise have been avoided) – does that make good public policy or fiscal sense? It is unclear as to how much effort the provider systems will have to undertake to ensure that the premiums have been met and the copays paid. It is unclear if the families don’t provide the copay at the time of the service as to whether the service can be provided. Will we be able to provide the service and "write-off" the copay if not paid – or use local funds to make up the budgetary difference? Presently, these questions remain unanswered. We are hearing that we will not be allowed to use state-allocated funds to make up the copay and will have to show the copay collections in our budget as a part of our method of financing children’s mental health services. Will it be morally, ethically and legally acceptable to not provide what our clinicians believe to be essential services for the child if the parents are unwilling or unable to provide the copay? I believe I know how our clinicians feel about this, but what will the public policy permit or prohibit? And, if the parents don’t pay their premium and/or copay for services, forcing the provider system to disengage services, will it be necessary if not appropriate to turn those families over to Children’s Protective Services for neglect? If so, under what conditions? Presently, these questions remain unanswered.

It is clear that the plan managers will need to have a very timely, tight method of tracking the premium payments and notifying the providers of qualified families to receive services under CHIP. At the beginning of each month, the provider system will be provided a detailed listing of currently eligible CHIP families/children enrolled in each plan so that families who no longer qualify may be appropriately addressed. What will we do if the family misses the cutoff toward the end of the month and isn't on the list in the next month? What will happen if we provide a service to a child during the first few working days of the month and then we find the child was "dropped" from CHIP? (We are not supposed to use state funds to provide services for CHIP eligible children – remember.) These, too, remain unanswered at this time.

What is clear is that MHMRA, like other health care providers, will have to "beef up" its managed care and support functions to more adequately ensure compliance with CHIP eligibility, enrollment, and family financial participation. We will have to develop timely methods of reconciling CHIP eligibility with agency caseloads at the beginning of each month and address children in care who are disenrolled. Policy along these lines will have to be created, procedures established, and staff trained. A method of copay collection and crediting each family’s account will have to be developed, implemented, and training provided. Tighter controls on caseload and client collections as well as establishing a mechanism for deposits to occur of collections from community-based (non-clinic) service locations (such as local school and day-care facilities) will become necessary. And, a method to track the copay "caps" depending on percent of poverty for the families will be necessary so folks are not overcharged. Likewise, a method of communication where medical services copays are occurring will be necessary, so the family is appropriately credited for all copays – health and behavioral health toward their financial "cap" under CHIP.

A massive enrollment and community education process will shortly be launched by HHSC through a series of private contracts. HHSC has set high expectations for rapid enrollment with increasing percentages of CHIP-eligible children enrolled over the first year. This ambitious roll out anticipates a much more successful process than the experience of other states which are farther along with the CHIP implementation process. What is anxiety-producing – really downright scary – is, we are told, that HHSC may be taking back State General Revenue funds (SGR) currently utilized to provide children’s mental health services in anticipation of the new federal funds that will flow to cover the CHIP-enrolled children.

TDMHMR is undertaking a survey of the uninsured children currently served by the public system between January 31 and March 31. The survey will try to identify which children are believed to be CHIP eligible, how much service is provided, and how much SGR is utilized to provide those services. From that, they will estimate the "freed up" SGR with the implementation of CHIP. We are advised HHSC may withdraw all or a portion of the "freed up" SGR (calculated on a prospective basis) to be redeployed to cover the budgeting deficits or other urgent matters to the HHSC agencies in FY2001. Unfortunately, if these funds which may actually be "freed up" once CHIP rolls out were left in the public system, services which are not CHIP-covered could be expanded – such as services for children in the juvenile justice facilities (a critical area of need which has been discussed in a previous article).

Furthermore, CHIP will not cover children who should be covered through Medicaid. MHMRA will have to facilitate referrals of these families to sign up for Medicaid if services are to be continued. How long will we be able to provide services to these children while families pursue Medicaid coverage? This too remains unanswered. If they fail the Medicaid process, they may then be eligible for CHIP coverage. Will we be allowed to continue services during this process? Also unanswered at this time. And, with our children being in care for shorter lengths of stay (usually 90 to 180 days), what happens if the eligibility determination processes take as long or longer? Will we be able to provide services?

Lastly, CHIP will not cover children of undocumented families. MHMRA is concerned that the process for determining eligibility may scare families who are undocumented from seeking the care their children need – again, potentially delaying access to care until the condition reaches crisis proportions.

CHIP is around the corner. It will touch all children’s mental health services delivered both through the Child and Adolescent Services Division as well as those provided through the Mental Retardation Services Division. Early Childhood Intervention may also be impacted. All offsite outpatient services (in schools, day care facilities, CPS, etc.) will be impacted (children will have to have eligibility determined and enrolled, if eligible for CHIP.) Much to do in a short period of time – more to come as we learn about CHIP. Many questions yet to be answered.