Anne R Markus, JD, PhD¹, Sara Rosenbaum, JD¹, Jill G. Joseph, MD, PhD², and Ruth EK Stein, MD³. (1) Department of Health Policy, The George Washington University Medical Center, 2021 K St, NW, Suite 800, Washington, DC 20006, 202-530-2339, armarkus@gwu.edu, (2) Center for Health Services and Community Research, Children's National Medical Center, 111 Michigan Ave, NW, Washington, DC 20010, (3) Department of Pediatric Endocrinology, Albert Einstein College of Medicine Montefiore Medical Center, 111 E. 210th Street, Rosenthal 4, Bronx, NY 10467

Objective: To explore the coverage decisions of Medicaid-and SCHIP-participating insurers for SCHIP-enrolled children with special health care needs (CSHCNs).

Design: Case studies of coverage decisions combining (1) SCHIP plan/contract language analysis of benefits critical to CSHCNs with (2) telephone interviews of the medical directors of Medicaid-and SCHIP-participating insurers, using two hypothetical patient scenarios to probe whether they would have provided a select number of services, identical in each scenario, without any limitations, with some limitations, or not at all.

Findings: First, insurers generally restricted certain services most needed by CSHCNs under SCHIP in ways not permissible under Medicaid. Second, with one exception, insurers were not in agreement on the coverage of any specific service, but overall they provided coverage beyond the limits and exclusions of the state program. Third, the less acute the condition experienced by the child, the more frequently insurers imposed exclusions. Finally, while insurers would have provided more generous coverage than required by the state in the majority of cases, in four states, some insurers’ decisions deviated from the state requirements, excluding services that arguably should have been covered according to the plan/contract language.

Conclusions/Implications: While SCHIP extends coverage to previously uninsured CSHCNs, its variability and limits in benefits can influence CSHCNs’ access to care. Under SCHIP, coverage at current levels may not be sufficient to care for CSHCNs, making the availability of external reviews of insurers’ coverage decisions and the coordination with other sources of care, such as Title V, important components of SCHIP program design.

Learning Objectives: At the conclusion of the session, the participant (learner) in this session will be able to

• Identify the variation in insurers’ decisions by type of coverage, category of benefit, acuity of the children’s medical condition, and state of residence; and
• Discuss the implications of this variation for CSHCNs' access to care

Keywords: Children With Special Needs, Access to Care

Presenting author's disclosure statement:
I do not have any significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.