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OVERVIEW

Role of Cost-Sharing

Experience With Cost-Sharing in Child Health Plus

- Premiums

- Copayments

Assessing Our Cost-Sharing Choices

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Deter Unnecessary Utilization

Encourage Personal Responsibility

Defray the Cost of the Subsidy

Reduce Substitution of Private Coverage

ROLE OF COST-SHARING

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State Subsidized Health Insurance Program for Children Between 100% and 222% of Poverty

Benefits Include Primary and Acute Care

Families Are Responsible for Small Premium Contributions and Copayments

Health Insurance Is Provided Through Managed Care Plans

OVERVIEW OF CHILD HEALTH PLUS

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Premium Contributions

Copayments

EXPERIENCE WITH COST-SHARING IN CHILD HEALTH PLUS

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Promote Personal Responsibility

Encourage Purchase of Coverage

Deter Substitution of Private Coverage

Align With Other States Cost-Sharing Requirements

DRIVING FACTORS IN SETTING PREMIUM CONTRIBUTIONS

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PREMIUM COST-SHARING IN CHILD HEALTH PLUS

Percent ofPoverty

Primary CareBenefit

Package Only

1996Expansion

Title XXIApproved

Plan

Governor’sLegislativeProposal

0-120% 0 0 0 0

120-150% 0 $9 per monthper child

0 0

150-160% 0 $9 per monthper child

$9 per monthper child

0

160-222% $25 per yearper child

$13 per monthper child

$13 per monthper child

$9 per monthper child

222+ Full premium Full premium Full premium Full premium

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Insurers Determine Eligibility and Enroll Families in Child Health Plus

Insurers Collect a Monthly Premium Contribution From Families

IMPLEMENTATION OF COST-SHARING

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CHILDREN ENROLLED IN CHILD HEALTH PLUS

Age

1-5

<1

15-18

13-14

6-12

Family Income Level

Less than 120%

Over 222%160-

222%

120-160%

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At What Income Level Should Premium Contributions Begin?

What Amount of Cost-Sharing Is Both Affordable and Does Not Encourage Crowd-Out?

How Should Premium Contributions Be Adjusted for Family Size?

ISSUES IN LEGISLATIVE DEBATE ON PREMIUM CONTRIBUTIONS

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Most Utilization Control Is Left to the Managed Care Plan

Copayments Are Used for Services Only Where Additional Utilization Controls Seem Necessary

- Outpatient visits

- Prescription drugs

- Emergency room visits

Implementation of Title XXI Limit on Out-of-Pocket Spending Is Creating Challenges

EXPERIENCE WITH COPAYMENTS IN CHILD HEALTH PLUS

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Examine Enrollment by Income Level

Analyze Utilization by Income Level

Assess Reasons for Disenrollment

Analyze Extent of Crowd-Out and Reasons for Dropping Private Coverage

ASSESSING OUR COST-SHARING CHOICES