State purchasing and enforcement quality care for children in Medicaid and SCHIP managed care.

State Medicaid/Children's Health Insurance Program (SCHIP) agencies play pivotal roles in ensuring that participating health plans provide quality care. In 2003, researchers interviewed SCHIP officials with oversight responsibilities in nine states and found that all agencies had formal monitoring procedures and that all of them regularly collected data that measured health plans' compliance with quantifiable standards. Several states designed a graduated incentive and penalty system, which they believed favored compliance. Many agencies also stressed the need for collaboration with participating plans, because of underlying systemic barriers. None of the surveyed states considered their contractual agreements with health plans as all-encompassing on quality improvement, which underscores the importance of additional, noncontractual strategies to improve the quality of care. The survey found a disparity between state expectations for health plan performance and the realities of the delivery system, including the priorities of health plans and providers. The sample states were good monitors who enforced general contractual standards of pediatric quality of care; however, one shortcoming was found. Few of the surveyed states focused on oral disease or lead poisoning as part of their overall quality improvement efforts.

Behavioral health and managed care contracting under SCHIP.

This Policy Brief examines behavioral health managed care contracting under separately administered State Children's Health Insurance Programs (SCHIP), i.e., programs that operate under the direct authority of Title XXI of the Social Security Act rather than as expansions of Medicaid. Most separate SCHIP programs buy managed care style health insurance for some or most of their enrolled children. Because Title XXI provides states with far greater administrative flexibility than Medicaid with respect to coverage and benefit design, provision of services, and administration of managed care arrangements,studying separate SCHIP managed care products sheds important light on how states might approach insurance and managed care design generally in the area of behavioral health were Medicaid modified through section 1115 demonstration or federal statutory authority to permit greater latitude. To conduct this analysis, two nationwide databases maintained by the George Washington University Center for Health Services Research and Policy (CHSRP) were used: a database consisting of all Medicaid MCO-style managed care contracts in use in Calendar Year 2000; and a nationwide database consisting of contracts used by separate SCHIP programs for the same calendar year. As of the point of collection in 2000 there were 33 such separate programs; according to CMS' latest website information, that total has now reached 35. Both sets of contracts were analyzed and separated into their components by lawyers experienced in managed care contract analysis and interpretation. The data were entered into working tables that organize the contents of the contracts into a series of searchable domains.