Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JUNE GIBBS BROWN 

Inspector General 

OCTOBER 1999 

OEI-06-98-00320 

CHIP’s Impact On Changing Service 

Delivery Of Federal Health Centers 

Six Case Studies 
OFFICE OF INSPECTOR GENERAL 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 

95-452, is to protect the integrity of the Department of Health and Human 

Services programs as well as the health and welfare of beneficiaries served by 

them. This statutory mission is carried out through a nationwide program of 

audits, investigations, inspections, sanctions, and fraud alerts. The Inspector 

General informs the Secretary of program and management problems and 

recommends legislative, regulatory, and operational approaches to correct them. 

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) is one of several components of the 

Office of Inspector General. It conducts short-term management and program 

evaluations (called inspections) that focus on issues of concern to the Department, 

the Congress, and the public. The inspection reports provide findings and 

recommendations on the efficiency, vulnerability, and effectiveness of 

departmental programs. 

OEI's Dallas office prepared this report under the direction of Chester Slaughter, 

Regional Inspector General and Judith V. Tyler, Deputy Regional Inspector General. 

Principal OEI staff included: 

REGION HEADQUARTERS 

Kristine Lykens, Project Leader Wynethea Walker, Program Specialist

Nancy Juhn Barbara Tedesco

Scott Whitaker

Lisa White

To obtain copies of this report, please call the Dallas Regional Office at 1-800-848-8960. 

Reports are also available on the World Wide Web at our home page address: 

http://www.dhhs.gov/progorg/oei 
OVERVIEW

PURPOSE 

To examine the experience of six Federally funded health centers during their State’s early 

implementation of the Children’s Health Insurance Program (CHIP) and/or concurrent Medicaid 

expansions within the context of the changing health care environment. 

RESULTS IN BRIEF 

With their tradition of serving low income children, Federally funded health centers have 

considerable potential for supporting the goals of CHIP. These centers possess great aptitude 

for outreach and enrollment due to the level of trust and service they have established in their 

communities. Recognizing the need to adapt to managed care environments, most centers 

have assertively joined managed care organizations or undertaken special developmental 

efforts, ranging from infrastructure enhancements to creation of entire managed care 

organizations. Not surprisingly, transition from cost-based reimbursement continues to be a 

challenge for centers as they seek to better manage costs and devise appropriate 

reimbursement formulae within their health plan contracting. 

BACKGROUND 

Legislation: Enacted as part of the Balanced Budget Act of 1997, CHIP was a response to 

increasing numbers of children lacking health coverage. The legislation gives States flexibility 

to institute a separate health insurance program, expand Medicaid eligibility or combine these 

approaches. A higher Federal match rate under CHIP than for primary Medicaid provides an 

incentive for States to implement the legislation. Children applying for insurance through 

these programs must first be screened for Medicaid eligibility. 

Federally funded health centers: Generally located in communities with low to moderate family 

incomes, Federally funded health centers have been major safety-net providers for low 

income children since the 1960s. Such centers were often, and continue to be, the primary 

health care source for growing numbers of children without health insurance when the CHIP 

was passed. Centers are funded by Section 330 of the Public Health Service Act, with some 

receiving State and local funds as well. In addition to primary health care services, these 

clinics also provide enabling services such as translation, health education, and transportation 

which are important to serving the CHIP population. Besides CHIP implementation, Federally 

funded health centers have experienced other substantial and related changes in the health 

care system, particularly due to increased use of managed care by State Medicaid programs 

in the 1990s. 

Federally Funded Health Centers and CHIP 1 OEI-06-98-00320 
Methodology: This qualitative case study report describes the experiences of six health 

centers’ involvement in CHIP implementation. We conducted site visits in August and 

September, 1998, during the very early implementation of the program. Using structured 

protocols, we interviewed executive and clinical directors, financial officers, and other staff 

members. Staff from State Medicaid programs, CHIP agencies, managed care organizations 

and Primary Care Associations (PCAs)1 who interacted with the health centers were also 

interviewed. Using qualitative data analysis software, we analyzed each center as an 

individual case. In a second phase of this study, we will apply issues and insights from these 

case studies to gather additional information from a sample of Federally funded health centers 

concerning their involvement in CHIP implementation. Knowledgeable staff from the Health 

Resources and Services Administration (HRSA), the Health Care Financing Administration 

(HCFA), and the Office of the Assistant Secretary for Planning and Evaluation (ASPE), as well 

as persons interviewed in during our site visits, reviewed and commented on the draft of this 

document. Their suggestions and technical corrections are reflected in this final report. 

The States selected represent the variety of possible CHIP model choices and geographic 

regions. Within each of these States we selected for study a center regarded as effective in 

implementing CHIP, by its State administrative agencies and area PCAs. The chart below 

identifies the State where the center is located, the CHIP model implemented by the State, 

program characteristics, and the actual center studied. 

State CHIP Program Models and Center Sites 

State Model Program Characteristics Center Visited/City 

New Mexico Medicaid 

Expansion 

closely followed earlier State-initiated expansion, except 

for a cost-sharing element for higher income families 

Health Centers of Northern New Mexico 

Espaòola, NM 

South 

Carolina 

Medicaid 

Expansion 

voluntary managed care with choice of HMO or one of 

two rural managed care alternatives 

Family Health Centers 

Orangeburg, SC 

Colorado Freestanding 

CHIP Plan 

preferring a private sector approach, even administrative 

functions often privatized 

Plan de Salud de Valle 

Fort Lupton, CO 

Connecticut Combination 

Model 

plans share same name, application form, and 

administrative agency 

Fair Haven Health Center 

New Haven, CT 

California Combination 

Model 

administered independently, both programs encourage 

inclusion of safety-net providers 

La Clínica de la Raza 

Oakland, CA 

Michigan Combination 

Model 

incentives to include safety-net providers in managed 

care via contract bidding preferences 

Cherry Street Health Services 

Grand Rapids, MI 

Benefits covered in States we visited generally were comprehensive, and based either upon standard Medicaid services 

(including EPSDT) or large employer group benefits. All States, except Colorado, covered dental services at the time of 

our visit. 

Federally Funded Health Centers and CHIP 2 OEI-06-98-00320 
<

CROSS-CUTTING ISSUES 

The following information identifies the most salient features and issues regarding the role of 

Federal health centers under CHIP. These specific issues are discussed at length in the 

individual case studies which follow. 

Health Center Services: 

< Except in Colorado, all centers visited operate school-based health clinics, and consider 

them a key element of CHIP health service delivery. Centers we visited offer 

comprehensive primary and preventative services, with some offering additional service 

enhancements such as mental health care, asthma and diabetes management, vision and 

dental services. 

< Dental care was identified as a critical service for children, with some centers giving 

children priority for appointments, since client demand often exceeds capacity. Yet, low 

Medicaid and dental insurance reimbursements are causing some centers to reconsider 

offering this service. 

< Capacity to serve uninsured families was identified as a problem by the large urban health 

center we visited in California. Over 600 families were on a waiting list for center services 

at the time of our site visit, even though the center was expanding. 

Outreach and Enrollment: Health centers visited pursued a variety of enrollment activities. 

< For existing patients, activities ranged from recruitment from families already seeking 

services to direct telephone contact of potentially eligible families. School-based clinics 

operated by the centers provided another avenue for outreach and enrollment. 

< These centers also reached out to surrounding communities to identify and enroll CHIP and 

Medicaid eligible children. Of the centers visited, Fair Haven in Connecticut best 

demonstrated such “grass-roots” community outreach through a “Sign-up for CHIP Day”, 

and “door-to-door canvassing” in a nearby housing project. Several centers were targeting 

schools, where they operated clinics, to provide information and application assistance to 

families of children attending there. 

< Outreach/enrollment efforts have not been without challenges for the health centers. 

Policy ambiguity raised concern that CHIP benefits would be deemed a “public charge” for 

immigrant families, increasing their fear of government, and hindering enrollment of their 

eligible children, particularly in California. Although this issue was recently resolved legally, 

respondents believed significant effort would be required to overcome this fear. However, 

health centers feel they are in a strong position to work with these families due to the trust 

established in caring for them as patients. Translation services available at most of the 

centers we visited would also facilitate reaching these populations. 

Federally Funded Health Centers and CHIP 3 OEI-06-98-00320 
<

<

< Desiring to engage in more outreach efforts, center and PCA directors we interviewed 

expressed frustration at being hampered by a lack of resources for outreach workers. 

Connecticut health centers had applied for outreach contracts with the State and the 

Michigan center planned to apply for similar monies as well. The health center and PCA 

staff in California expressed concern over the inadequacy of the $25 for application 

assistance reimbursement due to the amount of personnel time it requires. 

Planning and Implementation: The extent of direct health center involvement in the planning 

and implementation of the CHIP plans in their States varied widely. 

< Some centers testified at input forums and legislative hearings, while others participated 

exclusively through their PCA. Despite direct representation on planning committees, Plan 

de Salud in Colorado did not believe it heavily influenced the outcome. Advocacy for 

including a dental benefit did not secure its inclusion in the final plan. 

< Most centers visited noted that their primary role in CHIP planning and implementation was 

through their PCAs. In New Mexico, the PCA director is a member of the Medicaid Advisory 

Committee. The PCA director in California presented issues to the CHIP governing board 

and reported success in the managed care contracting system, which favors contracts that 

include safety-net providers, such as health centers. The Michigan PCA aided its 

legislature’s decision to include Medicaid expansions in their plan. 

< All health center directors we spoke to expressed a preference for Medicaid expansions to 

implement CHIP in their States. Their reasons focused on Medicaid’s comprehensive child 

health benefits plus its pre-existing infrastructure. New Mexico and South Carolina 

selected a Medicaid expansion model only. Center directors from most other States stated 

that preferences for privatization influenced their State’s decision to adopt a combination 

model or a free-standing program. 

< Three States we visited, California, Michigan and New Mexico, had provisions either 

requiring managed care organizations to contract with health centers or providing incentives 

to include them in their contract bidding process. 

Adapting to a Changing Healthcare Environment: Of the centers visited, all but one operate 

in States which employ mandatory managed care for their health delivery system. Valuable 

strategies pursued by these centers to adapt to an environment in flux included use of 

managed care organizations, consolidation, networking and shared services. 

< Formation of or participation in health center-based managed care organizations - Usually 

with assistance of Integrated Service Network funds from HRSA, these efforts are teaching 

health centers the managed care business and allowing participation in decision-making 

which affects them. The exception is the center in New Mexico, which contracts with the 

Medicaid managed care plans in its service area. 

Federally Funded Health Centers and CHIP 4 OEI-06-98-00320 
< Consolidation, networking and shared services - The health center in New Mexico grew 

from the consolidation of free-standing clinics from a seven-county service area. To 

enhance productivity, PCAs in Connecticut and South Carolina and the county-based health 

center network in California are coordinating such shared services as an auto-dial telephone 

contact system, payroll, pharmacy purchasing, auditing, laboratory contracting, and 

consulting services. 

< Infrastructure adjustments - Pervasive among health centers we saw, adjustments include 

upgrades to Management Information Systems, either made or planned, and addition of 

staff positions for financial management, managed care coordination and assistance to 

clinicians. Redesign or consultant projects to enhance productivity are also underway in 

centers visited in Connecticut, California and South Carolina. 

Medicaid reimbursement structures remain a major challenge for most health centers: 

< Most health center directors expressed concern over the phase-out of cost-based 

reimbursement by 2003, as stipulated by the Balanced Budget Act of 1997, particularly 

regarding the funding of enabling services they provide. Centers in South Carolina and 

Connecticut have undergone periods with and without caps on cost-based reimbursement 

rates which resulted in financial difficulties, requiring loans or financial recovery plans. 

Health centers in Michigan had agreed to a methodology to allow a phase-in to risk 

assumption, although HCFA approval was pending when we visited. 

< The health centers visited in California and Connecticut were assuming some risk for health 

services costs for managed care patients. The South Carolina center was starting a pilot 

project with the Medicaid program to capitate primary care services. Other centers were 

also considering assuming some risk as part of their strategy for transitioning from costbased reimbursement. 

CASE STUDIES 

The Health Resources and Services Administration and the Office of the Assistant Secretary 

for Planning and Evaluation expressed strong interest in this study of health centers’ early 

involvement in CHIP implementation. To meet their needs, we prepared the following resource 

document consisting of case studies of health centers we visited in six different States. In it, 

the issues described above are outlined in greater depth as they relate to specific centers. 

Federally Funded Health Centers and CHIP 5 OEI-06-98-00320 
TABLE OF CONTENTS

PAGE 

OVERVIEW ...................................................... 1

INTRODUCTION ................................................... 7

HEALTH CENTER CASE STUDIES

Fair Haven Health Center, New Haven, Connecticut .................... 12

La Clínica de la Raza, Oakland, California ............................ 19

Cherry Street Health Services, Grand Rapids, Michigan .................. 27

Plan de Salud del Valle, Fort Lupton, Colorado ........................ 34

Family Health Centers, Orangeburg, South Carolina ..................... 41

Health Centers of Northern New Mexico, Española, New Mexico ........... 48

ENDNOTES ...................................................... 55

BIBLIOGRAPHY .................................................. 60

APPENDIX A: Documents Reviewed ................................... A-1

Federally Funded Health Centers and CHIP 6 OEI-06-98-00320 
INTRODUCTION

PURPOSE 

To examine the experience of six Federally funded health centers during their State’s 

early implementation of the Children’s Health Insurance Program (CHIP) and/or 

concurrent Medicaid expansions within the context of the changing health care 

environment. 

BACKGROUND 

For the past three decades, Federally funded health centers have been a critical part 

of the health care safety-net for low income families. These centers have struggled 

in the 1990s to continue to fulfill this mission as States have moved to managed care 

for their Medicaid programs. Adaptation is also needed as States adopt a variety of 

approaches to implementing CHIP. Since services for children are a large component 

of their programs, these health centers hold considerable promise in helping realize the 

goals of the CHIP legislation. Thus, the Health Resources and Services Administration 

(HRSA) and the Office of the Assistant Secretary for Planning and Evaluation (ASPE) 

have expressed strong interest in looking at the involvement of centers in the early 

implementation of CHIP. 

Children’s Health Insurance Program 

As of 1999, an estimated ten million children in the United States were uninsured.2 

The Balanced Budget Act of 1997, in a new Title XXI of the Social Security Act, 

created CHIP. Authorized for ten years, and funded at $20.3 billion from 1998-

2002,3 the CHIP program targets children in low-income families (generally under 

200% of the Federal poverty level) with the intent of providing them with the same 

quality health care enjoyed by most privately insured children. 

The legislation gives States flexibility in designing their programs. They may simply 

expand Medicaid eligibility for children, institute a separate health insurance program 

or use a combination of these approaches. If Medicaid expansions are used, the same 

benefits and administrative rules used by the existing Medicaid program apply. States 

which previously expanded Medicaid for children, or created State-specific programs, 

are allowed to expand eligibility beyond 200 percent of the Federal poverty level to 50 

percentage points higher than their existing eligibility limits.4 If a State creates a new 

health insurance program for children, they may establish different benefits within 

Federally legislated minimum standards. For example, preventative services are 

required, but dental services are optional. These new programs may also establish a 

separate agency to administer the program. The Health Care Financing Administration 

(HCFA) is responsible for administering CHIP, with joint oversight by HRSA. 

Federally Funded Health Centers and CHIP 7 OEI-06-98-00320 
Because the CHIP legislation provides higher rates of Federal matching funds than the 

existing Medicaid program, the Medicaid benefits package frequently is richer than 

most private insurance. In addition, since Medicaid is an entitlement, screening children 

for Medicaid eligibility first is required. Studies have shown that the percentage of 

eligible children enrolled in the Medicaid program has been low (about 70% nationally 

5

) and is even lower in some States and among minority children. Consequently, policy 

makers and analysts anticipate large numbers of children applying for CHIP will actually 

enroll in existing Medicaid programs. 

Federally Funded Health Centers and CHIP 

Health Centers and Provider Networks 

Federally funded health centers are an integral part of the “safety net” of health 

providers for uninsured children and adults. These health centers, under the Public 

Health Services Act, Section 330, are generally located in neighborhoods or 

communities near low and moderate income families. They have long been the 

traditional health service provider for many of the children now eligible for CHIP. These 

clinics also provide enabling services such as translation, transportation, health 

education, case management and other social services important to meeting the needs 

of this population. 

Medicaid program contracting with managed care organizations has been developing 

since the early 1990s. Currently, the majority of States require managed care 

enrollment for at least some of their child and young adult populations. The CHIP 

legislation is expected to accelerate these changes in both Medicaid service delivery 

and reimbursement structures. However, some policy makers and analysts have 

expressed concern regarding the extent to which Federally funded health centers are 

incorporated into the provider networks for Medicaid managed care organizations.6 An 

analysis of Medicaid managed care contracts found substantial variance in whether 

States require or encourage managed care organizations to incorporate safety-net 

providers into their networks.7 

Adapting to Managed Care 

Assisting centers in the adaptation to health care systems changes is the focus of the 

HRSA’s Center for Managed Care. Created in 1996, it provides technical assistance 

and training opportunities for the health centers. HRSA commissioned a study of the 

impact of managed care on the health centers. The study described numerous 

adjustments and emerging issues for the centers in adapting to these changes, 

including strategic decision-making regarding managed care, formation of “safety-net” 

provider owned and operated managed care organizations, financing and 

reimbursement, contracting, staffing, patient care management and relationships with 

State governments.8 

The financial viability of “safety net” providers, including the health centers, has been 

of considerable concern to policy analysts beyond HRSA. Studies in several States 

Federally Funded Health Centers and CHIP 8 OEI-06-98-00320 
have shown centers to be under considerable pressure to compete with private 

providers for inclusion in managed care provider networks, and to gain or retain 

patients, and from cost competition.9,10 In order to meet contract requirements and 

operate effectively in managed care organizations, health centers need to make 

infrastructure and operational changes in areas such as management information, 

financial management, staffing, patient management, and quality assurance 

reporting.11,12 

Reimbursement is a major issue in health center viability due to managed care 

organizations’ preference for capitation of primary care providers. Since health centers 

often provide enabling services, typically not provided by private primary care 

providers, these services are not generally built into reimbursement methodologies, and 

recovery of the associated costs becomes a concern. The risk assumption implicit in 

capitation is very new to most health centers who may lack the necessary 

management information and financial management infrastructure to manage risk. Risk 

assumption also concerns centers, many of whom operate with small cash reserves. 

Cost-based reimbursement to health centers, currently required of Medicaid programs, 

is being phased-out by 2003. Furthermore, State CHIP Programs are not bound by this 

requirement and may not always provide cost-based reimbursement to the centers.13 

METHODOLOGY AND SCOPE 

This study provides a description of the early experiences of Federally funded health 

centers in the implementation of State CHIP and/or Medicaid expansions. We 

conducted the study in two phases. The first phase, reported here, involved case 

studies of six selected Community Health Centers and their interaction with State 

programs and their Primary Care Associations (PCAs). From this Phase I report we are 

designing a follow-up study to obtain representative, national information on centers’ 

experiences and issues regarding their participation in the implementation of CHIP and 

Medicaid children’s expansions. 

Site Selection 

We purposively selected six case study States: California, Colorado, Connecticut, 

Michigan, New Mexico, and South Carolina. The following criteria were used, resulting 

in the sample characteristics described below. 

< Type of Grantee: A combination of health centers which included funding for 

Community Health Centers and Migrant Health Centers.14 

< State Program Type: The States selected are using a combination of a CHIP 

program and Medicaid expansions, a CHIP program only, or 

Medicaid expansions only. 

Federally Funded Health Centers and CHIP 9 OEI-06-98-00320 
< Service Delivery: Although most States are primarily using managed care 

delivery systems (also true in our sample), one State used a 

fee-for-service delivery system for a small voluntary managed 

care component. 

< Geography: States represented include the east and west coast, the 

midwest, the inter-mountain west, the southwest and 

southeast regions of the country. The health centers are 

located in large and small cites, as well as rural areas. 

After selecting sample States, we contacted State officials and PCA directors in these 

areas for recommendations of health centers they considered to be successfully 

involved in the early implementation of CHIP and Medicaid expansions. One health 

center per State was chosen as the focus of Phase I of our study. The following 

health centers were selected: Fair Haven Health Center, New Haven, Connecticut; La 

Clínica de La Raza, Oakland, California; Cherry Street Health Services, Grand Rapids, 

Michigan; Plan De Salud Del Valle, Inc., Fort Lupton, Colorado, Health Centers of 

Northern New Mexico, Española, New Mexico; Family Health Centers, Inc., 

Orangeburg, South Carolina. 

Data Collection and Analysis 

We used three methods of obtaining data for our study. First, we conducted 

structured, in-person interviews at the Federally funded health center, the PCA, the 

State Medicaid and/or CHIP agency and, if applicable, a managed care organization 

which had a CHIP and/or Medicaid contract with the health center.15 We also analyzed 

data from the Uniform Data System of the Bureau of Primary Health Care for each of 

the health centers we visited. These interviews were conducted in August and 

September, 1998, during the very early in the implementation of CHIP. Finally, we 

reviewed documents requested from the interviewees concerning the implementation 

of CHIP and Medicaid expansions in their States. 

Structured interview protocols were developed to collect qualitative data from the 

health centers and the other actors. For the health center interviews, separate 

protocols were developed for the Executive Director, the Chief Financial Officer, and 

the Medical Director or senior pediatric medical staff member. In a few health centers 

we were fortunate to be able to interview an outreach worker or migrant health 

worker. We pretested our protocols in a site visit to Connecticut, with excellent 

results, and were thus able to fully use this site visit in our study.16 Site visits were 

then conducted in the remaining five States. All interviews were audio-taped with the 

permission of the persons interviewed. 

In addition to the interviews, we asked each health center to provide selected tables 

from their most recent Uniform Data System annual report for background information 

regarding patient demographics, revenue sources, services provided and staffing. 

Furthermore, we asked each entity we visited to provide documents which would help 

Federally Funded Health Centers and CHIP 10 OEI-06-98-00320 
us understand the CHIP and/or Medicaid program in their States, their role in the 

implementation of the program, and significant issues regarding the program. As a 

result, a considerable range of documents was collected and reviewed in the analysis 

of each case in this study. Examples of documents collected included general health 

center and CHIP outreach materials, application forms, State legislation and 

regulations, managed care contract templates, managed care provider and member 

manuals, and State guidance memoranda. A complete listing of these materials is 

found in Appendix A. 

To analyze the information obtained in our interviews, each tape was transcribed.17 

We then used a qualitative data analysis software package18 to code each transcript 

using descriptive and analytic categories developed by the study team. Reports were 

generated for each category, linking the responses of all interviewees in each State. 

Thus, we are able to summarize, compare and contrast a number of perspectives on 

each category or issue we identified. This report consists of a case description for 

each of the health centers within the context of their respective States. 

Since health system changes for children’s health care are expected to accelerate as 

a result of CHIP, we refer to necessary adjustments of health centers as “CHIP 

Readiness”. This report addresses these readiness issues, as well as health center 

involvement in CHIP implementation, outreach activities, and provision of children’s 

health care services. It also includes our assessment of the key factors underlying the 

health centers successful involvement in CHIP and/or Medicaid expansions. 

HRSA, HCFA, ASPE, and those we interviewed at the sites reviewed and commented 

on the material in this report. Their suggestions and technical corrections are reflected 

in this final report. None voiced any substantive objection to the material. A request 

was made for additional information on enrollment numbers at the time of our visits. 

Although these numbers were not always available, they were incorporated in the 

report where we had the information. 

A second phase of this study applies issues and insights from these case studies to 

developing a national survey of Federally funded health centers and CHIP 

implementation. In early 2000, we plan to release a report based on this survey and 

the insights gathered through the case studies. Due to comments regarding the draft 

of this report, we plan to explicitly ask for information on outstationing of Medicaid 

eligibility workers. 

We conducted our study in accordance with the Quality Standards for Inspections 

issued by the President’s Council on Integrity and Efficiency. 

Federally Funded Health Centers and CHIP 11 OEI-06-98-00320 
FAIR HAVEN HEALTH CENTER

New Haven, Connecticut

State Model: Combines Medicaid expansions with a free-standing program. Programs share name,

application form, and administrative agency for easy client transition/welfare stigma reduction.

Center Highlights:

< Prior experience with managed care; developer and member of a managed care organization of

Federally funded health centers; 

< Added managed care coordinator to staff, and plans future MIS upgrades; 

< Aggressive and creative outreach activities, largely self-funded with grant applications pending; 

Challenge: The center faces reduced reimbursement rates due to the capitation level for primary care versus 

the higher, fee-for-service rate received from another managed care plan. This disparity possibly threatens 

funds which subsidize enabling services and care for the uninsured. 

Connecticut CHIP Model

Several of those interviewed stated that various legislative and administrative 

components have been very supportive of health insurance for children in recent years. 

In fact, prior to the national Children’s Health Insurance Program (CHIP) legislation, 

Connecticut had instituted a set of optional Medicaid children’s expansions. This 

program, entitled “Healthy Start” (not a HRSA Healthy Start program), expanded 

Medicaid for pregnant women and children, through age 11, to 185 percent of the 

Federal poverty level (FPL). 

To implement the CHIP legislation, Connecticut utilizes a combination model of 

Medicaid children’s expansions, and a separate Children’s Health Insurance Program. 

Both parts of the model use continuous eligibility for 12 months before re-application 

is necessary, and are administered by the Department of Social Services. The Medicaid 

portion, called HUSKY A, expands Medicaid eligibility to children in families with 

incomes up to 200 percent of the FPL. Benefits for HUSKY A children match those of 

traditional Medicaid recipients. HUSKY B, the separate CHIP portion, is for children in 

families at incomes between 200 percent and 300 percent of the FPL and is Statespecific. Families at incomes greater than 300 percent of the FPL may purchase 

HUSKY B for their children for an unsubsidized premium. 

The HUSKY B benefits are based upon those of three State employee options. 

Benefits include required services, as well as mental health and substance abuse, 

prescription drugs, durable medical equipment and dental services.19 Service delivery 

is provided by contracting with managed care organizations, as has been the case for 

the majority of Connecticut Medicaid recipients since 1995. 

Federally Funded Health Centers and CHIP 12 OEI-06-98-00320 
Health Center Background

Fair Haven Health Center is a medium sized center, which served about 10,000 

patients in 1997, and has been in operation for over 25 years. The health center 

consists of one main clinic, three school health clinics, and a site at a housing project 

for the elderly. The main clinic is located in a largely Hispanic area of New Haven. 

Since nearly 60 percent of the center’s patients are Hispanic, about half of the centers’ 

patients are estimated to need bilingual services or translation. Children and 

adolescents comprise a substantial portion of the patient population (about 50%).20 

As described later, a full range of preventative and primary care services, as well as 

some specialty services, are provided to children. Our visit was conducted in August 

1998, during the early implementation of the Connecticut program. 

Planning and Implementation

Fair Haven and its Primary Care Association (PCA) reported that they had little 

influence on the final model chosen in Connecticut. However, all parties acknowledged 

that the required opportunities for input through legislative testimony were provided. 

The Connecticut Primary Care Association (CPCA) was in the process of hiring a new 

Executive Director during the period of CHIP deliberations and this may have decreased 

their level of influence. Both the health center and the PCA indicated that their 

preference was to use a Medicaid expansion for all children. Their rationale was that 

the administrative infrastructure was already in place, and Medicaid benefits are the 

most comprehensive. However, much of the State’s consultation regarding the 

development of the plan was with the legislatively funded Children’s Health Council, 

of which the CPCA is a member. 

Collaboration between the HUSKY Program and the Federally funded health centers 

appears to be growing. The CPCA annual meeting in June 1998 focused on 

collaboration generally, and “Planning for HUSKY” was the focus of one of the meeting 

sessions. The Deputy Commissioner of the Department of Social Services addressed 

the health centers regarding implementation and outreach for the program and provided 

applications and outreach materials for center use at that session. The CPCA has also 

submitted a grant proposal for HUSKY outreach, as discussed in the next section. 

Outreach for CHIP

Utilizing its existing resources, Fair Haven Health Center initiated HUSKY outreach 

activities from the very beginning of the program. These activities were good examples 

of local, “grass-roots” outreach in action. The health center outreach worker 

“blanketed” the business area of the Fair Haven neighborhood with a bilingual flier, 

specifically aimed at their potential patient population,21 and alerted them to the 

HUSKY insurance program and services offered by the health center. At a local 

housing project, door-to-door canvassing was also conducted to disseminate HUSKY 

program information and to take some “on-the-spot” applications, which an outreach 

worker would mail in. Area businesses were involved at the request of the health 

center, with a local branch bank co-sponsoring a “Sign-Up for HUSKY Day” in the bank 

Federally Funded Health Centers and CHIP 13 OEI-06-98-00320 
lobby on the busiest day of the month. The health center noted plans to conduct 

outreach and applications for the HUSKY program at their school sites, when the 

school year started. Although numerous applications were being submitted, only about 

50 children had been added to the Community Health Network, the plan formed by the 

health centers, at the time of our site visit when outreach activities were in an initial 

stage. 

State resources for HUSKY outreach include an allocation for community grants of 

$450,000.22 Shortly before our site visit, responses were due to a Request for 

Applications for outreach grants ranging from $20,000 to $100,000. Fair Haven is 

part of a local coalition in New Haven which is applying for a $20,000 grant to do local 

advertising and outreach activities to augment its activities described above. The 

CPCA also submitted a proposal to do a Statewide media campaign for HUSKY, that 

would target adolescents and young parents, a very hard to reach group. The CPCA 

also plans to utilize their “auto-dialer” phone system, a PCA shared service for the 

health centers, to tailor “customized” telephone messages to the existing clientele of 

the health centers. The Connecticut Children’s Health Council had also applied for 

$500,000 from the Robert Wood Johnson Foundation, “Covering Kids Initiative”. 

The Department of Social Services has contracted with Benova, an enrollment broker, 

to provide outreach and enrollment services. This is the same enrollment broker 

Connecticut uses for its regular Medicaid managed care program. Outreach materials 

and applications were printed and distributed Statewide. The health center indicated 

an early problem in obtaining application forms in Spanish from the enrollment broker. 

However, this was resolved by the direct distribution by DSS to the PCA. The 

enrollment broker accepts telephone applications via a 1 - 800 number as well. 

Some problems with outreach and enrollment were identified by the health center 

personnel. One was the interface between HUSKY A (Medicaid) and HUSKY B (the 

separate CHIP program) enrollment processes. Applications for HUSKY B are screened 

for Medicaid eligibility by the enrollment broker. If Medicaid eligibility is deemed likely, 

the application is referred to DSS for processing. This often requires additional 

documentation for the application, which is forwarded to the family for response. 

Concern was expressed that this procedure made it easier for families to get lost in the 

process. 

A second critical concern was expressed regarding children of immigrants and migrant 

workers engaged in seasonal farmwork. Some families may have children born in the 

U.S., and thus eligible for Medicaid or CHIP, whereas older children and parents are 

undocumented. The HUSKY application form does request citizenship status, but for 

the children only. However, some felt the concept that children of undocumented 

parents might be eligible for such benefits is hard to convey to the immigrant 

population. This issue was identified for additional training of outreach workers and 

application assistants. 

Federally Funded Health Centers and CHIP 14 OEI-06-98-00320 
Health Center Services for Children 

Primary/Preventive Services 

Fair Haven Health Center offers a comprehensive range of primary and preventative 

services to the children they serve. These services include well-child care, 

immunizations, pre-natal and delivery care by certified nurse midwives, pre-natal and 

other health education, family planning, and primary care for illnesses. This care is 

delivered at the main clinic and three school health clinics operated by the health 

center. The operation of the local Women, Infants and Children (WIC) program by the 

health center at their main clinic allows families to centralize most of their health care 

needs. Food vouchers and nutritional education are also provided by the WIC program. 

The health center operates three school-based health clinics, which are a key 

component of their delivery of health care to children. Connecticut strongly supports 

school-based health care. In this case, school-based clinics are funded through a State 

program under which the City of New Haven contracts with the health center. The 

main clinic’s child care is staffed by pediatricians and nurse practitioners, since their 

affiliated hospital does not grant admitting privileges to family practitioners. The 

school-based clinics, located in an elementary, middle, and high school, also provide 

preventative care and health education, as well as some episodic care for illness, such 

as nebulizer treatments for asthma. These clinics are staffed by nurse practitioners. 

Enabling and Specialty Services 

Several enabling services are also available to the families of children served by Fair 

Haven. The health center has a strong social service department which provides case 

management and outreach services. A particularly strong outreach program for wellchild care has contributed to the 98 percent immunization rate by this center for 

children under age two. This successful outreach effort also includes transportation, 

when necessary, by the outreach worker. Bilingual medical staff and translators at the 

clinic are also an important enabling service of the center, which serves a largely 

Hispanic population. This combination of bilingual staff and translation was reported 

to work well, with occasional difficulty encountered during after-hours telephone 

contacts where client family members or neighbors needed to assist. 

Fair Haven is able to provide some specialty services to children at the main clinic in 

addition to its central preventative and primary care services. With a board certified 

developmental pediatrician on staff, comprehensive developmental assessments can 

be conducted at the clinic which, otherwise, would require referral to a child guidance 

center, often with considerable waits. Mental health services are not provided by 

health center staff; however, child guidance center staff conduct evaluations at the 

clinic weekly. Obstetrical and gynecological services, including family planning and 

pre-natal education, are also provided by certified nurse midwives at the clinic. Dental 

services are not offered, although the other Federally funded health center in New 

Haven does offer them. Dental care was noted as a problem for children served by the 

center, since very few local dentists accept Medicaid patients. As a result, dental 

Federally Funded Health Centers and CHIP 15 OEI-06-98-00320 
service capacity was viewed as inadequate for the needs of poor children. The health 

center staff indicated that referral networks for children’s specialties are quite good, 

since most of these services are provided by the Yale faculty, who are members of 

local managed care organizations. 

Fair Haven staff were confident that many of the children already served by the health 

center would obtain HUSKY. The significance of this coverage, beyond additional 

revenue, was an improvement in the treatment options available for these children. 

For example, the medical staff indicated that concerns about prescribing some costly 

medications would be alleviated, as would delays in non-emergency specialty care due 

to waiting times to obtain subsidized care. However, availability of prosthetics, 

orthotics and durable medical equipment for disabled children was still perceived to be 

problematic. 

CHIP Readiness 

Managed care participation is a critical component of the Federal health centers’ 

readiness for CHIP and prior events in the Medicaid program had well-prepared Fair 

Haven. The State implemented a mandatory Medicaid managed care waiver for 

younger adults and children in 1995. In the words of the health center director, “...I 

think CHIP will all flow from this. So, I think that in some ways Medicaid managed 

care has prepared us for CHIP.”23 Connecticut Federally funded health centers 

responded to the introduction of Medicaid managed care through a strategy of forming 

their own managed care organizations. The Community Health Network (CHN) is the 

plan formed by the health centers and includes the New Haven area. This strategy 

was developed largely through a HRSA Integrated Service Network project coordinated 

by the PCA. Each of the original health centers contributed financially to the start-up 

costs as well. The PCA director at that time became the director of CHN. The health 

center and the PCA rationale for creating their own plan was to assure continuity and 

quality of care for their patients, as well as a desire for the care to be managed by the 

centers and their clinicians, rather than an insurance company. This health center also 

participates in a local managed care plan operated by Yale University. 

Although Fair Haven was already providing after-hours coverage and emergency room 

triage, they cited several adjustments necessary for managed care. The foremost of 

these was to augment staffing associated with referral management, a function of 

medical assistants in this center. Fair Haven is one of several health centers 

participating in a patient visit re-design project on the East coast. This project has 

identified a significant need for the center to augment their ancillary medical staff to 

achieve greater efficiency of clinician time. This center is also pursuing Joint 

Commission accreditation to strengthen its market position. In addition, substantial 

administrative adjustments are being made, as described below. 

Business infrastructure improvements in this health center largely focus on a new 

management information system (MIS). Fair Haven has issued a Request for Proposals 

to replace its current system, which is over 12 years old, although some upgrades 

have been made over the years. A key feature of the new MIS will be integration of 

Federally Funded Health Centers and CHIP 16 OEI-06-98-00320 
software modules and databases, many of which are now separate. An appointment 

component, billing, patient information and report writing capabilities are integral to the 

new system. Although a clinical information component will not be initially included 

in the system, it may be added in the future. 

Administrative staffing adjustments were necessitated, largely in the billing area. For 

example, considerable time of the billing coordinator is now allocated to coordination 

with the managed care organizations. Additionally, the center has added a managed 

care coordinator, who also has considerable interaction with the managed care 

organizations, particularly in credentialing activities. 

Reimbursement for health care services was the most critical concern identified by 

both Fair Haven and the PCA. When the Connecticut Medicaid program implemented 

managed care in 1995, they initially stopped payment of cost-based reimbursement 

for health centers in their contracts with managed care organizations. The health 

center and the PCA emphasized that this policy drastically reduced their Medicaid 

revenues, causing Fair Haven to deplete all its cash reserves, and take out a line of 

credit to cover operating expenses while this policy was disputed by the centers and 

the PCA. 

The HCFA and HRSA intervened to resolve this problem, resulting in the State 

Medicaid program negotiating a settlement for these disputed reimbursements in April, 

1998. The payments were made retroactive to April, 1996 when the centers first 

asserted their right to cost-based reimbursement under Medicaid managed care. The 

negotiated payment amounts to approximately 64 percent of the disputed payments.24 

The wrap-around payments for cost-based reimbursement, supplemental to capitation 

or fee-for-service payments, were initially paid to the managed care organization for 

pass-through distribution to the health centers. However, effective September 1998 

the Medicaid program began distributing these payments directly to the health centers, 

based upon submitted encounter data. 

Community Health Network is currently paying their health centers a capitated rate for 

primary care services, and fee-for-service for specialty care. Fair Haven’s other 

managed care plan reimburses all services on a fee-for-service basis. The health center 

emphasized that these wrap-around payments primarily support the enabling services 

offered by health centers, and subsidize their care for the uninsured. 

The reliance of the health centers on cost-based reimbursement, which is being phased 

out as a Federal requirement as of 2003, is a continuing issue for the Medicaid portion 

of the HUSKY plan. HUSKY B (the separate CHIP program) does not require costbased reimbursement to these centers. 

Key Factors for Success 

Fair Haven was identified to our study team as a health center which is successful in 

its early implementation of the CHIP program in Connecticut. Several reasons for its 

success are identified in the case study described here. Foremost of these elements 

Federally Funded Health Centers and CHIP 17 OEI-06-98-00320 
of success is the strong primary care program they offer for children in their 

community, since this positions them well to serve client needs under CHIP. Outreach 

to children, a vital factor, has been integral to their health care delivery model. This 

outreach includes three school-based clinics, well-child and immunization services, and 

recent, enthusiastic grass-roots efforts to enroll children in the HUSKY program. 

Another significant success factor for Fair Haven has been its commitment to making 

a broad range of adjustments to accommodate the changing health care environment 

in which it operates. These adjustments include active participation in a health center 

operated managed care organization, initiated when Connecticut made the transition 

to Medicaid managed care in 1995. Staffing realignments, participation in a patient 

visit re-design project, and upgrades to the management information system have also 

been essential adjustments. 

Challenges to continued success for the health center remain. The most pressing of 

these centers on reimbursement issues. When cost-based reimbursement for Medicaid 

patients was temporarily ended, a financial crisis arose which depleted the health 

center’s cash reserves and required a line of credit to maintain existing operating 

levels. Since cost-based reimbursement for Medicaid is being phased out and 

reimbursement for HUSKY B children will not be cost-based, the question remains 

whether this, and other health centers, can make the necessary adjustments to their 

revenues and costs. Lack of reimbursement for enabling services, such as outreach, 

health education, and translation have yet to be addressed. 

Federally Funded Health Centers and CHIP 18 OEI-06-98-00320 
LA CLÍNICA DE LA RAZA 

Oakland, California 

State Model: Combines Medicaid expansions with a freestanding CHIP program. Administered by separate

agencies; both include mechanisms to encourage inclusion of safety-net providers. 

Center Highlights:

< Use of extensive personal contact for CHIP outreach, to potentially eligible client families;

< Affiliation with a local organization of health centers yielded shared resources, including payroll,

hardware and software systems, and a patient database. Consolidation of MIS functions is a future 

consideration. 

Challenge: Difficulties have emerged in the recruitment of eligible children of undocumented parents, with 

prior ambiguous INS policies creating a “fear factor” within this community. 

California CHIP Model 

To implement CHIP, California utilizes a combination model of Medicaid children’s 

expansions, and a separate CHIP program which is called Healthy Families. The 

Medicaid children’s expansion, administered by the Department of Health Services, is 

only a small portion of the State CHIP Plan in California. Medicaid eligibility was 

increased to 100 percent of FPL for all children up to age 19, 200 percent FPL for 

children up to age one, and 133 FPL for children up to age six, and benefits match 

those of traditional Medicaid recipients. 

Eligible children, whose family income is between 100 and 200 percent of the FPL, 

will be enrolled in the separate Healthy Families Program which is administered by a 

free-standing State Agency called the Managed Risk Medical Insurance Board 

(MRMIB). The Board also administers a small business and other health insurance 

programs for California. Benefits for children in the Healthy Families Program are 

modeled after private employer health plans and include required services, as well as 

mental health and substance abuse services, prescription drugs, dental, vision, home 

health care services, and durable medical equipment. Co-payments are required for 

some services, but are limited to $5. Families pay a monthly premium of $4 to $9 per 

child with a maximum of $27 per family.25 

Prior to the CHIP legislation a small private program called Cal Kids was available for 

uninsured children. This program, has a limited benefits package, yet continues to be 

available for undocumented immigrant children since no public funds are used. 

Of particular interest to this study is that both the Medicaid and Healthy Families 

Programs employ managed care for service delivery in all major population areas. The 

Medicaid Program has a “two plan” requirement currently operating in 12 of the 26 

counties where managed care is available. The two plans required in each service area 

Federally Funded Health Centers and CHIP 19 OEI-06-98-00320 
are a commercial plan and a “local initiative” plan which must include traditional and 

safety-net providers such as health centers, county hospitals and county clinics. The 

Healthy Families Program uses a market-oriented approach which reduces the monthly 

premium to $4 for the “local initiative” plan in each service area, thus encouraging 

enrollment in those plans. A comprehensive methodology is used to weight providers 

based upon their actual experience in delivering services to low income children. 

Health Center Background 

La Clínica de la Raza in Oakland (Alameda County) California is a medium sized health 

center, which served about 13,000 patients in 1997, and has been in operation over 

27 years. The health center consists of three clinic sites and two school-based health 

programs. The main clinic is located in a largely Latino area of Oakland. Another clinic 

site is located in an ethnically diverse area of Oakland and serves Latinos, AfricanAmericans, Asians, and Africans. The third site is a teen clinic. Although the center 

is expanding its programs, over 600 families were on a waiting list for center services 

at the time of our visit, due to the large numbers of uninsured individuals in the area. 

Since 84 percent of the center’s patients are Latino or other ethnic groups, the health 

center employs many bilingual or multi-lingual staff. Children and adolescents comprise 

a significant portion of the patient population (about 54%).26 As described later, a full 

range of preventative and primary care services, as well as several specialty services, 

are provided to these children. We conducted our site visit in California early in the 

implementation of CHIP in September 1998. 

Planning and Implementation 

La Clínica and the California Primary Care Association (CPCA) were actively involved 

in the planning and implementation of the Healthy Families Program. The Chief 

Executive Officer of La Clínica is currently Chairman of the CPCA. Largely through this 

affiliation, she and other health center directors testified in support of the program 

during the legislative process and later oversight hearings. The position of the CPCA 

was to support an expansion of Medi-Cal, the State’s Medicaid program, since the 

infrastructure was in place and the health centers were major providers for the MediCal Program. However, those interviewed acknowledged that implementing CHIP 

solely by a Medicaid expansion was unlikely in California at the time the enabling 

legislation was passed due to the State’s preference for market-oriented programs. 

Since the formation of the Healthy Families Program, the CPCA has actively 

collaborated with the MRMIB on program planning and implementation. A health 

center director is on the MRMIB advisory panel and the CPCA frequently presents 

issues to the Board. One primary health center concern has been the inclusion of 

health centers in the provider networks of managed care plans which contract with the 

Healthy Families Program. In addition to the local initiative plans, the CPCA arranged 

for all health centers to be offered managed care contracts with Blue Cross, HealthNet 

and Omni where available. Another success for the health centers was obtaining a 

waiver from Vision Services Plan (VSP), the Statewide vision plan for Healthy Families. 

The waiver allows health centers to contract with VSP, when historically, it has 

Federally Funded Health Centers and CHIP 20 OEI-06-98-00320 
contracted with provider-owned practices only. 

Remaining implementation concerns of the health centers include capitation rates for 

dental providers, cultural and linguistic competency requirements for health plans, and 

implementation of the Special Populations Project and outreach. Although a fee-forservice dental plan is available Statewide, several health centers have noted that they 

have been unable to obtain a fee-for-service dental contract and that the capitation 

rates offered by the managed dental plans are too low for health centers to participate. 

The CPCA has been working with the California Dental Association on this issue. 

Medicaid cultural and linguisitic competency requirements for managed care plans in 

California are considered to be good, and efforts are being made to strengthen 

requirements in the Healthy Families Program in line with the Medicaid requirements. 

The CPCA also expressed concern regarding the implementation of a State-funded 

Special Population Project, under Healthy Families, which they hope will include 

migrant farm worker clinics, although they have currently been omitted. State outreach 

resources are discussed in the following section. 

Outreach for CHIP 

La Clínica de la Raza is actively engaged in outreach for Healthy Families and the 

Medicaid program. The health center has sponsored and participated in health fairs 

where information and applications for these programs were distributed. However, the 

major outreach activity of this health center is personal contact, via telephone, with 

families who are on the waiting list for health center services. The waiting list is due 

to the extensive need for services among the uninsured, although La Clínica continues 

to expand its capacity and clinic hours. Health center staff are working evening hours 

to telephone these families and notify them of the Medicaid expansions and Healthy 

Families Program, and to offer them assistance in completing applications. 

Unfortunately, due to the mobility of this population, many of the families no longer 

have the same telephone number. Nevertheless, contacting those recently placed on 

the waiting list has yielded a better response rate. Since our visit was early in the 

program, La Clínica knew of only three children served by their clinics who were 

enrolled in Healthy Families, although numerous applications were pending. 

The Community Health Center Network (CHCN), a local organization of health centers, 

is very active in outreach for the Medicaid and Healthy Families Programs. They have 

assisted the health centers in developing a patient database for use with letters, phone 

calls, and health center specific fliers explaining the new children’s programs. 

Community Health Network staff have also provided training to health center staff on 

the application process. Other local outreach activities, noted by CPCA, include 

distributing fliers in schools, malls, shopping centers, and daycare centers, and public 

service announcements and media releases. 

The most significant problem identified regarding outreach and enrollment is the fear 

among immigrant families with eligible children about whether receiving CHIP benefits 

will be considered a “public charge.” Public charge refers to Immigration and 

Naturalization Service policies regarding receiving legal immigration status and 

Federally Funded Health Centers and CHIP 21 OEI-06-98-00320 
sponsorship of family member immigration. Such sponsorship may be precluded if 

someone is deemed a “public charge” due to receipt of public benefits.27 Additionally, 

in California, a State program which monitored ports of entry for immigrants returning 

to California has previously requested repayment of benefits, including Medicaid, for 

re-entry. This practice has been stopped, monies were returned by the Medicaid 

program, and the program was ended in April 1999.28,29 However, immigration 

attorneys throughout the State have advised immigrants not to sign up for any public 

benefits. Fortunately, on May 25, 1999, the INS issued a policy statement explicitly 

stating that receipt of Medicaid and CHIP benefits will not lead to a public charge 

designation, except for certain Medicaid nursing facility services.30 However, due to 

the lengthy period of policy ambiguity and the hesitancy of the Latino community to 

trust such pronouncements, it will take time to overcome this former barrier. 

Because of these issues, all California respondents said the “fear factor” among 

immigrant families is the primary barrier to outreach and enrollment of their eligible 

children. Enrollment numbers were lower than anticipated, at the time of our visit, 

particularly among Latino children.31 The application for Medicaid and Healthy Families 

only requests information regarding the child’s immigration status and assures that 

information provided is confidential. However, income verification requirements for the 

parents continue to raise concerns among these families. La Clínica and CHCN staff 

verified the reality of this fear among their patient populations, and were very 

concerned about the lack of a clear INS policy regarding Healthy Families and public 

charge when assisting families with applications. Even with a clear policy, they felt 

the “fear factor” would remain a problem until immigrant families start to trust the 

programs after observing families enroll their children without repercussions. 

Allocation of State resources and procedures for Medicaid and Healthy Families 

outreach has been controversial in California. The Medicaid program is responsible for 

outreach for both programs. Although the health centers strongly supported allocation 

of grants for outreach, the State’s approach is to pay $25 per completed application 

to those providing certified application assistance to families. Certification is obtained 

by completing a one day training on application assistance. This policy is intended to 

diversify the sources of outreach and application assistance. Some outreach money 

will also be allocated to counties and health centers which may be able to sub-contract 

for these resources. 

La Clínica and the CPCA felt that $25 was inadequate payment for application 

assistance due to the length and complexity of the joint application. The application 

booklet is 28 pages; however, this includes detailed program information, and 

worksheets for pre-screening for program eligibility. The application is available in 10 

languages. The CHCN director emphasized the increasing need for an eligibility 

assistance function at each health center; yet some centers lack the resources to do 

this. Another concern expressed by the health center and CHCN was the requirement 

that the first month’s premium be paid at the time of application by cashier check or 

money order, an inconvenience to many of the families applying for the program. 

After our site visit, the Medicaid program provided updated information regarding 

Federally Funded Health Centers and CHIP 22 OEI-06-98-00320 
outreach resources. The application assistance reimbursement has been increased to 

$50. In fiscal year 1998/99 the State provided $1 million in mini-contracts to 

organizations and in fiscal year 1999/2000 the State recently released a Request for 

Proposals for $6 million in funds for outreach. Additionally, the State changed its 

policy that required the first month’s premium to be paid by cashier check or money 

order to also allow personal checks. In April 1999, a revised application was released 

which is only four pages long and which is available in 11 languages. 

Health Center Services for Children 

Primary/Preventive Services 

La Clínica de la Raza offers a comprehensive range of primary and preventive services 

to children. Adolescent patients are also served at the health center’s Teen Clinic. 

Provided services include well-child care, immunizations, primary care for illness, prenatal care and delivery, and a strong health education program which uses health 

promotion volunteers and community health workers. In addition to the two major 

clinic sites and the teen clinic, the health center operates two school-based clinics, one 

in an elementary school and the other at a high school. A major focus of the schoolbased clinics is prevention. At the high school, reproductive health education, 

parenting skills, dealing with peer pressure, and involving parents in health education 

programs are components of the prevention activity. 

Enabling and Specialty Services 

Preventive and community health workers conduct outreach, as well as health 

education, through a strong community health education program. In addition to health 

education, translation services are key enabling services provided by La Clínica de la 

Raza. The San Antonio clinic site is referred to as the International Clinic by health 

center staff. Languages spoken by patients of the health center include Spanish, 

Ethiopian, Chinese, and Korean, plus others. Most translation is provided through bilingual staff with occasional contractual assistance from a language center in Oakland, 

which also provides signing services for the hearing impaired. 

La Clínica also provides a sizeable range of specialty services to children. The health 

center has a mental health clinic which serves its patients, as well as referrals from 

other providers. Psychiatrists and psychologists are on staff and their mental health 

clinic has a contract to provide these specialty services for health plans. Staff noted 

that their clinic is the largest Spanish/English bi-lingual mental health provider in the 

area. Full vision services, including opthalmology, optometry and eye glasses, are also 

available at the health center. Individual providers from the health center have 

contracted with the Vision Services Plan as Healthy Families providers and the health 

center is expecting to secure a clinic contract as a result of the recent VSP policy 

change explained above. 

Dental services are provided by La Clínica at the main clinic site. A long waiting list 

for dental services has resulted in the health center giving children and pregnant 

Federally Funded Health Centers and CHIP 23 OEI-06-98-00320 
women priority for services. The health center also partners with the Colgate 

toothpaste company three times a year to provide mass dental triage screenings for 

children. They have found that about one third of the children just need preventive 

services, another third require priority services, and the remaining third are in need of 

specialty intervention. The health center currently has five dental chairs, serving 800 

to 900, cases a month, and they plan to add five more chairs soon. The health center 

has a periodontist on staff and hosts an orthodontal clinic staffed by dental residents 

bi-weekly. 

CHIP Readiness 

La Clínica de la Raza, and the local Community Health Network, have been in the 

forefront of California health centers ready for CHIP by virtue of their their proactive 

engagement in managed care. The Alameda Alliance Health Plan is the “local initiative 

plan” in Alameda County. It was formed under the two-plan model when the California 

Medicaid Program introduced managed care contracting. They were the first local 

initiative plan in the State, becoming operational in January, 1996. Community Health 

Center Network (CHCN) was formed as a Management Service Organization (MSO) by 

a 25 year old local association of clinics, whose member centers are key provider of 

primary care for the Alameda Alliance Health Plan. CHCN is the contracting entity for 

the health centers with this plan. When the Healthy Families Program was 

implemented, the Alameda Alliance was able to obtain reduced premium status based 

on having the most traditional and safety-net providers in their network.32 CHCN 

passes on primary care capitation to health centers which participate in CHCN and 

pays for specialist services from the remaining capitation funds. 

La Clínica management staff described several adjustments made by the health center 

in response to managed care. They are undergoing a re-design process, examining 

their administrative processes, health center procedures, staffing and management 

information system. Staff training has been an important component in adjusting to 

managed care. The health center is attempting to institutionalize training through 

regular staff meetings, video training tapes, and cross-training of front desk and billing 

personnel. Using a shared hand-held device purchased by CHCN, the health center has 

conducted waiting room surveys of their patient population to monitor satisfaction and 

reactions to changes in their operations. 

Clinic management has exerted considerable effort to involve clinical staff in decisions 

required by managed care. Changes implemented with clinician input include moving 

health education and psycho-social responsibilities from physicians and mid-level 

providers to nurses, health educators and social workers. Nursing staff, in particular, 

have been added. Additionally, the health center’s chief pharmacist has aggressively 

pursued pharmacy managed care contracts and drug price discounts. 

Business infrastructure improvements have also been made by La Clìnica and 

Community Health Network. Included are extensive revisions of their management 

information system. Since 1996 numerous software programming changes have been 

made to accommodate billing requirements, referral management and staff access to 

Federally Funded Health Centers and CHIP 24 OEI-06-98-00320 
multiple databases. Discussions are also underway regarding consolidation of 

management information functions through CHCN to include joint purchase of new 

hardware and software. Shared services, also through CHCN, currently include payroll, 

auditing, laboratory and pharmacy contracts. The health center has hired additional 

administrative staff, including a patient omsbudsman, a managed care coordinator for 

credentialing and patient record audits, and more front desk staff. A managed care 

committee, consisting of health center staff, has been formed to address issues 

regarding the managed care contracts. 

Our interviews identified some reimbursement issues which pose challenges for health 

centers. The California Medicaid program sets interim rates for the health centers 

based upon their most recent cost reports and will continue to provide retroactive cost 

settlements until cost-based reimbursement is phased out according to Federal 

legislation. The Healthy Families Program does not use cost-based reimbursement, 

which leaves reimbursement rate negotiations up to health plans and their contracting 

health centers. In preparation for the phase-out of cost-based reimbursement, La 

Clínica has accepted full risk professional services capitation, excluding hospital 

services, to gain experience in managing finances for primary and specialty care for 

commercial patients. As mentioned earlier, inadequate dental reimbursement from 

managed dental care plans is also an issue raised by La Clínica and the CPCA for the 

Healthy Families Program. Because of the low rates, La Clínica has decided to only 

contract with the fee-for-service dental plan. CPCA is working with the California 

Dental Association to address this issue on a Statewide basis. 

Key Factors for Success 

La Clínica de la Raza was identified to our study team as a health center which has 

been successful in early implementation of the CHIP program in California. Our 

interviews confirmed that the Community Health Center Network and the Alameda 

Alliance Health Plan are also in the forefront of traditional and safety-net managed care 

plans. In fact, they were the first to become operational in the State. Several reasons 

for this joint success are identified in this case study. Foremost of these elements of 

success is their proactive approach to entering the managed care market environment 

in California. A significant part of their approach has been partnering with the 

Community Health Center Network, negotiating provider contracts as a group instead 

of as individual health centers, accepting risk for specialty services as a group, and 

sharing services provided through CHCN. The Executive Director of La Clínica, when 

describing what makes an individual health center successful stated, “Networking. I 

don’t know ... how they could possibly survive outside of a network right now.”33 

Another aspect of La Clínica’s proactive approach to managed care is working 

extensively with their administrative and clinical staff to identify operational 

adjustments necessary for managed care work in their health center and involving the 

staff in the implementation of these adjustments. Examples of this include formation 

of an internal managed care committee, a commitment to staff training, and engaging 

in a re-design project. Expanding clinic hours and services, adding specialized staff 

with managed care responsibilities and realigning clínical staff responsibilities are also 

Federally Funded Health Centers and CHIP 25 OEI-06-98-00320 
important adjustments which La Clínica has made. 

The largest challenge to successful participation in the California CHIP program for La 

Clínica and other health centers is overcoming the significant barriers to outreach and 

enrollment described earlier. Even after clarification of the public charge policy the 

“fear factor” for California’s immigrant population will be difficult to overcome. 

However, having close ties with their community and the trust of their respective 

patient populations positions the health centers as key allies for alleviating fears and 

reaching these children and their families. 

Federally Funded Health Centers and CHIP 26 OEI-06-98-00320 
CHERRY STREET HEALTH SERVICES 

Grand Rapids, Michigan 

State Model: Combines Medicaid expansions with a free-standing program. Inclusion of safety-net providers 

in managed care not required, but default assignments of patients provide incentives to do so. 

Center Highlights: 

< Hired an outreach coordinator instead of an eligibility worker to conduct off-site recruitment and 

application assistance and tracking; 

< Designated a managed care coordinator to oversee development of MIS system improvements; 

Challenge: HCFA’s rejection of original reimbursement methodology forced return to cost-based settlements. 

Original plan included payment for recent program expansions, so a cost-based approach puts such 

programming at risk. 

Michigan CHIP Model 

Soon after the enactment of the CHIP legislation, Statewide forums were held, starting 

in October, 1997, to gather input on a CHIP proposal. With strong administrative 

support for privatization of governmental services, a totally free-standing program was 

proposed, and a plan using this model submitted to HCFA in December 1997. When 

the State legislature convened in January 1998, the House held hearings on this plan, 

and discussions ensued regarding a combined approach of Medicaid expansions along 

with a free-standing program. As a result, legislation was passed in March 1998 for 

a combination Medicaid expansion/private model. HCFA approved the revised State 

plan in April 1998. Implementation of the program began in May, and Statewide 

implementation was completed by September 1, 1998. 

Income eligibility levels for the Medicaid expansion are set at 185 percent of the 

Federal Poverty Level (FPL) for infants up to one year of age. The remaining children 

up through age 18 are eligible for Medicaid if family income is less than 150 percent 

FPL. The free-standing program, called MIChild, covers children in families at and 

below 200 percent FPL who are not Medicaid eligible.34 Both the Medicaid expansions 

for children and the MIChild program permit continuous eligibility for 12 months. 

Community health centers are among a group of providers who are allowed to deem 

presumptive eligibility for children. 

The Medicaid program and MIChild use an enrollment broker, Maximus, to process 

applications and choice of managed care plans. For families who do not select a plan 

for their children, Maximus makes default assignments for Medicaid. Although 

Medicaid health plans are not required to include health centers in their provider 

networks, the bidding procedure grants points to plans who contract with these 

centers in the allocation of default assignments. The plan pays fee-for-service if there 

is no contract with an Federally Qualified Health Center in the county. The three plans 

Federally Funded Health Centers and CHIP 27 OEI-06-98-00320 
with the highest points in each county receive default assignments. Other health 

plans in the county which are not among the top three in enrollments receive no 

default assignments. MIChild accepts any licensed HMO or PPO provider. 

Benefits for the Medicaid expansions are the same as the pre-existing Medicaid 

program. MIChild benefits were designed based upon the State employee benefit 

package and are fairly comprehensive, by including prescription drugs, vision, dental, 

and home health services, as well as durable medical equipment, but with limitations 

on some therapy services.35 Mental health and substance abuse services are provided 

separately through a carve-out from the health plans whereby the MIChild program 

contracts directly with community mental health programs. 

Health Center Background 

Cherry Street Health Services, based in Grand Rapids, is a medium-sized health center 

which served over 17,000 patients in 1997. The health center operates six clinic 

sites, including school-based health clinics, in Grand Rapids and Kent County. The 

patients seeking care at Cherry Street clinics are ethnically diverse and include African 

Americans (30%), Caucasians (30%), Hispanics (15%) and 25 percent in other 

categories . About 10 percent of the patient population are estimated to need bilingual 

or translation services. The majority (54%) of patients seen at the health center are 

children. Although Cherry Street does not receive Migrant Health Center grant funds, 

they do see some children from migrant farmworker families at various sites during the 

three month crop picking season. As described later, the center provides a full range 

of preventive and primary care services, as well as several specialty services to these 

children. We visited Michigan in September 1998, very soon after CHIP implementation 

was completed Statewide. 

Planning and Implementation 

Cherry Street Health Services was involved in the planning and implementation of 

MIChild and Medicaid expansions primarily through their Primary Care Association. The 

PCA members had extensive discussions within the Association regarding their support 

of Medicaid expansions over a free-standing CHIP program. Many assumed that the 

free-standing model was a given, but the PCA decided to support a Medicaid expansion 

because it had more comprehensive benefits and a pre-existing administrative 

structure. Since the Medicaid program had implemented managed care over a year 

before the passage of the CHIP legislation, provider networks and contracts were in 

place to serve a low income population through managed care plans, including one 

formed by the Federal health centers. When members of the legislature expressed 

interest to include a Medicaid expansion as part of the CHIP plan, the PCA worked 

with legislators and other advocates to realize its inclusion. 

Additionally, the health centers were represented at three or four State input forums 

regarding the original, free-standing plan submitted by the State. The PCA was also 

involved in meetings of a group of child health related agencies in Grand Rapids that 

commented on the State plan. When the combination plan for Medicaid expansions and 

Federally Funded Health Centers and CHIP 28 OEI-06-98-00320 
the MIChild program was ultimately developed, the PCA informed member clinics of 

implementation activities. In addition, it provided outreach information that assisted 

the health centers in enrolling their children in the appropriate CHIP program. 

Outreach for CHIP 

Cherry Street Health Services has actively engaged in outreach following the 

establishment of Medicaid expansions and MIChild. They have an outreach coordinator 

whose primary responsibility is to enroll children. Parents of its 2,400 self-pay children 

served by the health center were mailed a brochure explaining the program, eligibility 

requirements and how to apply. The center’s medical director has asked its providers 

to monitor child encounter forms for an indication of self-pay status so they can then 

inform parents about the programs and refer them to the outreach coordinator for 

application assistance. The outreach coordinator also tracks applications for families 

she has assisted with the process to ascertain eligibility status and/or need for 

additional documentation. At the beginning of the school year, the coordinator gave 

presentations during registration activities and distributed information and applications. 

The outreach coordinator also distributes information and applications at neighborhood 

picnics, church-sponsored health fairs, job fairs and other local activities. However, 

with six sites to cover, the center director noted that three or four outreach workers 

are needed, but that more staff resources aren’t available. This is, in part, due to the 

uncertainty regarding the amount of cost-based reimbursement which they would 

receive and the lack of supplemental CHIP funds being allocated to them. 

The Medicaid and MIChild programs have also conducted outreach activities on a 

Statewide basis. Although these programs accepted applications in July 1998 the 

“kick-off” press conference was held in late August after changes to the original 

application forms were made. Radio and television advertisements were being aired 

by September when we visited, and plans were announced to send applications to all 

schools. Additionally, regional contracts for outreach activities were initially granted 

only to “multi-group collaborative bodies”, which are county-based groups largely 

composed of governmental agencies. Some health centers are involved in these 

groups, but many are not. The health center and PCA expressed concern about 

restricting outreach contracts to these groups, since Federal health centers are not 

members of these groups in some areas. Shortly before our visit, the State program, 

in an effort to increase enrollments, issued a request for proposals for 30 more 

outreach contracts, for which health centers would independently be eligible. 

Applications for the MIChild program were accepted throughout the remainder of the 

year after April 1998 and in 1999. However, beginning in 1999, re-enrollment after 

failure to pay premiums will only be accepted during three open enrollment periods. 

Although health centers are allowed out-stationed Medicaid eligibility workers to deem 

presumptive eligibility, Cherry Street had not yet implemented this option. Since the 

health center would need to pay half of the eligibility worker’s expense they decided 

to employ an outreach coordinator as a member of their staff. The PCA director said 

health centers were wary of presumptive eligibility. They would receive capitated 

payments for the presumptive period, regardless of the final eligibility determination of 

Federally Funded Health Centers and CHIP 29 OEI-06-98-00320 
the child. However, if a child was initially sick and needed significant care, their costs 

would exceed capitated revenues if the child was subsequently deemed ineligible and 

these costs would be assumed through the HRSA grant resources, as though 

uninsured. 

The health center and PCA directors also expressed concerns regarding some 

administrative problems with the enrollment broker for both Medicaid expansions and 

MIChild. One problem cited by the health center’s managed care plan was that, at the 

time of our September site visit, the enrollment broker has been unable to transfer 

enrollment information to the health plans electronically. Updated information, after 

our site visit, indicated that electronic transfer of MIChild eligibility verification became 

available in October 1998 and an electronic bulletin board became operational in 

February 1999. Prior to October 1998, the health center indicated they expended 

considerable time on confirming program eligibility. Finally, although a short, four 

page, application form is being used, it has been revised three times since its inception, 

which has caused some confusion and delays. 

Health Center Services for Children 

Primary/Preventive Services 

Cherry Street Health Services offers a comprehensive range of children’s primary and 

preventive services, including well-child care, acute care, immunizations, prenatal care, 

family planning, and pharmacy services. The health center also has a Women, Infants, 

and Children nutrition program on-site. Services are provided at the six clinic sites, a 

school-based health clinic, and through a traveling school health program serving 16 

schools. The traveling program offers medical and dental screening to students. The 

health center has one part-time pediatrician on staff. Most providers are either nurse 

practitioners or family practitioners.36 

Enabling and Specialty Services 

Health education is a significant enabling service provided by the health center. For 

pregnant women they provide a State-funded program of maternal support services 

which focuses on health education, coupled with case management and home visits. 

Bilingual providers and translation services are available to non-English speaking 

families by two physicians and a number of medical assistants, all of whom speak 

Spanish. Other enabling services provided by the health center include eligibility 

assistance, case management, housing assistance, outreach and some 

transportation.37 

The health center also provides several specialty services to their patients. The center 

has a sizeable dental program consisting of five dentists, three hygienists, and ten 

assistants, aides and technicians. Mental health services are also provided at the clinic 

sites and mental health referrals for Medicaid and MIChild are available through 

community-based mental health providers. Limited vision services are also offered by 

the center. 

Federally Funded Health Centers and CHIP 30 OEI-06-98-00320 
Although still early in program implementation, the health center has begun to see 

MIChild eligible children assigned to their clinics. At the time of our site visit, 53 

children from the health center had been enrolled in MICHILD, and 123 had become 

newly eligible for Medicaid. However, the director is concerned about Cherry Street’s 

ability to maintain its current range of services, largely due to decreases in the numbers 

of families assigned to them with Medicaid coverage. This is, in part, due to 

competition for Medicaid patients as managed care was implemented in Michigan. 

However, the total Medicaid caseload Statewide has declined due to the effects of 

welfare reform. The center director noted that the total number of patients seen by 

the health center is not decreasing but that more families are now served under the 

self-pay, sliding fee category which is dependent on grant funds. 

CHIP Readiness 

When the Medicaid program began implementing mandatory managed care, Cherry 

Street Health Services joined a health center-owned and directed managed care plan. 

This plan, Community Choice of Michigan (CCM), was formed through efforts initiated 

in 1995, when a group of health centers obtained a HRSA Integrated Service Network 

Initiative grant. With the Medicaid program moving towards managed care, these 

health centers decided that creating their own health plan would best serve their 

patients’ interests. To assure involvement in plan decisions, particularly those regarding 

adequate reimbursement and maintenance of clinic enabling services, health centers 

invested $22,000 each and obtained a seat on the Board of Directors. Since Michigan 

phased-in its managed care program by counties, Cherry Street was not initially in 

CCM when the plan became operational in 1996. However, they joined the plan as 

Medicaid managed care was implemented in the Grand Rapids area. 

With the advent of Medicaid managed care, the health centers and CCM needed to 

address the issue of how cost-based reimbursement was going to be handled by the 

State. Initially, the Medicaid program thought managed care plans would place 

capitation bids which incorporated the higher reimbursement for the health centers, 

and then reflect this in the fees paid to the centers. However, the plans did not 

include these higher fees in their bids, and health centers feared this created 

disincentives for plans to work with them. The health centers, then, as a group, 

negotiated a memorandum of agreement with the Medicaid Program whereby the 

managed care plans would reimburse health centers at market rates, and the Medicaid 

program would supplement these payments38. The supplemental payments were 

based upon the 1996 cost reports, with an inflation factor of 15 percent for 1998 and 

1999. The agreement also allowed health centers to be paid for service expansions 

planned prior to the 1997 date of the agreement. Also, health centers could assume 

risk in their managed care contracts. Thus, they could realize gains from savings, and 

lose revenue for excess costs. 

However, the HCFA informed the Medicaid program that this reimbursement 

methodology was not acceptable under the Balanced Budget Act of 1997 (BBA), and 

they would need to return to cost-based settlements. Returning strictly to cost 

Federally Funded Health Centers and CHIP 31 OEI-06-98-00320 
settlements would negate any gains or losses from accepting risk. Additionally, under 

cost settlements, Cherry Street Health Services would not receive payments for their 

expansions already made. The health centers, their PCA and Michigan Medicaid have 

protested HCFA’s ruling, and a final determination on this issue was pending at the 

time of our visit. The outcome of this reimbursement issue was expected to have 

significant impact on the health center’s ability to adjust to managed care risk 

assumption, once cost-based reimbursement is phased out as required by the BBA, 

because they would have no Medicaid experience with capitated reimbursement. 

Cherry Street also anticipates a need to retreat from service expansions already 

underway if the Memorandum of Agreement is ultimately nullified by HCFA. 

Cherry Street and CCM noted several adjustments being made by health centers to 

facilitate their viability in a managed care environment. The director of Cherry Street 

stated that, as their participation in managed care evolved, they had become more 

“thirsty for Medicaid encounter data”. CCM provides them with their financial reports 

with costs, broken out by services and providers, as well as considerable education 

during their board meetings on how to use this information. CCM indicated that two 

of the most financially successful health centers in their plan had each hired a staff 

person with managed care experience to monitor financial aspects of managed care 

contracts. Cherry Street had designated one staff member as a managed care 

coordinator who was being educated to oversee this component of the center’s 

operation. The center also was considering adding a referral coordinator, if resources 

allowed. 

Another significant area of needed adjustment was in management information. 

Although Cherry Street had not yet invested in new hardware or software, the director 

indicated he was assessing their technical needs in this area. The PCA noted that 14 

of their health centers now contract with a common software company and that this 

vendor had recently dedicated a staff person to support the Michigan health centers. 

The Medicaid staff we interviewed reiterated that good information systems and 

business managers were critical to health center viability in the new managed care 

environment. 

Key Factors for Success 

Cherry Street Health Services has made a concerted effort to enroll children in 

Medicaid expansions and MIChild. Although the director indicated that they would like 

to do even more outreach if resources were available, this health center has clearly 

made CHIP/Medicaid outreach a priority. They demonstrated this by dedicating staff 

to this effort, informing their providers about the program, involving them in referring 

families to the outreach coordinator for application assistance, and by conducting a 

major mail outreach to their self-pay families with children. The health center is also 

making an effort to track the processing and outcome of these applications to ensure 

that applications needing follow-up don’t “fall between the cracks.” Due to welfare 

reform, their loss of patients previously covered by Medicaid is presenting financial 

challenges for the health center. This reinforces their need to enroll many of these 

children who then become eligible for Medicaid expansions or MIChild coverage. The 

Federally Funded Health Centers and CHIP 32 OEI-06-98-00320 
school health program operated by the health center reaches over 16 schools and 

provides an opportunity to achieve this goal. The State programs have shown intent 

to partner with the health centers in this effort by issuing a request for proposals for 

outreach contracts with them. 

Cherry Street has also partnered with several other health centers in the State in joint 

ownership and development of a managed care plan. This has required considerable 

effort to learn the business of managed care, as well as a willingness to accept 

financial risk for primary care patients. They have designated a staff member as a 

managed care coordinator and indicated desire to add a referral coordinator as well. 

As part of their managed care strategy for Medicaid, these centers negotiated an 

agreement for a modified version of cost-based reimbursement with the State, which 

incorporates some risk assumption, to facilitate the transition from cost-based to 

capitated reimbursement for services, although the agreement has not yet been signed. 

Several people we interviewed said that making the transition to capitation would be 

a major challenge if they were not allowed this intermediate step. 

Federally Funded Health Centers and CHIP 33 OEI-06-98-00320 
PLAN DE SALUD DEL VALLE 

Fort Lupton,Colorado 

State Model: Opted for a freestanding CHIP program only, in keeping with preference for privatization. 

Center Highlights: 

< Developed managed care experience prior to CHIP, through formation of an MCO, with 8 other 

centers and a safety-net hospital; 

< State hopes investment in the design/implementation of an on-line enrollment/eligibility determination 

system will compensate for the initial lack of direct funding for center outreach; 

< Capacity issues may arise since State funding levels will only cover half of the children estimated to 

be CHIP eligible; 

Challenge: Existence of a prior indigent care program, which also serves children and charges lower 

copayments and no premiums for many of the same services offered through CHIP. Families tend to stay 

in the old program until catastrophic illness requires CHIP benefits. A much lower reimbursement schedule 

for services under this older plan, adversely impacts center revenues. 

Colorado CHIP Model 

Early to recognize unmet healthcare needs of their citizens, Colorado had already 

instituted, prior to CHIP legislation, a State-only health insurance program. A specific 

children’s coverage program, named the Child Health Plan (CHP) was also formed. The 

State was planning an expansion of this CHP program prior to passage of CHIP. With 

design teams far into the development phase of the program, the State made 

alterations to comply with CHIP requirements, thus allowing Colorado to submit a plan 

to HCFA quickly. When we conducted our site visit in September 1998, the program 

had been operational for several months. 

As allowed under the Federal law, Colorado developed a freestanding program, called 

Child Health Plan Plus (CHP+), which is administered by the Office of Program 

Development. Operated by a separate office, the Medicaid program shares the same 

oversight agency as CHP+, the Colorado Department of Health Care Policy and 

Financing. Most interviewees describe Colorado as a fiscally conservative State, which 

operates under taxing and spending limits imposed by voters. They related the 

apprehension of legislators about expanding entitlements, preferring instead to design 

a program which closely mirrors private sector health insurance. Consistent with the 

State’s philosophy, the enabling legislation requires that many CHP+ functions be 

privatized. The oversight agency is required to issue contracts for outreach and 

eligibility enrollment. This does not preclude the use of contractors already doing 

similar work for Medicaid, but activities must be coordinated as a separate office. 

The Medicaid children’s program, titled Baby Care Kids Care, covers children in families 

with income up to 133 percent of the Federal poverty level (FPL) through age 5. For 

ages 6 through 15, the eligibility drops to 100 percent FPL.39 The separate CHP+ 

Federally Funded Health Centers and CHIP 34 OEI-06-98-00320 
program covers children, up to age 18, in families with income up to 185 percent FPL 

who are not Medicaid eligible. Premium payments are waived for children with family 

incomes under 100 percent FPL, while those with families above 100 percent FPL are 

on a graduated premium schedule.40 Some income levels are also assessed copayments for office visits. The omission of dental coverage and limits on mental health, 

and all therapies (physical, speech, vocational) distinguish it from Medicaid’s full 

benefit package. 

Health Center Background 

Plan de Salud del Valle health center in Fort Lupton, Colorado is a large center with 

nine service delivery sites. Salud served nearly 33,000 individuals in 1997. 

Surprisingly, although over 60 percent of their clients are Hispanic, the center reports 

only 14 percent of its patients require bilingual services or language interpretation. 

Nearly half (46%) of the center’s patient population are children and adolescents. The 

center has been an owner/provider within the Colorado Access health network, a nonprofit HMO providing a comprehensive medical plan for low-income individuals, since 

Colorado Access was formed in 1995. Salud health center provides a full range of 

preventative and primary care services as well as a wide array of enabling and 

specialty services. These will be discussed in greater depth later. 

Planning and Implementation 

During the design phase, Plan de Salud de Valle health center had both direct 

representation on planning committees, and was also represented by their PCA on all 

committees. Salud and its PCA had favored a Medicaid expansion from the beginning, 

but felt that the State political climate prevented that option from being fully explored. 

Although the PCA director felt that 50 percent of the resultant program was due to 

PCA involvement, the Salud center viewed its impact on the final CHP+ product as 

minimal. For example, although the center’s dental director sat on the benefits 

committee, he was disappointed when dental care was not made a part of the CHP+ 

benefits package, except in emergencies. Currently, the State is exploring whether it 

can afford to add a dental benefit. 

Although they utilize their PCA for advocacy, Salud has also joined with other health 

centers, using non-federal dollars, to hire a representative for the PCA to present their 

interests before the State Legislature. Believing that representatives were unaware of 

the extent to which their constituents were served by health centers like Salud, they 

perceived additional representation as necessary for survival in the current 

environment. 

Implementation of CHP+ has led to interface issues with the Colorado Indigent Care 

Program (CICP), since the onset of CHP+ did not mark the end of this pre-existing 

program. Covering both children and adults, the earlier CICP plan was intended to 

become more of an adult program as eligible children enrolled in CHP+. In the CHP+ 

program, beneficiaries are likely to be faced with higher premiums and co-payments 

than their co-payment for services under the CICP. For example, under CHP+, a family 

Federally Funded Health Centers and CHIP 35 OEI-06-98-00320 
of four at the maximum eligibility (185% FPL) would pay $30 a month in premiums and 

a $5 co-payment per office visit.41 In contrast, under the CICP plan, they would only 

be responsible for co-payments. 

The health center predicts many families will elect the CICP for children’s services 

during periods of good health, and enroll in CHP+ only when significant health 

problems emerge. At that point, most serious illnesses are likely to be referred out, so 

that specialists will benefit from CHP+ reimbursements, not the health center. The 

financial impact of this scenario on a center like Salud could be great as CICP costs are 

largely assumed by the clinic.42 The double effect is to reduce the Federal funds the 

center would receive under CHP+, as well as the pool of funds available to their adult 

population under the CICP. Additionally, Salud fears that the State will try to reduce 

funds to the CICP, proportional to eligible CHP+ children, in order to fund some of its 

financial commitment to CHP+. The end result would be an overall reduction in total 

dollars spent on health care for the underserved in Colorado. There was no indication 

that the State planned any redesign of the child segment of CICP or CHP+ to prevent 

these conflicts. 

As CHP+ enrollment increases, capacity issues may arise since the program was not 

funded to the level which qualifies for the maximum Federal dollars available. The PCA 

estimates that approximately 50,000 of the children they serve will qualify for CHP+, 

while the State currently has appropriated money to cover only 25,000. If such 

numbers were to enroll, any additional children above the 25,000 threshold would have 

to be placed on a waiting list until space or additional funding became available. 

Outreach for CHIP 

Salud health center receives no money from the State for outreach activities. As a 

result, they have no formal outreach program, but do attempt to enroll children when 

they access services in their clinics. The center views the CHIP expenditure limit of 10 

percent for administration and outreach as inadequate for financing additional outreach 

activities. The State has allocated some resources to the development of brochures 

and literature promoting the program. In addition, Colorado heavily invested in an online 

eligibility/enrollment process which, at the time of our visit, was not yet operational. 

A pilot project of approximately 40 sites, not all health centers, was scheduled to 

come online shortly. Once operational, a site would receive a negotiated fee, from the 

contractor developing the system, for each Internet enrollment application completed. 

Realizing that getting every health center online may require some capital investment, 

Colorado has instituted the Essential Community Provider Grants program. The program 

will allocate grant funds to those essential providers in need of software, networking 

capability, infrastructure improvement, or direct services. 

While only a few health centers currently are permitted to determine eligibility and 

receive compensation for it, all centers assist clients in completing and submitting 

enrollment applications to the State. Although Colorado prefers enrollees to fill out the 

applications themselves without center assistance, Salud observed that the low 

literacy level of many applicants prevents them from completing applications 

Federally Funded Health Centers and CHIP 36 OEI-06-98-00320 
independently. The original State plan classified all health centers as high-level 

eligibility determination sites which would receive training and be paid for application 

assistance based on a fee schedule negotiated by the contracted vendor and the 

center. Unfortunately, continuous mistakes by one health center resulted in the State 

not designating all centers as eligibility determination sites. Rather, Colorado has issued 

a Request for Proposals under which centers may apply to become an eligibility site. 

If chosen, a center would receive training at only one site, regardless of how many 

service locations they may have. Salud health center is a member of the PCA along 

with 14 other health centers for a total of 85 sites. At the time of our interview, 

between 3 and 5 of those 85 sites (none from Salud) had been trained to do high-level 

eligibility determination and were the only sites receiving reimbursement for enrollment 

activities. The PCA viewed this limitation on eligibility determination and lack of 

compensation as a serious problem in need of correction. Since our site visit, the PCA 

provided new information that they and the State program are conducting training 

sessions around the State to assist health centers in becoming CHP+ eligibility sites. 

Issues of eligibility determination are compounded by the lack of presumptive eligibility. 

Neither CHP+ nor the Medicaid program currently has this feature. However, planners 

are currently trying to expand presumptive eligibility for the Medicaid plan which 

currently extends only to pregnant women. Both programs allow continuous eligibility 

for 12 months before requalification is necessary. 

With health centers as the most common point of contact with potential CHP+ or 

Medicaid enrollees, clinics can complete an application with the client for the program 

for which they appear to be eligible. Yet, unless the clinic is one of the few high level 

eligibility determination sites, they must wait for the State to determine eligibility. At 

the time of our visit, this process was taking between seven and eight weeks. 

Updated information indicates that the processing time has been reduced to about one 

week. In the meantime, confusion occurs over whether and how to bill for those 

services which the client uses. Since CHP+ and Medicaid reimbursements are 

different, and the CICP program is based solely on co-payments, whether or not to 

charge fees at the time of service, and where to bill services while the client’s 

eligibility is being determined for a specific program become issues. 

Concern was also expressed regarding the impact of CHP+ on the children of migrant 

workers engaged in seasonal farmwork. While the Federal statute doesn’t require a 

Social Security number from a CHIP applicant, Colorado’s addition of this requirement 

on the joint CHP+/ Medicaid application is viewed as a barrier to the enrollment of 

migrant children. Most parents can obtain the necessary documentation, but either 

they don’t carry it with them, or they have little motivation to produce it. Even when 

an application is completed, the slow eligibility determination often insures that by the 

time they are approved, clients will most likely no longer reside within the State. 

Whether these families are aggressively seeking to enroll in CHP+ is unclear. However, 

in Salud’s view, every eligible, but unenrolled, child they treat forces them to divert 

scarce resources away from other uninsured persons. 

Federally Funded Health Centers and CHIP 37 OEI-06-98-00320 
Health Center Services for Children 

Primary/Preventive Services 

Salud health center provides a full range of primary and preventative care to the 

children they serve. Considering themselves primarily as a maternal and child health 

clinic, the center provides comprehensive care from pregnancy diagnosis through wellchild and ill-child care. Salud maintains the goal of providing a majority of their care to 

patients under the age of 21. Currently, with 53 percent of patients age 21 and under, 

they seem to be reaching their goal. The center is, however, also a full-service family 

clinic. Fearing compartmentalization of care, Salud employs just two pediatricians, and 

prefers that most of their physicians be family practitioners. Other primary and 

preventive services include Women, Infant and Children (WIC) nutrition services, full 

prenatal and delivery services, and family planning. Migrant worker clinics are also 

operated by the health center on a seasonal basis. 

Enabling and Specialty Services 

Salud is able to provide enabling and specialty services in addition to their primary care 

offerings. Although they lack funding for translation services, the center tries to hire 

bilingual staff, when possible, to better serve their majority Hispanic population. 

Colorado Access, the managed care network of which Salud is a part, also has 

providers who speak Russian and Vietnamese. Regular transportation is not provided 

by Salud’s managed care organization, and they admit this is an issue, especially in 

rural areas. However, limited reimbursement forces them to offer transportation only 

on an emergency basis. Additional enabling services provided by the health center 

include eligibility assistance for public programs, case management, health education, 

and outreach. 

Plan de Salud de Valle continues to offer limited mental health care, as well as on-site 

dental services. An agreement with a county behavioral health provider provides a 

psychologist at one site. Although a similar agreement in another county was 

discontinued, the psychologist has decided to continue working on a pro bono basis. 

Thus, two sites are able to offer mental health services. Dental services are provided 

at the clinic sites and at schools, Head Start programs, and migrant centers. Children 

are given priority for dental appointments, since the need for these services at the 

health center exceeds current capacity. 

CHIP Readiness 

Having already participated in the formation of a managed care organization, Plan de 

Salud de Valle was well-positioned to deal with the implementation challenges of 

CHP+. Predicting that Colorado would move to Medicaid managed care, nine Federally 

qualified health centers, including Salud, joined to create the Colorado Community 

Managed Care Network (CCMCN). CCMCN then organized in conjunction with 3 

hospitals and a physician’s group to form Colorado Access. A private, non-profit HMO, 

Colorado Access began operations in December 1995 with 17,000 enrollees on the 

Federally Funded Health Centers and CHIP 38 OEI-06-98-00320 
first day. Their goals included retaining the Medicaid population, using any surpluses 

to serve the medically indigent, and ensuring that safety net providers remained viable. 

Since its formation, Colorado Access has spread from 12 to 28 counties within the 

State and continues to look for areas of expansion. Salud operates as a provider 

contracted to the Colorado Access HMO. 

Having taken a proactive approach to managed care early on, Salud did not find it 

necessary to make significant operational changes to accommodate the CHP+ 

program. Determining their business infrastructure system to be adequate, the center 

only cites the need of an MIS manager to maximize their information capabilities. Since 

the new Community Health Center grant adds the MIS manager as part of the staff, 

Salud will be able to add this position. In addition, they are participating in a pilot 

project sponsored by the Federal government to test the Physician Service Practice 

Analysis software. Developed by a managed group medical association, it is a cost 

accounting software for health services which is heavily used in the private sector. The 

project is assessing its conversion for use in community health centers. 

With five other managed care organizations approved under the CHP+ plan, Colorado 

Access is not the sole managed care provider. However, their ability to garner 1,000 

of the 1,300 total CHP+ enrollees, at the time of our visit, attests to the effectiveness 

of the network they already had in place. A significant entity within Colorado Access, 

Salud estimates that between 400 and 500 of the network’s CHP+ enrollees are 

patients of its own clinic system, while they speculate that several thousand more are 

eligible. The center expressed concern regarding the possibility that with more provider 

networks available, enrollees might seek out private physicians due to perceptions that 

private care is better, and if their insurance status changes, return to Salud. The net 

effect is a rise in the number of uninsured patients at the centers. Under such 

circumstances, the center will lose capitated funds for patients while they are insured, 

yet become liable for the cost of treating them when, and if, their coverage status 

changes. Although this has not occurred on a widespread basis, Salud has observed 

this shift in one county where it has provider sites. 

Under CHP+ managed care, Plan de Salud de Valle health center has not experienced 

the reimbursement problems it did under the old Child Health Plan (CHP). 

Reimbursement was provided on a capitated basis, with some services “carved out” 

on a fee-for-service schedule. Due to delayed eligibility determinations and a slow 

payment system, the center would often go three to four months without receiving 

checks from CHP. The CHP+ plan is also capitated, but with the managed care 

organization rather than the center. Each managed care organization then, contracts 

with their providers independently. In the case of Salud, Colorado Access is giving 

them the same cost-based, fee-for-service they would receive under Medicaid. In 

addition, as an incentive to keep costs low, Colorado Access receives a designated 

premium from the State with the agreement that funds left over will be equally divided 

between themselves and Salud. 

The choice to operate a freestanding commercial program has presented an 

unexpected issue in regard to vaccines. Health centers receive highly reduced prices 

Federally Funded Health Centers and CHIP 39 OEI-06-98-00320 
for vaccines from pharmaceutical companies for Medicaid and the uninsured, but 

cannot use those under the freestanding CHIP program per Federal regulation. The 

State’s original capitation rate did not include these vaccines, so now they are trying 

to incorporate them into a new capitation rate. In the meantime, health centers are 

unclear about the reimbursement of cost for vaccines under CHP+. 43 

Key Factors for Success 

Plan de Salud de Valle’s previous affiliations with managed care appear to have been

of great benefit as they made the transition to CHP+. Having already worked with 

other member providers for years, the CHP+ program was more like an add-on than 

a new enterprise, which allowed their managed care network, Colorado Access, to sign 

up more CHP+ members than the other five networks combined. Salud has been 

particularly successful, since nearly a third (between 400 and 500) of the initial CHP+ 

enrollees Statewide reside within the Salud clinic system. With its emphasis on safety 

net viability, Colorado Access continues to work to insure its market share, and look 

for areas in which to expand. 

Prior to CHP+, the health center had proactively upgraded its business infrastructure. 

Approval of a MIS director position will further enhance their capability to manage the 

complex information needs associated with managed care. The progress they have 

made in this area is evidenced by their participation in the test pilot for service analysis 

software being sponsored by HRSA. 

The simultaneous operation of the CICP program along with CHP+ remains a challenge

for Salud and its financial future. They predict the CHP+ premiums and co-payments 

to be significant barriers to new members who have been accessing services under the 

co-payment only CICP plan. Like other insurance programs, the success of Colorado 

Access under CHP+ depends upon a sizeable pool of members paying premiums over 

time so that adequate funds will exist to cover care costs. If Salud’s clients opt to 

utilize the CICP for general care, the center will be responsible internally for the 

majority of costs incurred under the CICP plan and forgo potential CHP+ 

reimbursements for the same care. Yet, even if the centers are able to overcome the 

resistance of clients to convert to the CHP+ plan, the current financing limits to 

25,000 CHP+ enrollees, set by State appropriations levels, are likely to present a new 

barrier to success. 

Federally Funded Health Centers and CHIP 40 OEI-06-98-00320 
FAMILY HEALTH CENTERS 

Orangeburg, South Carolina 

State Model: Medicaid expansion with a voluntary managed care element. Providers may participate in an 

HMO or one of two managed care alternatives tailored for the State’s rural areas. 

Center Highlights: 

< Enrollment barriers avoided with a one-page, mail-in application, and adherence to a maximum 5-day 

processing period; 

< Established and funded, with other centers, a Managed care corporate structure, should managed 

care become mandatory; 

< Effective mode of outreach through expansion of school-based health programs; 

Challenge: Previous periods of capped reimbursement rates resulted in significant funding reductions to the 

center. While temporary, these periods raised concern over the approaching permanent phase-out of costbased reimbursement. 

South Carolina CHIP Model 

Prior to the Federal enactment of the CHIP legislation, the Governor of South Carolina, 

in February 1997, announced an initiative called Partners for Healthy Children, which 

aspired to provide health insurance to 50,000 additional children. With support from 

the legislature and private businesses, planning for a Medicaid expansion for children 

occurred as Congress deliberated the Federal legislation. The South Carolina 

Children’s Hospital Collaborative provided $3 million in matching funds for the 

expansion which, together with an appropriation by the General Assembly, allowed 

South Carolina to start accepting applications under the expanded eligibility rules on 

August 1, 1997. Because of its early start, South Carolina became the second State 

to have a CHIP plan approved, with Colorado being approved earlier on the same day.44 

With the enhanced Federal matching rate provided by CHIP, the estimated number of 

newly eligible children expanded to 75,000. We conducted our site visit to South 

Carolina in September 1998 when their CHIP Medicaid expansion had been in operation 

several months. 

South Carolina selected a Medicaid expansion model only for children whose family 

income is up to 150 percent of the Federal poverty level (FPL). These children receive 

all standard Medicaid benefits including Early Periodic Screening, Diagnosis and 

Treatment (EPSDT). Instead of instituting mandatory managed care, the State Medicaid 

program, in addition to its health maintenance organization option, developed two more 

voluntary managed care options tailored to the rural nature of the State. The first of 

these, called Physicians Enhanced Program (PEP), is a primary care capitation 

arrangement whereby physicians and health centers can contract for a bundle of 

primary care services, paid for by a monthly capitated fee. In this option, the primary 

care provider serves as a primary care case manager and must arrange referral services 

Federally Funded Health Centers and CHIP 41 OEI-06-98-00320 
for patients. The other option, called Healthy Options Program (HOP), is a model 

where the primary care provider agrees to serve as a “medical home” for the patient. 

For an enhanced office visit payment rate, the provider is available on-call to his/her 

patients and coordinates their care. However, this model does not include capitation 

or mandatory referrals for specialty care45. South Carolina has implemented 

continuous eligibility for 12 months, which should assist the process of establishing 

medical homes for children46. 

Health Center Background 

Family Health Centers in Orangeburg, a large center located in a rural area of the 

State, served about 36,000 patients in 1997. The health center consists of one main 

clinic, six satellite offices, and school-based clinics which operate at four locations. 

The health center director noted that expansion of their school-based program has been 

a priority in recent years. Due to this emphasis on school-based health care, over 43 

percent of the center’s patients are children and adolescents. This is the highest 

percentage of children served among all the Federal health centers in South Carolina. 

Overall, the health center population is 82 percent African-American.47 The main clinic 

provides a comprehensive range of preventive and primary care, as well as pharmacy 

and dental services. Additionally, for three months during the peak harvest season, the 

health center conducts outreach to migrant workers and provides services through use 

of a mobile clinic owned by the Medical University of South Carolina. 

Planning and Implementation 

Family Health Centers and the South Carolina Primary Care Association (PCA) reported 

some minor involvement in the planning and implementation of the Medicaid expansion 

for children. Legislative hearings were held in locations across the State, and 

testimony was provided by health centers in support of the expansion. The health 

centers were in agreement with the decision to implement CHIP by expanding the 

Medicaid program, since this provided the fastest and administratively easiest 

approach. The PCA member health centers considered pushing to expand income 

eligibility to 200 percent of the FPL. However, when the health centers examined their 

patient demographics, only small numbers of children came from families in the 150 

percent to 200 percent income range. Therefore, the Association did not press this 

issue. PCA staff indicated that implementation of the expansions had proceeded fairly 

smoothly with no major issues emerging. 

Outreach for CHIP 

South Carolina has enrolled over 50,000 of the projected 75,000 children newly 

eligible for Medicaid in the first year.48 This exceeded the State’s initial goal of 37,500 

for the first year of the program. To facilitate enrollment, the Medicaid program 

developed a one-page (two-sided) mail-in application form. Rather than using 

presumptive eligibility, they committed to processing eligibility applications within five 

days of receipt. Health centers have been a part of the State outreach effort. 

Federally Funded Health Centers and CHIP 42 OEI-06-98-00320 
Family Health Centers is serving as a site for an outreach demonstration project with 

the Medicaid program for targeted outreach activities. The center provided a list of all 

their uninsured children to the Medicaid office. Letters notifying the family of the 

expansions, with a mail-in application enclosed, were then sent by the Medicaid 

program. Of over 2,000 applications mailed only about 130 were returned. The health 

center director felt that a letter directly from the health center might have been more 

effective because of its relationship with the families and their ability to assist families 

in completing the applications. Beyond this project, Family Health Centers has an 

outstationed Medicaid intake worker at their main clinic to assist fee-for-service 

families with newly eligible children in completing applications for the Medicaid 

program. The center’s community health workers at the school-based clinics are also 

engaged in outreach activities. 

Schools were also the focus of Statewide outreach efforts. When the expansions 

were implemented in August 1997, the Medicaid program sent applications to all 

districts at the beginning of that school year. The number of submitted applications 

tripled to over 300 per week shortly after this mail-out. In addition to the health 

centers and schools, the State distributed applications to physicians’ offices, 

pharmacies, hospitals and child care centers throughout the State. Partnerships were 

also formed with the Baptist Convention, the African Methodist Episcopal Church and 

numerous other community groups to distribute applications through their networks. 

Even with the efforts described above, health center and PCA staff felt more outreach 

was necessary. The health center director felt without supplemental resources, centers 

should view these activities as short term investments with long-term payoffs. In 

particular, she emphasized the value of working with schools, since the health centers 

have established relationships there. The PCA director emphasized that families’ trust 

for their health providers is a significant factor in successful outreach, making health 

centers ideal focal points. She noted that the rural culture of South Carolina is more 

responsive to information provided by local people and organizations than Statewide 

initiatives. The ability of health centers to discuss the program with families and assist 

them with applications is critical in her view. 

However, resources for health center outreach activities are limited. No grants or 

application assistance payments are available. The PCA director stated that she would 

like to be able to assign staff to the health centers for two to three month periods. 

There they could devote full-time to explaining the program to children’s families or 

assisting them with applications while awaiting clinic appointments. This staff person 

could also call families and schedule appointments solely for outreach and enrollment 

purposes. 

Children in migrant and seasonal farm worker families were identified as needing 

intensified outreach activities. Because of South Carolina’s agricultural economy in 

rural areas, we also interviewed the coordinator of the State Migrant Health Program. 

The migrant worker population is very mobile, and follow-up regarding applications can 

be difficult. Currently, South Carolina does not have arrangements for portability or 

transferability49 of eligibility with surrounding States, and the migrant health staff we 

Federally Funded Health Centers and CHIP 43 OEI-06-98-00320 
met with would like to see this issue addressed. 

Some outreach regarding the Medicaid eligibility expansion has started in Migrant Head 

Start programs, and respondents felt that these activities should be increased. Family 

Health Centers and Carolina Health Centers,50 whose director we interviewed 

separately by telephone, were working with the Migrant Head Start programs on such 

efforts. Services to this population are often delivered by mobile clinic vans or in 

temporary clinics located at the migrant camps. Families in this population are now 

settling in the State to work in poultry processing plants, and more of their children are 

coming to the main clinic sites. There, language barriers need to be addressed, along 

with establishment of trust, since many citizen children have parents who may not be 

documented. 

Health Center Services for Children 

Primary/Preventive Services 

Family Health Centers offers children a comprehensive range of primary and preventive 

services. The services provided include prenatal care and delivery, immunizations, 

well-child care and primary care for illnesses. With a full pharmacy, the health center 

also participates in a pharmaceutical company’s cost-sharing program to assist low 

income, uninsured patients in receiving needed treatments. 

The health center has made a concerted effort in recent years to develop and expand 

its program of school-based clinics. It currently has four school clinics, staffed by nurse 

practitioners, and two additional schools have requested clinic services. The school 

clinics were implemented through Rural Demonstration Project funding through fiscal 

year 2000. The health center director is exploring sources of seed money to expand 

to these additional schools. Community health workers are also located at these 

school-based clinics to provide health education and outreach services. 

Enabling and Specialty Services 

Enabling services of case management, transportation and translation are also available 

to children served by the health center. Case management was emphasized as an 

important element in providing care. In particular, scheduling and follow-up on missed 

appointments for preventive care was felt to be significant. Although the Medicaid 

program had previously reimbursed the health centers directly for case management 

services, these functions are now provided under contract with the Health Department. 

However, the need for case management of services other than immunizations and 

well-child visits sites remains. Located in a very rural area, many of the health center’s 

patients have a significant need for transportation. Most specialty care for Medicaid 

and uninsured patients is provided by the University of South Carolina, located in 

Columbia, almost an hour’s drive away. However, only limited transportation is 

provided by the center. Of particular concern for pregnant women is the ambulance 

service based out of Columbia. In cases of pre-term labor, the hour long wait for an 

ambulance to transfer them to the University hospital represents a significant delay in 

Federally Funded Health Centers and CHIP 44 OEI-06-98-00320 
receiving needed specialty care. Although the majority of the health center’s patients 

are African American, bi-lingual staff and translation services are important to the 

provision of seasonal care to migrant worker families. Two physicians and one nurse 

speak Spanish. For translation needs in other families, and further outreach to the 

migrant population, the health center has an arrangement with South Carolina State 

University to provide additional translation services. 

Health education is another key component of Family Health Center’s program. For 

children, much of this is provided at the school-based clinic sites. The medical director 

indicated a desire to include substance abuse prevention education in their middle 

school sites. For young children, the health center staff is developing a parent’s 

education book on basic baby care and child health needs. Family Health Centers is 

one of several Federal health centers participating in a diabetes management, quality 

improvement project recently initiated by the Bureau of Primary Health Care. Children 

and adults with diabetes will be part of this initiative. 

The health center also provides a full dental program comprised of two dentists and 

four dental assistants. As we found in other health centers visited, the need for dental 

care by the center’s population strains their current capacity. Consequently, priority 

for dental appointments is given to children. 

CHIP Readiness 

Prior activities have prepared Family Health Centers for implementation of Medicaid 

managed care in South Carolina. The previous governor had submitted an 1115 Waiver 

to implement Medicaid managed care. As the waiver application was being developed, 

Family Health Centers, in conjunction with other Federally funded health centers in 

South Carolina and the PCA, obtained an Integrated Services Network grant from the 

Bureau of Primary Health Care to develop a managed care strategy. A for-profit 

corporation, Community Network, Inc., was formed with the director of Family Health 

Centers as president. Each health center made an investment of $25,000 and 

negotiations were conducted to partner with an existing managed care company in 

order to obtain additional capital and administrative expertise. When the waiver 

application was put on hold under a new State administration, Community Network 

decided not to enter into any Medicaid managed care contracts at that time. The 

corporate structure remains in place and provides the mechanism for the health centers 

to enter the managed care environment should Medicaid managed care expand beyond 

its currently limited voluntary program. 

Instead of instituting mandatory managed care, the State Medicaid program, in addition 

to its health maintenance organization option, developed two more voluntary managed 

care options tailored to the rural nature of the State. These programs, the Physicians 

Enhanced Program (PEP) and the Healthy Options Program (HOP) are types of primary 

care case management, as described in the State CHIP Model section. Family Health 

Centers is one of three Federal centers in South Carolina which, together with the 

PCA, is developing a demonstration project to experiment with PEP contracts in the 

Medicaid program. The Medicaid program and these health centers were, at the time 

Federally Funded Health Centers and CHIP 45 OEI-06-98-00320 
of our visit, negotiating the details of which health center services, such as 

transportation, outreach and social services, should be excluded from the capitation 

payment and billed separately to Medicaid. 

Family Health Centers and the PCA have made some business infra-structure 

enhancements, and would like to implement others, to adjust to these managed care 

options. They have automated their patient accounting function, including encounter 

data, accounts payable, Medicaid and Medicare billing, general ledger and pharmacy. 

Although they are not yet billing Medicaid on-line, the electronic claims are downloaded 

onto diskettes and sent to the carriers. The financial officer noted further 

enhancements being considered are converting from a UNIX system to a PC system, 

and adding an in-house MIS manager, a financial management staff person, another 

billing staff person, and a medical coder. 

The South Carolina PCA is also assisting the health centers in adjusting to the new 

health care environment through infra-structure assessments. They have arranged for 

a business consultant to assess each health center by looking for ways to decrease 

costs and enhance staff productivity. Each health center will be provided with a report 

of its assessment. The director of Carolina Health Centers whom we interviewed, 

also emphasized the importance of centers becoming more “business-minded.” He 

stated that more technical assistance to health centers on business operations is 

needed, and suggested that HRSA contract with private trainers specializing in medical 

practice and financial management. 

Although the health centers in South Carolina are currently receiving cost-based 

reimbursement, some issues were identified. During the 1990's, South Carolina has 

had two periods in which all Medicaid reimbursements, including those to health 

centers, were capped. Although the cap has recently been lifted, the Director of 

Family Health Centers noted that the center had lost about $14 per patient visit when 

the cap was in place. This caused the health center to enter a financial recovery plan 

to reduce costs when the cap was in effect. Dental reimbursements, at $38 per visit, 

were stated to be too low to cover the cost of providing these services. Currently, 

dental costs can be captured in the cost settlements. However, as cost-based 

reimbursement is phased out according to Federal requirements, further cost 

efficiencies will be needed. 

Key Factors for Success 

Family Health Centers is actively pursuing strategies to adjust to the Medicaid 

children’s expansion and the changing health care environment in South Carolina. 

They have made services to children a priority for the health center in recent years 

through expanding their school-based clinic program and looking forward to expansion 

in additional schools. Their dental program makes appointments for children a priority. 

Health education and outreach activities to children are also part of this strategy. 

Although mandatory Medicaid managed care has not yet come to this State, a 

corporate structure has been created to enable the health centers to enter such 

contracts in the future. Family Health Centers has been in the forefront of this effort. 

Federally Funded Health Centers and CHIP 46 OEI-06-98-00320 
This health center is also working with the PCA and the Medicaid program to launch 

a demonstration project involving health centers in the partially capitated Physician 

Enhanced Program for primary care 

Although most interviewees in South Carolina stated a need for increased outreach 

activities, the State has been one of the more successful in enrolling newly eligible 

children. By enrolling over 50,000 children in the first year of the expansion, South 

Carolina exceeded its program goal. Most respondents felt this success was due to 

simplified application processes, reaching children through the schools, and in-person 

contacts when families seek care for their children. Family Health Centers has 

engaged in these activities, as well as contacting fee-for-service families among their 

clientele to provide information about the expansions, encourage enrollment, and offer 

assistance with applications. However, the director felt that more activities, particularly 

in-person contacts, are needed. 

Two challenges to the success of the South Carolina children’s Medicaid expansions 

remain. One of them is to enroll children in migrant farm worker families and provide 

for their health care needs. Pursuing portability or transferability of eligibility was 

noted as one option to address this problem, but this policy change has not yet been 

developed. Additional bi-lingual outreach workers would also enhance the efforts to 

enroll this population. Family Health Centers has an opportunity to provide such 

outreach during the months when they operate the mobile clinic in migrant camps. 

Another challenge identified is to make the adjustments required by the phase-out of 

cost-based reimbursement for health center services, especially considering the 

enabling services the health center provides. Family Health Centers encountered 

serious financial difficulties when the Medicaid cap was in place in South Carolina and 

is quite concerned about this transition. The PCA and health centers are now studying 

ways to improve their cost efficiency in preparation for the revenue reductions which 

will result from this change. 

Federally Funded Health Centers and CHIP 47 OEI-06-98-00320 
HEALTH CENTERS OF NORTHERN N.M. 

Española, New Mexico 

State Model: Medicaid expansion only which closely followed an earlier State-initiated expansion, except 

for a cost-sharing element for families with higher incomes. 

Center Highlights: 

< Center development through the merger of small, independent clinics resulted in its continued 

existence and viability; 

< Provides specialty services targeting client needs, such as their Diabetes Control Program and an 

asthma clinic; 

< Demonstrates effective managed care in a rural setting; 

Challenge: Reimbursement issues remain, since center provides specialty services not included in current 

health plan contracts. Additionally, low and selective dental reimbursement rates are causing the center to 

consider discontinuing dental services altogether. 

New Mexico CHIP Model 

New Mexico had already experienced Medicaid expansion in a managed care setting 

when it came time to implement CHIP. In 1995, the State began expanding Medicaid 

eligibility for children in families with incomes up to 185 percent of the Federal poverty 

level (FPL), resulting in over 38,000 additional Medicaid children.51 Somewhat later, 

but still before CHIP, the State legislature decided that Medicaid in New Mexico would 

convert to a Statewide, managed care model. For a predominantly rural State, this was 

an ambitious plan. All Medicaid recipients are now under managed care except for 

Medicare-Medicaid eligibles and people in institutional care. 

As part of the Medicaid transition to managed care prior to CHIP, three managed care 

organizations succeeded in winning contracts with the Human Services Department. 

They are Presbyterian Salud, Lovelace Salud, and Cimmaron Salud, all Statewide 

organizations. Presbyterian and Lovelace are both Federally qualified health plans, while 

Cimmaron is not.52 Operating under the optional Medicaid expansions passed by the 

State, these organizations are poised to implement the additional expansion outlined 

in the State’s CHIP plan. 

At the time of our visit, in September 1998, the State’s CHIP proposal had been 

submitted to HCFA, but was still awaiting approval. Later, the plan was approved, 

basically as submitted, on January 11, 1999.53 Classified only as a Medicaid expansion 

State under CHIP, New Mexico’s approach is more creative than a standard expansion. 

The State proposed additional increases in Medicaid eligibility for families with incomes 

up to 235 percent FPL. Open to the Medicaid expansion concept, but uncomfortable 

with free entitlements to families above 185 percent FPL, the Governor and legislature 

compromised on a cost-sharing approach for families between 185 percent and 235 

Federally Funded Health Centers and CHIP 48 OEI-06-98-00320 
percent FPL. Under the proposal, each family pays a premium of 15 dollars per month 

regardless of household size or income level.54 Co-payments are assessed at the time 

of service delivery. However, once maximum annual limits are reached, families cease 

to have a co-payment requirement. The New Mexico CHIP proposal includes the 

implementation of continuous eligibility for 12 months to insure continuity of care, 

regardless of changes in income. This change should also reduce current administrative 

challenges of verifying eligibility on a monthly basis. 

Additional provisions discourage eligible families with private insurance from dropping 

their children’s coverage and enrolling them in the new program. When the State 

expanded Medicaid eligibility to 185 percent FPL, it found that 16 percent of those 

enrolled had private health insurance at the time of enrollment. Of that group, 25 

percent later dropped their private coverage.55 Thus, the State has proposed that 

children will be ineligible for 12 months from the date on which creditable health 

coverage was dropped. Exceptions are allowed for situations beyond the insured’s 

control. 

Health Center Background 

Health Centers of Northern New Mexico (HCNNM), a single health care entity with 

administrative offices in Española, is the result of the consolidation of various small, 

rural clinics. With the original Española clinic in operation since 1972, the other clinics 

merged with it in the 1980's and 1990's to ensure their longevity and financial 

stability. Today, HCNNM operates under a volunteer Board of Directors, many of whom 

are directors from the previously independent clinics. 

The center currently consists of 13 primary care clinic sites, one of which is a 

university student health center, and one dental facility. Services are provided in 12 

different towns, over seven counties. Despite their number of service delivery sites, 

HCNNM is a medium-sized health center with approximately 16,000 registered patients 

in 1997. Except for Las Vegas and Española, HCNNM sites are the only providers of 

health services in the rural communities. Since the counties served include some of the 

highest State rates of unemployment and families living below the Federal poverty 

level, HCNNM is vital to them. HCNNM also operates school-based clinics in Española 

at the middle and high school levels. Seventy-five percent of clients are Hispanic, with 

the center reporting that overall 13 percent of clients require bilingual or translation 

services. Approximately 40 percent of patients who receive services are children. 

Planning and Implementation 

HCNNM respondents felt they definitely had involvement in the CHIP planning process, 

but that it was almost exclusively through their Primary Care Association. Their PCA 

director sat on the State Medicaid advisory committee and advocated the health 

centers’ position in that forum. Yet, the process was not without controversy in the 

early design stages. A State official’s interpretation of regulations concluded that the 

State was only required to include one Federally Qualified Health Center (FQHC), a 

term which includes Federally funded health centers, in the managed care plan for the 

Federally Funded Health Centers and CHIP 49 OEI-06-98-00320 
whole State.56 Fearing that the health centers would have little influence in changing 

this direction, the PCA involved HCFA in the plan development process. Beyond center 

advocacy, networking through the PCA has also proved useful in the development of 

additional means for centers to compete in the managed care environment. HCNNM 

is involved, through a spin-off of the PCA, in the New Mexico Integrated Services 

Network. This entity was established among the FQHCs to function as the contracting 

entity with the health plans on behalf of the clinics. 

The end result of these involvements was a State requirement that each managed care 

contract with at least one FQHC within each service area. This was specifically defined 

as at least one FQHC per county. As a result, about three-quarters of New Mexico’s 

health centers would be covered under this agreement, but the rest could be 

considered duplicates within a county and subject to non-inclusion. However, due to 

the large geographic size of the counties and the State’s rural nature, respondents felt 

that more than one health center in some of these areas was needed to provide 

effective healthcare coverage. 

Overall, the HCNNM executive director indicated that the health centers developed 

many program suggestions by benchmarking with other States and were able to 

channel those recommendations into the CHIP planning process via their PCA. 

Examples of their proposals to the State included parameters of reasonable geographic 

and financial access and a specific model for cost-based reimbursement.57 

Outreach for CHIP 

New Mexico had undertaken a comprehensive outreach campaign following the 

implementation of Medicaid managed care. These actions are not considered CHIP 

outreach, since they involved the promotion of New Mexico’s Medicaid expansion prior 

to CHIP. However, because the State’s CHIP plan proposes to build on earlier Medicaid 

expansions, these outreach activities can be indicative of the State’s capabilities to 

market a new program to their population. A 24-hour phone bank was set up by the 

State to field calls and questions from the public regarding the Medicaid switch to 

managed care. Media campaigns were developed for TV, radio, and billboards to reach 

eligible populations. Six Statewide advocacy groups were also contracted to conduct 

outreach efforts to special needs populations, such as the mentally ill, American 

Indians, and those with HIV/AIDS. Each organization was paid between $15,000 and 

$20,000 to hold enrollment fairs Statewide. Since the State was continuing to mail out 

new paper Medicaid identification cards each month, informational mass mailings 

about Medicaid managed care were included with little additional effort. The Medicaid 

agency acknowledged that monthly identification cards are an out-dated method, 

which they hope to transition out of under CHIP. However, it did provide a regular 

communication link during the implementation of these new managed care programs. 

Federally Funded Health Centers and CHIP 50 OEI-06-98-00320 
HCNNM views the lack of both eligibility workers and compensation for enrollment 

activities as a hindrance to the enrollment of all eligible children into Medicaid managed 

care. For a time, the State only utilized about 20 out-stationed eligibility workers in 

hospitals. The PCA contends that placing workers in clinics is more effective for 

enrolling children than placing them in hospitals, since hospitals typically only see those 

who are very sick. However, at the time of our site visit, there were no eligibility 

workers, since the hospital workers had been withdrawn due to a breakdown in 

contract re-negotiations.58 Rather than replace these individuals, the State hoped that 

the institution of presumptive eligibility, along with an aggressive training/certification 

program, would allow all the significant partners a role in the outreach/enrollment 

process. At the time of our visit, 600 individuals, against a goal of 2,000, had already 

been trained in the outreach and enrollment process for placement in schools, 

hospitals, and community centers. 

The clinic director felt that HCNNM was effective in its ability to enroll the eligible 

children of undocumented families in managed care plans. Typically, these families first 

enter the system through provision of prenatal care or delivery services, and the health 

center is usually able to retain the child in the Medicaid program thereafter. 

Acknowledging parents’ fears, due to their status and the INS, the State’s policy of 

not asking for Social Security numbers from parents aids them in placing the children 

into the Medicaid program. 

HCNNM would like to play a significant role in outreach under the current Medicaid 

expansion, as well as CHIP, but is unsure if it will have the resources to do so. 

Currently, unable to add social workers to every clinic site, they are trying to target 

enrollment through their school-based clinics. The fact that school-based clinics only 

exist in Española at this time underscores the obvious limitations to this approach. Yet, 

the social workers who are on staff do serve other clinic sites on a rotating basis. 

Since every clinic is not always staffed with a social worker, the director admits that 

some hit and miss of contacting potential enrollees must be occurring. However, he 

thought that the bulk of eligible children who visited their clinics were being signed up. 

Clinic staff also noted that simplifying and shortening the application materials and 

form would improve the process. 

Health Center Services for Children 

Primary/Preventive Services 

HCNNM provides a full range of primary and preventative care to their children. 

HCNNM emphasizes family-oriented, comprehensive medical and dental health care 

with a focus on disease prevention and health promotion.59 Services include wellbaby/well-child care, immunizations, prenatal and OB/GYN care. The center is staffed 

with family practice physicians, physician assistants, family nurse practitioners, nurses, 

health educators, clinical social workers, dentists, dental hygienists, and dental 

assistants. Other primary and preventive services include nutrition counseling, 

communicable disease prevention, family planning, diet and weight management, and 

smoking cessation. 

Federally Funded Health Centers and CHIP 51 OEI-06-98-00320 
The health center operates school-based clinics at both the middle and high school in 

Española, and provides support for EPSDT screenings and immunizations for the 

elementary schools. These clinic sites operate with no Federal funding and rely instead 

upon the ability to bill some services to the State-supported Healthier Kids Fund. 

Clerical and administrative functions are funded by a small grant from the Department 

Of Health. Additional costs are covered by the HCNNM clinic system. 

HCNNM has a strong commitment to maintaining in-school delivery sites, despite the 

challenges of incorporating them into managed care. In general, health plans do not 

contract with the school-based clinics, although children do have the option of naming 

a school-based clinic as their primary care provider. Refusing to adopt a policy of only 

seeing select children in its school clinics, the center uses their Federal grant funds to 

subsidize costs incurred while treating children who do not select the school site as 

their primary care provider. HCNNM is trying to negotiate a role for the school-based 

clinics in the current managed care plans. One option is to allow reimbursement for 

services administered in the schools. These services could be limited to a list of the 

most frequently used CPT codes mutually identified by the center and health plan.60 

Enabling and Specialty Services 

HCNNM offers some enabling services in addition to their primary care offerings. 

Formal translation services are not provided per se, but a good share of the clinical 

staff, including nurses and front office personnel, are bilingual. With such a large, rural 

area to cover, transportation barriers are a constant challenge. The health center is 

able to offer transportation services through the managed care organizations, who 

contract with independent providers of travel services. In cases requiring extensive 

travel, food and travel benefits may also be covered. 

The center has shown a commitment to providing selective, but needed, specialty 

services for its patients. For example, their Diabetes Control Program has become an 

integral part of the HCNNM services. The center director contends that diabetes is the 

major medical problem, other than drugs and alcohol, among the Hispanic population. 

In addition, they’re seeing Type II diabetes at increasingly younger ages. With two 

certified diabetic educators on staff, the program utilizes lay health advisors, who are 

diabetics themselves, to educate and train patients about life-style changes important 

to controlling the disease. Other innovative programs include the development of an 

asthma clinic for children. Although the center currently subsidizes the programs, 

which are not reimbursed under managed care, they are working with plans to include 

them as billable services. With adequate funding, they feel that these programs could 

be expanded. Yet, since managed care plans are often slow to recognize the benefits 

of services which fall outside of standard practice, HCNNM must try to “sell” the idea 

that such enterprises actually contain or reduce costs and improve the health status 

of susceptible clients. 

Preventive and restorative dentistry is available from HCNNM through the dental clinic 

site. The only dental provider, other than the single HCNNM location, is roughly 50 

miles away. Although adult dental needs in the area are great, limited capacity has 

Federally Funded Health Centers and CHIP 52 OEI-06-98-00320 
forced HCNNM to only accept children at this time. Dental conditions observed among 

these children are comparable to those of the general U.S. population in the 1950's.61 

Some frustration has resulted because only selective benefits are covered under the 

current dental plan. As an example, expensive restorative measures, such as crowns, 

are covered, while preventive procedures, like pulp caps, are not.62 On another issue, 

the dental director believes that heavy metal amalgams should not be used for 

children’s fillings, yet the current plan won’t pay for composite fillings. Despite the 

obvious need, the current low dental reimbursement rates are causing HCNNM to 

consider discontinuance of its dental services altogether. 

CHIP Readiness 

To insure its viability, HCNNM had completed progressive restructuring before the 

introduction of managed care and CHIP. Through consolidation of free-standing clinics 

over the past two decades, the center now provides services from 13 sites in 12 

towns. As a result, it is almost guaranteed inclusion in any significant health network 

in Northern New Mexico due to the large territory it serves and, in many cases, its 

being the only health care provider in those areas. Having already experienced a 

Statewide conversion of Medicaid to managed care, the center’s mode of operation 

should not be impacted by expansions under CHIP. 

HCNNM has been aggressive in its provision of specialty services to its clients. The 

asthma clinic and Diabetes Control Program are being utilized, and may even warrant 

expansion, before reimbursement agreements have been secured with the managed 

care organizations. Although the health center is committed to these programs, 

securing adequate reimbursement is needed to guarantee funding for the long term. 

HCNNM provides dental services, that are reimbursed through a carve-out contract, 

which is administered by an out-of-State entity. The center considers dental 

reimbursement rates too low but reported the State’s intentions to provide additional 

dental funding with forthcoming legislation. It is hoped that raising the reimbursement 

level will entice other providers to offer dental services to Medicaid recipients, which 

will reduce the number of individuals not served due to limited capacity. 

Key Factors for Success 

The early foresight of HCNNM to merge with other small clinics is likely to be a 

significant factor in their continued existence. Well before managed care, they realized 

the increased stability and opportunities such action could bring. Being a larger 

organization, HCNNM is probably able to recruit management personnel of a higher skill 

and experience level than rural, free-standing clinics. This has aided them in their 

mission to serve their communities and maintain a significant service role under Stateinstituted managed care and Medicaid expansions. 

HCNNM has maintained its commitment to providing quality health care to the 

underserved and has been aggressive in addressing emerging issues through its 

programming. The development of services targeting those with asthma and diabetes 

is a response to the increase in these diseases among their target populations. HCNNM 

Federally Funded Health Centers and CHIP 53 OEI-06-98-00320 
has also realized that, because of transportation barriers and other factors, they could 

reach more children through schools and, therefore, have invested resources in their 

school-based clinics. These ventures make HCNNM highly effective in serving its 

clients. However, since many of these programs have not yet been included in 

contracts with health plans, HCNNM is not currently being reimbursed for them. 

Clearly, the center cannot continue to fund a variety of programs exclusively on its 

own, although it appears willing to do so if necessary. The ability of HCNNM to 

demonstrate, to the managed care plans, the long-term benefits and savings resulting 

from such innovative programming and the extent to which they can be incorporated 

into reimbursement contracts, will greatly impact the long term success of the center 

and the care it provides. 

Despite their own and the State’s efforts, HCNNM still perceives a deficit in outreach 

activities. Although the HCNNM took issue with both the State’s placement of 

eligibility workers in the hospitals, as well as the inability to settle the contract 

disputes, whether that loss will be compensated for by the additional 600 trained 

eligibility workers, and the promise of more, remains to be seen. It is likely that the 

training program will significantly improve outreach effectiveness. However, from the 

health center’s standpoint, they are still unable to staff every clinic site with a full-time 

outreach worker. They perceive that any State outreach agenda should include aid to 

clinics for adding their own outreach personnel. 

Federally Funded Health Centers and CHIP 54 OEI-06-98-00320 
ENDNOTES

1. Primary Care Associations (PCAs) are State-based membership organizations that 

represent safety-net providers in their efforts to increase access to preventative and 

primary care services and to improve the health status of underserved and vulnerable 

populations. The major sources of funding for PCAs are membership dues and grants 

from the Health Resources and Services Administration (HRSA) Bureau of Primary 

Health Care (BPHC). In addition, PCAs receive funding from other sources including 

States and private foundations. 

2. Sara Rosenbaum, Kay Johnson, Colleen Sonosky, Anne Markus and Chris DeGraw, “The 

Children’s Hour: The State Children’s Health Insurance Program,” Health Affairs, 

January/February 1998, pp. 75-89. 

3. Ibid. 

4. Neal Halfon, Moira Inkelas, Helen DuPlessis and Paul W. Newacheck, “Challenges in 

Securing Access to Care for Children,” Health Affairs, March/April 1999, pp. 48-63. 

5. The 70 percent enrollment rate refers to Medicaid eligible children who do not have 

private insurance. Thomas M. Selden, Jessica S. Banthin, and Joel W. Cohen, 

“Medicaid’s Problem Children: Eligible But Not Enrolled,” Health Affairs, May/June 

1998, pp. 192 -200. The authors used the 1996 data from the Medical Expenditure Panel 

Survey which is believed to capture the most comprehensive data available in a national 

survey regarding Medicaid enrollment. 

6. Margaret Edmunds and Molly Joel Coyce, eds., America’s Children: Health Insurance 

and Access to Care,” Institute of Medicine, National Research Council, 1998. 

7. Sara Rosenbaum, Barbara M. Smith, Peter Shin, Marcie H. Zakheim, Karen Shaw, 

Colleen A. Sonosky and Lee Repasch, Negotiating The New Health System: A National 

Study of Medicaid Managed Care Contracts, The George Washington University Center 

for Health Policy Research, February 1998. 

8. The Lewin Group, Evaluation of the Impact of the Medicaid Waivers on Consumers and 

Services of Federally Qualified Health Centers, November 1997. 

9. Stephen A. Norton and Debra J. Lipson, Public Policy, Market Forces, and the Viability 

of Safety Net Providers, The Urban Institute, 1998. 

10. Colleen M. Grogan and Michael K. Gusmano, “How Are Safety-Net Providers Faring 

Under Medicaid Managed Care?” Health Affairs, March/April 1999, pp. 233 - 237. 

Federally Funded Health Centers and CHIP 55 OEI-06-98-00320 
11. Debra J. Lipson and Naomi Naierman, “Effects of Health Systems Changes On Safety-Net 

Providers,” Health Affairs, Summer 1996, pp. 33 - 47. 

12. Debra J. Lipson, “Medicaid Managed Care and Community Providers: New Partnerships,” 

Health Affairs, July/August 1997, pp. 91 - 107. 

13. Ibid. 

14. We originally planned to visit a seventh site where the health center also received a grant 

to operate a Health Care for the Homeless program. However, injury of a study team 

member caused us to cancel this site visit. We conducted a telephone interview with the 

Executive Director of this center and members of his staff. Issues and insights from this 

interview are incorporated in the design of the national survey. 

15. Due to scheduling difficulties a few interviews were conducted by telephone with managed 

care organizations. 

16. We are very appreciative of the time spent and feedback from the Connecticut 

interviewees in honing our data collection tools. 

17. Due to taping problems in very few interviews, parts or all of these interviews were 

summarized from interviewer notes. 

18. QSR NUD*IST 4, 2nd edition. 

19. Connecticut State Child Health Plan Under Title XXI of the Social Security Act: The 

HUSKY Plan, John Rowland Governor, State of Connecticut, January 7, 1998. 

20. Fair Haven Health Center Uniform Data System Annual Report, 1997. 

21. The flier was targeted roughly at the estimated 4th grade reading level of their clientele. 

22. Connecticut Department of Social Services Request for Proposals, Outreach for the 

HUSKY Program, 1998. 

23. Interview of Katrina Clark, Executive Director, Fair Haven Community Health Center, 

August 18, 1998. 

24. Memorandum of Agreement, Connecticut Department of Social Services and the Federally 

Qualified Health Centers, May 15, 1998. 

25. Healthy Families Handbook, State of California, July 1998. 

26. La Clínica de la Raza Uniform Data System Annual Report, 1997. 

27. The public charge issue is discussed at more length in a separate OEI report regarding 

CHIP and Medicaid application processes, The Children’s Health Insurance Program: 

Federally Funded Health Centers and CHIP 56 OEI-06-98-00320 
State Application and Enrollment Processes: An Early Report from the Front Lines, 

OEI-05-98-00310. 

28. “Immigration Update,” California Primary Care Association, 1998. 

29. Memorandum from Pieternel Barel, July 23, 1999. 

30. “Public Charge Fact Sheet,” Department of Justice, Immigration and Naturalization 

Service, May 25, 1999. 

31. Although 60 percent of the Healthy Families target population is estimated to be Latino in 

California, only 22 percent of early enrollees were of Latin American descent. 

“Immigration Update,” California Primary Care Association, 1998. 

32. “Healthy Families Program 1988-1999 Community Provider Plan Designation,” Managed 

Risk Medical Insurance Board, 1998. 

33. Interview of Jane Garcia, Executive Director, La Clínica de la Raza, September 3, 1998. 

34. MIChild Bulletin, MIChild Eligibility 98-01, State of Michigan. 

35. MIChild Contract between the Michigan Department of Community Health (template). 

36. Cherry Street Health Services UDS report, February, 1998. 

37. Ibid. 

38. Memorandum of Agreement Between Medical Services Administration and a Federally 

Qualified Health Center (FQHC), July 1, 1997. 

39. Free & Low-Cost Health Insurance: Children You Know are Missing Out, Donna Cohen 

Ross and Wendy Jacobson, Center on Budget and Policy Priorities, 1998. 

40. From the State of Colorado CHP+/Baby Care Kids Care application. 

41. From the State of Colorado CHP+/Baby Care Kids Care application. 

42. A visit co-payment is usually five dollars. A center then submits a write-off to the State 

which reimburses 27 percent of the center’s costs. The remaining percent (roughly 70%) is 

absorbed by the center internally. 

43. According to the Primary Care Association director, HCFA made the decision, based on 

Federal law, that the health centers could not use the discounted vaccines under a 

freestanding commercial plan. Health centers would then need to find alternative ways to 

purchase vaccines for children under the CHP+ plan. The director noted that the Primary 

Care Association had plans to try to change the law at the national level so that States 

who chose a non-Medicaid approach could use these vaccines for children. 

Federally Funded Health Centers and CHIP 57 OEI-06-98-00320 
44. Partners for Healthy Children in South Carolina, Governor David M. Beasley, 

September 1, 1998. 

45. Medicaid Managed Care materials provided by South Carolina Medicaid Program, 

September, 1998. 

46. Informational materials provided by the South Carolina Medicaid Program, September, 

1998. 

47. Family Health Center Uniform Data System Annual Report, 1997. 

48. Partners for Healthy Children in South Carolina, Governor David M. Beasley, 

September 1, 1998. 

49. Portability of coverage refers to the ability of the family to use South Carolina Medicaid 

coverage in another State. Transferability refers to reciprocal agreements between States 

to accept the eligibility status as determined by the original State. 

50. We conducted a telephone interview with the director of Carolina Health Center because 

this center has a Migrant Health Center grant to serve this population. 

51. Model Application Template for State Child Health Plan Under Title XXI of the Social 

Security Act State Children’s Health Insurance Program, State of New Mexico. 

52. Cimmaron members can switch primary care providers or health plans every 30 days, 

while those under Presbyterian Salud or Lovelace are subject to a 6 month lock-in. 

53. A Health and Human Services press release dated January 11, 1999 announced the 

approval of New Mexico’s plan for children’s health insurance. 

54. Ibid. 

55. Model Application Template for State Child Health Plan Under Title XXI of the Social 

Security Act State Children’s Health Insurance Program, State of New Mexico. 

56. According to the PCA director, a previous Secretary of Human Services Department 

interpreted regulations as only requiring that at least one Federally Qualified Health Center 

(FQHC) be involved in the State’s managed care plan under CHIP. This official is no 

longer in the position, and HCFA got involved in the process which determined that 

HMOs would have to contract with one FQHC per county. 

57. Interviewees referred to this as the “Wisconsin model,” although we were unable to 

determine the specific characteristics of this “model.” 

58. The PCA director reported that contract negotiations broke down between the State and 

the hospitals. The Human Services Department stated that the contract simply couldn’t be 

re-negotiated. However, the hospitals claim that although the Human Services Department 

Federally Funded Health Centers and CHIP 58 OEI-06-98-00320 
was receiving 50 percent reimbursement from the Federal government, for the eligibility 

workers, and were responsible for matching the other 50 percent, they attempted to bill 

the hospital for the full amount. 

59. Health Centers of Northern New Mexico, Caring For You..., Informational Brochure. 

60. CPT stands for common procedural terminology. These codes are utilized by health care 

providers in billing insurers. 

61. This comparison was drawn by the Senior Dentist of Health Centers of Northern New 

Mexico. 

62. A pulp cap covers an area of small exposure due to decay and prevents further damage, 

while a crown covers the entire tooth when too much surface damage has occurred. 

Federally Funded Health Centers and CHIP 59 OEI-06-98-00320 
BIBLIOGRAPHY

Bureau of Primary Health Care, Department of Health and Human Services and National 

Association of Community Health Centers, Inc., Final Report: 1998 Health Center Clinic Hours 

and Services, 1999. 

Cousineau, Michael R. and Eve Wittenberg, Study of the Health Care for the Homeless Program, 

Bureau of Primary Health Care, September 1995. 

Edmunds, Margaret and Molly Joel Coyce, eds., America’s Children: Health Insurance and 

Access to Care, Institute of Medicine, National Research Council, 1998. 

Feld, Peter, Courtney Matlock, and David R. Sandman, Insuring the Children of New York City’s 

Low-Income Families: Focus Group Findings on Barriers to Enrollment in Medicaid and Child 

Health Plus, The Commonwealth Fund, December 1998. 

The George Washington University Center for Health Policy Research, “Expansions of Coverage, 

Managed Care Create New Outreach Challenges,” Health Policy, Child Health, Vol. 2, No. 1, 

Winter 1995. 

The George Washington University Center for Health Policy Research, “Implementing Title XXI: 

States Face Choices,” Health Policy, Child Health, Vol. 4, No. 4, Fall 1997. 

Grogan, Colleen M. and Michael K. Gusmano, “How Are Safety-Net Providers Faring Under 

Medicaid Managed Care,” Health Affairs, March/April 1999, pp. 233-237. 

Halfon, Neal, Moira Inkelas, Helen DuPlessis and Paul W. Newacheck, “Challenges in Securing 

Access to Care for Children,” Health Affairs, March/April 1999, pp. 48-63. 

Hall, Christopher H., Mary Alice Lee, and Judith Solomon, “The Children’s Health Council: A 

Community Foundation/State Government Partnership,” Health Affairs, July/August 1999, pp. 

167 - 171. 

Immigration and Naturalization Service, Department of Justice, “Public Charge Fact Sheet,” May 

25, 1999. 

The Lewin Group, Evaluation of the Impact of the Medicaid Waivers on Consumers and Services 

of Federally Qualified Health Centers, November 1997. 

Federally Funded Health Centers and CHIP 60 OEI-06-98-00320 
The Lewin Group, The Impact of Expanding Children’s Health Insurance on the Role of 

Maternal and Child Health Title V Programs, May 20, 1998. 

Lipson, Debra J., “Medicaid Managed Care and Community Providers: New Partnerships, Health 

Affairs, July/August 1997, pp.91-107. 

Lipson, Debra J. and Naomi Naierman, “Effects of Health Systems Changes on Safety-Net 

Providers, Health Affairs, Summer 1996, pp. 33-47. 

Norton, Stephen A. and Debra Lipson, Public Policy, Market Forces and the Viability of Safety 

Net Providers, The Urban Institute, 1998. 

Office of Inspector General, Department of Health and Human Services, School-Based Health 

Centers and Managed Care, OEI-05-92-00680, December 1993. 

Office of Inspector General, Department of Health and Human Services, The Children’s Health 

Insurance Program: State Application and Enrollment Processes An Early Report from the Front 

Lines, OEI-05-98-00310, 1999. 

Riley, Trish, “How Will We Know If CHIP Is Working?” Health Affairs, March/April 1999, 

pp.64-66. 

Rosenbaum, Sara, Kay Johnson, Colleen Sonosky, Anne Markus and Chris DeGray, “The 

Children’s Hour: The State Children’s Health Insurance Program,” Health Affairs, 

January/February 1998, pp. 75-89. 

Rosenbaum, Sara, Barbara M. Smith, Peter Shin, Marcie H. Zakheim, Karen Shaw, Colleen A. 

Sonosky and Lee Repasch, Negotiating The New Health System: A National Study of Medicaid 

Managed Care Contracts, The George Washington University Center for Health Policy Research, 

February 1998. 

Ross, Donna Cohen and Wendy Jacobson, Free and Low-Cost Health Insurance: Children You 

Know are Missing Out, Center on Budget and Policy Priorities, 1998. 

Schauffler, Helen Halpin and Jessica Wolin, “Community Health Clinics under Managed 

Competition: Navigating Uncharted Waters,” Journal of Health Politics, Policy and Law, Vol. 21, 

No. 3, Fall 1996, pp.461- 488 

Selden, Thomas M., Jessica S. Banthin, and Joel W. Cohen, “Medicaid’s Problem Children: 

Eligible But Not Enrolled,” Health Affairs, May/June 1998, pp.192-200. 

Federally Funded Health Centers and CHIP 61 OEI-06-98-00320 
APPENDIX A

DOCUMENTS REVIEWED

Title Author/Agency Date 

CALIFORNIA 

Expanding Healthy California Primary Care Association 10/98 

Horizons 

Community Health CPCA - Carmela Castellano, JD, CEO 07/98 

Centers and Healthy 

Families 

Immigration Update California Primary Care Association 08/98 

Newsletter - CPCA California Primary Care Association 08/98 

Strengthens Clinic Role in 

Rural Projects 

Letter to Sidney Trieger - CPCA - Carmela Castellano, Esq., CEO 07/98 

California Compliance 

with Balanced Budget 

Act 

Senate Bill - An act to Introduced by Senator Rosenthal 02/97 

amend Section 14087- (Principal coauthor: Senator Watson) 

325 of the Welfare and 

Institutions Code, relating 

to public social services. 

Healthy Families Program Managed Risk Medical Insurance 09/98 

Subscribers Enrolled By Board Home Page 

Ethnicity 

Letter to Carmela DHHS/Health Care Financing 09/98 

Castellano, Esq., CEO Administration 

Affordable Health Care State of California 07/98 

For Children and Teens 

Handbooks 

Federally Funded Health Centers and CHIP 62 OEI-06-98-00320 
Title Author/Agency Date 

CALIFORNIA continued 

Social Security Act1902(a)(55) 

Welfare and Institutions 

Code 

42 CAR 435.904 

OBRA 90 - Outstanding 

Mandate 

State Medicaid Manual -

Section 2905 

Letter to Hospital/Clinic 

Administrator 

Memo to All County 

Welfare Directors, 

Administrative Officers, 

Medi-Cal Program 

Specialist/Liaisons, 

Outstationed Eligibility 

Workers Coordinators 

Medical Service 

Agreement between 

Alameda Alliance for 

Health & Community 

Health Center Network 

Letter to Providers on 

Healthy Families Program 

Media Release 

California Kids Enrollment 

Form 

Social Security Administration N/A 

State of California N/A 

DHSS/HCFA N/A 

Social Security Administration N/A 

DHSS/HCFA 06/91 

DHSS/State of Carolina - Health and N/A

Welfare Agency

Outstanding Eligibility Worker (EW) 35856

Program Petitions and Reporting

Update

Community Health Center Network N/A

Blue Cross of California 35954

Latino Coalition for a Healthy 35977

California

La Clínica de La Raza N/A

Federally Funded Health Centers and CHIP 63 OEI-06-98-00320 
Title Author/Agency Date 

FQHC Reconciliation Alameda Alliance for Health 36041 

Statement 

CALIFORNIA continued 

Medical Service Alameda Alliance for Health N/A 

Agreement between 

Alameda Alliance for 

Health & Alameda 

County Ambulatory Care 

Amended and Restated Alameda Alliance for Health N/A 

Medical Service 

Agreement between 

Alameda Alliance for 

Health & Community 

Health Center Network 

Quality Health Care For Alameda Alliance for Health 

Your Children Brochure 

Instruction on usage of Alameda Alliance for Health N/A 

Co-Pay Card, Guidelines 

for Children’s Checkups, 

Customer Complaint 

Forms, Provider List 

Letter to Providers on Alameda County Health Care Services 35957 

Healthy Families Agency 

Combined Evidence of Alameda Alliance for Health N/A 

Coverage & Disclosure 

Form 

Article 4. Risk Categories N/A N/A 

and Family Contributions 

Health Plan Model Healthy Families Program N/A 

Contract 

Federally Funded Health Centers and CHIP 64 OEI-06-98-00320 
Title Author/Agency Date 

CALIFORNIA continued 

Memorandum to Sandra Sara Rosenbaum, GWUMC/CHPR 35748 

Shewry, MRMIB - Re: The George Washington University 

Defining what constitutes Medical Center 

a “community provider” 

under the Health Family 

Program 

Letter to Clifford L. Mark D. Smith, M.D., M.B.A. - 35767 

Allenby, Chair, Managed California Health Care Foundation 

Risk Medical Insurance 

Board 

HFP Subscribers Enrolled Healthy Families Program 36028 

in CPP By County 

1998-99 Community Healthy Families Program N/A 

Provider Plan Designation 

Hospital Providers By Healthy Families Program 35823 

County 

Clinic Providers By Healthy Families Program N/A 

County 

COLORADO 

Parents Handbook Child Health Plan Plus (CHP+) N/A 

Here’s How To Make Child Health Plan Plus (CHP+) N/A 

Your Monthly 

Payments... 

Benefits Booklet Child Health Plan Plus (CHP+) N/A 

Choose An MCO - Child Health Plan Plus (CHP+) N/A 

(Information Packet) 

Provider Manual Colorado Access 05/98 

Member Handbook, Colorado Access N/A 

Provider Directory, 

Evidence of Coverage, 

Provider Bulletin 

Federally Funded Health Centers and CHIP 65 OEI-06-98-00320 
Title Author/Agency Date 

. 

COLORADO continued 

Center/Grantee Profile - Plan de Salud del Valle, Inc 35840 

Cover Sheet 

Listing of Community Colorado Community Health Network N/A 

Health Centers/Federally 

Qualified Health Centers 

10 Ways To Tell the Colorado Community Health Network N/A 

Difference Between A 

Community Health Center 

& A Rural Health Clinic 

Charts on Health Center Colorado Community Health Network N/A 

Patients 

Application for Health Child Health Plan Plus (CHP+) N/A 

Care for Colorado 

Children 

CONNECTICUT 

MOA between Dept of Connecticut Department of Social 35928 

Social Services & Services 

Community Health 

Network of Connecticut, 

Inc. 

Center/Grantee Profile - Fair Haven Community Health Center 35840 

Cover Sheet 

Request For Application - Department of Social Services N/A 

Outreach for the HUSKY 

Program 

Utilization and Quality Connecticut Community Health N/A 

Data, Directory of Centers 

Members, 

Conference on Connecticut Primary Care Association 35969 

Collaboration 

Federally Funded Health Centers and CHIP 66 OEI-06-98-00320 
Title Author/Agency Date 

CONNECTICUT 

continued 

State Child Health Plan 

Under Title XXI of the 

Social Security Act 

Purchase of Service 

Contract Between The 

CT Dept of Social 

Services & HealthRight, 

Inc. 

Letter to Joyce Thomas, 

Commissioner, DSS 

MICHIGAN 

Memorandum of 

Agreement Between the 

Medical Services 

Administration and 

State of Connecticut 

State of Connecticut 

DHHS/HCFA 

Robert M. Smedes

Chief Executive Officer

Medical Services Administration

Michigan Department of Community

35801 

N/A 

34899 

35611 

1998 

35828 

36019 

Federally Qualified Health Health 

Centers 

Brochure: Cherry Street 

Health Services 

Introduces a New 

Opportunity for 

Uninsured Children in 

Michigan 

Testimony to House 

Appropriations SubCommittee Re: MIChild 

Proposed Plan 

Letter to Althia Carr Re: 

MIChild Application 

Chris Shea

Executive Director

Cherry Street Health Services

Michigan Primary Care Association

Katheryn Harstad

Farmworker Legal Services

Federally Funded Health Centers and CHIP 67 OEI-06-98-00320 
Title Author/Agency Date 

MICHIGAN continued 

Letter to Mr. Richard Robert M. Smedes 35858 

Fenton Re: Michigan’s Chief Executive Officer 

Response to HCFA Medical Services Administration 

questions regarding Michigan Department of Community 

SCHIP application Health 

Substitute for Michigan Michigan House of Representatives 1998 

House Bill No. 5532 

MiChild appropriations 

MIChild Contract Michigan Department of Community 35946 

Health 

MIChild Member Community Choice Michigan June 1998 

Handbook 

MIChild Application Michigan Department of Community 1998 

Health 

MIChild Certificate of Community Choice June 1998 

Coverage 

Primary Care Group Community Choice Michigan October 

Aggreement 1997 

Provider Services Community Choice Michigan August 

Agreement Risk Sharing 1997 

Addendum 

MIChild Eligibility Manual Michigan Department of Community 35946 

98-01 Health 

MIChild and Healthy Kids Michigan Family Independence 35960 

Application Agency 

NEW MEXICO 

Memo: Amendment to New Mexico Human Services 36055 

FQHC Agreement. From: 

Charles Milligan, Director 

Member Handbook Cimarron Salud (Health Plan) N/A 

(Bilingual) 

Michigan 

Federally Funded Health Centers and CHIP 68 OEI-06-98-00320 
Title Author/Agency Date 

NEW MEXICO continued 

Member Handbook Presbyterian Salud (Health Plan) N/A 

(Bilingual) 

Member Handbook 1998 Lovelace Community Health Plan 36068 

(A Salud Program) 

New Mexico Managed Health Centers of Northern New N/A 

Care Program- SALUD to Mexico 

Your Health: Pamplets, 

Newsletters 

Presumptive Eligibility Medical Assistance Division 35976 

and Medicaid On Site 

Application Assistance 

Training 

Provider Policies Health Care Professional Services 34730 

Intake/Admission Criteria N/A 34221 

Letter: Albuquerque Girl’s State of New Mexico - Children, N/A 

Community Residential Youth and Families Department -

Facility - Admission Juvenile Justice Division 

Criteria 

EPSDT Psychosocial New Mexico Child and Adolescent 05/96 

Rehabilitation Level of Mental Health Services 

Care Assessment 

Abstract Criteria 

Memo to: Steve Smith, New Mexico Human Services N/A 

Executive Account Department 

Manager - Re: Request 

for Ad hoc (Services) 

Memo to: Salud Managed New Mexico Human Services 35582 

Care - Re: Guidance Department 

Memorandum #8 - Native 

American Issues 

Federally Funded Health Centers and CHIP 69 OEI-06-98-00320 
Title Author/Agency Date 

New Mexico continued 

Memo to: Salud New Mexico Human Services 35572 

Managed Care - Re: Department 

Guidance Memorandum 

#7 - Questions 

Memo to: Salud Managed New Mexico Human Services 35571 

Care - Re: Guidance Department 

Memorandum #6 - MCO 

Client-specific Requests 

for Current UR Files 

Memo to: Salud Managed New Mexico Human Services 35565 

Care - Re: Guidance Department 

Memorandum #5 -

Marketing Guidelines 

Memo to: Salud Managed New Mexico Human Services 35555 

Care Contractors - Re: Department 

Guidance Implementation 

Memorandum #4 

Memo to: Salud Managed New Mexico Human Services 35549 

Care Contractors - Re: Department 

Guidance Implementation 

Memorandum #3 

HSD Response to Benefit New Mexico Human Services N/A 

Questions Department 

Memo To: Salud New Mexico Human Services 35535 

Managed Care Department 

Organization - Re: 

Guidance Implementation 

Memorandum #1 

Salud Managed Care N/A 35990 

General Program 

Description 

Federally Funded Health Centers and CHIP 70 OEI-06-98-00320 
Title Author/Agency Date 

NEW MEXICO continued

SALUD Enrollees By Plan N/A 36039 

For The September 98 

Capitation 

State Children’s Health New Mexico Human Services N/A 

Insurance Program Department 

(SCHIP) - (Title XIX) 

Medicaid - Proposed 

Regulations 

Evaluation of MCOs New Mexico Human Services N/A 

Performance Against NM Department 

Quality Management 

Standards 

Model Application N/A N/A 

Template for State Child 

Health Plan Under Title 

XXI of the Social Security 

Act - State Children’s 

Health Insurance Program 

Medicaid Managed Care State of New Mexico - New Mexico N/A 

Services Agreement - Human Services Department 

Presbyterian Health Plan. 

Inc. of Albuquerque, New 

Mexico 

Medicaid Managed Care State of New Mexico - New Mexico N/A 

Services Agreement - Human Services Department 

Cimarron Health 

Maintenance 

Organization, of Las 

Cruces 

Medicaid Managed Care State of New Mexico - New Mexico N/A 

Service Agreement - Human Services Department 

Lovelace Health Plan of 

Albuquerque, New 

Mexico 

Federally Funded Health Centers and CHIP 71 OEI-06-98-00320 
Title Author/Agency Date 

SOUTH CAROLINA.

Medicaid Program State of South Carolina 35550 

Handbook 

Migrant Health Program N/A 35838 

Chart 

Managed Care Options NA N/A 

A New Choice Booklet Medicaid Managed Care Health Plans N/A 

Partners for Healthy Family Health Centers, Inc., N/A 

Children Packet Orangeburg 

Packet for Applicants S. Carolina Partners for Healthy N/A 

whose Counties do not Children 

have HMOs 

Contract Between South N/A N/A 

Carolina DHSS and _____ 

For Purchase and 

Provision of Medical 

Services Under the S. 

Carolina Medicaid HMO 

Program 

Federally Funded Health Centers and CHIP 72 OEI-06-98-00320