Improving the Implementation of State Children's Health Insurance Programs for Adolescents Report of an Invitational Conference Sponsored by the American Academy of Pediatrics, Section on Adolescent Health*, September 26–27, 1999 (2000)

The enactment of the State Children's Health Insurance Program (SCHIP)‡ in 1997 and Medicaid eligibility expansions over the past decade have enormous implications for all children, and particularly for adolescents. While adolescents continue to lack insurance at a higher rate than most other age groups in the United States, large numbers of adolescents are eligible for, but not enrolled in, Medicaid and SCHIP. Even for those who are enrolled, additional barriers impede them from fully benefiting from the coverage they have.American Academy of Pediatrics (AAP) projections for the year 2000 suggest that 1 in 6 adolescents 13 through 18 years old will be without insurance, despite SCHIP and Medicaid expansions. Since 1991, adolescent uninsurance rates have averaged 16.5%. Many more adolescents are underinsured, with health insurance that does not include preventive care, mental health and substance abuse treatment, medications, or dental care. The importance of public programs such as Medicaid has grown in recent years, as the decline in the percentage of 10- through 18-year-old adolescents with private health insurance coverage has been offset by the increase in the proportion covered by public programs.1Uninsurance rates among adolescents are higher than those of most age groups in the United States. Yet recent year 2000 projections from the AAP suggest that nearly 2.4 million adolescents 13 through 18 years old are eligible for, but not enrolled in, Medicaid and SCHIP programs. If states were to raise their eligibility limits for SCHIP to the limits allowed by federal law, an additional 65 000 adolescents would be eligible. Together these programs could cover almost two thirds of the adolescents who lack insurance.2Insurance coverage through Medicaid and SCHIP is of critical importance because it can provide the majority of uninsured adolescents access to health care they urgently need. This can be a means of addressing their health status and risk behaviors, their past history of low utilization of health services, and their unmet health care needs.Billions of dollars are spent every year to provide treatment for adolescent health problems that are potentially preventable.3 Early intervention and preventive care could reduce morbidity and mortality, improve adolescent physical and mental health, and reduce the incidence and prevalence of major health threats to this age group.4 Consider the following:Despite these extraordinary vulnerabilities, adolescents use health care services at a lower rate than any other age group.13 In 1994, adolescents 11 to 21 years old represented >15% of the total US population and made only 9.1% of total office visits.14Adolescents with insurance coverage are healthier than those without it.15 Studies show that adolescents who have health insurance coverage are more likely to seek health care than are their uninsured peers. Uninsured adolescents are twice as likely to be without any physician contact in the course of a year, and 4 times as likely to have an unmet need for medical or dental care, eyeglasses, or prescription drugs.1Implementation of SCHIP has already made a difference for adolescents. By early September 1999, all 50 states and the District of Columbia (DC) had received approval for at least an original Title XXI SCHIP plan. As a result, only 11 states do not yet provide Medicaid coverage for all adolescents through 18 years old with family incomes at or below the federal poverty level (FPL).16The combined effect of Medicaid and state-designed non-Medicaid SCHIP programs is even more encouraging. In total, 49 states and DC have set a maximum family income level that is equal to or greater than 100% of the FPL. In 19 states, the maximum family income level is between 100% and 200% of the FPL; and in 26 states and DC, the level is equal to or greater than 200% of the FPL.17The challenge of addressing adolescent's health care needs is further complicated in the context of managed care.18 Most state Medicaid and SCHIP programs are using capitated managed care arrangements to serve their enrolled population. Although adolescents' needs could potentially be well served in a managed care environment, managed care plans have not yet fully addressed them. In particular, the need for confidentiality protection, the lack of coordination of services that occurs when managed care plans “carve out” mental health and substance abuse services, inadequate physician reimbursement rates, and copayments that are beyond the reach of many adolescents, have been significant access barriers.The adolescent medicine specialists, state SCHIP officials, health plan administrators, and health policy researchers who participated in the AAP invitational conference on SCHIP recognized that multiple barriers threaten adolescents' access to care. Conference participants sought to further the goal of increasing adolescents' access to health care by offering a set of recommendations designed to assist states in structuring their SCHIP and Medicaid programs to better meet the needs of adolescents. They began with a template of draft recommendations and refined those to create a collection of proposed approaches.19 The final recommendations address 4 areas: 1) eligibility, outreach, and enrollment; 2) benefit design; 3) service delivery and payment; and 4) quality assurance.Eligibility for adolescents in Medicaid and SCHIP programs should be raised to the maximum permissible levels. Outreach and enrollment strategies should target adolescents to increase the number of adolescents enrolled in Medicaid and SCHIP.States should expand SCHIP eligibility for adolescents to take full advantage of the maximum (in terms of age and income) that they are permitted to do with federal funds.State and local governments, together with a broad array of service organizations, agencies, schools, and health care providers, should develop and implement outreach targeted at adolescents and their families to ensure enrollment of eligible adolescents in Medicaid and SCHIP programs.States should simplify the application and enrollment process for Medicaid and SCHIP to ensure enrollment of all eligible adolescents.Benefit packages for adolescents should provide comprehensive preventive health, mental health, substance abuse, reproductive health, chronic care, and dental care services consistent with the AAP policy statement, “Scope of Health Care Benefits for Newborns, Infants, Children, Adolescents, and Young Adults Through Age 21 Years.”21States should ensure that Medicaid and SCHIP programs cover appropriate preventive services in accordance with the most current AAP guidelines,22 Bright Futures,23and the AMA Guidelines for Adolescent Preventative Services.24States and health plans should ensure that a continuum of comprehensive mental health and substance abuse services are available to adolescents and are integrated with physical health services.States should include in their Medicaid and SCHIP programs the full range of reproductive health services adolescents need. Such services should be provided on a confidential basis.States should provide a comprehensive set of specialized and multidisciplinary services for adolescents with chronic illnesses or disabilities, including ancillary therapies, home health care, durable medical equipment, nutritional services, and care coordination.States and health plans should ensure the participation of providers trained and experienced in providing the broad array of physical and mental health services needed by adolescents. Increasing reimbursement for adolescent services will improve the availability of providers interested in working with adolescents. In addition, prior authorization and utilization review should be conducted by individuals qualified to make those assessments, and plans should ensure adolescent's rights to confidentiality and consent.States and health plans should assure that adolescent-oriented physical, mental health, and substance abuse providers are accessible to adolescents enrolled in Medicaid and SCHIP programs.States and health plans should establish capitation rates and fee schedules that are adequate to support the range and intensity of health services needed by adolescents.States and health plans should take steps to ensure that prior authorization and utilization review personnel and procedures address the specific needs of adolescents.States and health plans should adopt procedures to protect the confidentiality of adolescents enrolled in Medicaid and SCHIP programs.States and health plans should adopt a uniform set of performance measures and other quality standards that can be used by public and private payers to ensure that adolescents receive age and developmentally appropriate care.States, working in collaboration with consumers (including adolescents), purchasers, health plans, and health care professionals with expertise in caring for adolescents should adopt adolescent-specific performance measures designed to monitor clinical effectiveness, use of services, access, and satisfaction with care.States should take steps to promote the adoption and use of adolescent-specific professional guidelines for preventive services and other aspects of clinical care for adolescents.The federal government, states, and health plans should coordinate efforts to provide timely information, by age group, to assist in quality assurance efforts.