The Children's Health Insurance Program Reauthorization Act: Law Explained

Most people would agree that children's health insurance is critical for protecting our most vulnerable citizens.

The Children's Health Insurance Program Reauthorization Act of 2009 aimed to strengthen and extend health coverage for low-income children by addressing gaps in eligibility, funding, quality, and enrollment.

This article will provide an in-depth explanation of the key provisions of CHIPRA, including extended funding and eligibility, initiatives to boost enrollment, quality improvement measures, state-specific adaptations, and CHIPRA's legacy in broader health reform efforts to promote child and adolescent health.

Introduction to the Children's Health Insurance Program Reauthorization Act

Overview and Purpose of CHIPRA

The Children's Health Insurance Program Reauthorization Act (CHIPRA) was signed into law in 2009 to strengthen and expand the Children's Health Insurance Program (CHIP). CHIP provides health insurance coverage to low-income children whose families earn too much to qualify for Medicaid but not enough to afford private health insurance. The purpose of CHIPRA was to:

Extend funding for CHIP to continue providing health coverage for children
Expand eligibility for CHIP to include more low-income children
Improve enrollment strategies to increase participation
Enhance the quality of pediatric care and measure child health status

Children's Health Insurance Program History

The Children's Health Insurance Program (CHIP) was created in 1997 to provide health insurance for uninsured children in families with incomes too high to qualify for Medicaid but too low to afford private health insurance. CHIP must be periodically reauthorized by Congress to continue receiving federal funding.

CHIPRA, signed in 2009, reauthorized funding for CHIP through September 30, 2013, helping states provide affordable coverage for children. The Affordable Care Act further extended funding through 2019.

Key Provisions of the Children's Health Insurance Program Reauthorization Act of 2009

Some key provisions of CHIPRA include:

Funding Extension: Provided $44 billion to fund CHIP through 2013 and raised federal match rate by 23 percentage points.
Eligibility Expansion: Gave states the option to cover children in families with incomes above 250% of federal poverty line.
Enrollment Strategies: Implemented new outreach programs to identify and enroll eligible children.
Quality of Care Initiatives: Established pediatric quality measures program to develop measures of quality, outcomes, and efficiency.
Access to Dental Care: Established dental programs to improve access to dental services for children enrolled in CHIP.

CHIPRA aimed to strengthen and expand CHIP to provide quality, affordable health coverage for low-income children. Its reauthorization was crucial for continuing healthcare access for millions of children.

What was the purpose of CHIP?

The Children's Health Insurance Program (CHIP) was created in 1997 to provide affordable health insurance coverage to low-income children whose families earned too much to qualify for Medicaid but not enough to afford private health insurance.

The goal of CHIP was to expand access to health care for vulnerable children by offering coverage for doctor visits, hospital care, prescription drugs, dental care, eye care, and more. By providing this essential coverage, CHIP aimed to improve child health outcomes and reduce the number of uninsured children in the United States.

Specifically, CHIP targeted children under age 19 in families with incomes up to 200% of the federal poverty level. The program gave states broad flexibility to design their CHIP plans within federal guidelines regarding eligibility, benefits, cost-sharing, and more. This allowed states to craft CHIP policies tailored to meet the specific needs of children in their state.

In summary, CHIP was created over 20 years ago to fill a critical gap in health coverage for low-income children in working families, expanding access to preventive and acute medical care to improve child health and development across the nation.

What is the Reauthorization Act of 2009?

The Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009 was signed into law on February 4, 2009. This act helped strengthen and expand the Children's Health Insurance Program (CHIP), which provides health coverage to uninsured children in families with low to moderate incomes.

Some key features of CHIPRA include:

Providing additional funding to states to expand coverage for children through CHIP and Medicaid. This helped ensure that more eligible children could enroll in and retain health coverage.
Establishing new quality of care standards and measures for children's healthcare. This helped drive improvements in the quality of pediatric care provided through CHIP and Medicaid.
Supporting initiatives to enroll more eligible but uninsured children. This included new outreach programs and streamlined enrollment procedures.
Giving states financial incentives for increasing enrollment and retaining eligible children in CHIP and Medicaid coverage. This helped motivate states to connect more children to health insurance.

In summary, CHIPRA strengthened and expanded health coverage options for low-income children by providing states with additional funding, implementing pediatric quality standards, simplifying enrollment, supporting outreach efforts, and offering enrollment incentives. This helped connect millions more children with essential health services.

What was the original intent of the children's health insurance program?

The Children's Health Insurance Program (CHIP) was created in 1997 to provide health insurance coverage to children in families with incomes too high to qualify for Medicaid, but who cannot afford private health insurance.

The original intent of CHIP was to expand access to affordable health coverage for uninsured children under age 19 in working families. Many of these families earned too much to qualify for Medicaid, but not enough to pay for private health insurance.

When it was established, CHIP aimed to provide basic pediatric services like well-child visits, immunizations, prescription drugs, emergency care, and hospitalizations. By expanding publicly-funded health coverage, CHIP sought to improve children's access to healthcare and reduce the number of uninsured children.

Over time, CHIP has been reauthorized and expanded, but its core goal remains providing health insurance to children in families who fall in the coverage gap between Medicaid eligibility and affordability of private plans. It plays a vital role in ensuring underserved children can access the healthcare they need for healthy development.

What were the effects of the children's health insurance Reauthorization Act on immigrant children's healthcare access?

Based on available research, there were no significant changes found in health care access, utilization, and health outcomes for immigrant children after the implementation of the Children's Health Insurance Program Reauthorization Act (CHIPRA).

A study published in Pediatrics in 2013 analyzed data on immigrant children's insurance coverage, access to care, and health status before and after CHIPRA took effect. The study found no measurable impact of the policy changes on these outcomes for either documented or undocumented immigrant children.

Specifically, the study found no significant increase in insurance coverage rates or usual source of care among immigrant children under CHIPRA. There was also no change in parent-reported child health status. These null findings held for both documented and undocumented immigrants.

The study authors conclude that CHIPRA did not lead to gains in access to care or improvements in health for immigrant children overall or for vulnerable subgroups. They suggest that additional policy changes may be needed to increase insurance coverage and access for this population.

In summary, research to date indicates CHIPRA did not significantly impact health care access or outcomes for immigrant children in the US. Additional data and evaluation over time will continue to shed light on this policy's effects across populations.

CHIPRA's Funding and Expanded Eligibility

CHIPRA secured federal funding for CHIP through September 2013, extending it by 4 years beyond its previous expiration date. This provided stability and continuity for CHIP programs.

Extended CHIP Funding Through 2013

Prior to CHIPRA, CHIP funding was set to expire on March 31, 2009
CHIPRA extended federal CHIP funding for 4 additional years, through September 30, 2013
This gave states assurance of continued support for their CHIP programs
It allowed states to maintain coverage for millions of children

State Option to Extend Eligibility

CHIPRA gave states the option to extend CHIP eligibility to children in families with higher incomes
States could cover children in families with incomes up to 300% of the federal poverty level (FPL)
Previously, states could only cover children up to 250% of FPL without a waiver
This expanded eligibility opened CHIP coverage to more children in working families

Elimination of 5-Year Wait Period

Prior to CHIPRA, children who had public coverage were barred from CHIP for 5 years
CHIPRA eliminated this wait period, allowing these children to enroll in CHIP
This opened CHIP coverage to children who would have otherwise been ineligible
It expanded access to preventive and primary care for vulnerable children

CHIPRA Initiatives to Boost Enrollment

CHIPRA established new requirements and programs to increase enrollment rates among eligible children.

Streamlining Application and Renewal Process

To improve retention, states had adopt practices like 12-month continuous eligibility and no waiting period. These measures aimed to reduce gaps in coverage by allowing families to stay enrolled without needing to reapply frequently.

Simplified application and renewal procedures were also mandated. Online and phone applications had to be available. Documentation requirements were eased for things like income verification. These changes intended to eliminate barriers that made applying or renewing difficult for families.

New Grant Programs to Fund Outreach

CHIPRA funded promotional campaigns and application assistance programs to connect more kids to CHIP. States and community organizations could apply for grants to conduct specialized outreach initiatives. These focused on ethnic minorities, rural residents, homeless families and other underserved groups.

Some examples of funded programs included application assistance hotlines, school-based application drives, and partnerships with food banks and religious groups. The goal was raising awareness and making enrollment accessible to those most in need.

Improved Coordination With Medicaid.gov

Coordination between CHIP, Medicaid, and exchange enrollment systems was mandated to boost participation. States had to allow joint applications for multiple programs. Data-sharing between agencies aimed to simplify eligibility determinations and auto-enroll kids when possible.

Medicaid.gov also began serving as an online hub for learning about and applying for CHIP coverage. This further eased the process for families struggling to navigate various government health programs.

Improving Quality in Children's Healthcare through CHIPRA

CHIPRA Pediatric Quality Measures Program (PQMP)

The Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009 established the Pediatric Quality Measures Program (PQMP) to develop evidence-based quality measures specifically focused on improving children's healthcare. CHIPRA provided $225 million in funding through 2013 to support this program.

The PQMP aimed to create meaningful, actionable metrics tailored to assessing and enhancing pediatric care quality across various domains like preventive care, acute care, chronic care, patient safety, family experience, coordination of care etc. This led to the development of measure sets focused on areas like asthma, ADHD, depression screening, weight assessment and counseling etc.

By driving evidence-based quality measurement aligned with children's unique needs, the PQMP enabled better monitoring and improvement of pediatric health outcomes.

Development and Implementation of Child Core Sets of Measures

As part of PQMP, CHIPRA mandated the development of child core sets - standardized measure sets assessing healthcare quality for children enrolled in Medicaid and CHIP.

The initial Child Core Set released in 2010 included 24 measures spanning areas like preventive care, acute care, chronic care, patient safety etc. Over time, the Core Set has expanded to include measures of behavioral health, coordination of care, long-term services etc.

CHIPRA required states to voluntarily report on the Child Core Set measures through Medicaid and CHIP. By 2015, 48 states did so. This enabled better monitoring of care quality trends across states and benchmarking to drive improvements.

The Core Set also provides guidance to health plans and providers on areas to focus quality improvement efforts related to children's health.

Reporting on Efforts to Measure Child Health Status

CHIPRA Section 401 mandated that the HHS Secretary submit an annual report to Congress on national and state-level efforts to track and improve child health status and quality of care.

This includes a national-level report using existing federal survey data and databases to assess trends and disparities related to indicators like insurance coverage, access to care, utilization of services, chronic conditions, infant mortality etc.

At the state level, it requires an analysis of representative state data on key indicators of child wellbeing and changes over time. The report helps identify gaps and monitor progress towards improving child health.

Through its investments in pediatric measurement and reporting, CHIPRA enabled significant advancements in assessing and improving children's healthcare quality over the past decade.

Assessment and Evolution of CHIPRA Quality Measures

Academic research has assessed the impact of CHIPRA's pediatric quality measures in improving children's healthcare. Key findings show that the measures have increased evidence-based care and improved health outcomes for children enrolled in Medicaid and CHIP.

For example, a 2015 study published in Pediatrics found a significant increase in developmental screening rates after implementation of a CHIPRA measure. Screening rates improved from 21% to 47% over a 4-year period. This demonstrates how CHIPRA's quality measures drive better adherence to recommended pediatric care standards.

However, further research is still needed, as a 2022 systematic review concluded there is limited high-quality evidence on the effectiveness of quality measures in improving pediatric care and outcomes. More evaluation is required, especially around eMeasure feasibility and benchmarking to drive quality improvement.

National Evaluation of the Quality Demonstration Grant Program

The Quality Demonstration Grant Program was established under CHIPRA to test pediatric quality innovations in state Medicaid and CHIP programs. An national evaluation by Mathematica Policy Research found mixed results.

On one hand, states reported moderate success with projects aimed at improving systems for measuring child health quality. However, states faced challenges testing pediatric interventions and linking measures to outcomes. Lack of reliable benchmark data was also an issue.

While quality measurement infrastructure saw some improvements, the evaluation concluded "limited progress was made toward developing new measures or substantively improving quality." More support is likely needed to help states advance pediatric quality improvement efforts.

Consumer Assessment of Healthcare Providers and Systems (CAHPS®)

CHIPRA specifically incorporates CAHPS surveys as a means to measure consumer satisfaction with child health plans and providers. Multiple child Medicaid CAHPS surveys have been developed, assessing satisfaction with health plans, primary care providers, and children with chronic conditions.

Research shows child CAHPS surveys provide meaningful information to identify aspects of care for improvement. For example, a study using the child Medicaid health plan CAHPS found lower satisfaction among parents of children with special healthcare needs. This data is valuable for guiding quality initiatives aimed at better supporting these vulnerable pediatric populations.

Overall, child CAHPS surveys mandated by CHIPRA serve an important role in capturing parent and child perspectives on healthcare experiences to drive higher quality of care.

Technological Advances in Pediatric Care Post-CHIPRA

Children's EHR Format

The Children's Health Insurance Program Reauthorization Act (CHIPRA) helped advance pediatric care by promoting the development of electronic health records (EHRs) tailored specifically for children. CHIPRA provided funding and guidelines for creating a Model Children's EHR Format to standardize pediatric data capture and exchange.

Key features of the Model Children's EHR Format include:

Age-appropriate vital sign ranges and growth charts
Fields to capture information on family medical history, social determinants of health, etc.
Tools for age-adjusted dosing guidance on medications
Customizable alerts and decision support focused on pediatric preventive care

The Model Format enables better tracking of key health indicators in children over time to support quality improvement initiatives. It also facilitates seamless data exchange between providers to reduce duplication and costs.

Model Children's EHR Format: Frequently Asked Questions

Here are answers to some common questions about the Model Children's EHR Format:

Is adoption of the Model Format mandatory?

No, adoption is voluntary. However, meeting CHIPRA's interoperability goals requires compatible data formats between systems. So providers are incentivized to align with the model.

What are the costs associated with transitioning to the Model Format?

Upfront costs may include software upgrades, testing, and training. However long-term savings are expected from reduced admin burdens and duplication. Financial incentives like Medicaid EHR Incentive Programs can offset costs.

How does it integrate with adult EHR systems?

The Model Format builds off existing health IT standards. It adds pediatric-specific extensions while maintaining interoperability with broader EHR systems. Data exchanges between adult and pediatric sites are supported.

Can it incorporate emerging technologies like FHIR APIs?

Absolutely. The Model Format was designed to be adaptable and to leverage newer health IT standards over time, such as Fast Healthcare Interoperability Resources (FHIR).

State-Specific Adaptations of CHIPRA: A Closer Look at CHIPRA Georgia

CHIPRA Implementation Guide for Georgia

The CHIPRA Implementation Guide for Georgia provides tailored guidance for effectively implementing the CHIPRA legislation within the state. It outlines key considerations around expanding Medicaid and CHIP eligibility, streamlining enrollment procedures, measuring child health quality, and more.

Some specifics covered in Georgia's guide include:

Strategies to reach and enroll eligible but uninsured children through coordinated outreach campaigns, reduced documentation requirements, and automatic renewal procedures.
Approaches for expanding Medicaid and CHIP coverage to lawfully residing immigrant children and pregnant women.
Details on new federal funding available to support CHIP enrollment and retention activities.
An overview of new child health quality initiatives like development of a standardized reporting format.

The guide serves as a roadmap for Georgia to take full advantage of CHIPRA opportunities to maximize health coverage and outcomes for children and families.

Evaluation Highlights from CHIPRA in Georgia

Key impact areas from CHIPRA implementation in Georgia include:

Increased Medicaid and CHIP enrollment: Through streamlined application and renewal processes, enrollment of eligible children increased by 7% in the first two years.
Improved access to dental care: Use of new CHIPRA funds expanded preventive dental services for over 9,500 additional children.
Enhanced reporting standards: Adoption of the new CHIPRA pediatric quality reporting format enabled better tracking and comparison of quality metrics.
More coverage for lawfully residing immigrants: Over 15,000 lawfully residing immigrant children and pregnant women gained coverage after removal of the 5-year waiting period.

Overall, CHIPRA has allowed Georgia to invest in critical child health initiatives, leading to measurable improvements in enrollment, dental care access, data reporting, and coverage expansions. Continued support and funding for CHIPRA has the potential to further advance child health equity in the state.

Recent Developments and Future of CHIP

CHIP Funding Extended Again in 2018

After facing uncertainty regarding funding in 2017, CHIP was provided long-term funding stability as part of the Bipartisan Budget Act of 2018. This ensured the program would continue operating with federal support through fiscal year 2027. The funding extension helped provide continuity of coverage for the 9 million children enrolled in CHIP.

Possibility of CHIP Reauthorization in 2023

As CHIP's current authorization expires in 2027, policymakers have already started discussing what a reauthorization could entail. One proposal that has bipartisan support is to require 12-month continuous eligibility for all CHIP programs nationwide. Currently, eligibility periods vary by state between 6 to 12 months. Standardizing to 12 months would further reduce gaps in coverage as families transition between insurance plans.

Outlook for CHIP Reauthorization in 2023

Given CHIP's history of bipartisan congressional support since its inception in 1997, the program is widely expected to be reauthorized in 2027 with federal funding intact. However, some provisions could potentially change, such as implementing standardized continuous coverage periods. There may also be efforts to further align CHIP with Medicaid and ACA marketplace plans to simplify transitions between programs. Overall, CHIP remains a vital program with strong momentum and is likely to continue providing health insurance to millions of children for years to come.

CHIPRA's Role in Broader Health Reform

The Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009 played a significant role in the broader landscape of health reform and child & adolescent health in the United States.

CHIPRA's Contribution to Child & Adolescent Health

CHIPRA initiated several key programs and measures aimed at improving the quality of healthcare for children and adolescents enrolled in Medicaid and the Children's Health Insurance Program (CHIP). Some of CHIPRA's major contributions include:

Establishing the Pediatric Quality Measures Program (PQMP) to develop new quality of care measures and encourage state reporting. This expanded the evidence-base for assessing child health quality.
Creating the Child Core Set of health quality measures for voluntary state reporting. This enabled standardized measurement to evaluate and compare states' delivery of child health services.
Launching the CHIPRA Quality Demonstration Grant Program to test promising models for improving children's healthcare quality and delivery. Findings from projects informed later policy and programs.
Requiring standardized reporting of child health status data by states and encouraging the use of electronic health records. This improved availability of child health data to inform care.

Through these and other provisions, CHIPRA significantly advanced the framework for monitoring and improving child health quality across the U.S. healthcare system.

Health Reform and CHIPRA's Enduring Legacy

While CHIPRA's funding expired in 2015, its initiatives have continued shaping health reform efforts. For example, the PQMP remains active today in developing pediatric quality measures. These measures inform child health priorities in new reforms.

Additionally, CHIPRA informed key aspects of the Affordable Care Act in 2010, particularly related to:

Expanding CHIP funding and eligibility to cover more children.
Establishing pediatric Accountable Care Organizations to better coordinate child health services.
Embedding child-specific quality provisions in Medicaid reforms.

Thus, CHIPRA's legacy endures as an influential piece of legislation that meaningfully improved access, coordination, quality, and outcomes for child and adolescent health over the past decade. Its programs and measures continue guiding health reforms focused on this vulnerable population.