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Medicaid Program and Children's Health Insurance Program; Model of Interstate Coordinated Enrollment and Coverage Process for Low-Income Children

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AGENCY:

Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION:

Notice with comment.

SUMMARY:

This notice requests comments to assist in the development of a model process for the coordination of enrollment, retention, and coverage for low-income Medicaid and Children's Health Insurance Program eligible children as required under the Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009. CHIPRA requires this model process to be developed by August 4, 2010 and the Secretary is required to submit a Report to Congress describing additional steps or authority needed to make further improvements to coordinate the enrollment, retention, and coverage under CHIP and Medicaid of low-income children who frequently change their State of residence.

DATES:

To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on January 19, 2010.

ADDRESSES:

In commenting, please refer to file code CMS-2311-NC. Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission.

You may submit comments in one of four ways (please choose only one of the ways listed):

1. Electronically. You may submit electronic comments on this regulation to http://www.regulations.gov. Follow the instructions under the “More Search Options” tab.Start Printed Page 67233

2. By regular mail. You may mail written comments to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-2311-NC, P.O. Box 8010, Baltimore, MD 21244-8010.

Please allow sufficient time for mailed comments to be received before the close of the comment period.

3. By express or overnight mail. You may send written comments to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-2311-NC, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.

4. By hand or courier. If you prefer, you may deliver (by hand or courier) your written comments before the close of the comment period to either of the following addresses:

a. For delivery in Washington, DC—Centers for Medicare & Medicaid Services, Department of Health and Human Services, Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 20201.

(Because access to the interior of the Hubert H. Humphrey Building is not readily available to persons without Federal government identification, commenters are encouraged to leave their comments in the CMS drop slots located in the main lobby of the building. A stamp-in clock is available for persons wishing to retain a proof of filing by stamping in and retaining an extra copy of the comments being filed.)

b. For delivery in Baltimore, MD—Centers for Medicare & Medicaid Services, Department of Health and Human Services, 7500 Security Boulevard, Baltimore, MD 21244-1850.

If you intend to deliver your comments to the Baltimore address, please call telephone number (410) 786-7195 in advance to schedule your arrival with one of our staff members.

Comments mailed to the addresses indicated as appropriate for hand or courier delivery may be delayed and received after the comment period.

For information on viewing public comments, see the beginning of the SUPPLEMENTARY INFORMATION section.

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FOR FURTHER INFORMATION CONTACT:

Wanda Pigatt-Canty, (410) 786-6177. Mary Corddry, (410) 786-6618.

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SUPPLEMENTARY INFORMATION:

Inspection of Public Comments: All comments received before the close of the comment period are available for viewing by the public, including any personally identifiable or confidential business information that is included in a comment. We post all comments received before the close of the comment period on the following Web site as soon as possible after they have been received: http://www.regulations.gov. Follow the search instructions on that Web site to view public comments.

Comments received timely will also be available for public inspection as they are received, generally beginning approximately 3 weeks after publication of a document, at the headquarters of the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view public comments, phone 1-800-743-3951.

I. Background

Section 213 “Model of Interstate Coordinated Enrollment and Coverage Process” of the Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009 requires the Secretary of Health and Human Services (HHS), in consultation with State Medicaid and Children's Health Insurance Program (CHIP) directors and organizations representing program beneficiaries, to develop a model process by August 4, 2010, that assures the continuity of coverage for low-income children under Medicaid and CHIP. The model process will be designed for the coordination of enrollment, retention, and coverage for children under the Medicaid and CHIP programs, who, because of migration of families, emergency evacuations, natural, or other disasters, public health emergencies, educational needs, or otherwise, frequently change their State of residence or are temporarily located outside their State of residence. American Indian and Alaska Native children who need care while attending boarding schools or need culturally appropriate care available only in a State where they do not reside are a key example of this population.

CHIPRA requires the Secretary, after developing a model process, to submit a Report to Congress that would describe additional steps or authority needed to make further improvements to coordinate the enrollment, retention, and coverage under CHIP and Medicaid of low-income children who frequently change their State of residence or are temporarily located outside their State of residence.

A. CMS Historical Experience Related to Continuity of Coverage

In 2006, CMS prepared a Report to Congress as required by section 404 of the Health Care Safety Net Amendments Act of 2002 (Pub. L. 107-251) entitled “Study Regarding Barriers to Participation of Farm Workers in Health Programs.” This report highlighted problems experienced by migrant farmworkers and their families related to the barriers encountered in accessing health services through Medicaid and CHIP, and the lack of portability of Medicaid and CHIP coverage for farmworkers who are determined eligible in one State but who, due to the seasonal nature of the their work, periodically move to other States. We published the outcome of this study in a Report to Congress which identified five options to address the portability issues related to Medicaid and CHIP. The recommended options included the following:

  • Interstate Compacts.
  • Demonstration Projects.
  • State Activities under Current Law Flexibility.
  • National Migrant Family Coverage.
  • Public-Private Partnerships.

The full Migrant Farmworkers Report to Congress can be viewed at: http://cms.hhs.gov/​Reports/​Downloads/​RTC-Leavitt2.pdf.

B. Proposed Models for Coordination

We are using some of the recommendations from the Migrant Farmworkers Report to Congress as the basis for proposing models of coordination/portability to attempt to solve the problem of gaps in healthcare coverage for Medicaid and CHIP children who frequently change their State of residence. We have identified four proposed models including a new model titled “National Children's Health Coverage Option” on which we are seeking input. These models include:

(1) Interstate Compacts. Under current Federal law and regulations, States may enter interstate agreements to facilitate administration of their Medicaid and CHIP programs. Interstate compacts are agreements between States that provide the framework for formalized interstate cooperation. The framework ranges from a more basic model in which States recognize each other's eligibility determinations to models with States fully reimbursing out-of-state providers. States may seek to develop interstate agreements or compacts to facilitate timely eligibility determinations or redeterminations for applicants and recipients, such as migrant farmworkers, and agree upon detailed mechanisms by which payment reciprocity can be made among two or more States. These interstate arrangements, however, do not necessarily require Federal approval. By establishing and joining an Start Printed Page 67234interstate compact on Medicaid and CHIP for children, States can more readily recognize each other's eligibility determinations and reimburse out-of-state providers. As a result, they can provide more seamless Medicaid and CHIP coverage to low-income children. States currently participate in a variety of interstate compacts including one pertaining to Federal adoption assistance/Medicaid recipients entitled the “Interstate Compact on Adoption and Medical Assistance” (ICAMA). Further information related to ICAMA can be viewed at: http://www.aaicama.org/​cms/​.

(2) Demonstration Projects. Section 1115(a) of the Social Security Act (the Act) provides the Secretary of Health and Human Services with the authority to authorize experimental, pilot, or demonstration projects which, in the judgment of the Secretary, are likely to assist in promoting the objectives of the Medicaid statute. States can request section 1115 authority to create a standard set of benefits or eligibility coverage across States that differ from the set of benefits provided under the State plan in each of those States or to expand coverage to groups of individuals, including parents and caretaker relatives, or to provide greater flexibility in their programs. Budget neutrality is required for title XIX programs approved under section 1115 authority under the policies of the Office of Management and Budget. A recent example of how CMS used section 1115 authority was in 2005, in response to the devastation caused by Hurricane Katrina on the health care system of the Gulf coast of Louisiana and Mississippi; the Secretary was granted the authority to approve section 1115 demonstration waivers that granted States time-limited waiver authority to facilitate expedited enrollment into Medicaid and CHIP programs for survivors of Hurricane Katrina who needed to access healthcare services in locations other than their home States. Under Hurricane Katrina demonstrations, we granted time-limited waiver authorities to States for the following:

  • Simplified eligibility criteria for Medicaid and CHIP eligible groups.
  • Comparability/amount, duration, and scope of benefit packages.
  • Simplified eligibility determination processes in order to permit evacuees to access needed health care services in their host State.

(3) State Activities under Current Law's Flexibility. States may explore current flexibility under State plan authority to improve the continuity of coverage for Medicaid and CHIP eligible children. Some of the flexibility offered under the State plan authority may be designed to improve service delivery coordination; enhance enrollment and portability arrangements; and enhance Medicaid and CHIP managed care coordination at the State and health plan levels to facilitate enrollment and portability. Under this model for example, a State may choose to align/standardize their eligibility and enrollment processes with a neighboring State in order to improve coordination of Medicaid and CHIP coverage for children.

(4) Public-Private Partnerships. States may engage in public-private partnerships in order to research or pilot initiatives that improve the portability of Medicaid and CHIP coverage for low-income children.

(5) National Children's Health Coverage Option. This model would develop a national health insurance plan for children with a minimum benefit plan to be offered by every State. Under this option, certain statutory changes would be required related to the definition of residency and eligibility criteria for children, specifically a minimum national coverage for all children under age 21 years and a change in the income standard to a specified minimum level for all children. State residency could be defined to make it easier to cover children in the State where they are living, even if they do not intend to remain there permanently or for an indefinite period.

C. Request for Comments

We request public comments on the proposed models to include the following:

(1) Advantages (benefits) and/or disadvantages (negatives) related to each of the proposed models.

(2) Best practices States may currently have in place to ensure interstate continuity and coordination of enrollment for Medicaid and CHIP children.

(3) Recommendations for new models that will facilitate coordination of enrollment, retention, and coverage for Medicaid and CHIP children.

(4) Additional comments related to programmatic operations and/or statutory changes that may be required in order to create the model process.

D. Use of Public Comments

We will review the public comments and consider the information received in the development of the model process for the coordination of enrollment, retention, and coverage for Medicaid and CHIP children who frequently move from their State of residence.

II. Provisions of the Notice With Comment

The purpose of this notice is to provide the opportunity for public input/consultation in developing a model process for the coordination of enrollment, retention and coverage for Medicaid and CHIP eligible children who, because of migration of families, emergency evacuations, natural or other disasters, public health emergencies, educational needs, or otherwise, frequently change their State of residency or otherwise are temporarily located outside the State of their residency.

III. Response to Comments

Because of the large number of public comments we normally receive on Federal Register documents, we are not able to acknowledge or respond to them individually. We will consider all comments we receive by the date and time specified in the DATES section of this preamble, and, when we proceed with a subsequent document, we will respond to the comments in the preamble to that document.

In accordance with the provisions of Executive Order 12866, this notice was not reviewed by the Office of Management and Budget.

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Authority: Section 1115 of the Social Security Act.

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(Catalog of Federal Domestic Assistance Program No. 93.778, Medical Assistance Program)

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Dated: November 2, 2009.

Charlene Frizzera,

Acting Administrator, Centers for Medicare & Medicaid Services.

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[FR Doc. E9-29724 Filed 12-17-09; 8:45 am]

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