Coverage of Vision Services under the State Children's Health Insurance Program (SCHIP)

Publication Date: October 2004

Publisher: Library of Congress. Congressional Research Service

Author(s):

Research Area: Health

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Abstract:

A small but significant proportion of children have visual impairments. When detected early, many childhood vision abnormalities are treatable, but the potential for correction and normal visual development diminishes with age. Under SCHIP, states may provide coverage by expanding Medicaid or creating a separate SCHIP program or both. Medicaid and SCHIP provide access to an array of vision-related services, including vision screening services that can help children in low- to moderate-income families overcome these difficulties.

Medicaid's mandatory Early, and Periodic, Screening, Diagnosis, and Treatment (EPSDT) benefit ensures access to vision screening services for children. However, there are several other Medicaid benefit categories where vision screening services may be delivered. Often such services are billed as a part of a well-child visit. Under SCHIP, state-specific benefit packages must provide well-baby and well-child care, which includes a vision screening component. As with Medicaid, the well-child coverage requirement is not the only service category where children could receive vision screening under SCHIP. Children may also receive vision screening services under other SCHIP-covered services such as physician services.

A June 2000 CRS benefits survey provides some clues as to access to vision services under SCHIP Medicaid expansion and separate state programs. At that time, nearly all Medicaid and SCHIP programs covered vision services for children, and most also covered eye glasses. The survey data indicates that the breadth of visionrelated benefits available under these two programs likely differs within and across states.

Coverage policies and benefit limits for the lowest-income children as described in state Medicaid plans are seldom absolute because of EPSDT. For nearly all Medicaid children, states are required to provide all federally allowed treatment to correct identified problems, even if the specific treatment needed is not otherwise covered under a state's Medicaid plan. As a result, when a Medicaid agency reports that a specific benefit is not covered for children, that means the service is available only when delivery of that service meets the EPSDT requirement.

Services for higher-income children under SCHIP are sometimes more restrictive. Unlike Medicaid, but consistent with federal statute, separate SCHIP programs are modeled after private sector, commercial insurance products. The requirement to use benchmark plans (or actuarial equivalents of those plans), most of which are state employee health plans or commercial HMO plans, provides the framework for defining benefit limits. Under commercial insurance products, benefits are always limited by medical necessity, but other limits may apply and will vary by insurance product, as do procedures to monitor for medical need and appropriateness. Payments to providers participating in these plans may be altered based on the outcome of such service utilization reviews, which can in turn affect access to care. This report will not be updated.