A Performance Audit of the Pennsylvania Insurance Department's Oversight of the CHIP

Doug-Hoy

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• Publié par: Theyl
• Nombre de lectures: 33
• Langue: English

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A Performance Audit of the Pennsylvania Insurance Department’s Oversight of the April 2002 Auditor General Robert P. Casey, Jr.April 30, 2002 The Honorable Mark S. Schweiker Governor Commonwealth of Pennsylvania 225 Main Capitol Building Harrisburg, Pennsylvania 17120 Dear Governor Schweiker: This report contains the results of the Department of the Auditor General’s performance audit of the Pennsylvania Insurance Department’s Children’s Health Insurance Program (CHIP) for the period July 1, 1997, to July 31, 2001. The audit was conducted pursuant to Section 402 of The Fiscal Code and in accordance with Government Auditing Standards as issued by the Comptroller General of the United States. As you know, the Children’s Health Insurance Program provides health care coverage to children who otherwise would not be able to afford insurance. There is no doubt that this program benefits many of Pennsylvania’s children by providing them the means to get regular checkups, immunizations, diagnoses and treatments of illness or injury, prescription drugs, and dental, vision, and hearing care. Despite the efforts made by the Insurance Department—and despite the CHIP staff’s professional work ethic, compassion for children, and cooperation with our audit—we found numerous deficiencies in the program. These deficiencies must be addressed to ensure that all eligible children receive health benefits, that such benefits are measured and monitored, and that the overall program is administered with the necessary oversight. As a result, we have offered 31 recommendations to improve the Children’s Health Insurance Program. Chapter One of the report makes recommendations to improve the process of enrolling children in CHIP. At the close of our fieldwork, approximately one-third of the eligible children were not enrolled in CHIP. More recent numbers supplied by the Insurance Department in its response to this audit show that, as of March 2002, the number of uninsured children has been reduced to one-fourth of the eligible children.The Honorable Mark S. Schweiker Page 2 April 30, 2002 Still, enrollment must be improved and, as ways to improve enrollment, we encourage the Insurance Department to use innovative outreach approaches, provide assistance to families applying for CHIP, and improve the follow-up procedures applicable to families that were denied CHIP coverage. Chapter Two of the report discusses the Insurance Department’s need to monitor the health care actually provided to children. If implemented, our recommendations in this chapter should allow the Insurance Department to ensure that, after enrollment, children actually receive the health care that they need. In Chapter Three of the report, we discuss the renewal process and how the Insurance Department should improve procedures to ensure that eligible children renew their health insurance coverage each year. Finally, Chapter Four discusses how the Children’s Health Insurance Program is financed. We are troubled by the fact that the Insurance Department has forfeited $103 million in federal and state funds and expects to forfeit an additional $38 million in federal funds. This money could have been used to increase enrollment and to address the program deficiencies. Our strong recommendation is that the Insurance Department take steps to ensure that, in the future, the available funds are used as necessary to enroll the maximum number of children and to make sure they get the health care they need. In closing, I note that we found the Insurance Department management to be aware of many of the deficiencies we pointed out, and that—in numerous instances— corrective actions were begun during our audit or were already under way. In fact, more often than not—except on the issue of using the available funds—the Insurance Department and this Department were in agreement. We wish to thank the Insuranceent for working with us to improve oversight of this important program. Sincerely, Robert P. Casey, Jr. Auditor GeneralOversight of the Page i Children’s Health Insurance Program: A Performance Audit of the Pennsylvania Insurance Department Table of Contents Pennsylvania Department of the Auditor General Executive Summary ivTable of Contents Introduction and Background 1 Objectives, Scope, and Methodology 6 Chapter One 7 Enrolling children in CHIP Conclusion 1: 10 The Insurance Department increased CHIP membership by 85 percent but did not enroll one-third of the eligible children. Conclusion 2: 16 The Insurance Department generated wide-ranging outreach—much of which was successful—but did not always provide effective oversight of that outreach. Conclusion 3: 33 The Insurance Department tested innovative outreach approaches. Conclusion 4: 40ent developed an application common to both CHIP and Medicaid but did not place enough emphasis on helping families to fill out the 10-page form.Page ii Oversight of the Children’s Health Insurance Program: A Performance Audit of the Table of Contents Pennsylvania Insurance Department Pennsylvania Department of the Auditor General Chapter One Table of Enrolling children in CHIP, continuedContents Conclusion 5: 48 The Insurance Department did not follow up with families that were denied CHIP coverage and referred to Medicaid. Conclusion 6: 51 The Insurance Department did not confirm that CHIP insurers made correct eligibility decisions. Conclusion 7: 56 The Insurance Department coordinated outreach activities effectively with the Departments of Health and Public Welfare. Chapter Two 59 Ensuring that CHIP-enrolled children get the health care they need Conclusion 1: 61 The Insurance Department did not know whether children received checkups, immunizations, or other basic services while enrolled in CHIP.Oversight of the Page iii Children’s Health Insurance Program: A Performance Audit of the Pennsylvania Insurance Department Table of Contents Pennsylvania Department of the Auditor General Chapter Two -Table of Ensuring that CHIP-enrolled childrenContents get the health care they need, continued Conclusion 2: 68 The Insurance Department barely monitored whether the CHIP insurers complied with their contracts. Chapter Three 74 Keeping children enrolled each year at renewal time Conclusion 1: 76 The Insurance Department took steps to improve annual renewals but still did not renew all eligible enrollees. Chapter Four 81 Using available funding to address unmet challenges Conclusion 1: 83 The Insurance Department has already forfeited $103 million in federal and state funds and expects to forfeit at least $38 million more in federal funds. Appendix A 93 Insurance Department s response to audit report Appendix B 109 Audit report distribution listPage iv Oversight of the Children’s Health Insurance Program: A Performance Audit of the Executive Summary Pennsylvania Insurance Department Pennsylvania Department of the Auditor General The Pennsylvania Insurance Department bears responsibility forExecutive four major problems with its Children’s Health Insurance Summary Program (CHIP), a program started in 1993 to cover children of working families who earned too much to qualify for Medical Assistance but not enough to buy health insurance on their own: 1. Nearly a third of all CHIP-eligible children remained without health insurance during the period of our audit—July 1, 1997, through July 31, 2001. 2. The Insurance Department failed to use more than half the state and federal money that was made available for CHIP. Stated another way, the Insurance Department left unspent more than it spent—despite the number of uninsured children and despite the deficiencies that needed correction. 3. The Insurance Department did not know whether most CHIP- enrolled children actually received basic services such as immunizations and checkups. 4. ent was not successful in ensuring that all enrollees were renewed annually. In other areas, the Insurance Department made progress in enhancing CHIP. Precipitated by the addition of very generous federal funding in 1998, outreach increased, enrollment climbed, waiting lists were eliminated, and benefits were expanded. Moreover, the Insurance Department took its CHIP oversight responsibilities seriously. The staff’s professional work ethic, compassion for children, and cooperation were evident throughout our audit process. Indeed, all but a few of the CHIP deficiencies were already known to Insurance Department management, and we saw numerous instances in which corrective actions either were under way at the time of our audit or were started during the course of our fieldwork.Oversight of the Page v Children’s Health Insurance Program: A Performance Audit of the Pennsylvania Insurance Department Executive Summary Pennsylvania Department of the Auditor General Our report is divided into four chapters addressing the critical areas of the Insurance Department’s oversight: enrolling children in CHIP, making sure they got the health care they needed, keeping children insured at renewal time, and using earmarked funding to the fullest extent possible. In enrolling children, the Insurance Department showed considerable initiative in implementing outreach strategies to increase families’ awareness and enrollment. But with an estimated 50,000 children still to be enrolled, the Insurance Department tended to cut off its outreach initiatives too soon— that is, before following through or following up completely, and before conducting the necessary evaluation or measurement. As far as ensuring that children got the health care services they needed, the Insurance Department’s performance was also weak. The Insurance Department did not require the CHIP insurers to maintain utilization data specific to each child, meaning that no one knew whether the children received even the most basic health services such as checkups and immunizations. Moreover, the Insurance Department conducted almost no monitoring of whethe