July 25, 2001

Tommy Thompson, Secretary
Department of Health and Human Services
200 Independence Avenue, SW
Washington, DC 20201

Dear Secretary Thompson:

Please find enclosed our comments on the revisions to the regulations implementing the State Children's Health Insurance Program (SCHIP) published in the Federal Register on June 25, 2001. As health care advocacy organizations, children's organizations, religious groups, and health care providers, many of whom were involved with the design and early implementation of SCHIP, we believe our recommendations deserve the same attention as that given states and other organizations with a stake in SCHIP. We know you share our commitment to providing health coverage to children and we look forward to working with you on these issues throughout your tenure.

We are pleased that there apparently will be no further delays in implementing the regulations, although we believe that the SCHIP program would have been better served if the final rule had been implemented on the original, effective date of April 11, 2001. Although we thought the interim final regulations made some improvements such as strengthening the presumptive eligibility option in SCHIP, we are concerned that the vast majority of the changes proposed in the interim final regulation could weaken important child health protections. Our key areas of concern include the following:

• Cost-sharing: The interim final regulation weakens important cost-sharing protections by eliminating the 2.5 percent cap on the cost-sharing obligations of families with income below 150 percent of the poverty line and by allowing states to require families to spend more than 5 percent of their income meeting cost-sharing obligations if the family as a whole (parents and children) secure coverage through SCHIP.
  
  
• Coordination between programs: The interim final regulation allows states to put additional burdens on families applying for coverage when the state does not have a coordinated system for screening potentially Medicaid-eligible children, creating the risk that they will fall through the cracks and remain uninsured. Indeed, the interim final regulation condones the possibility that children can be asked to file a second, duplicate application for coverage after being bounced back and forth between a separate SCHIP program and Medicaid.
  
  
• Consumer protections: The interim final regulation eliminates minimum standards for review procedures-such as external appeals, timelines, and notice requirements-in favor of allowing states to use a review process already in place in the state for private insurers, regardless of whether it meets minimum requirements.
  
  
• Benefits packages: The interim final rule defines an overly broad array of benefits packages as automatically qualified for "Secretary-approved coverage," undermining the ability of CMS to assure on a state-specific basis that the benefits provided to children are adequate.
  
  
• Provisions Affecting Immigrants: The interim final rule eliminates the requirement that states collect the primary language of families using SCHIP, creating a potentially major barrier to assuring that the program reaches eligible children in families in which English is not the primary language.

The rule also allows states to require children applying for separate state child health insurance programs to provide their social security number. The change represents a troubling and we believe incorrect interpretation of the Privacy Act that could create barriers to the enrollment of eligible children in immigrant families.

Please find enclosed a more detailed set of comments on these and other issues. If you have questions about these comments, please contact Judy Waxman at Families USA, (202) 628-3030.

Sincerely,

National Organizations:

Alliance for Children and Families
American Academy of Pediatrics
American Association on Mental Retardation
American Dental Education Association
American Medical Student Association
American Public Health Association
Carondelet Health System
Catholic Charities USA
Center for Budget and Policy Priorities
Child Welfare League of America
Children's Defense Fund
Children's Health Matters
Consumers Union
Families USA
Friends Committee on National Legislation (Quaker)
March of Dimes
Migrant Legal Action Program
National Association of Children's Hospitals
National Association of Community Health Centers, Inc.
National Association of Public Hospitals and Health Systems
National Mental Health Association
National Partnership for Women and Families
National Health Law Program
NETWORK: A National Catholic Social Justice Lobby
Summit Health Institute for Research and Education, Inc.
Universal Health Action Committee

State and Local Organizations:

ActionNOW!!, El Pas, TX
Advocates for Children & Youth, Baltimore, MD
AFFIRM, Washington, DC
AHEC/Community Partners, Amherst, MA
California WIC Association, Sacramento, CA
Care for the Homeless, New York, NY
Center for Civil Justice, Saginaw, MI
Center for Independence of the Disabled in New York, Inc., New York, NY
Center for Public Policy Priorities, Austin, TX
Citizen Action of New York, Albany, NY
Colorado Center on Law and Policy, Denver, CO
Colorado Community Health Centers, Denver, CO
Colorado Developmental Disabilities Planning Council, Denver, CO
Community Health Councils, Inc., Los Angeles, CA`
Covenant with North Carolina's Children, Durham, NC
Disabled Action Committee, Dale City, VA
Durham County Department of Social Services, Durham, NC
Durham County North Carolina Health Choice Coalition
Families First, Atlanta, GA
Florida Legal Services, Miami, FL
Franklin Primary Health Center, Inc., Mobile, AL
Friends of the Family, Inc., Baltimore, MD
Health and Medicine Policy Research Group, Chicago, IL
Health Care Council of Orange County, Orange, CA
Health Care for All, Boston, MA
Health Consumer Alliance, California
Hispanic Senior Action Council, New York, NY
Idaho Community Action Network
Illinois Campaign for Better Health Care, Champaign, IL
Illinois Primary Health Care Association, Springfield, IL
Indiana Coalition on Housing & Homeless Issues, Indianapolis, IN
Institute for the Puerto Rican, Hispanic Elderly, New York, NY
Kentucky Task Force on Hunger, Lexington, KY
Latin American Integration Center, Woodside, NY
Latino Issues Forum, San Francisco, CA
Legal Aid Foundation of Los Angeles, CA
Louisiana Covering Kids Initiative
Maryland Disability Law Center, Baltimore, MD
Massachusetts Children's Health Access Coalition, Boston, MA
Massachusetts Law Reform Institute, Boston, MA
Maternal and Child Health Access, Los Angeles, CA
Maternity Care Coalition, Philadelphia, PA
Mental Health Legal Advisors Committee, Boston, MA
Michigan Association for Children with Emotional Disorders, Southfield, MI
Mid-Ohio CHIP Outreach
Mississippi Human Services Coalition, Jackson, MS
Montana People's Action
National Association of Social Workers/Texas - Austin, TX
National Center on Poverty Law, Chicago, IL
New York Forum for Child Health, New York Academy of Medicine, New York, NY
New York Immigration Coalition, New York, NY
North Carolina Child Advocacy Institute, Raleigh, NC
North Carolina Health Choice Outreach
North Carolina Justice Center
Northwest Federation of Community Organizations, Seattle, WA
Northwest Health Law Advocates, Seattle, WA
Oregon Action
Pennsylvania Partnerships for Children, Harrisburg, PA
Piedmont Legal Services
Planned Parenthood of New York City
Protection and Advocacy System, Albuquerque, NM
Public Justice Center, Baltimore, MD
Resources for Children with Special Needs, New York, NY
South Carolina Appleseed Legal Justice Center, Columbia, SC
Statewide Youth Advocacy, Inc., Albany, NY
Tennessee Justice Center, Nashville, TN
Tri-County Commission on Alcohol and Drug Abuse, Orangeburg, SC
United Cerebral Palsy of Oregon & SW Washington, Inc., Portland, OR
Utah Issues: Center for Poverty Research & Action, Salt Lake City, UT
Utica Citizens in Action, Utica, NY
Virginia Poverty Law Center, Richmond, VA
Washington Association of Community & Migrant Health Centers, Kent, WA
Washington Citizen Action
West Virginia Healthy Kids Coalition, Charleston, WV
Women's Health and Family Planning Association of Texas, Austin, TX
Women's Policy Group, Atlanta, GA