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ALABAMA TITLE XXI STATE PLAN AMENDMENT
Background
Alabama submitted a State Plan Amendment (SPA) on May 20, 1998, for Phase II of its
Children's Health Insurance Program (CHIP), which will be implemented on September 1,
1998. Alabama's original Title XXI plan was approved on January 30, 1998:
Implementation of Phase I CHIP began on February 1, 1998, with a Medicaid expansion
of coverage for targeted low-income children under age 19, whose family income is below
100 percent of the Federal Poverty Level (FPL). The State is currently averaging
approximately 400 to 500 new enrollees per week, and anticipates enrolling up to 17,000
children in Phase I by the end of fiscal year 1999.
This amendment would implement Phase II of Alabama's CHIP plan, which creates a
separate State health insurance program for children under age 19 in families with incomes
up to 200 percent of the FPL and who are not eligible for Medicaid. This program will be
known as AL-Kids and is projecting an enrollment of 19,000 children in the first year
Administration
The Alabama Department of Public Health will have overall administrative responsibility
for
for the AL-Kids Program.
O
The Department of Public Health will contract with the State Employees Insurance Board
(ST
(SEIB) and other independent contractors to perform all eligibility determinations,
enrollment functions, and premium collections.
Health Care Delivery System
Services will be provided through indemnity and/or managed care plans. The State will be
awarding up to two contracts per region.
An enrollee will be locked in" to the plan in which they enroll for a year, unless the
child's parent or guardian moves from one provider region to another.
Benefit Package
he
o
The benefit package offered is that of the HMO with the largest insured commercial, non-
Medic
Medicaid enrollment in the State
in
the
overage of enrollees will be continuous for one year, unless the child moves out of state,
beco covered by other health insurance, becomes eligible for Medicaid or State
employ
employees' insurance becomes institutionalized or reaches 19 years of age.
the
Cost Sharing
There is no cost sharing for families with incomes at or below 150 percent of the FPL.
Families with incomes above 150 percent of the FPL will have an annual premium of $50
per child or $60 per child if paid in 10 monthly installments of $6. A family's total
premium payment will not exceed three times the selected payment method per year, i.e.,
$150 if premiums are paid annually or $180 if premiums are paid through the installment
plan.
Families with incomes above 150 percent of the FPL will not have copayments for
preventative services, well baby care or immunizations, but will have the following
copayments: $5 for inpatient hospital confinement, physician office visits, emergency room
visits where the patient is not admitted, urgent care services, each confinement for
inpatient chemical dependency, and dental services; $3 for brand name prescription drugs;
and $1 for generic prescription drugs.
There will be a $500 annual limit on copayments, which is well below the statutory limit of
5 percent of a family's annual income.
State Action to Avoid Crowd-Out and Outreach Activities
A common application form will be used for both the Title XIX and the Title XXI
program. If a child is found eligible for Medicaid, that child will be enrolled in the State's
Medicaid program.
Alabama has a 3-month waiting period for enrollment in Al-Kids for families that currently
have or have voluntarily dropped their health insurance coverage. Declaration of the lack
of coverage within the past three months on the application form will be verified, if
possible, with data from the Alabama Health Care Information Network.
The Alabama Health Care Information Network will operate a master patient index of
current private health care coverage of Alabama citizens starting in the fall of 1998. Blue
Cross/Blue Shield, which covers 85 percent of the State's insured population, will be
included in this data base. Additional insurance vendors throughout the State will be
included in the network by April 1999.
Outreach will be conducted through Statewide efforts and local partnerships. These
efforts will consist of a Statewide media campaign, outreach conducted by trained
workers, and outreach conducted through existing programs and agencies.
Financial Information
1998 CHIP Allotment -- $85,997,312
Enhanced Federal Matching Rate -- 78.52%
August 18, 1998
ALABAMA TITLE XIX STATE PLAN AMENDMENT AND TITLE XXI STATE PLAN
Background
On November 3, 1997, Alabama submitted a Title XIX State Plan Amendment and Title
XXI State Plan for providing expanded benefits under the Alabama Medicaid Agency's
Title XIX Plan. The Alabama Medicaid Agency is proposing amending its State Plan for
Medicaid Assistance by adding page 23b to attachment 2.2-A. The agency proposes
expanding Medicaid eligibility to children under age 19, who were born on or before
September 30, 1983, with family income levels at or below 100 percent of the Federal
Poverty Level (FPL). Eligible children will receive the full Medicaid benefit package. All
Medicaid program policies will apply.
Alabama expects to initiate expanded eligibility on February 1, 1998, which is the day the
90 day clock expires.
Administration and Phases
This expanded coverage for children will be administered by the Alabama Medicaid
Agency, Family Certification Division.
This State Plan Amendment represents the first of a two-phase approach to expanding
Medicaid eligibility. Phase I is defined as expanding Medicaid Program eligibility to
uninsured children who are less than 19 years of age, born on or before September 30,
1983, with family incomes equal to or less than 100 percent of the FPL. Phase I is
projected for implementation as of February 1, 1998. As of February 1, the capacity of
the Alabama Medicaid Agency's data systems, personnel, staff training, and
publications/documents will be expanded to meet the target of enrolling approximately
20,000 children in the first year.
By February 2, 1998, a plan to implement the second phase by expanding health care
coverage to children between 100 and 200 percent of the FPL will be submitted to
HCFA. Implementation in at least one-third of the counties in the State by August 1,
1998 is anticipated.
Health Care Delivery System
In 26 counties of the State, Medicaid operates a primary care case management program
through a 1915(b) waiver. This program, called Patient 1st, is expected to cover every
county in the State within the next year, with the exception of Mobile. Patient 1st links
each Medicaid beneficiary with a primary care physician who manages the patient's care.
o
In Mobile County, the State has an 1115 Waiver which provides health care coverage
through a managed care program, known as BAY Health Plan.
Title XXI eligible children will be primarily included in these managed care networks.
The Alabama Medicaid Agency will be providing documentation to HCFA within the
near future assuring the adequacy of the networks through each waiver and the
methodology for their inclusion.
Benefit Package
The Medicaid benefit package will be provided.
Cost Sharing
Medicaid rules will apply.
State Action to Avoid Crowd-Out and Outreach Activities
There will be no separate enrollment in the Children's Health Insurance Program (CHIP)
apart from enrollment in the Medicaid Program. The eligibility process is designed to
incorporate investigation of creditable health coverage using data matches and client
interviews to insure that only eligible, targeted low-income children are covered.
An additional 23 Medicaid eligibility workers will be hired, supplementing the State's
current 100 positions, in order to enroll the additional children under the State's
expanded eligibility. These workers will be located organizationally within the State
Medicaid Bureau. All 123 workers will enroll children who are eligible for Medicaid
under current eligibility rules as well as those eligible for Medicaid under Phase I of
CHIP. Workers will be stationed in health departments, hospitals, primary care centers,
and various locations throughout the state to facilitate enrollment in the Medicaid
Program.
In addition to current outreach avenues used by the Medicaid Program, information
regarding the expanded eligibility will be advertised through newspaper and newsletter
articles, a news conference, public service announcements, and publicity through the
public school system.
Potential Issues
o
The adequacy of the managed care networks in absorbing the additional children eligible
through the expanded eligibility as well as the length of time it may take the State in
providing Patient 1st Statewide, since this will affect the accessibility and availability of
services.
ARKANSAS TITLE XXI PROGRAM
FACT SHEET
Date Plan Submitted:
May 6, 1998
Date Plan Approved:
August 6, 1998
Effective Date:
July 1, 1998
Background
On May 6, 1998, Arkansas submitted a Title XXI plan to expand Medicaid eligibility to
children born after September 30, 1982, and prior to October 1, 1983, whose family
income is at or below 100 percent of the Federal Poverty Level (FPL). This is the first
phase of the State's CHIP initiative.
All program policies of the State's traditional Medicaid program, which operates under a
Section 1915(b) waiver, will apply.
Arkansas also has a separate Section 1115 demonstration entitled ARKids First. This
program covers uninsured children through age 18 in families with incomes up to 200
percent of the FPL, who do not qualify for the Section 1915(b) program. ARKids First
has a slightly modified benefits package and includes copayments.
Children Covered Under Program
The State expects to cover an additional 3,572 children under its Title XXI program when
it is fully phased in, which is projected to occur one year following implementation.
Administration
This program will be administered as a Medicaid expansion.
Arkansas is currently considering how to structure the second phase of its Title XXI
initiative, to cover the remainder of the population eligible under Title XXI.
Health Care Delivery System
The delivery system will be the primary care case management system (ConnectCare) that
operates on a fee-for-service basis in both the Medicaid and ARKids First programs.
Benefit Package
Children eligible for this phase of the Title XXI program will receive the full Medicaid
benefit package.
Cost Sharing
There is no cost sharing in this CHIP program.
Outreach Activities
The State has a contract with Arkansas Advocates for Children and Families, the State's
leading child advocacy agency, to provide a targeted outreach campaign to reach working
families with children. Arkansas Advocates for Children and Families will not work
directly with applicants, but will focus on providing information, training, and State-
prepared materials to grassroots organizations that are in daily contact with the targeted
population.
The State also has a contract with the Arkansas Department of Health to provide
information to applicants and recipients through a media campaign and a 24-hour toll-free
telephone Help Line Service. The Help Line Service responds to questions received from
Medicaid applicants, recipients, and providers by telephone concerning eligibility, access,
enrollment, rights and responsibilities and other issues. The media campaign will publicize
the existence of the telephone Help Line and will promote appropriate use of the medical
care system. The media campaign may include television and radio advertising, direct
mail, print media, telemarketing, and other viable methods.
Financial Information
Total Title XXI Reserved Allotment (FFY 1998) -- $46,878,527
Enhanced Federal Matching Rate -- 80.99%
First Year Costs (FFY 1998):
State Share -- $51,534
Federal Share -- $219,553
Total -- $271,087
ARIZONA TITLE XXI PROGRAM
FACT SHEET
Name of Plan:
KidsCare
Date Plan Submitted:
June 23, 1998
Date Plan Approved:
September 18, 1998
Effective Date:
October 1, 1997
Background
On June 23, 1998, Arizona submitted a Title XXI plan to extend health coverage to
children in families with gross incomes up to 150 percent of the Federal Poverty Level
(FPL) in the State's Fiscal Year from July 1998 through June 1999. As part of this plan,
the income limit will automatically increase to 175 percent of the FPL on July 1, 1999,
then to 200 percent of FPL on July 1, 2000. KidsCare will operate as a separate state
health insurance program.
Under the State's Medicaid program, the Arizona Health Care Cost Containment System
(AHCCCS), children in families with the following income limits would be covered: up to
140 percent FPL for children under age 1, up to 133 percent FPL for children ages 1 to 6,
and up to 100 percent FPL for children age 6 or over born after September 30, 1983.
Children Covered Under Program
The State expects to cover 28,800 children by the end of September 1999 and 49,900 by
the end of September 2000. By the end of September, 2001, when the program is fully
phased in, 63, 100 children are expected to be covered.
Administration
This program will be administered by the State Medicaid agency, the Arizona Health Care
Cost Containment System (AHCCCS).
The State is planning to submit an amendment for a sliding fee scale premium for families
with income above 150% of the FPL with the target effective date of July 1, 1999.
Health Care Delivery System
Arizona will provide KidsCare services through established AHCCCS health plans and
State employee Health Maintenance Organizations (HMOs) that elect to participate in the
program. American Indians may choose to receive services through the Indian Health
Service (IHS), 638 tribal facilities, one of the AHCCCS plans, or one of the participating
State employee HMOs. Under this plan, beginning October 1, 1999, the State will use a
portion of the 10 percent Title XXI administrative funds for direct services provided by
participating community health care clinics and hospitals that serve predominantly low
income children.
Benefit Package
The benefit package will be the same service package offered to State employees by the
least expensive commercial HMO (Intergroup), enhanced to include dental and vision
benefits. If a KidsCare eligible chooses to receive services through a direct service
provider, AHCCCS will provide any KidsCare services not provided by these entities on a
fee-for-service basis. If a Native American selects the IHS or a tribal facility, AHCCCS
will provide any KidsCare services not provided by these entities on a fee-for-service basis
off-reservation.
Cost Sharing
A $5 copayment on the non-emergency use of the emergency room will be assessed for all
members. This copayment can be waived if the member cannot afford to pay.
Health plans will include information in the Member Handbook about the maximum
amount that a family must pay for copayments and the fact that they do not have to
continue to pay once the cap on a family's out-of-pocket costs is reached. AHCCCS will
also flag the member's records so a hospital emergency room can verify that a copayment
should not be collected. If for some reason the cap is exceeded, AHCCCS will reimburse
the family for the exceeded amount.
Crowd-Out Strategy
Children must be without group health insurance for six months in order to be eligible for
KidsCare. Eligibility workers will obtain a declaration as to whether the family member or
employer has voluntarily discontinued employer-sponsored dependent insurance coverage
in order to allow a child to participate in KidsCare. (Exceptions to the six-month period
of uninsurance will be granted for newborans and if coverage was lost due to involuntary
loss of employment.) In addition, AHCCCS will select a monthly sample of approved
KidsCare cases (approximately 350 every 6 months) and interview the employer. If
problems are discovered in 10 percent or more of the cases, corrective action will be
taken.
Coordination Between CHIP and Medicaid
The State intends to enroll KidsCare applicants who appear to be Medicaid eligible into
KidsCare pending verification of Medicaid eligibility. If a child who has been approved
for KidsCare is subsequently determined to be eligible for Medicaid, he or she will be sent
a notice stating that the KidsCare eligibility is terminated and Medicaid eligibility is
approved. The child will be made Medicaid eligible back to the first day of the month in
which the child applied. The member will receive a Medicaid card, including a card carrier
listing covered services, and a member handbook listing all services.
If a child was approved for KidsCare pending a Medicaid eligibility determination and the
child is determined Medicaid eligible, the Medicaid eligibility will override the KidsCare
eligibility in the automated system and KidsCare capitation paid will be claimed at the
Medicaid matching rate rather than the KidsCare matching rate.
If the Medicaid eligible child is enrolled in an AHCCCS health plan under KidsCare, the
child will remain in the health plan following the transfer to Medicaid. If the child is
enrolled with a direct services provider under KidsCare, the child will be auto-assigned to
an AHCCCS health plan if a pre-enrollment health plan choice was not made following the
application for Medicaid. If the family did not have an opportunity to make a pre-
enrollment choice, a choice notice will be sent to the family following the auto-assignment
to a health plan.
Outreach Activities
The Governor's Outreach Work Group met several times to develop a comprehensive
outreach plan. AHCCCS has established an Outreach Coordinator position to ensure that
coordinated outreach efforts will include Medicaid, state-only funded programs, and the
KidsCare program. Both the Governor's Office and AHCCCS are working with tribal
entities to inform Native American families about KidsCare.
Outreach efforts and the distribution of applications will be targeted to those agencies,
organizations and other entities that currently serve targeted low income children.
Organizations distributing the applications and information about KidsCare will be offered
training to assist with completing the application form and collecting information. An
applicant will also receive assistance to complete the application form by calling the
AHCCCS 24-hour toll-free number.
Financial Information
Total Title XXI Reserved Allotment (FFY 1998) -- $113,138,521
Enhanced Federal Matching Rate -- 75.73%
First Year Costs (FFY 1999):
State Share -- $10,101,000
Federal Share -- $31,725,100
Total -- $41,826,100
Second Year Costs (FFY 2000):
State Share -- $17,003,000
Federal Share -- $53,402,800
Total -- $70,405,800
Third Year Costs (FFY 2001):
State Share -- $21,337,000
Federal Share -- $67,015,100
Total -- $88,352,100
9/16/98
CALIFORNIA TITLE XX1 STATE PLAN SUMMARY
Background
On November 19, California submitted a Title XXI State Plan to expand insurance
coverage to children within the State. The State will expand coverage through three
programs:
1)
Expansion of their Title XIX program, known as Medi-Cal, by implementing a
resource disregard and by making children under age 19, who were born before
September 30, 1983, eligible if they are at 100 percent or less of the Federal
Poverty Level (FPL).
2)
Expansion of their State program, known as the Access for Infants and Mothers
(AIM), which would cover infants up to age 1 from 200% to 250% of FPL.
3)
A State program, known as Healthy Families, which will provide coverage of
children from ages 1 through 19 with family incomes from 100 up to 200 percent
of FPL.
The State implemented the Medicaid expansion March 1, 1998, and plans to implement
the insurance program by July 1, 1998.
Administration
California will use the Managed Risk Medical Insurance Board (MRMIB) as the oversight
agency for the Healthy Families Program Administrative duties for this program will be
contracted through a private vendor. The MRMIB currently administers three health
insurance programs in the State, among them the AIM program. The other two programs
it administers are the Major Risk Medical Insurance Program, a program for medically
uninsurable people, and the Health Insurance Plan of California, a small employer
purchasing pool.
The Department of Health Services will be responsible for implementing the outreach and
the Medicaid changes proposed in the Title XXI State Plan.
Health Care Delivery System
Delivery of health services to Healthy Families members will be through managed care
organizations. Most of the participating plans will be HMOs, but it is possible that one or
more preferred provider organizations (PPOs) will also participate. The delivery system
for the AIM program is virtually identical to that of Healthy Families, with nine health care
service plans participating, providing statewide coverage.
To assure that health care providers currently serving low-income families are given the
opportunity to participate in the program, MRMIB will encourage private managed care
plans to subcontract with safety net providers by allow ing the health plan in each county
that has the highest percentage of traditional and safety net providers in its provider
network to charge a discounted premium; by allowing County Organized Health Systems
and local initiatives to participate; and by giving priority in awarding contracts to plans
with significant numbers of providers who serve uninsured children.
The delivery system for targeted low-income children served by Medi-Cal will be
consistent with the existing Title XIX State Plan.
Benefit Package
Health Families and AIM members will receive similar benefits to those provided to
California's state employees under the California Public Employees Retirement System
(CalPERS). The State will also provide enhanced services beyond the CalPERS package,
including comprehensive dental and vision coverage, screening and initial treatment
services though the Child Health and Disability Prevention (CHDP) program, and
treatment for severely ill children in a non-managed care delivery system.
Coverage for the Medi-Cal expansion is the Title XIX benefit package.
Cost Sharing
In the Healthy Families Program, premiums will be charged within the Title XXI limits.
Families who prepay three months of premiums will not have to pay for the fourth month.
In the Healthy Families Program, no copayments will be charged for prenatal, well baby,
well child, or immunization services. The copayment for all other services is $ 5. The
amount of copayments a family will pay in a given year for health services is limited to
$250.
Enrollees in the AIM program will pay premiums equal to 2% of the family's annual
income. No copayments are charged for AIM services.
State Action to Avoid Crowd-out and Outreach Activities
Children are ineligible for Healthy Families if they have been covered under
employer-sponsored coverage within the prior three months, or if they are eligible for
Medi-Cal or Medicare coverage. To participate in AIM, infants must not have
employer-sponsored coverage or no-cost Medi-Cal at the time of application.
California has planned a multifaceted approach to outreach. DHS will administer a $20
million media and outreach initiative. It will subcontract for a media campaign with a
private entity and with community based organizations, health brokers and insurance
agents to directly identify and assist potential enrollees in filling out the joint application
form for the Medi-Cal and the Healthy Families programs. A $ 25 application assistance
fee will be paid to these organizations for each beneficiary that is enrolled in one of these
programs. Additionally, California will conduct a provider education campaign in support
of its outreach campaign.
Additional Information
o
For Federal Fiscal Year (FFY) 1998, the State is proposing to spend $ 35,661,234, with
$ 26,850,179 in benefits. The Federal enhanced matching rate is 66.03 percent.
Approximately 34,000 children are anticipated for enrollment in the expanded Medi-Cal
program in FFY 1998. The anticipated enrollment in Healthy Families in FFY 1998 is
approximately 60,000 children.
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CALIFORNIA TITLE XX1 STATE PLAN SUMMARY
Background
On November 19, California submitted a Title XXI State Plan to expand insurance
coverage to children within the State. The State will combine a Medicaid expansion with
an insurance purchasing pool and an insurance purchasing credit, and also seeks Title
XXI match for a State program known as the Access for Infants and Mothers (AIM)
program. The State would cover children from age 1 to 19 with family incomes up to
200% of the federal poverty level (FPL) through the insurance program, and infants up to
age 1 from 200% to 250% of FPL through the AIM program. In addition, children ages
14 to 19 with family incomes 85% to 100% of FPL would become eligible for the State's
Medi-Cal program through a Medicaid expansion.
The State intends to implement the Medicaid expansion by March 1, 1998, and the
insurance program by July 1, 1998.
Administration
California plans to use the Managed Risk Medical Insurance Board (MRMIB) as the
mechanism for providing coverage to Healthy Families members. The MRMIB currently
administers three health insurance programs in the State: The Major Risk Medical
Insurance Program, a program for medically uninsurable people; the Health Insurance
Plan of California, a small employer purchasing pool; and the Access for Infants and
Mothers Program, a program for uninsured pregnant women and their newborns.
For the majority of eligible families, MRMIB will offer access to health plans through a
subsidized purchasing pool. MRMIB will use two mechanisms to provide managed care
to low-income children: A health insurance purchasing pool and an insurance purchasing
credit for children whose families have access to (but do not have) employer-sponsored
coverage.
Health Care Delivery System
Delivery of health services to Healthy Families members will be through managed care
organizations. Most of the participating plans will be HMOs, but it is possible that one or
more preferred provider organizations (PPOs) will also participate.
To assure that health care providers currently serving low-income families are given the
opportunity to participate in the program, MRMIB will encourage private managed care
plans to subcontract with safety net providers, will allow the health plan in each county
that has the highest percentage of traditional and safety net providers in its provider
network to charge a discounted premium, will allow County Organized Health Systems
and local initiatives to participate, and will give priority in awarding contracts to plans
with significant numbers of providers who serve uninsured children.
Benefit Package
In the insurance program, Health Families members will receive coverage like that
provided to California's state employees under the California Public Employees
Retirement System (CalPERS). The State will also provide enhanced services beyond
the CalPERS package, including comprehensive dental and vision coverage, screening
and initial treatment services though the Child Health and Disability Prevention (CHDP)
program, and treatment for severely ill children in a non-managed care delivery system.
Cost Sharing
In the insurance program, families with one child with incomes from 100% to 150% of
FPL will pay premiums of $4 to $7 per month (depending on the plan), and families in
that income range with two or more children will pay $8 to $14 per month. In the 150%
to 200% of FPL range, families with one child will pay $6 to $9, families with two
children will pay $12 to $18, and families with three or more children will pay $18 to
$27. Families who prepay three months of premiums will not have to pay for the fourth
month. Families will also have access to plans with higher premiums, but will be
expected to pay the premium differential.
In the purchasing credit program to help families buy into employer-sponsored insurance,
the amounts charged for coverage will be no greater than the amounts charged under the
high end of the purchasing pool coverage.
Enrollees in the AIM program will pay premiums equal to 2% of the family's annual
income for coverage of the pregnant woman and infant through age one.
MRMIB will establish copayment levels in amounts that reflect the copayment levels for
the CalPERS plan. However, no copayments will be charged for prenatal, well baby,
well child, or immunization services. The amount of copayments a family will pay in a
given year is limited to $250. The copayment for most services (office visits,
prescriptions) is $5.
State Action to Avoid Crowd-out and Outreach Activities
Children are ineligible for the insurance program if they have been covered under
employer-sponsored coverage within the prior three months, or if they are eligible for
Medi-Cal (at no cost) or Medicare coverage. To participate in AIM, infants must not
have employer-sponsored coverage or no-cost Medi-Cal at the time of application.
Potential Issues
The proposal includes administrative costs of 25.6%, well above the Title XXI limit of
10%. In addition, the State categorizes enrollment contractor and application assistance
fees as benefits costs.
The $5 copayment proposed for most services is above the "nominal" Medicaid level of
$3. The State projects that adjusting the $3 level for inflation, using the California
Consumer Price Index, would allow for a copayment level of $7.
The State plans to simplify Medicaid eligibility (to parallel Title XXI) by removing
resource requirements. The State requests enhanced Title XXI matching for the
additional Title XIX costs.
The program has a coverage "firewall" -- a prohibition against covering children who has
employer-sponsored coverage within three months prior to applying for the program.
Under the insurance purchasing credit option, the State requests the employer-sponsored
coverage to be 95 percent actuarially equivalent to coverage under the purchasing pool.
MRMIB is authorized to purchase supplemental coverage for services excluded from the
employer's plan.
COLORADO TITLE XX1 STATE PLAN SUMMARY
Background
On October 14, Colorado submitted a Title XXI State Plan to expand children's access to
health coverage by implementing state legislation and building on the experience and
infrastructure of the Colorado Child Health Plan, an existing program providing basic
medical services to low-income children. The Colorado Child Health Plan will adopt an
expanded benefits package and additional features which will bring it into compliance
with Title XXI. This Title XXI program will be called the Child Health Plan Plus
(CHP+). Coverage will be provided to children ages 0 through 17 with family income at
or below 185 percent of the Federal Poverty Level (FPL).
Administration and Phases
The Colorado Department of Health Care Policy and Financing will administer CHP+
with subcontracts to the Colorado Child Health Plan and the Colorado Foundation for
Families and Children.
This State Plan represents the first of a two-phase approach to implementing the CHP+.
The first phase, called CHP+, entails expanding the current Colorado Child Health Plan
from outpatient benefits to a comprehensive benefit package delivered through HMOs.
The Colorado Child Health Plan provider network will serve children who live in areas of
the State without HMO coverage. During the first phase, eligibility and enrollment
systems and information management infrastructure will be built, marketing and outreach
campaigns will be implemented, and identification of additional moneys for the State
match will be attempted to plan for the implementation of phase two.
The State anticipates coverage of 23,000 new children by the year 2000.
Health Care Delivery System
Delivery of health services to CHP+ members will be primarily through HMOs. The
existing Colorado Child Health Plan currently maintains its own statewide provider
network. This network will be expanded to care for children who are eligible for CHP+
but who have not yet been enrolled in an HMO, or those children who live in areas where
no HMO service is available. CHP+ will offer 12-months guaranteed eligibility
Benefit Package
Colorado is using a benchmark-equivalent package. The actuarial value of the proposed
benefit package exceeds the actuarial value of all three benchmark benefit packages.
The HMO benefit package will include hospital and emergency room transport; inpatient
services; outpatient/ ambulatory surgery; medical office visits (including physician,
mid-level practitioner, and specialist visits; laboratory and x-ray services; preventative
care; maternity care (prenatal, delivery, and inpatient well baby care);
neurobiologically-based mental illnesses; mental health care (institutional and outpatient
care); alcohol and substance abuse; physical, occupational, and speech therapy; durable
medical equipment; organ transplants, home health care; hospice care; outpatient
prescription drugs; skilled nursing facility care; vision services; audiological services,
intractable pain; autism coverage; and nutrition services.
The Child Health Plus provider network will provide a similar benefit package but will
not include organ transplants; hospice care; autism coverage; and skilled nursing facility
care.
Cost Sharing
Premiums for families through 100 percent FPL will be waived. For families between
101 percent and 150 percent with one child, premiums will be $9/child/month, and for
families with two or more children, $15/family/month. Between 150 percent and 169
percent FPL, families with one child will pay $15/child/month, and families with two or
more children will pay $25/family/month. For families between 170 percent and 185
percent FPL with one child, they will pay $20/child/month and families with two or more
children will pay $30/family/month. In addition, the State will inform the families of the
5 percent limit on cost-sharing and provide a mechanism for families to stop paying once
that limit has been reached.
Copayments for the HMO package and the provider network package are slightly
different. No cost sharing applies to well-baby and well-child care, including
age-appropriate immunizations. No child in a family with income less than 150 percent
FPL will incur cost sharing that is not permitted under 1916(b)(1).
State Action to Avoid Crowd-out and Outreach Activities
Legislation for the existing Colorado Child Health Plan denies coverage to any child who
is eligible for Medicaid. The mechanism which is currently in use will be used by CHP+.
CHP+ applicants will be screened for Medicaid eligibility. Application information will
be shared between Medicaid and CHP+ if the county social service agency and the family
agree to do so; therefore, initial processing can begin. CHP+ eligibility staff will follow
up on these referrals with clients and will notify county eligibility staff that they have
made a referral. Children who appear to be Medicaid eligible will only be enrolled in
CHP+ after they have received a denial letter from a county office.
In addition, the CHP+ application, like the existing current Colorado Child Health Plan's
application, will ask the applicant to report any health insurance coverage. If the family
reports creditable coverage, the child will be found ineligible. Providers contracting with
CHP+ will be required contractually to notify the plan whenever they have reason to
believe a member has coverage other than CHP+.
The CHP+ will be marketed statewide as a full benefit health plan following seven
primary strategies: direct appeal to eligible families through press releases, public service
announcements, and video; outreach through school districts; outreach through
employers; outreach through collaboration with local county agencies; outreach through
regional health and social agencies; outreach through other state programs; and outreach
through collaboration with the Colorado Foundation for Families and Children.
Financial Information
Total CHIP allotment -- $41.8 million
Enhanced Federal matching rate -- 66.38%
First year costs:
State Share -- $1.6 million
Federal Share -- $3.1 million
Total -- $4.7 million
CONNECTICUT TITLE XXI STATE PLAN SUMMARY
BACKGRGUND
On January 15, 1998 Connecticut submitted a Title XXI State Plan to expand coverage for
uninsured children through the combination of a Medicaid expansion for children and the creation
of a separate state health insurance program. State legislation authorizes the HUSKY Plan and
the HUSKY Plus Plan.
Under Part A of the HUSKY Plan, Medicaid eligibility will be expanded to include children ages
14 through 18 with household incomes up to 100 percent of the federal poverty level (FPL), using
an income disregard of 85 percent. (As of June 1, 1997 the Medicaid program covered children
ages 0-13 in families with incomes up to 185% of FPL. Expansion for children 14-16 was
effective 7/1/97; for children ages 16-18, effective 1/1/98.)
Part B of the HUSKY Program creates a separate state health insurance program for children
through age 18 with household incomes up to a gross income level of 235 percent of the FPL.
The State will apply an income disregard of up to 65 percent of family income to effectively bring
coverage to 300 percent of the FPL. Children who are eligible for HUSKY Part B and who
require intensive physical or behavorial health services will also receive medically necessary
services under HUSKY Plus.
The State also makes a buy-in option available to children in families with incomes above 300
percent of FPL with no federal or state subsidy. No Federal funds will be claimed for HUSKY
Part B Services provided to children in households above 300 percent of the FPL.
CHILDREN COVERED UNDER PROGRAM
Connecticut expects to cover approximately 15,000 additional children under its HUSKY
program by June 2000.
ADMINISTRATION and HEALTH CARE DELIVERY SYSTEM
A.
HUSKY Part A - The current administration of the Medicaid program will continue
under the State Medicaid Agency. Connecticut currently operates a 1915(b) waiver titled
"Health Connect."
B.
HUSKY Part B - State will contract with managed care plans through competitive
bidding process.
C.
HUSKY Plus - For children with special physical health needs, the plan will be jointly
administered by the Connecticut Children's Medical Center (CCMC) and the Yale New
Haven Children's Hospital (YNCH) in conjunction with the Yale University School of
Medicine. CCMC and YNCH will serve as the coordinating organizations but services
will be provided by the entities under contract to provide Title V services. The advisory
committee established by the Department of Public Health for Title V of the Social
Security Act will be the Steering Committee for the HUSKY Plus Plan along with
Fact Sheet - Page 2
representatives from the Departments of Social Services and Children and Families.
For children with intensive behavioral health needs, the Yale Child Study Center will
provide assessment services, case management, and develop and organize a statewide
network of providers. The plan will be responsible for all aspects of benefit management
under HUSKY Plus, including the direct reimbursement of HUSKY Plus providers
through contractual arrangements including, but not limited to, fee for service
reimbursement.
BENEFIT PACKAGE
The State is using a benchmark coverage benefit package based on the State employee coverage.
The coverage is based on the most generous benefits offered under the three state employee
options (Blue Cross, MD Health Plan, and Kaiser Permanente). The HUSKY Plus benefit
package is not available to State employees who already have health care coverage.
A.
HUSKY Part A - Medicaid Benefit Package
B.
HUSKY Part B - Includes the following services: hospital inpatient and outpatient,
physician, surgical, clinic, health center, ambulatory, prescription drugs, Lab and x-ray,
prenatal care, family planning and supplies, inpatient mental health, outpatient mental
health, durable medical equipment, disposable medical supplies, home and community-
based services, nursing care, abortion (to save life, rape, or incest), dental, inpatient and
outpatient substance abuse, enabling, emergency transportation.
C.
HUSKY Plus- Provides services for children with special physical health needs and
special behavioral health needs. Children must be eligible for HUSKY Part B with gross
household incomes under 300 percent of the FPL.
COST SHARING
Premiums:
HUSKY Part A:
None
HUSKY Part B:
For incomes up to 235 percent of the FPL: None
For incomes that exceeds 235 percent of the FPL before income disregards
are applied: $30 child/up to $50 family monthly
CoPays:
HUSKY Part A:
None
HUSKY Part B:
For incomes that exceed 235 percent of the FPL before income disregards,
the following apply:
Emergency care-- No copay unless service determined non-emergency
under State law, then $25 is charged.
$5 for practitioner visits
$6 for brand name drugs, $3 for generic drugs
The HUSKY Plan has no deductibles and coinsurance.
Fact Sheet - Page 3
Maximum Aggregate Cost Sharing (premiums and copays):
There is a $650 maximum for families with gross income (before disregards) between 185 percent
and 235 percent of the FPL. There is a $1,250 maximum for families with gross incomes that
exceed 235 percent of the FPL before income disregards. The State's cost sharing limits are
consistent with the statutory limits of Title XXI.
STATE ACTION TO AVOID CROWD-OUT
A person is ineligible for HUSKY Part B if they have been covered by employer-sponsored
insurance within the last six months. This may be extended to twelve months if the Commissioner
determines that six months is insufficient to deter applicants or employers from discontinuing
employer-sponsored dependent coverage. However, an application may be approved if the reason
for loss of employer-sponsored insurance is unrelated to the availability of the HUSKY Plan or
any of ten other reasons which include the loss of employment.
OUTREACH ACTIVITIES
The State will work with the Children's Health Council, Medicaid Managed Care Council,
Infoline of CT and local CAP agencies to develop outreach mechanisms. Outreach will include
radio and TV ads, direct mail campaign, brochures/flyers, video, toll-free number, web sites,
State presentations and mail-in applications.
Allotment: $34,968,061
Enhanced Matching Rate: 65%
Projected Budget: 1998 - $2,892,101 (State-only funds)
DELAWARE TITLE XXI PROGRAM
FACT SHEET
Name of Plan:
Delaware Healthy Children Program (DHCP)
Date of Plan Submitted:
June 30, 1998
Date Plan Approved:
September 1, 1998
Effective Date:
October 1, 1998
Background
On June 30, 1998, Delaware submitted a proposal to implement its children's health
insurance program (CHIP) which will expand health insurance coverage to children under
age 19 in families with incomes up to 200 percent of the Federal Poverty Level (FPL),
who are not eligible for Medicaid, through a separate state health insurance program.
Delaware's current Medicaid program, which is run under an 1115 waiver, covers children
up to age 6 in families with incomes up to 133 percent of the FPL and children from age 6
through age 18 in families with incomes up to 100 percent of the FPL.
Children Covered Under Program
The State expects to insure an additional 10,513 children by October 1, 1999.
Administration
This program will be administered by the Delaware Department of Health and Social
Services, Division of Social Services.
Health Care Delivery System
Enrollment will be managed using the State's existing statewide Section 1115 waiver, the
Diamond State Health Plan (DSHP). Delaware will use the existing health benefits
manager as the enrollment broker and the existing managed care organizations (MCOs) as
service delivery providers.
Benefit Package
The State employee health plan will be used as the benchmark plan for DHCP. All
services provided in the State employee health plan will be provided in the DHCP. In
addition to the services provided in the benchmark, the DHCP will cover over-the-counter
medications and additional mental health and substance abuse services. Although the
benchmark plan has copays for certain services, there will only be copays for non-
emergent use of the emergency room in the DHCP.
The service package will be provided through the fully capitated MCOs participating with
the DSHP. Services will be provided statewide and will not vary based on geography.
Cost Sharing
There is a $10 monthly premium for families with incomes between 101 percent and 133
percent of the FPL, a $15 monthly premium for families with incomes between 134
percent and 166 percent of the FPL, and a $25 monthly premium for families with
incomes between 167 percent and 200 percent of the FPL.
- There is a $10 co-payment per emergency room visit. This fee is waived if the visit results
in immediate inpatient hospitalization or if a prudent layperson would interpret the need
for the visit to the ER to be an emergency.
Crowd-Out Strategy
Children are not eligible for the program unless they have been without health coverage in
the preceding six months. However, exceptions to this requirement are made for good
cause.
Outreach Activities
The State plans to use the following methods of finding, notifying and assisting eligible
children to enroll in DHCP:
-
continue to outstation State Medicaid staff to complete Medicaid and DHCP
applications;
-
form partnerships with community based organizations that can help provide
outreach to children and their communities and service areas;
-
use non-traditional outreach strategies such as fliers on pizza boxes and fast food
trays; and
-
use cost effective media such as mailings, newspapers, busses, and public service
announcements on radio and TV.
Coordination Between CHIP and Medicaid
The State is using a single application form, incorporating the Title XXI program into the
Medicaid form. Eligibility will always be determined by staff under the administration of
the Title XIX program using abbreviated, mail-in applications and out-stationing eligibility
staff at various sites. Eligibility and redetermination of eligibility will be consistent with
the State's Medicaid program. A common computer eligibility system will also be used.
Individuals will be enrolled in MCO's using the same health benefits manager and the same
process of enrollment as is used by Delaware's Diamond State Health Program.
Individuals will be given a time frame to choose an MCO, and then, in the absence of any
indication of choice, will be automatically assigned to an MCO based on location and
availability of providers.
Financial Information
Total CHIP Allotment
$8,093,758
Enhanced Federal Matching Rate
65%
First Year Costs (January 1, 1999 - September 30, 1999):
State Share -- $2,535,431
Federal Share -- $4,708,655
Total -- $7,244,086
Second Year Costs (October 1, 1999 - September 30, 2000)
State Share -- $4,298,754
Federal Share -- $7,983,401
Total -- $12,282,155
FLORIDA TITLE XXI AMENDMENT SUMMARY
Fact Sheet
Name of Plan:
Florida Kidcare Program
Date Plan Approved:
March 6, 1998
Date Amendment Submitted:
July 17, 1998
Date Amendment Approved:
September 8, 1998
Background
o
On March 6, 1998, Florida's Title XXI plan was approved. This combination plan
expanded Medicaid coverage to children ages 15 through 19 in families with incomes up
to 100 percent of the Federal Poverty Level (FPL) and expanded the existing Healthy Kids
program, which provides subsidized premiums for children in families with incomes up to
185 percent of the FPL, to additional counties throughout the State, with modifications
deisigned to meet the requirements of the Title XXI legislation.
On July 17, 1998, Florida submitted an amendment to its Title XXI plan. The amendment
expands eligibility for Healthy Kids to children in families with incomes up to 200 percent
of the FPL, adds the MediKids program, and the Children's Medical Services (CMS)
Network. Between this amendment and the original plan, health care coverage will be
expanded to approximately 150,000 children by July 1, 1999. The entire program is called
the Florida Kidcare Program.
The amendment to Florida's CHIP plan includes the following components:
Extension of the current Florida Healthy Kids program to all counties throughout
the State, with modifications designed to meet the requirements of the Title XXI
legislation. The Healthy Kids program is a school-based health insurance program.
There are no income limitations for participation in Healthy Kids, but Title XXI
will provide subsidized premiums for children in families with incomes up to 200
percent of the FPL. The State expects to have approximately 107,000 children
enrolled in Florida Healthy Kids by July 1, 1999.
Creation of the MediKids program for children up to age 5 in families with
incomes below 200 percent of the FPL. The MediKids program was created to
capture the non-school aged children that the Healthy Kids program does not
capture. The MediKids program uses the Medicaid benefit package and has
periodic open enrollment periods. Once determined eligible for the program, a
child must enroll in a Medicaid managed care plan or the MediPass program,
Florida's primary care case management program. The State expects to have
approximately 11,000 children enrolled in MediKids by July 1, 1999.
The Children's Medical Services (CMS) Network will cover children under the age
of 18 with special health care needs in families with incomes below 200 percent of
the FPL. CMS allows children to have specialists as their primary care doctor
without any special authorizations. The State expects to have approximately 7,500
children enrolled in the CMS network by July 1, 1999.
Administration and Phases
o
The Healthy Kids, MediKids and CMS programs will be administered by the legislatively
created Florida Healthy Kids Corporation (FHKC), a not-for-profit organization which
operates subject to the supervision and approval of a board of directors, chaired by the
Insurance Commissioner or his designee, and composed of twelve other members.
Health Care Delivery System
o
Florida Healthy Kids services are delivered through state licensed managed health plans
that meet the requirements of the Department of Insurance and the Agency for Health
Care Administration. These health plans are responsible for developing service delivery
networks, claims processing and payment and risk assumption.
A child that is eligible for MediKids will have a choice between a Medicaid participating
HMO and MediPass.
The CMS Network providers are the same providers as those who serve Medicaid
children under the MediPass option for children with special health care needs. CMS
contracts with providers to offer a full range of services for these children. Families are
offered a choice of primary care providers in the network. The CMS Network provides
the standard Medicaid benefit package to its enrollees.
Benefit Package
o
The Healthy Kids benefit package is the existing program benefit package that was cited in
the Title XXI legislation as being an acceptable child health coverage program. This
benefit package includes a full range of inpatient and outpatient services. Limitations are
placed on psychiatric, rehabilitation and physical therapy inpatient admissions; alcohol and
drug services; chiropractic services; podiatric services; outpatient rehabilitation services;
and durable medical equipment and remedial devices. Dental services may be covered at
the county's option.
o
The MediKids benefit package and the CMS Network benefit package is the same as the
Medicaid benefit package.
Cost Sharing
Cost sharing is part of the Kidcare Program. Premiums for Title XXI participants will
range from $5 to a $15 maximum per household.
There will not be copayments for children in the MediKids or CMS programs.
Copayments are charged in the Healthy Kids program for a number of services and they
reflect Title XXI requirements.
The plan states that cost and utilization rates will be monitored on a quarterly basis to
ensure that costs associated with utilizing health care services do not exceed the five
percent maximum.
It is the responsibility of the family to detail their expenditures and to request exemption
from cost-sharing responsibilities and for reimbursement of out-of-pocket expenses that
exceed the allowable limit. Should a family spend in excess of five percent of their annual
income they will receive a letter from the State telling them that they are no longer
responsible for cost-sharing. If a family exceeds the 5 percent limit, they will be
reimbursed for excess expenses from the Corporation.
Coordination Between CHIP and Medicaid
The Healthy Kids corporation will screen all Kidcare applications for Medicaid eligibility.
Children who appear eligible will be processed for Medicaid eligibility by Department of
Children and Families eligibility specialists. These specialists are on-sight and co-located
in areas where families apply. All other children will be enrolled in the appropriate
Kidcare program
State Action to Avoid Crowd-Out and Outreach Activities
The Kidcare Program requires that children are uninsured at the time of application and
requires state residency. However, there is no waiting period of uninsurance for eligibility.
Florida has agreed to study the Healthy Kids program's impact on crowd-out. If there is a
problem, the State will implement a crowd-out policy.
Florida has convened a workgroup which consists of state agency representatives,
advocates and other parties, to develop a comprehensive outreach strategy for its child
health programs, including Title XIX and Title XXI programs. This workgroup will make
recommendations for improving outreach to Medicaid, and recommend a simplified
eligibility form and enrollment process for all child health programs.
The Healthy Kids corporation has contractual arrangements with school districts for
marketing and outreach. Outreach activities of the program are shared among the
Corporation, local steering committees, schools and participating health plans.
1
FLORIDA TITLE XXI PLAN SUMMARY
Background
On December 4, 1997, Florida submitted a Title XXI State Plan which proposes a
combination Title XIX and XXI program.
Medicaid coverage for children ages 15 through 19 will be extended from the current
family income level of 28 percent of the Federal Poverty Level up to 100 percent.
The current Florida Healthy Kids program will be extended to additional counties
throughout the State, with modifications designed to meet the requirements of the Title
XXI legislation. There are no income limitations for participation in Healthy Kids, but
Title XXI will provide subsidized premiums for individuals at or below 185 percent of the
Federal Poverty Level. Children must be in school to be eligible for the program. Eight
new counties have been selected for implementing Healthy Kids during SFY 1997-1998.
Additional counties that may be considered are currently engaged in planning activities. A
maximum of 118,725 children will be enrolled during each year.
Administration and Phases
Florida considers this plan to be only a beginning. The 1998 regular session of the Florida
Legislature will convene in March, 1998, during which time options will be debated for
fully implementing comprehensive health care coverage for children. The extension of
Medicaid coverage for children ages 15 to 19 anticipated in this plan submission will
require legislative review and ratification during this legislative session. The State
anticipates submitting amendments to this initial plan by early summer.
The Agency for Health Care Administration is Florida's designated single state agency for
the Medicaid program.
The Florida Healthy Kids is administered by the legislatively created Florida Healthy Kids
Corporation (FHKC), a not-for-profit organization which operates subject to the
supervision and approval of a board of directors, chaired by the Insurance Commissioner
or his designee, and composed of twelve other members.
Health Care Delivery System
The health care delivery system for the Medicaid expansion will be the same as is currently
provided to the Medicaid population, but it is not described in this application.
2
Florida Healthy Kids services are delivered through state licensed managed health plans
that meet the requirements of the Department of Insurance and the Agency for Health
Care Administration. These health plans are responsible for developing service delivery
networks, claims processing and payment and risk assumption. Plans are selected through
a competitive bidding process. Currently there are twelve health plans contracting with the
Corporation.
Benefit Package
The benefit package for the Medicaid expansion is the Medicaid benefit package.
The Healthy Kids benefit package is the existing program benefit package that was cited in
the Title XXI legislation as being an acceptable child health coverage program. This
benefit package includes a full range of inpatient and outpatient services. Limitations are
placed on psychiatric, rehabilitation and physical therapy inpatient admissions; alcohol and
drug services; chiropractic services; podiatric services; outpatient rehabilitation services;
and durable medical equipment and remedial devices. Dental services may be covered at
the county's option.
Cost Sharing
o
There is no cost sharing for the Medicaid expansion.
Cost sharing is part of the Healthy Kids Program. Premiums for Title XXI participants will
range from $5 to a $15 maximum per household. Copayments are charged for a number
of services. The State does say that copayments will be modified to reflect the Title XXI
legislation, specifically copayments for mental health services will be reduced to $3, which
is reflected in the attached benefit package. However, there are other copayments, i.e.,
those for emergency services and corrective lenses, which would not be in compliance
with Title XXI. So, it is not clear that the attached benefit package is for the Title XXI
Program to be implemented.
In the application, copayments are $3. for outpatient office visits, with the exception of
well child care visits and routing hearing and vision screening for which no copayments
are charged. There is also a $3 copayment for outpatient mental health visits; outpatient
rehabilitation services; home health services; refractions; and prescription drugs.
The plan states that cost and utilization rates will be monitored on a quarterly basis to
ensure that costs associated with utilizing health care services does not exceed the five
percent maximum. Should a family spend in excess of the five percent of their annual
income, the child's family will be reimbursed for excess expenses from the Corporation.
However, it will be the responsibility of the family to detail their expenditures and request
reimbursement of out-of-pocket expenses that exceed the allowable limit.
3
State Action to Avoid Crowd-Out and Outreach Activities
Once the Medicaid expansion has occurred, the Healthy Kids Corporation will review
children who are currently enrolled in the program for potential Medicaid eligibility.
Children who appear eligible will be processed for Medicaid eligibility by eligibility
specialists provided by the Department of Children and Families.
The Healthy Kids Program requires that children are uninsured at the time of application
and requires residency. There is no waiting period of uninsurance for eligibility.
Florida has convened a work group of state agency representatives, advocates and other
parties to develop a comprehensive outreach strategy for its child health programs,
including Title XIX and Title XXI programs that will make recommendations for
improving outreach to Medicaid, and recommend a simplified eligibility form and
enrollment process for all child health programs.
Healthy Kids has contractual arrangements with school districts for marketing and
outreach. Outreach activities of the program are shared among the Corporation, local
steering committees, schools and participating health plans.
GEORGIA TITLE XXI PROGRAM
FACT SHEET
Name of Plan:
Georgia CHIP
Date Plan Submitted:
May 29, 1998
Date Plan Approved:
September 3, 1998
Effective Date:
September 1, 1998
Background
On May 29, 1998, Georgia submitted a proposal to implement a children's health
insurance plan which will expand health care coverage to children through age 18 in
families with incomes below 200 percent of the Federal Poverty Level (FPL) who are not
eligible for Medicaid through a separate state health insurance program.
Georgia expects to enroll 20,783 children in the CHIP program in FY 1999, 58,475
children in FY 2000, and 66,732 children in FY 2001.
Administration and Phases
This expanded coverage for children will be administered by the Georgia Department of
Medicaid Assistance (DMA).
The implementation date for Georgia CHIP is September 1, 1998. The marketing and
outreach effort was rolled out for a pilot area of the state in August to begin developing
public awareness prior to implementation.
Benefit coverage in the pilot area will begin November 1, 1998. If all systems are
operating correctly, the statewide marketing and outreach campaign will begin in
November 1998. Applications will be accepted statewide on December 1, 1998 for
benefit coverage effective January 1, 1999.
Health Care Delivery System
Georgia's CHIP program will be delivered by the current Medicaid providers.
Benefit Package
Georgia's CHIP benefit package will be the BlueChoice Health Care Plan, the state's
largest HMO, with added services to bring the coverage to equal a Medicaid look-alike,
with the exception of non-emergency transportation and targeted case management.
Cost Sharing
There is no cost sharing for children under age 6. For children over age 6, there is a
monthly premium of $7.50 for one child and $15.00 for two or more children.
State Action to Avoid Crowd-Out
A child will be denied eligibility if it is determined that he or she is currently covered under
any health insurance, is eligible for Medicaid, is a member of a family that is eligible for
health benefits coverage under a State health benefit plan based on a family member's
employment with a public agency in the State, or voluntarily dropped coverage under an
employer plan during the last three months.
The CHIP application will contain questions about current and past coverage under group
health plans and family members employment with State Agencies. Employer information
will also be validated by checks of wage record data with the Georgia Department of
Labor (DOL) when available.
Once children are enrolled, there will be periodic checks of the DOL files to determine if
there have been changes in employers. In addition, as claims are paid, if the provders
report coverage under other health plans, eligibility will be terminated if the coverage
meets any of the four criteria listed above.
Outreach Activities
Outreach efforts will be completely coordinated for Georgia CHIP and Medicaid, so that
those children who are eligible for Medicaid will be reached and enrolled in Medicaid, and
those children eligible for Georgia CHIP will be reached and enrolled in Georgia CHIP.
The State will use the nationally-recognized Right From the Start Medicaid (RSM)
outreach strategies for Georgia CHIP. RSM outreach workers will have a variety of
program information on both creditable and non-creditable coverage and other ways to
access health care services, as well as all pertinent information on both Medicaid and
Georgia CHIP.
Financial Information
Total CHIP Reserved allotment --$125,283,859
Enhanced Federal Matching rate -- 72.33%
First year (FFY 99) costs -- $19,917,318
State share --$5,511,122
Premiums -- $1,417,864
Federal share --$14,406,196
Total Net Cost -- $19,917,318
Total Cost (with Premiums) -- $21,335,182
Expo and State and County fairs.
Page 3 - Indiana Title XXI Summary
The State is also working with seven community coalitions to draft an application for a
Robert Wood Johnson (RWJ) outreach grant.
Financial Information
ALLOTMENT:
$70,865,233
ENHANCED MATCHING RATE: 72.99%
PROJECTED BUDGET: FFY 98 (if all targeted children enroll)
Total Cost
State Cost
FFY 98
$14,959,084
$4,054,992
FFY 99
$42,625,397
$11,632,471
FFY 00
$60,230,504
$16,436,904
Updated 6/23/98
Page 2 - Indiana Title XXI Summary
Cost Sharing
Medicaid rules will apply for cost sharing.
State Action to Avoid Crowd-out
Indiana's Title XXI Medicaid expansion which limits family income to 150% of FPL
reduces the possibility of crowd-out since many of the lower income families do not have
the option of employer-based health insurance.
Poverty level children with other insurance will be covered by the State under the regular
Medicaid matching rate, thereby reducing the incentive for families to drop coverage.
At the time of application or recertification, parents must attest to the lack of current
coverage and indicate when the child last had coverage. The State will monitor this
information. The State plans to develop further recommendations to prevent substitution
of public coverage for private coverage in their Phase 2 program which will be submitted
as an amendment at a later time.
Outreach Activities
Short-term outreach efforts include: evaluating the viability of a toll-free telephone
number, analyzing the number of uninsured children per county, reviewing equipment
specifications and technical needs so that local providers and agencies can purchase
compatible equipment, developing a simplified shortened Medicaid application,
undertaking a media campaign to inform public about the program.
Outreach and case management will be provided by DFC directors in individual counties.
DFC is currently evaluating different out stationing models, including a co-location model
and several alternative options. Local DFC directors have considerable flexibility in
fashioning outstation designs and are required to work with organizations which include:
Head Start, First Steps, community action programs, community health centers, child care
voucher agents, disproportionate share hospitals, public school system school lunch
program, county hospitals, WIC clinics, MCH clinics, IV-D prosecutor staff, township
trustees, and community multi-service centers.
Long-term outreach efforts include establishing continuous coverage and presumptive
eligibility one-year pilot projects; coordinating the heightened outreach campaign among
the various State agencies, promoting new outreach efforts at a myriad of community
service and health service meetings, analyzing a business study that addresses the
feasibility of instituting a telephone interviewing process, delinking Medicaid from TANF
and Food Stamps in the computer system, and establishing presence at Indiana Black
INDIANA TITLE XXI STATE PLAN
Background
On April 17, 1998, Indiana submitted a Title XXI Plan to expand Medicaid eligibility to children
under the State's Medicaid Title XIX Plan. The State will expand Medicaid eligibility to include:
Effective 10/1/97, children born before 10/1/83 between the ages of 14 through 18 up to
100% of the Federal Poverty Level (FPL); and
Effective 7/1/98, children ages 0 through 18 up to 150% FPL.
Eligible children will receive the full Medicaid benefit package. All Medicaid program policies
will apply. Indiana expects to initiate expanded eligibility July 1, 1998.
Children Covered under Program
The State expects to cover approximately 23,750 children in year one, 49,250 children in
year two and 57,950 in year three.
Indiana's current Medicaid State plan covers infants up to 150% FPL, children under 6 up
to 133% FPL and children 6 through 18 to 100% FPL.
Administration
This expanded coverage for children is administered by the Office of Medicaid Planning
and Policy, Indiana Family and Social Services Administration
Individuals apply for Medicaid at one of the 105 DFC offices throughout the State.
Health Care Delivery System
The State currently has an approved 1915(b) waiver titled "Hoosier Healthwise"
comprised of a primary care case management system and a risk-based managed care
system. Primary medical providers (PMPs) provide preventive and primary medical care,
and furnish authorizations and referrals for most specialty services.
Children eligible for Medicaid through the Title XXI expansion will be integrated into
these managed care networks, thereby assuring they have a medical home.
Benefit Package
The current Medicaid benefit package will be provided.
Financial Information
Total CHIP allotment -- $123,141,631
Enhanced Federal matching rate -- 65%
First year costs:
State share -- $6,194,584
Federal share -- $11,504,227
Total -- $17,698,811
Health Care Delivery System
Care will be provided through the current delivery system for the Title XIX program.
When the State's 1115 demonstration waiver program is implemented (MediPlan Plus),
individuals will be transitioned in the same manner as current Title XIX participants.
Benefit Package
The Medicaid benefit package will be provided.
Cost Sharing
Medicaid rules will apply.
State Action to Avoid Crowd-Out and Outreach Activities
The State will closely monitor the implementation of the Medicaid expansion under Title
XXI to assess what effect the program has on existing health benefits coverage of optional
targeted low-income children. If the State should find that families are dropping privately
financed coverage to enroll in Medicaid, the State will take corrective action to prohibit
that practice.
The program will be fully integrated with the State's current Medicaid program; therefore,
the procedures currently in place for the identification of third party coverage will be
employed for this population as well.
The State will utilize a number of measures to encourage eligible children to enroll, utilize,
and stay in the health care system. These measures include:
-
Review of automated records to identify eligible participants followed by
notification to individuals.
Development of a new simplified application process and procedure to support
widespread offsite enrollments including sites at Federally Qualified Health Centers
(FQHCs), disproportionate share hospitals, local health departments, and WIC
sites.
Community health care providers, hospitals, clinics, emergency rooms, pharmacies,
schools, local health departments, hospitals, pharmacies, etc. will be utilized to the
fullest extent practical to identify potentially eligible individuals, for education, and
distribution of material.
The Department of Public Aid will send a notice to all non-assistance Child
Support families informing them of the program and of locations where the family
could enroll the child.
ILLINOIS TITLE XXI STATE PLAN
FACT SHEET
Background
On January 6, 1998, Illinois submitted a Title XXI Plan to provide expanded benefits
under the State's Medicaid Title XIX Plan. The Title XIX Plan amendments required to
implement the Title XXI program were submitted under separate cover on February 23,
1998. The State proposes to expand Medicaid eligibility to children between the ages of 0
and 19 and who are from families with incomes above the March 31, 1997 Medicaid
eligibility standard and at or below 133 percent of the Federal Poverty Level (FPL). The
State anticipates that the program will serve an additional 40,400 children by June 1998.
Eligible children will receive the full Medicaid benefit package. All Medicaid program
policies will apply.
At the end of 1997, Illinois covered 767,000 children under its Medicaid program. Prior
to the Title XXI expansion, the income level at which children were eligible for Medicaid
in Illinois varied based on the age of the children. Under the expansion, the threshold
income level has been simplified so that all children in Illinois with incomes up to 133% of
the FPL can be covered. The State now only covers children up to age 6.
Illinois will initiate expanded eligibility retroactive to January 5, 1998.
Administration and Phases
This expanded coverage for children will be administered by the State's Maternal and
Child Health (Title V) program in the Illinois Department of Human Services. Outreach
and case management will be provided through the Family Case Management program
which conducts these activities for low-income families that include a pregnant woman,
infant, or young child.
This State Plan Amendment represents the first stage of the Illinois Child Health Initiative
to be implemented under Title XXI. Phase I is defined as expanding the Medicaid
Program eligibility to uninsured children between 0 and 19 years of age who are from
families with incomes above the March 31, 1997 Medicaid eligibility standard and at or
below 133 percent of the FPL. The State anticipates that the program will serve an
additional 40,400 children. Phase I will be retroactive to January 5, 1998.
o
Later in 1998, the State intends to submit plan(s) to expand coverage further by way of
the HHS approval process. A legislative task force has been established to make a
recommendation for expansion of health benefits coverage for targeted low income
children up to 200 percent of FPL.
Children who have access to private health insurance will generally be excluded from
CHIP. Exceptions to this exclusion will be granted for "hardship" cases. Determinations
regarding both access to private coverage and hardship exceptions will be made by "self-
reliance specialists." The specialists will determine whether a child has access by
evaluating the available private coverage against HIPAA standards for "creditable
coverage." If the private coverage does not meet HIPAA standards, a child who meets all
eligibility criteria will be enrolled in CHIP. If the coverage does meet the HIPAA
standards, the child is presumed ineligible for CHIP and the family is notified. At this
point, if the family requests it, the self-reliance specialist will consider whether hardship or
extenuating circumstances exist, based on factors including family income, special needs
and expenses, and premium costs. All determinations regarding hardship are documented,
and applicants have the right to an appeal to a hearing officer.
Outreach Plan
The State will integrate outreach for expanded enrollment with current Medicaid
enrollment efforts.
The outreach plan is being developed by the Deputy Director of the Department of Health
and Welfare. Current efforts include mailing postcards to potential enrollees describing
Title XXI. The mailing list was comprised of families who have lost cash assistance
between April and December 1997.
After the Task Force determines the nature of the long term Title XXI program, it will be
responsible for developing recommendations for an appropriate outreach program.
Financial Information
Total CHIP Reserved Allotment -- $15,883,789
Enhanced Federal Matching Rate -- 78.71%
The State is proposing to spend 100 percent of its allotment.
IDAHO'S TITLE XXI STATE PLAN SUMMARY
Background
On February 17, 1998, Idaho submitted a Title XXI State Plan to expand Medicaid
coverage to optional targeted low-income children up to age 19.
Currently, the State is providing services to Title XXI-eligible infants and children up to
age 19 in families with incomes up to 160 percent of the FPL. State legislation has
reduced the CHIP income threshold to 150 percent of the FPL, effective July 1, 1998.
The State will convene a Children's Health Insurance Program Task Force to evaluate the
current Title XXI program and recommend alternatives to the State for the program in the
long term. The State has been informed that any changes to the approved plan must be
approved by HCFA prior to implementation.
The CHIP plan has an effective date of October 1, 1997.
Administration
The program will be administered by the State Medicaid Agency.
Health Care Delivery System
The State will utilize its current Medicaid delivery system to deliver services to the
expansion population.
Children Covered Under Program
The State is expecting to enroll 4,875 children in its Title XXI program.
Benefit Package
The standard Medicaid benefits package will be offered to the expansion population. The
benefit package will include inpatient and outpatient hospital, inpatient psychiatric,
physician services, dental services, other practitioners, clinic services, home health, family
planning, lab and x-ray services, prescriptions, and EPSDT services.
Cost Sharing
There will be no premiums or cost-sharing for enrollees.
State Action to Avoid Crowd-Out
Because the State's primary outreach for Title XXI eligibility will be the Medicaid
eligibility and enrollment system, potential Title XXI eligibles will first be evaluated for
Medicaid eligibility and enrolled if appropriate.
CHIP funds
Iowa is using
expand Medicaid.
IOWA TITLE XXI PROGRAM
Fact Sheet
Name of Plan:
Iowa Medicaid Expansion
Date Plan Submitted:
June 1, 1998
Date Plan Approved:
September 1, 1998
Effective Date:
July 1, 1998
Background
On June 1, 1998, Iowa submitted a proposal to expand Medicaid coverage to children
ages 6 through 18 in families with incomes up to 133 percent of the Federal Poverty Level
(FPL).
Iowa's current Medicaid program covers infants, up to one year of age, in families with
incomes up to 185 percent of the FPL, children under age 6 in families with incomes up to
133 percent of the FPL, children ages 6 through 14 in families with incomes up to 100
percent of the FPL, and children ages 15 through 18 in families with incomes up to 37
percent of the FPL.
This expansion will provide coverage to children ages 6 through 14 in families with
incomes between 100 percent and 133 percent of the FPL, and to children ages 15
through 18 in families with incomes between 37 percent and 133 percent of the FPL.
As of April 1, 1998, there were 95,189 children receiving Medicaid in Iowa. Iowa expects
its CHIP program to cover an additional 15,500 children by the end of June 1999.
Administration and Phases
Iowa implemented its CHIP program on July 1, 1998.
This expanded coverage for children will be administered by the Iowa Department of
Human Services (D.H.S.) in Des Moines and through the 104 D.H.S. offices located in the
99 Iowa counties.
Health Care Delivery System
Iowa's current Medicaid health care delivery system will be used for its CHIP program.
Benefit Package
The State's current Medicaid benefit package will be provided.
Cost Sharing
There is no cost sharing under this proposal.
State Action to Avoid Crowd-Out
The State anticipates that many of the children who will be covered through the expansion
will be siblings of younger children who are already receiving coverage through Medicaid
If experience proves that "crowd-out" is significant, the State will develop strategies to
address it.
Outreach Activities
Currently, the State conducts many activities to promote the enrollment of children in the
Medicaid program such as brochures, posters and TV spots, and health clinics are
conducted by several State agencies through a variety of means.
On May 14, 1998, a Request for Proposal (RFP) was released to contract for the
development and implementation of an outreach program.
Through this contract, the Iowa D.H.S. plans to provide education to provider
associations, State agencies, and advocacy groups such as Native American Tribal
Councils, Hispanic and African-American organizations, and refugee resettlement
programs. Applications will also be available for distribution by these groups.
Financial Information
Total CHIP Reserved allotment --$32,468,807
Enhanced Federal Matching rate -- 74.63%
First year (FFY 99) costs -- $13,101,568
State share --$3,323,868
Federal share --$9,777,700
KANSAS TITLE XXI PROGRAM
FACT SHEET
Name of Plan:
HealthWave
Date Plan Submitted:
July 14, 1998
Date Approved:
September 1, 1998
Effective Date:
July 1, 1998
Background
On July 14, Kansas submitted a proposal to implement a children's health insurance
program, HealthWave, which will expand health care coverage to low-income children in
families with incomes up to 200 percent of the Federal Poverty Program (FPL), who are
not eligible for Medicaid, through a separate state health insurance program.
Children Covered Under Program
The State expects to enroll approximately 30,000 children in CHIP by December 31,
2000.
Administration
This program will be administered by the Kansas Department of Social and Rehabilitation
Services.
Eligibility will be continuous for 12 months and re-established annually.
Health Care Delivery System
The State will contract with entities that will include insurance companies, health
maintenance organizations, nonprofit dental service corporation, or nonprofit hospital and
medical insurance corporations.
Benefit Package
The state employee benefit package will be used as the benchmark plan. In addition to the
benefits provided in the state employee benefit package, all medically necessary services
will be provided. The CHIP benefit package is equivalent to the State of Kansas EPSDT
benefit package.
Cost Sharing
Families above 150 percent FPL must pay a monthly premium. This premium will be
$10.00 per month for families with incomes between 151 and 175 percent of the FPL and
$15.00 per month for families with incomes between 176 and 200 percent of the FPL.
Crowd-Out Activities
Children are ineligible for CHIP if they are currently covered by any other health
insurance, or if they have been covered by health insurance in the previous six month
period and such coverage was terminated without good cause.
The CHIP application will be reviewed to determine if the child already has health
- insurance coverage. It will also be reviewed to identify other public or private health
insurance programs for which the child may qualify.
Outreach Activities
The State will market its CHIP program as a separate health insurance product. The State
will coordinate marketing efforts with state and local governmental entities as well as local
community programs.
The public schools will be the main focus of outreach to families with targeted low-income
children.
There will be a toll free number to access enrollment information.
Public program sites will participate as access points to the program and provide
enrollment materials and assistance.
Coordination between CHIP and Medicaid
The eligibility process for Title XIX and Title XXI will be coordinated through the use of
a joint application. All applications will be reviewed for Title XIX eligilibility.
The application and supporting documentation will be sent to a central clearinghouse. The
Medicaid State agency will administer the portion of the clearinghouse responsible for
Medicaid determination. Contracted staff will be responsible for CHIP determinations.
Families will enroll their children in a health plan through the Medicaid Fiscal Agent after
eligibility determination has been finalized.
Financial Information
Total 1998 CHIP allotment -- $30,664,400
Enhanced Federal Matching Rate -- 71.8%
Federal Fiscal Year 1999 Costs:
Federal Share: $7,266,160
State Share: $2,853,840
MAINE TITLE XXI PROGRAM
FACT SHEET
Name of Plan:
Cub Care
Date Plan Submitted:
May 19, 1998
Date Plan Approved:
August 7, 1998
Effective Date:
July 1, 1998 (Title XIX expansion)
August 1, 1998 (Title XXI)
Background
Maine's Title XXI program will expand coverage to children through age 18 in families
with incomes up to 185 percent of the Federal poverty level (FPL) using a combination of
a Medicaid expansion and a State Child Health Insurance Plan (CHIP). The Medicaid
expansion will cover children aged 1 through 18 in families with income up to 150 percent
of the FPL; the Cub Care program will cover children in families with income from 151
percent of FPL to 185 percent of the FPL.
Maine's current Medicaid program covers children from birth through 12 months with
family income up to 185 percent of the FPL, children 1 through 5 in families with income
up to 133 percent of the FPL, and children 6 through 18 in families with income up to 125
percent of the FPL.
Children Covered Under the Program
Maine estimates enrolling 6,968 children in the both the Medicaid expansion and Cub Care
by the end of the first year of the program. Maine expects enrollment to increase to
10,452 by the second year of the program.
Administration
Maine's Department of Human Services (DHS) oversees the administration of the
Medicaid program and will administer Cub Care in a similar manner. Three Bureaus
within DHS will share functional responsibility for the program: the Bureau of Medical
Services will have primary responsibility for administration and oversight; the Bureau of
Family Independence will determine eligibility; and the Bureau of Health will conduct
outreach and education activities.
Health Care Delivery System
The Cub Care program will utilize the Medicaid delivery system, which differs according
to county of residence. Beneficiaries in thirteen counties receive services through the fee-
for-service system, with an HMO option available in ten of these counties. In the three
remaining counties beneficiaries are required to participate in PrimeCare, a primary care
case management program.
The state has indicated its intent to submit a Medicaid state plan amendment to transition
to mandatory managed care statewide in the Fall of 1998. This managed care program
will use Managed Care Organizations to provide care. The Cub Care program will
transition to statewide managed care according to the same phase-in schedule as Medicaid
beneficiaries.
Benefit Package
The current Medicaid package will be provided for both the Medicaid expansion and the
Cub Care program.
Cost Sharing
The Cub Care program will have sliding scale premiums for children in families with gross
income above 151 percent of the FPL according to the following schedule:
- 151-160% FPL
5% of benefit cost per child ($5.00 per month), with a limit of 5%
of the cost for 2 children ($10.00 per month) per family.
- 160-170% FPL
10% of benefit cost per child ($10.00 per month), with a limit of
10% of the cost for 2 children ($20.00 per month) per family.
- 170-185% FPL
15% of benefit cost per child ($15.00 per month), with a limit of
15% of the cost for 2 children ($30.00 per month) per family.
Premiums will be limited to this predetermined percentage of the benefit cost, based on a
sliding scale and number of children enrolled. Thus, the aggregate cost sharing for a
family will not exceed 5 percent of a family's annual income, and indeed, based on initial
calculations, the premium will not be higher than the equivalent of 1.6 percent of family
income for those at the lowest end of the FPL range (150-185 percent of the FPL).
Crowd-Out Strategy
Maine plans to use a combined Medicaid/Cub Care application and the Bureau of Family
Independence will determine eligibility for both programs. Applicants will be enrolled in
the appropriate program according to eligibility criteria.
The joint application will request information about current and prior insurance coverage
for the most recent three-month period. If applicants have lost coverage for reasons
related to the availability of CHIP, eligibility will be denied. Children who lost coverage
for reasons unrelated to CHIP will remain eligible. If the coverage termination complies
with the following guidelines the children will be eligible for Cub Care:
the cost of the employee's share of family coverage exceeds 10 percent of family
income;
the loss of coverage for the child was due to a change in employment, termination
of COBRA coverage or termination was for a reason not in the control of the
employee (parent); or a determination of good cause exception is made by DHS.
Outreach Activities
The state will continue its current outreach activities under the Healthy Families Initiative,
a program that uses EPSDT/immunization workers and public health nurses to identify
health needs and increase awareness of Medicaid. These workers will be cross trained to
target potential Cub Care eligibles and to assist with enrollment. Home visitation under
this program will be expanded to target potential low-income children.
Other outreach efforts include a targeted media and direct mail campaign, adaption of the
Immpact system (an immunization tracking system) to collect information on insurance
coverage; and a streamlined combination application for Medicaid and Cub Care.
Coordination Between CHIP and Medicaid
The Cub Care program will be administered by DHS, the Department responsible for
administering the Medicaid program. Applicants for both program will use the same
simplified eligibility form and enrollment process, which will be conducted by the Bureau
of Family Independence. Those determined to be Medicaid eligible will be placed in the
Medicaid program. Children enrolled under the Medicaid expansion eligibility criteria and
those enrolled under Cub Care criteria will be given distinct eligibility codes in order to
track coverage under both programs.
Financial Information
Total CHIP Allotment for FY 1998 -- $12,490,186
Enhanced Federal Matching Rate -- 76.23%
FY 1998 (3 months)
Federal Share -- $635,452
State Share -- $195,421
Total (incl. admin costs) -- $830,873
FY 1999
Federal Share -- $8,123,966
State Share -- $2,498,374
Total (incl. admin costs) -- $10,622,340
MARYLAND TITLE XXI STATE PLAN
Background
On April 30, 1998, Maryland submitted a Title XXI Plan to expand Medicaid eligibility to
children up to age 19 in families with incomes at or below 200 percent of the Federal
Poverty Level (FPL). Eligible children will receive the full Medicaid benefit package and
all Medicaid program policies will apply.
Maryland expects to initiate expanded eligibility on July 1, 1998.
Administration and Phases
This expanded coverage for children will be administered by the State's Department of
Health and Mental Hygiene.
In addition to expanding benefits to children under Title XXI, the State will be
transitioning children receiving services under the Maryland Kids Count program into
Medicaid on July 1, 1998. Maryland Kids Count is a Section 1115 demonstration project
which provides primary and preventive care services to children born after September 30,
1983 who do not meet Medicaid eligibility requirements and whose family income is
below 185 percent of the FPL. The State previously requested to cover these children
under CHIP; however, the maintenance of effort (MOE) provision under Title XXI
(Section 2105(d)) does not allow states to adopt Medicaid eligibility standards that are
more restrictive than those in effect on March 31, 1997. The State is not requesting
enhanced match for these children in their CHIP proposal.
Children Covered Under Program
The State plans to cover 15,500 children under Title XXI by the end of SFY 1999.
Health Care Delivery System
Care will be provided through the current delivery system for the Title XIX program,
HealthChoice, a Section 1115 demonstration project. Most of the population will be
required to choose a Managed Care Organization (MCO) for delivery of health care
services.
Benefit Package
The Medicaid benefit package will be provided.
Cost Sharing
There is no cost sharing.
State Action to Avoid Crowd-Out
Any individual who is covered by employer-based health insurance, or who has voluntarily
refused or terminated employer-based health insurance within the preceding six months, is
ineligible for the program.
Maryland will verify insurance coverage and availability by requesting data during the
application process; performing data matches between the Medicaid Recipient file and
private insurers' beneficiary files; and reviewing selected sample cases.
Outreach Activities
The State will utilize many strategies to identify and enroll eligible children, which includes:
-
A grassroots information dissemination campaign involving a collaboration with State
agencies, advocacy and community-based groups and provider organizations.
-
A public media and advertising campaign, which will include television, radio,
billboards, mass transit posters, newspapers and a press conference.
-
A redesign of the application and eligibility determination process.
Financial Information
Total CHIP allotment -$61,643,199
Enhanced Federal matching rate -- 65%
First year costs:
State Share -- $8.4 million
Federal Share -- $15.6 million
Total -- $24 million
MASSACHUSETTS TITLE XXI PLAN SUMMARY
Background
On January 15, 1998, Massachusetts submitted a Title XXI State Plan to expand
children's access to health coverage by expanding Medicaid eligibility to children in
families with incomes up to 150 percent of the Federal poverty level (FPL) and by creating
a separate state health insurance program, the Family Assistance Plan, for children in
families with incomes between 150 percent and 200 percent of the FPL. The Family
Assistance Plan includes direct coverage and financial assistance to enable families to
participate in employer-sponsored health insurance (ESI). The State implemented a
streamlined eligibility process, which includes a gross income test, and an eligibility
expansion to 133 percent of the FPL through a Section 1115 demonstration on July 1,
1997.
The State intends to implement their children's health insurance program during July
1998, and has requested access to their allotment beginning on October 1, 1997.
Administration
The plan will be administered by the Single-State Agency.
Individuals Covered Under Program
Massachusetts expects to cover an additional 37,100 children under their CHIP plan by
the end of FY 1999.
In addition, the State expects to provide assistance to 6,000 adults through the employer-
sponsored health insurance portion of the Family Assistance Plan.
Health Care Delivery System
Health care services will be provided to the Medicaid expansion eligibles and to eligibles
of the direct coverage option of the Family Assistance Plan through the existing Medicaid
managed care delivery network, which consists of Primary Care Case Management, Health
Maintenance Organizations and a mental health and substance abuse managed care
contract.
Participants in the Premium Assistance Option will obtain services through contractual
arrangements of the ESI.
Benefit Package and Cost Sharing
o
Children eligible for Medicaid will receive the State's regular Medicaid benefit package
and have full protection from cost-sharing.
Children in families with incomes between 150 percent and 200 percent of the FPL will be
eligible for either a direct coverage option or financial assistance for ESI coverage, which
is the premium assistance option. The direct coverage option will provide FEHBP-
equivalent benchmark coverage These children will not be assessed co-payments, but
there will be a monthly premium of $10 per child to maximum of $30 per family.
Under the Premium Assistance Option, service delivery and access will be limited to the
contractual arrangements of the qualifying health plans of families with access to employer
sponsored insurance plans. The ESI plans will have to meet a Title XXI benchmark
benefit level. Children in families with access to cost-effective ESI family coverage will
have to utilize ESI. Premiums will be up to $10 per child per month to a maximum of up
to $30 per month. There is no cost sharing for well baby and well child services, nor will
there be cost sharing in excess of the 5 percent of income statutory limit.
State Action to Avoid Crowd-out and Outreach Activities
o
Proposed outreach includes school-based campaigns, community-wide enrollment
campaigns, creation and distribution of promotional materials, and funding community-
based organizations through mini-grants to assist in enrollment of hard to reach
individuals. There will be coordination and activity initiation with other state agencies and
collaboration with primary care providers.
This program builds upon their current Medicaid demonstration which includes provisions
to preserve and enhance ESI coverage. The Title XXI plan would continue support for
private coverage.
-
Families that are currently insured with existing ESI coverage will be able to obtain
premium assistance through the existing Medicaid 1115 demonstration at the
regular rate of Federal match.
-
If a family has access to employer sponsored insurance but is currently not
enrolled, and family coverage is determined to be cost-effective, then financial
assistance would be available through the Title XXI plan to enable these families to
obtain ESI.
The State will be monitoring the enrollment practices relating to ESI and the direct
coverage option. The State will also be studying statewide trends in ESI access
and employee participation in ESI. If it is determined that crowd out is occurring
the State will implement a 3-month period of no insurance coverage or HCFA and
the State will collaborate on an alternative corrective action.
Financial Information
Total CHIP Reserved Allotment -- $42,847,242
Enhanced Federal Matching Rate -- 65%
First Year Costs: (FFY 1998)
State Share -- $6.7 million
Federal Share -- $12.5 million
Total -- $19.2 million
MICHIGAN'S TITLE XXI PLAN SUMMARY
Background
On December 29, 1997 Michigan submitted a Title XXI State plan in order to implement
a new State Child Health Insurance Program called "MIChild." The program was
implemented in select parts of the State on May 1, 1998.
On April 17, 1998 Michigan submitted an amendment to their Title XXI plan in order to
make some programmatic changes to MIChild and to expand Medicaid eligibility. As a
result of the amendment, Michigan's Title XXI program now has both a Medicaid
expansion and the State program ("MIChild").
MIChild provides comprehensive health care coverage to all children under age 19 who
reside in families whose incomes are at or below 200 percent of poverty and who are
uninsured. Michigan estimates that there are approximately 133,000 that will be eligible
for the MIChild program.
Medicaid eligibility is being expanded to children 16 through 18 year of age through 150%
of poverty.
Michigan's Medicaid program currently provides coverage to children over the age of 6 in
families with incomes below 100% of poverty; children between the ages of 1-5 in families
with incomes below 133% of poverty; and infants to age 1 in families with incomes at or
below 185% of poverty.
Administration
Michigan has a single administrative contractor that is responsible for most MIChild
administrative duties. Final eligibility determination is made by State staff. The
administrative contractor is responsible for interacting with the medical benefits providers
and the State Department of Community Health.
Health Care Delivery System
Michigan has multiple managed care providers offering MIChild medical benefits.
Licensed insurers that offer a preferred provider product and HMOs may choose to
contract with the State at any time, provided that all the State standards are met (these
standards will be more stringent than normal licensing standards.
Benefit Package
The benefit package for MIChild is the same as the state employee's benefit package. The
benefit package is a comprehensive benefit package that includes a variety of hospital and
physicians services (including acupuncture therapy).
Cost Sharing
Michigan will not impose premium or co-payments on families with incomes less than or
equal to 150 percent of poverty
Michigan will charge premiums and co-payments for children in families with incomes
between 151 and 200 percent of poverty. The State will have the family of the children
keep track of their expenses and when they have reached their 5% limit they will notify the
health plan and the health plan will make certain that they are not charged and more
premiums or co-payments.
Families with one child will be required to pay a premium of $8 per month. Families with
two or more children will pay a maximum premium of $16 per month.
The following co-payments will be applied:
$5 for each non-formulary prescription not prior authorized
$5 for each pair of glasses or contact lenses
$5 for simple dental extractions and stainless steel crowns
$5 for each physical therapy visit
State Action to Avoid Crowd Out and Outreach Activities
Michigan will use a single application and children who are found eligible for Medicaid
will be enrolled in Medicaid. A child who is eligible for Medicaid is ineligible for MIChild.
The final Medicaid eligibility determinations will be made by State eligibility workers.
The MIChild application form will include a request for information regarding other
insurance coverage for each child. The contractor will not enroll any child who has
creditable group health coverage, access to employer-sponsored creditable health
coverage, or any child who has dropped coverage in the previous six months. The State
will allow for certain exceptions to the 6 month look back unless the reason for dropping
the coverage is approved by the State. The State will utilize tape matches to determine if
employer coverage is in place but was not reported by the family.
In addition, MIChild will refer custodial parents to an institution or group that has an
interest in the outcome of the court case and who have relevant knowledge to impart upon
the court, otherwise known as a Friend of the Court. The Friend of the Court will pursue
court ordered medical support by an absent parent. The child will still be enrolled in
MIChild for first six months. If at the end of six months, the parent has been actively
pursuing the support (as indicated by the Friend of the Court verification) the child will
continue to be enrolled in MIChild. If the parent has not been actively pursuing the
medical support, the child will be disenrolled from MIChild.
The State's marketing and outreach effort will be comprised of three components: general
marketing through the use of demographically targeted media campaigns and existing
information dissemination channels (demographic targeting maximizes the return for
advertising dollars by matching the timing and the placement of advertisements to the
habits of the target population); the solicitation of cooperation and outreach from
programs/agencies/systems likely to have contact with target families; and the solicitation
of community developed plans from existing county based multipurpose collaborative
bodies.
Allotment and Enhanced Match Rate
Michigan's total allotment is $92 million.
The State share for FY98 is $11.1 million.
The Federal for FY98 is $24.3 million.
Total for FY98: $36 million.
Michigan's enhanced matching rate is 67.51%.
MICHIGAN'S TITLE XXI PLAN AMENDMENT SUMMARY
On April 17 the State of Michigan submitted the following amendments to their title XXI plan:
Expand eligibility for Michigan's Medicaid program to children 16 through 18
years-of-age through 150% of the Federal poverty level;
Reduce family premiums for the MIChild program to $5.00 per month regardless of the
number of children in the family;
Eliminate all copays for MIChild covered services;
Require final eligibility determinations to be made by State staff;
Establish a twelve month lock-in to health plans with changes allowed in the first 30 days
of enrollment and for cause thereafter.
MICHIGAN'S TITLE XXI PLAN SUMMARY
Background
On December 29, 1997 Michigan submitted a Title XXI State plan in order to implement a
new State Child Health Insurance Program called "MIChild."
MIChild will provide comprehensive health care coverage to all children under age 19 who
reside in families whose incomes are at or below 200 percent of poverty and who are
uninsured. Michigan estimates that approximately 120,000 children will be covered under
the MIChild program by FY 2000.
Michigan's Medicaid program currently provides coverage to children over the age of 6 in
families with incomes below 100% of poverty, children between the ages of 1-5 in families
with incomes below 133% of poverty; and infants to age 1 in families with incomes at or
below 185% of poverty.
Administration and Phases
Michigan will have a single administrative contractor that is responsible for most MIChild
administrative duties (including final eligibility determination for the MIChild Program).
The administrative contractor will be responsible for interacting with the medical benefits
providers and the State Department of Community Health.
Health Care Delivery System
Michigan expects to have multiple managed care providers offering MIChild medical
benefits. Licensed insurers that offer a preferred provider product and HMOs may choose
to contract with the State at any time, provided that all the State standards are met (these
standards will be more stringent than normal licensing standards.
Benefit Package
The benefit package for MIChild is the same as the state employee's benefit package. The
benefit package is a comprehensive benefit package that includes a variety of hospital and
physicians services (including acupuncture therapy).
Cost Sharing
Michigan is not imposing any co-payments.
Michigan is charging premiums for children in families with incomes between 151 and 200
percent of poverty. The premium will be $5 a month regardless of the number of children
in the family.
State Action to Avoid Crowd Out and Outreach Activities
Michigan is using a single application and children who are found eligible for Medicaid
will be enrolled in Medicaid. A child that is eligible for Medicaid is ineligible for MIChild.
The MIChild application form includes a request for information regarding other insurance
coverage for each child. The contractor will not enroll any child that has creditable group
health coverage or any child who has dropped coverage in the previous six months, unless
the reason for dropping the coverage is approved by the State. Families that have
employer sponsored coverage available to them, but who are not availing themselves of
this coverage will also not be enrolled in MIChild. The State will utilize tape matches to
determine if employer coverage is in place but was not reported by the family.
In addition, MIChild will refer custodial parents to an institution or group that has an
interest in the outcome of the court case and who have relevant knowledge to impart upon
the court, other wise known as a Friend of the Court. The Friend of the Court will pursue
court ordered medical support by the absent parent. The child will still be enrolled in
MIChild for first six months. If at the end of six months, the parent has been actively
pursuing the support (as indicated by the Friend of the Court verification) the child will
continue to be enrolled in MIChild. If the parent has not been actively pursuing the
medical support, the child will be disenrolled from MIChild.
The State's marketing and outreach effort will be comprised of three components: general
marketing through the use of demographically targeted media campaigns and existing
information dissemination channels (demographic targeting maximizes the return for
advertising dollars by matching the timing and the placement of advertisements to the
habits of the target population); the solicitation of cooperation and outreach from
programs/agencies/systems likely to have contact with target families; and the solicitation
of community developed plans from existing county based multipurpose collaborative
bodies.
Allotment and Enhanced Match Rate
Michigan's total allotment is $92 million.
The State share for FY98 is $11.1 million.
The Federal share for FY98 is $24.3 million.
Total for FY98 is $36 million.
Michigan's enhanced match rate is 67.51%.
MINNESOTA TITLE XXI PROGRAM
FACT SHEET
Date Plan Submitted:
April 29, 1998
Date Plan Approved:
July 17, 1998
Effective Date:
September 30, 1998
Background
Minnesota's Title XXI plan proposes to expand Medicaid coverage to children under age
2 in families with incomes from 275 percent of the Federal Poverty Level (FPL) to 280
percent of the FPL. Minnesota has indicated that it intends to submit a plan amendment to
cover additional uninsured children. This CHIP plan will allow the State to have access to
its allotment while planning for future expansion.
Children Covered Under the Program
The State will enroll a small number of children in the first three years of the program in
order to access its allotment. The State estimates that only $176,585 in funds will be
drawn down in the first year. These expenditures are to provide health insurance coverage
and to cover start up costs while the State plans for future expansion to its CHIP plan.
Administration
The Minnesota Department of Human Services will administer the program.
Health Care Delivery System
Care will be provided through the current managed care delivery system for the Title XIX
program.
Benefit Package
The current Medicaid benefit package will be provided.
Cost Sharing
No cost sharing is proposed.
Outreach Activities
Because this expansion builds off of the current Medicaid program, Minnesota will utilize
many of the already existing resources to inform and enroll potential eligibles. These
outreach efforts include:
-
a toll free number for program inquiries and and eligibility questions;
-
application forms available at various community sites such as provider offices,
school districts, public and private elementary schools, community health offices,
WIC program sites and local human services agencies; and
-
targeted outreach efforts including media campaigns, partnerships between
community hospitals and schools to identify uninsured children, and discussions
with employers not offering health care coverage.
Financial Information
Total CHIP Allotment -- $28,403,279
Enhanced Federal Matching Rate -- 66.5%
Title XXI First Year Costs:
State Share -- $9,796
Federal Share -- $19,442
Total -- $29,238
Title XIX First Year Costs:
State Share -- $73,671
Federal Share -- $73,671
Total -- $147,342
MISSOURI'S TITLE XXI STATE PLAN SUMMARY
Background
On September 26, Missouri submitted a Title XXI State Plan to expand insurance
coverage to children within the State's existing Medicaid managed care delivery system,
MC+.
The State is proposing to use the Title XXI funding to expand Medicaid eligibility to
children in families with income up to 300% of the Federal Poverty Level (FPL).
The State proposes to begin enrollment and marketing on July 1, 1998 and providing
health care services on September 1, 1998.
Administration
The program will be administered by the State Medicaid agency.
Health Care Delivery System
The State will utilize its current managed care program, Managed Care Plus (MC+),
where available, to deliver services. MC+ is currently implemented in the eastern, central,
western, and northwestern areas. It is expected to be implemented in the southeast region
by August of 1998. Where managed care is not yet available, a fee-for-service system will
be utilized. When MC+ is implemented in these areas, the population will be enrolled in
managed care.
Benefit Package
The standard Medicaid benefit package, with the exception of non-emergency
transportation, will be offered. The benefit package will include: a full range of unlimited
inpatient and outpatient services; emergency room services; dental services including
orthodontics; hearing aids and related services; eye exams and glasses; private duty
nursing; psychological and counseling services; physical, occupational, and speech
therapy; all durable medical equipment; home health services; and all medically necessary
behavioral health services.
Cost Sharing
There will be no premiums and deductibles for enrollees.
State Action to Avoid Crowd-Out and Outreach Activities
Children who have had private coverage within the last six months will have a six month
waiting period for Medicaid coverage. Exceptions will be made in limited circumstances.
Outreach and eligibility efforts will take place throughout the State at the State offices in
every county. Free materials will also be available and used by other entities such as social
welfare organizations, schools, and health care providers to assist in outreach efforts.
Eligible Population Size
The State estimates that approximately 90,000 children would be eligible for enrollment in
the Title XXI program by June 30, 1999.
Funding Information
The State is proposing to spend 100 percent of their allotment.
The State's allotment is $51, 686,405.
The State's enhanced matching rate is 72.48 percent
MISSOURI STATEWIDE HEALTH REFORM DEMONSTRATION
FACT SHEET
Name of Section 1115 Demonstration:
Missouri Managed Care Plus (MC+)
Date Proposed Amendment Submitted:
September 2, 1997
Date Proposal Approved:
April 28, 1998
Proposed Implementation:
September 1, 1998
SUMMARY
On June 30, 1994, the Department of Social Services of Missouri requested section 1115
demonstration waivers to expand Medicaid eligibility to uninsured individuals with incomes up to
200 percent of the Federal Poverty Level (FPL). On September 2, 1997 the State submitted a
proposed amendment to its proposal; on February 13, 1998, the State revised its section 1115
proposal and indicated that the new submission was to be treated as a stand-alone document. The
approved demonstration will operate concurrently with the State's current section 1915(b)
waiver, also known as Managed Care Plus (MC+).
The demonstration will expand eligibility to children eligible under Title XXI, working parents
who are transitioning off of welfare and who have a Medicaid eligible child in the home, to absent
parents who are participating in Missouri's Parent's Fair Share program with incomes up to 100
percent of the FPL, and to absent parents who are actively paying their legally obligated amount
of child support. The State will lock-in these expansion eligible Medicaid beneficiaries for one
year in their managed care delivery system, MC+. The benefits package for the adults will be
more "commercially oriented" and will not include non-emergency transportation as a covered
benefit.
ELIGIBILITY
Adults transitioning off of welfare (TANF) who would not otherwise be insured or
Medicaid eligible and with family income over 27 percent and up to 300 percent of the
FPL. Coverage for this group will be limited to two years. After two years, they will
have the option of continuing their coverage by paying the premium cost directly to the
health plan for the remainder of the demonstration. The State and Federal governments
will not financially participate in this arrangment.
Uninsured non-custodial parents with family income up to 100 percent of the FPL who are
current in paying their child support. Coverage for this group will be limited to two years.
Uninsured non-custodial parents actively participating in Missouri's Parent's Fair Share
program.
Uninsured custodial parents with family income up to 100 percent of the FPL. Coverage
for this group will be limited to two years.
Uninsured women losing their Medicaid eligibility 60 days post-partum will be eligible for
Women's Health Services, regardless of income level, for a maximum of two consecutive
years.
Children eligible under Title XXI and who do not receive a full Medicaid benefit package
(i.e. do not receive non-emergency transportation as a covered benefit).
The following Medicaid recipients will be exempt under the section 1115 demonstration: dual
eligibles, the permanently and totally disabled, individuals in nursing homes or Intermediate Care
Facilities for the Mentally Retarded (ICF/MR), the mentally retarded, uninsured women eligible
because of their pregnancy, the blind, IMD residents, Medicaid recipients currently participating
in the 1915(c) waivers for the MR/DD and the AIDS population, and certain persons with private
commercial insurance.
BENEFIT PACKAGE
Working parents with children who are transitioning off of welfare, and low income
uninsured non-custodial and custodial parents, will receive a benefit package equivalent to
that offered to the employees of the State. For example, non-emergency transportation,
which is not available to State employees, also will not be a covered benefit for this group.
Uninsured women who are losing Medicaid eligibility 60 days post-partum will be eligible
for a limited package of women's health benefits, regardless of income level, for two
years. The Women's Health Services benefit package include contraception counseling,
devices, pharmaceuticals, and implants; pap smears and pelvic exams, and sexually
transmitted disease testing and treatment.
Managed behavioral health care services will be provided for 30 inpatient days and 20
outpatient days per year. Services required in excess of this 30/20 day limitation will be
paid on a fee-for-service basis.
ENROLLMENT/DISENROLLMENT PROCESS
The State will use an enrollment broker, as under the current 1915(b) MC+ waiver, to
help beneficiaries choose a plan.
The State will use a centralized application procedure and State employees will determine
eligibility.
Beneficiaries will be locked-in to a health plan for 12 months following a 90-day period
during which they can change health plans without cause. They will be notified at least 60
days before each enrollment of their option to change plans. Beneficiaries will be able to
change plans at any time during the year for good cause as determined by the Department
of Social Services.
Eligible beneficiaries who do not choose a health plan will be automatically assigned to
one.
The State is proposing that all eligibility determinations and redeterminations be initiated
through a direct mail process. Its toll-free telephone system would be expanded and
interviews with prospective eligible beneficiaries would be conducted by phone. The local
Division of Family Services offices will have program information available and will be
able to provide assistance in completing the application but will not serve as the
application site.
DELIVERY SYSTEM
The delivery system for the expansion population will be the State's current 1915(b)
waiver managed care delivery system.
QUALITY ASSURANCE
The State is using HEDIS as their base for quality control data collection specifications.
The State will also monitor the autoassignment rate, new enrollment by region, provider
and recipient comments and concerns.
The State will use Geo-Access or a GeoAccess-like program to monitor access.
The State is proposing to contract with an independent peer review organization (PRO) or
a PRO-like entity to perform an annual external review.
COST-SHARING
Adults made eligible under the demonstration will participate in a cost-sharing
arrangement. The beneficiary will be required to pay $10 for each provider visit and $5
per prescription.
No co-payment will be required for Parent's Fair Share participants, and those under the
Women's Health Program.
There is no cost sharing for children.
MONTANA TITLE XXI STATE PLAN SUMMARY
Name of Plan:
Montana's Children's Health Insurance Plan
Date of Plan Submitted:
April 10, 1998
Date Plan Approved:
September 11, 1998
Background
On April 13, 1998, Montana submitted a Title XXI State Plan to expand coverage to
children through a benchmark-equivalent benefit package. The State proposes to
provide coverage for children under the age of 19 and with family income at or below
150 percent of the Federal Poverty Level (FPL).
Children Covered Under Program
The State anticipates covering 9, 120 children in 2000.
Administration and Phases
The Health Policy and Services Division of the Montana Department of Health and
Human Services will administer Montana's Children's Health Insurance Program.
The State is requesting approval for their plan in the next legislative session and will
amend the plan if required by legislative changes.
Health Care Delivery System
Montana will seek contracts with indemnity insurance plans and health maintenance
organizations. Families will be given a choice of which type of coverage they wish
for their children, depending on availability of plans in their area.
Benefit Package
Utah will offer benchmark-equivalent coverage. An actuarial analysis comparing the
benefit package selected to the Basic Plan offered to employees of the State of
Montana is provided.
The benefit package will include inpatient and outpatient hospital services; emergency
room services; physician services; surgical services; lab and x-ray services; well-child
and well-baby services including age appropriate immunizations; prenatal and
prepregnancy services; abortion as permitted by law; prescription drugs; mental health
and substance abuse treatment services; and hearing and vision exams.
Cost Sharing
Montana will impose an annual enrollment fee as follows:
-No annual enrollment fee for families below 100% of FPL.
-A $12 annual enrollment fee for a family of one who is at or above 100% of
FPL.
-A $15 annual enrollment fee for families of two or more who are at or above
100% of FPL.
Montana will impose copayments as follows:
-No copayments for families below 100% of FPL.
-No copayments for well-baby or well-child care, including age-appropriate
immunizations
-For families at or above 100% of FPL:
-$25 per admission for inpatient hospital services
-$5 per visit for emergency room visits
-$5 per visit for outpatient hospital visits
-$3 per visit for physician, mid-level practitioner, optometrist,
audiologist,
mental health professional or substance abuse counselor
services
-$3 per prescription for generic drugs
-$5 per prescription for brand-name drugs
Copayments will be capped at $200 per family per year. Families will receive an
explanation of benefits from the insurer each time a claim is paid that specifies the
amount of copayments that have been incurred during the year. Once the family
reaches their limit, they can use this explanation of benefits to show providers that
they are exempt from copayment. If a family exceeds the $200 limit, the family may
contact the state for a refund.
State Action to Avoid Crowd-out
The application will ask the applicant to report any health insurance coverage.
A child will be found ineligible if the child's parent is employed by a state agency; if
the child is not a U.S. citizen or Qualified Alien as defined under federal statute; if the
child is eligible for Medicaid; if the child is covered under a group health plan or under
health insurance coverage as defined in section 2791 of the Public health Service Act;
or if the child has been covered under an individual or group health plan within the
three months prior to application for CHIP except under certain circumstances.
As a performance goal, the State will seek to maintain the proportion of children
<150% of FPL who are covered under an employer-based plan. The State will
measure and analyze the proportion of children 150% of FPL who are covered
under an employer-based plan taking into account economic factors.
Outreach Activities
The initial outreach for the program will be through direct mailings of enrollment
information and applications to families. Families receiving the mailing will be
children currently on the waiting list for the Caring Program for Children; Indian
Health Services children who are uninsured; families who receive subsidized child
care; families who have left the TANF program; and children participating in the
Mental Health Access Plan.
After legislative approval, outreach will be through direct appeals to eligible families
through press releases, public service announcements and video; outreach through
school districts; outreach through collaboration with local agencies, grass root
organizations and providers; and outreach collaboration with statewide maternal child
health organizations.
Coordination between CHIP and Medicaid
All applications will be screened for Medicaid eligibility by the CHIP program. If the
family is potentially eligible for Medicaid, information will be forwarded to the county
public assistance offices to begin the Medicaid application process (unless the family
indicates that they do not want this information forwarded.) Children who are
potentially Medicaid eligible will be sent a CHIP denial letter and a full Medicaid
application form. If a family is subsequently found ineligible for Medicaid, the family
must send the Medicaid denial letter to the CHIP program in order to have CHIP
eligibility determined.
Financial Information
Total CHIP allotment --$9,832,614
Enhanced Federal matching rate --79.39%
First year costs (July 1, 1998 -June 30, 1999):
State Share --$234,067
Federal Share --$901,630
Total --$1,135,697
Second year costs (July 1, 1999 -June 30, 2000):
State Share --$2,552,591
Federal Share --$9,832,614
Total --$12,385,204
NEBRASKA TITLE XXI PROGRAM
FACT SHEET
Name of Plan:
Kids Connection
Date Plan Submitted:
May 13, 1998
Date Plan Approved:
August 7, 1998
Effective Date:
May 1, 1998
Background
On May 13, 1998, Nebraska submitted a Title XXI State Plan to expand Medicaid
eligibility for individuals age 15 through 18 to 100 percent of the Federal poverty level
(FPL).
The State will use a more proactive approach to enroll eligible children ages 15 through
18 in families currently in households receiving public assistance. They will be identified
to eligibility workers to activate Medicaid eligibility for them along with their younger
siblings.
This plan is Phase I of Nebraska's CHIP program. The second phase is currently under
review by the Department of Health and Human Services.
Children Covered Under the Program
Kids Connection will add an estimated 950 children by July 1, 1999.
Administration
The Title XXI Program will be administered by the Nebraska Health and Human Services
System.
Health Care Delivery System
The existing Medicaid delivery system will be used to provide services.
Benefit Package
The Medicaid benefit package will be provided.
Cost Sharing
There are no cost-sharing requirements.
Crowd-Out Strategy
The State's current procedures in place for the identification of third party coverage will
be used for this population as well.
Outreach Activities
A number of outreach efforts have been developed for Phase I of Kids Connection which
include, but are not limited to the following :
using a one-page simplified Medicaid application form
allowing mail-in application forms
working with advocacy agencies in disseminating information on Medicaid
eligibility and the application process to low income communities
using information pamphlets and brochures
Financial Information
Total CHIP 1998 allotment $14, 866,746
Enhanced Federal matching rate: 72.82%
First Year Costs:
State Share -- $89,000
Federal Share -- $229,000
Total -- $318,000
NEBRASKA TITLE XXI PROGRAM
FACT SHEET
Name of Plan:
Kids Connection
Date Plan Submitted:
May 13, 1998
Date Plan Approved:
August 7, 1998
Effective Date:
May 1, 1998
Background
On May 13, 1998, Nebraska submitted a Title XXI State Plan to expand Medicaid
eligibility for individuals age 15 through 18 to 100 percent of the Federal poverty level
(FPL).
The State will use a more proactive approach to enroll eligible children ages 15 through
18 in families currently in households receiving public assistance. They will be identified
to eligibility workers to activate Medicaid eligibility for them along with their younger
siblings.
This plan is Phase I of Nebraska's CHIP program. The second phase is currently under
review by the Department of Health and Human Services.
Children Covered Under the Program
Kids Connection will add an estimated 950 children by July 1, 1999.
Administration
The Title XXI Program will be administered by the Nebraska Health and Human Services
System.
Health Care Delivery System
The existing Medicaid delivery system will be used to provide services.
Benefit Package
The Medicaid benefit package will be provided.
Cost Sharing
There are no cost-sharing requirements.
Crowd-Out Strategy
The State's current procedures in place for the identification of third party coverage will
be used for this population as well.
Outreach Activities
A number of outreach efforts have been developed for Phase I of Kids Connection which
include, but are not limited to the following
:
using a one-page simplified Medicaid application form
allowing mail-in application forms
working with advocacy agencies in disseminating information on Medicaid
eligibility and the application process to low income communities
using information pamphlets and brochures
Financial Information
Total CHIP 1998 allotment $14, 866,746
Enhanced Federal matching rate: 72.82%
First Year Costs:
State Share -- $89,000
Federal Share -- $229,000
Total -- $318,000
NEVADA TITLE XXI PROGRAM
FACT SHEET
Name of Plan:
Nevada Check Up
Date Plan Submitted:
March 11, 1998
Date Plan Approved:
August 13, 1998
Effective Date:
October 1, 1998
Background
Nevada's CHIP plan will create a separate state health insurance program to provide
coverage to children up to age 18 in families with incomes at or below 200 percent of the
Federal Poverty Level (FPL) who are not eligible for Medicaid.
Nevada's current Medicaid program covers children up to age 6 in families with incomes
up to 133 percent of the FPL and children age 6 and older born on or after October 1,
1983 in families with incomes up to 100 percent of the FPL.
Children Covered Under Program
The State anticipates covering 43,500 new children in the first year of its CHIP program.
Administration
Nevada Check Up will be administered by the Department of Human Resources,
Division of Health Care Financing and Policy.
Health Care Delivery System
Managed care organizations (MCOs) and other State qualified health care organizations
will deliver the benefit package. MCOs must offer a contract to federally qualified health
centers, rural health centers, public hospitals, and the University of Nevada School of
Medicine at terms that are at least equal to their standard provider contracts.
For areas not covered by an MCO, a fee-for-service benefit will be offered with the same
benefit package.
Medicaid covered services not included in the MCO benefit package will be provided
under fee-for-service. These services include dental, non-emergency transportation, and
school-based rehabilitative services.
Benefit Package
Nevada
Check Up will provide the same services as provided under Nevada's Title XIX
State plan.
Cost Sharing
For families above 175 percent of the Federal Poverty Level (FPL), there will be a
quarterly premium of $50.
For families between 151 percent and 175 percent of the FPL, there will be a quarterly
premium of $25
For families at or below 150 percent of the FPL, the quarterly premium will be $10, under
the guidelines specified in the statute. Families in this group will be given the choice of
paying the maximum monthly charge each month, or the $10 quarterly fee.
Crowd-Out Strategy
The application form includes questions regarding access to public and private health care
coverage. The State will randomly verify health insurance coverage by contacting
employers.
A child will be found ineligible if he/she:
-
has creditable health coverage;
-
is eligible for health benefits coverage under a State health benefits plan based on a
family members' employment with a public agency in the State; or
has had coverage under an employer plan on or after January 1, 1998, or for
applications submitted after July 1, 1998, six months prior to application. The six
month waiting period may be waived if the applicant provides evidence that the
loss of insurance was due to actions outside the applicant's control (e.g., employer
discontinues health benefits).
Outreach Activities
The State has simplified the CHIP eligibility application which will be available statewide
through schools, child care facilities, family resource centers, social service agencies, and
other locations where eligible children and/or their parents frequent. An 800 number has
been established and listed on the application as well as on posters and marketing
brochures. In addition, there will be press and media coverage of the program roll out as
well as public service announcements.
Coordination Between CHIP and Medicaid
For families who complete the current CHIP application and have either incomes below
that required for Medicaid or no more than 25 percent above the Medicaid income
"
requirement, their application will be considered a Medicaid application. Those families
who are determined not eligible for Medicaid could be enrolled in CHIP if they meet all of
the State's Title XXI requirements.
There will be close coordination between the Nevada Check Up program and Nevada's
Medicaid program. Medicaid enrollees will be compared monthly with Nevada
Check
Up enrollees to ensure that a child is not enrolled in both programs.
Financial Information
Total CHIP Allotment -- $30,414,882
Enhanced Federal Matching Rate --65%
FY 1998 Costs:
State Share -- $3,057,000
Federal Share -- $5,678,000
Premium/Enrollment Fee --$540,000
Total -- $ 9,275,000
FY 1999 Costs:
State Share-- $16,553,000
Federal Share-- $30,742,000
Premium/Enrollment Fee -- $2,730,000
Total -- $50,025,000
NEW HAMPSHIRE TITLE XXI STATE PLAN
Name of Plan:
Healthy Kids - Gold (Phase 1)
Healthy Kids - Silver (Phase 2)
Date of Plan Submitted:
May 21, 1998
Approval Date:
September 15, 1998
Effective Date:
May 1998 (Phase 1)
January 1999 (Phase 2)
Background
The State of New Hampshire submitted a Title XXI proposal to: 1)expand Medicaid to
infants to age 1 with family gross income greater than 185 percent and equal to or less
than 300 percent of FPL; and 2) implement and separate state health insurance program to
cover children ages 1 to 19 with family gross income greater than 185 percent and equal
to or less than 300 percent of the FPL.
Children Covered Under Program
The State anticipates covering approximately 4,000 children by September 2000.
Administration and Phases
The primary responsibility for the daily operations of the Title XXI program will be in the
managed care unit of the Medicaid Administration Bureau.
Phase 1 will expand Medicaid eligibility for newborns and infants from birth to age 1 in
families with gross income greater than 185 percent FPL and equal to or less than 300
percent FPL with an additional disregard of 65 percentage points of the FPL. This
program will be named Healthy Kids - Gold.
Phase 2 involves purchasing health care coverage for children ages 1 to 19 in families with
family gross income greater than 185 percent FPL and equal to or less than 300 percent of
the FPL with an additional disregard to 65 percentage points of the FPL. Coverage will
be purchased through the New Hampshire Healthy Kids Corporation. This plan includes
an emphasis on perinatal care coverage for pregnant adolescent girls not previously served
by the Healthy Kids Corporation. The phase 2 program will be named Healthy Kids -
Silver.
Health Care Delivery System
The phase 2 coverage for children will be administered by The Healthy Kids Corporation.
In 1993, the New Hampshire Legislature passed the Healthy Kids Act (RSA 126:H) to
address the growing problem of uninsured children. The Act created the Health Kids
Corporation, a private, non-profit, "deemed to be a public instrumentality and. by the
authority of the powers conferred by this chapter shall be deemed and held to be the
performance of public and essential government functions of the state." The Healthy Kids
Corporation provides comprehensive health and dental benefits which emphasize
preventative and primary care for children. The goal has been to design and operate a
program that would avoid the stigma often associated with Medicaid. Current coverage is
underwritten by Blue Cross Blue Shield of New Hampshire for health benefits including
mental health benefits, and Northeast Delta Dental for dental benefits. Selection of the
insurance carrier was conducted through a formal competitive Request For Proposal.
Benefit Package
Benchmark-equivalent coverage will be provided. An actuarial analysis comparing the
benefit package to the Federal Employees Health Benefit Program was provided that
demonstrated that the package was actuarially equivalent to a benchmark.
Cost Sharing
There will be no cost-sharing in phase 1.
Cost sharing in phase 2 will consist of premiums and co-pays. A mechanism will be
implemented to ensure that cost-sharing for a family will not exceed 5% of the family
income for a year. The family will be educated on the amount of their limit, how to track
cost-sharing and how to contact the State once they equal or exceed their limit. The
family will be sent a letter from the State advising them that cost-sharing will cease for the
remainder of the current 12 month eligibility period. The family can present this letter to
providers to show exemption from copayments.
Families whose income is greater than 185% and equal to or less than 250% FPL will have
a $20 per child per month premium. Families whose income is greater than 250% and
equal to or less than 300% FPL will have a $40 per child per month premium. There will
be a $100 cap on montly premiums for families with multiple children.
Co-pays will consist of: $5 co-pay for office visits, $5 co-pay for generic prescription
drugs, $10 co-pay for brand name prescription drugs and $25 co-pay for unauthorized or
determined non-emergent use of an emergency room will be implemented. Providers are
responsible for collection of co-pays. The office co-pay does not apply to well-child visits,
preventative health visits, or dental check-ups, x-rays, sealants, cleanings, and fluoride
treatments.
A family's eligibility may be terminated after sixty days due to non-payment of premium
except for pregnant teens. In addition, a family who fails to pay the montly premium will
be locked out from reapplying for a 3 month period. This will apply to families who do
not meet the good cause provisions.
State Action to Avoid Crowd-Out
An application will be disapproved if it is determined that the child was covered under a
health insurance plan within the last six months. However, an application may be
approved for good cause.
Outreach Activities
The state will build on its successful practices and efforts of its current Medicaid voluntary
managed care program as well as the Healthy Kids Corporation. The plan will also
capitalize on the collaborative relationships already developed by Healthy Kids
Corporation with schools and child care centers as well as expanding the existing network
of social service agencies and advocacy groups beyond those that have traditionally
worked with the state and Health Kids Corporation.
Outreach materials include a variety of brochures, posters, flyers, and enrollment package
materials. A broad-based public awareness campaign will be designed and directed
towards parents of uninsured children and the community at large. The outreach effort
will take advantage of seasonal and geographic differences and events, such as the start of
the school year. Campaigns include cause-related marketing activities promoting child
health such as immunization and lead screening outreach in addition to describing
insurance.
Coordination Between CHIP and Medicaid
Only eligible targeted low-income children will be covered under the Title XXI Plan. The
state will ensure that there is coordinated effort between the current state sponsored
Medicaid program and the coverage provided by its public private partnership with the
Healthy Kids Corporation. By using a single point of entry and eligibility determination,
the state will ensure those children eligible for coverage as funded by Title XXI or Title
XIX, will be informed of their option to enroll and will receive the support necessary to
complete the application.
Financial Information
Total CHIP allotment --$11,461,349
Enhanced Federal matching rate -- 65%
Federal Fiscal Year 1998 (May 1, 1998)
Federal Share $21,054.58
State Share $11,337.08
NEW JERSEY TITLE XXI STATE PLAN SUMMARY
Background
On February 6, 1998, New Jersey submitted a Title XXI State Plan (NJKidCare Plans B &
C) and a Medicaid Expansion (NJKidCare Plan A). The State's proposed effective dates
are February 1, 1998, for the Medicaid expansion and March 1, 1998, for the separate
state health insurance program.
The Medicaid proposal (NJKidCare Plan A) expands Title XIX coverage for children
under age 19 with family incomes up to 133 percent of the Federal Poverty Level (FPL).
There are no cost-sharing provisions.
The separate state health insurance program, which has two components, targets
low-income children in families with incomes between 133 percent and 200 percent of the
FPL pursuant to Title XI. NJKidCare Plan B has no cost-sharing provisions for
households with incomes up to 150 percent of the FPL. NJKidCare Plan C requires
cost-sharing and co-payments for children in families with incomes between 151 and 200
percent of the FPL, which is consistent with the Title XXI statute.
Administration and Phases
The Medicaid expansion proposal will extend Medicaid insurance coverage to an
estimated 34,000 children by February 1999. A family of four with an income below
$21,895 could qualify for the expanded Medicaid coverage.
The separate state health insurance program, which requires family premiums of $15 a
month, for families with incomes between 151 percent and 200 percent of the FPL, will
extend coverage to an estimated additional 68,000 children by March 1999. A family of
four with an income of $32,100 could qualify for the separate state health insurance
program. That family would have a yearly maximum of $1,605 in copayments.
Health Care Delivery System
The existing Medicaid delivery system will be used to provide services.
The State plans to maintain a waiting list of eligible clients if the demand for services
exceeds the projected enrollment for the separate state health insurance program. This list
will be monitored by the State. The client will be given enrollment preference based on
the date of application and income.
Benefit Package
The Medicaid benefit package will be provided for Title XIX expansion.
Benchmark coverage equal to the FEHBP Blue Cross/BlueShield plan will be provided for
the separate state health insurance program.
Cost Sharing
There is no cost-sharing for households below 150 percent of the FPL (NJ KidCare Plans
A & B). Cost-sharing and co-payments will be required for children in families with
incomes above 150 percent and up to and including 200 percent of FPL (NJ KidCare Plan
C).
Crowd-Out
A child with income greater than 133 percent of the FPL who meets the criteria for NJ
KidCare coverage under Plans B and C must have been uninsured for a minimum of 12
months before becoming eligible for coverage.
Exceptions will be granted for children who are losing Medicaid eligibility and have no
other health care coverage at the time of termination.
Exceptions will be made to the 12 month requirement in certain limited circumstances (for
example, prior coverage was lost because an employer went out of business or the
employee was laid off).
Outreach Activities
The State describes a fourfold outreach effort involving 1) public awareness, 2) targeted
outreach, 3) community education and 4) consumer education. There is also a
commitment by the State to conduct outreach targeting special populations such as HIV
and homeless populations.
All outreach workers will be trained in eligibility requirements for Title XIX and XXI
programs. Bilingual staff and/or language services will be offered to applicants when
needed.
Financial Information
Total CHIP Reserved allotment -$88,440,626
Enhanced Federal matching rate --65%
First year costs:
State share --$9,034,802
Federal share --$16,778,919
Total --$25,813,721
NEW YORK TITLE XXI PLAN SUMMARY
Background
On November 3, 1997, New York State submitted a Title XXI State Plan to expand
children's access to health coverage by expanding enrollment in its existing Statewide
Child Health Plus (CHPlus) program, which is based on a partnership between
government and private insurers through the subsidization of private health insurance
coverage. The CHPlus program currently provides coverage for children under the age of
19 with net household incomes at or below 185 percent of the Federal Poverty
Level (FPL). The State anticipates that approximately 224,000 children will be enrolled in
the program by the end of Federal FY 1998. Over 50,000 new uninsured children will be
covered, since the State currently covers 171,000 children. The State also estimates that
360,000 children will be enrolled by March 2000.
New York will implement its Title XXI Plan once all aspects of its plan are in full
compliance with Title XXI requirements. The State has provided an effective date of
April 15, 1998.
Administration
The New York Department of Health will continue to administer the CHPlus program.
Insurers will be chosen to participate in the program through a competitive RFP process,
and will contract with the State to provide a managed care product.
Health Care Delivery System
Health services to CHPlus members will be delivered through a managed care insurance
product. Children will have a primary care provider who will coordinate his/her health
care, including referrals to specialists when appropriate. To the extent possible, CHPlus
providers will also be Medicaid managed care providers to ensure a link between the
CHPlus program and the New York State Medicaid managed care program. Insurers will
be selected in every geographic region of the State to assure Statewide coverage.
A 60-day presumptive eligibility period will be available to applicant children as a means
of providing services under CHPlus when a child appears to be eligible for the program,
but pertinent documentation to establish eligibility is lacking.
Recertification of eligibility must be performed on an annual basis, by the anniversary date
of the child's enrollment. Children found to be eligible for Medicaid will be disenrolled
from the CHPlus program, and, with the families' permission, information will be
forwarded to Medicaid.
Benefit Package
The package of services for the Title XXI program is the same benefits package currently
offered by the CHPlus program. The benefit package includes inpatient services;
outpatient services; physician services; surgical services; clinical services (including health
center services) and other ambulatory health care services; prescription drugs; laboratory
and radiological services; prenatal and pre-pregnancy family services and supplies;
outpatient mental health and substance abuse treatment services; durable medical
equipment; disposable medical supplies; home and community-based health care services;
abortion only if necessary to save the life of the mother or if the pregnancy is the result of
an act of rape or incest; emergency medical services; and certain therapeutic services.
Cost Sharing
o
No premium contributions will be required from families with income levels at or below
150 percent of the FPL. A $9 per child per month premium will be imposed on families
with income levels between 151 and 159 percent of the FPL, up to a family maximum of
$36 per month. Families with income levels equal to or greater than 160 percent of the
FPL will be required to contribute $13 per month up to a family maximum of $52 per
month. No deductibles will be imposed.
A number of copayments will be imposed, irrespective of income level. A $2 copayment
will be required for all physician visits, except those provided on an inpatient basis and
well-baby/well-child care. A $1 to $3 copayment may be charged for prescriptions, with
the exception of insulin, which has no copayment. A $5 copayment may be charged for
failure to notify an insurer within 24 hours of emergency room use, and a $10 fee may be
charged for inappropriate emergency room utilization.
State Action to Avoid Crowd-out and Outreach Activities
o
The State claims that a previous evaluation of the CHPlus program has shown that
"crowd-out" has not been an issue--in the past, individuals have not been shown to drop
employer-based coverage for the CHPlus program. Crowd out will continue to be
analyzed from two perspectives. First using the Current Population Survey as a base, the
proportion of children covered under an employer-based plan will be evaluated, and an
analysis will be conducted to test for evidence of "crowding out." Second, the forms for
CHPlus eligibility determinations will include a number of questions related to past
employer-based insurance coverage. This will allow the State to track the number of
children who have access to employment-based coverage and to ensure that children
enrolling in CHPlus are uninsured and are not dropping employment-based coverage to
enroll in CHPlus.
If crowd out is found to be occurring after 9 months, one or both options below
will be employed:
1)
define children with access to employer-based coverage (with at least 50
percent employer contribution for a comprehensive benefit plan) as
ineligible for CHPlus; and/or
2)
impose a required period of uninsurance for those who dropped employer-
based insurance.
The State will also comply with an alternative standard promulgated in regulation
or policy guidance issued by the Secretary.
Under the program, community outreach and marketing activities will be conducted
through: a community outreach contractor that will be selected through a competitive
RFP process; participating insurers; local social services agencies; and the New York State
Department of Health (DOH). In addition, a Statewide media campaign will be conducted
by the New York State DOH.
Outreach and marketing of the program include: telephone hot lines to refer families to
CHPlus and/or Medicaid, distributing brochures and posters, and conducting training
sessions for interested organizations. Additional activities include health fairs,
immunization drives, and the establishment of linkages with schools and community-based
organizations. Insurers may use radio, television, billboards, newspapers, leaflets, posters,
brochures, yellow page advertisements, letters, and verbal presentations by marketing
representatives, as well as health fairs to market their product to eligible children.
However, door-to-door distribution of material is not permitted.
Financial Information
Total CHIP Allotment -- $255,992,571
Enhanced Federal Matching Rate -- 65%
First Year Costs (i.e., 6 months of FFY 1998)
State share -- $46,194,591
Federal share -- $85,789,955
Total -- $131,984,546
- NORTH CAROLINA TITLE XXI FACT SHEET
Background
On May 14, North Carolina submitted its title XXI State plan. North Carolina has created
a separate State health insurance program to provide coverage to uninsured children
whose family income does not exceed 200 percent of the Federal Poverty Level (FPL).
Enrollees whose annual income increases above 200 percent of the FPL to 225 percent
FPL will be allowed to buy into the program for one year at full cost.
The State estimates that over 71,000 children will be eligible for health insurance in the
State through Title XXI. Projected enrollment in the first year of the program's operation
is 35,000.
Administration and Phases
The program is being managed by the North Carolina Department of Health and Human
Services (NCDHHS). Benefits and claims processing will be administered by the North
Carolina Teachers' and State Employees' Comprehensive Major Medical Plan
(TSECMMP). Eligibility determinations will be made by local departments of Social
Services.
Health Care Delivery System
The delivery system is fee-for-service with some managed care options. Optional Prepaid
Health Plans (health maintenance organizations) are available under TSECMMP, but
require additional premium contributions. Should these plans choose to eliminate these
additional premiums so they may participate in Title XXI, they will also be made available
to enrollees. Under no circumstances will managed care plans participating in the Title
XXI program be permitted to require beneficiary cost-sharing above the limits specified by
statute.
Benefit Package
Beneficiaries will receive the State employee benefit package provided through
TSECMMP. Children identified as having special health care needs will receive an
enhanced benefit package that provides Medicaid-equivalent benefits. Dental, vision, and
hearing services are also provided.
Children are guaranteed 12 months of continuous enrollment, unless the child receives
other insurance coverage during this time period.
Cost Sharing
There are no deductibles, copayments, or premiums for children whose family income is at
or below 150 percent FPL.
Children in families with incomes from 150 to 200 percent FPL will be required to pay a
$50 enrollment fee for one child or $100 for two or more children.
Families above 150 percent FPL will pay the following copayments: $6 for prescription
drugs; $5 for physician visits, clinic visits, dental and optometry visits (with the exception
of preventative services for which there will be no copayment); $5 for outpatient hospital
visits; and $20 for non-emergency emergency room use.
The Division of Medical Assistance will notify the TSECMM, through the eligibility
information system, of the limit to the amount of family's copayment. This will ensure that
the annual aggregate cost-sharing for a family does not exceed 5 percent of the family's
annual income. The TSECMMP will track the amount of copayments paid by a family and
will notify the family when that limit has been met. This notification can then be taken by
the family on visits to providers so that they are not charged further copayments.
State Action to Avoid Crowd-Out and Outreach Activities
Eligibility determinations will be made by local departments of social services. Upon
application, the existing Title XIX eligibility information system will be queried to
ascertain if the child has Medicaid coverage. If not, the application will first be processed
for Title XIX eligibility. Should the child be determined ineligible, then Title XXI
eligibility will be pursued.
Children are eligible for North Carolina's Title XXI program if they are uninsured. The
State has defined uninsured as not having coverage under any private or employer-
sponsored creditable health insurance plan for the six-month period immediately preceding
the date the Title XXI program becomes effective. Six months after the program has been
implemented, the definition of the term is modified to mean that the applicant has not had
coverage for 60-days immediately preceding the date of the child's application.
Exceptions will be made if the child has lost Title XIX eligibility due to a change in family
income or the family has lost employer-sponsored coverage due to the termination of
employment, cessation by the employer of employer-sponsored coverage, or cessation of
the employer's business.
Outreach will be coordinated at the State level through existing public/private
partnerships, particularly through collaborative implementation efforts between local
departments of health and social services. The statewide guidance for this effort will be
provided through a committee co-chaired by the Division of Medical Assistance and the
Division of Women's and Children's Health.
o
The application process will be simplified through a series of initiatives including, a
simplified application for both programs, decentralized enrollment through out-stationed
staff, and application by mail.
Financial Information
First Year Costs (per the State's Budget):
Total CHIP allotment (1998) -- $79,528,899
Enhanced Federal Matching Rate -- 74.16%
First year costs:
Federal Share -- $44.8 million
State Share -- $15.6 million
Enrollment Fees -- $1.5 million
Total -- $61.9 million
OHIO XXI STATE PLAN
Background
On December 23, 1997, Ohio submitted a Title XXI Plan for providing expanded benefits
under the State's Medicaid Title XIX Plan. The State proposes to expand Medicaid
eligibility to children up to age 19 from families with incomes at or below 150 percent of
the Federal Poverty Level (FPL). Eligible children will receive the full Medicaid benefit
package. All Medicaid program policies will apply.
Ohio expanded eligibility on January 1, 1998.
Administration and Phases
This expanded coverage for children will be administered as a Medicaid expansion.
Outreach will be provided jointly through the Ohio Department of Health and the Ohio
Department of Human Services.
The State submitted 2 State Plan Amendments. The first amendment will expand
Medicaid eligibility under section 1902(s)(10)(A) for optional targeted low-income
children. The second amendment will expand coverage under section 1902 (accelerated
SOBRA) and 1902(r)(2) for children who meet the income requirements for the
expansion but who have creditable coverage. The State anticipates that the program will
serve an additional 133,000 children.
The State anticipates covering 133,000 children under the program.
Health Care Delivery System
Care will be provided through the current fee-for-service delivery system for the Title
XIX program. Once the State determines appropriate capitation rates, it may move new
eligibles into the managed care delivery systems currently in place in 16 counties.
Benefit Package
The current Medicaid benefit package will be provided.
Cost Sharing
No cost sharing is proposed.
State Outreach Activities
The State will utilize a number of measures to encourage eligible children to enroll,
utilize, and stay in the health care system. These measures include:
Surveying community agencies on how they conduct Medicaid eligibility
outreach activities.
-
Working with the Governor's Ohio Family and Children First initiative to
improve Medicaid enrollment in Head Start program.
-
Generating outreach ideas and sharing best practices in dialogue sessions with
local groups.
-
Developing media strategies for statewide education to Medicaid consumers and
providers.
-
Identifying age specific strategies based on different service utilization patterns of
different age groups.
-
Coordinating CHIP outreach efforts with welfare reform outreach activities.
Financial Information
Total CHIP allotment -- $115,764,112
Enhanced Federal matching rate -- 70.70%
First year costs:
State share -- $27,129,485
Federal share -- $65,462,612
Total -- $92,592,097
OKLAHOMA TITLE XXI STATE PLAN SUMMARY
Background
On January 23, 1998, Oklahoma submitted a Title XXI State Plan to expand health
insurance coverage to uninsured children through an expansion of the State's Title XIX
Medicaid program, effective on December 1, 1997. Oklahoma proposes using title XXI
to provide Medicaid coverage to children born on or after October 1, 1983 and pregnant
women with family incomes at or below 185 percent of the Federal Poverty Level (FPL).
This legislation is intended to utilize the State's Medicaid managed care programs as
vehicles to expand health care coverage to this group. This expansion has the potential to
increase eligibility to over 100,000 children and 4,000 pregnant women Statewide.
Administration and Phases
This expanded coverage for children and pregnant women will be administered by the
Oklahoma Health Care Authority.
In an effort to increase participation in the program, a simplified application will be
available to this group. In addition, face-to-face interviews as well as the asset test will be
eliminated. Applications for the expanded program will be available at a wide variety of
locations, including the Department of Human Services county offices, County Health
Departments, WIC offices, public libraries, and school systems.
Health Care Delivery System
Those eligible under the plan will enroll in either SoonerCare Plus (the State's HMO
delivery system) or SoonerCare Choice (the State's Primary Care Case Management
Program), depending on where they live. Information detailing where each program is
offered will be provided with the application.
Benefit Package
The Medicaid benefit package will be provided.
Cost Sharing
Medicaid rules will apply
State Action to Avoid Crowd-Out
The State will develop and implement a statistically-valid survey instrument to survey
certain Medicaid beneficiaries in order to determine whether or not they voluntarily
dropped existing private health insurance coverage due to the availability of publicly-
funded CHIP coverage.
Beneficiaries the State will survey will include children who: 1) enrolled on or after
December 1, 1997, 2) were determined to be eligible at the State's new (higher) income
eligibility standard, and 3) had no Third Party Liability indicator on their Medicaid
application.
Subsequently, the State will modify the "Simplified" Medicaid Application form in order
to be able to collect and analyze data specific to any "previous health insurance coverage"
which the Title XXI beneficiaries may have had prior to their application for Oklahoma
Medicaid.
Outreach Activities
The Oklahoma Health Care Authority is collaborating closely with the Department of
Human Services, The Oklahoma Commission on Children and Youth, the Oklahoma State
Department of Health, and the State Department of Education to develop and implement a
comprehensive marketing and outreach plan.
The marketing and outreach plan will consist of posters, postcards, public service
announcements, fact sheets, press releases, and outdoor advertising. Though the major
focus of the outreach campaign targets the uninsured population, it is hoped that these
messages will also reach those currently eligible for medical services who are not
participating.
Financial Information
Total CHIP Reserved allotment -- $81,568,137
Enhanced Federal Matching rate -- 79.36%
First year costs:
State share -- $3,766,456
Federal share -- $11,051,069
Total -- $14,817,525
OREGON'S TITLE XXI STATE PLAN SUMMARY
Background
On March 2, 1998, Oregon submitted a Title XXI State Plan to expand
insurance coverage to infants and children utilizing the Prioritized List of
Services in the State's current managed care delivery system as approved
under the State's existing section 1115 Medicaid waiver.
The State is proposing to use Title XXI enhanced matching funds to provide
services to children from birth to age 6 with incomes between 133 percent and
170 percent of the FPL and to children from age 6 to age 19 with incomes
between 100 percent and 170 percent of the FPL.
The State is proposing an effective date of July 1, 1998.
Administration
The program will be administered by the State's Office of Medical Assistance
Programs within the Department of Human Resources.
Children Covered Under Program
The State is proposing to enroll approximately 17,000 children in its CHIP
program by July 1, 1999.
Health Care Delivery System
The State will utilize its current section 1115 Medicaid managed care delivery
system, entitled the Oregon Health Plan (OHP), to deliver services to the
expansion population. The delivery system is comprised of prepaid health
plans (PHPs) and primary care case managers (PCCMs).
Benefit Package
The State's benefit package will be based on the OHP Prioritized List of
Health Services which is a modified Medicaid benefit packaged as allowed
under Oregon's section 1115 Medicaid demonstration waiver for their entire
Medicaid population. Medically necessary services are defined in the
Prioritized List.
The comprehensive benefit package will include medically necessary inpatient
and outpatient services; physician services; surgical services; clinic services;
prescription and over the counter drugs; lab and x-ray services; prenatal and
pregnancy services and supplies; inpatient and outpatient mental health
services; durable medical equipment which may include, prosthetic devices,
eyeglasses, hearing aids, and dental devices; disposable medical supplies;
home and community-based health care services; nursing care services; dental
services; inpatient and outpatient substance abuse treatment services; case
management services for targeted populations; physical and occupational
therapy; hospice care; medical transportation; and enabling services.
Cost Sharing
There will be no premiums or deductibles for enrollees
State Action to Avoid Crowd-Out
The State's eligibility determination and enrollment process will be
coordinated with the OHP Medicaid application process. The existing OHP
application will be amended to capture information to determine if the
applicant is eligible for Medicaid or CHIP.
The applications will first be reviewed for OHP Medicaid eligibility. If the
application does not meet Medicaid criteria, then it will be processed to
determine CHIP eligibility.
The State will also screen for access to creditable health coverage other than
Medicaid.
The State will evaluate their crowd-out policy in the future by looking at the
increase in the percentage of Medicaid-eligible children enrolled in Medicaid
and the reduction in the percentage of uninsured children.
Outreach Activities
The State will convene a task force of public and private partners to develop
a consolidated Medicaid and CHIP outreach plan. To inform this effort, the
State will have an outreach conference comprised of representatives from
around the State to identify geographic and cultural communities on which to
focus the outreach efforts. It is also expected that the conference will
generate ideas for general and specific outreach activities.
Financial Information
Total CHIP Reserved Allotment --$39,131,718
Enhanced Federal Matching Rate --73.02%
First Year Costs (FY 98)
Federal Share --$1,476,891
State Share --$563,295
Total --$2,040,186
Second Year Costs (FY 99)
Federal Share --$15,749,082
State Share --$6,006,798
Total --$21,755,880
PENNSYLVANIA TITLE XXI STATE PLAN SUMMARY
Background
On November 4, 1997, Pennsylvania submitted a Title XXI State Plan which expands
coverage to children within the existing Pennsylvania Children's Health Insurance
Program (PA CHIP), implemented in May 1993. Pennsylvania is one of three states
whose comprehensive benefit package was cited by Title XXI, section 2103(a)(3), as
having sufficient coverage to meet the requirements for a State Child Health Insurance
Plan. PA CHIP's Title XXI program will provide coverage to uninsured children through
age 16 in families with incomes at or below 185 percent of the Federal Poverty Level
(FPL).
The current State program serves approximately 55,000 children. In anticipation of
federal funding, approximately 1,500 children, who comprised the CHIP program waiting
list, were enrolled in the program on October 1, 1997. Enhanced matching will be
provided as of the effective date of the State's enacting legislation, which is anticipated by
the end of June.
Administration and Phases
The program is administered by the Commonwealth and overseen by a Management Team
comprised of three members of the Governor's cabinet: the Insurance Commissioner, the
Secretary of Health, and the Secretary of the Governor's Budget Office. Additionally,
there is a Children's Advisory Council, chaired by the Secretary of Health. Membership
on the Council includes the Secretary of Health, the Secretary of Public Welfare, the
Insurance Commissioner, members of the Pennsylvania General Assembly, representatives
from health care provider groups and a parent of an enrolled child. Its primary function is
to oversee outreach activities.
PA CHIP is considered to be the starting point for Title XXI. The State is planning on
using feedback from a series of public forums, stakeholder discussion series, the
Pennsylvania General Assembly, children and parents to analyze program options and
provide the outline for the future development of Pa CHIP. Pennsylvania anticipates
having 63,000 children enrolled in this program by the end of SFY 1999 (This 63,000
figure includes 55,000 children who were previously enrolled in Pennsylvania's state-only
program.)
Health Care Delivery System
PA CHIP is a statewide program with services provided through contracts with five health
insurance companies. One is a state-licensed HMO, while the other four are non-profit
subsidiary foundations of large health insurance providers that offer a range of managed
care and fee-for-service products. Pa CHIP purchases coverage through a managed care
model. Less than five percent of enrollees in rural areas do not have access to managed
care programs and are served through fee-for-service.
Benefit Package
0
The benefit package is the existing PA CHIP benefit package that includes a full range of
inpatient and outpatient services. Inpatient hospitalization up to 90 days is covered;
outpatient services; physician services; surgical services with the exception of cosmetic
surgery; clinic services; prescription drugs; laboratory and radiological services; inpatient
mental health services up to 90 days; outpatient mental health services up to 50 visits per
year; durable medical equipment and remedial devices; home and community-based health
care services; nursing care services; abortion to save the life of the mother or if the
pregnancy is the result of rape or incest; dental services; case management; physical,
occupational, and speech therapy; hospice care; and ambulance services when medically
necessary.
Children are guaranteed a minimum 12 months of coverage.
Cost Sharing
There is no cost sharing.
State Action to Avoid Crowd-Out and Outreach Activities
Pennsylvania requires that children be totally uninsured and ineligible for Medicaid to be
eligible for PA CHIP. Participating contractors have the capacity to compare eligible
families to their own company subscribers to verify whether the family has private or
employer sponsored coverage.
PA CHIP will eventually utilize a common application form for S-CHIP and Medicaid.
Prior to implementation of this form, an insert will be added to existing CHIP applications
to request additional information regarding income to assure that children are not enrolled
in S-CHIP when they may be eligible for Medicaid.
The State will conduct an annual analysis of crowd-out by asking potential enrollees
questions regarding previous insurance coverage. Should the data indicate that 12 percent
of the enrolled children are "crowd-out" children, the State will prepare an analysis to
examine possible eligibility criteria options that may include, but not be limited to,
implementing a waiting period prior to coverage by S-CHIP and denying coverage to
children whose families have access to employer-based coverage in which the employer
pays at least 50 percent of the cost of premiums. Following this analysis, the State will
identify appropriate option(s) and will administratively implement corrective measures as
possible for preventing crowd-out. If legislative changes are necessary to implement these
corrective actions, the Governor will seek the passage of legislation.
Each of the five health insurance companies under contract provide a range of outreach
activities. Outreach activities include canvassing local businesses, day care centers, school
districts, hospitals, providers, legislative offices, religious organizations and churches,
social service agencies, unions, and civic groups. Linkages to the Health Department's
Maternal Child Health and other programs such as WIC and Special Needs programs, and
the State's Medicaid programs have been developed to promote the Pa CHIP.
Financial Information
Total CHIP Reserved Allotment -- $117,486,712
Enhanced Federal Matching Rate 67.37%
First Year Costs :
Federal Funds $ 50.2 million
State Funds $ 24.3 million
Total
$ 74.5 million
PUERTO RICO TITLE XXI PLAN SUMMARY
Background
o
On March 30, 1998, Puerto Rico submitted a Title XXI Plan to expand benefits
under the Medicaid plan. Many of the children that will be enrolled in Puerto
Rico's Title XXI program are currently covered under Puerto Rico's public health
system, which existed prior to July 1997 and receives no Federal funding.
Puerto Rico's Title XXI program will provide coverage for children through age
18 with family income at or below 200 percent of the Commonwealth Poverty
Level.
o
Puerto Rico anticipates an average monthly enrollment of 165,411 by the end of
FY 1998. Of these children, 91,125 are currently enrolled in Puerto Rico's public
health system and 74,268 will be newly enrolled. Of the 165,411 estimated
children to be enrolled, approximately 20,000 will be covered by the Federal CHIP
allotment.
The effective date of Puerto Rico's program is January 1, 1998.
Administration
o
The Title XXI Program will be administered by the Department of Health, which
also administers the Title XIX Program.
Health Care Delivery System
Health services to children under Puerto Rico's Title XXI Plan will be delivered
through a managed care insurance product and through the public health system in
non-reform areas.
Benefit Package
o
The package of services for the Title XXI program is the same benefits package
currently provided through Puerto Rico's Medicaid program. The benefit package
includes, but is not limited to: preventive ambulatory services, surgical,
hospitalization, maternity, mental health, prescription drug services, dental,
emergency room, rehabilitation, ambulance, laboratory testing and catastrophic
coverage, including AIDS, TB, Cardiovascular, Cancer, Neonatal, and Intensive
Care.
Cost Sharing
o
There are no cost sharing requirements.
Commonwealth Action to Avoid Crowd-Out
o
Puerto Rico will monitor for crowd-out by asking applicants about previous health
insurance coverage. If crowd-out is determined to be a problem, Puerto Rico will
develop a strategy to discourage crowd-out.
Outreach Activities
o
A number of outreach efforts will be developed. The Puerto Rico Department of
Health will develop a broad-based media campaign that will include public service
announcements and press releases as a direct appeal to eligible children and
families. These will be made available in simple, readable Spanish language, the
main language in Puerto Rico. In addition, brochures, leaflets and posters that
provide information on Title XXI services will be created and disseminated.
Financial Information
Total CHIP allotment -- $9,835,550
Enhanced Federal matching rate -- 65%
First Year Costs (January 1, 1998 through September 30, 1998)
State share -- $5,296,065
Federal share -- $9,835,550
Total -- $15,131,615
RHODE ISLAND TITLE XXI STATE PLAN
Background
On January 5, 1998, the Rhode Island Department of Human Services submitted a Title
XXI State Plan to expand its Medicaid program. The State's current Medicaid
Section 1115 waiver program, entitled "RIte Care," was amended, effective May 1, 1997,
to include this population. Rhode Island's Medicaid expansion will cover uninsured
children between the ages of eight and eighteen in families with incomes up to 250 percent
of the Federal poverty level (FPL) as specifically allowed for under the law. The
following groups are eligible for enhanced matching payments under Rhode Island's Title
XXI program: 1) children between the ages of 8 and 15 with family incomes between 100
percent and 250 percent of the FPL and 2) children between the ages of 15 and 18 with
family incomes up to 250 percent of the FPL. The State estimates that there will be an
average monthly enrollment of 3,000 children in their CHIP program.
Administration and Phases
This expanded coverage will be administered by RIte Care.
This expansion has been accomplished under an approved amendment to Rhode Island's
Medicaid Section 1115 waiver, RIte Care, which was explicitly addressed in the Title XXI
law. The program was implemented on May 1, 1997, and the State will receive enhanced
match beginning on October 1, 1997.
Health Care Delivery System
The State will contract with licensed Health Maintenance Organizations (HMO) for a
comprehensive benefit package for the targeted low-income children.
Benefit Package
The licensed HMOs will be Health Plans participating in Rlte Care and the comprehensive
benefit package will be the RIte Care benefit package.
Cost Sharing
Individuals with family incomes between 185 and 250 percent of the FPL are subject to
cost-sharing on a sliding scale, consistent with Title XXI standards.
State Actions to Avoid Crowd-Out and Outreach Activities
In order to avoid crowd out, eligible children must be uninsured, and not have refused or
dropped insurance coverage which have cost less than $150 per month in premiums per
individual or $300 per month in premiums per family within one year prior to application.
To effectively reach the target population, multiple outreach methods will take place. The
first phase of outreach, a public information campaign, will last four months. The second
phase of outreach will include follow-up and evaluation activities which will last
approximately six months. The entire outreach plan will last ten months.
The types of outreach activities that will occur include targeted mailings, distribution of
materials to every school-age child in the State, using the print media, the Internet, piggy
back mailings, public service announcements, television and radio interviews and a press
conference.
The State also has outreach activities planned for its non-English speaking populations
including translating all print materials that are available to the general public into Spanish.
Financial Information
Total CHIP Reserved Allotment -- $10,687,168
Enhanced Federal Matching Rate -- 67.22%
First Year Costs:
State Share -- $907,186
Federal Share -- $1,860,314
Total -- $2,767,500
SOUTH CAROLINA TITLE XIX STATE PLAN AMENDMENT
AND TITLE XXI STATE PLAN
Background
On December 8, 1997, South Carolina submitted a Title XIX State Plan Amendment and
a Title XXI State Plan for providing expanded benefits under the South Carolina
Medicaid Agency's Title XIX Plan. South Carolina proposes using title XXI to provide
Medicaid coverage to children who are under age 19 with family incomes at or below 150
percent of the Federal Poverty Level (FPL).
The State began providing coverage to these children under their existing Medicaid
program effective retroactive to August 1, 1997. South Carolina has submitted a Title
XIX State Plan Amendment which requests approval to cover these children as Optional
Targeted Low Income Children, using Title XXI funds, and to implement the option to
provide 12-month continuous eligibility for Medicaid benefits to this group. The
effective date for these changes is retroactive to October 1, 1997.
Administration and Phases
This expanded coverage for children will be administered by the South Carolina
Department of Health and Human Services.
Initially, the State has elected to use Title XXI funds to expand Medicaid benefits to
children up to 150 percent of the FPL. South Carolina anticipates submission of a plan
amendment next year which will address how the State will approach children's health
insurance for other low-income children at slightly higher levels of poverty.
The State anticipates coverage of 75,000 new children.
Health Care Delivery System
The existing Medicaid delivery system will be used to provide services.
Benefit Package
The Medicaid benefit package will be provided.
Cost Sharing
Medicaid rules will apply. There will be no cost-sharing for children.
State Action to Avoid Crow-Out and Outreach Activities
Title XXI funds are being used to provide expanded eligibility up to 150 percent of the
FPL under the State's Medicaid program. During the application process, potential
beneficiaries will be asked about their current health insurance status. The State will
continue to study crowd-out issues.
Existing Medicaid outreach activities such as utilizing out-stationed eligibility workers
will be focused on this group. In addition, a more comprehensive outreach effort will be
implemented. Initial steps in that outreach involve a series of press conferences by the
Governor and information outreach brochures developed by the Southern Institute on
Children and Families, as well as, public service announcement and other efforts.
A revamped application process, which is more accessible and "user friendly", is also part
of the outreach activity. The application packages are being distributed through public
schools, local offices of six related public agencies, health clinics (including FQHCs),
pediatricians' and other primary care physicians' offices, pharmacies and state
legislators' offices across the State.
Financial Information
Total CHIP Allotment -- $63.5 million
Enhanced matching rate -- 79.16%
First year costs:
State Share -- $6.5 million
Federal Share -- $24.6 million
Total -- $31.1 million
SOUTH DAKOTA TITLE XXI PROGRAM
FACT SHEET
Name of Plan:
South Dakota Medicaid Expansion
Date Plan Submitted:
June 5, 1998
Date Plan Approved:
August 25, 1998
Effective Date:
July 1, 1998
Background
On June 5, 1998, South Dakota submitted a Medicaid-expansion proposal to implement
Title XXI. South Dakota's current Medicaid program covers children ages 0-5 in families
with incomes up to 133 percent of the Federal poverty level (FPL) and children ages 6-18
in families with incomes up to 100 percent of the FPL.
The state will expand Medicaid eligibility to cover children ages 6 - 18 in families with
incomes between 100 percent to 133 percent of Federal Poverty Level (FPL). This will
result in seamless coverage for all children in families with incomes below 133 percent of
the FPL.
Administration
Eligibility will continue to be the responsibility of the Department of Social Services
(DSS) and only DSS staff will be making eligibility determinations.
The State began enrollment on July 1, 1998, and expects to enroll 7,352 children in its first
year. South Dakota expects to increase enrollment by 5 percent each year thereafter.
Health Care Delivery System
Most persons enrolled in Medicaid in South Dakota participate in PRIME, a 1915(b)
waiver the state has operated since 1993. Each participating individual must choose a
primary care provider, who in turn refers for specialty services, provides case management
and 24-hour access. Rural health clinics, FQHCs and IHS clinics participate as primary
care providers.
Benefit Package
PRIME waiver services include, but are not limited to: EPSDT, physicians' services,
inpatient and outpatient hospital services, prescription drugs, mental health and other
medical services. Emergency services, family planning, dental, vision, chiropractic,
nursing facility and other specialized services are not included in the managed care
program and are provided on a fee for service basis.
Cost Sharing
There is no cost sharing.
State Action to Avoid Crowd-Out
In addition to verification of income, an eligibility screening will be completed to detect
the presence of other insurance coverage. A key advantage of Medicaid expansion for
CHIP is that children who would otherwise be turned away from coverage because of the
existence of another, non-comprehensive, or high deductible insurance policy, will still be
eligible for Medicaid at regular FMAP. Third party liability and benefit coordination for
those children will insure that private dollars continue to be used for the health care costs
of children.
Families with private insurance and Medicaid eligible children will be encouraged to retain
private insurance to ensure maximum coverage for the children and to avoid crowding-out
private insurance resources.
The State will monitor crowd-out through the Behavioral Risk Factor Surveillance System
survey and through its third party liability system.
Outreach Activities
The Department of Social Services has widespread availability with 41 full time and 22
itinerant offices staffed by DSS eligibility staff. Additionally, applications for Medicaid are
available at each Disproportionate Share Hospital and FQHC participating in Medicaid.
The state operates many programs that provide benefits to children. The Medicaid
program has entered into a number of partnerships with these programs to extend
Medicaid to low-income children. South Dakota has general eligibility workers who work
with the Medicaid, Food Stamp and TANF programs and the Department has a combined,
automated eligibility system for these programs to allow shared information and
communication. Child protective services also assists families and individuals obtain
Medicaid. Community Health Services offers high-risk pregnant women assistance with
Medicaid eligibility. The Children's Special Health Services Program and WIC have
referral mechanisms to identify and enroll eligible children, which includes three tribally
operated WIC programs on Indian reservations.
Each Indian Health Service location is an enrolled Medicaid service provider and the
physicians employed by IHS are primary care case managers. Each IHS Service Unit has
procedures in place to verify Medicaid eligibility and allow referral to DSS for application
and eligibility determination.
Statewide outreach will involve identifying eligible children and mailing applications
directly to families for completion. The state also plans personnel training at DSS and the
hiring of additional people to assist in outreach and the processing of applications.
A new shorter Medicaid application will be used by both Medicaid and CHIP children, and
such applications will be accepted by mail.
Local outreach to identify and enroll children will be made through DSS's Child Care
Services and Child Support Enforcement programs.
Financial Information
CHIP allotment FY 1998 -- $7,538,311
Enhanced Federal matching rate -- 77.43%
Fiscal Year 1998 (July 1, 1998-September 30, 1998)
Federal Share $1,246,710
State Share $ 363,402
Fiscal Year 1999
Federal Share $4,986,840
State Share $1,453,609
approved TEXAS TITLE XXI FACT SHEET
juere
Background
On April 1, 1998, Texas submitted its Title XXI Plan, which will expand Medicaid
eligibility to children between the ages of 15 and 18 in families with incomes below
100 percent of the Federal Poverty Level (FPL). All Medicaid policies will apply.
Texas intends to implement its CHIP program on July 1, 1998.
Texas currently provides Medicaid coverage to children up to age 1 to in families
with incomes up to 185 percent of the FPL, children ages 1 to 5 in families with
incomes up to 133 percent of the FPL, children ages 6 to 14 up to 100 percent of
the FPL and children ages 15 to 19 up to 47 percent of the FPL.
Administration and Phases
o
The State is studying options to further expand coverage to additional low-income
families and to provide additional low-income children with access to health
insurance. The State expects to submit an amendment to their CHIP program
sometime in 1999.
Children Covered Under Program
o
The State anticipates covering 57,488 children by FY 2000.
Health Care Delivery System
o
Care will be provided through the current delivery system for the State's Medicaid
program.
Benefit Package
o
Eligible children will receive the full Medicaid benefit package currently provided
by the State.
Cost Sharing
o
There is no cost sharing.
Crowd Out Strategy and State Outreach Activities
o
Texas will be monitoring enrollment in the program to determine the existence, if
any, of crowding-out of private coverage.
The State will utilize a number of mechanisms to identify and enroll eligible
children in the health care system. These measures include:
EPSDT outreach workers will contact families to assist in getting EPSDT
screens and services. The outreach workers will also talk with them about
the potential eligibility of children ages 15-18.
-
The State plans to work closely with the entire network of public health
providers to disseminate outreach materials to providers so that they may
supply information to families with potentially eligible children.
-
The State will conduct home visits and both face-to-face and telephone
interviews in approximately 500 local offices of the Texas Department of
Human Services (TDHS).
-
TDHS eligibility workers will be outstationed in clinics and hospitals.
-
The State will provide referral services to potentially eligible individuals
who make benefit inquiries when telephoning the State's TDHS Hotline.
-
The State will publicize the program in government blue page listings in
local telephone books and Worldwide Web Sites.
-
Applicants for food stamps and Temporary Assistance to Needy Families
will be screened for potential Medicaid eligibility.
Financial Information
Total CHIP Allotment --$561,475,805
Enhanced Federal Matching Rate --73.6%
First Year Costs (FFY 98):
Federal Share -- $7,213,522
State Share -- $3,362,411
Total --$10,575,933
UTAH TITLE XXI STATE PLAN SUMMARY
Background
On April 2, 1998, Utah submitted a Title XXI proposal which would create a separate
State health insurance program to expand coverage to children. The State proposes
to provide coverage for children under the age of 19 in families with income at or
below 200 percent of the Federal Poverty Level (FPL).
Administration and Phases
The Utah Department of Health will administer the Utah Children's Health Insurance
Program. The Division of Health Care Financing, within the Department of Health,
will contract with the managed care organizations and purchase services from the
health care providers.
The State anticipates covering 21,000 children by FY 2000.
Health Care Delivery System
Health services in the urban areas (Davis, Salt Lake, Utah and Weber counties)
will be delivered by managed care organizations (MCO's). The State currently
contracts with six MCO's for its Medicaid population.
Health services in the rural areas (all other counties) will be delivered by providers
on a fee-for-service basis. The State shows that nearly 100% of family and general
practitioners and pediatricians participate in its Medicaid program and expects the
same rate of participation for its CHIP program.
Benefit Package
Utah will offer benchmark-equivalent coverage. The State's plan includes an
actuarial analysis comparing the benefit package to the benefit plan provided to the
employees of the State of Utah.
The benefit package will include inpatient hospital; outpatient hospital; emergency
department services; physician services; vision care; lab and radiology services;
physical therapy and chiropractic; hearing services; podiatry services; end-stage
renal disease dialysis; home health services; speech therapy; hospice services;
durable medical equipment and supplies; abortions and sterilizations as permitted
by law; organ transplants; other outside medical services at the Health Plan's
discretion; ambulance transportation; preventive services; family planning services;
pharmacy services; mental health and substance abuse treatment; and dental
services.
Cost Sharing
There will be no premiums or enrollment fees charged to families. Utah is
proposing two cost-sharing schedules:
For families with incomes from 100% through 150% of FPL, the State proposes a
cap of $500 or 5 percent of family income, whichever is lowest, per family per year
out-of-pocket maximum. Copays are as follows:
-
$5 copay for an emergency room visit for emergent reasons
-
$10 copay for an emergency room visit for non-emergent reasons
-
$5 copay for outpatient office visits (no copay for well-baby care,
well-child care and immunizations)
-
$2 copay for prescription drugs
For families with incomes from 151% through 200% of FPL, the State proposes a
cap of $800 or 5 percent of family income, whichever is lowest, per family per year
out-of-pocket maximum. Some copays are as follows:
-
$30 copay for emergency room visit
-
10% coinsurance for hospital services
-
$10 copay for outpatient office visits (no copay for well-baby care,
well-child care and immunizations
-
$4 copay for generic and brand name prescription drugs on an
approved list
-
50% coinsurance for brand name drugs not on an approved list
-
No copay for laboratory services under $50 and x-ray services
under $100
-
10% coinsurance for laboratory services over $50 and x-ray
services over $100
-
Vision and hearing screening services are covered at 100% of an
allowed amount up to $30
-
10% coinsurance for first 10 days of inpatient mental health
services; 50% coinsurance for next 20 days of inpatient mental
health services
The State has a mechanism to ensure that once a family reaches their out-of-pocket
maximum that the family may cease paying further copayments and coinsurance.
The State will provide a quarterly report to families on out-of-pocket expenses
incurred. Providers will be notified when a family has reached their out-of-pocket
maximum. If a family incurs expenses that exceed the out-of-pocket maximum, the
State will reimburse the family.
State Action to Avoid Crowd-out
The application will request information about health insurance coverage for the
children in the household. Every CHIP application will be going through the
Medicaid eligibility determination process to determine if the child qualifies for
Medicaid.
A child will be found ineligible if the child is eligible for Medicaid (except for the
Medically Needy program with an unmet spenddown); if the child is found to have
access to insurance coverage or is already covered by a group health plan or other
health insurance; or if the child has been voluntarily terminated from health insurance
coverage within the three months prior to the application date for coverage under
CHIP.
Outreach Activities
The State will utilize many strategies to identify and enroll eligible children. These
include:
-
Computer match of families already on Medicaid who have children
without coverage and of families receiving child care assistance without
Medicaid.
-
Medicaid eligibility workers already in place in over 98 locations will
determine Eligibility for CHIP. These eligibility determination sites are
located in hospitals, community health centers, local health departments,
Department of Workforce Services offices and many other allied agencies.
-
Identify potentially eligible children through allied agencies, church groups,
schools, hospitals, early intervention programs, Children With Special
Health Care Needs Clinics and the Department of Workforce
Development.
Disseminate information through community presentations, press coverage,
toll-free telephone lines, brochures, flyers and postcards. Information will
be disseminated by housing assistance organizations, hospitals, medical
care sites, community-based organizations, employers not offering health
insurance existing Medicaid outreach campaigns.
Financial Information
Total CHIP allotment --$24,247,390
Enhanced Federal matching rate --80.81%
First year costs:
State Share --$1,857,716
Federal Share --$7,615,593
Total --$9,473,309
WEST VIRGINIA TITLE XXI PROGRAM
FACT SHEET
Date Plan Submitted:
June 18, 1998
Date Plan Approved:
September 15, 1998
Effective Date:
July 1, 1998
Background
On June 18, 1998, West Virginia submitted its CHIP plan which will expand Medicaid
eligibility for children between the ages of 1 and 5 in families with incomes up to 150
percent of the federal poverty level (FPL).
West Virginia's current Medicaid program covers children up to age one in families with
incomes up to and including 150 percent of the FPL, children ages one to six in families
with incomes up to 133 percent of the FPL, and children ages six to 19 in families with
incomes up to 100 percent of the FPL.
Administration
As a Medicaid expansion the program will be administered by the same agency that
administers the Medicaid program, the Bureau of Medical Services within the Department
of Health and Human Resources.
The current expansion represents Phase I of West Virginia's Children's Health Insurance
Program. Phase II is currently in the planning stage.
Health Care Delivery System
The delivery system for the Medicaid expansion will be the current Medicaid delivery
system, which consists of both a mandatory HMO program and a mandatory primary care
case management (PCCM) program. The HMO program is operational in 9 counties, the
State will begin to offer services in six additional counties on October 1, 1998. The
PCCM program is operational in all other counties.
Benefit Package
The benefit package will be the current Medicaid benefit package.
Cost Sharing
There will be no cost sharing.
Crowd-Out Strategy
Eligibility determination will be the same for both the Title XXI expansion population and
the Medicaid population. Prior coverage information will be obtained on the application
form and through applicant interviews.
Outreach Activities
West Virginia currently outstations eligibility workers in selected hospitals, federally
qualified health centers, and rural health clinics throughout the State. This effort will be
refined to target children who may be eligible for Title XXI services. In addition, trained
eligibility workers will be available at other sites around the State, such as schools and
pediatric clinics.
The state will also include information on Medicaid and Title XXI in all free or reduced
lunch and textbook application, and the State's toll-free 24-hour hotline will include
information on the Children's Health Insurance Program.
The State has developed a simplified application form and will be expanding the sites
where applications are available, such as libraries, churches, community centers, retail
centers, etc. The new application is also provided in a self-mailing form.
The State Department of Health and Human Resources is also working closely with the
West Virginia Children's Health Coalition to focus on special outreach at the community
level to children in rural areas and minority children in inner-city schools. Special
outreach efforts will also include education of provider groups, child support enforcement
workers, legal aid staff, and others.
Financial Information
Total CHIP Allotment -- $23,724,858
Enhanced Federal Matching Rate -- 81.57%
First Year Costs:
State Share -- $139,327
Federal Share -- $616,654
Total -- $755,981
WISCONSIN XXI STATE PLAN
FACT SHEET
Background
On March 13, 1998 Wisconsin submitted a Title XXI Plan to expand Medicaid eligibility
under Title XXI to children ages 15-18 in families with incomes below 100 percent of the
Federal Poverty Level (FPL). Presently, the State covers Medicaid children under age 6
in families with incomes less than 185 percent of the FPL, and children ages 6-14 in
families with incomes less than 100 percent of the FPL.
Children Covered Under Programs
The State anticipates covering 2,000 children during the first year of this plan. The State
also plans to amend this plan to expand coverage to additional uninsured children.
Health Care Delivery System
Care will be provided through the current managed care delivery system for the Title XIX
program.
Benefit Package
The current Medicaid benefit package will be provided.
Cost Sharing
No cost sharing is proposed.
State Action To Avoid Crowd-out and Outreach Activities
The State will conduct various surveys and other studies on changes in the scope and
extent of employer-based health insurance.
The State will utilize a number of measures to encourage eligible children to enroll, utilize,
and stay in the health care system. These measures will include:
expansion of school based clinics in 12 Milwaukee public schools in collaboration
with Medicaid managed care Health Maintenance Organizations (HMOs);
funding of public health agencies to conduct outreach activities in coordination
with schools, and
-
inclusion of schools as potential outstation sites for eligibility workers.
Financial Information
Total CHIP Allotment - $ 38,475,831
Enhanced Federal Matching Rate - -- 71.19%
CY 1998 (6 months)
--Federal Share (Phase I)*
$1,084,672
--State Share (Phase I) $438,958
--Total (includes 10% adm. costs) ----
$1,675,993
CY 1999
--Federal Share (Phase I) $1,815,023
--State Share (Phase I) $734,167
--Total (includes 10% adm. costs) ----
$2,804,109
CY 2000
--Federal Share (Phase I) ---- $1,306,000
--State Share (Phase I)
$528,270
--Total (includes 10% adm. costs) ----
$2,017,697
CY 2001
--Federal Share (Phase I) ---- $773,061
--State Share (Phase I) ---- $312,699
--Total (includes 10% adm. costs) ----
$1,194,336
CY 2002
--Federal Share (Phase I) ---- $215,594
--State Share (Phase I)
----
$87,206
--Total (includes 10% adm. costs)
$333,080
*Phase I refers to the expansion of coverage to children ages 15-18 in families with incomes
under 100% of the Federal poverty level (FPL). In addition, the State has submitted a Phase II
plan for approval that would further extend CHIP coverage.