Expanding Health Care Coverage among Alexandria s Children: A Technical Assistance Guide for ACPS Administrators and School Support Teams July 2013

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1 Expanding Health Care Coverage among Alexandria s Children: A Technical Assistance Guide for ACPS Administrators and School Support Teams July 2013 Prepared by the ACPS School Health Advisory Board for its Health Access Outreach Project and by Jennifer Tolbert, Director of State Health Reform for the Kaiser Family Foundation

2 Introduction Having health insurance is important to protecting children s health. It improves children s access to care and helps ensure they get preventive care to keep them healthy and treatment for illnesses when they develop. But, many children eligible for coverage for Medicaid or the Children s Health Insurance Program (CHIP), known as FAMIS in Virginia, are not enrolled. The reasons are many families do not know how to apply or do not think their children are eligible. Getting information from trusted sources, such as school officials, increases the likelihood that families will apply for coverage and ultimately get their children enrolled into coverage. This document provides resources for school administrators and support teams to enable them to assist families of uninsured children apply for and enroll in coverage. It also provides information on safety net providers to share with families whose children are not eligible for coverage, but who need to know where they can go when their children are sick or need care. Sharing this information with families will be important to give them the peace of mind that comes with knowing their children have health insurance coverage or a place to go when they get sick. Coverage Matters We know that not having health insurance affects children s access to health care. Uninsured children are more likely to lack a usual source of care, to delay care, or to have unmet medical or dental needs (Figure 1). As a result of these unmet needs, they are at higher risk for preventable hospitalizations and for missed diagnoses of serious health conditions. 1 Lack of insurance jeopardizes not only children s health, but can also affect family s financial situations. Uninsured families struggle financially to meet basic needs, and medical bills can stress already tight family budgets leading to medical debt. 2 Figure 1 Children s Access to Care by Health Insurance Status, % 20% 12% 3% 2% 2% 2% 3% 2% No Usual Source of Care* Uninsured Medicaid/ Other Public Employer/ Other Private Postponed Seeking Care Due to Cost* 22% 5% 4% 27% 13% 10% Last MD Contact >2 Unmet Dental Need Last Dental Visit >2 Years Ago Due to Cost* Years Ago NOTES: * In past 12 months. Questions about dental care were analyzed for children age All other questions were analyzed for all children under age 18. MD contact includes other health professionals. Respondents who said usual source of care was the emergency room were included among those not having a usual source of care. All differences between the uninsured and the two insurance groups are statistically significant (p<0.05). SOURCE: KCMU analysis of 2012 NHIS data. 1 Uninsured: A Primer, Kaiser Commission on Medicaid and the Uninsured, Kaiser Family Foundation, October 2012, p Op cit. p. 12 2

3 Uninsured Children in Alexandria Children in Alexandria are slightly more likely than children in the state of Virginia to be uninsured. The uninsured rate for children in the city is 6.8% compared to 6.6% for children in the state of Virginia. In 2011, 1,628 children in Alexandria lacked health insurance coverage. Half of these children have family incomes that would qualify them for FAMIS coverage (Figure 2). Another 35% have family incomes that would qualify them for subsidized coverage through new health insurance marketplaces beginning in January Figure 2 Uninsured Children in Alexandria by Federal Poverty Level, %+ FPL, 15% % FPL, 35% Children of color in the city are more likely to be uninsured than White children (Figure 3). Hispanic and Asian children are four times as likely as White children to be uninsured while African American children are twice as likely as White children to be uninsured. Immigration status may be an issue for some of these children, but citizen children, as well as most legal immigrant children, are eligible for coverage through FAMIS even if their parents are not legal residents. Also, language can be an important barrier to families of eligible children understanding what is available and how to apply. Providing targeted messages in multiple languages is important to reaching these hard-to-reach populations. SOURCE: Analysis of 2011 American Community Survey <100% FPL, 22% % FPL, 28% Potentially Eligible for FAMIS Total Uninsured Children 1,628 School-age children, especially teens, are more likely to be uninsured than younger children. In Alexandria, children age 6-17 are 2.5 times more likely than children under age 6 to be uninsured. This makes schools an important place where families can obtain information they need. Figure 3 Uninsured Rates for Children in Alexandria by Race, % 12% 6% 3% Low-income children are at risk of churning on and off coverage during White African American Asian Hispanic the year. Changes in family income or SOURCE: Analysis of 2011 American Community Survey failure to renew coverage means that eligible children may only be enrolled in coverage for part 3

4 of the year. Many families face similar barriers to renewing their coverage that they faced at enrollment. To ensure children maintain their health coverage, it is important to check in with families throughout the year and especially when they are due to renew their coverage. Outreach Is Important Experience with Medicaid and CHIP nationally has identified many of the barriers families face to enrolling in coverage, as well as the outreach strategies that can help overcome these challenges. Some of the barriers families confront are lack of knowledge about how and where to apply and difficulty completing the enrollment process, including providing required documentation. 3 Low literacy levels or language barriers can also make completing an application challenging. As mentioned earlier, immigrant families may worry about whether applying for FAMIS will threaten their ability to attain permanent status or expose undocumented family members. 4 Administrators and school support teams can play an important role in breaking down these barriers. They are perceived by families as a trusted source of information and the multiple opportunities to interact with families means they can reinforce messages and provide ongoing assistance as needed. Understanding the needs of their students can help school staff provide culturally and linguistically appropriate messages and information that will motivate families into action. But, ensuring successful enrollment of eligible children into coverage may require more than simply providing families with an application. Evidence suggests that offering direct assistance with completing and submitting the application and gathering the necessary documentation greatly improves the likelihood that children will enroll in coverage. Having information about what coverage options are available for children and the eligibility requirements will enable Administrators and school support teams to answer families questions and provide them with the support they need to get their children enrolled. School officials, including nurses, administrators, social workers, guidance counselors, psychologists and teachers, interact with children daily and can have conversations about insurance coverage or needs for care and provide information. Because families and children may move on and off coverage, it is important for engagement with families about health insurance coverage to occur throughout the year. This report is intended to serve as a resource for administrators and school support teams to assist them with helping more children in Alexandria obtain health coverage. It provides detailed information on eligibility requirements for FAMIS and for new 3 Getting into Gear: Key Lessons from Medicaid and CHIP for Outreach and Enrollment under the Affordable Care Act, Kaiser Commission on Medicaid and the Uninsured, Kaiser Family Foundation, June 2013, p Op. cit., p. 3. 4

5 subsidies for private coverage that will be available beginning on January 1, 2014 for moderate income families. It also provides a list of safety net providers that will treat uninsured children on a sliding scale basis. Coverage Options FAMIS Plus (Medicaid) FAMIS Plus is the Virginia Medicaid program for children from birth to age 19. Eligible children: Live in families with income at or below 133% of the annually adjusted Federal Poverty Level. Both income and the number of people in a family are considered in determining eligibility. Annual gross income limits currently range from $15,282 for a family of one to $52,708 for a family of eight. For example, a family of four can make up to $31,322 a year and still be eligible for FAMIS Plus. Are Virginia residents and U.S. citizens or legal immigrants. (Information on the immigration status of adults in the child s family is not required.) FAMIS Plus covers a broad range of services, with no premiums or co-payments. It covers doctors and clinic visits, well-child check-ups, vaccinations, dental and vision care, hospital stays, emergency care, prescription drugs, tests and x-rays, and some mental health services. FAMIS Family Access to Medical Insurance Security (FAMIS) is the Virginia program which provides health care for children and pregnant women. FAMIS provides coverage for children without insurance who are not eligible for Medicaid (FAMIS Plus) and meet certain income criteria. Uninsured children under age 19 may be eligible for FAMIS if they: Are Virginia residents not covered by health insurance within the past four months. Live in families who meet the FAMIS income limit of 200% of the annually adjusted Federal Poverty Level. Both income and the number of people in a family are considered in determining eligibility. Current annual gross income limits range from $22,980 for one person to $79, 260 for a family of eight. For example, a family of four can make up to $47,100 a year for the children to meet FAMIS income eligibility. Are United States citizens or legal immigrants. (Information on the immigration status of adults in the child s family is not required.) Some children with limited insurance are considered uninsured for FAMIS eligibility purposes, including if the insurance does not have doctors in the area where the child lives; only covers dental or vision; only covers a specific disease such as cancer; or only covers hospitalization. 5

6 FAMIS benefits include: doctor visits; well-baby and well-child checkups; hospital visits; vaccinations; prescription medicines; tests and x-rays; dental care; emergency care; vision care; mental health care. There are no premiums and only minimal co-payments for some visits. FAMIS Select FAMIS Select helps families pay for private or employer-sponsored health insurance if at least one child is eligible for FAMIS. This allows families to choose between covering their children through FAMIS or through a private or employer-sponsored health plan. Families who choose to enroll in FAMIS Select can get up to $100 per FAMIS Select enrolled child per month to help pay their family premium. How to Enroll Applicants for all FAMIS programs must submit a Health Insurance Application for Children and Pregnant Women which can be found at Applications can be sent directly to the state via mail, fax or made online through One-on-one application assistance is available through community outreach projects such as: Inova Partnership for Healthier Kids at which is available weekdays 8:30am-7:00pm and 8:30am- 5:00pm on Fridays; or the Alexandria Neighborhood Health Services at available on weekdays from 8:00am-4:30pm (when calling, select option for appointment scheduling and ask for application assistance). Applications may also be made through a local social services department, such as Alexandria s Division of Human Services. All application methods are confidential. Applicants must provide information on family income, resources and size, school attendance and child care/medical expenses. Applicants are also asked for: Social Security number; Virginia residency; and U.S. citizenship status or documentation of legal immigrant status for the child applicant only. Citizenship is not required for FAMIS programs; most legal immigrants are eligible. A face-to-face interview is not necessary. (See Appendix A for summary of primary information needed for FAMIS Plus and FAMIS application.) Health Insurance Marketplace The health reform law, the Affordable Care Act, establishes new Health Insurance Marketplaces where individuals and families who do not have access to other coverage can shop for private health insurance. Coverage will be available beginning January 1, 2014 with enrollment starting on October 1, Premium subsidies, in the form of tax credits, will be available for low and moderate-income families to make the coverage more affordable. 6

7 To be eligible to purchase insurance through the Virginia Marketplace individuals and families must be U.S. citizens, nationals, or legal residents and must be Virginia residents (marketplaces will be established in DC and Maryland for families in those states). Families purchasing insurance through the Marketplace will be required to pay a monthly premium. Those with incomes between 100% and 400% of the federal poverty level (or $23,550 to $94,200 for a family of four) will be eligible for premium tax credits to lower the cost of the premiums. Specific details on the plans that will be available in the Virginia Marketplace, including premiums, will be released before October 1, State implementation will include establishing Navigators and other assisters to help educate and guide families through the application and eligibility process. Information on the Marketplace is available at: Beginning on October 1, 2013, consumers will be able to apply for coverage through this website. Safety Net Providers for Ineligible Children Some children are ineligible for insurance coverage. For example, a family s income may be too high to qualify for FAMIS Plus or FAMIS, but they may not have access to health insurance through an employer or unable to afford the premiums for insurance offered through work or other private plan. Some children may be ineligible due to immigration status. Many immigrants, even some with legal and eligible status, may be reluctant to apply for coverage due to fears of residency consequences. Families concerned about immigration status as a barrier to care may call Alexandria Neighborhood Health Services at or Inova Partnership for Healthier Kids for confidential guidance about eligibility for safety net services. If a child has no other access to health care coverage, safety net providers such as community health centers and public health departments are available to provide a wide spectrum of health care services. Safety net services are typically available on a sliding scale and may be free for some children. (See Appendix B for list of local safety net providers.) 7

8 Appendix A: Primary Information Needed for FAMIS Plus and FAMIS Application Families applying for FAMIS Plus and FAMIS will need to submit supporting documentation, such as proof of income and citizenship, along with their application. Making sure these documents are included with the application will shorten the time it takes for an eligibility determination to be made and will increase the likelihood that an eligible child is enrolled in coverage. Below is a list of the types of documentation they must provide. - Proof of Income for the prior month (three-months prior if income varies) which may include: o Paycheck stubs or a signed letter from an employer documenting gross pay from employment. Tax returns or business records are requested for self-employed. o Print out from the Division of Child Support Enforcement Web site for any child support or copies of child support checks received. A signed statement from the absent parent stating how much they pay each month, or a recent court order are also acceptable. o Current year award letter from the Social Security Administration or the Veteran s Administration. o Print out from the Employment Commission of payments, benefits award letter, or a copy of checks received. - Proof of the child's citizenship and identity: o Social Security number for children who have one. o Legal immigrants may provide the child s Alien/INS #, country of birth and date of entry into the U.S., and copy of the child s Resident Alien Card or other proof of immigration status. o Information on the immigration status of adults in the child s family is not required unless those adults are applying for health insurance. The INS (now known as USCIS) cannot use a FAMIS application to deny admission to the U.S., harm permanent resident status, or for deportation. - Report amount spent regularly on child or adult daycare expenses. - Current address which must be updated every time the child moves: o FAMIS and FAMIS Plus must be renewed at least every 12 months. o If the child moves but the address is not updated with FAMIS, the child will be cancelled from the program. 8

9 Appendix B: Safety Net Providers in Alexandria City Alexandria Neighborhood Health Services, Inc. (ANHSI) ANHSI provides accessible, coordinated community based health care to people in Alexandria and surrounding communities. ANHSI serves all persons regardless of income, ability to pay, age, sex, place of residence, immigration status, and health insurance. Fees are charged on a sliding-scale fee based on income and family size; some services may be free. Call for appointments and fee information; some walk-in service is also provided. Limited evening and Saturday hours are available for some services. Services for children include: well child care, sick child care, immunizations, physicals, diagnostic screening for cognitive, physical and developmental delays, health education, parenting education and outreach, mental health services, dental services, and assistance with child health insurance enrollment. Pediatric Wellness and Illness Care (Arlandria Health Center) 2 East Glebe Road, Alexandria, VA Accessible via the DASH AT10 and AT3 buses. Casey Health Center (Primary Care for Newborns) 1200 N. Howard Street, Alexandria, VA Accessible via the DASH AT2 and AT5 buses. Alexandria Health Department The Alexandria Health Department (AHD) offers limited primary health services for children and teens. Some services require verification of Alexandria City residence; families can call to determine eligibility. AHD does not require verification of immigration status. Fees are charged on a sliding-scale fee based on income and family size; some services may be free. A summary of services for children and teens follows. Please call to make an appointment or see if a walk-in clinic is available. Appointment scheduling in Spanish is available on Alexandria Health Department Clinical Services 4480 King Street, Alexandria, VA The clinic is accessible via the DASH AT6 bus. Child Health, Provides routine preventive health services for infants and children through age 5, and physicals for day care and school entrance through age 11. Dental, Services for children ages 4-20 include cleaning, fluoride, sealant, complete oral examinations, fillings, and some extractions. 9

10 Immunization, Offers routine immunizations for newborns through teenagers; all immunization records should be presented at registration. Nutrition, The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) provides vouchers for nutritious food, nutrition counseling and health information to pregnant, postpartum and breastfeeding women, and for infants and children up to the age of 5 years. Nutrition counseling is available on a limited basis to other Health Department clients. The Teen Wellness Center 3330 King Street, Alexandria, VA or, text "APPT" to The Teen Wellness Center, run by the Alexandria City Health Department in coordination with Department of Community and Human Services and ACPS Heath Services, is located at T.C. Williams High School. All teens aged years old who are residents of Alexandria are eligible for free and confidential health services. Some services require parental consent under Virginia Law. Services provided include: school/sports physicals; minor illness, immunization, health education; counseling; HIV counseling and testing; pregnancy prevention and testing; and sexually transmitted infections testing, treatment and counseling. The center entrance faces King Street. Free parking is available in the garage to the rear of the school. The clinic is accessible via DASH AT5 and AT6 buses. Other Resources InovaCares Clinic for Children 6400 Arlington Boulevard, Suite 200, Falls Church, VA InovaCares Clinic for Children is a certified Patient Centered Medical Home. The clinic offers both sick and well child visits for newborn through adolescence. Patients who have applied for and been rejected by Medicaid may qualify for financial aid and a sliding-scale fee. Services include: yearly check-ups; sick visits; immunizations; and school forms. Care Connection for Children 6400 Arlington Boulevard, Suite 100, Falls Church, VA Care Connection for Children, sponsored by the Virginia Department of Health, is a statewide network of regional programs that provides health care coordination, community support, and resources for children with special health care needs. Virginia residents under the age of 21 with a diagnosed physical condition expected to last more than one year may be eligible. Some financial assistance may be available to uninsured children based upon review of family finances. 10