Frequently Asked Questions The State Children s Health Insurance Program

Transcription

1 NATIONAL CONFERENCE of STATE LEGISLATURES FORUM for STATE HEALTH POLICY LEADERSHIP Frequently Asked Questions The State Children s Health Insurance Program In this FAQ What is SCHIP? How is SCHIP different from Medicaid? Why is SCHIP important? Who is covered by SCHIP? What services does SCHIP cover? How is care delivered under SCHIP programs? Can states use SCHIP funds to cover other populations aside from low income children? How can we get kids to enroll in the SCHIP program? Why aren t they knocking down our doors? How does my state pay for SCHIP? How does federal oversight of my state s SCHIP program work? What is SCHIP? The State Children s Health Insurance Program (SCHIP) 1 is a partnership between the federal government and the states designed to provide health insurance coverage for low-income children under age 19 who are not eligible for Medicaid. It was created as part of the Balanced Budget Act of 1997, passed with bipartisan support, and enacted as Title XXI of the Social Security Act. Congress allocated over $20 billion dollars for SCHIP over five years, making it the largest federal expansion of health insurance coverage since the passage of Medicaid in The federal agency with oversight authority for all state SCHIP programs, activities and expenditures is the Health Care Financing Administration (HCFA) of the Department of Health and Human Services (DHHS). Under Title XXI, Congress gave states much freedom in designing their SCHIP programs. States were allowed to use SCHIP funds in three ways: Forum for State Health Policy Leadership National Conference of State Legislatures

2 to expand Medicaid to cover older children or children from families with incomes too high for them to qualify for regular Medicaid (a Medicaid expansion plan); to create an entirely new program (called a state-designed or private plan) with a benefit package consistent with provisions of Title XXI (see below); or both expand Medicaid and create a separate private plan, for different populations (a combination plan). In Medicaid expansion states, all Medicaid rules apply. Delivery is through the same providers and systems, Medicaid s restrictions on cost sharing apply, and the state may not cap enrollment (i.e. turn away applicants that qualify for eligibility) after a certain number of children have enrolled or after the state has exhausted its funds. In state-designed plans or state-designed portions of combination plans the program is not required to accept enrollees if the program s capacity has been reached or if the state has expended all available funds. At the state s election, however, it can continue to enroll kids in the program after spending its full SCHIP allotment, and still receive some money from the federal government. The federal contribution for these kids, however, will only be at the regular Medicaid match rate (for more on the federal contribution, see question 8, below). In other words, in these states SCHIP is not an entitlement. In states that design their own SCHIP programs, service delivery, quality assurance mechanisms, enrollment procedures, benefits and even the name of the program may be different from those of Medicaid. Alternatively, several state designed programs are virtually identical to the Medicaid program in all respects except that they are not entitlements and may be capped. These programs are sometimes called Medicaid look alike programs. 2 How is SCHIP different from Medicaid? SCHIP is a much smaller program than Medicaid in cost and in the number of participants receiving insurance coverage and health services. Medicaid covers the poorest of poor children as well as their parents, pregnant women, and several categories of low-income people with significant illnesses and disabilities. As of December 1999, Medicaid covered 31 million people, about 19 million of whom were children, parents, or pregnant women. SCHIP is designed to provide health insurance coverage only to children from families with low incomes, but incomes that are above Medicaid levels. About two million children were enrolled in SCHIP in all states and territories as of July, Children applying for SCHIP coverage must first be screened for eligibility for Medicaid, and must enroll in Medicaid if eligible. While many states have worked toward coordinating the SCHIP and Medicaid programs such that they appear seamless from the applicant s perspective, the two may have different application procedures, documentation requirements, eligibility periods, and assets tests. Many states that designed their own programs use managed care networks, health care providers, and provider payment rates that are different from those of Medicaid. These differences reflect the federal intention to allow the states to craft SCHIP programs specific to their individual needs and challenges. Another key distinction involves the use of cost sharing. Cost sharing refers to the practice of requiring financial contributions from participating families, possibly including premiums, deductibles, copayments, and enrollment fees. Under Medicaid (and Medicaid expansion SCHIP 2 Forum for State Health Policy Leadership National Conference of State Legislatures

3 programs), cost sharing may not be charged for services delivered to children under 18 who are eligible for those programs because of family income. Under private SCHIP programs (including the portion of SCHIP programs that are state-designed, in combination states), cost sharing is allowed up to a maximum amount of 5 percent of family income. Finally, SCHIP has an unprecedented emphasis on outreach. Under SCHIP, states may spend up to 10 percent of their total matched state expenditures on administrative costs, including direct contracting expenses, enrollment, and significantly, outreach. Under Medicaid, outreach efforts represent an administrative expense, for which the federal government only contributes 50 percent of costs. Under SCHIP, the government contributes the enhanced match rate, between 65 and 85 percent of expenses (see below). Why is SCHIP important? Health coverage programs are a crucial concern of state governments. State authorities have many roles in the process of delivering health care to the poor, including that of negotiator and purchaser of services; regulator of quality and licensure of practitioners; and promoter of public health. These responsibilities require significant expenditures by the states: health care programs can comprise 20 percent or more of state budgets. Currently, states spend an average of 77 percent of their health care expenditures on Medicaid alone. SCHIP, while a much smaller program than Medicaid, is interesting and important in several respects. Because of its small size, states may use innovations in the SCHIP program to learn more about how to improve coverage, access and quality of care in all health programs. Many such experiments are less costly and easier to implement on a small scale initially. Also, SCHIP has had a large impact on Medicaid. Because states had not previously conducted significant outreach for the Medicaid program, outreach for SCHIP has had a spillover effect, and many states are reporting that many families applying for SCHIP are eligible for and enroll in Medicaid. In many states, states have enrolled as many or more children in Medicaid as they have in SCHIP programs as a result of SCHIP outreach. In an attempt to promote and support the new program, many states that simplified their SCHIP application process. Reexamining the application process encouraged many states to then simplify their Medicaid application process, as well, and both programs in those states have become more convenient and appealing for applicants. Examples of such streramlining and improvements in state programs have included: Changing the name of both programs to be family friendly and to remove the stigma associated with government aid programs; Shortening the application to two pages; Eliminating requests for information not crucial to the application process; Eliminating documentation requirements, including proof of income, residency, employment, or birth certificates; and Eliminating tests for assets such as savings, property or equity in life insurance. Forum for State Health Policy Leadership National Conference of State Legislatures 3

4 While some state agencies believe that the documentation and assets tests listed above protect the integrity of the program by preventing fraud and abuse, many others believe that the extent of fraud and abuse is too limited to justify the barriers to receiving coverage these requirements represent. TABLE 1 Children Enrolled in SCHIP by State, December 2000 State Enrollment State Enrollment Alabama 37,587 Montana 8,317 Alaska 13,413 Nebraska 11,400 Arizona 60,803 Nevada 15,946 Arkansas 1,892 New Hampshire 4,272 California 477,615 New Jersey 89,034 Colorado 34,889 New Mexico 6,106 Connecticut 18,804 New York 769,457 Delaware 4,474 North Carolina 103,567 District of Columbia 2,264 North Dakota 2,573 Florida 227,463 Ohio 111,436 Georgia 120,626 Oklahoma 57,719 Hawaii 2,256 Oregon 37,092 Idaho 12,449 Pennsylvania 119,710 Illinois 62,507 Rhode Island 11,539 Indiana 44,373 South Carolina 59,853 Iowa 19,958 South Dakota 5,888 Kansas 26,306 Tennessee 14,861 Kentucky 55,593 Texas 130,519 Louisiana 49,995 Utah 25,294 Maine 22,742 Vermont 4,081 Maryland 93,081 Virginia 37,681 Massachusetts 113,034 Washington 2,616 Michigan 37,148 West Virginia 21,659 Minnesota 24 Wisconsin 47,140 Mississippi 20,451 Wyoming 2,547 Missouri 73,825 Total 3,333,879 Source: HCFA, SCHIP Program Enrollment: January Who is covered by SCHIP? In all SCHIP plans, eligibility is limited to kids under 19 years of age (absent a waiver, as explained below). Also, coverage can only be expanded to children from families earning up to 200 percent of the poverty level or 50 percentage points higher than the state had previously covered under Medicaid. Applicants must be uninsured at the time of application (although for how long varies by state), not eligible for Medicaid or state employee coverage through a parent, and must not be a resident of a state institution. 4 Forum for State Health Policy Leadership National Conference of State Legislatures

5 Some states, such as Connecticut and Florida, sponsor buy-in programs for families above the income levels in their SCHIP plans. Under this arrangement, parents may purchase insurance from the state for their children for the full premium cost. These programs do not receive matching funds from the federal government. As of December 1999, SCHIP covered about 1.8 million kids. While an exact number for current enrollment is not available, the figure would be well over 2 million. Numbers of children covered in the states varies widely, as Table II illustrates. Some reasons for these disparities include number of urban areas, extent of outreach, and coverage of the state s Medicaid program. What services does SCHIP cover? Congress gave states several options in designing their SCHIP benefit package. State benefit packages had to be equivalent to benefits provided by one of the following: the state s Medicaid program, the state s benefit package for state employees, the Federal Employee s Health Benefit Package (FEHBP), the benefit package of the commercial insurer covering the largest number of lives in the state, or a benefit package of equal value to any of the above, determined by a qualified actuary. These equivalencies are the state s available benchmarks. The last option is a benchmark equivalent package. All states cover inpatient, outpatient and emergency care (though many states charge comparatively high copayments or inappropriate use of the emergency room) and many kinds of specialist care. Almost all states cover dental, mental health, and substance abuse services, although there may be limits to these services, such as maximum numbers of visits or total costs incurred per year. In states that use managed care services to deliver SCHIP benefits, these last three types of services are often delivered through a fee for service arangement or through separately-administered managed care groups that deliver only that type of specialty service. Specialty services provided by a plan, but through a separate delivery system, are often referred to as carve-outs. How is care delivered under SCHIP programs? Most states use some type of managed care arrangement to provide services to children enrolled in SCHIP. In many of these programs, states contract with the same managed care organizations (MCOs) for both SCHIP and Medicaid. In others, SCHIP and Medicaid services are provided through separate MCOs or under separate plans offered by the same MCOs. Note, however, that physicians, hospitals and other health services providers commonly contract with many managed care organizations, and so even in states where the plans are administered separately, individual and group practices may be affiliated with both programs. While managed care is now extremely common among state health programs, there are counties in many states where managed care organizations do not conduct significant business activities. States Forum for State Health Policy Leadership National Conference of State Legislatures 5

6 with many such localities are said to have low managed care penetration, and are often rural or sparsely-populated. In these areas, services will most commonly be provided under a fee for service or primary care case management (PCCM) structure. (Under a PCCM, a primary care case manager receives a monthly fee for coordinating an enrollee s primary and specialty care. Case managers are typically enrollees primary care physicians). Even in some states with high managed care penetration, federal law prevents states from contracting for managed care unless they can provide each enrollee with a choice of at least two MCOs. In some states that provide services to enrollees through managed care, some specialty services are administered through a separate plan or by a separate MCO. Arrangements like this are often called carve outs. 3 Services provided under carve outs are usually those that are expensive, difficult to manage and coordinate, or require a high degree of experience in a specialized health area. The most commonly carved out services are mental health, substance abuse, vision, and dental services. There are both risks and possible benefits associated with implementing carve outs, and in different programs and states the practice has had both positive and negative effects on cost, quality and health results. Can states use SCHIP funds to cover other populations aside from low income children? SCHIP funds may not be used to cover adults except in very limited circumstances. 4 States may request a variance from the Health Care Financing Administration (HCFA) for a family coverage waiver. Under one of these variances, states pay premiums for private insurance for entire families, if they can do so for an equal or lesser cost than the cost of enrolling just the kids into SCHIP (which is possible when, for example, private employers contribute part of the cost of coverage). Many other restrictions apply. The employer s benefit package and contribution levels, for example, must conform to certain federal requirements. States can apply for a Section 1115 waiver, a research and demonstration waiver. Under these waivers, states may expand coverage to new groups, provide new services, or otherwise redesign their programs in ways not normally allowed under the SCHIP statute, Title XXI of the Social Security Act. States must design these waivers to prove a specific hypothesis that they can be evaluated. This opportunity is only open to states that have at least a year of experience in operating their SCHIP programs that have substantially met Title XXI s intended goal of covering low income kids. States may be able to use an 1115 waiver to extend SCHIP coverage to, for example, parents or older siblings of SCHIP eligible kids or pregnant women. How can we get kids to enroll in the SCHIP program? Why aren t they knocking down our doors? Outreach and enrollment has been and will be a challenge for most states. In trying to promote their state programs, states must: impress upon parents the importance of signing up children for insurance (and not just when they re sick), combat perceptions that Medicaid is a second-class form of insurance or that the treatment received is inferior, overcome cultural or linguistic barriers, and 6 Forum for State Health Policy Leadership National Conference of State Legislatures

7 reform the application process to be as simple as possible so that families trying to apply are not discouraged by complicated procedures. Successful strategies for enrolling children in SCHIP have included: working with community groups (including faith based organizations), employers, and school systems, having application materials and assistance available in multiple languages, sending eligibility workers out to locations other than a welfare office, or certifying enrollment brokers to seek out eligible children and families, and using multiple media outreach methods including television, radio, websites, hotlines, and print ads. States with high rural or non-english speaking populations have had particular difficulties. In these states, labor-intensive (in some cases, door-to-door) outreach campaigns have proven to be one of the few ways to reach families that are reluctant to participate or families that do not know that their children are eligible for these programs. 5 How does my state pay for SCHIP? The federal government shares the expense of the SCHIP program by paying a percentage of the costs of covering kids. The percentages of expenses that the federal government contributes to each state is equivalent to 70 percent of the federal government s match rate for the Medicaid program (known as the Federal Medical Assistance Percentage Matching Rate, or the FMAP) plus 30 percentage points, up to a maximum of 85%. The SCHIP match rate is sometimes known as the enhanced FMAP. The federal government also has a maximum allocation for each state. If a state uses up this amount, it only receives the regular Medicaid FMAP for all services provided above the maximum. The first year for which Congress allocated money for SCHIP was fiscal year 1998 (beginning October 1, 1997). States were allowed two years to spend their original 1998 allotments, until September 30, After that date, Title XXI indicates the Secretary of Health and Human Services should determine a formula to reallocate 1998 SCHIP funds, dispersing all funds to states that have used up their 1998 allotments. Because allocations were available almost immediately and programs take time to get started, only a few states spent all of their 1998 federal funds. Spending in many states, however, has increased rapidly, and it may be too soon to determine which states will and won t need unspent funds the most. Furthermore, there is a dip in federal SCHIP funding in fiscal years 2004 and 2005, when federal funds will decrease by approximately 25 percent. The dip in funding was intended by Congress to correspond to a drop in the number of uninsured children. Some states, especially ones in which yearly spending has increased rapidly, may be hard-hit during the dip. Mindful of these pressures, Congress is currently reconsidering the reallocation provision of Title XXI, and may provide states with more time to spend their 1998 funds in order to keep those dollars from ultimately reverting back to the Treasury. Forum for State Health Policy Leadership National Conference of State Legislatures 7

8 How does federal oversight of my state s SCHIP program work? To apply to receive federal funds, states submitted applications to HCFA. All fifty states, five territories, and the district of Columbia chose to participate, submitted plans, and received HCFA approval for their programs. Most received approval by December, The last two states to apply Washington and Wyoming received approval September 8, Plans had to include such information as the eligibility standards used, the state s plans to prevent crowd out (the substitution of public for private insurance), the benefit package the state would provide, and any cost sharing the state planned to impose on enrolled family members. Now, if a state wants to change or amend its practices as described in the original plan, it must first submit a written amendment to HCFA. In addition, states must assess the effectiveness of their SCHIP programs annually, including an analysis of the progress made in reducing the number of low-income children without health insurance. Annual reports are due to HCFA by January first and must cover the previous fiscal year. Under Title XXI, states were also required to submit a comprehensive evaluation of their SCHIP programs by March 31, 2000 (and the vast majority of jurisdictions met that deadline). Title XXI specified that evaluations had to address the effectiveness of the state plan in providing children with health insurance coverage, a profile of the population served by the state s SCHIP program, a description and analysis of elements of the state s plan, and narrative responses on other elements of the health care environment in the state. Most of these evaluations exceeded 100 pages, and included numerous charts and tables. Because they were so comprehensive, HCFA accepted the state evaluations in lieu of the 2000 annual report. The Secretary of Health and Human Services will review these evaluations and report to Congress on the effectiveness of the program and make future recommendations by December 31, Most are available online at init/chpa-map.htm. Summaries of these evaluations may be found on the NCSL website (see footnote 1 of this document). Other clarifications from the federal government are available on the HCFA website as well. As the program began, states looked to frequntly asked questions publications and letters to state Medicaid directors for guidance on implementation. Comprehensive proposed regulations were published in the Federal Register In November of The open comment period ended January 7, Final federal regulations for the program are still pending. TABLE 2. Allocations and Federal Match Rate by State, 2000 State 2000 Allocation MCD FMAP Enhanced FMAP ($ Millions, (Percent) Rounded) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Forum for State Health Policy Leadership National Conference of State Legislatures

9 Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Total (States) 4,204.3 Puerto Rico Guam Virgin Islands American Samoa North Mariana Islands Total (Territories) 44.9 Total 4,249.2 (States & Territories) Note: The Commonwealth Territories receive block payments earmarked for provision of Medicaid services in addition to their federal matching funds. Source: Allotments adapted from the Federal Register Vol. 65 No. 101, May 24, Totals May be inexact due to rounding. Enhanced FMAP from the Federal Register Vol. 62, November 24, 1997.ta Forum for State Health Policy Leadership National Conference of State Legislatures 9

10 Glossary Carve-out This is a capitated system for delivery of a defined set of services that is separate from a managed care plan. Services provided under carve-outs usually are those that are expensive, difficult to manage or highly specialized, such as mental health, substance abuse, vision and dental. Combination plan ASCHIP plan that incorporates a Medicaid expansion to extend coverage under Medicaid to specific groups, along with a separate state-designed insurance plan to cover additional groups of children. Cost-sharing Financial contributions from participating families. These may include premiums, enrollment fees, deductibles, copayments, coinsurance or other out-of-pocket expenses. Costsharing is permitted in private and combination plans provided that it does not exceed 5 percent of family income. In Medicaid, copayments for children under age 18 are not permitted, but limited premiums based on family size and annual income may be imposed. Crowd out The substitution of public for private insurance; this can occur when individuals or employers drop employer-sponsored or individual health insurance coverage and enroll in a public insurance program such as SCHIP. Title XXI of the Social Security Act requires states to include measures to prevent crowd out, which may include waiting periods and verification of insurance status. Enrollment cap Limits the total number of enrollees in a state SCHIP program. Caps may be imposed if a state has expended all its available SCHIP funds. Enrollment caps are not permitted in Medicaid. Entitlement Medicaid is an entitlement program. This means that any person who is eligible must be enrolled, even if a state s appropriation for its portion of Medicaid expenses in a given year has been expended. SCHIP is not an entitlement and may be capped. Federal Medical Assistance Percentage (FMAP) This is commonly referred to as the match rate or the percentage of total Medicaid expenses that the federal government contributes to each state. The federal government s contribution to SCHIP is an enhanced FMAP, which is equivalent to 70 percent of the FMAP plus 30 percentage points, up to a maximum of 85 percent. Fee-for-service This is a traditional payment system for medical services in which physicians, hospitals and other providers are reimbursed for each service performed. Medicaid look-alike A state-designed SCHIP program that closely resembles that state s Medicaid program (in terms of benefits packages, eligibility requirements, etc.) but are not considered entitlement programs and may have enrollment caps. Primary care case management (PCCM) An arrangement for providing health care services in which the state contracts directly with primary care providers to act as gatekeepers who approve and monitor all services provided to patients. The providers are paid a fee for coordinating an enrollee s primary and specialty care, but the services are reimbursed on a fee-for-service basis. Both PCCM and fee-for-service arrangements commonly are provided in areas where managed care arrangements are not as prevalent. 10 Forum for State Health Policy Leadership National Conference of State Legislatures

11 State-designed plan This SCHIP plan is not a Medicaid expansion, but are separate insurance programs that conform with SCHIP requirements. They are also called private plans. Variances Under SCHIP, states apply to Health Care Financing Administration for a variance, or waiver, to use program funds to provide insurance coverage for families of eligible children. A state also may apply for an 1115 waiver for its SCHIP program (as in Medicaid) to make broad changes in eligibility, services and/or the service delivery system. NOTES 1 Some sources refer to SCHIP as CHIP or CHIPS, but in 1999 Congress specified that all official sources must refer to SCHIP and the State Children s Health Insurance Program. 2 NCSL and the Forum for state health policy leadership have many resoures available on SCHIP in the fifty states. To view our summaries of all state programs and 50-state tables on key aspects of the program, visit or pubhome.nsf, and see the State Children s Health Insurance Program 1999 Annual Report, a joint publication of the National Conference of State Legislatures and the National Governors Association. 3 Note that the term carve out can refer to carved out services, patients, or administrative practices, and is used differently by different sources. In some states, for example, children with special health care needs aer enrolled in entirely separate plans, under which they receive all care, including primary care. In these states, children with special needs are a carved out population. 4 For more information on these expansions, see Dan Steinberg, Expanding Health Coverage to Working Families: State Options. National Conference of State Legislatures, June 2000 and the State Medicaid Director s Letter from HCFA dated July 31, 2000, available online at 5 For more information on outreach, see Michael Perry, Marketing and CHIP: A Study of State Advertising Campaigns. Kaiser Commission on Medicaid and the Uninsured, October 2000; and the National Conference of State Legislatures Audiotape and Guide, What Works to Get Kids to Enroll? Social Marketing and CHIP, April 1999; and Gretchen Flanders and Rhonda Gonzalez, The State Children s Health Insurance Program, Insuring More Kids: CHIP: Outreach and Enrollment. Denver, Colo.: National Conference of State Legislatures, August Forum for State Health Policy Leadership National Conference of State Legislatures 11

12 For More Information: STAFF CONTACT: Shelly Gehshan Program Director (202) OTHER SOURCES: Websites: NCSL s two websites ( and contain a wealth of information on SCHIP, including summary descriptions of each state s program and charts and tables. The American Academy of Pediatrics posts resources such as the SCHIP evaluation tool, under In addition, the Health Care Financing Administration is the authoritative source of information about state plans and amendments, as well as program administration and regulation, at children. The National Governors Association also posts research results and issue briefs at The Covering Kids Program, funded by The Robert Wood Johnson Foundation, assists states with outreach and enrollment issues. They can be reached at Covering Kids, 1821 Hampton St., Columbia, S.C., 29201, or at (803) Forum for State Health Policy Leadership National Conference of State Legislatures