Order Code RL32389
CRS Report for Congress
Received through the CRS Web
A State-by-State Compilation of Key State
Children’s Health Insurance Program
(SCHIP) Characteristics
May 19, 2004
(name redacted)
Specialist in Social Legislation
Domestic Social Policy Division
Evelyne Baumrucker
Analyst in Social Legislation
Domestic Social Policy Division
(name redacted)
Contractor
Domestic Social Policy Division
Congressional Research Service ˜ The Library of Congress

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A State-by-State Compilation of Key State Children’s
Health Insurance Program (SCHIP) Characteristics
Summary
The Balanced Budget Act of 1997 (BBA 97; P.L. 105-33) established the State
Children’s Health Insurance Program (SCHIP) under a new Title XXI of the Social
Security Act. In general, SCHIP provides states with federal matching funds to cover
uninsured children in families with income that is above Medicaid eligibility levels.
To date, the upper income eligibility limit under SCHIP has reached 350% of the
federal poverty level or FPL (in one state).
States may choose among three options when designing their SCHIP programs.
They may expand Medicaid, create a new “separate state” insurance program, or use
a combination of both approaches. All 50 states and the District of Columbia have
SCHIP programs in operation. As of June 30, 2003, among these 51 jurisdictions,
15 were Medicaid expansions, 18 were separate state programs, and 18 used a
combination approach.
Medicaid expansion programs must provide all mandatory benefits and covered
optional services offered in the state’s Medicaid program. Cost-sharing is prohibited
for children. Separate state programs must follow certain coverage and benefit
options outlined in SCHIP law. While cost-sharing provisions in separate state
programs vary by family income in a number of states, the total annual aggregate
cost-sharing (including premiums, enrollment fees, deductibles, copayments,
coinsurance, and other similar charges) for any family may not exceed 5% of total
income in a year. Preventive services are exempt from cost-sharing.
States must ensure that SCHIP does not substitute for coverage under group
health plans, a phenomenon known as “crowd-out.” The primary method for
preventing substitution is requiring a waiting period during which applicants must
be uninsured prior to enrollment in SCHIP.
States that want to make changes to their SCHIP programs that go beyond what
the law allows may do so through what is called a Section 1115 waiver. These
waivers allow states to use SCHIP funds to cover populations not normally covered
under SCHIP, such as pregnant women and parents of SCHIP children, as well as to
modify certain statutory provisions such as cost-sharing limitations and benefit
requirements.
This report provides an overview of state program characteristics under SCHIP
in each of the areas summarized above (eligibility, benefits packages, cost sharing,
crowd-out prevention, and Section 1115 waivers). Several sources were used to
compile the program data shown in this report. These data represent program status
as of December 31, 2002 through July 31, 2003, depending on the source.
Information is summarized across states, and detailed, state-specific fact sheets are
also provided.

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Contents
Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Financial Eligibility Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Other Eligibility and Enrollment Characteristics . . . . . . . . . . . . . . . . . . . . . . 4
Benefit Packages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Cost Sharing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Cost-Sharing Under Medicaid Expansions . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Cost-Sharing Under Separate State Programs . . . . . . . . . . . . . . . . . . . . . . . . 8
Substitution of SCHIP for Private Health Insurance . . . . . . . . . . . . . . . . . . . . . . 10
Section 1115 Waivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Appendices. State by State Program Characteristics . . . . . . . . . . . . . . . . . . . . . 13
Appendix 1. Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Alabama . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Alaska . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Arizona . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Arkansas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
California . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Colorado . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Connecticut . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Delaware . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
District of Columbia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Florida . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Georgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Hawaii . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Idaho . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Illinois . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Indiana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Iowa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Kansas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Kentucky . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Louisiana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Maine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Maryland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Massachusetts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Michigan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Minnesota . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Mississippi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Missouri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Montana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Nebraska . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Nevada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
New Hampshire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
New Jersey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

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New Mexico . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
New York . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
North Carolina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
North Dakota . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Ohio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Oklahoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Oregon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Pennsylvania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Rhode Island . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
South Carolina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
South Dakota . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Tennessee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Texas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Utah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Vermont . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Virginia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Washington . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
West Virginia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Wisconsin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Wyoming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
List of Tables
Table 1. General Eligibility Criteria for States, as of December 31, 2002
through July 31, 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Table 2. Benefits Packages in Separate State Programs, as of June 30, 2003 . . . 7
Table 3. Cost-Sharing Patterns in Separate State Programs, as of July 31, 2003 . 9
Table 4. Premiums/Enrollment Fees and Selected Co-Payment Amounts in
Separate State Programs, as of July 31, 2003 . . . . . . . . . . . . . . . . . . . . . . . 10
Appendix 2. Selected SCHIP Program Characteristics by State, as of
December 31, 2002 through July 31, 2003 . . . . . . . . . . . . . . . . . . . . . . . . . 16
Appendix 3. SCHIP Premiums/Enrollment Fees and Selected Co-Payment
Amounts by State, as of July 31, 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Appendix 4. SCHIP State Tables, Status as of December 31, 2002 through
July 31, 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

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A State-by-State Compilation of Key State
Children’s Health Insurance Program
(SCHIP) Characteristics
The Balanced Budget Act of 1997 (BBA 97, P.L. 105-33) established the State
Children’s Health Insurance Program (SCHIP) under a new Title XXI of the Social
Security Act. The program offers federal matching funds for states and territories to
provide health insurance coverage to uninsured children from families whose annual
incomes are higher than Medicaid eligibility thresholds. Total federal funding is
nearly $40 billion for FY1998 through FY2007.
Eligibility
In general, Title XXI defines a targeted low-income child as one who is under
the age of 19 years with no health insurance, and who would not have been eligible
for Medicaid under the rules in effect in the state on March 31, 1997. States can set
the upper income level for targeted low-income children up to 200% of the federal
poverty level (FPL),1 or if the applicable Medicaid income level for children was at
or above 200% FPL prior to SCHIP, the upper income limit may be raised an
additional 50 percentage points above that level.2
Within these general rules, states may provide medical assistance to qualifying
children in two basic ways. They may cover such children under their Medicaid
programs, and/or they may create a separate SCHIP program for this purpose. When
states provide Medicaid coverage to targeted low-income children, Medicaid rules
typically apply. When states provide coverage to targeted low-income children
through separate SCHIP programs, Title XXI rules typically apply. In both cases, the
federal share of program costs comes from federal SCHIP appropriations.
1 For example, in 2003, the poverty guideline in the 48 contiguous states and the District of
Columbia for a family of four is $18,400. (Department of Health and Human Services,
“Annual Update of the HHS Poverty Guidelines,” 68 Federal Register 6456, Feb. 7, 2003).
2 Under Medicaid, states must cover all pregnant women and children under age 6 living in
families with income at or below 133% of FPL and all children ages 6 through 18 living in
families with income at or below 100% of FPL. States also have the option of covering: (1)
pregnant women and infants with income up to 185% of FPL, (2) using more liberal income
and asset standards to determine eligibility than those required under current law for certain
groups, and (3) using waiver authority (e.g., Section 1115) to cover persons who would not
otherwise be eligible for Medicaid.

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CRS-2
Title XXI does not establish an individual entitlement to benefits. Instead, Title
XXI entitles states with approved state plans for Medicaid coverage or separate
SCHIP programs to pre-determined federal allotments based on a distribution
formula set in the law. However, targeted low-income children covered under
Medicaid are entitled to the benefits offered under that program as dictated by
Medicaid law. These children retain their entitlement to Medicaid benefits even if
SCHIP terminates (unless the state eliminates this coverage group). No such
individual entitlement exists for targeted low-income children covered in separate
SCHIP programs.
Under Medicaid, states may cover targeted low-income children in the following
ways: (1) by establishing a new optional eligibility group for such children as
authorized in Title XXI, and/or (2) by liberalizing the financial rules for any of
several existing Medicaid eligibility categories.
States may also provide coverage to targeted low-income children by creating
a separate SCHIP program. States define the group of targeted low-income children
who may enroll in separate SCHIP programs. Title XXI allows states to use the
following factors in determining eligibility under separate state programs: geography
(e.g., sub-state areas or statewide), age (e.g., subgroups under 19), income and
resources, residency, disability status (so long as any standard relating to that status
does not restrict eligibility), access to other health insurance, and duration of SCHIP
enrollment.
As of June 30, 2003, among the 50 states and the District of Columbia, 15 were
Medicaid expansions, 18 were separate state programs, and 18 used a combination
approach.
Financial Eligibility Standards
Table 1 presents a summary of state eligibility thresholds and other eligibility
information under SCHIP.3 The first column shows counts of Medicaid expansions,
the second column shows counts of separate state programs, and the last column
shows counts of states. Note that the total number of programs does not add up to
51 (the 50 states and the District of Columbia) because states with combination
programs have a Medicaid expansion and at least one separate state program.
Several states have two or more separate state programs.
3 Appendix 1 describes the information sources and methods used to compile the data
presented in this report.

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CRS-3
Table 1. General Eligibility Criteria for States, as of December
31, 2002 through July 31, 2003
Number of
Number of
Medicaid
separate state
expansions (33 in
programs (44
33 states)
in 36 states)
Number of states
Upper income level < 200% FPL
17
8
12
Upper income level = 200% FPL
11
25
26
Upper income level 201-250% FPL
2
6
6
Upper income level 251-300% FPL
3
4
6
Upper income level > 300% FPL
0
1
1
Lowest upper income level
100%
140%
100%
Highest upper income levelb
300%
350%
350%
Basic income disregard
32
32
46a
Asset tests
1
1
2
Presumptive eligibility
7
5
9a
Continuous eligibility (ranges from one
to 12 months)
13
32
36a
Enrollment cap or waiting list
0
5
3
Prenatal coverage of unborn children
0
4
3
Sources: See Appendix 1.
a. Combination states that have this characteristic in at least one of their programs are included in this
count.
b. In determining income eligibility for SCHIP and Medicaid, some states apply “income disregards”
(see the next row in this table). Typically, these are dollar amounts subtracted from gross
income to compute net income which is then compared to the state’s income standard for
determining eligibility. The number, type and amount of disregarded income varies from
applicant to applicant, depending on each person’s specific financial circumstances. Some states
apply selected disregards to all applicants. For example, in New Jersey’s separate SCHIP
program, all income between 200 to 350% of the FPL is disregarded for every applicant. In
state SCHIP plans and related documentation, the sources for information on applicable income
levels used in this table and elsewhere in this report, it is unclear whether the reported income
levels reflect the applicable standards before or after income disregards are applied. In most
cases, the reported income levels probably reflect the standards before any income disregards
are taken into account. Use of disregards increases the effective income level above the stated
standard. The exception is those states, like New Jersey, that apply a specific disregard for all
applicants. In these cases, the reported income standard most likely accounts for universally
applied disregards, and more closely reflects the effective income level.
As seen in the first row, last column of Table 1, 12 states had an upper income
eligibility threshold below 200% FPL, 26 states had an upper income eligibility
threshold of exactly 200% FPL, and 13 states had an upper income eligibility
threshold above 200% FPL.
Eligibility thresholds among separate state programs tend to be higher than
among Medicaid expansions. States with combination programs use their Medicaid
expansion program for lower income children and one or more separate state
programs for children with higher income levels.

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CRS-4
In determining financial eligibility for SCHIP, states may elect to disregard
some portion of income and/or deduct certain expenses when calculating a family’s
net income, which is then compared against the income thresholds reported above.
With these methods, states extend eligibility beyond the stated financial standards.
For example, many states disregard some amount of earned income and/or deduct
specified amounts of child support payments. In other cases, states may disregard all
income within a specified range. For example, New Jersey has expanded eligibility
to 350% FPL — the highest of any state — in one of its separate state programs by
disregarding all income between 200% FPL and 350% FPL. As shown in Table 1,
46 states use basic income disregards.4
States may also take resources, or assets, into account in determining financial
eligibility for SCHIP. States determine what items constitute countable assets and
how those countable items are valued. Generally, resources such as homes and
wedding rings have not been counted, regardless of their value, while cars, savings
accounts and savings bonds, for example, have generally been counted. As shown
in Table 1, only two states (one under its Medicaid expansion program and one in
its separate state program) use an asset test.
Other Eligibility and Enrollment Characteristics
Presumptive eligibility and continuous eligibility (see Table 1) are policies
designed to assist children in getting and staying enrolled in Medicaid and SCHIP.
Under presumptive eligibility, states are allowed to enroll children whose family
income and resources appear to be below the applicable financial standards until a
formal eligibility determination is completed. Nine states offer presumptive
eligibility. Continuous eligibility allows a child to remain enrolled for a set period
of time regardless of whether the child’s circumstances change (e.g., the family’s
income rises above the eligibility threshold), thus making it easier for a child to stay
enrolled. Thirty-six states offer continuous eligibility, the majority of them for a 12
month-period.
Capping enrollment is one means states can use to control program spending.
While an individual entitlement exists for children enrolled in Medicaid expansions,
there is no such entitlement under separate state programs. States with separate
SCHIP programs can cap enrollment by receiving Centers for Medicare and Medicaid
Services (CMS) approval to amend their state SCHIP plans to include such a cap.
Two states (Montana and Utah) have specific enrollment caps written into their state
plans, and another state (Florida) has language in its state plan allowing the state to
cap enrollment at any time without additional CMS approval.
Under Medicaid, states must provide coverage to pregnant women of any age
living in families with income at or below 133% of FPL. States also have the option
to extend such coverage up to 185% of FPL.
4 States are classified as using a basic income disregard if they (1) disregard some amount
of earnings, (2) allow a deduction for child care expenses, and/or (3) disregard all income
between a specified range of the federal poverty level. See Appendix 1 for further details.

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CRS-5
While SCHIP does not include pregnancy status among its eligibility criteria,
and as a rule does not cover persons over age 18, there are three circumstances under
which pregnant women over 18 could be covered in separate SCHIP programs. First,
the “family coverage option” allows states to provide coverage under a group health
plan that may include maternity care. States may cover the entire family including
parents if the purchase of such family coverage is cost effective when compared to
the cost of covering only the targeted low-income children in the family, and would
not substitute for other health insurance. There are no official data that identify for
which states this circumstance applies. Second, states can apply for waivers of
program rules to extend coverage to adults. As of June, 2003, 10 states had Section
1115 waivers that expanded SCHIP coverage to include one or more categories of
adults with children, typically parents of Medicaid/SCHIP children, caretaker
relatives, legal guardians, and/or pregnant women. Finally, in a rule published in
October of 2002, the definition of a “child” for SCHIP purposes was changed such
that states may consider an unborn child to be a targeted low-income child if all other
applicable eligibility requirements are met. This change allowed states to extend
SCHIP coverage to pregnant women of any age who meet all financial eligibility
requirements of the program. Three states (Illinois, Michigan and Rhode Island)
provide prenatal care to unborn children in their separate SCHIP programs.
State by state detail on income disregards, asset tests, presumptive and
continuous eligibility, enrollment caps and waiting lists, and prenatal coverage for
unborn children can be found in Appendices 2 and 4.
Benefit Packages
As noted above, when designing their SCHIP program, states may expand their
current Medicaid program, create a new “separate state” insurance program, or devise
a combination of both approaches.
States that choose to cover targeted low-income children under Medicaid must
provide the full range of mandatory Medicaid benefits, as well as all optional services
specified in their state Medicaid plans.
States that create separate state programs choose any of three benefit options:
(1) a benchmark benefit package, (2) benchmark equivalent coverage, or (3) any
other health benefits plan that the Secretary of Health and Human Services
determines will provide appropriate coverage to the targeted population of uninsured
children (referred to as a Secretary approved benefits plan). In addition, for Florida,
New York, and Pennsylvania, specific programs already in existence when the law
establishing SCHIP was enacted were designated as meeting the minimum benefit
requirements under SCHIP. These grandfathered programs are called existing
comprehensive state-based programs.
A benchmark benefit package is one of the following three plans: (1) the
standard Blue Cross/Blue Shield preferred provider option plan offered under the
Federal Employees Health Benefits Program (FEHBP), (2) the health coverage that
is offered and generally available to state employees in the state involved, and (3) the

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CRS-6
health coverage that is offered by a health maintenance organization (HMO) with the
largest commercial (non-Medicaid) enrollment in the state involved.
Benchmark equivalent coverage is defined as a package of benefits that has the
same actuarial value as one of the benchmark benefit packages. A state choosing to
provide benchmark equivalent coverage must cover each of the benefits in the “basic
benefits category.” The benefits in the basic benefits category are inpatient and
outpatient hospital services, physicians’ surgical and medical services, lab and x-ray
services, and well-baby and well-child care, including age-appropriate
immunizations. Benchmark equivalent coverage must also include at least 75% of
the actuarial value of coverage under the benchmark plan for each of the benefits in
the “additional service category.” These additional services include prescription
drugs, mental health services, vision services, and hearing services. States are
encouraged to cover other categories of service not listed above. Abortions may not
be covered, except in the case of a pregnancy resulting from rape or incest, or when
an abortion is necessary to save the mother’s life.
Six categories of Secretary approved coverage are defined in regulation.5 These
include coverage that (a) is the same as the coverage provided to children under the
state Medicaid plan; (b) is the same as the coverage provided to children under a
comprehensive Medicaid Section 1115 waiver; (c) either includes the full Early and
Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit6 or that the state has
extended to the entire Medicaid population in the state; (d) includes benchmark
health benefits coverage plus any additional coverage; (e) is the same as the coverage
provided under existing comprehensive state-based programs in Florida,
Pennsylvania, or New York; or (f) is substantially equivalent to or greater than
coverage under a benchmark health benefits plan, determined via a benefit-by-benefit
comparison demonstrating that coverage for each benefit meets or exceeds the
corresponding coverage under the benchmark health benefits plan. Secretary-
approved benefit plans are not limited to these six categories, as long as the coverage
provided is determined to be appropriate for the target population.
Table 2 summarizes the types of benefit packages used by the 44 separate state
programs that existed as of June, 2003.
5 Department of Health and Human Services, “State Child Health; Revisions to the
Regulations Implementing the State Children’s Health Insurance Program,” 66 Federal
Register, 33810, June 25, 2001.
6 The EPSDT program provides screening and preventive care to nearly all groups of
Medicaid beneficiaries under 21 years old, as well as services necessary to correct a health
problem identified through screening,

---

CRS-7
Table 2. Benefits Packages in Separate State Programs,
as of June 30, 2003
Existing
Benchmark
Secretary approved:
comprehensive
Benchmark: 12
equivalent: 11
18
state based: 3
FEHBP: 2
FEHBP: 2
Benchmark plus
Florida
State Employee: 6
State employee: 8
additional: 4
New York
Largest HMO: 4
Largest HMO: 0
Comprehensive
Pennsylvania
Equivalent to all three:
Medicaid Section 1115
1
waiver: 3
Same as Medicaid: 9
State employee: 1
Other: 1
Source: See Appendix 1
Cost Sharing
Federal law permits states to require cost-sharing7 for some beneficiaries and
some services under SCHIP. Cost-sharing policies and limits are different for
Medicaid expansions versus separate state programs as described below. A total of
38 states require some form of cost-sharing in either a Medicaid expansion, separate
state program or both (see Appendix 3 for details).
Cost-Sharing Under Medicaid Expansions
States that choose to implement SCHIP as a Medicaid expansion must follow
the cost-sharing rules of the Medicaid program, which prohibits cost-sharing for
children under 18. Nominal cost-sharing is allowed for persons 18 years of age and
older. However, if a state has a Section 1115 waiver that allows cost-sharing for
children enrolled in its Medicaid program, the state may also impose cost-sharing for
children enrolled in a Medicaid expansion under SCHIP.
Six states — Arkansas, Missouri, New Mexico, Ohio, Rhode Island, and
Wisconsin — have Section 1115 waiver programs that include cost-sharing for
children in Medicaid expansions. Five of these states are Medicaid expansion-only
states; i.e., they do not also have a separate SCHIP program. Rhode Island is a
combination state for which cost-sharing applies to children in its Medicaid
expansion under a Section 1115 waiver and in its separate state program for unborn
children (also under Section 1115 waiver authority).
7 Three forms of cost-sharing for beneficiaries are most common. A premium, usually paid
on a monthly basis, represents the price beneficiaries must pay for insurance coverage,
regardless of whether services are actually received. A copayment is an item- or service-
specific fee (e.g., $10 for an office visit) that is paid at the time that item or service is
rendered. A deductible, typically applied on an annual basis (e.g., a $250 deductible per
year), is the amount beneficiaries must incur before the insurance begins to cover the
subsequent costs of care. Premiums do not count toward a deductible requirement.

---

CRS-8
These six states fall into two cost-sharing groups. Three of these states
(Arkansas, Missouri and New Mexico) require more than nominal co-payments for
selected services and do not require any form of premium payments or annual fees.
Two of the remaining states (Rhode Island and Wisconsin) require monthly
premiums only with no co-payments for services, and one state (Ohio)8 has approval
to implement an annual fee only.
Cost-Sharing Under Separate State Programs
If a state implements SCHIP through a separate state program, premiums or
enrollment fees for program participation may be imposed, but the maximum
allowable amount is dependent on family income. For all families with incomes
under 150% FPL and enrolled in separate state programs, premiums may not exceed
the amounts set forth in federal Medicaid regulations. Additionally, these families
may be charged service-related cost-sharing, but such cost-sharing is limited to (1)
nominal amounts defined in federal Medicaid regulations for the subgroup with
income below 100% FPL, and (2) slightly higher amounts defined in SCHIP
regulations for families with income between 101-150% FPL. For a family with
income above 150% FPL, cost-sharing may be imposed in any amount, provided that
cost-sharing for higher income children is not less than cost-sharing for lower income
children.
The total annual aggregate cost-sharing (including premiums, deductibles,
copayments and any other charges) for all children in any SCHIP family may not
exceed 5% of total family income for the year. In addition, states must inform
families of these limits and provide a mechanism for families to stop paying once the
cost-sharing limits have been reached.
Most separate state programs require cost-sharing in the form of either
premiums, copayments or both. Some states charge a quarterly or annual enrollment
fee instead of a monthly premium. Table 3 shows cost-sharing patterns among the
44 separate state programs in the 36 states with such programs. Most of these
programs have a sliding scale for cost sharing; i.e., the amount paid depends on
family income. Eight programs require co-pays, but no premiums. Sixteen programs
require premiums, but no co-pays. Finally, 16 programs require both premiums and
co-pays. While states have the option to require deductibles, only one state does so
(data not shown).9
8 Ohio has not implemented its Section 1115 waiver.
9 North Dakota requires enrollees to pay a $50 deductible for the first day of each inpatient
hospital admission in a general hospital or a psychiatric or substance abuse inpatient facility.

---

CRS-9
Table 3. Cost-Sharing Patterns in Separate State Programs,
as of July 31, 2003
Flat scale
Sliding scale
programsa
programsb
Total programs
Cost sharing required
14
26
40
Co-pay, no premium
4
4
8
Premium, no co-pay
7
9
16
Premium and co-pay
3
13
16
Cost sharing not required
—
—
4
Sources: See Appendix 1.
Note: This table shows cost-sharing patterns among the 44 separate state programs in 36 states.
a Flat scale programs are those for which cost-sharing does not vary across income or age groups.
b All states except for one base their sliding scales on family income. Georgia bases its sliding scale
on the child’s age. In addition, Alaska and Kentucky impose cost-sharing on 18-year olds only.
See Appendix 3 and 4 for further details.
Table 4 shows premiums/enrollment fees and selected co-payment amounts in
separate state programs. The “high” and “low” columns show the highest and lowest
charges among all flat-scale programs only and among all sliding scale programs
only. The amounts charged by sliding-scale programs for a given service tend to
reflect a wider range of values than the amounts charged by flat-scale programs. This
result is largely because charges for sliding scale programs vary across multiple
income bands. Among the 24 programs that charge co-pays (see Table 3), 20 charge
co-pays for prescription drugs, 18 charge for office visits, six charge for inpatient
services, 15 charge for emergency use of an emergency room, and 22 charge for non-
emergency use of an emergency room. The specific amounts charged under each
program can be seen in Appendices 3 and 4.

---

CRS-10
Table 4. Premiums/Enrollment Fees and Selected Co-Payment
Amounts in Separate State Programs, as of July 31, 2003
14 flat scale
26 sliding scale
programsa
programsb
Number of
Number of
Total
programs
Lowc
High
programs
Lowc
High
programs
Premium/enrollment fees
No premium or
enrollment fee
4
—
—
4
—
—
8
Monthly premiums
required
10
$5
$50
16
$4
$135
26
Quarterly enrollment fee
required
0
—
—
2
$10
$50
2
Annual enrollment fee
required
0
—
—
4
$35
$150
4
Co-payments
Brand name Rx drugs
7
$2
$5
13
$1
$20
20
Generic Rx drugs
7
$1
$3
12
$1
$6
19
Office visits
6
$2
$5
12
$2
$15
18
Inpatient services
1
$25
$25
5
$5
$100
6
Emergency room
6
$2
$10
9
$3
$50
15
Non-emergency use of
ER
7
$2
$25
15
$3
$50
22
Sources: See Appendix 1.
Note: This table shows cost-sharing patterns in 44 separate state programs in 36 states.
a. Flat scale programs are those for which cost-sharing does not vary across income or age groups.
b. All states except for one base their sliding scales on family income. Georgia bases its sliding scale
on the child’s age. In addition, Alaska and Kentucky impose cost-sharing on 18 year-olds only.
c. This column shows values other than zero which apply to some groups of children, typically those
in the lowest income coverage groups.
Substitution of SCHIP for Private Health Insurance
Finally, states that establish SCHIP programs must ensure that SCHIP does not
substitute for coverage under group health plans, a phenomenon known as “crowd
out.”10 The primary method for preventing crowd-out is requiring a waiting period,
that is, specified lengths of time for which applicants must be uninsured, prior to
enrollment in SCHIP. Waiting periods are only permitted in Medicaid expansions
under a Section 1115 waiver. As seen in the third to last column of Appendix 2, 30
states require a waiting period, ranging from one to six months
10 For further information, see CRS Report RL30657 Limiting and Measuring the
Substitution of the State Children’s Health Insurance Program (SCHIP) for Private Health
Insurance, by Debra Cohan.

---

CRS-11
Requiring cost-sharing under SCHIP may also serve as a crowd-out prevention
measure, by discouraging applicants from viewing SCHIP as more attractive than
employer-sponsored insurance for which cost-sharing is common. As noted above,
38 states require cost-sharing.
Finally, premium subsidy programs can encourage use of private instead of
public insurance for low-income children whose parents have access to employer-
sponsored insurance (ESI) but cannot afford their share of the premium.11 Under
separate state programs, states that provide premium assistance for employer-
sponsored insurance to the families of targeted low-income children must require: (1)
with some exceptions, a waiting-period of six to twelve months without group health
plan coverage before coverage through the premium assistance program begins; (2)
identify a reasonable minimum employer contribution level and provide justification
for that level; and (3) a premium subsidy that does not exceed the payment the state
would otherwise make on the child’s behalf. As shown in Appendix 2, six states
provide access to ESI under at least one of their separate state programs (as noted
above, some states have multiple separate SCHIP programs). Two of these states have
Section 1115 waivers; one waives the minimum employer contribution, and the other
requires a 50% employer contribution. The remaining states require employer
contributions ranging from 30 to 50%.
States may also provide premium assistance for employer-sponsored health
insurance through Medicaid expansions. Under Medicaid, states may pay a
beneficiary’s share of the costs for group health coverage for any Medicaid enrollee
for whom employer-based coverage is available and that coverage is both
comprehensive and cost-effective for the state. An individual’s enrollment in an
employer plan is cost-effective if paying the premiums, deductibles, coinsurance and
other cost-sharing obligations of the employer plan is less expensive than the state’s
expected cost of directly providing Medicaid-covered services. Two states offer ESI
through their Medicaid expansions using Section 1115 waiver authority; one requires
a minimum employer contribution of 40%.
Section 1115 Waivers
States that want to make changes to their SCHIP programs that go beyond what
the law will allow may do so through what is called a Section 1115 waiver (named for
the section of the Social Security Act that defines the circumstances under which such
waivers may be granted). The Secretary of Health and Human Services may waive
certain statutory requirements for conducting research and demonstration projects
under SCHIP that allow states to adapt their programs to specific needs.
11 Unless the state has a waiver specifying otherwise, states must insure that the benefit
packages and cost-sharing obligations under employer-sponsored insurance programs meet
the requirements in SCHIP statute. If the ESI benefit package falls short of the statute’s
requirements, states must provide “wrap-around” services to bridge any gaps between the
ESI benefit package and the SCHIP benefits package offered by the state.

---

CRS-12
On August 4, 2001, the Bush Administration announced the Health Insurance
Flexibility and Accountability (HIFA) Demonstration Initiative. Using Section 1115
waiver authority, this initiative is designed to encourage states to extend Medicaid and
SCHIP to the uninsured, with a particular emphasis on statewide approaches that
maximize private health insurance coverage options and target populations with
income below 200% FPL.
As of July, 2003, CMS had approved 14 SCHIP Section 1115 waivers in 13
states.12 Eight of the 14 approved waivers are HIFA demonstrations in Arizona,
California, Colorado, Illinois, New Jersey, New Mexico, New York and Oregon. In
10 of the 13 states with approved Section 1115 waivers (excluding Maryland, New
York, and Ohio), SCHIP coverage is expanded to include one or more categories of
adults13 with children, typically parents of Medicaid/SCHIP children, caretaker
relatives, legal guardians, and/or pregnant women. Three states (Arizona, New
Mexico and Oregon) also cover childless adults under their HIFA demonstrations.
In addition to expanding coverage to new populations under waivers, some states
have used this authority for other purposes. Rhode Island has been granted approval
to use redistributed SCHIP funds to finance coverage of adults with children in its
waiver program. Through HIFA, New Jersey will offer the same (separate SCHIP
program) benefit package to adults covered under its SCHIP and Medicaid waiver
demonstrations. Using Section 1115 waiver authority, both Maryland and New
Mexico require a six-month period of no insurance prior to enrollment under their
waivers.14 New Mexico has also modified its cost-sharing rules for targeted low-
income children under its Medicaid program. New York’s HIFA demonstration
provided temporary disaster relief in New York City due to the events of September
11, 2001. Finally, Ohio received approval to implement an annual enrollment fee and
to give 12 months of continuous eligibility for certain targeted low-income children
in its Medicaid program.15
States can also modify their SCHIP programs using a Medicaid 1115 waiver. In
addition to the states identified above, four other states (Arkansas, Hawaii, Missouri,
and Tennessee) with Medicaid expansions only used waiver authority to expand an
existing comprehensive Medicaid 1115 demonstration program. Other modifications
affecting the Medicaid expansions in these states included, for example, establishing
12 The 13 states are AZ, CA, CO, IL, MD, MN, NJ, NM, NY, OH, OR, RI, and WI. NM has
two approved SCHIP Section 1115 waivers. The remaining states have one waiver each.
13 States have the option to purchase family coverage under a group health plan that may
cover adults as long as it is cost-effective to do so (relative to the amount paid for
comparable coverage for the children only), and it must not substitute for health insurance
that would otherwise be provided to the children. For states seeking greater flexibility both
in selecting which adults to cover and in the benefit package offered to those adults, a
waiver is required.
14 In general, for Medicaid expansions under SCHIP, all Medicaid rules apply. Thus, when
states with SCHIP Medicaid expansions want to implement other rules (e.g., establish
waiting periods before enrollment, implement enrollment fees, etc.), a waiver is required.
15 Due to a variety of budget and resource constraints, in May 2002, OH decided not to
pursue implementation of its waiver.

---

CRS-13
a six-month waiting period prior to enrollment, higher cost-sharing requirements that
exceed otherwise allowable limits, and authority to implement enrollment caps as
necessary.
Appendices. State by State Program Characteristics
Appendix 1 describes the methodology employed throughout this report.
Appendices 2 and 3 are state-by-state matrices of selected program characteristics
and selected cost-sharing amounts, respectively. Appendix 4 consists of 51 tables
that provide an overview of general SCHIP program characteristics for each of the 50
states and the District of Columbia.
As of October 1, 2002, all children under age 19 in families with income up to
100% FPL must be covered by Medicaid and thus cannot be enrolled in SCHIP.
Therefore, there is no Medicaid expansion information presented for the four states16
that had such programs prior to October 1, 2002 solely to cover such children.
For more information about SCHIP, see CRS Report RL30642, The State
Children’s Health Insurance Program: Eligibility, Enrollment and Program Funding,
by Evelyne Baumrucker, and CRS Report RL30473, State Children’s Health
Insurance Program: A Brief Overview, by Elicia Herz and (name redacted).
16 AL, MS, TN, and TX.

---

CRS-14
Appendix 1. Methodology
The main source of data presented in this report is a CRS database that is based
primarily on information contained in official SCHIP state plans and accompanying
documentation, including all amendments approved by CMS as of June 30, 2003.
SCHIP state plans do not contain detailed information on certain program
characteristics, in particular for Section 1115 waivers and for Medicaid expansion
programs. In addition to the CRS database, other sources of data used in this report
include the following:
! Information on SCHIP Section 1115 waivers is from the Centers for
Medicare and Medicaid Services, Section 1115 Demonstrations: State
Profiles, July 25, 2003, at [http://www.cms.hhs.gov/schip/
1115waiv.pdf], as well as CMS/State Terms and Conditions and/or
Operational Protocol documents. In some cases, we also contacted
CMS and state officials to clarify or expand on information contained
in these documents.
! For Medicaid expansion programs, information on income eligibility
thresholds (lower and upper bounds) is taken from documentation
accompanying SCHIP state plans, SCHIP annual evaluation reports,
and CRS Report RL30642, The State Children’s Health Insurance
Program: Eligibility, Enrollment and Program Funding, by Evelyne
Baumrucker.
! Data as of April, 2003, on asset tests, continuous and presumptive
eligibility, waiting periods, and cost-sharing for Medicaid expansion
programs are taken from Donna Cohen Ross and Laura Cox,
Preserving Recent Progress On Health Coverage For Children and
Families: New Tensions Emerge A 50 State Update On Eligibility,
Enrollment, Renewal And Cost-Sharing Practices In Medicaid and
SCHIP, Center on Budget and Policy Priorities, (prepared for the
Kaiser Commission on Medicaid and the Uninsured), July 2003.
! A CRS survey of states on selected program characteristics for
separate SCHIP programs as of December 31, 2002, is the basis for
the “presumptive eligibility” information for such programs.
! States are not required to provide detailed information on income
counting methods in their state SCHIP plans. Data on “basic income
disregards” for Medicaid expansions and separate SCHIP programs
are taken from two surveys: (1) a CRS survey of selected program
characteristics for separate SCHIP programs as of December 31,
2002, and (2) a survey conducted under contract to CRS by the
George Washington University of selected program characteristics for
Medicaid expansions (and eligibility rules for other groups of
Medicaid children) as of December 31, 2002. Throughout this report,
a “yes” entry for the “basic income disregards” field means that the
state: (a) disregards some amount of earnings, or (2) allows a
deduction for child-care expenses, or (3) disregards all income

---

CRS-15
between a specified range of the federal poverty level (e.g., in its
separate SCHIP program, New Jersey disregards all income between
200-350% FPL). Coding of “basic income disregards” among
Medicaid expansion programs requires additional explanation.
SCHIP law defines a SCHIP eligible as a targeted low-income child
under the age of 19 with no health insurance, and who would not
have been eligible for Medicaid under the rules in effect on March 31,
1997. Under Medicaid, states may cover targeted low-income
children in one or more of the following ways: (1) by establishing a
new optional eligibility group for such children as authorized in
SCHIP law, (2) by liberalizing the financial rules for any of several
existing Medicaid eligibility categories (e.g., the poverty-related
groups) using Section 1902(r)(2) authority, and/or (3) by liberalizing
the income standards or methodologies applicable to family coverage
under Section 1931. Many states have chosen to cover targeted low-
income children under existing Medicaid eligibility pathways,
especially the poverty-related groups, rather than by establishing the
optional coverage group identified in SCHIP law. On the CRS-
sponsored Medicaid eligibility survey conducted by George
Washington University, there was no field indicating which of these
options a state used to create its SCHIP Medicaid expansion group.
The “basic income disregards” field was coded as “yes” if the criteria
described above were met for any of the relevant groups.
! There are inconsistencies in state SCHIP plans in how states report
lower income boundaries that apply to different age groups under
SCHIP. The lower income boundaries shown in this report reflect the
upper income boundary applicable to the next adjacent age or income
group. For example, children up to six years of age in families with
income up to 133% of the federal poverty level (FPL) must be
covered in the regular Medicaid program. For a state implementing
a separate SCHIP program for the same age group, the lower income
boundary shown in this report would equal 133% FPL.

---

CRS-16
Appendix 2. Selected SCHIP Program Characteristics by State, as of December 31, 2002 through July 31, 2003
Waiting
Min.
period
employer
Waiver to
Waiver
Enroll-
to
Subsidy
premium
Upper
cover groups
affecting
Prenatal
ment
prevent for private
share
income
not
other
Basic
Continuous Presump-
care for
cap or
crowd-
or
required
MXP
SSP
Com-
threshold
otherwise
SCHIP
income
Asset
eligibility
tive
unborn
waiting
out
employer for subsidy
State
only
Only
bination
(% FPL)
eligible
provisions
disregard
tests
(months)
eligibility
children
list
Type
Option
(mos.)
coverage
(%)
Largest
AL
X
200
no
no
yes
no
12
no
no
no
Benchmark
3
no
NA
HMO
AK
X
200
no
no
yes
no
6
no
NA
no
NA
NA
a
no
NA
Secretary
Same as
AZ
X
200
yes
no
no
no
12
no
no
no
3
no
NA
Approved
Medicaid
Compre-
hensive
Medicaid
AR
X
200
no
yes
yes
no
12
no
NA
no
NA
6
no
NA
Section
1115
Waiver
MXP: 0
MXP: yes
MXP: NA
State
CA X
250
yes
no
yes
no
12
no
Benchmark
SSP: 3
no
NA
SSP: no
SSP: no
Employee
or 0
FEHBP,
State
Benchmark Employee
CO
X
185
yes
no
yes
no
12
no
no
no
3
no
NA
Equivalent
and
Largest
HMO
State
CT
X
300
no
no
yes
no
0
no
no
no
Benchmark
2
no
NA
Employee
MXP: 0
MXP: NA
State
MXP:0
DE
X
200
no
no
yes
no
no
no
Benchmark
no
NA
SSP: 12
SSP: no
Employee SSP: 6
DC
X
200
no
no
yes
no
0
no
NA
no
NA
NA
0
no
NA
Existing
state-based
NA;
MXP: NA
FL
X
200
no
no
yes
no
12 or 6
no
yes
and
Same as
0
no
NA
SSP: no
Secretary
Medicaid
Approved
Bench-
Secretary
GA
X
235
no
no
yes
no
12
no
no
no
mark plus
3
no
NA
Approved
additional

---

CRS-17
Waiting
Min.
period
employer
Waiver to
Waiver
Enroll-
to
Subsidy
premium
Upper
cover groups
affecting
Prenatal
ment
prevent for private
share
income
not
other
Basic
Continuous Presump-
care for
cap or
crowd-
or
required
MXP
SSP
Com-
threshold
otherwise
SCHIP
income
Asset
eligibility
tive
unborn
waiting
out
employer for subsidy
State
only
Only
bination
(% FPL)
eligible
provisions
disregard
tests
(months)
eligibility
children
list
Type
Option
(mos.)
coverage
(%)
Compre-
hensive
Medicaid
HI
X
200
no
yes
yes
no
0
no
NA
no
NA
0
no
NA
Section
1115
Waiver
ID
X
150
no
no
yes
yes
12
no
NA
no
NA
NA
0
no
NA
MXP: no
MXP: NA
Benchmark
State
MXP: no
IL
X
185
yes
yes
no
12
no
no
0
b
SSP: yes
SSP: yes
Equivalent Employee
SSP: yes
MXP: 0
MXP: NA
Benchmark
MXP: 0
IN
X
200
no
no
yes
no
no
no
FEHBP
no
NA
SSP: 12
SSP: no
Equivalent
SSP: 3
MXP: 0
MXP: NA
Benchmark
State
MXP: 0
IA
X
200
no
no
yes
no
no
no
no
NA
SSP: 12
SSP: no
Equivalent Employee SSP: 6
Bench-
Secretary
KS
X
200
no
no
yes
no
12
no
no
no
mark plus
0
no
NA
Approved
additional
Bench-
MXP: NA
Secretary
MXP: 0
KY
X
200
no
no
yes
no
0
no
no
mark plus
no
NA
SSP: no
Approved
SSP: 6
additional
LA
X
200
no
no
yes
no
12
no
NA
no
NA
NA
0
no
NA
MXP: yes
MXP: NA
Secretary
Same as
MXP: 0
ME
X
200
no
no
no
12
no
no
no
NA
SSP:no
SSP: no
Approved
Medicaid
SSP: 3
MXP: yes
MXP: 6
MXP: NA
Secretary
Same as
MXP: 6
MXP: no
MD
X
300
no
yes
no
no
no
30%
SSP: no
SSP: 12
SSP: no
Approved
Medicaidc SSP: 6
SSP: yes
Largest
HMO,
Compre-
MXP: no
MXP: yes
Bnchmark;
MXP: NA
hensive
SSP:
MA
X
200
no
no
no
no
0
SSP:
no
Secretary
0
50%
SSP: no
Medicaid
yes/no
yes/no
Approved
Section
1115
Waiver
MXP: 0
MXP: no
MXP: NA
State
MXP: 0
MI
X
200
no
no
yes
no
no
Benchmark
no
NA
SSP: 12
SSP: yes
SSP: yes
Employee SSP: 6
MN
X
280
yes
no
yes
no
0
no
NA
no
NA
NA
0
no
NA

---

CRS-18
Waiting
Min.
period
employer
Waiver to
Waiver
Enroll-
to
Subsidy
premium
Upper
cover groups
affecting
Prenatal
ment
prevent for private
share
income
not
other
Basic
Continuous Presump-
care for
cap or
crowd-
or
required
MXP
SSP
Com-
threshold
otherwise
SCHIP
income
Asset
eligibility
tive
unborn
waiting
out
employer for subsidy
State
only
Only
bination
(% FPL)
eligible
provisions
disregard
tests
(months)
eligibility
children
list
Type
Option
(mos.)
coverage
(%)
Bench-
Secretary
MS
X
200
no
no
yes
no
12
nod
no
no
mark plus
0
nod
NAd
Approved
additional
Compre-
hensive
Medicaid
MO
X
300
no
yes
yes
no
0
yes
NA
no
NA
6
no
NA
Section
1115
Waiver
Benchmark
State
MT
X
150
no
no
yes
no
12
no
no
yes
3
no
NA
Equivalent Employee
NE
X
185
no
no
yes
no
6
yes
NA
no
NA
NA
0
no
NA
Secretary
Same as
NV
X
200
no
no
no
no
12
no
no
no
6
no
NA
Approved
Medicaid
MXP: yes
MXP: NA
Benchmark
MXP: 0
NH
X
300
no
no
yes
no
0
no
FEHBP
no
NA
SSP: no
SSP: no
Equivalent
SSP: 6
FEHBP
MXP: yes
MXP: yes
MXP: NA
and
MXP: 0
MXP: no
NJ
X
350
yes
no
SSP:
no
0
SSP:
no
Benchmark
50%
SSP: no
Largest
SSP: 6
SSP: yes
yes/no
yes/no
HMO
Compre-
hensive
Medicaid
NM
X
235
yes
yes
yes
no
12
yes
NA
no
NA
0
no
NA
Section
1115
Waiver
Existing
MXP: 12
MXP: no
MXP: NA
Compre-
NY
X
250
noe
noe
MXP: yes
no
no
NA
0
no
NA
SSP: no
SSP: 0
SSP: yes
SSP: no
hensive
state-based
State
NC
X
200
no
no
yes
no
12
no
no
no
Benchmark
0
no
NA
Employee
MXP: 0
MXP: NA
Benchmark
State
MXP: 0
ND
X
140
no
no
yes
no
no
no
no
NA
SSP: 12
SSP: no
Equivalent Employee SSP: 6
OH
X
200
no
yesf
yes
no
0
no
NA
no
NA
NA
0
no
NA
OK
X
185
no
no
yes
no
0
no
NA
no
NA
NA
0
no
NA

---

CRS-19
Waiting
Min.
period
employer
Waiver to
Waiver
Enroll-
to
Subsidy
premium
Upper
cover groups
affecting
Prenatal
ment
prevent for private
share
income
not
other
Basic
Continuous Presump-
care for
cap or
crowd-
or
required
MXP
SSP
Com-
threshold
otherwise
SCHIP
income
Asset
eligibility
tive
unborn
waiting
out
employer for subsidy
State
only
Only
bination
(% FPL)
eligible
provisions
disregard
tests
(months)
eligibility
children
list
Type
Option
(mos.)
coverage
(%)
Compre-
hensive
Secretary
Medicaid
OR
X
185
yes
yes
no
yes
6
no
no
no
6
yes
50%
Approved
Section
1115
Waiver
Existing
Compre-
PA
X
200
no
no
yes
no
12
no
no
no
NA
0
no
NA
hensive
state-based
Compre-
hensive
Compre-
Medicaid
hensive
MXP: yes
MXP: 0
MXP: NA
Section
Medicaid
MXP: yes
RI
X
250
yes
yes
no
no
no
0
b
SSP: no
SSP: 12
SSP: yes
1115
Section
SSP: no
Waiver;
1115
Secretary
Waiver
approved
SC
X
150
no
no
yes
no
12
no
NA
no
NA
NA
0
no
NA
MXP: NA
Secretary
Same as
MXP: 0
SD
X
200
no
no
yes
no
0
no
no
no
NA
SSP: no
Approved
Medicaid
SSP: 3
Compre-
hensive
Medicaid
TN
X
g
no
yes
yes
no
0
no
NA
nog
NA
0
no
NA
Section
1115
Waiver
Benchmark
State
TX
X
200
no
no
yes
no
12
no
no
no
3
no
NA
Equivalent Employee
Benchmark
State
UT
X
200
no
no
no
no
12
no
no
yes
3
no
NA
Equivalent Employee
Secretary
Same as
VT
X
300
no
no
yes
no
12
no
no
no
1
no
NA
Approved
Medicaid

---

CRS-20
Waiting
Min.
period
employer
Waiver to
Waiver
Enroll-
to
Subsidy
premium
Upper
cover groups
affecting
Prenatal
ment
prevent for private
share
income
not
other
Basic
Continuous Presump-
care for
cap or
crowd-
or
required
MXP
SSP
Com-
threshold
otherwise
SCHIP
income
Asset
eligibility
tive
unborn
waiting
out
employer for subsidy
State
only
Only
bination
(% FPL)
eligible
provisions
disregard
tests
(months)
eligibility
children
list
Type
Option
(mos.)
coverage
(%)
State
Employee
MXP: yes
MXP: NA
Secretary
MXP: 0
MXP: NA
VA
X
200
no
no
no
0
no
no
and Same
yes
SSP: no
SSP: no
Approved
SSP: 6
SSP: 40%
as
Medicaid
Secretary
Same as
WA
X
250
no
no
yes
no
12
no
no
no
4
no
NA
Approved
Medicaid
Benchmark
State
WV
X
200
no
no
yes
no
12
no
no
no
6
no
NA
Equivalent Employee
Compre-
hensive
Medicaid
WI
X
185
yes
yes
yes
no
0
no
NA
no
NA
3
yes
40%
Section
1115
Waiver
Secretary
WY
X
185
no
no
yes
no
12
no
no
no
Other
1
no
NA
Approved
Total
count
15
18
18
140 - 350
10
11
46
2
36
9
3
3
see Table 3
30
8
0-50
of
states
Note: For combination programs, if there is one entry in a cell, the entry applies to both the Medicaid expansion (MXP) and the separate state program (SSP). If there is a difference between programs, both
characteristics are reported. For states with more than one SSP in which there are differences between SSP programs for a given characteristic, multiple answers are provided. “Type” and “Option” are
always not applicable (NA) for MXPs. For combination programs, the Type and Option shown are for the SSPs. In the counts provided in the last row, combination states that have this characteristic in
at least one of their programs are counted as having the characteristic. For the column showing the “upper income threshold,” see table note b on Table 1 in the text for additional information.
a. AK has an 1115 waiver pending that would allow it to require a 12-month waiting period prior to enrollment for children in families with income over 150% FPL.
b. Illinois’ Section 1115 HIFA demonstration waives the minimum employer contribution requirement. RI does not have a minimum requirement because such a requirement is not applicable for MXPs, and
Rhode Island’s employer sponsored insurance (ESI) premium assistance program is done through Medicaid.
c. When applicable, ESI must be benchmarked against or benchmark equivalent to the state’s largest HMO.
d. MS has CMS approval to use presumptive eligibility but has chosen not to implement it. MS also has CMS approval to subsidize ESI, but the program has not been implemented and is on hold indefinitely.
e. New York City had a Medicaid and SCHIP Disaster Relief waiver to address the effects of Sept. 11, 2001. The waiver was effective Aug. 1, 2001 through Jan. 31, 2003.
f. OH has received approval for a Section 1115 waiver allowing an annual enrollment fee and 12 months continuous coverage for beneficiaries with income between 151-200% FPL; however, the state has chosen
not to implement the waiver.
g. At the start of SCHIP, several states, including TN, created MXPs to cover older children in families with income up to 100% FPL sooner than required by Medicaid law. As of Oct. 1, 2002, such children
were covered as a mandatory group under Medicaid, and thus, previously established MXPs for these children ceased to exist. Thus, TN has no SCHIP enrollment. Tennessee’s Section 1115 waiver allows
an enrollment cap, but such a cap has not been implemented.

---

CRS-21
Appendix 3. SCHIP Premiums/Enrollment Fees and Selected Co-Payment Amounts by State, as of July 31, 2003
Sliding
scale for
cost
Co-pays for
Co-pays for
Cost
sharing
Co-pays
Co-pays
emergency
non-emer-
sharing
(based on
Premium or
for brand
for generic
Co-pays
Co-pays for
use of emer-
gency use of
MXP
SSP
Combi-
required
income or
enrollment
Premium or fee Family cap
name Rx
Rx drugs
for office
inpatient
gency room
emergency
State
only
only
nation
(yes/no)
age)
fee required
per child ($)
($)
drugs ($)
($)
visits ($)
services ($)
($)
room ($)
AL
X
yes
income
annually
0-50
0-150
0-3
0-1
0-5
0-5
0-5
0-5
AK
X
yesa
age
no
—
—
0-2
0-2
0-3
0-50
—
0-5% of charge
AZ
X
yes
income
monthly
0-15
0-20
—
—
—
—
—
5
ARb
20% of first
X
yes
no
no
—
—
5
5
10
10
10
hospital day
CAc
X
yes
income
d
4-9
8-27
5
5
5
—
5
5
CO
X
yes income
annually
0-25
0-35
1-5
1-3
2-5

—
3-15
3-15
CT
X
yes
income
monthly
0-30
0-50
6
3
5
—
—
25
DE
X
yes
income
monthly
10-25
10-25
—
—
—
—
—
10
DC
X
^
^
^
^
^
^
^
^
^
^
^
FLc
X
yes
no
monthly
15
15
0-3
0-3
0-3
—
—
0-10
GA
X
yes
age
monthly
0-7.50
0-15
—
—
—
—
—
—
HI
X
^
^
^
^
^
^
^
^
^
^
^
ID
X
^
^
^
^
^
^
^
^
^
^
^
ILc
X
yes
no
monthly
0-15
0-30
2-5
2-3
2-5
—
2-no info
2-25
IN
16.50-
X
yes
income
monthly
11-16.50
10
3
—
—
—
—
24.75
IA
X
yes
income
monthly
0-10
0-20
—
—
—
—
—
0-25
KS
X
yes
income
monthly
10-15
10-15
—
—
—
—
—
—
KY
X
yesa
age
no
—
—
0-1
0-1
—
—
—
—
LA
X
^
^
^
^
^
^
^
^
^
^
^
ME
X
yes
income
monthly
5-20
10-40
—
—
—
—
—
—

---

CRS-22
Sliding
scale for
cost
Co-pays for
Co-pays for
Cost
sharing
Co-pays
Co-pays
emergency
non-emer-
sharing
(based on
Premium or
for brand
for generic
Co-pays
Co-pays for
use of emer-
gency use of
MXP
SSP
Combi-
required
income or
enrollment
Premium or fee Family cap
name Rx
Rx drugs
for office
inpatient
gency room
emergency
State
only
only
nation
(yes/no)
age)
fee required
per child ($)
($)
drugs ($)
($)
visits ($)
services ($)
($)
room ($)
MD
X
yes
income
monthly
40-50
40-50
—
—
—
—
—
—
MAc
X
yes
income
monthly
12-35
15-36
—
—
—
—
—
—
MI
X
yes
no
monthly
5
5
—
—
—
—
—
—
MN
X
^
^
^
^
^
^
^
^
^
^
^
MS
X
yes
income
no
—
—
—
—
0-5
—
0-15
0-15
MOb
X
yes
income
monthly
0-78
0-225
0-9
0-9
5-10
—
—
—
MT
X
yes
no
no
—
—
5
3
3
25
5
5
NE
X
^
^
^
^
^
^
^
^
^
^
^
NV
X
yes
income
quarterly
10-50
10-50
—
—
—
—
—
—
NH
X
yes
income monthly
25-45
100-135
10
5
10

—
50
50
NJc
X
yes
income
monthly
0-100
0-100
0-5
0-5
0-5
—
0-35
0-35
NMb
X
yes
no
no
—
—
2
2
5
25
15
15
NY
X
yes
income
monthly
0-15
0-45
—
—
—
—
—
—
NC
X
yes
income
annually
0-50
0-100
0-6
0-6
0-5
—
—
0-20
ND
X
yes
no
no
—
—
2
2
—
—
5
5
OHb
X
e
^
^
^
^
^
^
^
^
^
^
OK
X
^
^
^
^
^
^
^
^
^
^
^
OR
X
no
—
—
—
—
—
—
—
—
—
—
PA
X
no
—
—
—
—
—
—
—
—
—
—
RIb
X
yes
income
monthly
0-92
0-92
—
—
—
—
—
—
SC
X
^
^
^
^
^
^
^
^
^
^
^
SD
X
no
—
—
—
—
—
—
—
—
—
—

---

CRS-23
Sliding
scale for
cost
Co-pays for
Co-pays for
Cost
sharing
Co-pays
Co-pays
emergency
non-emer-
sharing
(based on
Premium or
for brand
for generic
Co-pays
Co-pays for
use of emer-
gency use of
MXP
SSP
Combi-
required
income or
enrollment
Premium or fee Family cap
name Rx
Rx drugs
for office
inpatient
gency room
emergency
State
only
only
nation
(yes/no)
age)
fee required
per child ($)
($)
drugs ($)
($)
visits ($)
services ($)
($)
room ($)
TN
X
^
^
^
^
^
^
^
^
^
^
^
TX
X
yes
income
monthlyf
15-18
15-18
5-20
0-5
2-10
25-100
5-50
5-50
UT
5 or10% of
X
yes
income
quarterly
13-25
13-25
2-5
2-5
5-15
5-35
10-35
allowed amt
VT
X
yes
no
monthly
50
50
—
—
—
—
—
—
VA
X
yes
income
no
—
—
2-5
2-5
2-5
15-25
—
10-25
WA
X
yes
no
monthly
10
30
—
—
—
—
—
—
WV
X
yes
income
no
—
—
5-15
—
0-15
0-25
0-35
0-35
WIb
0 or 3% of
0 or 3% of
X
yes
income
monthly
—
—
—
—
—
—
income
income
WY
X
yes
no
no
—
—
5
3
5
—
5
5
Total
22 monthly
count
25 income
2 quarterly
15
18
18
38
28
28
22
21
20
9
15
23
of
3 age
3 annually
states
2 mixed
Note: Cost-sharing for children is not permitted under Medicaid unless the state has a Section 1115 waiver allowing the state to impose cost sharing. This also applies to SCHIP Medicaid expansion programs.
Medicaid expansion only states without an 1115 waiver have a ‘^’ in the cost-sharing columns. For the combination states, the values shown reflect cost-sharing in the separate state program(s) only. Some states
have employer-sponsored insurance (ESI) programs as a component of their Medicaid expansion or separate state programs. Information on cost-sharing in ESI programs varies by participating employer and
is typically not available in state SCHIP documents and other sources used for this analysis. Thus, such data are not represented in this table.
a. In AK, 18-year-olds are subject to the Medicaid co-payment requirements for adults. Likewise, KY charges 18-year-olds copayments on prescription drugs.
b. State has a Section 1115 waiver allowing cost-sharing in a Medicaid expansion program.
c. These states have multiple separate state programs. The amounts shown in these cells represent cost-sharing ranges across all SSPs within the state.
d. In one of California’s SSPs, the Access for Infants and Mothers Program, an enrollment fee of 2% of family income is required for infants (paid on a monthly or annual basis). No co-payments apply to this
group. The monthly premiums and co-payments shown for CA are for the state’s other SSP called Healthy Families.
e. OH has received approval for a Section 1115 waiver allowing an annual enrollment fee and 12 months continuous coverage for children in families with income between 151-200% FPL; however, the state
has chosen not to implement the waiver.
f. In TX, children in families with income between 100-150% FPL pay a $15 annual enrollment fee only. Monthly premiums apply to other children.

---

CRS-24
Appendix 4. SCHIP State Tables, Status
as of December 31, 2002 through July 31, 2003
Program Info
State
Alabama. Separate State Program Only
Program Name
CHIP Phase II- ALL Kids
Type Of Program
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this Program
no
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
no
Eligibility
Age
Income (% FPL)
Lower
Upper
Lower
Upper
Youngest
0
5
133
200
Next Youngest
6
18
100
200
Older
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
12
Presumptive Eligibility
no
Prenatal Care for Unborn Children
no
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
yes
Sliding Scale for Cost-Sharing
income
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
100
150
Range (%FPL)
150
200
Premium or Enrollment Fee Required
annually
Premium/Fee Per Child
$
0
$
50
Family Cap
$
0
$ 150
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
0
$
3
Co-Payment For Generic Rx Drugs
$
0
$
1
Co-Payment For Office Visits
$
0
$
5
Co-Payment For Inpatient Services
$
0
$
5
Co-Payment For Emerg Use Of Emerg-Room
$
0
$
5
Co-Payment For Non-Emerg Use Of Emerg-Room
$
0
$
5
Coverage Type/Option
Type
Benchmark
Option
Largest HMO
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
3
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA

---

CRS-25
Program Info
State
Alaska. Medicaid Expansion Only
Program Name
Denali KidCare
Type Of Program
Medicaid Expansion
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this Program
no
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
no
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
5
133
200
Next Youngest
6
18
100
200
Older
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
6
Presumptive Eligibility
no
Prenatal Care for Unborn Children
NA
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
yesa
Sliding Scale for Cost-Sharing
agea
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
0
18
Range (%FPL)
17
18
Premium or Enrollment Fee Required
no
Premium/Fee Per Child
Family Cap
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
0 $
2
Co-Payment For Generic Rx Drugs
$
0 $
2
Co-Payment For Office Visits
$
0 $
3
Co-Payment For Inpatient Services
$
0
$50b
Co-Payment For Emerg Use Of Emerg-Room
$
0 $
0
5% of
Co-Payment For Non-Emerg Use Of Emerg-Room
$
0
charge
Coverage Type/Option
Type
NA
Option
NA
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
c
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA
a. In AK, 18 year olds are subject to the Medicaid co-payment requirements for adults.
b. Up to a maximum of $200 for inpatient hospital services, not to exceed 50% of the payment made for the first
day of hospital care.
c. AK has a Section 1115 waiver pending that would allow it to require a 12-month waiting period prior to
enrollment for children in families with income over 150%.

---

CRS-26
Program Info
State
Arizona. Separate State Program Only
Program Name
KidsCare
Type Of Program
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this Program
no
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
yesa
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
1
140
200
Next Youngest
1
5
133
200
Older
6
18
100
200
Oldest
Basic Income Disregard
no
Asset Tests
no
Continuous Eligibility (months)
12
Presumptive Eligibility
no
Prenatal Care for Unborn Children
no
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
yes
Sliding Scale for Cost-Sharing
income
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
100
150
175
Range (%FPL)
150
175
200
Premium or Enrollment Fee Required
monthly
Premium/Fee Per Child
$
0 $
10 $
15
Family Cap
$
0 $
15 $
20
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
0 $
0 $
0
Co-Payment For Generic Rx Drugs
$
0 $
0 $
0
Co-P

ayment For Office Visits
$
0 $
0 $
0
Co-Payment For Inpatient Services
$
0 $
0 $
0
Co-Payment For Emerg Use Of Emerg-Room
$
0 $
0 $
0
Co-Payment For Non-Emerg Use Of Emerg-Room
$
5 $
5 $
5
Coverage Type/Option
Type
Secretary Approved
Option
Same as Medicaid
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
3
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA
a. Arizona’s HIFA waiver allows the state to use SCHIP funds to cover parents of SCHIP and Medicaid children
in families with income between 100%-200% FPL and adults without dependent children with income
below 100% FPL.

---

CRS-27
Program Info
State
Arkansas. Medicaid Expansion Only
Program Name
ARKids B
Type Of Program
Medicaid Expansion
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this Program
yesa
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
no
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
18
150
200
Next Youngest
Older
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
12
Presumptive Eligibility
no
Prenatal Care for Unborn Children
NA
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
yes
Sliding Scale for Cost-Sharing
no
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
Range (%FPL)
Premium or Enrollment Fee Required
no
Premium/Fee Per Child
Family Cap
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
5
Co-Payment For Generic Rx Drugs
$
5
Co-Payment For Office Visits
$
10
Co-Payment For Inpatient Services
20% of 1st hospital day
Co-Payment For Emerg Use Of Emerg-Room
$
10
Co-Payment For Non-Emerg Use Of Emerg-Room
$
10
Coverage Type/Option
Type
Comprehensive Medicaid Section 1115 waiver
Option
NA
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
6
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA
a. AR uses SCHIP funds to provide coverage under its comprehensive Medicaid Section 1115 waiver, which,
among other things, allows a six-month waiting period and cost sharing that exceeds Medicaid allowable
amounts.

---

CRS-28
Program Info
State
California. Combination
Program Name
MediCal
Access for Infants and Mothersb
Healthy Families Program
Type Of Program
Medicaid Expansion
Separate State Program
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
no
no
Allowing Use of SCHIP Funds to Cover Groups
Not Eligible for this Program
yesc
yesc
yesc
Eligibility
Age
Income (%FPL)
Age
Income (%FPL)
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Lower
Upper
Lower
Upper
Lower
Upper
Lower
Upper
Youngest
1
5
1a
133a
0
1
200
250
0
1
200
250
Next Youngest
6
18
1a
100a
1
5
133
250
Older
6
18
100
250
Oldest
Basic Income Disregard
yes
yes
yes
Asset Tests
no
no
no
Continuous Eligibility (months)
12
12
12
Presumptive Eligibility
yes
no
no
Prenatal Care for Unborn Children
NA
no
no
Enrollment Cap / Waiting List
no
no
no
Cost Sharing
Cost Sharing Required
NA
yes
yes
Sliding Scale for Cost-Sharing
NA
yes
incomee
Group
Group
Group
Group
Group
Group
Group
Group
Group
Group
Group
Group
Sliding Scale Group Defined
1
2
3
4
1
2
3
4
1
2
3
4
100
150
100
150
Range (%FPL)
150
200
150
200
Premium or Enrollment Fee Required
monthly or annuallyd
monthlye
Premium/Fee Per Child
$
4 $
6 $
7 $
9
2% of family income
Family Cap
$
8 $
18 $
14 $
27
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
5 $
5 $
5 $
5
Co-Payment For Generic Rx Drugs
$
5 $
5 $
5 $
5
Co-Payment For Office Visits
$
5 $
5 $
5 $
5
Co-Payment For Inpatient Services
$
0 $
0 $
0 $
0
Co-Payment For Emerg Use Of Emerg-Room
$
5 $
5 $
5 $
5
Co-Payment For Non-Emerg Use Of Emerg-Room
$
5 $
5 $
5 $
5

---

CRS-29
Coverage Type/Option
Type
NA
Benchmark
Benchmark
Option
NA
State Employee
State Employee
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
0
0
3
Subsidy For Private/Employer Coverage
no
no
no
Min. Employer Premium Share Required for
Subsidy
NA
NA
NA
a. The income thresholds shown are used for both Medicaid and SCHIP purposes. CA eliminated asset tests from its Medicaid program in 1998. Title XIX
financing is used for children who meet the income thresholds shown and who have assets below the Title XIX asset test thresholds in place in 1997 (the
maintenance of effort point for SCHIP). Title XXI financing is used for children who meet the income thresholds shown and who have assets exceeding
the Title XIX asset test thresholds in place in 1997.
b. Only infants born to women already enrolled in California’s non-SCHIP AIM program are enrolled in AIM. Other infants 200-250% FPL are enrolled in the
Healthy Families program.
c. California’s HIFA waiver allows the state to use SCHIP funds to cover parents, relative caretakers, and legal guardians of eligible children in families who are
not eligible for Medicaid with family income up to 200% FPL (The waiver was approved Jan. 2002 but had not yet been implemented as of June 12, 2003).
d. The AIM family contribution can be either (1) paid at the time of the application and the applicant will receive a $50 discount, or (2) spread over a 12 month
period. If the applicant chooses monthly payments, she must send $50 with the application and the program will send her a payment booklet.
e. Enrollees may choose from two provider plans. Premiums for the “Community Provider Plan” are presented in the first two columns; premiums for the “Family
Value Package” are presented in the second two columns. Families who pre-pay three months do not have to pay the fourth month.

---

CRS-30
Program Info
State
Colorado. Separate State Program Only
Program Name
Child Health Plan Plus
Type Of Program
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this Program
no
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
yesa
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
5
133
185
Next Youngest
6
18
100
185
Older
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
12
Presumptive Eligibility
no
Prenatal Care for Unborn Children
no
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
yes
Sliding Scale for Cost-Sharing
income
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
100
150
Range (%FPL)
150
185
Premium or Enrollment Fee Required
annually
Premium/Fee Per Child
$
0 $
25
Family Cap
$
0 $
35
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
1 $
5
Co-Payment For Generic Rx Drugs
$
1 $
3
Co-Payment For Office Visits
$
2 $
5
Co-Payment For Inpatient Services
$
0 $
0
Co-Payment For Emerg Use Of Emerg-Room
$
3 $
15
Co-Payment For Non-Emerg Use Of Emerg-Room
$
3 $
15
Coverage Type/Option
Type
Benchmark Equivalent
Option
FEHBP, State Employee, and Largest HMO
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
3
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA
a. Colorado’s HIFA waiver allows the state to use SCHIP funds to expand coverage to pregnant women with
family incomes between 133-185% FPL.

---

CRS-31
Program Info
State
Connecticut. Separate State Program Only
Program Name
HUSKY Plans B and Ca
Type Of Program
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this Program
no
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
no
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
18
185
300
Next Youngest
Older
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
0
Presumptive Eligibility
no
Prenatal Care for Unborn Children
no
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
yes
Sliding Scale for Cost-Sharing
income
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
185
235
Range (%FPL)
235
300
Premium or Enrollment Fee Required
monthly
Premium/Fee Per Child
$
0 $
30
Family Cap
$
0 $
50
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
6 $
6
Co-Payment For Generic Rx Drugs
$
3 $
3
Co-Payment For Office Visits
$
5 $
5
Co-Payment For Inpatient Services
$
0 $
0
Co-Payment For Emerg Use Of Emerg-Room
$
0 $
0
Co-Payment For Non-Emerg Use Of Emerg-Room
$
25 $
25
Coverage Type/Option
Type
Benchmark
Option
State Employee
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
2
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA
a. Children who are eligible for HUSKY Part B and who require intensive physical or behavioral health services
receive medically necessary services under HUSKY Plus Plan Part C.

---

CRS-32
Program Info
State
Delaware. Combination
Delaware Healthy Children
Program Name
Medicaid
Program
Type Of Program
Medicaid Expansion
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
no
Allowing Use of SCHIP Funds to Cover
Groups Not Eligible for this Program
no
no
Eligibility
Income
Income
Age
(%FPL)
Age
(%FPL)
Lower Upper Lower Upper Lower Upper Lower Upper
Youngest
0
1
185
200
1
5
100
200
Next Youngest
6
18
100
200
Older
Oldest
Basic Income Disregard
yes
yes
Asset Tests
no
no
Continuous Eligibility (months)
0
12
Presumptive Eligibility
no
no
Prenatal Care for Unborn Children
NA
no
Enrollment Cap / Waiting List
no
no
Cost Sharing
Cost Sharing Required
NA
yes
Sliding Scale for Cost-Sharing
NA
income
Group Group Group Group Group Group Group Group
Sliding Scale Group Defined
1
2
3
4
1
2
3
4
100
133
166
Range (%FPL)
133
166
200
Premium or Enrollment Fee Required
monthly
Premium/Fee Per Child
$
10 $
15 $
25
Family Cap
$
10 $
15 $
25
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
0 $
0 $
0
Co-Payment For Generic Rx Drugs
$
0 $
0 $
0
Co-Paym
ent
For Of
fice Visits
$
0 $
0 $
0
Co-Payment For Inpatient Services
$
0 $
0 $
0
Co-Payment For Emerg Use Of
Emerg-Room
$
0 $
0 $
0
Co-Payment For Non-Emerg Use Of
Emerg-Room
$
10 $
10 $
10
Coverage Type/Option
Type
NA
Benchmark
Option
NA
State Employee
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out
(months)
0
6
Subsidy For Private/Employer Coverage
no
no
Min. Employer Premium Share Required for
Subsidy
NA
NA

---

CRS-33
Program Info
District of Columbia. Medicaid Expansion
State
Only
Program Name
DC Healthy Families
Type Of Program
Medicaid Expansion
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this Program
no
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
no
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
1
185
200
Next Youngest
1
5
133
200
Older
6
18
100
200
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
0
Presumptive Eligibility
no
Prenatal Care for Unborn Children
NA
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
NA
Sliding Scale for Cost-Sharing
NA
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
Range (%FPL)
Premium or Enrollment Fee Required
Premium/Fee Per Child
Family Cap
Co-Payments
Co-Payment For Brand Name Rx Drugs
Co-Payment For Generic Rx Drugs
Co-Payment For Office Visits
Co-Payment For Inpatient Services
Co-Payment For Emerg Use Of Emerg-Room
Co-Payment For Non-Emerg Use Of Emerg-Room
Coverage Type/Option
Type
NA
Option
NA
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
0
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA

---

CRS-34
Program Info
State
Florida. Combination
Program Name
Medicaid
MediKids
Florida CMS Networka
Healthy Kids
Type Of Program
Medicaid Expansion
Separate State Program
Separate State Program
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
no
no
no
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
no
no
no
no
Eligibility
Age
Income (%FPL)
Age
Income (%FPL)
Age
Income (%FPL)
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Lower
Upper
Lower
Upper
Lower
Upper
Lower
Upper
Lower
Upper
Lower
Upper
Youngest
0
1
185
200
1
4
133
200
1
5
133
200
5
5
133
200
Next Youngest
6
18
100
200
6
18
100
200
Older
Oldest
Basic Income Disregard
yes
yes
yes
yes
Asset Tests
no
no
no
no
under age 5: 12
Continuous Eligibility (months)
age 5 and up: 6
6
12
6
Presumptive Eligibility
no
no
no
no
Prenatal Care for Unborn Children
NA
no
no
no
Enrollment Cap / Waiting List
no
yesb
yesb
yesb
Cost Sharing
Cost Sharing Required
NA
yes
yes
yes
Sliding Scale for Cost-Sharing
NA
no
no
no
Group
Group
Group
Group
Group
Group
Group
Group
Group
Group
Group
Group
Group
Group
Group
Group
Sliding Scale Group Defined
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
133
100
100
Range (%FPL)
200
200
200
Premium or Enrollment Fee Required
monthly
monthly
monthly
Premium/Fee Per Child
$
15
$
15
$
15
Family Cap
$
15
$
15
$
15
Co-Payments

---

CRS-35
Co-Payment For Brand Name Rx Drugs
$
3
Co-Payment For Generic Rx Drugs
$
3
Co-Payment For Office Visits
$
3
Co-Payment For Inpatient Services
$
0
Co-Payment For Emerg Use Of Emerg-Room
$
0
Co-Payment For Non-Emerg Use Of Emerg-Room
$
10
Coverage Type/Option
Type
NA
Secretary Approved
Secretary Approved
Existing Comprehensive
Option
NA
Same as Medicaid
Same as Medicaid
State-Based
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
0
0
0
0
Subsidy For Private/Employer Coverage
no
no
no
no
Min. Employer Premium Share Required for Subsidy
NA
NA
NA
NA
a. The Children’s Medical Services Network is for children with special health care needs.
b. FL has approval from CMS to impose a cap in its separate state program if in a given fiscal year the state has utilized all of its budgeted funds.

---

CRS-36
Program Info
State
Georgia. Separate State Program Only
Program Name
PeachCare for Kids
Type Of Program
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this Program
no
Allowing Use of SCHIP Funds to Cover Groups Not Eligible
for this Program
no
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
1
185
235
Next Youngest
1
5
133
235
Older
6
18
100
235
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
12
Presumptive Eligibility
no
Prenatal Care for Unborn Children
no
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
yes
Sliding Scale for Cost-Sharing
age
Sliding Scale Group Defined
Group 1a
Group 2a Group 3
Group 4
0
6
Range (%FPL)
5
18
Premium or Enrollment Fee Required
monthly
Premium/Fee Per Child
$
0 $
7.50
Family Cap
$
0 $
15
Co-Payments
Co-Payment For Brand Name Rx Drugs
Co-Payment For Generic Rx Drugs
Co-Payment For Office Visits
Co-Payment For Inpatient Services
Co-Payment For Emerg Use Of Emerg-Room
Co-Payment For Non-Emerg Use Of Emerg-Room
Coverage Type/Option
Type
Secretary Approved
Option
Benchmark Plus Additionalb
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
3
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA
a. GA bases its sliding scale on age rather than income.
b. Largest HMO plus additional benefits.

---

CRS-37
Program Info
State
Hawaii. Medicaid Expansion Only
Program Name
QUEST and Medicaid FFS
Type Of Program
Medicaid Expansion
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
yesa
Program
Allowing Use of SCHIP Funds to Cover
Groups Not Eligible for this Program
no
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
1
185
200
Next Youngest
1
5
133
200
Older
6
18
100
200
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
0
Presumptive Eligibility
no
Prenatal Care for Unborn Children
NA
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
NA
Sliding Scale for Cost-Sharing
NA
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
Range (%FPL)
Premium or Enrollment Fee Required
Premium/Fee Per Child
Family Cap
Co-Payments
Co-Payment For Brand Name Rx Drugs
Co-Payment For Generic Rx Drugs
Co-Payment For Office Visits
Co-Payment For Inpatient Services
Co-Payment For Emerg Use Of
Emerg-Room
Co-Payment For Non-Emerg Use Of
Emerg-Room
Coverage Type/Option
Type
Comprehensive Medicaid Section 1115 waiver
Option
NA
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out
(months)
0
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for
Subsidy
NA
a. HI uses SCHIP funds to expand QUEST, its comprehensive Medicaid Section 1115 waiver program. Children
with disabilities are served through the Medicaid fee-for-service (FFS) program.

---

CRS-38
Program Info
State
Idaho. Medicaid Expansion Only
Program Name
Idaho CHIP
Type Of Program
Medicaid Expansion
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
no
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
5
133
150
Next Youngest
6
18
100
150
Older
Oldest
Basic Income Disregard
yes
Asset Tests
yes
Continuous Eligibility (months)
12
Presumptive Eligibility
no
Prenatal Care for Unborn Children
NA
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
NA
Sliding Scale for Cost-Sharing
NA
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
Range (%FPL)
Premium or Enrollment Fee Required
Premium/Fee Per Child
Family Cap
Co-Payments
Co-Payment For Brand Name Rx Drugs
Co-Payment For Generic Rx Drugs
Co-Payment For Office Visits
Co-Payment For Inpatient Services
Co-Payment For Emerg Use Of Emerg-Room
Co-Payment For Non-Emerg Use Of Emerg-Room
Coverage Type/Option
Type
NA
Option
NA
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
0
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA

---

CRS-39
Program Info
State
Illinois. Combination
Program Name
KidCare Assist Expansion
KidCare Share
KidCare Premium
Type Of Program
Medicaid Expansion
Separate State Program
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
yesa
yesa
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
yesa
yesa
yesa
Eligibility
Age
Income (%FPL)
Age
Income (%FPL)
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Lower
Upper
Lower
Upper
Lower
Upper
Lower
Upper
Youngest
6
18
100
133
0
18
133
150
0
18
150
185
Next Youngest
Older
Oldest
Basic Income Disregard
yes
yes
yes
Asset Tests
no
no
no
Continuous Eligibility (months)
12
12
12
Presumptive Eligibility
no
no
no
Prenatal Care for Unborn Children
NA
yesb
yesb
Enrollment Cap / Waiting List
no
no
no
Cost Sharing
Cost Sharing Required
NA
yes
yes
Sliding Scale for Cost-Sharing
NA
no
no
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
Group 1
Group 2
Group 3
Group 4
Group 1
Group 2
Group 3
Group 4
133
150
Range (%FPL)
150
185
Premium or Enrollment Fee Required
no
monthly
Premium/Fee Per Child
$
15
Family Cap
$
30
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
2
$
5
Co-Payment For Generic Rx Drugs
$
2
$
3

---

CRS-40
Co-Payment For Office Visits
$
2
$
5
Co-Payment For Inpatient Services
$
0
$
0
missing
Co-Payment For Emerg Use Of Emerg-Room
$
2
info
Co-Payment For Non-Emerg Use Of Emerg-Room
$
2
$
25
Coverage Type/Option
Type
NA
Benchmark Equivalent
Benchmark Equivalent
Option
NA
State Employee
State Employee
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
0
0
0
Subsidy For Private/Employer Coverage
no
yesa
yesa
Min. Employer Premium Share Required for Subsidy
NA
a
a
a. Illinois’ HIFA waiver allows the state to use Medicaid and SCHIP funds to cover parents of Medicaid and SCHIP children. The demonstration also provides Title XXI funding for the Illinois
Comprehensive Health Insurance Program and hemophiliacs (both previously state-funded programs). Illinois’ waiver also allows the state to provide a subsidy for ESI that can (1) offer a reduced
benefits package (however, the state must ensure that all age-appropriate immunizations are covered), and (2) impose cost-sharing that exceeds the aggregate, annual 5% of family income limitation
in the SCHIP statute. The terms and conditions of the waiver proscribe that enrollment in ESI is voluntary and that the state must inform enrollees of the implications of choosing private or
employer-sponsored insurance. The waiver also waives the minimum employer contribution requirement.
b. IL offers prenatal care from confirmation of pregnancy through birth to pregnant women in families with income up to 200% FPL.

---

CRS-41
Program Info
State
Indiana. Combination
Program Name
Hoosier Healthwise Phase I
Hoosier Healthwise Phase II
Type Of Program
Medicaid Expansion
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting
this Program
no
no
Allowing Use of SCHIP Funds to Cover
Groups Not Eligible for this Program
no
no
Eligibility
Income
Age
(%FPL)
Age
Income (%FPL)
Lower Upper Lower Upper Lower Upper Lower
Upper
Youngest
1
5
133
150
0
18
150
200
Next Youngest
6
18
100
150
Older
Oldest
Basic Income Disregard
yes
yes
Asset Tests
no
no
Continuous Eligibility (months)
0
12
Presumptive Eligibility
no
no
Prenatal Care for Unborn Children
NA
no
Enrollment Cap / Waiting List
no
no
Cost Sharing
Cost Sharing Required
NA
yes
Sliding Scale for Cost-Sharing
NA
income
Group Group Group Group Group Group Group
Group
Sliding Scale Group Defined
1
2
3
4
1
2
3
4
150
175
Range (%FPL)
175
200
Premium or Enrollment Fee Required
monthly
Premium/Fee Per Child
$
11 $16.50
Family Cap
$ 16.50 $24.75
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
10 $
10
Co-Payment For Generic Rx Drugs
$
3 $
3
Co-Payment For Office Visits
$
0 $
0
Co-Payment For Inpatient Services
$
0 $
0
Co-Payment For Emerg Use Of
Emerg-Room
$
0 $
0
Co-Payment For Non-Emerg Use Of
Emerg-Room
$
0 $
0
Coverage Type/Option
Type
NA
Benchmark Equivalent
Option
NA
FEHBP
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out
(months)
0
3
Subsidy For Private/Employer Coverage
no
no
Min. Employer Premium Share Required
for Subsidy
NA
NA

---

CRS-42
Program Info
State
Iowa. Combination
Healthy Well Kids Iowa
Program Name
Medicaid
(HAWK-I)
Type Of Program
Medicaid Expansion
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
no
Allowing Use of SCHIP Funds to Cover
Groups Not Eligible for this Program
no
no
Eligibility
Income
Income
Age
(%FPL)
Age
(%FPL)
Lower Upper Lower Upper Lower Upper Lower Upper
Youngest
0
1
185
200
1
18
133
200
Next Youngest
6
18
100
133
Older
Oldest
Basic Income Disregard
yes
yes
Asset Tests
no
no
Continuous Eligibility (months)
0
12
Presumptive Eligibility
no
no
Prenatal Care for Unborn Children
NA
no
Enrollment Cap / Waiting List
no
no
Cost Sharing
Cost Sharing Required
NA
yes
Sliding Scale for Cost-Sharing
NA
income
Group Group Group Group Group Group Group Group
Sliding Scale Group Defined
1
2
3
4
1
2
3
4
133
150
Range (%FPL)
150
200
Premium or Enrollment Fee Required
monthly
Premium/Fee Per Child
$
0 $
10
Family Cap
$
0 $
20
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
0 $
0
Co-Payment For Generic Rx Drugs
$
0 $
0
Co-Payment For Office Visits
$
0 $
0
Co-Payment For Inpatient Services
$
0 $
0
Co-Payment For Emerg Use Of
Emerg-Room
$
0 $
0
Co-Payment For Non-Emerg Use Of
Emerg-Room
$
0 $
25
Coverage Type/Option
Type
NA
Benchmark Equivalent
Option
NA
State Employee
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out
(months)
0
6
Subsidy For Private/Employer Coverage
no
no
Min. Employer Premium Share Required for
Subsidy
NA
NA

---

CRS-43
Program Info
State
Kansas. Separate State Program Only
Program Name
Health Wave
Type Of Program
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
no
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
1
150
200
Next Youngest
1
5
133
200
Older
6
18
100
200
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
12
Presumptive Eligibility
no
Prenatal Care for Unborn Children
no
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
yes
Sliding Scale for Cost-Sharing
income
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
150
175
Range (%FPL)
175
200
Premium or Enrollment Fee Required
monthly
Premium/Fee Per Child
$
10 $
15
Family Cap
$
10 $
15
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
0 $
0
Co-Payment For Generic Rx Drugs
$
0 $
0
Co-Payment For Office Visits
$
0 $
0
Co-Payment For Inpatient Services
$
0 $
0
Co-Payment For Emerg Use Of Emerg-Room
$
0 $
0
Co-Payment For Non-Emerg Use Of Emerg-Room
$
0 $
0
Coverage Type/Option
Type
Secretary Approved
Option
Benchmark Plus Additionala
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
0
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA
a. State employee plan plus dental and mental health.

---

CRS-44
Program Info
State
Kentucky. Combination
KCHIP Separate Insurance
Program Name
KCHIP Medicaid Expansion
Program
Type Of Program
Medicaid Expansion
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
no
Allowing Use of SCHIP Funds to Cover
Groups Not Eligible for this Program
no
no
Eligibility
Income
Income
Age
(%FPL)
Age
(%FPL)
Lower Upper Lower Upper Lower Upper Lower Upper
Youngest
1
5
133
150
0
1
185
200
Next Youngest
6
18
100
150
1
18
150
200
Older
Oldest
Basic Income Disregard
yes
yes
Asset Tests
no
no
Continuous Eligibility (months)
0a
0
Presumptive Eligibility
no
no
Prenatal Care for Unborn Children
NA
no
Enrollment Cap / Waiting List
no
no
Cost Sharing
Cost Sharing Required
yesb
yesb
Sliding Scale for Cost-Sharing
ageb
ageb
Group Group Group Group Group Group Group Group
Sliding Scale Group Defined
1
2
3
4
1
2
3
4
0
18
0
18
Range (%FPL)
17
18
17
18
Premium or Enrollment Fee Required
no
no
Premium/F ee
Per Child
$
0 $
0
$
0 $
0
Family Cap
$
0 $
0
$
0 $
0
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
0 $
1
$
0 $
1
Co-Payment For Generic Rx Drugs
$
0 $
1
$
0 $
1
Co-Paym
ent
For Off
ice Visits
$
0 $
0
$
0 $
0
Co-Payment For Inpatient Services
$
0 $
0
$
0 $
0
Co-Payment For Emerg Use Of Emerg-Room $
0 $
0
$
0 $
0
Co-Payment For Non-Emerg Use Of
Emerg-Room
$
0 $
0
$
0 $
0
Coverage Type/Option
Type
NA
Secretary Approved
Option
NA
Benchmark Plus Additionalc
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out
(months)
0
6
Subsidy For Private/Employer Coverage
no
no
Min. Employer Premium Share Required for
Subsidy
NA
NA
a. Children living in regions covered by Kentucky’s sub-state Health Care Partnership Section 1115 waiver
receive six months continuous eligibility.

---

CRS-45
b. KY charges 18-year olds a $1 co-pay for pharmacy prescriptions, which is the same cost-sharing requirement
that is imposed through the state’s Title XIX state plan.
c. State employee plus additional benefits.

---

CRS-46
Program Info
State
Louisiana. Medicaid Expansion Only
Program Name
LaCHIP
Type Of Program
Medicaid Expansion
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
no
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
5
133
200
Next Youngest
6
18
100
200
Older
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
12
Presumptive Eligibility
no
Prenatal Care for Unborn Children
NA
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
NA
Sliding Scale for Cost-Sharing
NA
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
Range (%FPL)
Premium or Enrollment Fee Required
Premium/Fee Per Child
Family Cap
Co-Payments
Co-Payment For Brand Name Rx Drugs
Co-Payment For Generic Rx Drugs
Co-Payment For Office Visits
Co-Payment For Inpatient Services
Co-Payment For Emerg Use Of Emerg-Room
Co-Payment For Non-Emerg Use Of Emerg-Room
Coverage Type/Option
Type
NA
Option
NA
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
0
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA

---

CRS-47
Program Info
State
Maine. Combination
Program Name
MaineCare
MaineCare
Type Of Program
Medicaid Expansion
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
no
Allowing Use of SCHIP Funds to Cover
Groups Not Eligible for this Program
no
no
Eligibility
Income
Income
Age
(%FPL)
Age
(%FPL)
Lower Upper Lower Upper Lower Upper Lower Upper
Youngest
1
5
133
150
0
1
185
200
Next Youngest
6
18
125
150
1
18
150
200
Older
Oldest
Basic Income Disregard
yes
no
Asset Tests
no
no
Continuous Eligibility (months)
12
12
Presumptive Eligibility
no
no
Prenatal Care for Unborn Children
NA
no
Enrollment Cap / Waiting List
no
no
Cost Sharing
Cost Sharing Required
NA
yes
Sliding Scale for Cost-Sharing
NA
income
Group Group Group Group Group Group Group Group
Sliding Scale Group Defined
1
2
3
4
1
2
3
4
150
160
170
185
Range (%FPL)
160
170
185
200
Premium or Enrollment Fee Required
monthly
Premium/Fee Per Child
$
5 $
10 $
15 $
20
Family Cap
$
10 $
20 $
30 $
40
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
0 $
0 $
0 $
0
Co-Payment For Generic Rx Drugs
$
0 $
0 $
0 $
0
Co-Payment For Office Visits
$
0 $
0 $
0 $
0
Co-Payment For Inpatient Services
$
0 $
0 $
0 $
0
Co-Payment For Emerg Use Of Emerg-Room
$
0 $
0 $
0 $
0
Co-Payment For Non-Emerg Use Of
Emerg-Room
$
0 $
0 $
0 $
0
Coverage Type/Option
Type
NA
Secretary Approved
Option
NA
Same as Medicaid
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out
(months)
0
3
Subsidy For Private/Employer Coverage
no
no
Min. Employer Premium Share Required for
Subsidy
NA
NA

---

CRS-48
Program Info
State
Maryland. Combination
Maryland Children’s Health
Maryland Children’s Health
Program Name
Program (I)
Program (II)
Type Of Program
Medicaid Expansion
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
yesa
no
Allowing Use of SCHIP Funds to Cover
Groups Not Eligible for this Program
no
no
Eligibility
Income
Age
(%FPL)
Age
Income (%FPL)
Lower Upper Lower Upper Lower Upper Lower Upper
Youngest
0
1
185
200
0
18
200
300
Next Youngest
1
5
133
200
Older
6
18
100
200
Oldest
Basic Income Disregard
yes
yes
Asset Tests
no
no
Continuous Eligibility (months)
6
12
Presumptive Eligibility
no
no
Prenatal Care for Unborn Children
NA
no
Enrollment Cap / Waiting List
no
no
Cost Sharing
Cost Sharing Required
NA
yes
Sliding Scale for Cost-Sharing
NA
income
Group Group Group Group Group Group Group Group
Sliding Scale Group Defined
1
2
3
4
1
2
3
4
200
250
Range (%FPL)
250
300
Premium or Enrollment Fee Required
monthly
Premium/Fee Per Child
$
40 $
50
Family Cap
$
40 $
50
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
0 $
0
Co-Payment For Generic Rx Drugs
$
0 $
0
Co-Payment For Office Visits
$
0 $
0
Co-Payment For Inpatient Services
$
0 $
0
Co-Payment For Emerg Use Of Emerg-Room
$
0 $
0
Co-Payment For Non-Emerg Use Of
Emerg-Room
$
0 $
0
Coverage Type/Option
Type
NA
Secretary Approved
Option
NA
Same as Medicaid
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out
(months)
6a
6
Subsidy For Private/Employer Coverage
no
yesb
Min. Employer Premium Share Required for
Subsidy
NA
30%
a. MD has a Section 1115 waiver allowing a six-month waiting period prior to enrollment in the state’s SCHIP
Medicaid Expansion program.

---

CRS-49
b. For Employer Sponsored Insurance (ESI) to qualify for a subsidy through the state’s separate state program,
a plan offered by small employers must use the state’s largest HMO as a benchmark. A plan offered by
large employers must either be (1) the benchmark-equivalent of the state’s largest HMO, or (2)
substantially equivalent to or greater than the state’s largest HMO through a benefit by benefit comparison
(Secretary-Approved coverage). A child who has access to qualifying ESI is required to enroll in ESI if
the employed parent is already enrolled in ESI for him- or herself. If the parent is not already enrolled in
ESI, it is the family’s choice whether to enroll in ESI or in the state’s separate state program.

---

CRS-50
Program Info
State
Massachusetts. Combination
MassHealth Family Assist Direct
Program Name
MassHealth Standard
MassHealth CommonHealtha
Coverage (DC)
MassHealth Premium Assistance
Type Of Program
Medicaid Expansion
Separate State Program
Separate State Program
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
no
no
no
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
no
no
no
no
Eligibility
Income
Income
Age
(%FPL)
Age
(%FPL)
Age
Income (%FPL)
Age
Income (%FPL)
Lower Upper Lower Upper Lower Upper
Lower Upper Lower
Upper
Lower
Upper
Lower
Upper
Lower
Upper
Youngest
0
1
185
200
1
18
150
200
1
18
150
200
1
18
150
200
Next Youngest
1
5
133
150
Older
6
14
115
150
Oldest
15
18
100
150
Basic Income Disregard
no
no
no
no
Asset Tests
no
no
no
no
Continuous Eligibility (months)
0
0
0
0
Presumptive Eligibility
yes
no
yes
no
Prenatal Care for Unborn Children
NA
no
no
no
Enrollment Cap / Waiting List
no
no
no
no
Cost Sharing
Cost Sharing Required
NA
yes
yes
yes
Sliding Scale for Cost-Sharing
NA
income
no
no
Group Group Group Group Group Group Group Group Group Group
Group
Group
Group
Group
Group
Group
Group
Sliding Scale Group Defined
1
2
3
4
1
2
3
4
5
1
2
3
4
1
2
3
4
150
160
170
180
190
150
150
Range (%FPL)
160
170
180
190
200
200
200
Premium or Enrollment Fee Required
monthly
monthly
monthly
Premium/Fee Per Child
$
15 $
20 $
25 $
30 $
35 $
12
$
12
Family Cap
$
15 $
20 $
25 $
30 $
35 $
36
$
36

---

CRS-51
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
0 $
0 $
0 $
0 $
0 $
0
b
Co-Payment For Generic Rx Drugs
$
0 $
0 $
0 $
0 $
0 $
0
b
Co-Payment For Office Visits
$
0 $
0 $
0 $
0 $
0 $
0
b
Co-Payment For Inpatient Services
$
0 $
0 $
0 $
0 $
0 $
0
b
Co-Payment For Emerg Use Of Emerg-Room
$
0 $
0 $
0 $
0 $
0 $
0
b
Co-Payment For Non-Emerg Use Of Emerg-Room
$
0 $
0 $
0 $
0 $
0 $
0
b
Coverage Type/Option
Type
NA
Benchmark
Benchmark
Secretary Approved
Comprehensive Medicaid Section
Option
NA
Largest HMO
Largest HMO
1115 Waiver
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
0
0
0
0
Subsidy For Private/Employer Coverage
no
noc
noc
yesc
Min. Employer Premium Share Required for Subsidy
NA
NA
NA
50%
a. The CommonHealth Program is for children who are permanently and totally disabled and provides benefits that are common in Medicaid but not necessarily in separate state programs, such as nursing
home and personal care.
b. Employer sponsored insurance can charge copays, coinsurance, and deductibles. The state will pay these amounts for children eligible for premium assistance provided: (1) the copay, coinsurance or
deductible was incurred as the result of a well-baby/well-child care visit; or (2) the policyholder’s annualized share of the employer-sponsored health insurance premiums, combined with copays,
coinsurance,and deductibles incurred and paid by members, exceeds 5% of the family group’s gross income in a 12-month period beginning with the date of eligibility for premium assistance.
Members receive an initial notice at the time of eligibility explaining the state’s policy on payment of copays, coinsurance and deductibles. Providers may bill the state directly or members may
seek reimbursement from the state.
c. Children eligible for Family Assist DC are required to enroll in employer sponsored coverage through the Premium Assistance program if their family has access to a qualified plan. Children eligible
for CommonHealth have the option to enroll in employer sponsored coverage through the Premium Assistance program if their family has access to a qualified plan.
Note: MA also covers pregnant adolescents with self-declared income between 185-200% FPL for which the unborn child(ren) are counted as if born in determining family size for the purpose of evaluating
income eligibility.

---

CRS-52
Program Info
State
Michigan. Combination
Program Name
Healthy Kids
MIChild
Type Of Program
Medicaid Expansion
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
no
Allowing Use of SCHIP Funds to Cover
Groups Not Eligible for this Program
no
no
Eligibility
Income
Income
Age
(%FPL)
Age
(%FPL)
Lower Upper Lower Upper Lower Upper Lower Upper
Youngest
16
18
100
150
0
1
185
200
Next Youngest
1
18
150
200
Older
Oldest
Basic Income Disregard
yes
yes
Asset Tests
no
no
Continuous Eligibility (months)
0
12
Presumptive Eligibility
no
yes
Prenatal Care for Unborn Children
NA
yesa
Enrollment Cap / Waiting List
no
no
Cost Sharing
Cost Sharing Required
NA
yes
Sliding Scale for Cost-Sharing
NA
no
Group Group Group Group Group Group Group Group
Sliding Scale Group Defined
1
2
3
4
1
2
3
4
150
Range (%FPL)
200
Premium or Enrollment Fee Required
monthly
Premium/Fee Per Child
$
5
Family Cap
$
5
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
0
Co-Payment For Generic Rx Drugs
$
0
Co-Payment For Office Visits
$
0
Co-Payment For Inpatient Services
$
0
Co-Payment For Emerg Use Of Emerg-Room
$
0
Co-Payment For Non-Emerg Use Of
Emerg-Room
$
0
Coverage Type/Option
Type
NA
Benchmark
Option
NA
State Employee
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out
(months)
0
6
Subsidy For Private/Employer Coverage
no
no
Min. Employer Premium Share Required for
Subsidy
NA
NA
a. MI offers prenatal care from conception through birth to pregnant women in families with income up to 185%
FPL.

---

CRS-53
Program Info
State
Minnesota. Medicaid Expansion Only
Program Name
Minnesota Medical Assistance Program
Type Of Program
Medicaid Expansion
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
yesa
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
2
275
280
Next Youngest
Older
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
0
Presumptive Eligibility
no
Prenatal Care for Unborn Children
NA
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
NA
Sliding Scale for Cost-Sharing
NA
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
Range (%FPL)
Premium or Enrollment Fee Required
Premium/Fee Per Child
Family Cap
Co-Payments
Co-Payment For Brand Name Rx Drugs
Co-Payment For Generic Rx Drugs
Co-Payment For Office Visits
Co-Payment For Inpatient Services
Co-Payment For Emerg Use Of Emerg-Room
Co-Payment For Non-Emerg Use Of Emerg-Room
Coverage Type/Option
Type
NA
Option
NA
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
0
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA
a. Minnesota’s Section 1115 waiver allows the state to use SCHIP funds to cover parents and relative
caretakers of Medicaid and SCHIP eligible children whose income level is between 100 to
200% FPL.

---

CRS-54
Program Info
State
Mississippi. Separate State Program Only
Program Name
Mississippi Health Benefits Program (II)
Type Of Program
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
no
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
1
185
200
Next Youngest
1
5
133
200
Older
6
18
100
200
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
12
Presumptive Eligibility
noa
Prenatal Care for Unborn Children
no
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
yes
Sliding Scale for Cost-Sharing
incomeb
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
100
150
175
Range (%FPL)
150
175
200
Premium or Enrollment Fee Required
no
Premium/Fee Per Child
Family Cap
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
0 $
0 $
0
Co-Payment For Generic Rx Drugs
$
0 $
0 $
0
Co-Payment For Office Visits
$
0 $
5 $
5
Co-Payment For Inpatient Services
$
0 $
0 $
0
Co-Payment For Emerg Use Of Emerg-Room
$
0 $
15 $
15
Co-Payment For Non-Emerg Use Of Emerg-Room
$
0 $
15 $
15
Coverage Type/Option
Type
Secretary Approved
Option
Benchmark Plus Additionalc
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
0
Subsidy For Private/Employer Coverage
nod
Min. Employer Premium Share Required for Subsidy
NAd
a. MS has CMS approval to use presumptive eligibility but has chosen not to implement it.
b. The difference in cost-sharing between Groups 2 and 3 is that the out-of-pocket maximum is $800 for Group
2 and $950 for Group 3.
c. State employee plan plus dental and vision benefits.
d. MS has CMS approval to subsidize ESI, but the program has not been implemented and is on hold
indefinitely.

---

CRS-55
Program Info
State
Missouri. Medicaid Expansion Only
Program Name
Managed Care Plus for Kids
Type Of Program
Medicaid Expansion
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
yesa
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
no
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
1
185
300
Next Youngest
1
5
133
300
Older
6
18
100
300
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
0
Presumptive Eligibility
yes
Prenatal Care for Unborn Children
NA
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
yesa
Sliding Scale for Cost-Sharing
incomeb
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
185
225
250
275
Range (%FPL)
225
250
275
300
Premium or Enrollment Fee Required
monthlyc
Premium/Fee Per Child
$
0 $
59 $
69 $
78
Family Cap
$
0 $
206 $
225 $
225
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
0 $
9 $
9 $
9
Co-Payment For Generic Rx Drugs
$
0 $
9 $
9 $
9
Co-Payment For Office Visits
$
5 $
10 $
10 $
10
Co-Payment For Inpatient Services
$
0 $
0 $
0 $
0
Co-Payment For Emerg Use Of Emerg-Room
$
0 $
0 $
0 $
0
Co-Payment For Non-Emerg Use Of Emerg-Room
$
0 $
0 $
0 $
0
Coverage Type/Option
Type
Comprehensive Medicaid Section 1115 waiver
Option
NA
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
6a
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA
a. MO uses SCHIP funds to expand its comprehensive Medicaid Section 1115 waiver, which, among other
things, allows a six month waiting period and cost sharing that exceeds Medicaid allowable amounts.
b. There is no cost-sharing for enrollees with family income between 100-185% FPL.
c. The per-child amount shown is cost of the first child; successive children are charged a lower premium.

---

CRS-56
Program Info
State
Montana. Separate State Program Only
Program Name
Montana CHIP
Type Of Program
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
no
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
5
133
150
Next Youngest
6
18
100
150
Older
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
12
Presumptive Eligibility
no
Prenatal Care for Unborn Children
no
Enrollment Cap / Waiting List
yes
Cost Sharing
Cost Sharing Required
yes
Sliding Scale for Cost-Sharing
no
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
100
Range (%FPL)
150
Premium or Enrollment Fee Required
no
Premium/Fee Per Child
Family Cap
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
5
Co-Payment For Generic Rx Drugs
$
3
Co-Payment For Office Visits
$
3
Co-Payment For Inpatient Services
$
25
Co-Payment For Emerg Use Of Emerg-Room
$
5
Co-Payment For Non-Emerg Use Of Emerg-Room
$
5
Coverage Type/Option
Type
Benchmark Equivalent
Option
State Employee
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
3
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA

---

CRS-57
Program Info
State
Nebraska. Medicaid Expansion Only
Program Name
Kids Connection
Type Of Program
Medicaid Expansion
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
no
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
1
150
185
Next Youngest
1
5
133
185
Older
6
18
100
185
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
6a
Presumptive Eligibility
yes
Prenatal Care for Unborn Children
NA
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
NA
Sliding Scale for Cost-Sharing
NA
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
Range (%FPL)
Premium or Enrollment Fee Required
Premium/Fee Per Child
Family Cap
Co-Payments
Co-Payment For Brand Name Rx Drugs
Co-Payment For Generic Rx Drugs
Co-Payment For Office Visits
Co-Payment For Inpatient Services
Co-Payment For Emerg Use Of Emerg-Room
Co-Payment For Non-Emerg Use Of Emerg-Room
Coverage Type/Option
Type
NA
Option
NA
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
0
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA
a. In NE, only the first six months of coverage are continuous.

---

CRS-58
Program Info
State
Nevada. Separate State Program Only
Program Name
Nevada Check Up
Type Of Program
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
no
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
5
133
200
Next Youngest
6
18
100
200
Older
Oldest
Basic Income Disregard
no
Asset Tests
no
Continuous Eligibility (months)
12
Presumptive Eligibility
no
Prenatal Care for Unborn Children
no
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
yes
Sliding Scale for Cost-Sharing
income
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
100
150
175
Range (%FPL)
150
175
200
Premium or Enrollment Fee Required
quarterly
Premium/Fee Per Child
$
10 $
25 $
50
Family Cap
$
10 $
25 $
50
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
0 $
0 $
0
Co-Payment For Generic Rx Drugs
$
0 $
0 $
0
Co-Payment For Office Visits
$
0 $
0 $
0
Co-Payment For Inpatient Services
$
0 $
0 $
0
Co-Payment For Emerg Use Of Emerg-Room
$
0 $
0 $
0
Co-Payment For Non-Emerg Use Of Emerg-Room
$
0 $
0 $
0
Coverage Type/Option
Type
Secretary Approved
Option
Same as Medicaid
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
6
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA

---

CRS-59
Program Info
State
New Hampshire. Combination
Program Name
Healthy Kids - Gold
Healthy Kids - Silver
Type Of Program
Medicaid Expansion
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
no
Allowing Use of SCHIP Funds to Cover
Groups Not Eligible for this Program
no
no
Eligibility
Income
Income
Age
(%FPL)
Age
(%FPL)
Lower Upper Lower Upper Lower Upper Lower Upper
Youngest
0
1
185
300
1
18
185
300
Next Youngest
Older
Oldest
Basic Income Disregard
yes
yes
Asset Tests
no
no
Continuous Eligibility (months)
0
0
Presumptive Eligibility
yes
no
Prenatal Care for Unborn Children
NA
no
Enrollment Cap / Waiting List
no
no
Cost Sharing
Cost Sharing Required
NA
yes
Sliding Scale for Cost-Sharing
NA
income
Group Group Group Group Group Group Group Group
Sliding Scale Group Defined
1
2
3
4
1
2
3
4
185
250
Range (%FPL)
250
300
Premium or Enrollment Fee Required
monthly
Premium/Fee Per Child
$
25 $
45
Family Cap
$ 100 $
135
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
10 $
10
Co-Payment For Generic Rx Drugs
$
5 $
5
Co-Payment For Office Visits
$
10 $
10
Co-Payment For Inpatient Services
$
0 $
0
Co-Payment For Emerg Use Of Emerg-Room
$
50 $
50
Co-Payment For Non-Emerg Use Of
Emerg-Room
$
50 $
50
Coverage Type/Option
Type
NA
Benchmark Equivalent
Option
NA
FEHBP
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out
(months)
0
6
Subsidy For Private/Employer Coverage
no
no
Min. Employer Premium Share Required for
Subsidy
NA
NA

---

CRS-60
Program Info
State
New Jersey. Combination
Program Name
NJ FamilyCare Plan A
NJ Family Care Plan B
NJ Family Care Plan C
NJ Family Care Plan D
Type Of Program
Medicaid Expansion
Separate State Program
Separate State Program
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
no
no
no
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
yesa
yesa
yesa
yesa
Eligibility
Age
Income (%FPL)
Age
Income (%FPL)
Age
Income (%FPL)
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Lower
Upper
Lower
Upper
Lower
Upper
Lower
Upper
Lower
Upper
Lower
Upper
Youngest
6
18
100
133
1
18
133
150
0
1
185
200
0
18
200
350
Next Youngest
1
18
150
200
Older
Oldest
Basic Income Disregard
yes
no
no
yesb
Asset Tests
no
no
no
no
Continuous Eligibility (months)
0
0
0
0
Presumptive Eligibility
yes
yes
yes
no
Prenatal Care for Unborn Children
NA
no
no
no
Enrollment Cap / Waiting List
no
no
no
no
Cost Sharing
Cost Sharing Required
NA
no
yes
yes
Sliding Scale for Cost-Sharing
NA
NA
no
income
Group
Group
Group
Group
Group
Group
Group
Group
Group
Group
Group
Group
Group
Group
Group
Group
Sliding Scale Group Defined
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
150
200
250
300
Range (%FPL)
200
250
300
350
Premium or Enrollment Fee Required
monthly
monthly
Premium/Fee Per Child
$
15
$
30 $
60 $
100
Family Cap
$
15
$
30 $
60 $
100

---

CRS-61
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
5
$
5 $
5 $
5
Co-Payment For Generic Rx Drugs
$
1
$
5 $
5 $
5
Co-Payment For Office Visits
$
5
$
5 $
5 $
5
Co-Payment For Inpatient Services
$
0
$
0 $
0 $
0
Co-Payment For Emerg Use Of Emerg-Room
$
10
$
35 $
35 $
35
Co-Payment For Non-Emerg Use Of Emerg-Room
$
10
$
35 $
35 $
35
Coverage Type/Option
Type
NA
Benchmark
Benchmark
Benchmark
Option
NA
FEHBP
FEHBP
Largest HMO
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
0
6
6
6
Subsidy For Private/Employer Coverage
no
yesc
yesc
yesc
Min. Employer Premium Share Required for Subsidy
NA
50%
50%
50%
a. New Jersey’s Section 1115 waiver allows the state to cover (1) parents of children eligible for the NJ KidCare program, including parents with income below 133% of the FPL in the Medicaid Expansion
program and parents between 134 and 200% FPL in the separate child health program, and (2) pregnant women between 185 and 200% FPL who are not eligible for Medicaid.
b. The state disregards all income between 200%-350% FPL to determine eligibility for Family Care Plan D.
c. Children whose parents have access to employer-sponsored insurance that is cost-effective and that meets the benefits qualifications must enroll in the employer plan for family coverage.

---

CRS-62
Program Info
State
New Mexico. Medicaid Expansion Only
Program Name
Salud! Medicaid
Type Of Program
Medicaid Expansion
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
yesa
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
yesb
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
18
185
235
Next Youngest
Older
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
12
Presumptive Eligibility
yes
Prenatal Care for Unborn Children
NA
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
yesa
Sliding Scale for Cost-Sharing
no
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
185
Range (%FPL)
235
Premium or Enrollment Fee Required
no
Premium/Fee Per Child
Family Cap
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
2
Co-Payment For Generic Rx Drugs
$
2
Co-Payment For Office Visits
$
5
Co-Payment For Inpatient Services
$
25
Co-Payment For Emerg Use Of Emerg-Room
$
15
Co-Payment For Non-Emerg Use Of Emerg-Room
$
15
Coverage Type/Option
Type
Comprehensive Medicaid Section 1115 waiver
Option
NA
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
0
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA
a. NM uses SCHIP funds to expand its comprehensive Medicaid Section 1115 waiver, which, among other
things, allows cost sharing that exceeds Medicaid allowable amounts.
b. New Mexico’s HIFA waiver allows the state to cover uninsured parents and childless adults with incomes up
to 200% FPL.

---

CRS-63
Program Info
State
New York. Combination
Child Health Plus A: Growing Up
Child Health Plus B: Growing Up
Program Name
Healthy
Healthy
Type Of Program
Medicaid Expansion
Separate State Program
State Has 1115 Waiver:
Waiving Provisions
Otherwise Affecting this
Program
noa
noa
Allowing Use of SCHIP
Funds to Cover Groups Not
Eligible for this Program
noa
noa
Eligibility
Age
Income (%FPL)
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Lower
Upper
Lower
Upper
Youngest
6
18
100
133
0
1
185
250
Next Youngest
1
18
133
250
Older
Oldest
Basic Income Disregard
yes
no
Asset Tests
no
no
Continuous Eligibility
(months)
12
0
Presumptive Eligibility
no
yes
Prenatal Care for Unborn
Children
NA
no
Enrollment Cap / Waiting
List
no
no
Cost Sharing
Cost Sharing Required
NA
yes
Sliding Scale for
Cost-Sharing
NA
income
Sliding Scale Group
Defined
Group 1 Group 2 Group 3 Group 4 Group 1 Group 2 Group 3 Group 4
133
160
223
Range (%FPL)
160
223
250
Premium or Enrollment
monthly
Fee Required
Premium/Fee Per Child
$
0 $
9 $
15
Family Cap
$
0 $
27 $
45
Co-Payments
Co-Payment For Brand
Name Rx Drugs
$
0 $
0 $
0
Co-Payment For Generic Rx
Drugs
$
0 $
0 $
0
Co-Payment For Office
Visits
$
0 $
0 $
0
Co-Payment For Inpatient
Services
$
0 $
0 $
0
Co-Payment For Emerg Use

Of Emerg-Room
$
0 $
0 $
0
Co-Payment For
Non-Emerg Use Of
Emerg-Room
$
0 $
0 $
0

---

CRS-64
Coverage Type/Option
Type
NA
Existing Comprehensive State-Based
Option
NA
NA
Relationship To
Private/Other Coverage
Waiting Period to Prevent
Crowd-Out (months)
0
0
Subsidy For
Private/Employer Coverage
no
no
Min. Employer Premium
Share Required for Subsidy
NA
NA
a. New York City had a Medicaid and SCHIP Disaster Relief waiver to address the effects of Sept. 11, 2001.
The waiver was effective Sept. 11, 2001 through Jan. 31, 2003.

---

CRS-65
Program Info
State
North Carolina. Separate State Program Only
Program Name
NC Health Choice for Children
Type Of Program
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
no
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
1
185
200
Next Youngest
1
5
133
200
Older
6
18
100
200
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
12
Presumptive Eligibility
no
Prenatal Care for Unborn Children
no
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
yes
Sliding Scale for Cost-Sharing
income
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
100
150
Range (%FPL)
150
200
Premium or Enrollment Fee Required
annually
Premium/Fee Per Child
$
0 $
50
Family Cap
$
0 $
100
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
0 $
6
Co-Payment For Generic Rx Drugs
$
0 $
6
Co-Payment For Office Visits
$
0 $
5
Co-Payment For Inpatient Services
$
0 $
0
Co-Payment For Emerg Use Of Emerg-Room
$
0 $
0
Co-Payment For Non-Emerg Use Of Emerg-Room
$
0 $
20
Coverage Type/Option
Type
Benchmark
Option
State Employee
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
0
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA

---

CRS-66
Program Info
State
North Dakota. Combination
Program Name
North Dakota Medicaid
Healthy Steps
Type Of Program
Medicaid Expansion
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
no
Allowing Use of SCHIP Funds to Cover Groups
Not Eligible for this Program
no
no
Eligibility
Income
Income
Age
(%FPL)a
Age
(%FPL)
Lower Upper Lower Upper Lower Upper Lower Upper
Youngest
0
5
1
133
0
5
133
140
Next Youngest
6
18
1
100
6
18
100
140
Older
Oldest
Basic Income Disregard
yes
yes
Asset Tests
noa
no
Continuous Eligibility (months)
0
12
Presumptive Eligibility
no
no
Prenatal Care for Unborn Children
NA
no
Enrollment Cap / Waiting List
no
no
Cost Sharing
Cost Sharing Required
NA
yes
Sliding Scale for Cost-Sharing
NA
no
Group Group Group Group Group Group Group Group
Sliding Scale Group Defined
1
2
3
4
1
2
3
4
100
Range (%FPL)
140
Premium or Enrollment Fee Required
no
Premium/Fee Per Child
Family Cap
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
2
Co-Payment For Generic Rx Drugs
$
2
Co-Payment For Office Visits
$
0
Co-Payment For Inpatient Services
$ 0b
Co-Payment For Emerg Use Of Emerg-Room
$
5
Co-Payment For Non-Emerg Use Of
Emerg-Room
$
5
Coverage Type/Option
Type
NA
Benchmark Equivalent
Option
NA
State Employee
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
0
6
Subsidy For Private/Employer Coverage
no
no
Min. Employer Premium Share Required for
Subsidy
NA
NA
a. The income thresholds shown are used for both Medicaid and SCHIP purposes. ND eliminated asset tests
from its Medicaid program in Jan. 2002. Title XIX financing is used for children who meet the income
thresholds shown and who have assets below the Title XIX asset test thresholds in place in 1997 (the

---

CRS-67
maintenance of effort point for SCHIP). Title XXI financing is used for children who meet the income
thresholds shown and who have assets exceeding the Title XIX asset test thresholds in place in 1997.
b. ND requires a $50 deductible for the first day of each inpatient hospital admission in a general hospital or a
psychiatric or substance abuse inpatient facility.

---

CRS-68
Program Info
State
Ohio. Medicaid Expansion Only
Program Name
Healthy Start
Type Of Program
Medicaid Expansion
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
yesa
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
no
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
5
133
200
Next Youngest
6
18
100
200
Older
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
0
Presumptive Eligibility
no
Prenatal Care for Unborn Children
NA
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
NA
Sliding Scale for Cost-Sharing
NA
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
Range (%FPL)
Premium or Enrollment Fee Required
Premium/Fee Per Child
Family Cap
Co-Payments
Co-Payment For Brand Name Rx Drugs
Co-Payment For Generic Rx Drugs
Co-Payment For Office Visits
Co-Payment For Inpatient Services
Co-Payment For Emerg Use Of Emerg-Room
Co-Payment For Non-Emerg Use Of Emerg-Room
Coverage Type/Option
Type
NA
Option
NA
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
0
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA
a. OH has received approval for a Section 1115 waiver allowing an annual enrollment fee and 12 months
continuous coverage for children in families with income between 151-200% FPL; however, the state has
chosen not to implement the waiver.

---

CRS-69
Program Info
State
Oklahoma. Medicaid Expansion Only
Program Name
SoonerCare
Type Of Program
Medicaid Expansion
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
no
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
1
150
185
Next Youngest
1
5
133
185
Older
6
17
100
185
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
0
Presumptive Eligibility
no
Prenatal Care for Unborn Children
NA
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
NA
Sliding Scale for Cost-Sharing
NA
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
Range (%FPL)
Premium or Enrollment Fee Required
Premium/Fee Per Child
Family Cap
Co-Payments
Co-Payment For Brand Name Rx Drugs
Co-Payment For Generic Rx Drugs
Co-Payment For Office Visits
Co-Payment For Inpatient Services
Co-Payment For Emerg Use Of Emerg-Room
Co-Payment For Non-Emerg Use Of Emerg-Room
Coverage Type/Option
Type
NA
Option
NA
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
0
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA

---

CRS-70
Program Info
State
Oregon. Separate State Program Only
Program Name
Oregon Children’s Health Insurance Program
Type Of Program
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
yesa
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
yesa
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
1
5
133
185
Next Youngest
6
18
100
185
Older
Oldest
Basic Income Disregard
no
Asset Tests
yes
Continuous Eligibility (months)
6
Presumptive Eligibility
no
Prenatal Care for Unborn Children
no
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
no
Sliding Scale for Cost-Sharing
NA
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
Range (%FPL)
Premium or Enrollment Fee Required
Premium/Fee Per Child
Family Cap
Co-Payments
Co-Payment For Brand Name Rx Drugs
Co-Payment For Generic Rx Drugs
Co-Payment For Office Visits
Co-Payment For Inpatient Services
Co-Payment For Emerg Use Of Emerg-Room
Co-Payment For Non-Emerg Use Of Emerg-Room
Coverage Type/Option
Type
Secretary Approved
Option
Comprehensive Medicaid Section 1115 Waiver
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
6
Subsidy For Private/Employer Coverage
yesa
Min. Employer Premium Share Required for Subsidy
50%
a. Oregon’s HIFA waiver allows the state to use Medicaid and SCHIP funds to cover pregnant women, children,
parents of Medicaid and SCHIP children, and childless adults. The waiver also expands the state’s
premium assistance program to provide a subsidy for ESI that can (1) offer a reduced benefits package
(however, the state must ensure that all age-appropriate immunizations are covered), and 2) impose
cost-sharing that exceeds the aggregate, annual 5% of family income limitation in the SCHIP statute. The
terms and conditions of the waiver proscribe that enrollment in ESI is voluntary and that the state must
inform enrollees of the implications of choosing private or employer-sponsored insurance.

---

CRS-71
Program Info
State
Pennsylvania. Separate State Program Only
Program Name
Pennsylvania CHIP
Type Of Program
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
no
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
1
185
200
Next Youngest
1
5
133
200
Older
6
18
100
200
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
12
Presumptive Eligibility
no
Prenatal Care for Unborn Children
no
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
no
Sliding Scale for Cost-Sharing
NA
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
Range (%FPL)
Premium or Enrollment Fee Required
Premium/Fee Per Child
Family Cap
Co-Payments
Co-Payment For Brand Name Rx Drugs
Co-Payment For Generic Rx Drugs
Co-Payment For Office Visits
Co-Payment For Inpatient Services
Co-Payment For Emerg Use Of Emerg-Room
Co-Payment For Non-Emerg Use Of Emerg-Room
Coverage Type/Option
Type
Existing Comprehensive State-Based
Option
NA
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
0
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA

---

CRS-72
Program Info
State
Rhode Island. Combination
Program Name
RIte Care
RIte Care
Type Of Program
Medicaid Expansion
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting
this Program
yesa
no
Allowing Use of SCHIP Funds to Cover
Groups Not Eligible for this Program
yesb
yesb
Eligibility
Income
Income
Age
(%FPL)
Age
(%FPL)
Lower Upper
Lower Upper Lower Upper Lower Upper
Youngest
8
18
100
250
c
c
c
c
Next Youngest
Older
Oldest
Basic Income Disregard
yes
yes
Asset Tests
no
no
Continuous Eligibility (months)
0
12
Presumptive Eligibility
no
no
Prenatal Care for Unborn Children
NA
yesc
Enrollment Cap / Waiting List
no
no
Cost Sharing
Cost Sharing Required
yes
yes
Sliding Scale for Cost-Sharing
income
income
Group Group
Group Group Group Group Group Group
Sliding Scale Group Defined
1
2
3
4
1
2
3
4
100
150
185
200
100
150
185
200
Range (%FPL)
150
185
200
250
150
185
200
250
Premium or Enrollment Fee Required
monthly
monthly
Premium/Fee Per Child
$
0 $
61 $
77 $
92 $
0 $
61 $
77 $
92
Family Cap
$
0 $
61 $
77 $
92 $
0 $
61 $
77 $
92
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
0 $
0 $
0 $
0 $
0 $
0 $
0 $
0
Co-Payment For Generic Rx Drugs
$
0 $
0 $
0 $
0 $
0 $
0 $
0 $
0
Co-Paym
ent
For Off
ice Visits
$
0 $
0 $
0 $
0 $
0 $
0 $
0 $
0
Co-Payment For Inpatient Services
$
0 $
0 $
0 $
0 $
0 $
0 $
0 $
0
Co-Payment For Emerg Use Of
Emerg-Room
$
0 $
0 $
0 $
0 $
0 $
0 $
0 $
0
Co-Payment For Non-Emerg Use Of
Emerg-Room
$
0 $
0 $
0 $
0 $
0 $
0 $
0 $
0
Coverage Type/Option
Comprehensive Medicaid
Type
Section 1115 Waiver
Secretary Approved
Comprehensive Medicaid
Option
NA
Section 1115 Waiver
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out
(months)
0
0
Subsidy For Private/Employer Coverage
yesd
no
Min. Employer Premium Share Required
for Subsidy
0%
NA

---

CRS-73
a. RI uses SCHIP funds to expand its comprehensive Medicaid Section 1115 waiver. Cost-sharing is permitted
under this waiver.
b. This waiver allows the state to use SCHIP funds to cover parents of Medicaid or SCHIP-eligible children with
income between 100 and 185% FPL, and pregnant women with income between 185-250% FPL.
c. The SSP’s sole purpose is to provide prenatal care to unborn children with income up to 250% FPL.
d. Enrollment in RIte Share, the state’s premium assistance program, is mandatory for Medicaid-eligible
individuals whose employers offered an approved health plan.

---

CRS-74
Program Info
State
South Carolina. Medicaid Expansion Only
Program Name
Partners for Healthy Children
Type Of Program
Medicaid Expansion
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
no
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
1
5
133
150
Next Youngest
6
18
100
150
Older
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
12
Presumptive Eligibility
no
Prenatal Care for Unborn Children
NA
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
NA
Sliding Scale for Cost-Sharing
NA
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
Range (%FPL)
Premium or Enrollment Fee Required
Premium/Fee Per Child
Family Cap
Co-Payments
Co-Payment For Brand Name Rx Drugs
Co-Payment For Generic Rx Drugs
Co-Payment For Office Visits
Co-Payment For Inpatient Services
Co-Payment For Emerg Use Of Emerg-Room
Co-Payment For Non-Emerg Use Of Emerg-Room
Coverage Type/Option
Type
NA
Option
NA
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
0
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA

---

CRS-75
Program Info
State
South Dakota. Combination
Program Name
South Dakota CHIP
CHIP-NM
Type Of Program
Medicaid Expansion
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting
this Program
no
no
Allowing Use of SCHIP Funds to Cover
Groups Not Eligible for this Program
no
no
Eligibility
Age
Income (%FPL)
Age
Income (%FPL)
Lower Upper Lower Upper Lower Upper Lower Upper
Youngest
0
5
133
140
0
18
140
200
Next Youngest
6
18
100
140
Older
Oldest
Basic Income Disregard
yes
yes
Asset Tests
no
no
Continuous Eligibility (months)
0
0
Presumptive Eligibility
no
no
Prenatal Care for Unborn Children
NA
no
Enrollment Cap / Waiting List
no
no
Cost Sharing
Cost Sharing Required
NA
no
Sliding Scale for Cost-Sharing
NA
NA
Group Group Group Group Group Group Group Group
Sliding Scale Group Defined
1
2
3
4
1
2
3
4
Range (%FPL)
Premium or Enrollment Fee Required
Premium/Fee Per Child
Family Cap
Co-Payments
Co-Payment For Brand Name Rx Drugs
Co-Payment For Generic Rx Drugs
Co-Payment For Office Visits
Co-Payment For Inpatient Services
Co-Payment For Emerg Use Of
Emerg-Room
Co-Payment For Non-Emerg Use Of
Emerg-Room
Coverage Type/Option
Type
NA
Secretary Approved
Option
NA
Same as Medicaid
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out
(months)
0
3
Subsidy For Private/Employer Coverage
no
no
Min. Employer Premium Share Required
for Subsidy
NA
NA

---

CRS-76
Program Info
State
Tennessee. Medicaid Expansion Only
Program Name
TennCare for Children
Type Of Program
Medicaid Expansion
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
yesa
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
no
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
b
b
b
b
Next Youngest
Older
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
0
Presumptive Eligibility
no
Prenatal Care for Unborn Children
NA
Enrollment Cap / Waiting List
noa
Cost Sharing
Cost Sharing Required
NAa
Sliding Scale for Cost-Sharing
NA
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
Range (%FPL)
Premium or Enrollment Fee Required
Premium/Fee Per Child
Family Cap
Co-Payments
Co-Payment For Brand Name Rx Drugs
Co-Payment For Generic Rx Drugs
Co-Payment For Office Visits
Co-Payment For Inpatient Services
Co-Payment For Emerg Use Of Emerg-Room
Co-Payment For Non-Emerg Use Of Emerg-Room
Coverage Type/Option
Type
Comprehensive Medicaid Section 1115 waiver
Option
NA
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
0
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA
a. TN had used SCHIP funds to expand its comprehensive Medicaid Section 1115 waiver. Among other things,
the waiver gives the state authority to cap enrollment for certain expansion eligibles.
b. TN had used SCHIP solely to cover older children in families with income up to 100% FPL. Since all such
children must be covered by Medicaid as of Oct. 1, 2002, TN has no SCHIP enrollment.

---

CRS-77
Program Info
State
Texas. Separate State Program Only
Program Name
CHIP (Phase II)
Type Of Program
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
no
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
1
185
200
Next Youngest
1
5
133
200
Older
6
18
100
200
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
12
Presumptive Eligibility
no
Prenatal Care for Unborn Children
no
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
yes
Sliding Scale for Cost-Sharing
income
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
100
150
185
Range (%FPL)
150
185
200
Premium or Enrollment Fee Required
monthlya
Premium/Fee Per Child
a $
15 $
18
Family Cap
a $
15 $
18
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
5 $
20 $
20
Co-Payment For Generic Rx Drugs
$
0 $
5 $
5
Co-Payment For Office Visits
$
2 $
5 $
10
Co-Payment For Inpatient Services
$
25 $
50 $
100
Co-Payment For Emerg Use Of Emerg-Room
$
5 $
50 $
50
Co-Payment For Non-Emerg Use Of Emerg-Room
$
5 $
50 $
50
Coverage Type/Option
Type
Benchmark Equivalent
Option
State Employee
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
3
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA
a. Children in families with income between 100-150% FPL pay a $15 annual enrollment fee.

---

CRS-78
Program Info
State
Utah. Separate State Program Only
Program Name
Utah CHIP
Type Of Program
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
no
Program
Allowing Use of SCHIP Funds to Cover Groups Not
no
Eligible for this Program
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
5
133
200
Next Youngest
6
18
100
200
Older
Oldest
Basic Income Disregard
no
Asset Tests
no
Continuous Eligibility (months)
12
Presumptive Eligibility
no
Prenatal Care for Unborn Children
no
Enrollment Cap / Waiting List
yesa
Cost Sharing
Cost Sharing Required
yes
Sliding Scale for Cost-Sharing
income
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
100
150
Range (%FPL)
150
200
Premium or Enrollment Fee Required
quarterly
Premium/Fee Per Child
$
13 $
25
Family Cap
$
13 $
25
Co-Payments
Co-Payment For Brand Name Rx Drugs
$ 2b
$ 5b
Co-Payment For Generic Rx Drugs
$ 2b
$ 5b
Co-Payment For Office Visits
$
5 $
15
10% of
Co-Payment For Inpatient Services
$
5 allowed amtc
Co-Payment For Emerg Use Of Emerg-Room
$
5 $
35
Co-Payment For Non-Emerg Use Of Emerg-Room
$
10 $
35
Coverage Type/Option
Type
Benchmark Equivalent
Option
State Employee
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
3
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA
a. A cap of 24,000 was imposed by an amendment approved by CMS in June 2002.
b. Amounts shown are for drugs on the state’s preferred drug list. Co-payments are higher for drugs not on this
list: $5 for children with income between 100-150% FPL and 50% of the cost of the drug for children with
income between 150-200% FPL.
c. The allowed amount is the billed charges less 25%.

---

CRS-79
Program Info
State
Vermont. Separate State Program Only
Program Name
Dr. Dynasaur
Type Of Program
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
no
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
17
225
300
Next Youngest
Older
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
12a
Presumptive Eligibility
no
Prenatal Care for Unborn Children
no
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
yes
Sliding Scale for Cost-Sharing
no
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
225
Range (%FPL)
300
Premium or Enrollment Fee Required
monthlyb
Premium/Fee Per Child
$
50
Family Cap
$
50
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
0
Co-Payment For Generic Rx Drugs
$
0
Co-Payment For Office Visits
$
0
Co-Payment For Inpatient Services
$
0
Co-Payment For Emerg Use Of Emerg-Room
$
0
Co-Payment For Non-Emerg Use Of Emerg-Room
$
0
Coverage Type/Option
Type
Secretary Approved
Option
Same as Medicaid
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
1
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA
a. However, a parent’s enrollment in one of Vermont’s state-only funded health programs for adults might result
in a shorter period of continuous eligibility, due to the other programs’ more frequent eligibility
redetermination for parents.
b. The monthly program fee is billed quarterly.

---

CRS-80
Program Info
State
Virginia. Combination
Family Access to Medical
Family Access to Medical
Insurance Security Plan
Insurance Security Plan
Program Name
(FAMIS) Plus
(FAMIS)
Type Of Program
Medicaid Expansion
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
no
Allowing Use of SCHIP Funds to Cover
Groups Not Eligible for this Program
no
no
Eligibility
Income
Income
Age
(%FPL)
Age
(%FPL)
Lower Upper Lower Upper Lower Upper Lower Upper
Youngest
6
18
100
133
0
18
133
200
Next Youngest
Older
Oldest
Basic Income Disregard
yes
no
Asset Tests
no
no
Continuous Eligibility (months)
0
0
Presumptive Eligibility
no
no
Prenatal Care for Unborn Children
NA
no
Enrollment Cap / Waiting List
no
no
Cost Sharing
Cost Sharing Required
NA
yes
Sliding Scale for Cost-Sharing
NA
income
Group Group Group Group Group Group Group Group
Sliding Scale Group Defined
1
2
3
4
1
2
3
4
100
150
Range (%FPL)
150
200
Premium or Enrollment Fee Required
no
Premium/Fee Per Child
Family Cap
Co-Paymentsa
Co-Payment For Brand Name Rx Drugs
$2
$5
Co-Payment For Generic Rx Drugs
$2
$5
Co-Payment For Office Visits
$2
$5
Co-Payment For Inpatient Services
$15
$25
Co-Payment For Emerg Use Of
Emerg-Room
$0
$0
Co-Payment For Non-Emerg Use Of
Emerg-Room
$10
$25
Coverage Type/Option
Type
NA
Secretary Approved
NA
State Employee and Same as
Option
Medicaida
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out
(months)
0
6
Subsidy For Private/Employer Coverage
yesb
yesc
Min. Employer Premium Share Required for
Subsidy
0%
40%

---

CRS-81
a. Children enrolled in a Managed Care Entity (MCE) receive coverage based upon the state employee health
plan. Children in geographic areas without such an MCE obtain services through a Primary Care Case
Management (PCCM) program that provides benefits similar to Medicaid, until such an MCE is available.
Co-payments apply only to MCE children.
b. FAMIS Plus Children whose parents have access to employer-sponsored insurance with dependent coverage
must apply for such coverage.
c. FAMIS Children whose parents have access to employer-sponsored insurance that is cost-effective and that
meets the benefits qualifications have the option of receiving the subsidy for employer-sponsored coverage
or enrolling in the state’s plan. No co-pays apply to such children.

---

CRS-82
Program Info
State
Washington. Separate State Program Only
Program Name
Washington State CHIP
Type Of Program
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
no
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
18
200
250
Next Youngest
Older
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
12
Presumptive Eligibility
no
Prenatal Care for Unborn Children
no
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
yes
Sliding Scale for Cost-Sharing
no
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
200
Range (%FPL)
250
Premium or Enrollment Fee Required
monthly
Premium/Fee Per Child
$
10
Family Cap
$
30
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
0
Co-Payment For Generic Rx Drugs
$
0
Co-Payment For Office Visits
$
0
Co-Payment For Inpatient Services
$
0
Co-Payment For Emerg Use Of Emerg-Room
$
0
Co-Payment For Non-Emerg Use Of Emerg-Room
$
0
Coverage Type/Option
Type
Secretary Approved
Option
Same as Medicaid
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
4
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA

---

CRS-83
Program Info
State
West Virginia. Separate State Program Only
Program Name
West Virginia CHIP (Phase III)
Type Of Program
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
no
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
1
150
200
Next Youngest
1
5
133
200
Older
6
18
100
200
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
12
Presumptive Eligibility
no
Prenatal Care for Unborn Children
no
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
yes
Sliding Scale for Cost-Sharing
income
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
100
150
Range (%FPL)
150
200
Premium or Enrollment Fee Required
no
Premium/Fee Per Child
Family Cap
Co-Payments
Co-Payment For Brand Name Rx Drugsa
$5/$5
$10/$15
Co-Payment For Generic Rx Drugs
$
0 $
0
Co-Payment For Office Visits
$
0 $
15
Co-Payment For Inpatient Services
$
0 $
25
Co-Payment For Emerg Use Of Emerg-Room
$
0 $
35
Co-Payment For Non-Emerg Use Of Emerg-Room
$
0 $
35
Coverage Type/Option
Type
Benchmark Equivalent
Option
State Employee
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
6
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA
a. Amounts shown are for brand-name drugs that are/are not on the state’s prescription drug formulary.

---

CRS-84
Program Info
State
Wisconsin. Medicaid Expansion Only
Program Name
BadgerCare
Type Of Program
Medicaid Expansion
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
yesa
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
yesb
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
6
18
100
185
Next Youngest
Older
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
0
Presumptive Eligibility
no
Prenatal Care for Unborn Children
NA
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
yes
Sliding Scale for Cost-Sharing
income
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
100
150
Range (%FPL)
150
185
Premium or Enrollment Fee Required
monthly
Premium/Fee Per Child
$
0 3% of family
incomec
Family Cap
$
0
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
0 $
0
Co-Payment For Generic Rx Drugs
$
0 $
0
Co-Payment For Office Visits
$
0 $
0
Co-Payment For Inpatient Services
$
0 $
0
Co-Payment For Emerg Use Of Emerg-Room
$
0 $
0
Co-Payment For Non-Emerg Use Of Emerg-Room
$
0 $
0
Coverage Type/Option
Type
Comprehensive Medicaid Section 1115 waiver
Option
NA
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
3
Subsidy For Private/Employer Coverage
yesd
Min. Employer Premium Share Required for Subsidy
40%d
a. WI uses SCHIP funds to expand its comprehensive Medicaid Section 1115 waiver under which cost-sharing
is permitted.
b. The SCHIP waiver covers parents of SCHIP and Medicaid children with income between 100-185% FPL.
c. Premiums are paid on behalf of the family. The lowest possible premium is $30 per family per month.
d. Children whose parents have access to employer-sponsored insurance that is cost-effective and that meets the
benefits qualifications must enroll in the employer plan for family coverage. To qualify, the employer
must pay at least 40%, but less than 80%, of a family premium.

---

CRS-85
Program Info
State
Wyoming. Separate State Program Only
Program Name
Kid Care CHIP
Type Of Program
Separate State Program
State Has 1115 Waiver:
Waiving Provisions Otherwise Affecting this
Program
no
Allowing Use of SCHIP Funds to Cover Groups Not
Eligible for this Program
no
Eligibility
Age
Income (%FPL)
Lower
Upper
Lower
Upper
Youngest
0
5
133
185
Next Youngest
6
18
100
185
Older
Oldest
Basic Income Disregard
yes
Asset Tests
no
Continuous Eligibility (months)
12
Presumptive Eligibility
no
Prenatal Care for Unborn Children
no
Enrollment Cap / Waiting List
no
Cost Sharing
Cost Sharing Required
yes
Sliding Scale for Cost-Sharing
no
Sliding Scale Group Defined
Group 1
Group 2
Group 3
Group 4
100
Range (%FPL)
185
Premium or Enrollment Fee Required
no
Premium/Fee Per Child
Family Cap
Co-Payments
Co-Payment For Brand Name Rx Drugs
$
5
Co-Payment For Generic Rx Drugs
$
3
Co-Payment For Office Visits
$
5
Co-Payment For Inpatient Services
$
0
Co-Payment For Emerg Use Of Emerg-Room
$
5
Co-Payment For Non-Emerg Use Of Emerg-Room
$
5
Coverage Type/Option
Type
Secretary Approved
Option
Other
Relationship To Private/Other Coverage
Waiting Period to Prevent Crowd-Out (months)
(months)
1
Subsidy For Private/Employer Coverage
no
Min. Employer Premium Share Required for Subsidy
NA

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