A State-by-State Compilation of Key State Children's Health Insurance Program (SCHIP) Characteristics

May 19, 2004 RL32389

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.

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 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. 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 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 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. 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. CRS-3 Table 1. General Eligibility Criteria for States, as of December 31, 2002 through July 31, 2003 Upper income level < 200% FPL Upper income level = 200% FPL Upper income level 201-250% FPL Upper income level 251-300% FPL Upper income level > 300% FPL Lowest upper income level Highest upper income levelb Basic income disregard Asset tests Presumptive eligibility Continuous eligibility (ranges from one to 12 months) Enrollment cap or waiting list Prenatal coverage of unborn children Number of Medicaid expansions (33 in 33 states) 17 11 2 3 0 100% 300% 32 1 7 Number of separate state programs (44 in 36 states) Number of states 8 12 25 26 6 6 4 6 1 1 140% 100% 350% 350% 32 46a 1 2 5 9a 13 0 32 5 36a 3 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. 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. 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 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. Secretaryapproved 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 Benchmark: 12 FEHBP: 2 State Employee: 6 Largest HMO: 4 Benchmark equivalent: 11 Secretary approved: 18 FEHBP: 2 State employee: 8 Largest HMO: 0 Equivalent to all three: 1 Benchmark plus additional: 4 Comprehensive Medicaid Section 1115 waiver: 3 Same as Medicaid: 9 State employee: 1 Other: 1 Existing comprehensive state based: 3 Florida New York Pennsylvania 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 servicespecific 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 9 Ohio has not implemented its Section 1115 waiver. 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 programsa Sliding scale 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 b Flat scale programs are those for which cost-sharing does not vary across income or age groups. 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 nonemergency 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 programsa Number of High programs Lowc Premium/enrollment fees No premium or enrollment fee Monthly premiums required Quarterly enrollment fee required Annual enrollment fee required Co-payments Brand name Rx drugs Generic Rx drugs Office visits Inpatient services Emergency room Non-emergency use of ER 26 sliding scale programsb Number of programs Lowc High Total programs 4 — — 4 — — 8 10 $5 $50 16 $4 $135 26 0 — — 2 $10 $50 2 0 — — 4 $35 $150 4 7 7 6 1 6 $2 $1 $2 $25 $2 $5 $3 $5 $25 $10 13 12 12 5 9 $1 $1 $2 $5 $3 $20 $6 $15 $100 $50 20 19 18 6 15 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 employersponsored insurance (ESI) but cannot afford their share of the premium.11 Under separate state programs, states that provide premium assistance for employersponsored 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 lowincome 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 lowincome 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 CRSsponsored 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 MXP State only AL AK X 200 X AZ AR Waiver to Waiver Upper cover groups affecting income not other SSP Comthreshold otherwise SCHIP Only bination (% FPL) eligible provisions X X CA X no no Basic income disregard Asset tests yes no Continuous Presumpeligibility tive (months) eligibility 12 no Prenatal care for unborn children Enrollment cap or waiting list no no Type Option Largest Benchmark HMO NA NA Secretary Same as Approved Medicaid Comprehensive Medicaid NA Section 1115 Waiver 200 no no yes no 6 no NA no 200 yes no no no 12 no no no 200 no yes yes no 12 no NA no 250 yes no yes no 12 MXP: yes SSP: no MXP: NA SSP: no no Benchmark X 185 yes no yes no 12 no no no Benchmark Equivalent CT X 300 no no yes no 0 no no no Benchmark 200 no no yes no no Benchmark 200 no no yes no MXP: 0 SSP: 12 0 no 200 no no yes no 12 or 6 no MXP: NA SSP: no yes 235 no no yes no 12 no no no NA Existing state-based NA; and Same as Secretary Medicaid Approved BenchSecretary mark plus Approved additional DC X X FL GA X X no no MXP: NA SSP: no NA 3 no NA a no NA 3 no NA 6 no NA no NA no NA no NA no NA no NA 0 no NA 3 no NA MXP: 0 State SSP: 3 Employee or 0 FEHBP, State Employee 3 and Largest HMO State 2 Employee State MXP:0 Employee SSP: 6 NA 0 CO DE Waiting Min. period employer to Subsidy premium prevent for private share crowdor required out employer for subsidy (mos.) coverage (%) CRS-17 MXP State only Waiver to Waiver Upper cover groups affecting income not other SSP Comthreshold otherwise SCHIP Only bination (% FPL) eligible provisions Basic income disregard Asset tests Continuous Presumpeligibility tive (months) eligibility Prenatal care for unborn children Enrollment cap or waiting list HI X 200 no yes yes no 0 no NA no ID X 150 no no MXP: no SSP: yes yes yes 12 no no yes no 12 no NA MXP: NA SSP: yes MXP: NA SSP: no MXP: NA SSP: no IL X 185 yes IN X 200 no no yes no IA X 200 no no yes no 200 no no yes no 12 no no no 200 no no yes no 0 no MXP: NA SSP: no no 200 no no yes MXP: yes SSP:no no 12 no no 12 no KS X KY LA X X MXP: 0 SSP: 12 MXP: 0 SSP: 12 no no NA MXP: NA SSP: no MXP: NA SSP: no ME X 200 no no MD X 300 no MXP: yes SSP: no yes no MXP: 6 SSP: 12 no MA X 200 no no no no 0 MXP: yes SSP: yes/no MXP: NA SSP: no MI X 200 no no yes no 280 yes no yes no MXP: 0 SSP: 12 0 MXP: no SSP: yes no MXP: NA SSP: yes NA MN X no no no no no no no no no Waiting Min. period employer to Subsidy premium prevent for private share crowdor required out employer for subsidy (mos.) coverage (%) Type Option Comprehensive Medicaid NA 0 no Section 1115 Waiver NA NA 0 no Benchmark State MXP: no 0 Equivalent Employee SSP: yes Benchmark MXP: 0 FEHBP no Equivalent SSP: 3 Benchmark State MXP: 0 no Equivalent Employee SSP: 6 BenchSecretary mark plus 0 no Approved additional BenchSecretary MXP: 0 mark plus no Approved SSP: 6 additional NA NA 0 no Secretary Same as MXP: 0 no Approved Medicaid SSP: 3 Secretary Same as MXP: 6 MXP: no Approved Medicaidc SSP: 6 SSP: yes Largest HMO, CompreMXP: no Bnchmark; hensive SSP: Secretary 0 Medicaid yes/no Approved Section 1115 Waiver State MXP: 0 Benchmark no Employee SSP: 6 NA NA 0 no NA NA b NA NA NA NA NA NA 30% 50% NA NA CRS-18 MXP State only MS MO X X MT NE Waiver to Waiver Upper cover groups affecting income not other SSP Comthreshold otherwise SCHIP Only bination (% FPL) eligible provisions X X NV X Basic income disregard Asset tests Continuous Presumpeligibility tive (months) eligibility Prenatal care for unborn children Enrollment cap or waiting list 200 no no yes no 12 nod no no 300 no yes yes no 0 yes NA no 150 no no yes no 12 no no yes 185 no no yes no 6 yes NA no 200 no no no no 12 no no no NH X 300 no no yes no 0 MXP: yes SSP: no MXP: NA SSP: no no NJ X 350 yes no MXP: yes SSP: yes/no no 0 MXP: yes SSP: yes/no MXP: NA SSP: no no 235 yes yes yes no 12 yes NA no 250 noe noe MXP: yes SSP: no no MXP: 12 SSP: 0 MXP: no SSP: yes MXP: NA SSP: no no 200 no no yes no 12 no no no 140 no no yes no 200 185 no no yesf no yes yes no no NM X NY X NC X ND OH OK X X X MXP: 0 SSP: 12 0 0 no no no MXP: NA SSP: no NA NA no no no Type Option BenchSecretary mark plus Approved additional Comprehensive Medicaid NA Section 1115 Waiver Benchmark State Equivalent Employee NA NA Secretary Same as Approved Medicaid Benchmark FEHBP Equivalent FEHBP and Benchmark Largest HMO Comprehensive Medicaid NA Section 1115 Waiver Existing CompreNA hensive state-based State Benchmark Employee Benchmark State Equivalent Employee NA NA NA NA Waiting Min. period employer to Subsidy premium prevent for private share crowdor required out employer for subsidy (mos.) coverage (%) 0 nod NAd 6 no NA 3 no NA 0 no NA 6 no NA MXP: 0 SSP: 6 no NA MXP: 0 SSP: 6 MXP: no SSP: yes 50% 0 no NA 0 no NA 0 no NA no NA no no NA NA MXP: 0 SSP: 6 0 0 CRS-19 MXP State only OR Waiver to Waiver Upper cover groups affecting income not other SSP Comthreshold otherwise SCHIP Only bination (% FPL) eligible provisions X PA X RI SC 200 X X SD TN 185 X X yes no yes no Basic income disregard Asset tests no yes yes no Continuous Presumpeligibility tive (months) eligibility 6 12 no no Prenatal care for unborn children Enrollment cap or waiting list no no no MXP: NA SSP: yes no 250 yes MXP: yes SSP: no yes no MXP: 0 SSP: 12 no 150 no no yes no 12 no 200 no no yes no 0 no g no yes yes no 0 no NA nog NA MXP: NA SSP: no no no no TX X 200 no no yes no 12 no no no UT X 200 no no no no 12 no no yes VT X 300 no no yes no 12 no no no Type Secretary Approved Existing Comprehensive state-based Comprehensive Medicaid Section 1115 Waiver; Secretary approved NA Secretary Approved Comprehensive Medicaid Section 1115 Waiver Benchmark Equivalent Benchmark Equivalent Secretary Approved Option Comprehensive Medicaid Section 1115 Waiver Waiting Min. period employer to Subsidy premium prevent for private share crowdor required out employer for subsidy (mos.) coverage (%) 6 yes 50% NA 0 no NA Comprehensive Medicaid Section 1115 Waiver 0 MXP: yes SSP: no b no NA no NA 0 no NA 3 no NA 3 no NA 1 no NA NA 0 Same as MXP: 0 Medicaid SSP: 3 NA State Employee State Employee Same as Medicaid CRS-20 MXP State only Waiver to Waiver Upper cover groups affecting income not other SSP Comthreshold otherwise SCHIP Only bination (% FPL) eligible provisions VA X Basic income disregard Asset tests Continuous Presumpeligibility tive (months) eligibility Prenatal care for unborn children Enrollment cap or waiting list 200 no no MXP: yes SSP: no no 0 no MXP: NA SSP: no no WA X 250 no no yes no 12 no no no WV X 200 no no yes no 12 no no no 185 yes yes yes no 0 no NA no 185 no no yes no 12 no no no 140 - 350 10 11 46 2 36 9 3 3 WI X WY Total count of states X 15 18 18 Type Secretary Approved Secretary Approved Benchmark Equivalent Comprehensive Medicaid Section 1115 Waiver Secretary Approved Waiting Min. period employer to Subsidy premium prevent for private share crowdor required out employer for subsidy (mos.) coverage (%) Option State Employee MXP: 0 and Same SSP: 6 as Medicaid Same as 4 Medicaid State 6 Employee yes MXP: NA SSP: 40% no NA no NA NA 3 yes 40% Other 1 no NA 30 8 0-50 see Table 3 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 State MXP only AL AK Combination X X AZ ARb SSP only X X CAc X Cost sharing required (yes/no) Sliding scale for cost sharing (based on income or age) yes income annually 0-50 yesa age no yes income yes Co-pays for inpatient services ($) Co-pays for emergency use of emergency room ($) Co-pays for non-emergency use of emergency room ($) 0-5 0-5 0-5 0-5 0-2 0-3 0-50 — 0-5% of charge — — — — — 5 — 5 5 10 20% of first hospital day 10 10 4-9 8-27 5 5 5 — 5 5 Co-pays for brand name Rx drugs ($) Co-pays for generic Rx drugs ($) Co-pays for office visits ($) 0-150 0-3 0-1 — — 0-2 monthly 0-15 0-20 no no — yes income d Premium or enrollment Premium or fee Family cap fee required per child ($) ($) CO X yes income annually 0-25 0-35 1-5 1-3 2-5 — 3-15 3-15 CT X yes income monthly 0-30 0-50 6 3 5 — — 25 yes income monthly 10-25 10-25 — — — — — 10 ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ yes no monthly 15 15 0-3 0-3 0-3 — — 0-10 yes age monthly 0-7.50 0-15 — — — — — — DE DC X X FLc X GA X HI X ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ID X ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ X yes no monthly 0-15 0-30 2-5 2-3 2-5 — 2-no info 2-25 X yes income monthly 11-16.50 16.5024.75 10 3 — — — — X yes income monthly 0-10 0-20 — — — — — 0-25 yes income monthly 10-15 10-15 — — — — — — yesa age no — — 0-1 0-1 — — — — ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ yes income monthly 5-20 10-40 — — — — — — ILc IN IA KS X KY LA ME X X X CRS-22 Combination Cost sharing required (yes/no) Sliding scale for cost sharing (based on income or age) MD X yes income monthly 40-50 MAc X yes income monthly MI X yes no ^ State MN MXP only X MS MOb X X MT NE SSP only X X NV X Co-pays for inpatient services ($) Co-pays for emergency use of emergency room ($) Co-pays for non-emergency use of emergency room ($) — — — — — — — — — — — — — — — ^ ^ ^ ^ ^ ^ ^ — — — — 0-5 — 0-15 0-15 monthly 0-78 0-225 0-9 0-9 5-10 — — — no no — — 5 3 3 25 5 5 ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ yes income quarterly 10-50 10-50 — — — — — — Co-pays for brand name Rx drugs ($) Co-pays for generic Rx drugs ($) Co-pays for office visits ($) 40-50 — — 12-35 15-36 — monthly 5 5 ^ ^ ^ yes income no yes income yes Premium or enrollment Premium or fee Family cap fee required per child ($) ($) NH X yes income monthly 25-45 100-135 10 5 10 — 50 50 NJc X yes income monthly 0-100 0-100 0-5 0-5 0-5 — 0-35 0-35 yes no no — — 2 2 5 25 15 15 yes income monthly 0-15 0-45 — — — — — — yes income annually 0-50 0-100 0-6 0-6 0-5 — — 0-20 yes no no — — 2 2 — — 5 5 NMb X NY X NC X ND X OHb X e ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ OK X ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ OR X no — — — — — — — — — — PA X no — — — — — — — — — — yes income monthly 0-92 0-92 — — — — — — ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ no — — — — — — — — — — RIb SC SD X X X CRS-23 State TN MXP only Cost sharing required (yes/no) Sliding scale for cost sharing (based on income or age) ^ ^ ^ ^ X yes income monthlyf X yes income X yes SSP only Combination X TX UT VT VA X Co-pays for inpatient services ($) Co-pays for emergency use of emergency room ($) Co-pays for non-emergency use of emergency room ($) ^ ^ ^ ^ 0-5 2-10 25-100 5-50 5-50 2-5 2-5 5-15 5 or10% of allowed amt 5-35 10-35 50 — — — — — — — — 2-5 2-5 2-5 15-25 — 10-25 Co-pays for brand name Rx drugs ($) Co-pays for generic Rx drugs ($) Co-pays for office visits ($) ^ ^ ^ 15-18 15-18 5-20 quarterly 13-25 13-25 no monthly 50 yes income no Premium or enrollment Premium or fee Family cap fee required per child ($) ($) WA X yes no monthly 10 30 — — — — — — WV X yes income no — — 5-15 — 0-15 0-25 0-35 0-35 yes income monthly 0 or 3% of income 0 or 3% of income — — — — — — yes no no — — 5 3 5 — 5 5 38 25 income 3 age 22 monthly 2 quarterly 3 annually 2 mixed 28 28 22 21 20 9 15 23 WIb X WY Total count of states X 15 18 18 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Alabama. Separate State Program Only CHIP Phase II- ALL Kids Separate State Program no no Age Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Lower 0 6 Upper 5 18 Income (% FPL) Lower Upper 133 200 100 200 yes no 12 no no no yes income Group 1 Group 2 Group 3 100 150 150 200 annually $ 0 $ 50 $ 0 $ 150 $ $ $ $ $ $ 0 0 0 0 0 0 $ $ $ $ $ $ 3 1 5 5 5 5 Benchmark Largest HMO 3 no NA Group 4 CRS-25 Program Info State Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Alaska. Medicaid Expansion Only Denali KidCare Medicaid Expansion no no Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Upper 0 6 5 18 Income (%FPL) Lower Upper 133 200 100 200 yes no 6 no NA no yesa agea Group 1 Group 2 Group 3 0 18 17 18 no $ $ $ $ $ 0 0 0 0 0 $ 0 $ $ $ $ Group 4 2 2 3 $50b 0 5% of charge NA NA c no 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Arizona. Separate State Program Only KidsCare Separate State Program no yesa Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Income (%FPL) Lower Upper 140 200 133 200 100 200 Upper 0 1 6 1 5 18 no no 12 no no no $ $ 0 0 yes income Group 2 Group 3 150 175 175 200 monthly $ 10 $ 15 $ 15 $ 20 $ $ $ $ $ $ 0 0 0 0 0 5 $ $ $ $ $ $ Group 1 100 150 0 0 0 0 0 5 $ $ $ $ $ $ Group 4 0 0 0 0 0 5 Secretary Approved Same as Medicaid 3 no 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Arkansas. Medicaid Expansion Only ARKids B Medicaid Expansion yesa no Age Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined Lower 0 Income (%FPL) Lower Upper 150 200 Upper 18 yes no 12 no NA no Group 1 yes no 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy no $ 5 $ 5 $ 10 20% of 1st hospital day $ 10 $ 10 Comprehensive Medicaid Section 1115 waiver NA 6 no 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined MediCal Medicaid Expansion California. Combination Access for Infants and Mothersb Separate State Program Healthy Families Program Separate State Program no no no yesc yesc yesc Age Income (%FPL) Age Income (%FPL) Age Income (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper Lower Upper Lower Upper 1 5 1a 133a 0 1 200 250 0 1 200 250 a 6 18 1 100a 1 5 133 250 6 18 100 250 yes no 12 yes NA no Group 1 NA NA Group Group Group 2 3 4 yes no 12 no no no Group 1 yes yes Group Group Group 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 yes no 12 no no no $ $ 4 8 yes incomee Group Group Group 2 3 4 150 100 150 200 150 200 e monthly $ 6$ 7$ 9 $ 18 $ 14 $ 27 $ $ $ $ $ $ 5 5 5 0 5 5 $ $ $ $ $ $ Group 1 100 150 monthly or annuallyd 2% of family income 5 5 5 0 5 5 $ $ $ $ $ $ 5 5 5 0 5 5 $ $ $ $ $ $ 5 5 5 0 5 5 CRS-29 Coverage Type/Option Type Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy NA NA Benchmark State Employee Benchmark State Employee 0 no 0 no 3 no 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Colorado. Separate State Program Only Child Health Plan Plus Separate State Program no yesa Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Upper 0 6 5 18 Income (%FPL) Lower Upper 133 185 100 185 yes no 12 no no no $ $ 0 0 yes income Group 2 Group 3 150 185 annually $ 25 $ 35 $ $ $ $ $ $ 1 1 2 0 3 3 $ $ $ $ $ $ Group 1 100 150 Group 4 5 3 5 0 15 15 Benchmark Equivalent FEHBP, State Employee, and Largest HMO 3 no 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Connecticut. Separate State Program Only HUSKY Plans B and Ca Separate State Program no no Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Upper 18 0 Income (%FPL) Lower Upper 185 300 yes no 0 no no no Group 1 185 235 $ $ 0 0 $ $ $ $ $ $ 6 3 5 0 0 25 yes income Group 2 Group 3 235 300 monthly $ 30 $ 50 $ $ $ $ $ $ Group 4 6 3 5 0 0 25 Benchmark State Employee 2 no 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Delaware. Combination Delaware Healthy Children Medicaid Program Medicaid Expansion Separate State Program no no no no Income Income Age (%FPL) Age (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper 0 1 185 200 1 5 100 200 6 18 100 200 yes no 0 no NA no yes no 12 no no no NA yes NA income Group Group Group Group Group Group Group Group 1 2 3 4 1 2 3 4 100 133 166 133 166 200 monthly $ 10 $ 15 $ 25 $ 10 $ 15 $ 25 $ $ $ $ 0 0 0 0 $ $ $ $ $ $ 0 0 0 0 $ $ $ $ 0 0 0 0 0$ 0$ 0 10 $ 10 $ 10 NA NA Benchmark State Employee 0 no 6 no NA NA CRS-33 Program Info State Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility District of Columbia. Medicaid Expansion Only DC Healthy Families Medicaid Expansion no no Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined Upper 0 1 6 1 5 18 Income (%FPL) Lower Upper 185 200 133 200 100 200 yes no 0 no NA no Group 1 Group 2 NA NA Group 3 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy NA NA 0 no NA Group 4 CRS-34 Program Info State Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Medicaid Medicaid Expansion Range (%FPL) Premium or Enrollment Fee Required Premium/Fee Per Child Family Cap Co-Payments Healthy Kids Separate State Program no no no no no no no no 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 0 1 185 200 1 4 133 200 1 5 133 200 5 5 133 200 6 18 100 200 6 18 100 200 Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined Florida. Combination MediKids Florida CMS Networka Separate State Program Separate State Program Group 1 yes no under age 5: 12 age 5 and up: 6 no NA no yes no yes no yes no 6 no no yesb 12 no no yesb 6 no no yesb NA NA Group Group 2 3 yes no Group Group 2 3 yes no Group Group 2 3 yes no Group Group 2 3 Group 4 Group 1 133 200 Group 4 Group 1 100 200 monthly $ $ 15 15 Group 4 Group 1 100 200 monthly $ $ 15 15 monthly $ $ 15 15 Group 4 CRS-35 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy $ $ $ $ $ $ 3 3 3 0 0 10 NA NA Secretary Approved Same as Medicaid Secretary Approved Same as Medicaid Existing Comprehensive State-Based 0 no NA 0 no NA 0 no NA 0 no 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Georgia. Separate State Program Only PeachCare for Kids Separate State Program no no Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy a. GA bases its sliding scale on age rather than income. b. Largest HMO plus additional benefits. 0 1 6 Income (%FPL) Upper Lower Upper 1 185 235 5 133 235 18 100 235 yes no 12 no no no Group 1a 0 5 $ $ 0 0 yes age Group 2a Group 3 6 18 monthly $ 7.50 $ 15 Group 4 Secretary Approved Benchmark Plus Additionalb 3 no NA CRS-37 Program Info State Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Hawaii. Medicaid Expansion Only QUEST and Medicaid FFS Medicaid Expansion yesa no Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined Income (%FPL) Lower Upper 185 200 133 200 100 200 Upper 0 1 6 1 5 18 yes no 0 no NA no Group 1 Group 2 NA NA 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Comprehensive Medicaid Section 1115 waiver NA 0 no 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Idaho. Medicaid Expansion Only Idaho CHIP Medicaid Expansion no no Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined Upper 0 6 5 18 yes yes 12 no NA no NA NA Group 1 Group 2 Group 3 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Income (%FPL) Lower Upper 133 150 100 150 NA NA 0 no NA Group 4 CRS-39 Program Info State Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility KidCare Assist Expansion Medicaid Expansion Illinois. Combination KidCare Share Separate State Program KidCare Premium Separate State Program no yesa yesa yesa yesa yesa Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined Upper 6 Group 1 18 Group 2 Income (%FPL) Lower Upper 100 133 Age Lower 0 18 Age Lower 0 Upper 18 yes no 12 no NA no yes no 12 no yesb no yes no 12 no yesb no NA NA yes no yes no Group 3 Group 4 Group 1 Group 2 133 150 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 Income (%FPL) Lower Upper 133 150 Upper Group 3 no $ $ 2 2 Group 4 Income (%FPL) Lower Upper 150 185 Group 1 Group 2 Group 3 150 185 monthly $ 15 $ 30 $ $ 5 3 Group 4 CRS-40 Co-Payment For Office Visits Co-Payment For Inpatient Services $ $ 2 0 Co-Payment For Emerg Use Of Emerg-Room Co-Payment For Non-Emerg Use Of Emerg-Room Coverage Type/Option Type Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy $ $ 2 2 $ $ 5 0 missing info $ 25 NA NA Benchmark Equivalent State Employee Benchmark Equivalent State Employee 0 no NA 0 yesa 0 yesa 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Indiana. Combination Hoosier Healthwise Phase I Hoosier Healthwise Phase II Medicaid Expansion Separate State Program no no no no Income Age (%FPL) Age Income (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper 1 5 133 150 0 18 150 200 6 18 100 150 yes no 0 no NA no yes no 12 no no no NA yes NA income Group Group Group Group Group Group Group Group 1 2 3 4 1 2 3 4 150 175 175 200 monthly $ 11 $16.50 $ 16.50 $24.75 $ $ $ $ 10 3 0 0 $ $ $ $ 10 3 0 0 $ 0 $ 0 $ 0 $ 0 NA NA Benchmark Equivalent FEHBP 0 no 3 no NA NA CRS-42 Program Info State Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Iowa. Combination Healthy Well Kids Iowa Medicaid (HAWK-I) Medicaid Expansion Separate State Program no no no no Income Income Age (%FPL) Age (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper 0 1 185 200 1 18 133 200 6 18 100 133 yes no 0 no NA no yes no 12 no no no NA yes NA income Group Group Group Group Group Group Group Group 1 2 3 4 1 2 3 4 133 150 150 200 monthly $ 0 $ 10 $ 0 $ 20 $ $ $ $ 0 0 0 0 $ $ $ $ 0 0 0 0 $ 0$ 0 $ 0$ 25 NA NA Benchmark Equivalent State Employee 0 no 6 no NA NA CRS-43 Program Info State Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Kansas. Separate State Program Only Health Wave Separate State Program no no Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy a. State employee plan plus dental and mental health. Upper 0 1 6 1 5 18 Income (%FPL) Lower Upper 150 200 133 200 100 200 yes no 12 no no no yes income Group 1 Group 2 Group 3 150 175 175 200 monthly $ 10 $ 15 $ 10 $ 15 $ $ $ $ $ $ 0 0 0 0 0 0 $ $ $ $ $ $ 0 0 0 0 0 0 Secretary Approved Benchmark Plus Additionala 0 no NA Group 4 CRS-44 Program Info State Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Kentucky. Combination KCHIP Separate Insurance KCHIP Medicaid Expansion Program Medicaid Expansion Separate State Program no no no no Income Income Age (%FPL) Age (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper 1 5 133 150 0 1 185 200 6 18 100 150 1 18 150 200 yes no 0a no NA no yes no 0 no no no $ $ 0 0 yesb yesb b age ageb Group Group Group Group Group Group Group 2 3 4 1 2 3 4 18 0 18 18 17 18 no no $ 0 $ 0$ 0 $ 0 $ 0$ 0 $ $ $ $ $ 0 0 0 0 0 $ $ $ $ $ 1 1 0 0 0 $ $ $ $ $ 0 0 0 0 0 $ $ $ $ $ 1 1 0 0 0 $ 0$ 0 $ 0$ 0 Group 1 0 17 NA NA Secretary Approved Benchmark Plus Additionalc 0 no 6 no 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Louisiana. Medicaid Expansion Only LaCHIP Medicaid Expansion no no Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined Upper 0 6 5 18 yes no 12 no NA no NA NA Group 1 Group 2 Group 3 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Income (%FPL) Lower Upper 133 200 100 200 NA NA 0 no NA Group 4 CRS-47 Program Info State Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Maine. Combination MaineCare MaineCare Medicaid Expansion Separate State Program no no no no Income Income Age (%FPL) Age (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper 1 5 133 150 0 1 185 200 6 18 125 150 1 18 150 200 yes no 12 no NA no no no 12 no no no NA yes NA income Group Group Group Group Group Group Group Group 1 2 3 4 1 2 3 4 150 160 170 185 160 170 185 200 monthly $ 5 $ 10 $ 15 $ 20 $ 10 $ 20 $ 30 $ 40 $ $ $ $ $ 0 0 0 0 0 $ $ $ $ $ $ 0$ 0 0 0 0 0 $ $ $ $ $ 0$ 0 0 0 0 0 $ $ $ $ $ 0 0 0 0 0 0$ 0 NA NA Secretary Approved Same as Medicaid 0 no 3 no NA NA CRS-48 Program Info State Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Maryland. Combination Maryland Children’s Health Maryland Children’s Health Program (I) Program (II) Medicaid Expansion Separate State Program yesa no no no Income Age (%FPL) Age Income (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper 0 1 185 200 0 18 200 300 1 5 133 200 6 18 100 200 yes no 6 no NA no yes no 12 no no no NA yes NA income Group Group Group Group Group Group Group Group 1 2 3 4 1 2 3 4 200 250 250 300 monthly $ 40 $ 50 $ 40 $ 50 $ $ $ $ $ 0 0 0 0 0 $ $ $ $ $ 0 0 0 0 0 $ 0$ 0 NA NA Secretary Approved Same as Medicaid 6a no 6 yesb 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined Range (%FPL) Premium or Enrollment Fee Required Premium/Fee Per Child Family Cap MassHealth Standard Medicaid Expansion Massachusetts. Combination MassHealth Family Assist Direct Coverage (DC) MassHealth Premium Assistance MassHealth CommonHealtha Separate State Program Separate State Program Separate State Program no no no no no no no no Income Age (%FPL) Age Lower Upper Lower Upper Lower Upper 0 1 185 200 1 18 1 5 133 150 6 14 115 150 15 18 100 150 no no 0 yes NA no Income (%FPL) Age Income (%FPL) Age Income (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper Lower Upper 150 200 1 18 150 200 1 18 150 200 no no 0 no no no no no 0 yes no no no no 0 no no no NA yes yes yes NA income no no Group Group Group Group Group Group Group Group Group Group Group Group Group Group Group Group Group 1 2 3 4 1 2 3 4 5 1 2 3 4 1 2 3 4 150 160 170 180 190 150 150 160 170 180 190 200 200 200 monthly monthly monthly $ 15 $ 20 $ 25 $ 30 $ 35 $ 12 $ 12 $ 15 $ 20 $ 25 $ 30 $ 35 $ 36 $ 36 CRS-51 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy $ $ $ $ $ $ 0 0 0 0 0 0 $ $ $ $ $ $ 0 0 0 0 0 0 $ $ $ $ $ $ 0 0 0 0 0 0 $ $ $ $ $ $ 0 0 0 0 0 0 $ $ $ $ $ $ 0 0 0 0 0 0 $ $ $ $ $ $ b 0 0 0 0 0 0 b b b b b NA Benchmark Benchmark NA Largest HMO Largest HMO Secretary Approved Comprehensive Medicaid Section 1115 Waiver 0 no NA 0 noc NA 0 noc NA 0 yesc 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Michigan. Combination Healthy Kids MIChild Medicaid Expansion Separate State Program no no no no Income Income Age (%FPL) Age (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper 16 18 100 150 0 1 185 200 1 18 150 200 yes no 0 no NA no yes no 12 yes yesa no NA yes NA no Group Group Group Group Group Group Group Group 1 2 3 4 1 2 3 4 150 200 monthly $ 5 $ 5 $ $ $ $ $ 0 0 0 0 0 $ 0 NA NA Benchmark State Employee 0 no 6 no 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Minnesota. Medicaid Expansion Only Minnesota Medical Assistance Program Medicaid Expansion no yesa Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined Upper 0 2 Income (%FPL) Lower Upper 275 280 yes no 0 no NA no NA NA 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy NA NA 0 no 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Mississippi. Separate State Program Only Mississippi Health Benefits Program (II) Separate State Program no no Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 0 1 6 1 5 18 yes no 12 noa no no yes incomeb Group 2 Group 3 150 175 175 200 no Group 1 100 150 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Income (%FPL) Lower Upper 185 200 133 200 100 200 Upper $ $ $ $ $ $ 0 0 0 0 0 0 $ $ $ $ $ $ 0 0 5 0 15 15 $ $ $ $ $ $ Group 4 0 0 5 0 15 15 Secretary Approved Benchmark Plus Additionalc 0 nod 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Missouri. Medicaid Expansion Only Managed Care Plus for Kids Medicaid Expansion yesa no Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Income (%FPL) Lower Upper 185 300 133 300 100 300 Upper 0 1 6 1 5 18 yes no 0 yes NA no yesa incomeb Group 1 Group 2 Group 3 Group 4 185 225 250 275 225 250 275 300 monthlyc $ 0$ 59 $ 69 $ 78 $ 0$ 206 $ 225 $ 225 $ $ $ $ $ $ 0 0 5 0 0 0 $ $ $ $ $ $ 9 9 10 0 0 0 $ $ $ $ $ $ 9 9 10 0 0 0 $ $ $ $ $ $ 9 9 10 0 0 0 Comprehensive Medicaid Section 1115 waiver NA 6a no 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Montana. Separate State Program Only Montana CHIP Separate State Program no no Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 0 6 5 18 Income (%FPL) Lower Upper 133 150 100 150 yes no 12 no no yes yes no Group 1 100 150 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Upper Group 2 Group 3 no $ $ $ $ $ $ 5 3 3 25 5 5 Benchmark Equivalent State Employee 3 no NA Group 4 CRS-57 Program Info State Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Nebraska. Medicaid Expansion Only Kids Connection Medicaid Expansion no no Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined Upper 0 1 6 1 5 18 Income (%FPL) Lower Upper 150 185 133 185 100 185 yes no 6a yes NA no NA NA Group 1 Group 2 Group 3 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy a. In NE, only the first six months of coverage are continuous. NA NA 0 no NA Group 4 CRS-58 Program Info State Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Nevada. Separate State Program Only Nevada Check Up Separate State Program no no Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Income (%FPL) Lower Upper 133 200 100 200 Upper 0 6 5 18 no no 12 no no no yes income Group 1 Group 2 Group 3 100 150 175 150 175 200 quarterly $ 10 $ 25 $ 50 $ 10 $ 25 $ 50 $ $ $ $ $ $ 0 0 0 0 0 0 $ $ $ $ $ $ 0 0 0 0 0 0 $ $ $ $ $ $ Secretary Approved Same as Medicaid 6 no NA 0 0 0 0 0 0 Group 4 CRS-59 Program Info State Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy New Hampshire. Combination Healthy Kids - Gold Healthy Kids - Silver Medicaid Expansion Separate State Program no no no no Income Income Age (%FPL) Age (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper 0 1 185 300 1 18 185 300 yes no 0 yes NA no yes no 0 no no no NA yes NA income Group Group Group Group Group Group Group Group 1 2 3 4 1 2 3 4 185 250 250 300 monthly $ 25 $ 45 $ 100 $ 135 $ $ $ $ $ 10 5 10 0 50 $ $ $ $ $ 10 5 10 0 50 $ 50 $ 50 NA NA Benchmark Equivalent FEHBP 0 no 6 no NA NA CRS-60 Program Info State Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined Range (%FPL) Premium or Enrollment Fee Required Premium/Fee Per Child Family Cap NJ FamilyCare Plan A Medicaid Expansion New Jersey. Combination NJ Family Care Plan B NJ Family Care Plan C Separate State Program Separate State Program NJ Family Care Plan D Separate State Program no no no no yesa yesa yesa yesa 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 6 18 100 133 1 18 133 150 0 1 185 200 0 18 200 350 1 18 150 200 Group 1 yes no 0 yes NA no no no 0 yes no no no no 0 yes no no NA NA Group Group 2 3 no NA Group Group 2 3 yes no Group Group 2 3 Group 4 Group 1 Group 4 Group 1 150 200 yesb no 0 no no no Group 4 Group 1 200 250 monthly $ $ 15 15 $ $ 30 30 yes income Group Group Group 2 3 4 250 300 300 350 monthly $ 60 $ 100 $ 60 $ 100 CRS-61 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy $ $ $ $ $ $ 5 1 5 0 10 10 $ $ $ $ $ $ 5 5 5 0 35 35 $ $ $ $ $ $ 5 5 5 0 35 35 $ $ $ $ $ $ 5 5 5 0 35 35 NA NA Benchmark FEHBP Benchmark FEHBP Benchmark Largest HMO 0 no NA 6 yesc 50% 6 yesc 50% 6 yesc 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility New Mexico. Medicaid Expansion Only Salud! Medicaid Medicaid Expansion yesa yesb Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 0 18 Income (%FPL) Lower Upper 185 235 yes no 12 yes NA no yesa no Group 1 185 235 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Upper Group 2 Group 3 Group 4 no $ $ $ $ $ $ 2 2 5 25 15 15 Comprehensive Medicaid Section 1115 waiver NA 0 no 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 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 New York. Combination Child Health Plus A: Growing Up Child Health Plus B: Growing Up Healthy Healthy Medicaid Expansion Separate State Program noa noa noa noa Age Income (%FPL) Age Income (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper 6 18 100 133 0 1 185 250 1 18 133 250 yes no no no 12 no 0 yes NA no no no NA yes NA income Group 1 Group 2 Group 3 Group 4 Group 1 Group 2 Group 3 Group 4 133 160 223 160 223 250 monthly $ $ 0$ 0$ 9$ 27 $ 15 45 $ 0$ 0$ 0 $ 0$ 0$ 0 $ 0$ 0$ 0 $ 0$ 0$ 0 $ 0$ 0$ 0 $ 0$ 0$ 0 CRS-64 Coverage Type/Option Type Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy NA NA Existing Comprehensive State-Based NA 0 0 no no 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility North Carolina. Separate State Program Only NC Health Choice for Children Separate State Program no no Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Upper 0 1 6 1 5 18 Income (%FPL) Lower Upper 185 200 133 200 100 200 yes no 12 no no no yes income Group 1 Group 2 Group 3 100 150 150 200 annually $ 0$ 50 $ 0$ 100 $ $ $ $ $ $ 0 0 0 0 0 0 $ $ $ $ $ $ 6 6 5 0 0 20 Benchmark State Employee 0 no NA Group 4 CRS-66 Program Info State Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy North Dakota. Combination North Dakota Medicaid Healthy Steps Medicaid Expansion Separate State Program no no no no Income Income Age (%FPL) Age (%FPL)a Lower Upper Lower Upper Lower Upper Lower Upper 0 5 1 133 0 5 133 140 6 18 1 100 6 18 100 140 yes noa 0 no NA no yes no 12 no no no NA yes NA no Group Group Group Group Group Group Group Group 1 2 3 4 1 2 3 4 100 140 no $ $ $ $ $ 2 2 0 0b 5 $ 5 NA NA Benchmark Equivalent State Employee 0 no 6 no 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Ohio. Medicaid Expansion Only Healthy Start Medicaid Expansion yesa no Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined Upper 0 6 5 18 Income (%FPL) Lower Upper 133 200 100 200 yes no 0 no NA no NA NA 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy NA NA 0 no 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Oklahoma. Medicaid Expansion Only SoonerCare Medicaid Expansion no no Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined Upper 0 1 6 1 5 17 yes no 0 no NA no NA NA Group 1 Group 2 Group 3 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Income (%FPL) Lower Upper 150 185 133 185 100 185 NA NA 0 no NA Group 4 CRS-70 Program Info State Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Oregon. Separate State Program Only Oregon Children’s Health Insurance Program Separate State Program yesa yesa Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined Upper 1 6 5 18 Income (%FPL) Lower Upper 133 185 100 185 no yes 6 no no no no NA 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Secretary Approved Comprehensive Medicaid Section 1115 Waiver 6 yesa 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Pennsylvania. Separate State Program Only Pennsylvania CHIP Separate State Program no no Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined Upper 0 1 6 1 5 18 Income (%FPL) Lower Upper 185 200 133 200 100 200 yes no 12 no no no no NA 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Existing Comprehensive State-Based NA 0 no NA CRS-72 Program Info State Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Rhode Island. Combination RIte Care RIte Care Medicaid Expansion Separate State Program yesa no yesb yesb Income Income Age (%FPL) Age (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper c c c c 8 18 100 250 yes no 0 no NA no yes no 12 no yesc no $ $ 0 0 yes yes income income Group Group Group Group Group Group Group 2 3 4 1 2 3 4 150 185 200 100 150 185 200 185 200 250 150 185 200 250 monthly monthly $ 61 $ 77 $ 92 $ 0$ 61 $ 77 $ 92 $ 61 $ 77 $ 92 $ 0$ 61 $ 77 $ 92 $ $ $ $ 0 0 0 0 $ $ $ $ $ 0$ 0$ 0$ 0 $ 0$ $ 0$ 0$ 0$ 0 $ 0$ Group 1 100 150 0 0 0 0 $ $ $ $ 0 0 0 0 $ $ $ $ Comprehensive Medicaid Section 1115 Waiver 0 0 0 0 $ $ $ $ 0 0 0 0 $ $ $ $ 0 0 0 0 $ $ $ $ 0 0 0 0 $ $ $ $ 0 0 0 0 0$ 0$ 0 0$ 0$ 0 NA Secretary Approved Comprehensive Medicaid Section 1115 Waiver 0 yesd 0 no 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility South Carolina. Medicaid Expansion Only Partners for Healthy Children Medicaid Expansion no no Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined Upper 1 6 5 18 yes no 12 no NA no NA NA Group 1 Group 2 Group 3 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Income (%FPL) Lower Upper 133 150 100 150 NA NA 0 no NA Group 4 CRS-75 Program Info State Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined South Dakota. Combination South Dakota CHIP CHIP-NM Medicaid Expansion Separate State Program no no no no Age Income (%FPL) Age Income (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper 0 5 133 140 0 18 140 200 6 18 100 140 yes no 0 no NA no yes no 0 no no no NA no NA NA Group Group Group Group Group Group Group Group 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy NA NA Secretary Approved Same as Medicaid 0 no 3 no NA NA CRS-76 Program Info State Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Tennessee. Medicaid Expansion Only TennCare for Children Medicaid Expansion yesa no Age Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined Lower Upper b b Income (%FPL) Lower Upper b b Group 3 Group 4 yes no 0 no NA noa NAa NA Group 1 Group 2 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Comprehensive Medicaid Section 1115 waiver NA 0 no 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Texas. Separate State Program Only CHIP (Phase II) Separate State Program no no Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 0 1 6 1 5 18 yes no 12 no no no yes income Group 1 Group 2 Group 3 100 150 185 150 185 200 monthlya a $ 15 $ 18 a $ 15 $ 18 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Income (%FPL) Lower Upper 185 200 133 200 100 200 Upper $ $ $ $ $ $ 5 0 2 25 5 5 $ $ $ $ $ $ 20 5 5 50 50 50 $ $ $ $ $ $ 20 5 10 100 50 50 Benchmark Equivalent State Employee 3 no NA a. Children in families with income between 100-150% FPL pay a $15 annual enrollment fee. Group 4 CRS-78 Program Info State Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Utah. Separate State Program Only Utah CHIP Separate State Program no no Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 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 Upper 0 6 5 18 Income (%FPL) Lower Upper 133 200 100 200 no no 12 no no yesa yes income Group 1 Group 2 Group 3 100 150 150 200 quarterly $ 13 $ 25 $ 13 $ 25 $ $ $ 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy 2b 2b 5$ Group 4 5b 5b 15 10% of 5 allowed amtc 5$ 35 10 $ 35 $ $ Benchmark Equivalent State Employee 3 no 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Vermont. Separate State Program Only Dr. Dynasaur Separate State Program no no Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 0 17 Income (%FPL) Lower Upper 225 300 yes no 12a no no no yes no Group 1 225 300 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Upper Group 2 Group 3 Group 4 monthlyb $ $ 50 50 $ $ $ $ $ $ 0 0 0 0 0 0 Secretary Approved Same as Medicaid 1 no 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined Range (%FPL) Premium or Enrollment Fee Required Premium/Fee Per Child Family Cap Co-Paymentsa 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Virginia. Combination Family Access to Medical Family Access to Medical Insurance Security Plan Insurance Security Plan (FAMIS) Plus (FAMIS) Medicaid Expansion Separate State Program no no no no Income Income Age (%FPL) Age (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper 6 18 100 133 0 18 133 200 yes no 0 no NA no no no 0 no no no NA yes NA income Group Group Group Group Group Group Group Group 1 2 3 4 1 2 3 4 100 150 150 200 no $2 $2 $2 $15 $5 $5 $5 $25 $0 $0 $10 $25 NA NA Secretary Approved State Employee and Same as Medicaida 0 yesb 6 yesc 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Washington. Separate State Program Only Washington State CHIP Separate State Program no no Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 0 18 Income (%FPL) Lower Upper 200 250 yes no 12 no no no yes no Group 1 200 250 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Upper Group 2 Group 3 monthly $ $ 10 30 $ $ $ $ $ $ 0 0 0 0 0 0 Secretary Approved Same as Medicaid 4 no NA Group 4 CRS-83 Program Info State Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility West Virginia. Separate State Program Only West Virginia CHIP (Phase III) Separate State Program no no Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 0 1 6 1 5 18 Income (%FPL) Lower Upper 150 200 133 200 100 200 yes no 12 no no no Group 1 100 150 Range (%FPL) Premium or Enrollment Fee Required Premium/Fee Per Child Family Cap Co-Payments Co-Payment For Brand Name Rx Drugsa 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Upper $5/$5 $ $ $ $ $ 0 0 0 0 0 yes income Group 2 Group 3 150 200 no $10/$15 $ $ $ $ $ Group 4 0 15 25 35 35 Benchmark Equivalent State Employee 6 no 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Wisconsin. Medicaid Expansion Only BadgerCare Medicaid Expansion yesa yesb Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 6 18 Income (%FPL) Lower Upper 100 185 yes no 0 no NA no yes income Group 2 Group 3 150 185 monthly Group 1 100 150 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Upper $ $ 0 3% of family incomec 0 $ $ $ $ $ $ 0 0 0 0 0 0 $ $ $ $ $ $ Group 4 0 0 0 0 0 0 Comprehensive Medicaid Section 1115 waiver NA 3 yesd 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 Program Name Type Of Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program Eligibility Wyoming. Separate State Program Only Kid Care CHIP Separate State Program no no Age Lower Youngest Next Youngest Older Oldest Basic Income Disregard Asset Tests Continuous Eligibility (months) Presumptive Eligibility Prenatal Care for Unborn Children Enrollment Cap / Waiting List Cost Sharing Cost Sharing Required Sliding Scale for Cost-Sharing Sliding Scale Group Defined 0 6 5 18 Income (%FPL) Lower Upper 133 185 100 185 yes no 12 no no no yes no Group 1 100 185 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 Option Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) (months) Subsidy For Private/Employer Coverage Min. Employer Premium Share Required for Subsidy Upper Group 2 Group 3 no $ $ $ $ $ $ 5 3 5 0 5 5 Secretary Approved Other 1 no NA Group 4 EveryCRSReport.com The Congressional Research Service (CRS) is a federal legislative branch agency, housed inside the Library of Congress, charged with providing the United States Congress non-partisan advice on issues that may come before Congress. EveryCRSReport.com republishes CRS reports that are available to all Congressional staff. The reports are not classified, and Members of Congress routinely make individual reports available to the public. Prior to our republication, we redacted names, phone numbers and email addresses of analysts who produced the reports. We also added this page to the report. We have not intentionally made any other changes to any report published on EveryCRSReport.com. CRS reports, as a work of the United States government, are not subject to copyright protection in the United States. 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