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
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