For other versions of this document, see http://wikileaks.org/wiki/CRS-RL32389 ------------------------------------------------------------------------------ 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 Elicia J. Herz Specialist in Social Legislation Domestic Social Policy Division Evelyne Baumrucker Analyst in Social Legislation Domestic Social Policy Division Peter Kraut 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 Number of Number of Medicaid separate state expansions (33 in programs (44 33 states) in 36 states) Number of states Upper income level < 200% FPL 17 8 12 Upper income level = 200% FPL 11 25 26 Upper income level 201-250% FPL 2 6 6 Upper income level 251-300% FPL 3 4 6 Upper income level > 300% FPL 0 1 1 Lowest upper income level 100% 140% 100% Highest upper income levelb 300% 350% 350% Basic income disregard 32 32 46a Asset tests 1 1 2 Presumptive eligibility 7 5 9a Continuous eligibility (ranges from one to 12 months) 13 32 36a Enrollment cap or waiting list 0 5 3 Prenatal coverage of unborn children 0 4 3 Sources: See Appendix 1. a. Combination states that have this characteristic in at least one of their programs are included in this count. b. In determining income eligibility for SCHIP and Medicaid, some states apply "income disregards" (see the next row in this table). Typically, these are dollar amounts subtracted from gross income to compute net income which is then compared to the state's income standard for determining eligibility. The number, type and amount of disregarded income varies from applicant to applicant, depending on each person's specific financial circumstances. Some states apply selected disregards to all applicants. For example, in New Jersey's separate SCHIP program, all income between 200 to 350% of the FPL is disregarded for every applicant. In state SCHIP plans and related documentation, the sources for information on applicable income levels used in this table and elsewhere in this report, it is unclear whether the reported income levels reflect the applicable standards before or after income disregards are applied. In most cases, the reported income levels probably reflect the standards before any income disregards are taken into account. Use of disregards increases the effective income level above the stated standard. The exception is those states, like New Jersey, that apply a specific disregard for all applicants. In these cases, the reported income standard most likely accounts for universally applied disregards, and more closely reflects the effective income level. As seen in the first row, last column of Table 1, 12 states had an upper income eligibility threshold below 200% FPL, 26 states had an upper income eligibility threshold of exactly 200% FPL, and 13 states had an upper income eligibility threshold above 200% FPL. Eligibility thresholds among separate state programs tend to be higher than among Medicaid expansions. States with combination programs use their Medicaid expansion program for lower income children and one or more separate state programs for children with higher income levels. 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. Secretary- approved benefit plans are not limited to these six categories, as long as the coverage provided is determined to be appropriate for the target population. Table 2 summarizes the types of benefit packages used by the 44 separate state programs that existed as of June, 2003. 5 Department of Health and Human Services, "State Child Health; Revisions to the Regulations Implementing the State Children's Health Insurance Program," 66 Federal Register, 33810, June 25, 2001. 6 The EPSDT program provides screening and preventive care to nearly all groups of Medicaid beneficiaries under 21 years old, as well as services necessary to correct a health problem identified through screening, CRS-7 Table 2. Benefits Packages in Separate State Programs, as of June 30, 2003 Existing Benchmark Secretary approved: comprehensive Benchmark: 12 equivalent: 11 18 state based: 3 FEHBP: 2 FEHBP: 2 Benchmark plus Florida State Employee: 6 State employee: 8 additional: 4 New York Largest HMO: 4 Largest HMO: 0 Comprehensive Pennsylvania Equivalent to all three: Medicaid Section 1115 1 waiver: 3 Same as Medicaid: 9 State employee: 1 Other: 1 Source: See Appendix 1 Cost Sharing Federal law permits states to require cost-sharing7 for some beneficiaries and some services under SCHIP. Cost-sharing policies and limits are different for Medicaid expansions versus separate state programs as described below. A total of 38 states require some form of cost-sharing in either a Medicaid expansion, separate state program or both (see Appendix 3 for details). Cost-Sharing Under Medicaid Expansions States that choose to implement SCHIP as a Medicaid expansion must follow the cost-sharing rules of the Medicaid program, which prohibits cost-sharing for children under 18. Nominal cost-sharing is allowed for persons 18 years of age and older. However, if a state has a Section 1115 waiver that allows cost-sharing for children enrolled in its Medicaid program, the state may also impose cost-sharing for children enrolled in a Medicaid expansion under SCHIP. Six states -- Arkansas, Missouri, New Mexico, Ohio, Rhode Island, and Wisconsin -- have Section 1115 waiver programs that include cost-sharing for children in Medicaid expansions. Five of these states are Medicaid expansion-only states; i.e., they do not also have a separate SCHIP program. Rhode Island is a combination state for which cost-sharing applies to children in its Medicaid expansion under a Section 1115 waiver and in its separate state program for unborn children (also under Section 1115 waiver authority). 7 Three forms of cost-sharing for beneficiaries are most common. A premium, usually paid on a monthly basis, represents the price beneficiaries must pay for insurance coverage, regardless of whether services are actually received. A copayment is an item- or service- specific fee (e.g., $10 for an office visit) that is paid at the time that item or service is rendered. A deductible, typically applied on an annual basis (e.g., a $250 deductible per year), is the amount beneficiaries must incur before the insurance begins to cover the subsequent costs of care. Premiums do not count toward a deductible requirement. CRS-8 These six states fall into two cost-sharing groups. Three of these states (Arkansas, Missouri and New Mexico) require more than nominal co-payments for selected services and do not require any form of premium payments or annual fees. Two of the remaining states (Rhode Island and Wisconsin) require monthly premiums only with no co-payments for services, and one state (Ohio)8 has approval to implement an annual fee only. Cost-Sharing Under Separate State Programs If a state implements SCHIP through a separate state program, premiums or enrollment fees for program participation may be imposed, but the maximum allowable amount is dependent on family income. For all families with incomes under 150% FPL and enrolled in separate state programs, premiums may not exceed the amounts set forth in federal Medicaid regulations. Additionally, these families may be charged service-related cost-sharing, but such cost-sharing is limited to (1) nominal amounts defined in federal Medicaid regulations for the subgroup with income below 100% FPL, and (2) slightly higher amounts defined in SCHIP regulations for families with income between 101-150% FPL. For a family with income above 150% FPL, cost-sharing may be imposed in any amount, provided that cost-sharing for higher income children is not less than cost-sharing for lower income children. The total annual aggregate cost-sharing (including premiums, deductibles, copayments and any other charges) for all children in any SCHIP family may not exceed 5% of total family income for the year. In addition, states must inform families of these limits and provide a mechanism for families to stop paying once the cost-sharing limits have been reached. Most separate state programs require cost-sharing in the form of either premiums, copayments or both. Some states charge a quarterly or annual enrollment fee instead of a monthly premium. Table 3 shows cost-sharing patterns among the 44 separate state programs in the 36 states with such programs. Most of these programs have a sliding scale for cost sharing; i.e., the amount paid depends on family income. Eight programs require co-pays, but no premiums. Sixteen programs require premiums, but no co-pays. Finally, 16 programs require both premiums and co-pays. While states have the option to require deductibles, only one state does so (data not shown).9 8 Ohio has not implemented its Section 1115 waiver. 9 North Dakota requires enrollees to pay a $50 deductible for the first day of each inpatient hospital admission in a general hospital or a psychiatric or substance abuse inpatient facility. CRS-9 Table 3. Cost-Sharing Patterns in Separate State Programs, as of July 31, 2003 Flat scale Sliding scale programsa programsb Total programs Cost sharing required 14 26 40 Co-pay, no premium 4 4 8 Premium, no co-pay 7 9 16 Premium and co-pay 3 13 16 Cost sharing not required -- -- 4 Sources: See Appendix 1. Note: This table shows cost-sharing patterns among the 44 separate state programs in 36 states. a Flat scale programs are those for which cost-sharing does not vary across income or age groups. b All states except for one base their sliding scales on family income. Georgia bases its sliding scale on the child's age. In addition, Alaska and Kentucky impose cost-sharing on 18-year olds only. See Appendix 3 and 4 for further details. Table 4 shows premiums/enrollment fees and selected co-payment amounts in separate state programs. The "high" and "low" columns show the highest and lowest charges among all flat-scale programs only and among all sliding scale programs only. The amounts charged by sliding-scale programs for a given service tend to reflect a wider range of values than the amounts charged by flat-scale programs. This result is largely because charges for sliding scale programs vary across multiple income bands. Among the 24 programs that charge co-pays (see Table 3), 20 charge co-pays for prescription drugs, 18 charge for office visits, six charge for inpatient services, 15 charge for emergency use of an emergency room, and 22 charge for non- emergency use of an emergency room. The specific amounts charged under each program can be seen in Appendices 3 and 4. CRS-10 Table 4. Premiums/Enrollment Fees and Selected Co-Payment Amounts in Separate State Programs, as of July 31, 2003 14 flat scale 26 sliding scale programsa programsb Number of Number of Total programs Lowc High programs Lowc High programs Premium/enrollment fees No premium or enrollment fee 4 -- -- 4 -- -- 8 Monthly premiums required 10 $5 $50 16 $4 $135 26 Quarterly enrollment fee required 0 -- -- 2 $10 $50 2 Annual enrollment fee required 0 -- -- 4 $35 $150 4 Co-payments Brand name Rx drugs 7 $2 $5 13 $1 $20 20 Generic Rx drugs 7 $1 $3 12 $1 $6 19 Office visits 6 $2 $5 12 $2 $15 18 Inpatient services 1 $25 $25 5 $5 $100 6 Emergency room 6 $2 $10 9 $3 $50 15 Non-emergency use of ER 7 $2 $25 15 $3 $50 22 Sources: See Appendix 1. Note: This table shows cost-sharing patterns in 44 separate state programs in 36 states. a. Flat scale programs are those for which cost-sharing does not vary across income or age groups. b. All states except for one base their sliding scales on family income. Georgia bases its sliding scale on the child's age. In addition, Alaska and Kentucky impose cost-sharing on 18 year-olds only. c. This column shows values other than zero which apply to some groups of children, typically those in the lowest income coverage groups. Substitution of SCHIP for Private Health Insurance Finally, states that establish SCHIP programs must ensure that SCHIP does not substitute for coverage under group health plans, a phenomenon known as "crowd out."10 The primary method for preventing crowd-out is requiring a waiting period, that is, specified lengths of time for which applicants must be uninsured, prior to enrollment in SCHIP. Waiting periods are only permitted in Medicaid expansions under a Section 1115 waiver. As seen in the third to last column of Appendix 2, 30 states require a waiting period, ranging from one to six months 10 For further information, see CRS Report RL30657 Limiting and Measuring the Substitution of the State Children's Health Insurance Program (SCHIP) for Private Health Insurance, by Debra Cohan. CRS-11 Requiring cost-sharing under SCHIP may also serve as a crowd-out prevention measure, by discouraging applicants from viewing SCHIP as more attractive than employer-sponsored insurance for which cost-sharing is common. As noted above, 38 states require cost-sharing. Finally, premium subsidy programs can encourage use of private instead of public insurance for low-income children whose parents have access to employer- sponsored insurance (ESI) but cannot afford their share of the premium.11 Under separate state programs, states that provide premium assistance for employer- sponsored insurance to the families of targeted low-income children must require: (1) with some exceptions, a waiting-period of six to twelve months without group health plan coverage before coverage through the premium assistance program begins; (2) identify a reasonable minimum employer contribution level and provide justification for that level; and (3) a premium subsidy that does not exceed the payment the state would otherwise make on the child's behalf. As shown in Appendix 2, six states provide access to ESI under at least one of their separate state programs (as noted above, some states have multiple separate SCHIP programs). Two of these states have Section 1115 waivers; one waives the minimum employer contribution, and the other requires a 50% employer contribution. The remaining states require employer contributions ranging from 30 to 50%. States may also provide premium assistance for employer-sponsored health insurance through Medicaid expansions. Under Medicaid, states may pay a beneficiary's share of the costs for group health coverage for any Medicaid enrollee for whom employer-based coverage is available and that coverage is both comprehensive and cost-effective for the state. An individual's enrollment in an employer plan is cost-effective if paying the premiums, deductibles, coinsurance and other cost-sharing obligations of the employer plan is less expensive than the state's expected cost of directly providing Medicaid-covered services. Two states offer ESI through their Medicaid expansions using Section 1115 waiver authority; one requires a minimum employer contribution of 40%. Section 1115 Waivers States that want to make changes to their SCHIP programs that go beyond what the law will allow may do so through what is called a Section 1115 waiver (named for the section of the Social Security Act that defines the circumstances under which such waivers may be granted). The Secretary of Health and Human Services may waive certain statutory requirements for conducting research and demonstration projects under SCHIP that allow states to adapt their programs to specific needs. 11 Unless the state has a waiver specifying otherwise, states must insure that the benefit packages and cost-sharing obligations under employer-sponsored insurance programs meet the requirements in SCHIP statute. If the ESI benefit package falls short of the statute's requirements, states must provide "wrap-around" services to bridge any gaps between the ESI benefit package and the SCHIP benefits package offered by the state. CRS-12 On August 4, 2001, the Bush Administration announced the Health Insurance Flexibility and Accountability (HIFA) Demonstration Initiative. Using Section 1115 waiver authority, this initiative is designed to encourage states to extend Medicaid and SCHIP to the uninsured, with a particular emphasis on statewide approaches that maximize private health insurance coverage options and target populations with income below 200% FPL. As of July, 2003, CMS had approved 14 SCHIP Section 1115 waivers in 13 states.12 Eight of the 14 approved waivers are HIFA demonstrations in Arizona, California, Colorado, Illinois, New Jersey, New Mexico, New York and Oregon. In 10 of the 13 states with approved Section 1115 waivers (excluding Maryland, New York, and Ohio), SCHIP coverage is expanded to include one or more categories of adults13 with children, typically parents of Medicaid/SCHIP children, caretaker relatives, legal guardians, and/or pregnant women. Three states (Arizona, New Mexico and Oregon) also cover childless adults under their HIFA demonstrations. In addition to expanding coverage to new populations under waivers, some states have used this authority for other purposes. Rhode Island has been granted approval to use redistributed SCHIP funds to finance coverage of adults with children in its waiver program. Through HIFA, New Jersey will offer the same (separate SCHIP program) benefit package to adults covered under its SCHIP and Medicaid waiver demonstrations. Using Section 1115 waiver authority, both Maryland and New Mexico require a six-month period of no insurance prior to enrollment under their waivers.14 New Mexico has also modified its cost-sharing rules for targeted low- income children under its Medicaid program. New York's HIFA demonstration provided temporary disaster relief in New York City due to the events of September 11, 2001. Finally, Ohio received approval to implement an annual enrollment fee and to give 12 months of continuous eligibility for certain targeted low-income children in its Medicaid program.15 States can also modify their SCHIP programs using a Medicaid 1115 waiver. In addition to the states identified above, four other states (Arkansas, Hawaii, Missouri, and Tennessee) with Medicaid expansions only used waiver authority to expand an existing comprehensive Medicaid 1115 demonstration program. Other modifications affecting the Medicaid expansions in these states included, for example, establishing 12 The 13 states are AZ, CA, CO, IL, MD, MN, NJ, NM, NY, OH, OR, RI, and WI. NM has two approved SCHIP Section 1115 waivers. The remaining states have one waiver each. 13 States have the option to purchase family coverage under a group health plan that may cover adults as long as it is cost-effective to do so (relative to the amount paid for comparable coverage for the children only), and it must not substitute for health insurance that would otherwise be provided to the children. For states seeking greater flexibility both in selecting which adults to cover and in the benefit package offered to those adults, a waiver is required. 14 In general, for Medicaid expansions under SCHIP, all Medicaid rules apply. Thus, when states with SCHIP Medicaid expansions want to implement other rules (e.g., establish waiting periods before enrollment, implement enrollment fees, etc.), a waiver is required. 15 Due to a variety of budget and resource constraints, in May 2002, OH decided not to pursue implementation of its waiver. CRS-13 a six-month waiting period prior to enrollment, higher cost-sharing requirements that exceed otherwise allowable limits, and authority to implement enrollment caps as necessary. Appendices. State by State Program Characteristics Appendix 1 describes the methodology employed throughout this report. Appendices 2 and 3 are state-by-state matrices of selected program characteristics and selected cost-sharing amounts, respectively. Appendix 4 consists of 51 tables that provide an overview of general SCHIP program characteristics for each of the 50 states and the District of Columbia. As of October 1, 2002, all children under age 19 in families with income up to 100% FPL must be covered by Medicaid and thus cannot be enrolled in SCHIP. Therefore, there is no Medicaid expansion information presented for the four states16 that had such programs prior to October 1, 2002 solely to cover such children. For more information about SCHIP, see CRS Report RL30642, The State Children's Health Insurance Program: Eligibility, Enrollment and Program Funding, by Evelyne Baumrucker, and CRS Report RL30473, State Children's Health Insurance Program: A Brief Overview, by Elicia Herz and Peter Kraut. 16 AL, MS, TN, and TX. CRS-14 Appendix 1. Methodology The main source of data presented in this report is a CRS database that is based primarily on information contained in official SCHIP state plans and accompanying documentation, including all amendments approved by CMS as of June 30, 2003. SCHIP state plans do not contain detailed information on certain program characteristics, in particular for Section 1115 waivers and for Medicaid expansion programs. In addition to the CRS database, other sources of data used in this report include the following: ! Information on SCHIP Section 1115 waivers is from the Centers for Medicare and Medicaid Services, Section 1115 Demonstrations: State Profiles, July 25, 2003, at [http://www.cms.hhs.gov/schip/ 1115waiv.pdf], as well as CMS/State Terms and Conditions and/or Operational Protocol documents. In some cases, we also contacted CMS and state officials to clarify or expand on information contained in these documents. ! For Medicaid expansion programs, information on income eligibility thresholds (lower and upper bounds) is taken from documentation accompanying SCHIP state plans, SCHIP annual evaluation reports, and CRS Report RL30642, The State Children's Health Insurance Program: Eligibility, Enrollment and Program Funding, by Evelyne Baumrucker. ! Data as of April, 2003, on asset tests, continuous and presumptive eligibility, waiting periods, and cost-sharing for Medicaid expansion programs are taken from Donna Cohen Ross and Laura Cox, Preserving Recent Progress On Health Coverage For Children and Families: New Tensions Emerge A 50 State Update On Eligibility, Enrollment, Renewal And Cost-Sharing Practices In Medicaid and SCHIP, Center on Budget and Policy Priorities, (prepared for the Kaiser Commission on Medicaid and the Uninsured), July 2003. ! A CRS survey of states on selected program characteristics for separate SCHIP programs as of December 31, 2002, is the basis for the "presumptive eligibility" information for such programs. ! States are not required to provide detailed information on income counting methods in their state SCHIP plans. Data on "basic income disregards" for Medicaid expansions and separate SCHIP programs are taken from two surveys: (1) a CRS survey of selected program characteristics for separate SCHIP programs as of December 31, 2002, and (2) a survey conducted under contract to CRS by the George Washington University of selected program characteristics for Medicaid expansions (and eligibility rules for other groups of Medicaid children) as of December 31, 2002. Throughout this report, a "yes" entry for the "basic income disregards" field means that the state: (a) disregards some amount of earnings, or (2) allows a deduction for child-care expenses, or (3) disregards all income CRS-15 between a specified range of the federal poverty level (e.g., in its separate SCHIP program, New Jersey disregards all income between 200-350% FPL). Coding of "basic income disregards" among Medicaid expansion programs requires additional explanation. SCHIP law defines a SCHIP eligible as a targeted low-income child under the age of 19 with no health insurance, and who would not have been eligible for Medicaid under the rules in effect on March 31, 1997. Under Medicaid, states may cover targeted low-income children in one or more of the following ways: (1) by establishing a new optional eligibility group for such children as authorized in SCHIP law, (2) by liberalizing the financial rules for any of several existing Medicaid eligibility categories (e.g., the poverty-related groups) using Section 1902(r)(2) authority, and/or (3) by liberalizing the income standards or methodologies applicable to family coverage under Section 1931. Many states have chosen to cover targeted low- income children under existing Medicaid eligibility pathways, especially the poverty-related groups, rather than by establishing the optional coverage group identified in SCHIP law. On the CRS- sponsored Medicaid eligibility survey conducted by George Washington University, there was no field indicating which of these options a state used to create its SCHIP Medicaid expansion group. The "basic income disregards" field was coded as "yes" if the criteria described above were met for any of the relevant groups. ! There are inconsistencies in state SCHIP plans in how states report lower income boundaries that apply to different age groups under SCHIP. The lower income boundaries shown in this report reflect the upper income boundary applicable to the next adjacent age or income group. For example, children up to six years of age in families with income up to 133% of the federal poverty level (FPL) must be covered in the regular Medicaid program. For a state implementing a separate SCHIP program for the same age group, the lower income boundary shown in this report would equal 133% FPL. CRS-16 Appendix 2. Selected SCHIP Program Characteristics by State, as of December 31, 2002 through July 31, 2003 Waiting Min. period employer Waiver to Waiver Enroll- to Subsidy premium Upper cover groups affecting Prenatal ment prevent for private share income not other Basic Continuous Presump- care for cap or crowd- or required MXP SSP Com- threshold otherwise SCHIP income Asset eligibility tive unborn waiting out employer for subsidy State only Only bination (% FPL) eligible provisions disregard tests (months) eligibility children list Type Option (mos.) coverage (%) Largest AL X 200 no no yes no 12 no no no Benchmark 3 no NA HMO a AK X 200 no no yes no 6 no NA no NA NA no NA Secretary Same as AZ X 200 yes no no no 12 no no no 3 no NA Approved Medicaid Compre- hensive Medicaid AR X 200 no yes yes no 12 no NA no NA 6 no NA Section 1115 Waiver MXP: 0 MXP: yes MXP: NA State CA X 250 yes no yes no 12 no Benchmark SSP: 3 no NA SSP: no SSP: no Employee or 0 FEHBP, State Benchmark Employee CO X 185 yes no yes no 12 no no no 3 no NA Equivalent and Largest HMO State CT X 300 no no yes no 0 no no no Benchmark 2 no NA Employee MXP: 0 MXP: NA State MXP:0 DE X 200 no no yes no no no Benchmark no NA SSP: 12 SSP: no Employee SSP: 6 DC X 200 no no yes no 0 no NA no NA NA 0 no NA Existing state-based NA; MXP: NA FL X 200 no no yes no 12 or 6 no yes and Same as 0 no NA SSP: no Secretary Medicaid Approved Bench- Secretary GA X 235 no no yes no 12 no no no mark plus 3 no NA Approved additional CRS-17 Waiting Min. period employer Waiver to Waiver Enroll- to Subsidy premium Upper cover groups affecting Prenatal ment prevent for private share income not other Basic Continuous Presump- care for cap or crowd- or required MXP SSP Com- threshold otherwise SCHIP income Asset eligibility tive unborn waiting out employer for subsidy State only Only bination (% FPL) eligible provisions disregard tests (months) eligibility children list Type Option (mos.) coverage (%) Compre- hensive Medicaid HI X 200 no yes yes no 0 no NA no NA 0 no NA Section 1115 Waiver ID X 150 no no yes yes 12 no NA no NA NA 0 no NA MXP: no MXP: NA Benchmark State MXP: no IL X 185 yes yes no 12 no no 0 b SSP: yes SSP: yes Equivalent Employee SSP: yes MXP: 0 MXP: NA Benchmark MXP: 0 IN X 200 no no yes no no no FEHBP no NA SSP: 12 SSP: no Equivalent SSP: 3 MXP: 0 MXP: NA Benchmark State MXP: 0 IA X 200 no no yes no no no no NA SSP: 12 SSP: no Equivalent Employee SSP: 6 Bench- Secretary KS X 200 no no yes no 12 no no no mark plus 0 no NA Approved additional Bench- MXP: NA Secretary MXP: 0 KY X 200 no no yes no 0 no no mark plus no NA SSP: no Approved SSP: 6 additional LA X 200 no no yes no 12 no NA no NA NA 0 no NA MXP: yes MXP: NA Secretary Same as MXP: 0 ME X 200 no no no 12 no no no NA SSP:no SSP: no Approved Medicaid SSP: 3 MXP: yes MXP: 6 MXP: NA Secretary Same as MXP: 6 MXP: no MD X 300 no yes no no no 30% SSP: no SSP: 12 SSP: no Approved Medicaidc SSP: 6 SSP: yes Largest HMO, Compre- MXP: no MXP: yes Bnchmark; MXP: NA hensive SSP: MA X 200 no no no no 0 SSP: no Secretary 0 50% SSP: no Medicaid yes/no yes/no Approved Section 1115 Waiver MXP: 0 MXP: no MXP: NA State MXP: 0 MI X 200 no no yes no no Benchmark no NA SSP: 12 SSP: yes SSP: yes Employee SSP: 6 MN X 280 yes no yes no 0 no NA no NA NA 0 no NA CRS-18 Waiting Min. period employer Waiver to Waiver Enroll- to Subsidy premium Upper cover groups affecting Prenatal ment prevent for private share income not other Basic Continuous Presump- care for cap or crowd- or required MXP SSP Com- threshold otherwise SCHIP income Asset eligibility tive unborn waiting out employer for subsidy State only Only bination (% FPL) eligible provisions disregard tests (months) eligibility children list Type Option (mos.) coverage (%) Bench- Secretary MS X 200 no no yes no 12 nod no no mark plus 0 nod NAd Approved additional Compre- hensive Medicaid MO X 300 no yes yes no 0 yes NA no NA 6 no NA Section 1115 Waiver Benchmark State MT X 150 no no yes no 12 no no yes 3 no NA Equivalent Employee NE X 185 no no yes no 6 yes NA no NA NA 0 no NA Secretary Same as NV X 200 no no no no 12 no no no 6 no NA Approved Medicaid MXP: yes MXP: NA Benchmark MXP: 0 NH X 300 no no yes no 0 no FEHBP no NA SSP: no SSP: no Equivalent SSP: 6 FEHBP MXP: yes MXP: yes MXP: NA and MXP: 0 MXP: no NJ X 350 yes no SSP: no 0 SSP: no Benchmark 50% SSP: no Largest SSP: 6 SSP: yes yes/no yes/no HMO Compre- hensive Medicaid NM X 235 yes yes yes no 12 yes NA no NA 0 no NA Section 1115 Waiver Existing MXP: yes MXP: 12 MXP: no MXP: NA Compre- NY X 250 noe noe no no NA 0 no NA SSP: no SSP: 0 SSP: yes SSP: no hensive state-based State NC X 200 no no yes no 12 no no no Benchmark 0 no NA Employee MXP: 0 MXP: NA Benchmark State MXP: 0 ND X 140 no no yes no no no no NA SSP: 12 SSP: no Equivalent Employee SSP: 6 OH X 200 no yesf yes no 0 no NA no NA NA 0 no NA OK X 185 no no yes no 0 no NA no NA NA 0 no NA CRS-19 Waiting Min. period employer Waiver to Waiver Enroll- to Subsidy premium Upper cover groups affecting Prenatal ment prevent for private share income not other Basic Continuous Presump- care for cap or crowd- or required MXP SSP Com- threshold otherwise SCHIP income Asset eligibility tive unborn waiting out employer for subsidy State only Only bination (% FPL) eligible provisions disregard tests (months) eligibility children list Type Option (mos.) coverage (%) Compre- hensive Secretary Medicaid OR X 185 yes yes no yes 6 no no no 6 yes 50% Approved Section 1115 Waiver Existing Compre- PA X 200 no no yes no 12 no no no NA 0 no NA hensive state-based Compre- hensive Compre- Medicaid hensive MXP: yes MXP: 0 MXP: NA Section Medicaid MXP: yes RI X 250 yes yes no no no 0 b SSP: no SSP: 12 SSP: yes 1115 Section SSP: no Waiver; 1115 Secretary Waiver approved SC X 150 no no yes no 12 no NA no NA NA 0 no NA MXP: NA Secretary Same as MXP: 0 SD X 200 no no yes no 0 no no no NA SSP: no Approved Medicaid SSP: 3 Compre- hensive g Medicaid TN X no yes yes no 0 no NA nog NA 0 no NA Section 1115 Waiver Benchmark State TX X 200 no no yes no 12 no no no 3 no NA Equivalent Employee Benchmark State UT X 200 no no no no 12 no no yes 3 no NA Equivalent Employee Secretary Same as VT X 300 no no yes no 12 no no no 1 no NA Approved Medicaid CRS-20 Waiting Min. period employer Waiver to Waiver Enroll- to Subsidy premium Upper cover groups affecting Prenatal ment prevent for private share income not other Basic Continuous Presump- care for cap or crowd- or required MXP SSP Com- threshold otherwise SCHIP income Asset eligibility tive unborn waiting out employer for subsidy State only Only bination (% FPL) eligible provisions disregard tests (months) eligibility children list Type Option (mos.) coverage (%) State Employee MXP: yes MXP: NA Secretary MXP: 0 MXP: NA VA X 200 no no no 0 no no and Same yes SSP: no SSP: no Approved SSP: 6 SSP: 40% as Medicaid Secretary Same as WA X 250 no no yes no 12 no no no 4 no NA Approved Medicaid Benchmark State WV X 200 no no yes no 12 no no no 6 no NA Equivalent Employee Compre- hensive Medicaid WI X 185 yes yes yes no 0 no NA no NA 3 yes 40% Section 1115 Waiver Secretary WY X 185 no no yes no 12 no no no Other 1 no NA Approved Total count 15 18 18 140 - 350 10 11 46 2 36 9 3 3 see Table 3 30 8 0-50 of states Note: For combination programs, if there is one entry in a cell, the entry applies to both the Medicaid expansion (MXP) and the separate state program (SSP). If there is a difference between programs, both characteristics are reported. For states with more than one SSP in which there are differences between SSP programs for a given characteristic, multiple answers are provided. "Type" and "Option" are always not applicable (NA) for MXPs. For combination programs, the Type and Option shown are for the SSPs. In the counts provided in the last row, combination states that have this characteristic in at least one of their programs are counted as having the characteristic. For the column showing the "upper income threshold," see table note b on Table 1 in the text for additional information. a. AK has an 1115 waiver pending that would allow it to require a 12-month waiting period prior to enrollment for children in families with income over 150% FPL. b. Illinois' Section 1115 HIFA demonstration waives the minimum employer contribution requirement. RI does not have a minimum requirement because such a requirement is not applicable for MXPs, and Rhode Island's employer sponsored insurance (ESI) premium assistance program is done through Medicaid. c. When applicable, ESI must be benchmarked against or benchmark equivalent to the state's largest HMO. d. MS has CMS approval to use presumptive eligibility but has chosen not to implement it. MS also has CMS approval to subsidize ESI, but the program has not been implemented and is on hold indefinitely. e. New York City had a Medicaid and SCHIP Disaster Relief waiver to address the effects of Sept. 11, 2001. The waiver was effective Aug. 1, 2001 through Jan. 31, 2003. f. OH has received approval for a Section 1115 waiver allowing an annual enrollment fee and 12 months continuous coverage for beneficiaries with income between 151-200% FPL; however, the state has chosen not to implement the waiver. g. At the start of SCHIP, several states, including TN, created MXPs to cover older children in families with income up to 100% FPL sooner than required by Medicaid law. As of Oct. 1, 2002, such children were covered as a mandatory group under Medicaid, and thus, previously established MXPs for these children ceased to exist. Thus, TN has no SCHIP enrollment. Tennessee's Section 1115 waiver allows an enrollment cap, but such a cap has not been implemented. CRS-21 Appendix 3. SCHIP Premiums/Enrollment Fees and Selected Co-Payment Amounts by State, as of July 31, 2003 Sliding scale for cost Co-pays for Co-pays for Cost sharing Co-pays Co-pays emergency non-emer- sharing (based on Premium or for brand for generic Co-pays Co-pays for use of emer- gency use of MXP SSP Combi- required income or enrollment Premium or fee Family cap name Rx Rx drugs for office inpatient gency room emergency State only only nation (yes/no) age) fee required per child ($) ($) drugs ($) ($) visits ($) services ($) ($) room ($) AL X yes income annually 0-50 0-150 0-3 0-1 0-5 0-5 0-5 0-5 AK X yesa age no -- -- 0-2 0-2 0-3 0-50 -- 0-5% of charge AZ X yes income monthly 0-15 0-20 -- -- -- -- -- 5 ARb 20% of first X yes no no -- -- 5 5 10 10 10 hospital day d CAc X yes income 4-9 8-27 5 5 5 -- 5 5 CO X yes income annually 0-25 0-35 1-5 1-3 2-5 -- 3-15 3-15 CT X yes income monthly 0-30 0-50 6 3 5 -- -- 25 DE X yes income monthly 10-25 10-25 -- -- -- -- -- 10 DC X ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ FLc X yes no monthly 15 15 0-3 0-3 0-3 -- -- 0-10 GA X yes age monthly 0-7.50 0-15 -- -- -- -- -- -- HI X ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ID X ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ILc X yes no monthly 0-15 0-30 2-5 2-3 2-5 -- 2-no info 2-25 IN 16.50- X yes income monthly 11-16.50 10 3 -- -- -- -- 24.75 IA X yes income monthly 0-10 0-20 -- -- -- -- -- 0-25 KS X yes income monthly 10-15 10-15 -- -- -- -- -- -- KY X yesa age no -- -- 0-1 0-1 -- -- -- -- LA X ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ME X yes income monthly 5-20 10-40 -- -- -- -- -- -- CRS-22 Sliding scale for cost Co-pays for Co-pays for Cost sharing Co-pays Co-pays emergency non-emer- sharing (based on Premium or for brand for generic Co-pays Co-pays for use of emer- gency use of MXP SSP Combi- required income or enrollment Premium or fee Family cap name Rx Rx drugs for office inpatient gency room emergency State only only nation (yes/no) age) fee required per child ($) ($) drugs ($) ($) visits ($) services ($) ($) room ($) MD X yes income monthly 40-50 40-50 -- -- -- -- -- -- MAc X yes income monthly 12-35 15-36 -- -- -- -- -- -- MI X yes no monthly 5 5 -- -- -- -- -- -- MN X ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ MS X yes income no -- -- -- -- 0-5 -- 0-15 0-15 MOb X yes income monthly 0-78 0-225 0-9 0-9 5-10 -- -- -- MT X yes no no -- -- 5 3 3 25 5 5 NE X ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ NV X yes income quarterly 10-50 10-50 -- -- -- -- -- -- NH X yes income monthly 25-45 100-135 10 5 10 -- 50 50 NJc X yes income monthly 0-100 0-100 0-5 0-5 0-5 -- 0-35 0-35 NMb X yes no no -- -- 2 2 5 25 15 15 NY X yes income monthly 0-15 0-45 -- -- -- -- -- -- NC X yes income annually 0-50 0-100 0-6 0-6 0-5 -- -- 0-20 ND X yes no no -- -- 2 2 -- -- 5 5 e OHb X ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ OK X ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ OR X no -- -- -- -- -- -- -- -- -- -- PA X no -- -- -- -- -- -- -- -- -- -- RIb X yes income monthly 0-92 0-92 -- -- -- -- -- -- SC X ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ SD X no -- -- -- -- -- -- -- -- -- -- CRS-23 Sliding scale for cost Co-pays for Co-pays for Cost sharing Co-pays Co-pays emergency non-emer- sharing (based on Premium or for brand for generic Co-pays Co-pays for use of emer- gency use of MXP SSP Combi- required income or enrollment Premium or fee Family cap name Rx Rx drugs for office inpatient gency room emergency State only only nation (yes/no) age) fee required per child ($) ($) drugs ($) ($) visits ($) services ($) ($) room ($) TN X ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ TX X yes income monthlyf 15-18 15-18 5-20 0-5 2-10 25-100 5-50 5-50 UT 5 or10% of X yes income quarterly 13-25 13-25 2-5 2-5 5-15 5-35 10-35 allowed amt VT X yes no monthly 50 50 -- -- -- -- -- -- VA X yes income no -- -- 2-5 2-5 2-5 15-25 -- 10-25 WA X yes no monthly 10 30 -- -- -- -- -- -- WV X yes income no -- -- 5-15 -- 0-15 0-25 0-35 0-35 WIb 0 or 3% of 0 or 3% of X yes income monthly -- -- -- -- -- -- income income WY X yes no no -- -- 5 3 5 -- 5 5 Total 22 monthly count 25 income 2 quarterly 15 18 18 38 28 28 22 21 20 9 15 23 of 3 age 3 annually states 2 mixed Note: Cost-sharing for children is not permitted under Medicaid unless the state has a Section 1115 waiver allowing the state to impose cost sharing. This also applies to SCHIP Medicaid expansion programs. Medicaid expansion only states without an 1115 waiver have a `^' in the cost-sharing columns. For the combination states, the values shown reflect cost-sharing in the separate state program(s) only. Some states have employer-sponsored insurance (ESI) programs as a component of their Medicaid expansion or separate state programs. Information on cost-sharing in ESI programs varies by participating employer and is typically not available in state SCHIP documents and other sources used for this analysis. Thus, such data are not represented in this table. a. In AK, 18-year-olds are subject to the Medicaid co-payment requirements for adults. Likewise, KY charges 18-year-olds copayments on prescription drugs. b. State has a Section 1115 waiver allowing cost-sharing in a Medicaid expansion program. c. These states have multiple separate state programs. The amounts shown in these cells represent cost-sharing ranges across all SSPs within the state. d. In one of California's SSPs, the Access for Infants and Mothers Program, an enrollment fee of 2% of family income is required for infants (paid on a monthly or annual basis). No co-payments apply to this group. The monthly premiums and co-payments shown for CA are for the state's other SSP called Healthy Families. e. OH has received approval for a Section 1115 waiver allowing an annual enrollment fee and 12 months continuous coverage for children in families with income between 151-200% FPL; however, the state has chosen not to implement the waiver. f. In TX, children in families with income between 100-150% FPL pay a $15 annual enrollment fee only. Monthly premiums apply to other children. CRS-24 Appendix 4. SCHIP State Tables, Status as of December 31, 2002 through July 31, 2003 Program Info State Alabama. Separate State Program Only Program Name CHIP Phase II- ALL Kids Type Of Program Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no Eligibility Age Income (% FPL) Lower Upper Lower Upper Youngest 0 5 133 200 Next Youngest 6 18 100 200 Older Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 12 Presumptive Eligibility no Prenatal Care for Unborn Children no Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required yes Sliding Scale for Cost-Sharing income Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 100 150 Range (%FPL) 150 200 Premium or Enrollment Fee Required annually Premium/Fee Per Child $ 0 $ 50 Family Cap $ 0 $ 150 Co-Payments Co-Payment For Brand Name Rx Drugs $ 0 $ 3 Co-Payment For Generic Rx Drugs $ 0 $ 1 Co-Payment For Office Visits $ 0 $ 5 Co-Payment For Inpatient Services $ 0 $ 5 Co-Payment For Emerg Use Of Emerg-Room $ 0 $ 5 Co-Payment For Non-Emerg Use Of Emerg-Room $ 0 $ 5 Coverage Type/Option Type Benchmark Option Largest HMO Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 3 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA CRS-25 Program Info State Alaska. Medicaid Expansion Only Program Name Denali KidCare Type Of Program Medicaid Expansion State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 5 133 200 Next Youngest 6 18 100 200 Older Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 6 Presumptive Eligibility no Prenatal Care for Unborn Children NA Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required yesa Sliding Scale for Cost-Sharing agea Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 0 18 Range (%FPL) 17 18 Premium or Enrollment Fee Required no Premium/Fee Per Child Family Cap Co-Payments Co-Payment For Brand Name Rx Drugs $ 0 $ 2 Co-Payment For Generic Rx Drugs $ 0 $ 2 Co-Payment For Office Visits $ 0 $ 3 Co-Payment For Inpatient Services $ 0 $50b Co-Payment For Emerg Use Of Emerg-Room $ 0 $ 0 5% of Co-Payment For Non-Emerg Use Of Emerg-Room $ 0 charge Coverage Type/Option Type NA Option NA Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) c Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA a. In AK, 18 year olds are subject to the Medicaid co-payment requirements for adults. b. Up to a maximum of $200 for inpatient hospital services, not to exceed 50% of the payment made for the first day of hospital care. c. AK has a Section 1115 waiver pending that would allow it to require a 12-month waiting period prior to enrollment for children in families with income over 150%. CRS-26 Program Info State Arizona. Separate State Program Only Program Name KidsCare Type Of Program Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program yesa Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 1 140 200 Next Youngest 1 5 133 200 Older 6 18 100 200 Oldest Basic Income Disregard no Asset Tests no Continuous Eligibility (months) 12 Presumptive Eligibility no Prenatal Care for Unborn Children no Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required yes Sliding Scale for Cost-Sharing income Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 100 150 175 Range (%FPL) 150 175 200 Premium or Enrollment Fee Required monthly Premium/Fee Per Child $ 0 $ 10 $ 15 Family Cap $ 0 $ 15 $ 20 Co-Payments Co-Payment For Brand Name Rx Drugs $ 0 $ 0 $ 0 Co-Payment For Generic Rx Drugs $ 0 $ 0 $ 0 Co-Payment For Office Visits $ 0 $ 0 $ 0 Co-Payment For Inpatient Services $ 0 $ 0 $ 0 Co-Payment For Emerg Use Of Emerg-Room $ 0 $ 0 $ 0 Co-Payment For Non-Emerg Use Of Emerg-Room $ 5 $ 5 $ 5 Coverage Type/Option Type Secretary Approved Option Same as Medicaid Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 3 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA a. Arizona's HIFA waiver allows the state to use SCHIP funds to cover parents of SCHIP and Medicaid children in families with income between 100%-200% FPL and adults without dependent children with income below 100% FPL. CRS-27 Program Info State Arkansas. Medicaid Expansion Only Program Name ARKids B Type Of Program Medicaid Expansion State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program yesa Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 18 150 200 Next Youngest Older Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 12 Presumptive Eligibility no Prenatal Care for Unborn Children NA Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required yes Sliding Scale for Cost-Sharing no Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 Range (%FPL) Premium or Enrollment Fee Required no Premium/Fee Per Child Family Cap Co-Payments Co-Payment For Brand Name Rx Drugs $ 5 Co-Payment For Generic Rx Drugs $ 5 Co-Payment For Office Visits $ 10 Co-Payment For Inpatient Services 20% of 1st hospital day Co-Payment For Emerg Use Of Emerg-Room $ 10 Co-Payment For Non-Emerg Use Of Emerg-Room $ 10 Coverage Type/Option Type Comprehensive Medicaid Section 1115 waiver Option NA Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 6 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA a. AR uses SCHIP funds to provide coverage under its comprehensive Medicaid Section 1115 waiver, which, among other things, allows a six-month waiting period and cost sharing that exceeds Medicaid allowable amounts. CRS-28 Program Info State California. Combination Program Name MediCal Access for Infants and Mothersb Healthy Families Program Type Of Program Medicaid Expansion Separate State Program Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no no no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program yesc yesc yesc Eligibility Age Income (%FPL) Age Income (%FPL) Age Income (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper Lower Upper Lower Upper Youngest 1 5 1a 133a 0 1 200 250 0 1 200 250 a Next Youngest 6 18 1 100a 1 5 133 250 Older 6 18 100 250 Oldest Basic Income Disregard yes yes yes Asset Tests no no no Continuous Eligibility (months) 12 12 12 Presumptive Eligibility yes no no Prenatal Care for Unborn Children NA no no Enrollment Cap / Waiting List no no no Cost Sharing Cost Sharing Required NA yes yes Sliding Scale for Cost-Sharing NA yes incomee Group Group Group Group Group Group Group Group Group Group Group Group Sliding Scale Group Defined 1 2 3 4 1 2 3 4 1 2 3 4 100 150 100 150 Range (%FPL) 150 200 150 200 Premium or Enrollment Fee Required monthly or annuallyd monthlye Premium/Fee Per Child $ 4 $ 6$ 7$ 9 2% of family income Family Cap $ 8 $ 18 $ 14 $ 27 Co-Payments Co-Payment For Brand Name Rx Drugs $ 5 $ 5 $ 5 $ 5 Co-Payment For Generic Rx Drugs $ 5 $ 5 $ 5 $ 5 Co-Payment For Office Visits $ 5 $ 5 $ 5 $ 5 Co-Payment For Inpatient Services $ 0 $ 0 $ 0 $ 0 Co-Payment For Emerg Use Of Emerg-Room $ 5 $ 5 $ 5 $ 5 Co-Payment For Non-Emerg Use Of Emerg-Room $ 5 $ 5 $ 5 $ 5 CRS-29 Coverage Type/Option Type NA Benchmark Benchmark Option NA State Employee State Employee Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 0 3 Subsidy For Private/Employer Coverage no no no Min. Employer Premium Share Required for Subsidy NA NA NA a. The income thresholds shown are used for both Medicaid and SCHIP purposes. CA eliminated asset tests from its Medicaid program in 1998. Title XIX financing is used for children who meet the income thresholds shown and who have assets below the Title XIX asset test thresholds in place in 1997 (the maintenance of effort point for SCHIP). Title XXI financing is used for children who meet the income thresholds shown and who have assets exceeding the Title XIX asset test thresholds in place in 1997. b. Only infants born to women already enrolled in California's non-SCHIP AIM program are enrolled in AIM. Other infants 200-250% FPL are enrolled in the Healthy Families program. c. California's HIFA waiver allows the state to use SCHIP funds to cover parents, relative caretakers, and legal guardians of eligible children in families who are not eligible for Medicaid with family income up to 200% FPL (The waiver was approved Jan. 2002 but had not yet been implemented as of June 12, 2003). d. The AIM family contribution can be either (1) paid at the time of the application and the applicant will receive a $50 discount, or (2) spread over a 12 month period. If the applicant chooses monthly payments, she must send $50 with the application and the program will send her a payment booklet. e. Enrollees may choose from two provider plans. Premiums for the "Community Provider Plan" are presented in the first two columns; premiums for the "Family Value Package" are presented in the second two columns. Families who pre-pay three months do not have to pay the fourth month. CRS-30 Program Info State Colorado. Separate State Program Only Program Name Child Health Plan Plus Type Of Program Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program yesa Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 5 133 185 Next Youngest 6 18 100 185 Older Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 12 Presumptive Eligibility no Prenatal Care for Unborn Children no Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required yes Sliding Scale for Cost-Sharing income Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 100 150 Range (%FPL) 150 185 Premium or Enrollment Fee Required annually Premium/Fee Per Child $ 0 $ 25 Family Cap $ 0 $ 35 Co-Payments Co-Payment For Brand Name Rx Drugs $ 1 $ 5 Co-Payment For Generic Rx Drugs $ 1 $ 3 Co-Payment For Office Visits $ 2 $ 5 Co-Payment For Inpatient Services $ 0 $ 0 Co-Payment For Emerg Use Of Emerg-Room $ 3 $ 15 Co-Payment For Non-Emerg Use Of Emerg-Room $ 3 $ 15 Coverage Type/Option Type Benchmark Equivalent Option FEHBP, State Employee, and Largest HMO Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 3 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA a. Colorado's HIFA waiver allows the state to use SCHIP funds to expand coverage to pregnant women with family incomes between 133-185% FPL. CRS-31 Program Info State Connecticut. Separate State Program Only Program Name HUSKY Plans B and Ca Type Of Program Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 18 185 300 Next Youngest Older Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 0 Presumptive Eligibility no Prenatal Care for Unborn Children no Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required yes Sliding Scale for Cost-Sharing income Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 185 235 Range (%FPL) 235 300 Premium or Enrollment Fee Required monthly Premium/Fee Per Child $ 0 $ 30 Family Cap $ 0 $ 50 Co-Payments Co-Payment For Brand Name Rx Drugs $ 6 $ 6 Co-Payment For Generic Rx Drugs $ 3 $ 3 Co-Payment For Office Visits $ 5 $ 5 Co-Payment For Inpatient Services $ 0 $ 0 Co-Payment For Emerg Use Of Emerg-Room $ 0 $ 0 Co-Payment For Non-Emerg Use Of Emerg-Room $ 25 $ 25 Coverage Type/Option Type Benchmark Option State Employee Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 2 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA a. Children who are eligible for HUSKY Part B and who require intensive physical or behavioral health services receive medically necessary services under HUSKY Plus Plan Part C. CRS-32 Program Info State Delaware. Combination Delaware Healthy Children Program Name Medicaid Program Type Of Program Medicaid Expansion Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no no Eligibility Income Income Age (%FPL) Age (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper Youngest 0 1 185 200 1 5 100 200 Next Youngest 6 18 100 200 Older Oldest Basic Income Disregard yes yes Asset Tests no no Continuous Eligibility (months) 0 12 Presumptive Eligibility no no Prenatal Care for Unborn Children NA no Enrollment Cap / Waiting List no no Cost Sharing Cost Sharing Required NA yes Sliding Scale for Cost-Sharing NA income Group Group Group Group Group Group Group Group Sliding Scale Group Defined 1 2 3 4 1 2 3 4 100 133 166 Range (%FPL) 133 166 200 Premium or Enrollment Fee Required monthly Premium/Fee Per Child $ 10 $ 15 $ 25 Family Cap $ 10 $ 15 $ 25 Co-Payments Co-Payment For Brand Name Rx Drugs $ 0 $ 0 $ 0 Co-Payment For Generic Rx Drugs $ 0 $ 0 $ 0 Co-Payment For Office Visits $ 0 $ 0 $ 0 Co-Payment For Inpatient Services $ 0 $ 0 $ 0 Co-Payment For Emerg Use Of Emerg-Room $ 0$ 0$ 0 Co-Payment For Non-Emerg Use Of Emerg-Room $ 10 $ 10 $ 10 Coverage Type/Option Type NA Benchmark Option NA State Employee Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 6 Subsidy For Private/Employer Coverage no no Min. Employer Premium Share Required for Subsidy NA NA CRS-33 Program Info District of Columbia. Medicaid Expansion State Only Program Name DC Healthy Families Type Of Program Medicaid Expansion State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 1 185 200 Next Youngest 1 5 133 200 Older 6 18 100 200 Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 0 Presumptive Eligibility no Prenatal Care for Unborn Children NA Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required NA Sliding Scale for Cost-Sharing NA Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 Range (%FPL) Premium or Enrollment Fee Required Premium/Fee Per Child Family Cap Co-Payments Co-Payment For Brand Name Rx Drugs Co-Payment For Generic Rx Drugs Co-Payment For Office Visits Co-Payment For Inpatient Services Co-Payment For Emerg Use Of Emerg-Room Co-Payment For Non-Emerg Use Of Emerg-Room Coverage Type/Option Type NA Option NA Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA CRS-34 Program Info State Florida. Combination Program Name Medicaid MediKids Florida CMS Networka Healthy Kids Type Of Program Medicaid Expansion Separate State Program Separate State Program Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no no no no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no no no no Eligibility Age Income (%FPL) Age Income (%FPL) Age Income (%FPL) Age Income (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper Lower Upper Lower Upper Lower Upper Lower Upper Youngest 0 1 185 200 1 4 133 200 1 5 133 200 5 5 133 200 Next Youngest 6 18 100 200 6 18 100 200 Older Oldest Basic Income Disregard yes yes yes yes Asset Tests no no no no under age 5: 12 Continuous Eligibility (months) age 5 and up: 6 6 12 6 Presumptive Eligibility no no no no Prenatal Care for Unborn Children NA no no no Enrollment Cap / Waiting List no yesb yesb yesb Cost Sharing Cost Sharing Required NA yes yes yes Sliding Scale for Cost-Sharing NA no no no Group Group Group Group Group Group Group Group Group Group Group Group Group Group Group Group Sliding Scale Group Defined 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 133 100 100 Range (%FPL) 200 200 200 Premium or Enrollment Fee Required monthly monthly monthly Premium/Fee Per Child $ 15 $ 15 $ 15 Family Cap $ 15 $ 15 $ 15 Co-Payments CRS-35 Co-Payment For Brand Name Rx Drugs $ 3 Co-Payment For Generic Rx Drugs $ 3 Co-Payment For Office Visits $ 3 Co-Payment For Inpatient Services $ 0 Co-Payment For Emerg Use Of Emerg-Room $ 0 Co-Payment For Non-Emerg Use Of Emerg-Room $ 10 Coverage Type/Option Type NA Secretary Approved Secretary Approved Existing Comprehensive Option NA Same as Medicaid Same as Medicaid State-Based Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 0 0 0 Subsidy For Private/Employer Coverage no no no no Min. Employer Premium Share Required for Subsidy NA NA NA NA a. The Children's Medical Services Network is for children with special health care needs. b. FL has approval from CMS to impose a cap in its separate state program if in a given fiscal year the state has utilized all of its budgeted funds. CRS-36 Program Info State Georgia. Separate State Program Only Program Name PeachCare for Kids Type Of Program Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 1 185 235 Next Youngest 1 5 133 235 Older 6 18 100 235 Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 12 Presumptive Eligibility no Prenatal Care for Unborn Children no Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required yes Sliding Scale for Cost-Sharing age Sliding Scale Group Defined Group 1a Group 2a Group 3 Group 4 0 6 Range (%FPL) 5 18 Premium or Enrollment Fee Required monthly Premium/Fee Per Child $ 0 $ 7.50 Family Cap $ 0 $ 15 Co-Payments Co-Payment For Brand Name Rx Drugs Co-Payment For Generic Rx Drugs Co-Payment For Office Visits Co-Payment For Inpatient Services Co-Payment For Emerg Use Of Emerg-Room Co-Payment For Non-Emerg Use Of Emerg-Room Coverage Type/Option Type Secretary Approved Option Benchmark Plus Additionalb Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 3 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA a. GA bases its sliding scale on age rather than income. b. Largest HMO plus additional benefits. CRS-37 Program Info State Hawaii. Medicaid Expansion Only Program Name QUEST and Medicaid FFS Type Of Program Medicaid Expansion State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this yesa Program Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 1 185 200 Next Youngest 1 5 133 200 Older 6 18 100 200 Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 0 Presumptive Eligibility no Prenatal Care for Unborn Children NA Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required NA Sliding Scale for Cost-Sharing NA Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 Range (%FPL) Premium or Enrollment Fee Required Premium/Fee Per Child Family Cap Co-Payments Co-Payment For Brand Name Rx Drugs Co-Payment For Generic Rx Drugs Co-Payment For Office Visits Co-Payment For Inpatient Services Co-Payment For Emerg Use Of Emerg-Room Co-Payment For Non-Emerg Use Of Emerg-Room Coverage Type/Option Type Comprehensive Medicaid Section 1115 waiver Option NA Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA a. HI uses SCHIP funds to expand QUEST, its comprehensive Medicaid Section 1115 waiver program. Children with disabilities are served through the Medicaid fee-for-service (FFS) program. CRS-38 Program Info State Idaho. Medicaid Expansion Only Program Name Idaho CHIP Type Of Program Medicaid Expansion State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 5 133 150 Next Youngest 6 18 100 150 Older Oldest Basic Income Disregard yes Asset Tests yes Continuous Eligibility (months) 12 Presumptive Eligibility no Prenatal Care for Unborn Children NA Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required NA Sliding Scale for Cost-Sharing NA Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 Range (%FPL) Premium or Enrollment Fee Required Premium/Fee Per Child Family Cap Co-Payments Co-Payment For Brand Name Rx Drugs Co-Payment For Generic Rx Drugs Co-Payment For Office Visits Co-Payment For Inpatient Services Co-Payment For Emerg Use Of Emerg-Room Co-Payment For Non-Emerg Use Of Emerg-Room Coverage Type/Option Type NA Option NA Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA CRS-39 Program Info State Illinois. Combination Program Name KidCare Assist Expansion KidCare Share KidCare Premium Type Of Program Medicaid Expansion Separate State Program Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no yesa yesa Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program yesa yesa yesa Eligibility Age Income (%FPL) Age Income (%FPL) Age Income (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper Lower Upper Lower Upper Youngest 6 18 100 133 0 18 133 150 0 18 150 185 Next Youngest Older Oldest Basic Income Disregard yes yes yes Asset Tests no no no Continuous Eligibility (months) 12 12 12 Presumptive Eligibility no no no Prenatal Care for Unborn Children NA yesb yesb Enrollment Cap / Waiting List no no no Cost Sharing Cost Sharing Required NA yes yes Sliding Scale for Cost-Sharing NA no no Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 Group 1 Group 2 Group 3 Group 4 Group 1 Group 2 Group 3 Group 4 133 150 Range (%FPL) 150 185 Premium or Enrollment Fee Required no monthly Premium/Fee Per Child $ 15 Family Cap $ 30 Co-Payments Co-Payment For Brand Name Rx Drugs $ 2 $ 5 Co-Payment For Generic Rx Drugs $ 2 $ 3 CRS-40 Co-Payment For Office Visits $ 2 $ 5 Co-Payment For Inpatient Services $ 0 $ 0 missing Co-Payment For Emerg Use Of Emerg-Room $ 2 info Co-Payment For Non-Emerg Use Of Emerg-Room $ 2 $ 25 Coverage Type/Option Type NA Benchmark Equivalent Benchmark Equivalent Option NA State Employee State Employee Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 0 0 Subsidy For Private/Employer Coverage no yesa yesa Min. Employer Premium Share Required for Subsidy NA a a a. Illinois' HIFA waiver allows the state to use Medicaid and SCHIP funds to cover parents of Medicaid and SCHIP children. The demonstration also provides Title XXI funding for the Illinois Comprehensive Health Insurance Program and hemophiliacs (both previously state-funded programs). Illinois' waiver also allows the state to provide a subsidy for ESI that can (1) offer a reduced benefits package (however, the state must ensure that all age-appropriate immunizations are covered), and (2) impose cost-sharing that exceeds the aggregate, annual 5% of family income limitation in the SCHIP statute. The terms and conditions of the waiver proscribe that enrollment in ESI is voluntary and that the state must inform enrollees of the implications of choosing private or employer-sponsored insurance. The waiver also waives the minimum employer contribution requirement. b. IL offers prenatal care from confirmation of pregnancy through birth to pregnant women in families with income up to 200% FPL. CRS-41 Program Info State Indiana. Combination Program Name Hoosier Healthwise Phase I Hoosier Healthwise Phase II Type Of Program Medicaid Expansion Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no no Eligibility Income Age (%FPL) Age Income (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper Youngest 1 5 133 150 0 18 150 200 Next Youngest 6 18 100 150 Older Oldest Basic Income Disregard yes yes Asset Tests no no Continuous Eligibility (months) 0 12 Presumptive Eligibility no no Prenatal Care for Unborn Children NA no Enrollment Cap / Waiting List no no Cost Sharing Cost Sharing Required NA yes Sliding Scale for Cost-Sharing NA income Group Group Group Group Group Group Group Group Sliding Scale Group Defined 1 2 3 4 1 2 3 4 150 175 Range (%FPL) 175 200 Premium or Enrollment Fee Required monthly Premium/Fee Per Child $ 11 $16.50 Family Cap $ 16.50 $24.75 Co-Payments Co-Payment For Brand Name Rx Drugs $ 10 $ 10 Co-Payment For Generic Rx Drugs $ 3 $ 3 Co-Payment For Office Visits $ 0 $ 0 Co-Payment For Inpatient Services $ 0 $ 0 Co-Payment For Emerg Use Of Emerg-Room $ 0 $ 0 Co-Payment For Non-Emerg Use Of Emerg-Room $ 0 $ 0 Coverage Type/Option Type NA Benchmark Equivalent Option NA FEHBP Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 3 Subsidy For Private/Employer Coverage no no Min. Employer Premium Share Required for Subsidy NA NA CRS-42 Program Info State Iowa. Combination Healthy Well Kids Iowa Program Name Medicaid (HAWK-I) Type Of Program Medicaid Expansion Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no no Eligibility Income Income Age (%FPL) Age (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper Youngest 0 1 185 200 1 18 133 200 Next Youngest 6 18 100 133 Older Oldest Basic Income Disregard yes yes Asset Tests no no Continuous Eligibility (months) 0 12 Presumptive Eligibility no no Prenatal Care for Unborn Children NA no Enrollment Cap / Waiting List no no Cost Sharing Cost Sharing Required NA yes Sliding Scale for Cost-Sharing NA income Group Group Group Group Group Group Group Group Sliding Scale Group Defined 1 2 3 4 1 2 3 4 133 150 Range (%FPL) 150 200 Premium or Enrollment Fee Required monthly Premium/Fee Per Child $ 0 $ 10 Family Cap $ 0 $ 20 Co-Payments Co-Payment For Brand Name Rx Drugs $ 0 $ 0 Co-Payment For Generic Rx Drugs $ 0 $ 0 Co-Payment For Office Visits $ 0 $ 0 Co-Payment For Inpatient Services $ 0 $ 0 Co-Payment For Emerg Use Of Emerg-Room $ 0$ 0 Co-Payment For Non-Emerg Use Of Emerg-Room $ 0$ 25 Coverage Type/Option Type NA Benchmark Equivalent Option NA State Employee Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 6 Subsidy For Private/Employer Coverage no no Min. Employer Premium Share Required for Subsidy NA NA CRS-43 Program Info State Kansas. Separate State Program Only Program Name Health Wave Type Of Program Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 1 150 200 Next Youngest 1 5 133 200 Older 6 18 100 200 Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 12 Presumptive Eligibility no Prenatal Care for Unborn Children no Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required yes Sliding Scale for Cost-Sharing income Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 150 175 Range (%FPL) 175 200 Premium or Enrollment Fee Required monthly Premium/Fee Per Child $ 10 $ 15 Family Cap $ 10 $ 15 Co-Payments Co-Payment For Brand Name Rx Drugs $ 0 $ 0 Co-Payment For Generic Rx Drugs $ 0 $ 0 Co-Payment For Office Visits $ 0 $ 0 Co-Payment For Inpatient Services $ 0 $ 0 Co-Payment For Emerg Use Of Emerg-Room $ 0 $ 0 Co-Payment For Non-Emerg Use Of Emerg-Room $ 0 $ 0 Coverage Type/Option Type Secretary Approved Option Benchmark Plus Additionala Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA a. State employee plan plus dental and mental health. CRS-44 Program Info State Kentucky. Combination KCHIP Separate Insurance Program Name KCHIP Medicaid Expansion Program Type Of Program Medicaid Expansion Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no no Eligibility Income Income Age (%FPL) Age (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper Youngest 1 5 133 150 0 1 185 200 Next Youngest 6 18 100 150 1 18 150 200 Older Oldest Basic Income Disregard yes yes Asset Tests no no Continuous Eligibility (months) 0a 0 Presumptive Eligibility no no Prenatal Care for Unborn Children NA no Enrollment Cap / Waiting List no no Cost Sharing Cost Sharing Required yesb yesb b Sliding Scale for Cost-Sharing age ageb Group Group Group Group Group Group Group Group Sliding Scale Group Defined 1 2 3 4 1 2 3 4 0 18 0 18 Range (%FPL) 17 18 17 18 Premium or Enrollment Fee Required no no Premium/Fee Per Child $ 0 $ 0 $ 0$ 0 Family Cap $ 0 $ 0 $ 0$ 0 Co-Payments Co-Payment For Brand Name Rx Drugs $ 0 $ 1 $ 0 $ 1 Co-Payment For Generic Rx Drugs $ 0 $ 1 $ 0 $ 1 Co-Payment For Office Visits $ 0 $ 0 $ 0 $ 0 Co-Payment For Inpatient Services $ 0 $ 0 $ 0 $ 0 Co-Payment For Emerg Use Of Emerg-Room $ 0 $ 0 $ 0 $ 0 Co-Payment For Non-Emerg Use Of Emerg-Room $ 0$ 0 $ 0$ 0 Coverage Type/Option Type NA Secretary Approved Option NA Benchmark Plus Additionalc Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 6 Subsidy For Private/Employer Coverage no no Min. Employer Premium Share Required for Subsidy NA NA a. Children living in regions covered by Kentucky's sub-state Health Care Partnership Section 1115 waiver receive six months continuous eligibility. CRS-45 b. KY charges 18-year olds a $1 co-pay for pharmacy prescriptions, which is the same cost-sharing requirement that is imposed through the state's Title XIX state plan. c. State employee plus additional benefits. CRS-46 Program Info State Louisiana. Medicaid Expansion Only Program Name LaCHIP Type Of Program Medicaid Expansion State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 5 133 200 Next Youngest 6 18 100 200 Older Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 12 Presumptive Eligibility no Prenatal Care for Unborn Children NA Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required NA Sliding Scale for Cost-Sharing NA Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 Range (%FPL) Premium or Enrollment Fee Required Premium/Fee Per Child Family Cap Co-Payments Co-Payment For Brand Name Rx Drugs Co-Payment For Generic Rx Drugs Co-Payment For Office Visits Co-Payment For Inpatient Services Co-Payment For Emerg Use Of Emerg-Room Co-Payment For Non-Emerg Use Of Emerg-Room Coverage Type/Option Type NA Option NA Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA CRS-47 Program Info State Maine. Combination Program Name MaineCare MaineCare Type Of Program Medicaid Expansion Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no no Eligibility Income Income Age (%FPL) Age (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper Youngest 1 5 133 150 0 1 185 200 Next Youngest 6 18 125 150 1 18 150 200 Older Oldest Basic Income Disregard yes no Asset Tests no no Continuous Eligibility (months) 12 12 Presumptive Eligibility no no Prenatal Care for Unborn Children NA no Enrollment Cap / Waiting List no no Cost Sharing Cost Sharing Required NA yes Sliding Scale for Cost-Sharing NA income Group Group Group Group Group Group Group Group Sliding Scale Group Defined 1 2 3 4 1 2 3 4 150 160 170 185 Range (%FPL) 160 170 185 200 Premium or Enrollment Fee Required monthly Premium/Fee Per Child $ 5 $ 10 $ 15 $ 20 Family Cap $ 10 $ 20 $ 30 $ 40 Co-Payments Co-Payment For Brand Name Rx Drugs $ 0 $ 0 $ 0 $ 0 Co-Payment For Generic Rx Drugs $ 0 $ 0 $ 0 $ 0 Co-Payment For Office Visits $ 0 $ 0 $ 0 $ 0 Co-Payment For Inpatient Services $ 0 $ 0 $ 0 $ 0 Co-Payment For Emerg Use Of Emerg-Room $ 0 $ 0 $ 0 $ 0 Co-Payment For Non-Emerg Use Of Emerg-Room $ 0$ 0$ 0$ 0 Coverage Type/Option Type NA Secretary Approved Option NA Same as Medicaid Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 3 Subsidy For Private/Employer Coverage no no Min. Employer Premium Share Required for Subsidy NA NA CRS-48 Program Info State Maryland. Combination Maryland Children's Health Maryland Children's Health Program Name Program (I) Program (II) Type Of Program Medicaid Expansion Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program yesa no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no no Eligibility Income Age (%FPL) Age Income (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper Youngest 0 1 185 200 0 18 200 300 Next Youngest 1 5 133 200 Older 6 18 100 200 Oldest Basic Income Disregard yes yes Asset Tests no no Continuous Eligibility (months) 6 12 Presumptive Eligibility no no Prenatal Care for Unborn Children NA no Enrollment Cap / Waiting List no no Cost Sharing Cost Sharing Required NA yes Sliding Scale for Cost-Sharing NA income Group Group Group Group Group Group Group Group Sliding Scale Group Defined 1 2 3 4 1 2 3 4 200 250 Range (%FPL) 250 300 Premium or Enrollment Fee Required monthly Premium/Fee Per Child $ 40 $ 50 Family Cap $ 40 $ 50 Co-Payments Co-Payment For Brand Name Rx Drugs $ 0 $ 0 Co-Payment For Generic Rx Drugs $ 0 $ 0 Co-Payment For Office Visits $ 0 $ 0 Co-Payment For Inpatient Services $ 0 $ 0 Co-Payment For Emerg Use Of Emerg-Room $ 0 $ 0 Co-Payment For Non-Emerg Use Of Emerg-Room $ 0$ 0 Coverage Type/Option Type NA Secretary Approved Option NA Same as Medicaid Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 6a 6 Subsidy For Private/Employer Coverage no yesb Min. Employer Premium Share Required for Subsidy NA 30% a. MD has a Section 1115 waiver allowing a six-month waiting period prior to enrollment in the state's SCHIP Medicaid Expansion program. CRS-49 b. For Employer Sponsored Insurance (ESI) to qualify for a subsidy through the state's separate state program, a plan offered by small employers must use the state's largest HMO as a benchmark. A plan offered by large employers must either be (1) the benchmark-equivalent of the state's largest HMO, or (2) substantially equivalent to or greater than the state's largest HMO through a benefit by benefit comparison (Secretary-Approved coverage). A child who has access to qualifying ESI is required to enroll in ESI if the employed parent is already enrolled in ESI for him- or herself. If the parent is not already enrolled in ESI, it is the family's choice whether to enroll in ESI or in the state's separate state program. CRS-50 Program Info State Massachusetts. Combination MassHealth Family Assist Direct Program Name MassHealth Standard MassHealth CommonHealtha Coverage (DC) MassHealth Premium Assistance Type Of Program Medicaid Expansion Separate State Program Separate State Program Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no no no no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no no no no Eligibility Income Income Age (%FPL) Age (%FPL) Age Income (%FPL) Age Income (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper Lower Upper Lower Upper Lower Upper Lower Upper Youngest 0 1 185 200 1 18 150 200 1 18 150 200 1 18 150 200 Next Youngest 1 5 133 150 Older 6 14 115 150 Oldest 15 18 100 150 Basic Income Disregard no no no no Asset Tests no no no no Continuous Eligibility (months) 0 0 0 0 Presumptive Eligibility yes no yes no Prenatal Care for Unborn Children NA no no no Enrollment Cap / Waiting List no no no no Cost Sharing Cost Sharing Required NA yes yes yes Sliding Scale for Cost-Sharing NA income no no Group Group Group Group Group Group Group Group Group Group Group Group Group Group Group Group Group Sliding Scale Group Defined 1 2 3 4 1 2 3 4 5 1 2 3 4 1 2 3 4 150 160 170 180 190 150 150 Range (%FPL) 160 170 180 190 200 200 200 Premium or Enrollment Fee Required monthly monthly monthly Premium/Fee Per Child $ 15 $ 20 $ 25 $ 30 $ 35 $ 12 $ 12 Family Cap $ 15 $ 20 $ 25 $ 30 $ 35 $ 36 $ 36 CRS-51 Co-Payments Co-Payment For Brand Name Rx Drugs $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 b Co-Payment For Generic Rx Drugs $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 b Co-Payment For Office Visits $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 b Co-Payment For Inpatient Services $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 b Co-Payment For Emerg Use Of Emerg-Room $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 b Co-Payment For Non-Emerg Use Of Emerg-Room $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 b Coverage Type/Option Type NA Benchmark Benchmark Secretary Approved Comprehensive Medicaid Section Option NA Largest HMO Largest HMO 1115 Waiver Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 0 0 0 Subsidy For Private/Employer Coverage no noc noc yesc Min. Employer Premium Share Required for Subsidy NA NA NA 50% a. The CommonHealth Program is for children who are permanently and totally disabled and provides benefits that are common in Medicaid but not necessarily in separate state programs, such as nursing home and personal care. b. Employer sponsored insurance can charge copays, coinsurance, and deductibles. The state will pay these amounts for children eligible for premium assistance provided: (1) the copay, coinsurance or deductible was incurred as the result of a well-baby/well-child care visit; or (2) the policyholder's annualized share of the employer-sponsored health insurance premiums, combined with copays, coinsurance,and deductibles incurred and paid by members, exceeds 5% of the family group's gross income in a 12-month period beginning with the date of eligibility for premium assistance. Members receive an initial notice at the time of eligibility explaining the state's policy on payment of copays, coinsurance and deductibles. Providers may bill the state directly or members may seek reimbursement from the state. c. Children eligible for Family Assist DC are required to enroll in employer sponsored coverage through the Premium Assistance program if their family has access to a qualified plan. Children eligible for CommonHealth have the option to enroll in employer sponsored coverage through the Premium Assistance program if their family has access to a qualified plan. Note: MA also covers pregnant adolescents with self-declared income between 185-200% FPL for which the unborn child(ren) are counted as if born in determining family size for the purpose of evaluating income eligibility. CRS-52 Program Info State Michigan. Combination Program Name Healthy Kids MIChild Type Of Program Medicaid Expansion Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no no Eligibility Income Income Age (%FPL) Age (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper Youngest 16 18 100 150 0 1 185 200 Next Youngest 1 18 150 200 Older Oldest Basic Income Disregard yes yes Asset Tests no no Continuous Eligibility (months) 0 12 Presumptive Eligibility no yes Prenatal Care for Unborn Children NA yesa Enrollment Cap / Waiting List no no Cost Sharing Cost Sharing Required NA yes Sliding Scale for Cost-Sharing NA no Group Group Group Group Group Group Group Group Sliding Scale Group Defined 1 2 3 4 1 2 3 4 150 Range (%FPL) 200 Premium or Enrollment Fee Required monthly Premium/Fee Per Child $ 5 Family Cap $ 5 Co-Payments Co-Payment For Brand Name Rx Drugs $ 0 Co-Payment For Generic Rx Drugs $ 0 Co-Payment For Office Visits $ 0 Co-Payment For Inpatient Services $ 0 Co-Payment For Emerg Use Of Emerg-Room $ 0 Co-Payment For Non-Emerg Use Of Emerg-Room $ 0 Coverage Type/Option Type NA Benchmark Option NA State Employee Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 6 Subsidy For Private/Employer Coverage no no Min. Employer Premium Share Required for Subsidy NA NA a. MI offers prenatal care from conception through birth to pregnant women in families with income up to 185% FPL. CRS-53 Program Info State Minnesota. Medicaid Expansion Only Program Name Minnesota Medical Assistance Program Type Of Program Medicaid Expansion State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program yesa Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 2 275 280 Next Youngest Older Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 0 Presumptive Eligibility no Prenatal Care for Unborn Children NA Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required NA Sliding Scale for Cost-Sharing NA Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 Range (%FPL) Premium or Enrollment Fee Required Premium/Fee Per Child Family Cap Co-Payments Co-Payment For Brand Name Rx Drugs Co-Payment For Generic Rx Drugs Co-Payment For Office Visits Co-Payment For Inpatient Services Co-Payment For Emerg Use Of Emerg-Room Co-Payment For Non-Emerg Use Of Emerg-Room Coverage Type/Option Type NA Option NA Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA a. Minnesota's Section 1115 waiver allows the state to use SCHIP funds to cover parents and relative caretakers of Medicaid and SCHIP eligible children whose income level is between 100 to 200% FPL. CRS-54 Program Info State Mississippi. Separate State Program Only Program Name Mississippi Health Benefits Program (II) Type Of Program Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 1 185 200 Next Youngest 1 5 133 200 Older 6 18 100 200 Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 12 Presumptive Eligibility noa Prenatal Care for Unborn Children no Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required yes Sliding Scale for Cost-Sharing incomeb Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 100 150 175 Range (%FPL) 150 175 200 Premium or Enrollment Fee Required no Premium/Fee Per Child Family Cap Co-Payments Co-Payment For Brand Name Rx Drugs $ 0 $ 0 $ 0 Co-Payment For Generic Rx Drugs $ 0 $ 0 $ 0 Co-Payment For Office Visits $ 0 $ 5 $ 5 Co-Payment For Inpatient Services $ 0 $ 0 $ 0 Co-Payment For Emerg Use Of Emerg-Room $ 0 $ 15 $ 15 Co-Payment For Non-Emerg Use Of Emerg-Room $ 0 $ 15 $ 15 Coverage Type/Option Type Secretary Approved Option Benchmark Plus Additionalc Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 Subsidy For Private/Employer Coverage nod Min. Employer Premium Share Required for Subsidy NAd a. MS has CMS approval to use presumptive eligibility but has chosen not to implement it. b. The difference in cost-sharing between Groups 2 and 3 is that the out-of-pocket maximum is $800 for Group 2 and $950 for Group 3. c. State employee plan plus dental and vision benefits. d. MS has CMS approval to subsidize ESI, but the program has not been implemented and is on hold indefinitely. CRS-55 Program Info State Missouri. Medicaid Expansion Only Program Name Managed Care Plus for Kids Type Of Program Medicaid Expansion State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program yesa Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 1 185 300 Next Youngest 1 5 133 300 Older 6 18 100 300 Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 0 Presumptive Eligibility yes Prenatal Care for Unborn Children NA Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required yesa Sliding Scale for Cost-Sharing incomeb Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 185 225 250 275 Range (%FPL) 225 250 275 300 Premium or Enrollment Fee Required monthlyc Premium/Fee Per Child $ 0$ 59 $ 69 $ 78 Family Cap $ 0$ 206 $ 225 $ 225 Co-Payments Co-Payment For Brand Name Rx Drugs $ 0 $ 9 $ 9 $ 9 Co-Payment For Generic Rx Drugs $ 0 $ 9 $ 9 $ 9 Co-Payment For Office Visits $ 5 $ 10 $ 10 $ 10 Co-Payment For Inpatient Services $ 0 $ 0 $ 0 $ 0 Co-Payment For Emerg Use Of Emerg-Room $ 0 $ 0 $ 0 $ 0 Co-Payment For Non-Emerg Use Of Emerg-Room $ 0 $ 0 $ 0 $ 0 Coverage Type/Option Type Comprehensive Medicaid Section 1115 waiver Option NA Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 6a Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA a. MO uses SCHIP funds to expand its comprehensive Medicaid Section 1115 waiver, which, among other things, allows a six month waiting period and cost sharing that exceeds Medicaid allowable amounts. b. There is no cost-sharing for enrollees with family income between 100-185% FPL. c. The per-child amount shown is cost of the first child; successive children are charged a lower premium. CRS-56 Program Info State Montana. Separate State Program Only Program Name Montana CHIP Type Of Program Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 5 133 150 Next Youngest 6 18 100 150 Older Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 12 Presumptive Eligibility no Prenatal Care for Unborn Children no Enrollment Cap / Waiting List yes Cost Sharing Cost Sharing Required yes Sliding Scale for Cost-Sharing no Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 100 Range (%FPL) 150 Premium or Enrollment Fee Required no Premium/Fee Per Child Family Cap Co-Payments Co-Payment For Brand Name Rx Drugs $ 5 Co-Payment For Generic Rx Drugs $ 3 Co-Payment For Office Visits $ 3 Co-Payment For Inpatient Services $ 25 Co-Payment For Emerg Use Of Emerg-Room $ 5 Co-Payment For Non-Emerg Use Of Emerg-Room $ 5 Coverage Type/Option Type Benchmark Equivalent Option State Employee Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 3 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA CRS-57 Program Info State Nebraska. Medicaid Expansion Only Program Name Kids Connection Type Of Program Medicaid Expansion State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 1 150 185 Next Youngest 1 5 133 185 Older 6 18 100 185 Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 6a Presumptive Eligibility yes Prenatal Care for Unborn Children NA Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required NA Sliding Scale for Cost-Sharing NA Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 Range (%FPL) Premium or Enrollment Fee Required Premium/Fee Per Child Family Cap Co-Payments Co-Payment For Brand Name Rx Drugs Co-Payment For Generic Rx Drugs Co-Payment For Office Visits Co-Payment For Inpatient Services Co-Payment For Emerg Use Of Emerg-Room Co-Payment For Non-Emerg Use Of Emerg-Room Coverage Type/Option Type NA Option NA Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA a. In NE, only the first six months of coverage are continuous. CRS-58 Program Info State Nevada. Separate State Program Only Program Name Nevada Check Up Type Of Program Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 5 133 200 Next Youngest 6 18 100 200 Older Oldest Basic Income Disregard no Asset Tests no Continuous Eligibility (months) 12 Presumptive Eligibility no Prenatal Care for Unborn Children no Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required yes Sliding Scale for Cost-Sharing income Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 100 150 175 Range (%FPL) 150 175 200 Premium or Enrollment Fee Required quarterly Premium/Fee Per Child $ 10 $ 25 $ 50 Family Cap $ 10 $ 25 $ 50 Co-Payments Co-Payment For Brand Name Rx Drugs $ 0 $ 0 $ 0 Co-Payment For Generic Rx Drugs $ 0 $ 0 $ 0 Co-Payment For Office Visits $ 0 $ 0 $ 0 Co-Payment For Inpatient Services $ 0 $ 0 $ 0 Co-Payment For Emerg Use Of Emerg-Room $ 0 $ 0 $ 0 Co-Payment For Non-Emerg Use Of Emerg-Room $ 0 $ 0 $ 0 Coverage Type/Option Type Secretary Approved Option Same as Medicaid Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 6 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA CRS-59 Program Info State New Hampshire. Combination Program Name Healthy Kids - Gold Healthy Kids - Silver Type Of Program Medicaid Expansion Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no no Eligibility Income Income Age (%FPL) Age (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper Youngest 0 1 185 300 1 18 185 300 Next Youngest Older Oldest Basic Income Disregard yes yes Asset Tests no no Continuous Eligibility (months) 0 0 Presumptive Eligibility yes no Prenatal Care for Unborn Children NA no Enrollment Cap / Waiting List no no Cost Sharing Cost Sharing Required NA yes Sliding Scale for Cost-Sharing NA income Group Group Group Group Group Group Group Group Sliding Scale Group Defined 1 2 3 4 1 2 3 4 185 250 Range (%FPL) 250 300 Premium or Enrollment Fee Required monthly Premium/Fee Per Child $ 25 $ 45 Family Cap $ 100 $ 135 Co-Payments Co-Payment For Brand Name Rx Drugs $ 10 $ 10 Co-Payment For Generic Rx Drugs $ 5 $ 5 Co-Payment For Office Visits $ 10 $ 10 Co-Payment For Inpatient Services $ 0 $ 0 Co-Payment For Emerg Use Of Emerg-Room $ 50 $ 50 Co-Payment For Non-Emerg Use Of Emerg-Room $ 50 $ 50 Coverage Type/Option Type NA Benchmark Equivalent Option NA FEHBP Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 6 Subsidy For Private/Employer Coverage no no Min. Employer Premium Share Required for Subsidy NA NA CRS-60 Program Info State New Jersey. Combination Program Name NJ FamilyCare Plan A NJ Family Care Plan B NJ Family Care Plan C NJ Family Care Plan D Type Of Program Medicaid Expansion Separate State Program Separate State Program Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no no no no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program yesa yesa yesa yesa Eligibility Age Income (%FPL) Age Income (%FPL) Age Income (%FPL) Age Income (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper Lower Upper Lower Upper Lower Upper Lower Upper Youngest 6 18 100 133 1 18 133 150 0 1 185 200 0 18 200 350 Next Youngest 1 18 150 200 Older Oldest Basic Income Disregard yes no no yesb Asset Tests no no no no Continuous Eligibility (months) 0 0 0 0 Presumptive Eligibility yes yes yes no Prenatal Care for Unborn Children NA no no no Enrollment Cap / Waiting List no no no no Cost Sharing Cost Sharing Required NA no yes yes Sliding Scale for Cost-Sharing NA NA no income Group Group Group Group Group Group Group Group Group Group Group Group Group Group Group Group Sliding Scale Group Defined 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 150 200 250 300 Range (%FPL) 200 250 300 350 Premium or Enrollment Fee Required monthly monthly Premium/Fee Per Child $ 15 $ 30 $ 60 $ 100 Family Cap $ 15 $ 30 $ 60 $ 100 CRS-61 Co-Payments Co-Payment For Brand Name Rx Drugs $ 5 $ 5 $ 5 $ 5 Co-Payment For Generic Rx Drugs $ 1 $ 5 $ 5 $ 5 Co-Payment For Office Visits $ 5 $ 5 $ 5 $ 5 Co-Payment For Inpatient Services $ 0 $ 0 $ 0 $ 0 Co-Payment For Emerg Use Of Emerg-Room $ 10 $ 35 $ 35 $ 35 Co-Payment For Non-Emerg Use Of Emerg-Room $ 10 $ 35 $ 35 $ 35 Coverage Type/Option Type NA Benchmark Benchmark Benchmark Option NA FEHBP FEHBP Largest HMO Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 6 6 6 Subsidy For Private/Employer Coverage no yesc yesc yesc Min. Employer Premium Share Required for Subsidy NA 50% 50% 50% a. New Jersey's Section 1115 waiver allows the state to cover (1) parents of children eligible for the NJ KidCare program, including parents with income below 133% of the FPL in the Medicaid Expansion program and parents between 134 and 200% FPL in the separate child health program, and (2) pregnant women between 185 and 200% FPL who are not eligible for Medicaid. b. The state disregards all income between 200%-350% FPL to determine eligibility for Family Care Plan D. c. Children whose parents have access to employer-sponsored insurance that is cost-effective and that meets the benefits qualifications must enroll in the employer plan for family coverage. CRS-62 Program Info State New Mexico. Medicaid Expansion Only Program Name Salud! Medicaid Type Of Program Medicaid Expansion State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program yesa Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program yesb Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 18 185 235 Next Youngest Older Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 12 Presumptive Eligibility yes Prenatal Care for Unborn Children NA Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required yesa Sliding Scale for Cost-Sharing no Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 185 Range (%FPL) 235 Premium or Enrollment Fee Required no Premium/Fee Per Child Family Cap Co-Payments Co-Payment For Brand Name Rx Drugs $ 2 Co-Payment For Generic Rx Drugs $ 2 Co-Payment For Office Visits $ 5 Co-Payment For Inpatient Services $ 25 Co-Payment For Emerg Use Of Emerg-Room $ 15 Co-Payment For Non-Emerg Use Of Emerg-Room $ 15 Coverage Type/Option Type Comprehensive Medicaid Section 1115 waiver Option NA Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA a. NM uses SCHIP funds to expand its comprehensive Medicaid Section 1115 waiver, which, among other things, allows cost sharing that exceeds Medicaid allowable amounts. b. New Mexico's HIFA waiver allows the state to cover uninsured parents and childless adults with incomes up to 200% FPL. CRS-63 Program Info State New York. Combination Child Health Plus A: Growing Up Child Health Plus B: Growing Up Program Name Healthy Healthy Type Of Program Medicaid Expansion Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program noa noa Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program noa noa Eligibility Age Income (%FPL) Age Income (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper Youngest 6 18 100 133 0 1 185 250 Next Youngest 1 18 133 250 Older Oldest Basic Income Disregard yes no Asset Tests no no Continuous Eligibility (months) 12 0 Presumptive Eligibility no yes Prenatal Care for Unborn Children NA no Enrollment Cap / Waiting List no no Cost Sharing Cost Sharing Required NA yes Sliding Scale for Cost-Sharing NA income Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 Group 1 Group 2 Group 3 Group 4 133 160 223 Range (%FPL) 160 223 250 Premium or Enrollment monthly Fee Required Premium/Fee Per Child $ 0$ 9$ 15 Family Cap $ 0$ 27 $ 45 Co-Payments Co-Payment For Brand Name Rx Drugs $ 0$ 0$ 0 Co-Payment For Generic Rx Drugs $ 0$ 0$ 0 Co-Payment For Office Visits $ 0$ 0$ 0 Co-Payment For Inpatient Services $ 0$ 0$ 0 Co-Payment For Emerg Use Of Emerg-Room $ 0$ 0$ 0 Co-Payment For Non-Emerg Use Of Emerg-Room $ 0$ 0$ 0 CRS-64 Coverage Type/Option Type NA Existing Comprehensive State-Based Option NA NA Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 0 Subsidy For Private/Employer Coverage no no Min. Employer Premium Share Required for Subsidy NA NA a. New York City had a Medicaid and SCHIP Disaster Relief waiver to address the effects of Sept. 11, 2001. The waiver was effective Sept. 11, 2001 through Jan. 31, 2003. CRS-65 Program Info State North Carolina. Separate State Program Only Program Name NC Health Choice for Children Type Of Program Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 1 185 200 Next Youngest 1 5 133 200 Older 6 18 100 200 Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 12 Presumptive Eligibility no Prenatal Care for Unborn Children no Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required yes Sliding Scale for Cost-Sharing income Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 100 150 Range (%FPL) 150 200 Premium or Enrollment Fee Required annually Premium/Fee Per Child $ 0$ 50 Family Cap $ 0$ 100 Co-Payments Co-Payment For Brand Name Rx Drugs $ 0 $ 6 Co-Payment For Generic Rx Drugs $ 0 $ 6 Co-Payment For Office Visits $ 0 $ 5 Co-Payment For Inpatient Services $ 0 $ 0 Co-Payment For Emerg Use Of Emerg-Room $ 0 $ 0 Co-Payment For Non-Emerg Use Of Emerg-Room $ 0 $ 20 Coverage Type/Option Type Benchmark Option State Employee Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA CRS-66 Program Info State North Dakota. Combination Program Name North Dakota Medicaid Healthy Steps Type Of Program Medicaid Expansion Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no no Eligibility Income Income Age (%FPL)a Age (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper Youngest 0 5 1 133 0 5 133 140 Next Youngest 6 18 1 100 6 18 100 140 Older Oldest Basic Income Disregard yes yes Asset Tests noa no Continuous Eligibility (months) 0 12 Presumptive Eligibility no no Prenatal Care for Unborn Children NA no Enrollment Cap / Waiting List no no Cost Sharing Cost Sharing Required NA yes Sliding Scale for Cost-Sharing NA no Group Group Group Group Group Group Group Group Sliding Scale Group Defined 1 2 3 4 1 2 3 4 100 Range (%FPL) 140 Premium or Enrollment Fee Required no Premium/Fee Per Child Family Cap Co-Payments Co-Payment For Brand Name Rx Drugs $ 2 Co-Payment For Generic Rx Drugs $ 2 Co-Payment For Office Visits $ 0 Co-Payment For Inpatient Services $ 0b Co-Payment For Emerg Use Of Emerg-Room $ 5 Co-Payment For Non-Emerg Use Of Emerg-Room $ 5 Coverage Type/Option Type NA Benchmark Equivalent Option NA State Employee Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 6 Subsidy For Private/Employer Coverage no no Min. Employer Premium Share Required for Subsidy NA NA a. The income thresholds shown are used for both Medicaid and SCHIP purposes. ND eliminated asset tests from its Medicaid program in Jan. 2002. Title XIX financing is used for children who meet the income thresholds shown and who have assets below the Title XIX asset test thresholds in place in 1997 (the CRS-67 maintenance of effort point for SCHIP). Title XXI financing is used for children who meet the income thresholds shown and who have assets exceeding the Title XIX asset test thresholds in place in 1997. b. ND requires a $50 deductible for the first day of each inpatient hospital admission in a general hospital or a psychiatric or substance abuse inpatient facility. CRS-68 Program Info State Ohio. Medicaid Expansion Only Program Name Healthy Start Type Of Program Medicaid Expansion State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program yesa Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 5 133 200 Next Youngest 6 18 100 200 Older Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 0 Presumptive Eligibility no Prenatal Care for Unborn Children NA Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required NA Sliding Scale for Cost-Sharing NA Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 Range (%FPL) Premium or Enrollment Fee Required Premium/Fee Per Child Family Cap Co-Payments Co-Payment For Brand Name Rx Drugs Co-Payment For Generic Rx Drugs Co-Payment For Office Visits Co-Payment For Inpatient Services Co-Payment For Emerg Use Of Emerg-Room Co-Payment For Non-Emerg Use Of Emerg-Room Coverage Type/Option Type NA Option NA Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA a. OH has received approval for a Section 1115 waiver allowing an annual enrollment fee and 12 months continuous coverage for children in families with income between 151-200% FPL; however, the state has chosen not to implement the waiver. CRS-69 Program Info State Oklahoma. Medicaid Expansion Only Program Name SoonerCare Type Of Program Medicaid Expansion State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 1 150 185 Next Youngest 1 5 133 185 Older 6 17 100 185 Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 0 Presumptive Eligibility no Prenatal Care for Unborn Children NA Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required NA Sliding Scale for Cost-Sharing NA Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 Range (%FPL) Premium or Enrollment Fee Required Premium/Fee Per Child Family Cap Co-Payments Co-Payment For Brand Name Rx Drugs Co-Payment For Generic Rx Drugs Co-Payment For Office Visits Co-Payment For Inpatient Services Co-Payment For Emerg Use Of Emerg-Room Co-Payment For Non-Emerg Use Of Emerg-Room Coverage Type/Option Type NA Option NA Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA CRS-70 Program Info State Oregon. Separate State Program Only Program Name Oregon Children's Health Insurance Program Type Of Program Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program yesa Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program yesa Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 1 5 133 185 Next Youngest 6 18 100 185 Older Oldest Basic Income Disregard no Asset Tests yes Continuous Eligibility (months) 6 Presumptive Eligibility no Prenatal Care for Unborn Children no Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required no Sliding Scale for Cost-Sharing NA Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 Range (%FPL) Premium or Enrollment Fee Required Premium/Fee Per Child Family Cap Co-Payments Co-Payment For Brand Name Rx Drugs Co-Payment For Generic Rx Drugs Co-Payment For Office Visits Co-Payment For Inpatient Services Co-Payment For Emerg Use Of Emerg-Room Co-Payment For Non-Emerg Use Of Emerg-Room Coverage Type/Option Type Secretary Approved Option Comprehensive Medicaid Section 1115 Waiver Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 6 Subsidy For Private/Employer Coverage yesa Min. Employer Premium Share Required for Subsidy 50% a. Oregon's HIFA waiver allows the state to use Medicaid and SCHIP funds to cover pregnant women, children, parents of Medicaid and SCHIP children, and childless adults. The waiver also expands the state's premium assistance program to provide a subsidy for ESI that can (1) offer a reduced benefits package (however, the state must ensure that all age-appropriate immunizations are covered), and 2) impose cost-sharing that exceeds the aggregate, annual 5% of family income limitation in the SCHIP statute. The terms and conditions of the waiver proscribe that enrollment in ESI is voluntary and that the state must inform enrollees of the implications of choosing private or employer-sponsored insurance. CRS-71 Program Info State Pennsylvania. Separate State Program Only Program Name Pennsylvania CHIP Type Of Program Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 1 185 200 Next Youngest 1 5 133 200 Older 6 18 100 200 Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 12 Presumptive Eligibility no Prenatal Care for Unborn Children no Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required no Sliding Scale for Cost-Sharing NA Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 Range (%FPL) Premium or Enrollment Fee Required Premium/Fee Per Child Family Cap Co-Payments Co-Payment For Brand Name Rx Drugs Co-Payment For Generic Rx Drugs Co-Payment For Office Visits Co-Payment For Inpatient Services Co-Payment For Emerg Use Of Emerg-Room Co-Payment For Non-Emerg Use Of Emerg-Room Coverage Type/Option Type Existing Comprehensive State-Based Option NA Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA CRS-72 Program Info State Rhode Island. Combination Program Name RIte Care RIte Care Type Of Program Medicaid Expansion Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program yesa no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program yesb yesb Eligibility Income Income Age (%FPL) Age (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper Youngest 8 18 100 250 c c c c Next Youngest Older Oldest Basic Income Disregard yes yes Asset Tests no no Continuous Eligibility (months) 0 12 Presumptive Eligibility no no Prenatal Care for Unborn Children NA yesc Enrollment Cap / Waiting List no no Cost Sharing Cost Sharing Required yes yes Sliding Scale for Cost-Sharing income income Group Group Group Group Group Group Group Group Sliding Scale Group Defined 1 2 3 4 1 2 3 4 100 150 185 200 100 150 185 200 Range (%FPL) 150 185 200 250 150 185 200 250 Premium or Enrollment Fee Required monthly monthly Premium/Fee Per Child $ 0 $ 61 $ 77 $ 92 $ 0$ 61 $ 77 $ 92 Family Cap $ 0 $ 61 $ 77 $ 92 $ 0$ 61 $ 77 $ 92 Co-Payments Co-Payment For Brand Name Rx Drugs $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 Co-Payment For Generic Rx Drugs $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 Co-Payment For Office Visits $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 Co-Payment For Inpatient Services $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 Co-Payment For Emerg Use Of Emerg-Room $ 0$ 0$ 0$ 0 $ 0$ 0$ 0$ 0 Co-Payment For Non-Emerg Use Of Emerg-Room $ 0$ 0$ 0$ 0 $ 0$ 0$ 0$ 0 Coverage Type/Option Comprehensive Medicaid Type Section 1115 Waiver Secretary Approved Comprehensive Medicaid Option NA Section 1115 Waiver Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 0 Subsidy For Private/Employer Coverage yesd no Min. Employer Premium Share Required for Subsidy 0% NA CRS-73 a. RI uses SCHIP funds to expand its comprehensive Medicaid Section 1115 waiver. Cost-sharing is permitted under this waiver. b. This waiver allows the state to use SCHIP funds to cover parents of Medicaid or SCHIP-eligible children with income between 100 and 185% FPL, and pregnant women with income between 185-250% FPL. c. The SSP's sole purpose is to provide prenatal care to unborn children with income up to 250% FPL. d. Enrollment in RIte Share, the state's premium assistance program, is mandatory for Medicaid-eligible individuals whose employers offered an approved health plan. CRS-74 Program Info State South Carolina. Medicaid Expansion Only Program Name Partners for Healthy Children Type Of Program Medicaid Expansion State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 1 5 133 150 Next Youngest 6 18 100 150 Older Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 12 Presumptive Eligibility no Prenatal Care for Unborn Children NA Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required NA Sliding Scale for Cost-Sharing NA Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 Range (%FPL) Premium or Enrollment Fee Required Premium/Fee Per Child Family Cap Co-Payments Co-Payment For Brand Name Rx Drugs Co-Payment For Generic Rx Drugs Co-Payment For Office Visits Co-Payment For Inpatient Services Co-Payment For Emerg Use Of Emerg-Room Co-Payment For Non-Emerg Use Of Emerg-Room Coverage Type/Option Type NA Option NA Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA CRS-75 Program Info State South Dakota. Combination Program Name South Dakota CHIP CHIP-NM Type Of Program Medicaid Expansion Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no no Eligibility Age Income (%FPL) Age Income (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper Youngest 0 5 133 140 0 18 140 200 Next Youngest 6 18 100 140 Older Oldest Basic Income Disregard yes yes Asset Tests no no Continuous Eligibility (months) 0 0 Presumptive Eligibility no no Prenatal Care for Unborn Children NA no Enrollment Cap / Waiting List no no Cost Sharing Cost Sharing Required NA no Sliding Scale for Cost-Sharing NA NA Group Group Group Group Group Group Group Group Sliding Scale Group Defined 1 2 3 4 1 2 3 4 Range (%FPL) Premium or Enrollment Fee Required Premium/Fee Per Child Family Cap Co-Payments Co-Payment For Brand Name Rx Drugs Co-Payment For Generic Rx Drugs Co-Payment For Office Visits Co-Payment For Inpatient Services Co-Payment For Emerg Use Of Emerg-Room Co-Payment For Non-Emerg Use Of Emerg-Room Coverage Type/Option Type NA Secretary Approved Option NA Same as Medicaid Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 3 Subsidy For Private/Employer Coverage no no Min. Employer Premium Share Required for Subsidy NA NA CRS-76 Program Info State Tennessee. Medicaid Expansion Only Program Name TennCare for Children Type Of Program Medicaid Expansion State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program yesa Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest b b b b Next Youngest Older Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 0 Presumptive Eligibility no Prenatal Care for Unborn Children NA Enrollment Cap / Waiting List noa Cost Sharing Cost Sharing Required NAa Sliding Scale for Cost-Sharing NA Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 Range (%FPL) Premium or Enrollment Fee Required Premium/Fee Per Child Family Cap Co-Payments Co-Payment For Brand Name Rx Drugs Co-Payment For Generic Rx Drugs Co-Payment For Office Visits Co-Payment For Inpatient Services Co-Payment For Emerg Use Of Emerg-Room Co-Payment For Non-Emerg Use Of Emerg-Room Coverage Type/Option Type Comprehensive Medicaid Section 1115 waiver Option NA Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA a. TN had used SCHIP funds to expand its comprehensive Medicaid Section 1115 waiver. Among other things, the waiver gives the state authority to cap enrollment for certain expansion eligibles. b. TN had used SCHIP solely to cover older children in families with income up to 100% FPL. Since all such children must be covered by Medicaid as of Oct. 1, 2002, TN has no SCHIP enrollment. CRS-77 Program Info State Texas. Separate State Program Only Program Name CHIP (Phase II) Type Of Program Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 1 185 200 Next Youngest 1 5 133 200 Older 6 18 100 200 Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 12 Presumptive Eligibility no Prenatal Care for Unborn Children no Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required yes Sliding Scale for Cost-Sharing income Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 100 150 185 Range (%FPL) 150 185 200 Premium or Enrollment Fee Required monthlya Premium/Fee Per Child a $ 15 $ 18 Family Cap a $ 15 $ 18 Co-Payments Co-Payment For Brand Name Rx Drugs $ 5 $ 20 $ 20 Co-Payment For Generic Rx Drugs $ 0 $ 5 $ 5 Co-Payment For Office Visits $ 2 $ 5 $ 10 Co-Payment For Inpatient Services $ 25 $ 50 $ 100 Co-Payment For Emerg Use Of Emerg-Room $ 5 $ 50 $ 50 Co-Payment For Non-Emerg Use Of Emerg-Room $ 5 $ 50 $ 50 Coverage Type/Option Type Benchmark Equivalent Option State Employee Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 3 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA a. Children in families with income between 100-150% FPL pay a $15 annual enrollment fee. CRS-78 Program Info State Utah. Separate State Program Only Program Name Utah CHIP Type Of Program Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this no Program Allowing Use of SCHIP Funds to Cover Groups Not no Eligible for this Program Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 5 133 200 Next Youngest 6 18 100 200 Older Oldest Basic Income Disregard no Asset Tests no Continuous Eligibility (months) 12 Presumptive Eligibility no Prenatal Care for Unborn Children no Enrollment Cap / Waiting List yesa Cost Sharing Cost Sharing Required yes Sliding Scale for Cost-Sharing income Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 100 150 Range (%FPL) 150 200 Premium or Enrollment Fee Required quarterly Premium/Fee Per Child $ 13 $ 25 Family Cap $ 13 $ 25 Co-Payments Co-Payment For Brand Name Rx Drugs $ 2b $ 5b Co-Payment For Generic Rx Drugs $ 2b $ 5b Co-Payment For Office Visits $ 5$ 15 10% of Co-Payment For Inpatient Services $ 5 allowed amtc Co-Payment For Emerg Use Of Emerg-Room $ 5$ 35 Co-Payment For Non-Emerg Use Of Emerg-Room $ 10 $ 35 Coverage Type/Option Type Benchmark Equivalent Option State Employee Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 3 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA a. A cap of 24,000 was imposed by an amendment approved by CMS in June 2002. b. Amounts shown are for drugs on the state's preferred drug list. Co-payments are higher for drugs not on this list: $5 for children with income between 100-150% FPL and 50% of the cost of the drug for children with income between 150-200% FPL. c. The allowed amount is the billed charges less 25%. CRS-79 Program Info State Vermont. Separate State Program Only Program Name Dr. Dynasaur Type Of Program Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 17 225 300 Next Youngest Older Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 12a Presumptive Eligibility no Prenatal Care for Unborn Children no Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required yes Sliding Scale for Cost-Sharing no Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 225 Range (%FPL) 300 Premium or Enrollment Fee Required monthlyb Premium/Fee Per Child $ 50 Family Cap $ 50 Co-Payments Co-Payment For Brand Name Rx Drugs $ 0 Co-Payment For Generic Rx Drugs $ 0 Co-Payment For Office Visits $ 0 Co-Payment For Inpatient Services $ 0 Co-Payment For Emerg Use Of Emerg-Room $ 0 Co-Payment For Non-Emerg Use Of Emerg-Room $ 0 Coverage Type/Option Type Secretary Approved Option Same as Medicaid Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 1 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA a. However, a parent's enrollment in one of Vermont's state-only funded health programs for adults might result in a shorter period of continuous eligibility, due to the other programs' more frequent eligibility redetermination for parents. b. The monthly program fee is billed quarterly. CRS-80 Program Info State Virginia. Combination Family Access to Medical Family Access to Medical Insurance Security Plan Insurance Security Plan Program Name (FAMIS) Plus (FAMIS) Type Of Program Medicaid Expansion Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no no Eligibility Income Income Age (%FPL) Age (%FPL) Lower Upper Lower Upper Lower Upper Lower Upper Youngest 6 18 100 133 0 18 133 200 Next Youngest Older Oldest Basic Income Disregard yes no Asset Tests no no Continuous Eligibility (months) 0 0 Presumptive Eligibility no no Prenatal Care for Unborn Children NA no Enrollment Cap / Waiting List no no Cost Sharing Cost Sharing Required NA yes Sliding Scale for Cost-Sharing NA income Group Group Group Group Group Group Group Group Sliding Scale Group Defined 1 2 3 4 1 2 3 4 100 150 Range (%FPL) 150 200 Premium or Enrollment Fee Required no Premium/Fee Per Child Family Cap Co-Paymentsa Co-Payment For Brand Name Rx Drugs $2 $5 Co-Payment For Generic Rx Drugs $2 $5 Co-Payment For Office Visits $2 $5 Co-Payment For Inpatient Services $15 $25 Co-Payment For Emerg Use Of Emerg-Room $0 $0 Co-Payment For Non-Emerg Use Of Emerg-Room $10 $25 Coverage Type/Option Type NA Secretary Approved NA State Employee and Same as Option Medicaida Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 0 6 Subsidy For Private/Employer Coverage yesb yesc Min. Employer Premium Share Required for Subsidy 0% 40% CRS-81 a. Children enrolled in a Managed Care Entity (MCE) receive coverage based upon the state employee health plan. Children in geographic areas without such an MCE obtain services through a Primary Care Case Management (PCCM) program that provides benefits similar to Medicaid, until such an MCE is available. Co-payments apply only to MCE children. b. FAMIS Plus Children whose parents have access to employer-sponsored insurance with dependent coverage must apply for such coverage. c. FAMIS Children whose parents have access to employer-sponsored insurance that is cost-effective and that meets the benefits qualifications have the option of receiving the subsidy for employer-sponsored coverage or enrolling in the state's plan. No co-pays apply to such children. CRS-82 Program Info State Washington. Separate State Program Only Program Name Washington State CHIP Type Of Program Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 18 200 250 Next Youngest Older Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 12 Presumptive Eligibility no Prenatal Care for Unborn Children no Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required yes Sliding Scale for Cost-Sharing no Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 200 Range (%FPL) 250 Premium or Enrollment Fee Required monthly Premium/Fee Per Child $ 10 Family Cap $ 30 Co-Payments Co-Payment For Brand Name Rx Drugs $ 0 Co-Payment For Generic Rx Drugs $ 0 Co-Payment For Office Visits $ 0 Co-Payment For Inpatient Services $ 0 Co-Payment For Emerg Use Of Emerg-Room $ 0 Co-Payment For Non-Emerg Use Of Emerg-Room $ 0 Coverage Type/Option Type Secretary Approved Option Same as Medicaid Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 4 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA CRS-83 Program Info State West Virginia. Separate State Program Only Program Name West Virginia CHIP (Phase III) Type Of Program Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 1 150 200 Next Youngest 1 5 133 200 Older 6 18 100 200 Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 12 Presumptive Eligibility no Prenatal Care for Unborn Children no Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required yes Sliding Scale for Cost-Sharing income Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 100 150 Range (%FPL) 150 200 Premium or Enrollment Fee Required no Premium/Fee Per Child Family Cap Co-Payments Co-Payment For Brand Name Rx Drugsa $5/$5 $10/$15 Co-Payment For Generic Rx Drugs $ 0 $ 0 Co-Payment For Office Visits $ 0 $ 15 Co-Payment For Inpatient Services $ 0 $ 25 Co-Payment For Emerg Use Of Emerg-Room $ 0 $ 35 Co-Payment For Non-Emerg Use Of Emerg-Room $ 0 $ 35 Coverage Type/Option Type Benchmark Equivalent Option State Employee Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 6 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA a. Amounts shown are for brand-name drugs that are/are not on the state's prescription drug formulary. CRS-84 Program Info State Wisconsin. Medicaid Expansion Only Program Name BadgerCare Type Of Program Medicaid Expansion State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program yesa Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program yesb Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 6 18 100 185 Next Youngest Older Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 0 Presumptive Eligibility no Prenatal Care for Unborn Children NA Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required yes Sliding Scale for Cost-Sharing income Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 100 150 Range (%FPL) 150 185 Premium or Enrollment Fee Required monthly Premium/Fee Per Child $ 0 3% of family Family Cap $ 0 incomec Co-Payments Co-Payment For Brand Name Rx Drugs $ 0 $ 0 Co-Payment For Generic Rx Drugs $ 0 $ 0 Co-Payment For Office Visits $ 0 $ 0 Co-Payment For Inpatient Services $ 0 $ 0 Co-Payment For Emerg Use Of Emerg-Room $ 0 $ 0 Co-Payment For Non-Emerg Use Of Emerg-Room $ 0 $ 0 Coverage Type/Option Type Comprehensive Medicaid Section 1115 waiver Option NA Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) 3 Subsidy For Private/Employer Coverage yesd Min. Employer Premium Share Required for Subsidy 40%d a. WI uses SCHIP funds to expand its comprehensive Medicaid Section 1115 waiver under which cost-sharing is permitted. b. The SCHIP waiver covers parents of SCHIP and Medicaid children with income between 100-185% FPL. c. Premiums are paid on behalf of the family. The lowest possible premium is $30 per family per month. d. Children whose parents have access to employer-sponsored insurance that is cost-effective and that meets the benefits qualifications must enroll in the employer plan for family coverage. To qualify, the employer must pay at least 40%, but less than 80%, of a family premium. CRS-85 Program Info State Wyoming. Separate State Program Only Program Name Kid Care CHIP Type Of Program Separate State Program State Has 1115 Waiver: Waiving Provisions Otherwise Affecting this Program no Allowing Use of SCHIP Funds to Cover Groups Not Eligible for this Program no Eligibility Age Income (%FPL) Lower Upper Lower Upper Youngest 0 5 133 185 Next Youngest 6 18 100 185 Older Oldest Basic Income Disregard yes Asset Tests no Continuous Eligibility (months) 12 Presumptive Eligibility no Prenatal Care for Unborn Children no Enrollment Cap / Waiting List no Cost Sharing Cost Sharing Required yes Sliding Scale for Cost-Sharing no Sliding Scale Group Defined Group 1 Group 2 Group 3 Group 4 100 Range (%FPL) 185 Premium or Enrollment Fee Required no Premium/Fee Per Child Family Cap Co-Payments Co-Payment For Brand Name Rx Drugs $ 5 Co-Payment For Generic Rx Drugs $ 3 Co-Payment For Office Visits $ 5 Co-Payment For Inpatient Services $ 0 Co-Payment For Emerg Use Of Emerg-Room $ 5 Co-Payment For Non-Emerg Use Of Emerg-Room $ 5 Coverage Type/Option Type Secretary Approved Option Other Relationship To Private/Other Coverage Waiting Period to Prevent Crowd-Out (months) (months) 1 Subsidy For Private/Employer Coverage no Min. Employer Premium Share Required for Subsidy NA ------------------------------------------------------------------------------ For other versions of this document, see http://wikileaks.org/wiki/CRS-RL32389