Coordinating Publicly Funded Healthcare Coverage for Children
State Approaches
The following descriptions present the approaches five States have taken to coordinate their Medicaid and State Children's Health Insurance Program (SCHIP)-funded separate programs.
Georgia / Kansas / Massachusetts / New Jersey / Oregon
Georgia
PeachCare, Georgia's SCHIP-funded program, is a separate child health program with a number of important links to Medicaid. For example, both programs use the same income-counting rules to determine eligibility, and neither program has an assets test. In addition, verification requirements for both programs have been largely eliminated and they both accept the applicant's self-declaration of income, residency, and other information.
A short Medicaid application for pregnant women and children is still in use, but the new PeachCare application also can be used to apply for Medicaid. If the Medicaid application is used, a face-to-face interview is required. However, a team of eligibility workers from the State's Right from the Start Medicaid (RSM) program routinely meet with families in a host of settings—including schools, child care centers, churches, worksites, and applicants' homes—to help with Medicaid applications. These meetings satisfy the face-to-face interview requirement. RSM workers also can assist families with the PeachCare application if it appears the children are more likely to qualify for PeachCare.
Families that complete the PeachCare application on their own mail the form to a central post office box. All applications are screened by a private contractor to assess whether the child is likely to be eligible for Medicaid. If so, the data on the PeachCare application are retained in the computer system and a paper copy of the form is forwarded to the Department of Medical Assistance in Atlanta, where a team of RSM workers makes final eligibility determinations.
Keeping the data from the PeachCare application in the contractor's computer file helps to avoid delays in making the final determination. For example, if an application has been screened and forwarded to Medicaid, but upon closer scrutiny it turns out that the child is actually not eligible, the RSM worker can alert the PeachCare contractor. The application then can be reviewed for PeachCare eligibility without further delay.
The PeachCare application includes an "opt in" box. Applications for children whose parents do not opt in are not automatically considered for Medicaid. Over a 10-month period, parents applying for a total of 4,880 children who appeared to be eligible for Medicaid indicated that they did not want the application forwarded to Medicaid. When such families were contacted by an RSM worker and given more information, most decided to enroll their children in Medicaid. The State cannot say, however, how many of the families that did not opt in have been reached.
Once enrollment is accomplished, families are issued different enrollment cards depending on whether they are enrolled in Medicaid or PeachCare. The Department of Medical Assistance issues families paper verification of Medicaid eligibility each month. PeachCare issues a laminated card once a year.
An important connection between the two programs exists on the delivery side. Both programs use a primary care case-management system. The Department of Medical Assistance, which administers both programs, reports that every Medicaid provider is a PeachCare provider, and every PeachCare provider is a Medicaid provider. Since income eligibility for Medicaid varies based on the age of the child, two children in the same family could qualify for different programs, but both could go to the same providers for care.
The schedule for recertification is different for the two programs. Medicaid requires a redetermination of eligibility every 6 months; in PeachCare, redeterminations are done at 12-month intervals. If children are found at redetermination to be ineligible for Medicaid, the family is given a PeachCare application. They must reapply in order to be transferred to PeachCare. When a child enrolled in PeachCare becomes eligible for Medicaid, the information is transferred to Medicaid. No new application is required. The State has not adopted continuous eligibility either for PeachCare or for Medicaid.
Coordination Indicators: Georgia
No: One program/one name.
No: One agency to determine eligibility.
Yes: Simplified joint application and single point of entry.
No: All applications forwarded to proper agency.
No: Age-based eligibility rules ended.
Yes: Verification requirements simplified and the same for both programs.
Yes: Income and asset rules aligned.
No: Easy transitions when eligibility is redetermined.
No: Continuous eligibility.
Yes: Common service delivery system.
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Kansas
Two programs—Medicaid and the new, SCHIP-funded HealthWave program—provide health insurance to low-income children in Kansas. The State's interest in creating an easy enrollment process and concern about reducing the stigma families may associate with Medicaid participation catalyzed the development of one application system for both Medicaid and SCHIP-funded coverage. The programs continue to operate separately in many ways, although the Department of Social and Rehabilitation Services anticipates further changes that would bring the programs closer together.
Before HealthWave was implemented in January 1999, families seeking Medicaid coverage for their children had to complete a lengthy application form and have a face-to-face interview. Currently, a single, four-page HealthWave form is used to apply for coverage under either program and all families can submit their applications by mail. The same income-counting rules are used for both programs, and neither program has an asset test. Both programs use the same verification rules. However, because of age-based eligibility rules, a family could have one child covered under Medicaid and another child covered under HealthWave.
Both Medicaid and HealthWave are administered by the Kansas Department of Social and Rehabilitation Services, although eligibility determinations for HealthWave are done by a private contractor. All applications are mailed to a central location which houses State agency workers as well as private contractor employees responsible for HealthWave. Information from the application is entered into the computer system and an initial eligibility screening is done automatically.
Applications for children who are likely to be Medicaid eligible are assigned to State workers for a final determination; those that appear more likely to be eligible for HealthWave are handled by the contract workers at the same site. Co-locating workers who are responsible for both programs makes it easy to transfer applications back and forth, if necessary. (Some applications are not handled on site. When the initial computer check indicates that the family has an open Food Stamp or cash assistance case, the application is forwarded to the local office of the Department, where the other benefits are administered.)
Once eligibility is determined, families are sent enrollment cards. They are not the same for the two programs: the State agency issues a paper Medicaid card and the managed care plan issues a plastic card for children enrolled in HealthWave. While the benefits in the two programs are essentially the same, in some parts of the State the programs rely on different delivery systems.
Kansas has adopted 12-month continuous eligibility for both programs. At 12-month intervals, families are asked to complete a new application, attach income verification, and submit the form by mail. The State reports that the redetermination system "is seamless." A child who is no longer eligible for the program in which he or she is enrolled will automatically be enrolled in the other program, if appropriate. There is no lapse in coverage or additional paperwork.
Coordination Indicators: Kansas
No: One program/one name.
No: One agency to determine eligibility.
Yes: Simplified joint application and single point of entry.
Yes: All applications forwarded to proper agency.
No: Age-based eligibility rules ended.
Yes: Verification requirements simplified and the same for both programs.
Yes: Income and asset rules aligned.
Yes: Easy transitions when eligibility is redetermined.
Yes: Continuous eligibility.
No: Common service delivery system.
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Massachusetts
In response to the Federal SCHIP law, Massachusetts revamped its system for providing health insurance for children by expanding coverage under the State's MassHealth program. From the perspective of Massachusetts residents, MassHealth is one program with several components. The Medicaid component, referred to as MassHealth Standard, covers all children, regardless of age, if their family income is below 150 percent of the Federal poverty line. Children enrolled in this component of MassHealth are Medicaid recipients with the full range of Medicaid benefits (subject to the Medicaid rules adopted pursuant to a section 1115 waiver).
SCHIP funds were used to create a second layer of coverage for children within MassHealth, referred to as MassHealth Family Assistance. SCHIP finances coverage for children with family income between 150 percent and 200 percent of the Federal poverty line. This component of MassHealth offers slightly more limited benefits than the Medicaid component and families must pay a premium. In addition, since it is subject to the Federal SCHIP rules, not the Federal Medicaid rules, enrollment under MassHealth Family Assistance depends on the availability of SCHIP funds. (Massachusetts also operates a separate, wholly State-funded child health program for children who are not eligible for MassHealth, called the Children's Medical Security Plan (CMSP). CMSP does not rely on SCHIP or Medicaid funds. MassHealth also has several other components, including SCHIP-funded employer-based family coverage.
One application is used to apply for all MassHealth components. Eligibility for MassHealth is determined by the Division of Medical Assistance. The Division uses a gross income test to assess whether children's family income qualifies them for MassHealth Standard or MassHealth Family Assistance. (Certain disabled children may qualify for a third component, MassHealth Commonhealth.) No asset test is applied to any group. If family income puts the child over the MassHealth income standard (200 percent of the Federal poverty line), the child can be enrolled in CMSP without having to fill out a separate application.
All children enrolled in MassHealth have access to the same providers. MassHealth uses the same enrollment card and a common recertification system for all "members." Children are transferred between MassHealth components without additional paperwork or a lapse in coverage. The State has not adopted continuous eligibility for either its Medicaid or its SCHIP-funded children.
Coordination Indicators: Massachusetts
Yes: One program/one name.
No: One agency to determine eligibility.
Yes: Simplified joint application and single point of entry.
Yes: All applications forwarded to proper agency.
Yes: Age-based eligibility rules ended.
Yes: Verification requirements simplified and the same for both programs.
Yes: Income and asset rules aligned.
Yes: Easy transitions when eligibility is redetermined.
No: Continuous eligibility.
Yes: Common service delivery system.
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New Jersey
New Jersey's KidCare Program brings four child health coverage options under one name—Plan A (Medicaid), Plan B (SCHIP-funded non-Medicaid coverage with no cost-sharing), and Plans C and D (both are SCHIP-funded non-Medicaid coverage with cost-sharing). A single KidCare application is used for all components; the application can be mailed to a central KidCare office or to the county social services office. Families also have the option to apply for KidCare in person at the county office.
In most cases, all children in a family are eligible for the same KidCare component, except that infants almost always are eligible for Plan A. Eligibility for Plan A is based on different income-counting rules than those used in the SCHIP-funded plans. Deductions for work and child care expenses are applied to the family's income to determine Plan A eligibility, but Plans B, C, and D use a gross income test.
All KidCare components are administered by the New Jersey Department of Human Services, but a private contractor determines eligibility for the SCHIP-funded components. The private contractor receives all applications mailed to the central KidCare office and screens them for potential Plan A eligibility. State workers at the same site conduct a final Medicaid eligibility determination for these applications.
Many applications arrive at the central location incomplete and eligibility workers call families to obtain missing information, including verification documents. Contacting families to help them complete their application is important. For example, a family that appears to be eligible for Plan B could actually qualify for Plan A if the child care deduction is taken. Proof of child care expenses would then be needed. If a family completes the KidCare application in person at a county office, a Plan A determination can be made by county staff. If the applicant appears to be eligible for Plans B, C, or D, the county worker forwards the application to the private contractor.
Benefits for all components of KidCare are similar, although the scope of certain benefits is limited in the SCHIP-funded plans. All benefits are delivered through a managed care system, and providers are the same for all components in the program. The KidCare cards are essentially the same for all beneficiaries; the card indicates the plan (A, B, C, or D) for which the child is eligible.
None of the KidCare plans relies on continuous eligibility. Although the redetermination period is different for different components—6 months for Plan A and 12 months for Plans B, C, and D—a similar mail-in process is used to determine whether children can retain their eligibility. Children who become eligible for a different plan are transferred without a lapse in coverage. However, if a child becomes eligible for Plans C and D, a premium is required and coverage could lapse if the premium is not paid within a specified time period.
Coordination Indicators: New Jersey
Yes: One program/one name.
No: One agency to determine eligibility.
Yes: Simplified joint application and single point of entry.
Yes: All applications forwarded to proper agency.
Yes: Age-based eligibility rules ended.
Yes: Verification requirements simplified and the same for both programs.
No: Income rules aligned.
Yes: Asset rules aligned.
No: Easy transitions when eligibility is redetermined.
No: Continuous eligibility.
Yes: Common service delivery system.
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Oregon
The Oregon Health Plan (OHP) provides coverage to low-income families with children. (Other publicly financed health coverage programs are also available to some families in Oregon.) Prior to SCHIP, coverage for children under the OHP was based on a Medicaid section 1115 waiver. In 1998, the State decided to use its SCHIP funds to expand coverage for children by creating a non-Medicaid component of the OHP. A gross income test and an asset limit of $5,000 (in liquid assets) apply to all children under the OHP. Verification requirements are the same for all applicants. Since the age of the child is a factor in determining eligibility, it is possible for children in the same family to be eligible for different components of the program, but all the children in the family will be enrolled in OHP.
To obtain coverage, families complete the OHP application and mail it to the Office of Medical Assistance, the agency that administers all components of the OHP. Within this agency, Adult and Family Services operates a central processing unit for most applications. Applications for children whose families have an open Food Stamp or cash assistance case are forwarded to a local office of the same agency for eligibility determination.
At the same time that the agency determines whether family income is below the OHP income standards, it also determines whether coverage will be financed using Medicaid or SCHIP funds. This distinction is invisible to families, and will remain so as long as SCHIP funding can sustain coverage for all SCHIP-eligible children who apply. Since the benefit package and choice of providers is the same regardless of the funding stream, the funding source has no impact on how families obtain care for their children.
All families go through the same recertification process every 6 months; the State has not adopted the continuous eligibility option. Families must submit a redetermination form and provide documents to verify their income. These materials can be submitted by mail. Children will remain covered as long as their family income is below the OHP eligibility standard; a change in their status as an SCHIP-funded or a Medicaid-funded enrollee will not result in a lapse in coverage or in additional paperwork for the family.
Coordination Indicators: Oregon
Yes: One program/one name.
Yes: One agency to determine eligibility.
Yes: Simplified joint application and single point of entry.
Yes: All applications forwarded to proper agency.
Yes: Age-based eligibility rules ended.
Yes: Verification requirements simplified and the same for both programs.
Yes: Income and asset rules aligned.
Yes: Easy transitions when eligibility is redetermined.
No: Continuous eligibility.
Yes: Common service delivery system.
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