children’s health insurance coverage and schip reauthorization presentation for the university of...

Children’s Health Insurance Coverage and SCHIP

Reauthorization

Presentation for the University of Florida Medical College Council

February 4, 2009

Jill Boylston Herndon, Ph.D.Institute for Child Health Policy

Department of Epidemiology and Health Policy ResearchCollege of MedicineUniversity of Florida

© 2009 Jill Boylston Herndon, all rights reserved.

Children’s Insurance Coverage Nationally 2007

Employment Based, 55.3%

Uninsured, 11.3%

Other Public, 1.4%

Medicaid & Title XXI, 27.6%

Private, Individually Purchased, 4.4%

Source: Kaiser Family Foundation, statehealthfacts.org. Data Source: U.S. Census Bureau Current Population Survey.


Medicaid

What is Medicaid? Federal-state health insurance program; established in 1965 as Title XIX of the

SSA General guidelines established by the federal government Program requirements and eligibility established by each state Financed jointly by federal and state governments; federal match based on

relative per capita income Means-tested – based on Federal Poverty Level; 100% FPL for a family of 4 in 2008

was approximately $21,200 (http://aspe.hhs.gov/poverty/index.shtml)

Who’s Covered? Eligibility varies by state, but there are “mandatory” groups who must be covered

including families meeting AFDC requirements, pregnant women and children younger than age 6 with family income at or below 133% FPL, children ages 6-19 in families with income up to 100% FPL, SSI recipients, and low-income Medicare beneficiaries

States may establish “medically needy” groups. States may also expand coverage through Section 1115 Medicaid waivers.

NOTE: Medicaid does not provide medical assistance for all poor persons (<100% FPL). Only those poor persons who are in one of the designated eligibility groups receive coverage.

http://aspe.hhs.gov/poverty/index.shtml


Medicaid Enrollment and Expenditures By Enrollment Group, FY 2005

58.9 million enrollees 10% aged 14% disabled 26% adults 50% children

Expenditures - $304 billion 26% aged 41% disabled 12% adult 17% children 4% unknown

Source: Kaiser Family Foundation, http://www.statehealthfacts.org

http://www.statehealthfacts.org/


Recent Changes in Medicaid – Deficit Reduction Act of 2005

Citizenship documentation requirements

Prior to DRA, 47 states allowed self-declaration

Beginning July 1, 2006, documentation to prove citizenship and identity required for applications and renewals

States have reported slowed enrollment growth and declines in enrollment; increased administrative costs; processing delays

Premiums and cost sharing

Prior to DRA, no premiums and very limited copayments

Patients who have not paid premiums can be denied services

Exemption is maintained for mandatory children and pregnant women

Few states to date have imposed new cost sharing

Increased flexibility in specifying benefit packages


SCHIP: State Children’s Health Insurance Program

What is SCHIP? Established under the Balanced Budget Act of 1997 as Title XXI of the SSA Federal-state health insurance program designed to reduce the number of

uninsured children General guidelines established by the federal government Program requirements and eligibility established by each state Financed jointly by federal and state governments with federal match based

on relative per capita income – higher federal match than for Medicaid Means-tested and not an entitlement program Cost sharing, including premiums, is permitted as long as it does not exceed

5% of family income

Who’s Covered? Eligibility varies by state Some states chose to expand their Medicaid program using SCHIP funding;

others created a separate program; some used a combination approach Most states cover children in families up to 200% FPL; the lowest is 150% FPL

in North Dakota and the highest is 350% FPL in New Jersey


SCHIP: Successes & Shortcomings Successes

Popular program – received widespread support Reduced uninsurance rates among children and covers about 5

million children at a given point in time and 7 million during one year

Improved access to care for children Positive spillover effects on Medicaid

Shortcomings/Challenges State flexibility in program design has resulted in fluctuating

policies that reflect states’ fiscal health Many Medicaid and SCHIP eligible children remain uninsured Data quality and evaluation of what works and what doesn’t

varies across states Limited research on access, quality, and outcomes SCHIP coverage has substituted for private coverage in some

cases

Source: Kenney G., Yee J. 2007. “SCHIP at a Crossroads: Experiences to Date and Challenges Ahead.” Health Affairs. 26(2):356-369.


SCHIP Reauthorization

Reauthorization: what is it? The original SCHIP legislation was passed in 1997 and was

authorized for 10 years.

The program was due to be re-authorized in 2007.

In 2007, Congress twice passed legislation to renew SCHIP; both times the legislation was vetoed by President Bush.

The debate in 2007 was not about whether to continue the program; rather, it was about the extent to which it should be expanded.

Congress extended the program through March 31, 2009, and SCHIP renewal legislation is currently in process.


SCHIP ReauthorizationCurrent Status of Legislation

Congressional leaders have made reauthorization a priority.

Both the House and the Senate have passed legislation that corresponds closely to the 2007 legislation.

The House passed its version on January 14 by 289 to 139 votes.

The Senate passed its version on January 29 by 66 to 32 votes.

Next step: The Senate bill goes to the House. If the House passes the same bill, then it will go to the President. If the House does not pass, then it will go to Conference Committee to work out the differences.


SCHIP ReauthorizationKey Features of Legislation

Extends coverage of the approximately 7 million children currently covered and expands coverage to approximately 4 million children over the next 4 ½ years (through FFY 2013)

Provides state options for “Express Lane” eligibility and increases federal funding for outreach to enroll currently eligible but uninsured children

Performance bonuses for increasing enrollment of currently eligible but uninsured children

Preserves state option to determine income eligibility limit; but federal government’s contribution for children above 300% FPL is reduced to Medicaid matching rate rather than SCHIP rate

Provides state option to cover low-income pregnant women, but prohibits new waivers to cover parents and childless adults


SCHIP ReauthorizationKey Features of Legislation (cont.)

Eliminates 5-year waiting period eligibility requirement for documented immigrant children and pregnant women (now state option)

Extends Medicaid citizenship documentation requirement to SCHIP, but allows option of documenting citizenship by using existing databases (e.g., Social Security Administration)

Provides for development of child-specific quality measures

Requires SCHIP plans to include dental coverage and provides state option to offer stand-alone dental coverage to underinsured children (e.g., if ESI doesn’t cover)

Increases SCHIP spending (relative to no expansions in coverage) by about $32 billion over 4 ½ years; funded by 62¢ per pack increase in federal cigarette tax


Children’s Insurance Coverage in Florida 2007

Employment Based, 50.3%

Uninsured, 12.6%

Other, 1.0%

Medicare, Military & Other Public, 4.9%

Medicaid & Title XXI, 24.8%

Private, Individually Purchased, 6.4%

Source: Herndon J.B., Shenkman E.A. 2008. “The Florida Children’s Health Insurance Study 2007.” Institute for Child Health Policy. University of Florida.

Note: The Census Bureau estimates that 19.5% of children in Florida are uninsured.


Overview of Children’s Public Health Insurance Coverage in Florida: Florida KidCare

Florida KidCare provides Medicaid (Title XIX) and SCHIP (Title XXI) coverage to the state’s uninsured children through the following four program components:

Medicaid for Children - provides coverage for children birth through age 18 meeting the eligibility requirements with Title XIX funding;

MediKids - a “Medicaid look alike” program that provides the equivalent of the Medicaid benefit package for children ages 1 through 4 with Title XXI funding;

Florida Healthy Kids - provides health coverage for children ages 5-18 with Title XXI funding; and

Children’s Medical Services Network (hereafter, CMSN) - provides coverage for children ages 0-18 who have special physical or behavioral health care needs and who are eligible for either Title XIX or Title XXI funding. Children in this program must meet specific clinical eligibility criteria.

KidCare covered 1,401,038 children ages 0-18 in January 2008.


Florida KidCare Title XXI Enrollment and Major Program Changes

July 03:

• “No Growth”budget enacted

• Program over-enrolled, wait list started

• No Title XIX toTitle XXI transfers

• Federal and state funding forFlorida KidCare Outreach eliminated

Apr. 04:

Begin enrolling Title XXI Wait ListDec. 03:

• 6-month cancellation for premium non-payment

• No reinstatements for breaks in coverage

• Jan. 04: Only CMSN accepts Medicaid to Title XXI transfers (ended Mar. 04)

• Mar. 04: Legislation enacted — wait list funded, other program changes

July 04: • New income

documentation& access to employer health insurance requirements (delayed due to hurricanes)

• New enrollees accepted only during open enrollment

• Loss of Medicaid for over-income eligible to apply outside of open enrollment, 7/1/04

• FY 04-05 Appropriated Avr. Monthly Caseload: 389,515

Fall 2004:

• Premium non-payment penalty reverts to 60 days

• Reinstatements allowed if in the data system before 3/12/04

• Hurricane Relief Provisions: No disenrollments for failure to provide renewal documents or failure to pay premiums, credits for those who did pay (3 months)

December 04:

• Open enrollment announced

• Disenrollments for renewal non-compliance and unpaid premiums implemented

• Legislature reduced income documentation requirements

July 05:

Year-round open enrollment reinstituted; application valid for 120 days

FY 05-06 Appropriated Avr. Monthly Caseload: 388,862

Aug. 05: Back-to-School campaign, post cards

Jan. 05: Open enrollment Jan. 1-30, 2005; applicationsprocessed, children start enrolling Winter 06: Marketing

campaign, online application

180,000

200,000

220,000

240,000

260,000

280,000

300,000

320,000

340,000

Jul-02

Oct-02

Jan-03

Apr-03

Jul-03

Oct-03

Jan-04

Apr-04

Jul-04

Oct-04

Jan-05

Apr-05

Jul-05

Oct-05

Jan-06

Apr-06

Jul-06

Oct-06

Jan-07

Apr-07

Jul-07

Oct-07

202,615

202,433

220,533

252,209

323,262

331,281

336,689

315,222

326,755322,997

264,278

195,826

186,080

204,214

224,175

214,988

FY 07-08 Appropriated Avr. Monthly Caseload: 236,609

226,899

Fall 07: Back-to-School campaign; 5,000 additional slots appropriated in legislative Special Session


Uninsured Children in Florida

62% of uninsured children in Florida were without coverage for more than one year.

The following segments of the child population are at disproportionate risk for being uninsured: children ages 12-18, Hispanic children, non-Hispanic black children, children in households below 200% of the FPL, and children whose parents are uninsured.

Uninsured children are more likely to have parents who are self-employed, employed part-time, or employed seasonally than insured children.

Uninsured children are less likely to have a usual source of care and more likely to use the ER and walk-in clinics as their usual source of care than insured children.

72% of uninsured children in Florida are eligible for KidCare coverage.Source: Herndon J.B., Shenkman E.A. 2008. “The Florida Children’s Health Insurance Study 2007.” Institute for Child Health Policy. University of Florida.


Strategies for Increasing Children’s Health Insurance Coverage

Marketing and outreach strategies to identify eligible but uninsured children and facilitate their enrollment

Identify barriers to enrollment – e.g., lack of program awareness, barriers in the application process, communication gaps, language and cultural barriers, etc.

Campaigns targeted toward the segments that are disproportionately uninsured and most difficult to reach (example: FHKP Act-Out for Health campaign)

Streamline enrollment processes and provide application assistance “Express Lane” enrollment – auto-enrollment

Improve program retention through outreach and streamlined renewal processes

Facilitate family access to coverage

For children who do not meet eligibility criteria and do not have access to other sources of coverage – options include:

expand public coverage (e.g., broaden eligibility) provide buy-in options to public programs private market solutions – likely in the context of broader health care reform

and improving access for the family as a whole


References and Resources

For information on Medicaid, SCHIP, and Medicare and how these programs are administered, see: www.cms.hhs.gov.

Center for Children and Families. 2009. Georgetown University Health Policy Institute. “SCHIP Reauthorization in 2009: An Update on the Debate and Side-by-Side of Key Bills Under Consideration.” Available at: http://ccf.georgetown.edu/index/schipreauthorization.

Florida KidCare. http://www.floridakidcare.org.

Florida Healthy Kids Program. http://www.healthykids.org.

Herndon J.B., Vogel B., Bucciarelli R., Shenkman E. 2008. “The Effect of Premium Changes on SCHIP Enrollment Duration.” Health Services Research. 43(2):458-477.

Herndon J.B., Vogel B., Bucciarelli R., Shenkman E. 2008. “The Effect of Renewal Policy Changes on SCHIP Disenrollment.” Health Services Research. 43(6):2086-2105.

Herndon J.B., Shenkman E. 2008. “The Florida Children’s Health Insurance Study 2007.” Institute for Child Health Policy. University of Florida. Available at: http://www.healthykids.org/evaluation/institute.php?lang=ENG.

Kaiser Family Foundation, http://www.statehealthfacts.org.

Kenney G., Yee J. 2007. “SCHIP at a Crossroads: Experiences to Date and Challenges Ahead.” Health Affairs. 26(2):356-369.

Nogle J.M., Shenkman E. “The Florida KidCare Evaluation.” Institute for Child Health Policy. University of Florida. http://www.ichp.ufl.edu.

U.S. Census Bureau. Income, Poverty, and Health Insurance Coverage in the United States: 2007, U.S. Census Bureau: http://www.census.gov/hhes/www/hlthins/hlthin07.html.

children’s health insurance coverage and schip reauthorization presentation for the university of...

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