If a State Chooses a Separate Insurance Program
While expanding Medicaid to at least 200 percent of federal poverty guidelines ($26,660 for a family of three in 1997) is the best option for most states, those that choose a separate insurance program can make the most of the new Title XXI of the Social Security Act:
TAKE FULL ADVANTAGE OF AVAILABLE FEDERAL FUNDS TO COVER ALL ELIGIBLE UNINSURED CHILDREN.
- There are over 10 million children without health insurance for 12 months or longer in a two-year period and, despite a strong economy, the number is growing.
- Uninsured children receive significantly less medical care than insured children. Lack of medical care not only may jeopardize children's health, education and welfare, but also may be more costly to society in the long run.
- State government can expand children's health insurance by paying only 15 to 35 percent of total program costs. Depending on the state, one dollar of state funds will be matched by $1.85 to $5.23 in federal dollars in 1998.
EXPAND MEDICAID TO AN INCOME LEVEL HIGH ENOUGH TO INCLUDE ALL CHILDREN OF DIFFERENT AGES IN THE SAME FAMILY.
- Currently all children under age 6 in families with income at or under 133 percent of federal poverty guidelines must be enrolled in Medicaid, but older children have a lower income ceiling. All states should at least expand Medicaid to 133 percent of poverty in order to keep all children in the same family in the same insurance program.
- Expansion to 133 percent of poverty also assures that children are not forced to change plans and providers when they turn six or when family income fluctuates between 133 percent and 100 percent of poverty.
OFFER A COMPREHENSIVE BENEFIT PACKAGE DESIGNED TO MEET CHILDREN'S NEEDS.
- Supplement the coverage of commercial plans in order to offer children all medically necessary services. Group health plans designed for working age adults are unlikely to offer adequate coverage of services particularly important to children's development like vision, hearing, mental health and dental services, and benefits required by children with special health care needs.
- Consider adopting a benefit package that mirrors the benefits in the Medicaid Early and Periodic, Screening, Diagnosis and Treatment program.
KEEP INSURANCE AFFORDABLE TO ASSURE THAT NEAR-POOR FAMILIES OBTAIN COVERAGE AND USE IT APPROPRIATELY.
- Exempt the lowest income families from premiums and the most vital services from any cost sharing.
- Set family and service cost-sharing ceilings to protect children with special health needs.
- Adopt the current Medicaid rule that prohibits providers from denying care based on the beneficiary's inability to pay.
- Don't permit managed care organizations to impose cost-sharing on beneficiaries. Managed care plans already have procedures to control the use of services (such as gatekeeper requirements) without the use of cost-sharing.
- Consider giving families an option of either premiums or cost-sharing as Rhode Island does.
ADOPT INNOVATIVE STRATEGIES TO IMPROVE APPLICATION PROCESSING, OUTREACH, AND COORDINATION WITH OTHER CHILDREN'S HEALTH PROGRAMS.
- Streamline application processing by shortening forms, accepting mail-in applications without face-to-face interviews, eliminating asset tests, speeding up processing, and placing eligibility workers at convenient locations.
- Enlist the help of the community in devising new outreach strategies geared to diverse population. Advertise widely on billboards, television and radio. Use community health advocates, children's agencies and parents' networks to spread the word.
- Integrate enrollment in Medicaid and other children's health programs. Use one simple application form for different programs. Identify children with special health needs during enrollment and help their families make effective use of all available support services.
ASSURE THAT DELIVERY SYSTEMS HAVE THE CAPACITY TO PROVIDE ACCESS TO HIGH QUALITY, APPROPRIATE CARE FOR AN EXPANDED POPULATION OF ELIGIBLE CHILDREN.
- Expand participating primary care providers and specialists for the expanded number of eligible children.
- Increase provider and plan payment rates if necessary to assure an adequate number of participating providers.
- Monitor standards for reasonable access to providers and services.
ASSURE THAT SUFFICIENT DATA ARE GATHERED AND EVALUATED TO ENABLE THE STATE TO ASSESS AND IMPROVE THE PROGRAM.
- Evaluate what is working and what is not, and be prepared to adjust subsidies, benefits, contracting and enrollment procedures, and other aspects of the program as needed to meet its objectives.
- Consumers, advocacy organizations, providers and other stakeholders must be involved in the on-going implementation, evaluation and improvement of the program.
REFRAIN FROM IMPOSING BARRIERS TO ELIGIBILITY FOR UNINSURED CHILDREN AS A WAY OF AVOIDING "CROWD OUT" (THE SUBSTITUTION OF PUBLIC HEALTH INSURANCE COVERAGE FOR EMPLOYER-BASED COVERAGE).
- The experiences of states that have already expanded insurance to the near poor suggest that fears of significant crowd out are exaggerated.
- States are not required to do more than restrict eligibility to children who are currently uninsured. Better measures to avoid crowd out than further restricting eligibility for uninsured children include carefully designed premium scales, and regulations and incentives for employers to retain or expand coverage.
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