History and Implementation

Pre-Title XXI
Massachusetts has a long and active history of state initiatives to expand health coverage for the uninsured. Prior to the Title XXI legislation, the State Legislature had already created a separate children’s health insurance program, expanded Medicaid eligibility through a waiver and explored ways to subsidize employer-sponsored insurance. As a result of these initiatives, Massachusetts’ presents a unique Title XXI program. An abbreviated history follows which helps explain certain elements of the state’s Title XXI program:

• The Children’s Medical Security Plan (CMSP) began in 1993 to serve uninsured children. Over time, its age and income eligibility criteria expanded to cover children up to age 19, living in families who were not eligible for Medicaid. The CMSP provides basic primary care to children, with a very limited benefits package.

• The state submitted a request for a Medicaid waiver in 1994 to expand program eligibility, simplify eligibility rules, and create an Insurance Reimbursement Program (IRP) to help subsidize employer-sponsored insurance. The original idea was to offer tax credits to businesses covering 50 percent of the insurance costs for their employees with incomes under 200 percent FPL. A Study Commission convened to discuss the waiver. The Commission included administration officials, legislators, and representatives of the public. Although there was consensus about simplifying Medicaid and expanding eligibility up to 133 percent FPL, there was disagreement about whether tax credits to employers would reduce the number of uninsured. Part of the debate focused on the plan to finance a portion of the waiver demonstration from the Uncompensated Care Pool, which was then funded by an assessment on hospitals. The concern was the extent to which using the Pool to cover the subsidy costs would deplete funding available to help uninsured hospital patients.

• During the legislative discussion in 1996 to approve the state’s Medicaid waiver request, it was decided to fund the state’s share of the expansion costs through an increase in the tobacco tax and to convene an IRP Study Commission. The State Legislature approved:
• expanding Medicaid for families (among others) up to 133 percent FPL and for those under 12 up to 200 percent FPL;
• creating a senior pharmacy fund; and
• expanding eligibility for CMSP to age 18.

• Governor Weld vetoed the legislation because it raised taxes and had no IRP, but the legislature overrode the veto. The tobacco tax idea inspired Senator Kennedy to use the same financing approach in the Federal Child Health Insurance Program legislative proposal.

• The new Governor proposed and the State Legislature approved legislation in 1997 that further expanded Medicaid (renamed as MassHealth) to children with family incomes below 200 percent FPL. An Uncompensated Care Commission convened to discuss how to finance the Pool. The Commission recommended changing the Pool financing so that the IRP became a direct cash subsidy only for small businesses (under 50 workers) that provide employer-sponsored insurance for employees with family incomes under 200 percent poverty.

• Expanding Medicaid (MassHealth Standard) coverage for uninsured children through the age of 18 from the previous level of 133 percent FPL to 150 percent FPL.

• Providing a new program for uninsured children between 150-200 percent FPL (MassHealth Family Assistance). This program, based on a modification of the IRP, requires children in families where employer-provided coverage is available, to enroll in that coverage.

• Limiting eligibility for the state-funded Children’s Medical Security Plan to children who are ineligible for MassHealth programs, including non-qualified aliens who are ineligible for Federal benefits.

• Providing limited (60 days) presumptive MassHealth eligibility for children while verification of income and other information is obtained.

• Expanding MassHealth coverage for pregnant women from 185 percent FPL to 200 percent FPL to create a continuum of care for all low-income children beginning with comprehensive pre-natal care.

• Children through age 18 with family incomes under 150 percent FPL are eligible for MassHealth Standard through either Medicaid or Title XXI. They have access to full Medicaid coverage and no premiums are charged.

• Children with disabilities through age 18 with family incomes between 150-200 percent FPL who are ineligible for the standard program qualify for MassHealth CommonHealth. This fee-for-service program provides all Medicaid services.

• Non-disabled children through age 18 with family incomes between 150-200 percent FPL are eligible for MassHealth Family Assistance. Children are placed in one of two components, depending on their insurance status:
• if they are uninsured, they receive coverage directly from the state; or
• if they have access to or are enrolled in private insurance, they receive premium assistance.

• Pregnant women with family incomes up to 200 percent FPL are eligible for MassHealth Prenatal. They have access to MassHealth Standard coverage. (See Exhibit 1, MassHealth Expansions.)

Federal/State Financing
Massachusetts’ Title XXI allocation of Federal funds in the first year was up to $43 million. The state matching rate is 35 percent, funded through a tobacco tax so no new state appropriation is required. The state is projecting they will spend $6.7 million in state matching funds.

Current Enrollment

• MassHealth Standard enrolled about 15,000 children as of November 1998.
• MassHealth Family Assistance covered about 28,500 children of whom:
• Direct Coverage paid for about 12,500 children
• Premium Assistance enrolled about 16,000 children

Key Factors in Massachusetts Implementation

• Precedent was key. Massachusetts has a long history of expanding public health insurance for children dating back several administrations, so the political climate was very supportive of additional expansions.

• Outreach funds were already available. The State Legislature had already appropriated state funds to conduct outreach to locate more children eligible under state expansions.

• Provider collaboration was essential. The Division of Medical Assistance was already working with providers to serve more children eligible under state expansions.

• Automation helped. For the state expansions, an automated eligibility "decision tree" was developed which was easily modified to accommodate additional children eligible under Title XXI.

• A known pool of eligible children was tapped. There was already a large pool of CHIP-eligible children in the state-funded program, Children’s Medical Security Plan. To enroll this group, the Department of Public Health was able to transfer their cases to the Division of Medical Assistance, which was less labor intensive than organizing a statewide outreach campaign to locate uninsured children.

• Good data were useful. The Division of Medical Assistance already had some initial baseline data about the number of uninsured children in the state. These data were not dependent on CPS estimates, so it will be possible to measure enrollment changes in the different children’s health insurance programs now available.

State Approach
Massachusetts has a multi-pronged outreach approach involving both community-based and statewide activities. While the statewide agency efforts are significant, a creative feature of Massachusetts’ approach to involving communities and finding hard-to-reach populations is their mini-grant program (described in detail on page 13).

Key Players and Administration

• Division of Medical Assistance (DMA) — the Medicaid agency — formerly part of the Department of Public Welfare, that administers MassHealth.

• Department of Public Health (DPH) — the Maternal and Child Health agency (Title V) that administers the Children’s Medical Security Plan (the state-funded children’s health insurance program).

• Area Health Education Center/Community Partners — A private, non-profit organization that supports a mini-grant program to find hard-to-reach populations.

State Agencies

• Department of Public Health (DPH). There was a major effort undertaken to move 20,000-30,000 children enrolled in the Children’s Medical Security Program into MassHealth as they became income eligible for a better benefit package in CHIP. DPH sent a letter to all these families explaining their potential eligibility for MassHealth, describing the advantages and enclosing the MassHealth application form to complete and return.

• The Department of Transitional Assistance provides the Division of Medical Assistance with lists of families recently terminated from the time-limited welfare program. These families are often unaware of their continued eligibility for MassHealth, so DMA notifies them of their continued eligibility.

• The Department of Education and Office of Child Care Services play major roles in the distribution of material for the state’s annual school-based outreach effort.

• The University of Massachusetts at Worcester administers half of the mini-grants, with the Department of Public Health administering the other half.

• School-based outreach. This effort was developed by the Division of Medical Assistance to disseminate information through every public and private school, and every child care program in the state.

• Area Health Education Center (AHEC) coordinates the Health Access Networks, which provides an infrastructure of support for the mini-grant program. The 52 mini-grant organizations and many others who attend the Health Access Networks make up the bulk of community-based activity on outreach and enrollment in the state. (Additional detail is provided on page 14.)

• Coaches Campaign. Organized by five teenagers in the Boston area, this effort was supported by Health Care for All, a statewide health care advocacy organization. The campaign wants to "spread the word that no one should be left on the sidelines." The brochure explains that there are six health insurance options that teenagers should explore with their families before deciding which is best for them. The brochure slogan says: "There are many worthy opponents. Health insurance shouldn’t be one of them."

• The Community Partnerships Initiative was developed by DMA to identify and disseminate information and applications through key community stakeholders. Stakeholders included school nurses, municipal skating rink directors, librarians, summer camp directors, public housing heads, civic and neighborhood association leaders, and others.

• The Targeted Cities Initiative was developed by the Executive Office of Health and Human Services and involved working with municipal governments to highlight MassHealth and enroll uninsured children and families.

• DMA held a series of statewide meetings with Latino community leaders in an effort to increase awareness about MassHealth availability and develop effective outreach and marketing strategies to Latino neighborhoods.

• The State Hospital Association promoted the American Hospital Association’s Campaign for Coverage using press events, posters, brochures, mailings, and buttons to generate publicity.

• The Massachusetts Medical Society sponsored a statewide series of ten free seminars called "What are the Health Care Options for Massachusetts’ Uninsured"? Physicians and office staff who receive inquires from families about health insurance were encouraged to attend. The same seminar was offered twice, at 4 PM and 6 PM, with a light dinner in between as an incentive to attend.

• The Massachusetts League of Community Health Centers recently promoted child and family health insurance enrollment through an English/Spanish poster campaign.

• The state chapter of American Academy of Pediatrics and DMA are sponsoring Children’s Health Care Access Seminars to familiarize pediatricians and their office staff with MassHealth. The effort includes a take-back-to-your-office kit that contains enrollment applications, a "What to do" instruction card, posters, brochures, rolodex cards, a list of community mini-grant programs, and a MassHealth outreach worker contact.

• DMA held several press events and disseminated subsequent news stories with particular attention to weekly and ethnic publications.

• The agency arranged for two PSAs to be developed by a Boston radio station with the highest 18 to 34-year-old audience demographics.

• The agency worked with a Latino television station and Univision affiliate to develop three PSAs.

• DMA is currently working with an advertising agency (pro bono) to finalize an FY2000 public awareness and enrollment campaign.

Presumptive Eligibility
Children have presumptive eligibility in MassHealth for up to 60 days while verification of income and other information is obtained.

To determine eligibility for one of the two MassHealth Family Assistance programs, the state contracted with a health insurance identification vendor, Public Consulting Group of Boston. This company investigates applicant families with incomes between 150-200 percent FPL to check the status of their access to employer health insurance, which determines which type of coverage the children receive. Enrollment of the children while these investigations are pending is time-limited for another 60 days, during which they are covered by fee-for-service. However:

• If families already have insurance, their children are not eligible for 60-day fee-for-service benefits;
• If families have potential access to employer health insurance, their children are enrolled in direct coverage on a fee-for-service basis.

Simplified Application and Eligibility Decisions
There is a single application for MassHealth (including CHIP) and CMSP, called the Medical Benefit Request (MBR). The MBR goes to the Division of Medical Assistance which uses a computerized "decision tree" that automatically assigns children to the appropriate program, depending on their family income and whether they have access to employer health insurance.

Working together, the Division of Medical Assistance and Department of Public Health reduced the application to four pages with supplements for additional questions in four areas: health insurance status; injury, illness or disability; absent parent¹; and immigrant status.

Families can enroll by calling a toll-free number or visiting one of the four MassHealth enrollment centers across the state. After qualifying, the family receives an information package in the mail to select its provider. The number of choices varies statewide, but in general families may have a choice among six managed care organizations or the state-contracted Primary Care Clinicians Program.

Funding for Outreach
Even before Title XXI passed, the State Legislature appropriated $1.5 million to conduct outreach to find children who were eligible under its own pre-CHIP expansion plan. No additional funding was allocated for CHIP outreach.

The Division of Medical Assistance and Department of Public Health allocated $647,000 for a mini-grant program that is designed to find hard-to-reach families. Some of this funding will be charged to Title XIX, to Title XXI, and to the TANF block grant for federal reimbursement.

Marketing to Hard-to-Reach Populations
The Mini-Grant Program is jointly administered by three agencies and has two components: (1) to conduct outreach activities and enroll eligible children and families, and (2) to create innovative programs to alleviate pressure on the Uncompensated Care Pool which serves children who are ineligible for MassHealth.

The Mini-Grant Program is a direct outgrowth of discussions among staff of the three agencies — Division of Medical Assistance, Health Care Finance and Policy, and Department of Health — seeking a more coordinated approach to multi-layered outreach on health insurance programs. It is supported by an organization in the western part of the state that has worked for years to establish and expand community health centers. The Area Health Education Center (AHEC) has a contract with the state Division of Medical Assistance to convene Health Access Network meetings for mini-grantees and others. AHEC convenes regional Health Access Networks monthly in five areas of the state. Attended by a wide range of health-related community groups together with local and state public agency staff, participants share "best practices" for outreach and discuss policy and program developments. They also develop linkages and relationships to facilitate outreach. Finally, the Networks afford an opportunity for the community groups to provide feedback to state agencies about how to expand enrollment and decrease unnecessary emergency room use.

The mini-grants are designed for organizations that have successfully demonstrated their ability to serve their communities, especially hard-to-reach families who would not otherwise be found. In 1998, 52 community-based organizations received grants of $5,000-$20,000. Grantees include:

• community health centers;
• local organizations serving specific populations (e.g., Latino, Vietnamese, Portuguese, Hispanic, Cambodian);
• community coalitions;
• housing groups;
• child care agencies;
• mental health agencies;
• visiting nurses associations;
• immigrant and refugee service organizations;
• multi-service centers; and
• hospital community programs.

• holding a Saturday raffle for a chain saw at the town dump to attract fathers;
• using billboards that show pictures of the local outreach workers in rural communities where many families know and trust each other;
• placing announcements on cable television;
• canvassing homeless shelters;
• attaching stickers about health insurance to applications for school-sponsored sports teams.

AHEC produced a free guide, Health Access Tips: Making Outreach Work, based on ideas used by community groups in MA and elsewhere. The guide is available at AHEC’s Web site, http://www.ahecpartners.org/resources or by calling (413)253-4283.

Woodwork Effect
DMA staff assert that all of their planning for the Medicaid waiver demonstration was designed to cause a woodwork effect. They hoped to attract many families who were previously eligible for but not enrolled in Medicaid. They estimate that two of every three families applying this past year fall into that category, and they hope that CHIP outreach will cause the same woodwork effect.

Advice for Other States on Outreach

• Working with providers produces the greatest impact on increasing initial enrollment. First, staff must convey to providers that "it’s good for them to inform patients about the program." Providers see a lot of uninsured families, from whom they may never receive payment for services. Once you point out the benefit to providers, you get buy-in from them, and you will begin to see a dramatic surge in applications. Of course, providers cannot help with families that do not see doctors.

• To reach the maximum number of children, state administering agencies need as many partners as they can establish partnerships with — other state agencies, providers, community groups, Universities, and private non-profits.

State’s Response
Under state legislation, the Division of Medical Assistance can provide premium assistance to maximize the use of employer-sponsored health insurance. To prevent crowd-out and encourage employer-based coverage, the Division funds premium assistance payments to employees and incentive payments to employers by using a combination of Federal revenue available through its Medicaid waiver and Title XXI. Massachusetts has the first approved State Plan in the country that subsidizes private health insurance for workers who cannot afford employer-based insurance.

State officials believe that its premium assistance plan (authorized through its Insurance Reimbursement Program) is the best defense against crowd-out among both currently uninsured families and the increasing numbers who might drop coverage because of rising costs. Indeed, they point to the goal of "horizontal equity" as the most compelling reason for trying to help everyone at a given income level, insured and uninsured alike. Thus, the premium assistance plan is designed to prevent families from canceling their employer-based coverage, especially families with children who are eligible through state and Title XXI expansions who may already have private insurance. However, state officials additionally support using public funds to provide coverage for families who are already insured because they believe that the state’s long term goal is to encourage the private insurance market to serve lower income families.

There was political debate over the size of the financial contribution to require from families through their premium payments. The State Legislature approved a compromise between DMA and the advocates that limits monthly premiums to $10 per child up to a maximum of $30 per family when the family income is between 150-200 percent FPL.

Some debate continues within Massachusetts about the state’s premium assistance plan, though it should be noted that HCFA(now known as CMS) has approved the plan. Among the issues that are raised by advocates and others are the following:

• Should the state be permitted to establish different benchmarks for benefits, one for children enrolled in the MassHealth Family Assistance premium assistance component (funded through the state’s Medicaid authority and state legislation) and one for children enrolled in the MassHealth Family Assistance direct coverage (funded through Title XXI)? State officials believe it is permissible to have different benefits for the premium assistance component, which offers fewer benefits. Advocates maintain that Title XXI establishes a Federal floor for children’s health benefits (as a condition for federal reimbursement). Children affected by this disagreement are those with incomes between 150-200 percent FPL who are enrolled in one of two Family Assistance programs depending on their access to private insurance (MassHealth Family Plan, Title XXI benefits, if no access; Mass Health Premium Assistance Plan, if have access).

• Does the premium assistance plan itself promote crowd-out by using public dollars to help subsidize the cost of private health coverage for insured children? State officials maintain that the answer is, "Yes, precisely for horizontal equity reasons." They believe that by accepting a certain amount of crowd-out up front, they dampen future crowd-out.

• Will the premium assistance plan significantly increase the number of insured children or will it instead offer subsidized coverage for children who are already insured? Again, state officials respond that subsidizing coverage for insured children is part of their program design, to maintain equity.

• Has the state structured the different types of family plans in a way that can ensure continuous coverage for children, as family circumstances alter that affect their eligibility status? For example, consider these situations:
• What happens to a child’s existing coverage when a parent changes jobs and suddenly has access or loses access to private insurance?
• What happens when a parent loses a job and the family income decreases?
• What happens when another sibling is born or adopted and the family size changes but income does not?

• MassHealth Family Plan (Title XXI program). The family pays a $10 per child premium monthly and receives comprehensive benefits similar to, but not equal to, Medicaid (prescriptions drugs are included but not long term care or transportation). Families may choose among any managed care plans available in Medicaid, or the Primary Care Clinicians Program. Federal law requires that the out-of-pocket expenses for premiums and co-payments must be capped at five percent of the family’s annual income. This group — often called the "shoebox" children — must keep track of their expenses to avoid exceeding the five percent cap. (Note: Children who were previously enrolled in the state health insurance program who are now eligible for this coverage do not pay premiums.)

• MassHealth Premium Assistance Plan. The family pays a $10 per child premium monthly and the state subsidizes employee and employer coverage through its Insurance Reimbursement Program, authorized by its Medicaid waiver. This plan is different than Title XXI in that the minimum benefit package is lower. The state cannot claim the enhanced match through Title XXI for these children who were previously insured, because Federal law does not allow states to assist currently insured families.

Co-payments
If a child is enrolled in the Family Assistance Plan direct coverage component, there are no co-payments. If a child is enrolled in the Family Assistance Plan premium assistance component, there may be co-payments depending on family income, and the co-payments are included in the calculation of the aggregate five percent cap on out-of-pocket costs.

A Health Care Kit was prepared — to remedy the need for shoeboxes — that helps eligible families track their out-of-pocket expenses and send all receipts to the Division of Medical Assistance. After meeting the cap, DMA will notify the family so that when the next medical bill arrives, the family can forward it to the agency for payment or the provider can bill DMA directly. Families will receive a letter to show providers that the family must no longer be charged co-payments. Alternatively, the provider can access the Recipient Eligibility Verification System (through the child’s Social Security number) to check if the family has reached its cap.

Employer Buy-In
Massachusetts officials believe that employer and employee subsidies offer the most effective way to discourage further erosion of employer-sponsored health insurance. Through its Medicaid waiver, the state has the authority to implement an Insurance Reimbursement Program to provide:

• premium assistance payments for families (and individuals) with incomes below 200 percent FPL; and
• incentive payments for small employers providing insurance to lower income employees.

• Children are covered through the standard small group plan where benefits can vary (e.g., some lack prescription drugs, dental or other services) from Title XXI benefits.

For Employers
The employer subsidy program began phase-in in January 1999 and includes employers paying at least 50 percent of the insurance premium costs for lower income employees.

• The program will begin with employers who have less than ten employees and later will expand to companies with less than 50 employees. Small businesses were targeted for the program because they are the fastest growing group of employers and the state wants to encourage them to offer employee health benefits.

• The program will provide subsidies of $400-$1,000 for small businesses.

Data for Program Design

• A special commission conducted a study of uncompensated care in the state. It was delivered to the State Legislature in February 1997. The report is briefly described on the Web site of the Division of Health Care Finance and Policy, www.magnet.state.ma.us/dhcfp, and is available in full, hard copy, from the Division.

• A survey on the number of uninsured in the state was conducted by the Division of Health Care Finance and Policy and the University of Massachusetts, Survey Research division. This survey was designed to have a larger sample than, and improve on the scope of, the Current Population Survey.

• The Division of Health Care Finance and Policy conducted a study to compare various approaches to covering working families who are uninsured. This report was filed with the State Legislature in April 1998, and is available from the Division only in hard copy.

• The University of Massachusetts is helping the Division of Medical Assistance (DMA) collect baseline data about the number of uninsured individuals. One method is through a state survey of 3,600 families that asks "Are you uninsured today?" to compare responses to earlier work done by CPS and the Urban Institute. No report is available at this time.

• The second method will supplement this information by developing more targeted, regional baseline estimates. DMA has commissioned the University to compare results from the 3 surveys — the Urban Institute’s, the University’s, and the University Survey Research division’s — to compile better forward-looking projections on regional uninsured rates.

• The Division of Health Care Finance and Policy reported on an independent evaluation of the effectiveness of all MassHealth Programs in March 1998 and a second report is due March 2000. A hard-copy report is available from the Division.

• HCF&P will conduct a comprehensive survey of uninsured individuals by November 1999.

• To monitor outreach, DMA will track enrollment data by zip code, primary language, outreach site, and mini-grant recipient to monitor where and with what populations outreach efforts should be modified.

• To monitor the new, simplified application process, DMA will track the number of applications filed, number approved, number denied, number needing further verification and the decision turnaround time. This study will also examine the success of presumptive eligibility and whether families submit necessary verification or lose coverage because they fail to do so.

• To monitor the new Premium Assistance Plan, DMA will track the number of children receiving this new coverage and whether they already had private insurance, as well as how many plans meet the benchmark package of benefits. It will also track the impact of premiums and whether they contribute to families’ disenrollment.

• To monitor quality of care, DMA can collect data from its claims system showing what services are provided by managed care organizations across the state. This allows the Medicaid agency to match encounter data with eligibility files to examine access and quality measures for specific subpopulations (e.g., number of visits to specialists; screening rates; well-child visits; inpatient and outpatient visits; and number of children with specific diagnoses).

• DMA will monitor the employer assistance plan once there are enough small employers subscribed so that the data is meaningful.

• Consumer Assessment of Health Care Survey (CAHCS). The survey will include information about consumers’ access to and experience with quality of care. It is mailed directly to individuals (in English and Spanish) to determine their experiences over six months. The state is testing ways to determine how to ensure the highest response rate by combining mailings and telephone follow-ups and possibly some face-to-face interviews.

• Child and Adolescent Health Measurement Advisory Panel. Massachusetts is one state participating in this national initiative that is trying to determine how to measure certain health issues such as getting healthier, staying healthy and living with chronic illness. The state will pilot a survey of adolescents to determine how to ensure an adequate response rate.

• A Robert Wood Johnson Foundation grant will be used to evaluate all of Massachusetts’ health care expansions that use either state or Federal funds. So far, the state is working under a planning grant, and will apply for the next phase.

• As the state begins to implement both its employee and employer subsidies, state staff anticipate a challenging change to their outreach strategies. With subsidies, outreach becomes more of a workplace activity. This will require the state or the contractor running the subsidy program (Public Consulting Group of Boston) to work with personnel offices and companies across the state to ensure program enrollment. This type of outreach is very different than strategies historically associated with finding lower income families who may be eligible for public services.