Appendix C: Overviews of State Programs
CALIFORNIA KIDS
HISTORY:
California Kids is a non-profit organization sponsored by private donations that was founded July 30, 1992. The program was initially based in Los Angeles, and has since expanded to 33 counties. CaliforniaKids offers children a limited health insurance product that focuses on preventive care. The program coordinates with MediCal, the state Medicaid program, to obtain care for children who need inpatient treatment or other serious care that CaliforniaKids does not provide. CaliforniaKids partners with community organizations to identify and enroll eligible children. Children enrolled in CaliforniaKids pay no monthly premiums, but are responsible for small co-payments for their care. CaliforniaKids has provided coverage for 17,000 children since its inception in 1992.
TARGET POPULATION:
Uninsured children ages 2-18 who are unmarried, ineligible for coverage under any federal or state health benefit program, not currently enrolled under a private health care contract, and enrolled and attending school (if school-age) are eligible for CaliforniaKids if their family income is below 200% of the poverty level. In August 1997, a pilot program was initiated in San Diego that will expand income eligibility up to 300% of the poverty level in that county.
BENEFIT PACKAGE:
Benefits covered by CaliforniaKids include primary and preventive care, immunizations, prescriptions, a 24-hour nurse hotline, hearing screening and aids without co-payment, emergency treatment with a $25 co-payment, outpatient care and doctor visits with a $5 co-payment each, and dental and vision with a $10 co-payment each.
PROVIDER NETWORKS AND REIMBURSEMENTS:
CaliforniaKids utilizes a managed care, capitated system to maintain cost-effectiveness, minimize risk and unnecessary administrative expense due to excessive claims processing, and provide a "medical home" for the child. The network, administered by Health Affairs International, maintains choice and is sensitive to access, culture, language, gender, and age of child. Over 15,000 health care providers are contracted to provide services throughout the State and a 24-hour nurse hotline is available to all members to provide health care information and re-direct care from the emergency room to a lower cost, appropriate alternative. Plans donate their direct administrative expenses. CaliforniaKids partners with medical groups and IPAs, which offer wellness education to its members. Services are administered by Blue Cross of California, Delta Dental, Vision Service Plan, Wellpoint Pharmacy, and Access Health.
FINANCING:
CaliforniaKids is financed through private donations. CaliforniaKids does not collect premiums, but charges nominal co-payments for care. Costs are kept low by offering a limited benefit package and minimizing administrative costs.
COLORADO CHILDREN'S HEALTH PLAN
HISTORY:
The Colorado Child Health Plan (CCHP) was established in 1992 as a community-based health care reimbursement program for low-income children. CCHP operates as a health maintenance organization that is administered by the University of Colorado Health Sciences Center. The program initially targeted rural counties with a low number of safety net providers, and built its own network of physicians. Recent legislation established the Children’s Basic Health Plan (CBHP), a program which will expand eligibility under CCHP up to age 18 and extend the network into every county in the state. CBHP will be a full benefit program administered by private HMOs. The CBHP will be funded in part by the Title XXI block grant. The Colorado Child Health Plan will provide the basic infrastructure for the establishment of the Children’s Basic Health Plan which will be implemented in March 1998. The Colorado Child Health Plan will sunset on June 30, 1998.
TARGET POPULATION:
The target population of CCHP is children age 18 and under with incomes up to 185% of the poverty level who are not eligible for Medicaid. Enrollment in FY1996 was 4,893 children. In FY1997 the target is 6,217 children, and in FY1998 the target enrollment in the CCHP/CBHP is estimated to be 14,000 children.
BENEFIT PACKAGE:
The benefit package was modeled after the Blue Cross/Blue Shield Caring Programs. Benefits include most preventive services such as well child care, immunizations, laboratory tests, visits for illness and injury, chronic care and outpatient surgery; but do not include inpatient hospital care, eyeglasses, hearing aids or dental care. There is a maximum annual benefit of $10,000 per child. The program expansion will include inpatient and mental health care.
PROVIDER NETWORK AND REIMBURSEMENT:
CCHP is administered by the state of Colorado through the University of Colorado Health Sciences Center. The program has a statewide network of pediatric physicians. Primary care physicians are reimbursed on a capitated basis and bear risk. Medical specialists are reimbursed on a fee-for-service basis.
FINANCING:
Funding is obtained for CCHP through a combination of state appropriations and private donations. Funding comes from several sources: General Fund; intergovernmental transfer cash reserves and interest paid on those reserves; private donations; and enrollment fees. The enrollment fee is a $25 per child yearly payment in lieu of premium contributions. Co-payments are required on doctor visits, health screenings, and prescriptions. Blue Cross/Blue Shield HMO donates all claims processing services
FLORIDA HEALTHY KIDS CORPORATION
HISTORY:
The Florida Healthy Kids Corporation was established in November 1990 to create a comprehensive insurance product for school children using Florida school districts as a grouping mechanism. A HCFA(now known as CMS)-funded demonstration project of Healthy Kids was initiated in Volusia County in 1992 and was completed in 1995. In late 1993, Healthy Kids began expanding into additional counties utilizing both state and local government funds. Healthy Kids currently serves 24 of Florida’s 67 counties, which contain over half the state’s uninsured children. The program is designed to provide affordable access to health insurance for all Florida children. Children who are not on the school lunch program pay the entire cost of their insurance, while children who are on the school lunch program have access to subsidized insurance. Participation by Florida counties in the Healthy Kids program is strictly voluntary.
TARGET POPULATION:
Once a school district elects to participate in the program, qualified children become eligible for Healthy Kids. Children must be between the ages of 5 and 19, uninsured (i.e. not enrolled in Medicaid or private insurance), and enrolled in school up to the 12th grade. Counties may expand eligibility to allow children of other age groups the ability to participate (e.g. children who are less than school age whose families are enrolled in Healthy Kids).
BENEFIT PACKAGE:
Program benefits are extensive, including inpatient care, surgery, emergency services and transportation, eyeglasses, hearing aids, physical therapy, mental health services, pre-natal care and delivery, and organ transplants. Co-payments are required for certain benefits. Counties may add additional services such as dental care to the package. Healthy Kids has a $1,000,000 lifetime cap on services received.
PROVIDER NETWORK AND REIMBURSEMENT:
Twelve managed care networks serve Healthy Kids enrollees. Insurers are selected on the basis of five variables: price, benefits, provider network, reporting capabilities, and general criteria such as accreditation and solvency. Healthy Kids aggregates state, local and family funds to pay premiums to commercial health plans that assume the insurance risk.
FINANCING:
All individuals enrolled in the Healthy Kids program are required to pay some portion of the cost of their insurance. Sliding-scale premiums are based on reported family income required for participation in the school lunch program. The three cost-sharing levels are "Free Lunch", "Reduced Lunch", and "Not on Lunch Program". Premium levels vary by county. Funding for the demonstration project in Volusia county came from a HCFA(now known as CMS) waiver. All subsequent funding has been granted through a combination of state, local and family contributions.
CHILDREN’S MEDICAL SECURITY PLAN OF MASSACHUSETTS
HISTORY:
Authorizing legislation for the Children’s Medical Security Plan (CMSP) was passed in 1993 to provide access to preventive and primary care services for Massachusetts' uninsured children. The plan originally covered uninsured children age 12 or younger. The impetus for the program was initially the national attention to health care reform and access to health care for all individuals. The passage of the Health Access Law in July 1996 expanded CMSP program eligibility to include adolescents up to age 18. In 1997 administration of the plan was transferred to the state Department of Public Health.
TARGET POPULATION:
The target population for CMSP is uninsured children under the age of 19 who are residents of Massachusetts and who are not eligible for Medicaid. The number of projected children eligible for CMSP is 76,000.
BENEFIT PACKAGE:
The Children's Medical Security Plan offers a range of benefits designed to cover the services most frequently used by children. Routine well-child check-ups, immunizations, and smoking prevention services are covered without co-payment. All other covered benefits require a co-payment of are $1, $3 or $5 based on family income guidelines.
Limited coverage is offered for emergency care, prescription drugs, durable medical equipment, and outpatient mental health services. CMSP does not pay for OTC drugs, ambulance transport, inpatient care, dental care, or early intervention. However, children enrolled in CMSP may be eligible to receive inpatient care in any of the state hospitals or community health clinics through the state free care pool.
PROVIDER NETWORK AND REIMBURSEMENT:
The Community Health Plan (CHP) and John Hancock administer the health insurance program. The Community Health Plan serves three rural counties with approximately 3,000 participants. John Hancock serves the remainder of the state, with roughly 34,000 enrollees. John Hancock reimburses its providers on a fee-for-service basis, while CHP reimburses both through capitation and fee-for-service arrangements.
FINANCING:
There are three sources of funding for the program: tobacco taxes, general funds, and family premium contributions. Families earning 200% or less of the federal poverty level receive the insurance free of charge. Those families earning below 400% of the poverty level are charged a reduced premium rate of $10.50 per child per month, with a $32.50 maximum per family per month. Families with income over 400% of poverty are charged the full premium, which is currently set at $52.50 per month.
MINNESOTA CARE
HISTORY:
MinnesotaCare began in 1992 as part of a package of legislation aimed at reducing the number of uninsured in the state of Minnesota. With the advent of the MinnesotaCare demonstration project, all Minnesotan enrollees were transitioned to mandatory managed care. Phase I of the demonstration extended Medicaid coverage to families with children under 275% FPL and with no insurancae coverage. Under the demonstration, childdren and pregnant women receive all benefits available to traditional Medicaid enrollees. In May 1997, a bill was approved to expand MinnesotaCare eligibility for adults without children with income from 135% FPL to 175% FPL. The legislation also reduced provider taxes and added non-preventive dental coverage for adults in families below 175%.
TARGET POPULATION:
MinnesotaCare is available to families with children who have incomes of less than 275% FPL and individuals who have incomes of less than 175% FPL. TO become eligible for MinnesotaCare, one must have been uninsured for at least four months and have had no access to employer subsidized coverage for 18 months or more. An asset test will be implemented when the amended demonstration waiver is approved by HCFA(now known as CMS). Under the asset test, families cannot have more than $30,000 in assets, and individuals cannot have more than $15,000 in assetss to be eligible for the plan.
BENEFIT PACKAGE:
The program offers a comprehensive benefit package including inpatient hospital benefits. However, inpatient benefits are capped at $10,000 annually for adults without children and for parents with incomes greater than 175% FPL.
PROVIDER NETWORK AND REIMBURSEMENT:
Enrollees have the opportunity to choose a health plan upon enrollment into the program. Provider reimbursement was originally structured on a fee-for-service basis but now is a capitated payment system.
FINANCING:
MinnesotaCare was originally funded through a cigarette tax, a provider tax, and family contributions. The cigarette tax is no longer used for MinnesotaCare support; it was only applied from July 1992 through January 1994. In July 1995, the state 1115 demonstration waiver was implemented, and the federal match was added to the funding mix. In 1997 a reduction was made in the provider taxes due to a surplus in MinnesotaCare funds.
NEW YORK CHILD HEALTH PLUS
HISTORY:
The Child Health Plus program was passed by the New York State legislature in 1990, and by August of 1991, children began receiving coverage under the program. New York’s Child Health Plus is the largest of 13 non-Medicaid, taxpayer-funded child health insurance programs in the country. As of July 1, 1997, the program was providing coverage to over 135,000 children. The program has estimated target enrollment over the next few years to total 250,000; this number may increase significantly due to recent federal legislation. The overall intent of the Child Health Plus Program is the following:
· To improve the health status of children participating in the program by providing a "medical home"
· To provide primary, preventive, outpatient and inpatient health insurance coverage to low income children by removing financial barriers to purchasing such coverage through an individual subsidy program
· To increase children’s access to primary comprehensive, preventive and inpatient health care services
· To reduce and more effectively target bad debt and charity care expenditures in the state of New York
TARGET POPULATION:
Children considered eligible for the program must be either uninsured or underinsured, residents of New York State, under the age of 19, and not eligible for state Medicaid benefits. Children under age 19 in families with an income below 222% FPL are eligible for an income-variable premium subsidy. Children in families above 222% FPL are permitted to buy into the program without any premium subsidy.
BENEFIT PACKAGE:
The program began providing coverage to children in August of 1991, initially providing subsidized primary and preventive outpatient care to children under age 13. In 1997, the program extended benefits to include inpatient care (excluding inpatient services for mental health and substance abuse) and extended coverage to include children through age 18.
PROVIDER NETWORK AND REIMBURSEMENT:
The provider network currently consists of 15 insurance plans contracted to provide health services to enrollees, of which 11 are MCOs and 4 are traditional indemnity plans. As of October 1, 1997, 24 insurance plans, with almost all providing a managed care product, will participate in Child Health Plus. Additionally, a marketing and outreach organization has been contracted to promote the plan throughout the state. This will be complemented by an in-house statewide marketing effort.
FINANCING:
The program is financed through a provider surcharge established under the New York Health Care Reform Act of 1996. The premium contribution from families participating in the program is an additional funding source.
OREGON HEALTH PLAN
HISTORY:
Between 1989 and 1995, the Oregon Legislature passed a series of laws to reform the state health care system. These laws provided the basis for a major overhaul of the method of providing and paying for health care to Oregon's needy populations and the establishment of the Oregon Health Plan. A coalition including consumers and health care industry representatives undertook the weighty task of ranking health care procedures according to their public good. Those items deemed most beneficial are covered by the Oregon Health Plan. The Oregon Health Plan went into effect in February 1994 and enrolled nearly 120,000 new members in its first year. A high risk insurance pool is also available for those denied private coverage because of pre-existing medical conditions, with rates limited to a maximum of 125% of private insurance rates.
TARGET POPULATION:
The Oregon Health Plan is available to all Oregon residents whose income is less than 100% of the poverty level. In addition, pregnant women and children ages 0-5 are eligible for services if their family income is less than 133% of the poverty level. All enrollees must be citizens or legal aliens who reside in Oregon. Coverage is also available to people who were refused health coverage by private insurers because of pre-existing medical conditions through the high risk pool.
BENEFIT PACKAGE:
The legislation enabling the Oregon Health Plan established an eleven-member Health Services Commission that was charged with the task of prioritizing health care services for coverage based on the benefit to the entire population of the state. The ranking of health services was conducted through an analysis that rated health services and treatment according to cost, duration of benefit, physician opinion on the effectiveness of treatment and prevention of death, and consumer opinions on the seriousness of specific health conditions. Coverage is provided for services above a certain threshold on this list. The exact threshold is determined by the legislature each year. All services frequently utilized by children have historically been covered.
PROVIDER NETWORK AND REIMBURSEMENT:
Most individuals enrolled in the Plan are required to join a health maintenance organization; however, the frail elderly, the disabled, and certain others (approximately 1/5 of total enrollment) are permitted to receive services on a structured fee-for-service basis through a designated case manager.
FINANCING:
The central principle of the Oregon Health Plan is that eligibility for publicly sponsored coverage can be expanded if costs are contained through managed care and prioritization of benefits. By increasing the number of covered individuals, it is expected that charity care and cost shifting will decline. The program is funded by the state general fund, federal match, and a newly-passed initiative raising Oregon’s tobacco taxes.
RITECARE (Rhode Island)
HISTORY:
RIteCare is an 1115 Waiver program that was implemented August 1, 1994. Rhode Island's statewide initiative seeks to increase access to primary and preventive health care services for all Aid to Families with Dependent Children (AFDC) beneficiaries and certain low-income women and children through a fully capitated managed care delivery system. RIteCare expands Medicaid eligibility and provides an enhanced set of primary care and preventive benefits through a fully capitated managed care system. Unlike the traditional Medicaid program, RIteCare requires cost sharing for individuals with family incomes between 185% and 250% of the poverty level.
TARGET POPULATION:
The Rhode Island Department of Human Services estimates that approximately 7,000 previously uninsured persons will find themselves able to access care through RIteCare. RIteCare provides coverage to pregnant women and children up to 8 years of age with family incomes at or below 250 percent of the FPL; in addition, women who would otherwise lose Medicaid eligibility post-partum remain eligible for family planning services. RIteCare currently serves 73,500 people. Seventy thousand of these are AFDC and AFDC-related Medicaid beneficiaries. The remaining 3,500 are children up to age 8 and pregnant women with incomes of 185-250% of the federal poverty level. On May 1, 1997, coverage was made available to all uninsured children up to age 18 in families up to 250% of the poverty level.
BENEFIT PACKAGE:
Each health plan offers medical, dental and mental health benefits, and enhanced outreach services such as provision of bus passes. Participating health plans are required to offer a package of services intended to overcome non-financial barriers to care, such as outreach, home visits, nutrition counseling, childbirth education, and parenting classes.
PROVIDER NETWORK AND REIMBURSEMENT:
Four managed care plans are currently serving RIteCare enrollees: Harvard Pilgrim Health Care, Coordinated Health Partners, Neighborhood Health Plan of Rhode Island, and United HealthCare of New England. Rhode Island has made significant strides in improving access to primary care through RIteCare. Primary care physician participation in Medicaid has increased from 350 to over 800 physicians. The average number of physician visits per enrollee increased from two per year to five per year in RIteCare's first year (1995). Both hospital utilization and emergency room visits fell by more than one third from 1993 to 1995.
FINANCING:
RIteCare is funded through a mix of Medicaid dollars, state funds and individual premiums. Individuals with family incomes between 185% and 250% of the poverty level contribute to the cost of their insurance through monthly premium payments.
WASHINGTON BASIC HEALTH PLUS
HISTORY:
In 1993, Washington State created the Basic Health Plus program for children under 200% of the federal poverty level through a Medicaid expansion. These children were previously eligible for health insurance through the full state-subsidized Basic Health Plan established in 1988, under which adults below 200% of the federal poverty level still receive coverage. The Basic Health Plus program was established to take advantage of the federal funding available through Medicaid. Children covered under the program receive a comprehensive benefit package at no cost to their family. Provider networks are aligned between the Basic Health Plus program and the Basic Health Plan so that families can visit the same physicians.
TARGET POPULATION:
Children ages 0-19 whose families earn less than 200% of the poverty level are the target population of Basic Health Plus.
BENEFIT PACKAGE:
The Washington Basic Health Plus program has the same rich benefit package traditionally provided under the state Medicaid program. This includes all preventive services, plus benefits such as inpatient care, dental care, eyeglasses and hearing aids. Basic Health Plus provides routine screenings of up to $125 per child per calendar year without co-payment (this does not apply to well-baby care). Immunizations and well-child visit are covered up to a maximum of $400 per calendar year for children ages 1-4. Children receive a 50% discount on glasses and a 25% discount on contact lenses. There is an unlimited inpatient stay, but care must be authorized within 48 hours of admission.
PROVIDER NETWORK AND REIMBURSEMENT:
There are currently fourteen managed care plans contracting with Basic Health Plus. There is almost a complete overlap between the provider network utilized by Basic Health Plus and that used by the Basic Health Plan.
FINANCING:
The program is funded through a combination of state and federal funds through the Medicaid match. State funds are obtained primarily through state taxes on cigarettes and alcohol.