States employed four types of cost-sharing policies: (1) annual enrollment fees; (2) monthly premiums; (3) copayments; and (4) deductibles (Table 17). States vary in the income thresholds at which they apply cost-sharing requirements, the amounts of enrollment fees, premiums, copayments, and deductibles, and the administrative rules governing the payment process, including policies on non-payment of cost sharing. Most states have modified their policies since they began.
Colorado and Texas currently charge an annual enrollment fee and four states (California, Missouri, New York, and Texas) require families to pay monthly premiums. This cost sharing begins at different income levels across the states. Only two of the study states require cost sharing of families whose income is between 100 and 150 percent of the FPL: California charges families in this income range a monthly premium, while Texas charges a $15 annual enrollment fee (see Table 17).
Colorado charges an annual enrollment fee for families above 150 percent of the FPL, New York requires families with incomes above 160 percent of the FPL to pay premiums, and Missouri requires families with incomes above 225 percent of the FPL to pay premiums. According to state officials, the different policies lead to varying proportions of enrolled families who are subject to premiums or enrollment fees: from 100 percent in California, to 40 percent in New York, 25 percent in Texas, and 5 percent in Missouri. 60, 61
Missouri changed its premium program significantly in July 2001. It changed monthly premium levels from a fixed $80 per family to a sliding fee ranging from $55 to $218, depending on income and family size. As a result, the highest premium payments are now close to the full cost of coverage under the state employee health benefit plan, as required by the state's authorizing legislation. Importantly, families are required to pay premiums only if their income is above 225 percent of the federal poverty level.
Three states (California, New York, and Texas) require initial payments to be submitted along with the application, as a condition of eligibility. Colorado and Missouri wait until after eligibility has been determined to invoice families for the annual fee or initial premium payment;
TABLE 17 (continued)
N.A. = not applicable.
Blackout period = length of time following disenrollment that a participant must wait before they are allowed to reenroll in the program.
aLower amount is for families who opt to participate in a Community Provider Plan (which involves safety net providers).
bPremiums were eliminated and replaced by enrollment fees in October 2000.
cAs a Medicaid expansion state without a Section 1115 demonstration, Louisiana could not require cost-sharing.
dAs of August 2001, the state had not yet acted on this provision to disenroll any family for nonpayment of premiums.
eBefore July 1, 2001, the premium was $80 per family
fUp to $250 annual limit (excluding vision and dental).
gTexas has since dropped the deductible.
enrollment takes effect when payment is received. Both California and Texas allow families to pay premiums in advance for multiple months; but only California provides an incentive to do so--families paying for three months in advance get their fourth month of coverage free. Also, to facilitate premium payment, California allows families to make their premium payments at any Rite Aid drugstore.
Every study state with a premium offers a grace period of 30 to 90 days before families are disenrolled for nonpayment. To strengthen its ability to take action against families who fail to pay, Missouri received approval from CMS in January 1999 to disenroll families after four or more instances of nonpayment. To date, however, the state has taken no action to disenroll any families using this authority.
With the exception of New York, families disenrolled for nonpayment may not reenroll during a "blackout" period ranging from three to six months. In New York, families may reenroll at any time. New York's policy has raised concerns about potential adverse selection; some health plan officials in the state believe that some families avoid paying monthly premiums when their children are healthy, and allow their coverage to lapse until their children need care.
Four states impose copayments on selected services. Copayment amounts vary but are comparable, or lower than, copayments imposed by private insurers. Except for emergency room copayments in Texas ($25 or $35 for families in the higher-income groups), copayment amounts typically are no more than $5 or $10 per visit or prescription (Table 17). California imposes a $5 copayment for each type of service and for families in all income groups. Similarly, all families in Texas must make copayments, although lower-income families pay less than others. Colorado and Missouri base copayments on family income but exempt the lowest-income families. Providers are expected to collect copayments at the point of service. Whether or not health plans deduct copayment amounts from the fees they pay providers varies from plan to plan and from state to state. In no state that requires copayments may providers deny service for refusal to pay and some providers are reported to write off copayments as "a cost of doing business." New York eliminated copayments when it introduced premiums during the conversion of its state-funded program to SCHIP.
Texas is the only state in the nation that incorporated a deductible in its SCHIP program. Families with incomes above 185 percent FPL had to meet an annual deductible of $200 for inpatient hospital care and $50 for outpatient care. Texas since dropped the deductible.
60. New York is the only state among the six study states that allows families to buy coverage by paying the full cost. Families with incomes above 250 percent FPL may purchase coverage at an average cost of $115 per month per family.
61. Colorado revised its cost-sharing policies in January 2001. Before this revision, all enrollees with family incomes above 100 percent of the FPL, 72 percent of families with enrolled children, were subject to monthly premiums. Beginning in January 2001, children with family incomes above 150 percent of the FPL, 30 percent of families with enrolled children, were subject to an annual enrollment fee (Colorado Department of Health Care Policy and Financing 2000).