Periods of uninsurance can sometimes create barriers to enrolling individuals in need of coverage. For example, this type of restriction may prohibit individuals who have access to, but cannot afford the private insurance for them and their dependents. A similar situation may arise when private insurance benefit packages offered to employees and their dependents are limited and do not cover many essential services. Such concerns have prompted states to allow for exceptions to current uninsurance requirements.
- In Pennsylvania, if a family is able to document that copayments and/or premiums make it difficult to afford existing private insurance coverage, CHIP will waive the period of uninsurance requirement.
- MinnesotaCare has addressed this issue by defining "employer-based coverage" as private insurance coverage in which an employer contributes at least fifty percent or more to the cost of coverage. MinnesotaCare has also exempted children in families below 150% of poverty from periods of uninsurance when a benefit package offered under private coverage is less comprehensive than the package offered under the state's Medicaid program.
States interviewed suggested that it is difficult to verify and enforce limitations on coverage and periods of uninsurance among applicants. This has resulted in states dropping or modifying such provisions within their programs.
- Florida's Healthy Kids initially required families to have no access to private insurance for six months prior to becoming eligible for the program. As it was difficult for the program to verify applicants' access to coverage, Florida eliminated this requirement.
- The Washington Basic Health Plan had difficulty enforcing a requirement that permitted enrollees to have access to private insurance only if it was less comprehensive than that offered by BHP. As a result of the administrative burden involved with defining and verifying "less comprehensive" coverage, the Basic Health Plan dropped this provision.
Table 1: Basic Eligibility Criteria for Children
|State and Program||Age||Income||Residency Requirements|
|CaliforniaKids||2-18||100-200% FPL||Must live in California but legal residency is not required. If school age, must be enrolled and attending school.|
|Colorado Children’s Health Plan (CCHP)||<13||<185% FPL||Must reside in Colorado and be a U.S. citizen or a documented immigrant.*|
|Florida Healthy Kids||5-19||No Income Limits||Florida relies on the school district to screen for residency. Healthy Kids is offered to any child enrolled in the school district.|
|Massachusetts Children’s Medical Security Plan (CMSP)||<19||No Income Limits|
|MinnesotaCare||<21||<275% FPL||Must be a permanent resident of Minnesota.|
|New York Child Health Plus||1-19||<222% FPL||Must live in New York but legal residency is not required.|
|Pennsylvania Children’s Health Insurance Program (CHIP)||<16||<185% FPL
0-6 years: 185-235% FPL
|Must reside in Pennsylvania for at least 30 days. Must be a U.S. citizen or legal immigrant.|
|Tennessee TennCare||<18||No Income Limits||Must reside in Tennessee and be a legal U.S. resident, but proof of legal U.S. residency is not required by application.|
|Washington Basic Health Plus||0-19||<200% FPL||Must be a legal resident of Washington.|
*The Colorado Child Health Plan also allows the children of migrant workers to enter the program if they meet three criteria: first, the child's parents must maintain a residence in Colorado for at least part of the year; second, the child must meet U.S. citizenship criteria; and third, one member of the child's family must be employed in Colorado.
Table 2: Eligibility Limitations Based on Access to Other State Programs
|Program||Medicaid Ineligibility Required||Access to Program Limited Based on Availability of Private Insurance||Period of Prior Uninsurance Required|
|CaliforniaKids||Yes.||Access to private insurance prohibited. (Exceptions occasionally made for families with high co-pays or deductibles.)||None.|
|Colorado Children’s Health Plan (CCHP)||Yes.||No restriction. CCHP actively encourages families to also carry private insurance so that everyone in the family has health insurance.*||None.**|
|Florida Healthy Kids||No. Children do not need to be ineligible for Medicaid, however they may not be enrolled in both Medicaid and Healthy Kids at the same time.||No restriction.||None.|
|Massachusetts Children’s Medical Security Plan (CMSP)||Yes.||Access to private insurance prohibited. (Exception made for families with only catastrophic coverage.)|
|MinnesotaCare||N/A. MinnesotaCare was created as a Medicaid expansion.||Must not have access to employer–paid insurance (50% or more) for 18 months. Children in families under 150%FPL can enroll if the benefit package offered by their private insurance plan is less rich than the benefit package offered through Medicaid.||Must be uninsured for previous 4 months.|
|New York Child Health Plus||Yes.||No restriction based on access to private insurance, although a child may not be currently enrolled in other equivalent private insurance.||None.|
|Pennsylvania's Children’s Health Insurance Program (CHIP)||Yes.||Access to private insurance prohibited. (Exceptions occasionally made for families with high co-pays or deductibles.)||None.|
|TennCare||N/A. TennCare was created as a Medicaid expansion.||There is no uninsurance requirement for children. Access to private insurance prohibited for adults. TennCare mails a form to all employers each year asking them to specify whether or not their employees are offered insurance. This information is used to verify eligibility for TennCare.||None.|
|Washington Basic Health Plus||N/A. Basic Health Plus was created as a Medicaid expansion.||There is no uninsurance requirement for children.||None.|
*Due to Title XXI restrictions, the new Colorado Basic Health Plan will require that families be without access to employer-based coverage (where the employer pays fifty percent or more of the cost) for a minimum of three months before becoming eligible for the program.
**The new Children's Basic Health Plan will require that a child be without employer-based coverage for the prior three months. Employer-based coverage is defined as health insurance coverage where the employer paid for 50% or more of the cost.