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
*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
*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.