Federal Flexibility Issues Under Medicaid and SCHIP

Assembly on State Issues - Children, Families and Health Committee--December 2000

Joint ASI/AFI Meeting in Washington, D.C.

Federal Flexibility Issues Under Medicaid and SCHIP

Presiding:	Senator-elect Linda Evans Parlette Chair, Children Families and Health Committee
Speakers:	Wendy Wolf, M.D. M.P.H., Senior Advisor, Health Resources and Services Administration (HRSA)
	Cindy Mann, Family and Children's Health Program Group, Health Care Financing Administration (HCFA)

Senator Parlette introduced the session and the speakers, noting the committee's desire to help state policymakers better understand the options available to them under Medicaid and the State Children's Health Insurance Program (SCHIP) related to covering additional uninsured people in the states.

Wendy Wolf presented an overview of state flexibility issues under SCHIP and also highlighted a number of other initiatives sponsored by the Health Resources and Services Administration (HRSA) that help states address health care for low-income families. Dr. Wolf noted that before SCHIP was implemented, only four states provided insurance coverage for children in families with incomes equal to or greater than 200 percent of federal poverty guidelines; now 36 states do so. States have flexibility under SCHIP to determine income eligibility guidelines, effective enrollment strategies, benefits, cost-sharing, the service delivery system, and performance measures.

Dr. Wolf indicated that states face challenges that continue to limit SCHIP enrollment, including barriers to enrollment (such as long application forms), difficult to reach populations (such as adolescents), cultural and language barriers, and perceptions that working families may not qualify for assistance. She noted that states have ways to overcome many of those barriers, including the ability to shorten application forms, eliminate asset tests, allow 12 months of enrollment eligibility and presumptive eligibility, provide assistance for application, and conduct outreach. States also may design programs to provide specialized services to children with special health care needs.

Dr. Wolf also highlighted other HRSA access initiatives, including community and migrant health centers, Health Care for the Homeless Programs, Public Housing Primary Care Programs, School-Based Health Centers, the Community Access Program (CAP), the State Planning Grant Program, and the "100% Access/0% Disparities" campaign to improve access to health care for all Americans and eliminate disparities in health status by income and ethnicity.

Ms. Mann explained that the Medicaid program's coverage of families started with fairly narrow eligibility, targeting only those adults and children who qualified for welfare assistance through the Aid to Families with Dependent Children program. Congress expanded eligibility to children and pregnant women in the 1980s and 1990s. The 1996 welfare reform legislation gave states new options to cover families to virtually whatever income level they choose, by allowing deductions for child care expenses and disregarding certain income. In addition, new regulations issued by HCFA in 1998, allow states to cover two-parent families to the same extent as single-parent families.

Ms. Mann also indicated that states can take several steps to make Medicaid enrollment easier for families, including simplify the enrollment form, reduce enrollment documentation (the only federal requirement relates to immigration status), eliminate the face-to-face interview, and adopt presumptive eligibility and 12-month continuous eligibility for children.

Ms. Mann also addressed potential Section 1115 demonstration waivers for the SCHIP program. She emphasized that SCHIP provides a limited amount of money and that children remain its focus. She said that in order to qualify for 1115 SCHIP waivers, states must have at least one year of SCHIP experience, include children with family income of at least 200 percent of federal poverty guidelines, have no waiting list for children, and promote enrollment and retention of SCHIP- and Medicaid-eligible children. So far, five states have expressed interest in 1115 SCHIP waivers to expand eligibility to parents or pregnant women, or to provide additional benefits and services.

NCSL Contacts: Martha King at martha.king@ncsl.org, Leah Oliver at leah.oliver@ncsl.org, or Laura Tobler at laura.tobler@ncsl.org, NCSL Health Care Program or by phone at 303-364-7700.