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State Health Programs To Cover The Uninsured 2009

State Health Programs To Cover The Uninsured

State programs that provide or expand health coverage to low-income and previously uninsured populations often display the types of innovations that have earned states their reputation as policy laboratories. This guide profiles the programs in which states cover individuals directly and those where they provide a subsidy for private insurance. It covers programs that are funded by both federal and state tax revenue; those funded solely by states; and some that are state-sponsored and often involve public-private partnerships to extend coverage without use of public funds.

This guide discusses four categories of programs, based on the source of funding: Medicaid, CHIP, state-only and other. Federal standards and options under the Medicaid and CHIP programs—those that draw federal matching funds under titles XIX and XXI of the Social Security Act, respectively—play a prominent role in state coverage programs. State-only programs are those for which most funding comes from state revenue sources; other programs do not receive significant state funding. The guide also highlights three program types: private/public partnership, typically in the form of premium assistance, high-risk pools, and county or local programs.  In addition, a separate NCSL Report, State Pharmaceutical Assistance Programs, provides descriptions of programs in 38 states focused solely on prescription drugs. Unless otherwise noted, coverage levels associated with each program are the implemented coverage level and may be lower than the enacted level for a program.

State Coverage Programs and Health Reform

Medicaid and CHIP Eligibility

Under the new federal health reform legislation, Medicaid will be expanded to all Americans with incomes up to 133 percent of federal poverty guidelines ($29,327 a year for a family of four in 2010) effective in 2014. This represents a significant change for state Medicaid programs, which will expand to cover additional people who do not currently qualify. The new law provides states with 100 percent federal financing for all those who are newly eligible for Medicaid for the first three years through 2016. The federal match decreases to 95 percent in 2017; 94 percent in 2018; 93 percent in 2019 and 90 percent for 2020 and beyond. Currently the states share the cost of the Medicaid program with the federal government. The federal government share, called the federal medical assistance percentage or FMAP, is calculated based on a three-year average of state per capita personal income compared to the national average. A state with average per capita personal income receives an FMAP of 55 percent; no state may receive less than 50 percent.

The Children's Health Insurance Program (CHIP), provides insurance for certain children who are ineligible for Medicaid but cannot afford private insurance. States receive a higher federal match to pay for CHIP coverage than for their Medicaid programs. This match can either be used to create a separate CHIP program or to create an expansion of the state's Medicaid program, which raises the Medicaid eligibility level for children.

For current eligibility by state, click here.

While the federal government has set minimum eligibility and benefit standards for Medicaid, many states have expanded their coverage to other populations, such as people with higher incomes and others who would not otherwise qualify, no matter how poor they are, such as childless adults. States have also used the Children's Health Insurance Program (CHIP) to extend coverage to more children and to pregnant women. All 50 states and the District of Columbia use Medicaid or CHIP to provide coverage beyond federal standards. Click on the state links above to see how each state is using Medicaid and CHIP funding to expand coverage.

American Health Benefit Exchange

The Affordable Care Act requires the creation of state-based American Benefit Exchanges. Exchanges create a marketplace for health insurance purchasers by providing choices to consumers in picking their health coverage. They will also provide coverage options for people who do not qualify for Medicaid or have employer sponsored insurance.

Premium assistance, in the form of a credit, will be provided through the exchange to individuals between 133 and 400 percent of the federal poverty guidelines to ensure affordable options. The premiums for individuals and/or families will be limited based on income; the maximum premium cost will be limited to 2 percent of income for those with incomes at or below 133 percent of the federal poverty guidelines and up to 9.5 percent of income for those between 300 to 400 percent of FPL.

States have the option to create an exchange it is not a requirement. Each state must notify the secretary of Health and Human Services of its decision to operate a qualified exchange by  2012. If a state chooses to establish an exchange, they must do so by January 1, 2014. Those states creating exchanges have decisions to make regarding the administration of exchanges and whether or not they will be statewide, regional, or merged with other states. If the state chooses not to operate and establish an exchange the federal government will establish the exchange in the state by January 1, 2013. Planning grants are available to states to establish exchanges.

 

Small Business Employers 

Many employees of small businesses are uninsured because insurance premiums can be much higher when there are fewer employees to spread the risk.  Many states help small employers to provide insurance to their employees through premium assistance, reinsurance, tax incentives and multi-employer pooling.

Under the new federal health reform law, there are two new provisions that take effect in 2010 aimed at assisting small businesses employees or employers.  Between calendar year 2010 and 2013, a federal tax credit of up to 35 percent is available to small businesses (with up to 25 Full Time Employees) that choose to offer coverage to make employee coverage more affordable.  Beginning in 2014, the small business tax credits will cover 50 percent of premiums, for more information click here.    Effective July 2010, the law creates a temporary re‐insurance program (until the Exchanges are available) to help offset the costs of expensive health claims for employers that provide health benefits for retirees age 55‐64.  Enrollee claims between $15,000 and $90,000 per plan year may be mostly covered by this new federally established reinsurance pool.  For more information, click here.

The following states have programs intended to assist small employers in attaining affordable insurance: Arizona, Arkansas, Georgia, Idaho, Kansas, Kentucky, Maine, Maryland, Massachusetts, Montana, Nevada, New Mexico, New York, Oklahoma, Tennessee, Washington and West Virginia

State Profiles

***These state profiles are current as of August 2009, unless otherwise indicated.  NCSL project staff is currently updating these profiles***

Alabama | Alaska | Arizona | Arkansas | California | Colorado | Connecticut | DelawareFlorida | Georgia | Hawaii | Idaho | Illinois | Indiana | Iowa | Kansas | KentuckyLouisiana | Maine | Maryland | Massachusetts | Michigan | Minnesota | Mississippi | Missouri  | MontanaNebraska | Nevada | New Hampshire | New Jersey | New Mexico | New YorkNorth Carolina | North Dakota | Ohio | Oklahoma | Oregon | Pennsylvania | Rhode IslandSouth Carolina | South Dakota | TennesseeTexas | Utah | Vermont | Virginia | Washington | West Virginia | Wisconsin | Wyoming | District of Columbia

Additional NCSL Resources on Access | Program Definitions | GlossarySources


 

Alabama

Medicaid
Alabama Medicaid meets minimum federal standards.

CHIP
ALL Kids covers children up to 300 percent of federal poverty guidelines.

State-Only Programs
High-Risk Pool: The Alabama Health Insurance Plan (AHIP) covers HIPAA-eligible people exclusively. Adults file individually for AHIP, but dependent children are eligible if a parent is. The program is funded by a combination of premiums and insurance carrier assessments.

Other Programs
The Alabama Child Caring Program (ACCP) provides limited coverage for uninsured children up to 235 percent of federal poverty guidelines, funded by private donations that are matched by Blue Cross/Blue Shield.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Alaska

Medicaid
In addition to meeting minimum federal Medicaid standards, Denali KidCare covers pregnant women up to 175 percent of federal poverty guidelines and children up to 150 percent of federal poverty guidelines.

CHIP
KidCare covers children up to 175 percent of federal poverty guidelines, using CHIP matching funds, if the child has been uninsured for at least 12 months.

State-Only Programs
The Chronic and Acute Medical Assistance (CAMA) program covers those with a qualifying medical condition who do not qualify for any other programs, are below 30 percent of federal poverty guidelines, and have no other payment alternatives, including charity. Coverage is limited to treatment of the qualifying condition.

High-Risk Pool: The Alaska Comprehensive Health Insurance Association (ACHIA) covers those not eligible for other state, federal or private coverage who either have an eligible medical condition, have been rejected for coverage, would have to accept restrictive riders that greatly downgrade coverage, or have federal eligibility under HIPAA or TAA. The program is funded by premiums and insurance carrier assessments.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Arizona

Medicaid
In addition to meeting minimum federal Medicaid standards, the Arizona Health Care Cost Containment System (AHCCCS) covers pregnant women up to 150 percent of federal poverty guidelines, infants under age 1 up to 140 percent of federal poverty guidelines, and parents up to 100 percent of federal poverty guidelines.

CHIP
KidsCare covers all children up to 200 percent of federal poverty guidelines who have been without insurance for six months and do not qualify for another program. Through a HIFA waiver, AHCCCS uses CHIP funds to cover parents of AHCCCS or KidsCare eligible children up to 200 percent of federal poverty guidelines and childless adults up to 100 percent of federal poverty guidelines, however, parental coverage has been eliminated due to budget constraints.

State-Only Programs
The Primary Care Program offers discounted services for uninsured residents up to 200 percent of federal poverty guidelines for those who are not eligible for other programs. It covers a variety of medical services on a sliding scale and is funded by a tobacco tax.

Private/Public Partnership: The Health Insurance Premium Tax Credits program allows small businesses (two to 25 employees) that have been in existence for at least a year and have not offered insurance for at least six months to apply for a tax credit on a first-come, first-served basis. Individuals who have been without insurance for six months, are not eligible for other programs, and are under 250 percent of federal poverty guidelines also can apply for a tax credit. The credit amount is the lowest option among $1,000 per individual plus $500 per dependent child, $3,000 per family, or 50 percent of the premium. The program is capped at $5 million, and additional applications are added to a wait list.

Other Programs
The Healthcare Group was created in 1986 through a grant from the Robert Wood Johnson Foundation and an annual $8 million state subsidy. Starting in 2005, the program became an unsubsidized, self-sufficient state-sponsored program. It covers small businesses (two to 50 employees) that have existed for at least 60 days and have not offered insurance for three months. Self-employed individuals are also eligible. This program achieves reduced premiums for small businesses through a purchasing alliance.

County Program: HealthCare Connect is a discount service program for Maricopa County (Phoenix) residents between 100 percent and 250 percent of federal poverty guidelines. The Pima Community Access Program offers a similar program in the Tucson area.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Arkansas

Medicaid
In addition to meeting minimum federal Medicaid standards, the Arkansas Medicaid program, ConnectCare, covers pregnant women up to 200 percent of federal poverty guidelines.

Private/Public Partnership: ARHealthNet (formerly Arkansas Safety Net Benefit Program), authorized through a HIFA waiver, is a group health insurance program for small to medium businesses (two to 500 employees) that have not offered insurance for 12 months. ARHealthNet is a limited benefit plan with premiums subsidized for employees under 200 percent of federal poverty guidelines. The program has employee participation requirements. Spouses who have no insurance are eligible.

CHIP
ARKids First B covers children up to 200 percent of federal poverty guidelines. Coverage will increase to 250 percent of federal poverty guidelines based on legislation enacted in 2009. Funding for the expansion comes from an increase in tobacco taxes.

State-Only Programs
High-Risk Pool: Arkansas's Comprehensive Health Insurance Pool  provides coverage for those who have received a rejection notice on an individual plan, were offered only a plan at more than 150 percent of the pool's premium rate, were a member of another state's high-risk pool, or have federal eligibility through HIPAA or TAA. The program is funded by a combination of premiums and insurance carrier assessments.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

California

Medicaid
In addition to meeting minimum federal Medicaid standards, Medi-Cal covers pregnant women and infants under age 1 up to 200 percent of federal poverty guidelines and children age 19 and 20 and parents who meet certain criteria up to 100 percent of federal poverty guidelines.

The Medi-Cal Hospital/Uninsured Care section 1115 waiver covers uninsured adults up to 200 percent of federal poverty guidelines and provides preferred referral of Medi-Cal enrollees to participating hospitals. Coverage under this waiver has reduced benefits compared with Medi-Cal.

Private/Public Partnership: The Health Insurance Premium Payment (HIPP) Program allows Medicaid to pay beneficiary premiums in private insurance when it is cost effective, specifically for high-cost medical conditions.

CHIP
Healthy Families covers children under 19 above Medicaid coverage levels up to 250 percent of federal poverty guidelines. Access for Infants and Mothers (AIM) covers pregnant women up to 300 percent of federal poverty guidelines. The premium is 1.5 percent of adjusted annual income. Infants born under the AIM program are eligible for Healthy Families if they are not enrolled in employer-sponsored insurance.

County Program: The County Children's Health Initiative Program (C-CHIP) draws country resources to the state level to secure federal matching funds and extends coverage in those counties to or above 300 percent of federal poverty guidelines. Some counties also have Children's Health Initiative programs to improve participation among previously eligible groups.

State-Only Programs

High-Risk Pool: The Major Risk Medical Insurance Program (MRMIP) covers those who cannot obtain affordable insurance. Eligibility requirements include previous rejection for individual insurance, involuntary termination from insurance for reasons other than fraud or nonpayment, or individual insurance offered at a premium higher than the MRMIP rate within the last 12 months. It is possible to apply based on anticipated future eligibility. Participation is capped, and applicants are added to a wait list. The program is funded by premiums and tobacco tax.

County Program: The County Medical Services Program (CMSP) covers adults up to 200 percent of federal poverty guidelines, in certain—mostly rural—counties, who do not qualify for Medicaid and meet resource limitation standards.

Other Programs
County Program: Healthy San Francisco offers a medical discount program to any uninsured San Francisco County resident up to 500 percent of federal poverty guidelines who is not eligible for other programs. Premiums and copayments are based on a sliding scale. It also includes an employer mandate for businesses with more than 20 employees, although this provision is, at time of publication, facing a legal challenge under the Employee Retirement Income Security Act (ERISA).

County Program: California counties are responsible for medically indigent adults, although the level of coverage varies.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Colorado

Medicaid
Colorado meets minimum federal Medicaid standards. Legislation enacted in 2009 will expand coverage of adults to 100 percent of federal poverty guidelines, pending federal approval, with state funding coming from an assessment on hospitals.

The Colorado Indigent Care Program (CICP) provides reduced cost services for those up to 250 percent of federal poverty guidelines who do not qualify for Medicaid or CHP+ by partially reimbursing health providers for uncompensated care. The program includes a cap on copayments of 10 percent of income. Those with other insurance can qualify for assistance for uncovered costs. The program is funded by disproportionate share Medicaid and state funds.

CHIP
The Child Health Plan Plus (CHP+) covers pregnant women up to 200 percent of federal poverty guidelines and children up to 205 percent of federal poverty guidelines. Recent legislation expands coverage up to 250 percent of federal poverty guidelines.

Private/Public Partnership: A HIFA waiver also makes premium assistance available for children up to 205 percent of federal poverty guidelines whose parents are offered employee-sponsored health coverage.

State-Only Programs
High-Risk Pool: CoverColorado insures those who have been denied coverage due to a medical condition, have been offered coverage with premiums exceeding CoverColorado premiums, have been offered coverage with reduction or exclusion of a preexisting condition for longer than six months, are transferring from another state's high-risk pool, or have federal eligibility under HIPAA or TAA. CoverColorado is funded by premiums, the state's unclaimed property fund and insurance carrier assessments.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Connecticut

Medicaid
In addition to meeting minimum federal Medicaid standards, Healthcare for UninSured Kids and Youth (HUSKY) A provides free coverage for children and parents or related guardians up to 185 percent of federal poverty guidelines and pregnant women up to 250 percent of federal poverty guidelines.

CHIP
HUSKY B provides coverage with cost-sharing on a sliding scale for children up to 300 percent of federal poverty guidelines. Buy-in coverage is available to all children above 300 percent of federal poverty guidelines. Additional coverage for special needs also is available through HUSKY Plus up to 300 percent of federal poverty guidelines.

State-Only Programs
High-Risk Pool: The Connecticut Health Reinsurance Association (HRA) provides insurance for adults who have not had group or qualifying individual coverage for 150 days (preexisting conditions are excluded for one year), those who have had group or qualifying coverage for at least one year whose application is received within 120 days of voluntary loss or 150 days of involuntary loss of coverage, or those who have federal eligibility under HIPAA or TAA. The program is funded through premiums and insurance carrier assessments. Residents below 200 percent of federal poverty guidelines can qualify for reduced premiums.

The Charter Oak Health Plan offers all adults access to affordable health insurance with premium subsidies on a sliding scale up to 300 percent of federal poverty guidelines.

State Administered General Assistance (SAGA) provides fully subsidized medical assistance to childless adults who are not eligible or are waiting for eligibility determination for other state or federal programs and are below monthly income, approximately 60 percent of federal poverty guidelines depending on region, and $1,000 household asset limits.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Delaware

Medicaid
In addition to meeting minimum federal Medicaid standards, the Diamond State Health Plan covers pregnant women and infants under age 1 up to 200 percent of federal poverty guidelines. Through a Section 1115 waiver, Delaware used savings from managed care to expand Medicaid coverage to all individuals up to 100 percent of federal poverty guidelines.

CHIP
The Delaware Health Children Program (DHCP) covers children up to 200 percent of federal poverty guidelines. Those over 200 percent of federal poverty guidelines can buy coverage at full cost.

State-Only Programs
The Community Healthcare Access Program (CHAP) uses tobacco settlement funds to pay for discounted medical services with participating providers for uninsured people up to 200 percent of federal poverty guidelines.

Screening For Life provides free screening services for breast, cervical and colorectal cancer for those up to 250 percent of federal poverty guidelines.

The Delaware Cancer Treatment Program provides free cancer treatment for up to two years for those diagnosed with cancer whose incomes are up to 650 percent of federal poverty guidelines and who lack comprehensive health insurance.

The Chronic Renal Disease Program covers treatment costs for those diagnosed with end stage renal disease up to 300 percent of federal poverty guidelines.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Florida

Medicaid
In addition to meeting minimum federal Medicaid standards, Florida Medicaid covers pregnant women up to 185 percent of federal poverty guidelines and infants under age 1 up to 200 percent of federal poverty guidelines.

Private/Public Partnership: Florida received a Section 1115 waiver that, among other aspects, allows the Medicaid premium amount to be applied to employer-sponsored private insurance. Implementation currently is limited to select counties.

CHIP
KidCare covers all children up to 200 percent of federal poverty guidelines. Those over 200 percent of federal poverty guidelines can receive unsubsidized coverage.

State-Only Programs
The Florida Health Choices program was enacted but has not been implemented. It will act as a statewide marketplace for health insurance to serve small businesses and financially limited public entities. If implemented, the program is expected to cost the state $1.5 million.

High-Risk Pool: Florida has no active high-risk pool. The Florida Comprehensive Health Association (FCHA) acts as a high-risk pool but was closed to new members in 1992. It covers those who have received two notices of rejection for coverage, coverage with benefit reduction, or coverage at a higher premium than offered by FCHA. The program is funded by premiums and insurance carrier assessments.

Other Programs
The Health Flex Plan provides basic, affordable health care services to Florida residents up to 300 percent of federal poverty guidelines who are not eligible for another public or private health plan and have been uninsured for six months. An employment group can apply if 75 percent of employees are under 300 percent of federal poverty guidelines. This provides low-cost insurance by allowing a limited benefit plan that is exempt from state insurance coverage mandates.

Cover Florida is an unsubsidized state insurance mandate for private insurers to offer limited benefit plans with and without catastrophic coverage, using guaranteed issue with some exclusions for preexisting conditions as allowed by the state. It is a low-cost option for uninsured Floridians who do not qualify for state programs.

County Program: The Hillsborough County HealthCare Program provides comprehensive managed care to those up to 100 percent of federal poverty guidelines who are not eligible for another plan. The plan is paid for by allocating property tax revenues intended to reimburse uncompensated hospital and by sales tax.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Georgia

Medicaid
In addition to meeting minimum federal Medicaid standards, Georgia's Right From The Start Medicaid (RSM) program covers pregnant women and their infants under age 1 up to 200 percent of federal poverty guidelines and infants who are not delivered under the program up to 185 percent of federal poverty guidelines.

CHIP
Georgia's PeachCare for Kids program covers children up to 235 percent of federal poverty guidelines.

State-Only Programs
Private/Public Partnership: Georgia offers a tax credit of $250 per year per employee for small businesses that offer high-deductible, health savings account (HSA) coverage to their employees. Insurers also receive tax benefits on HSA plans.

Other Programs
The Georgia Volunteer Health Care Program (GVHCP) provides legal immunities to service providers who volunteer to treat uninsured populations under 200 percent of federal poverty guidelines.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Hawaii

Medicaid
In addition to meeting minimum federal Medicaid standards, Hawaii's QUEST program has a Section 1115 waiver that allows it to provide Medicaid coverage for pregnant women up to 185 percent of federal poverty guidelines and infants under age 1 up to 300 percent of federal poverty guidelines. It covers all adults up to 100 percent of federal poverty guidelines and allows those up to 200 percent of federal poverty guidelines who previously qualified for Medicaid to retain coverage with a premium. Other adults up to 200 percent of federal poverty guidelines can qualify for the limited benefit plan, QUEST-ACE.

CHIP
Hawaii covers children up to 300 percent of federal poverty guidelines. In November 2008, Hawaii dissolved the Keiki Care Plan, a pilot program for all uninsured children, due to budget constraints and program abuse.

Other Programs
Through the Prepaid Health Care Act of 1974, Hawaii remains the only state to require employer coverage. Coverage is required for all employees who work more than 20 hours per week for at least four consecutive weeks. Employers cover at least 50 percent of the premium, and employees are responsible for no more than 1.5 percent of their income. Because the law is provided with an ERISA waiver, it likely cannot be replicated in other states at this point without violating ERISA.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Idaho

Medicaid
Idaho Medicaid meets federal Medicaid standards.

CHIP
The Idaho Health Plan for Children uses CHIP funds for a Medicaid expansion to cover children ages 6 through 18 up to 133 percent of federal poverty guidelines and CHIP coverage for all children from 133 percent to 185 percent of federal poverty guidelines.

Private/Public Partnership: Authorized by a HIFA waiver, CHIP funds and the state's premium tax on insurers support a pair of premium assistance programs. Instead of joining CHIP, families between 133 percent and 185 percent of federal poverty guidelines can receive an access card that provides $100 per month per child (up to three children) in premium assistance to add a child to private insurance. Access to Health Insurance is a premium assistance program for adults up to 185 percent of federal poverty guidelines who work for a small business (under 50 employees) that does not offer health insurance. The employer is responsible for 50 percent of the premium, and the state pays $100 per month each for the employee, a spouse and up to three children. The employee is responsible for the remaining premium. The program is limited to 1,000 members.

State-Only Programs
High-Risk Pool: The Idaho Individual High Risk Reinsurance Pool provides insurance for those who have been rejected for individual coverage based on health status, can obtain coverage only at a rate exceeding the pool's rate, or have federal eligibility under HIPAA or TAA. The program is funded by premiums, a state premium tax allocation and, in the event of losses, insurance carrier assessment.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Illinois

Medicaid
In addition to meeting minimum federal Medicaid standards, All Kids fully covers pregnant women and infants under age 1 up to 200 percent of federal poverty guidelines and children ages 6 to 19 up to 133 percent of federal poverty guidelines.

FamilyCare covers parents up to 185 percent of federal poverty guidelines.

Private/Public Partnership: A HIFA waiver allows FamilyCare premium assistance toward employer-sponsored insurance for parents between 134 percent and 200 percent of federal poverty guidelines.

CHIP
All Kids is available to children from families of any income level, with premiums and copayments determined by a sliding scale related to income. Subsidies for coverage above 200 percent of federal poverty guidelines are provided with state-only funding.

Private/Public Partnership: The HIFA waiver noted above allows premium assistance toward a child's inclusion on a parent's employer-sponsored insurance for those between 134 percent and 200 percent of federal poverty guidelines.

State-Only Programs
High-Risk Pool: The Illinois Comprehensive Health Insurance Plan (ICHIP) covers those who have been denied coverage for an equivalent private plan, those offered a plan only at a higher rate than ICHIP, and those with federal eligibility through HIPAA or TAA. The program is funded by premiums and the state general fund; insurance carrier assessments fund the HIPAA portion.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Indiana

Medicaid
In addition to meeting minimum federal Medicaid standards, Hoosier Healthwise covers pregnant women and infants under age 1 up to 200 percent of federal poverty guidelines and children up to 150 percent of federal poverty guidelines.

The Healthy Indiana Plan (HIP) uses a Section 1115 waiver to cover adults who have been uninsured for more than six months and are not eligible for another public or employer-sponsored group plan, up to 200 percent of federal poverty guidelines based on a cost-sharing sliding scale up to 4.5 percent of income. Enrollment of childless adults is capped. HIP is a high-deductible, health savings account-based plan with a fixed allotment that can be applied toward preventive care; sanctions are included for those who do not seek appropriate preventive screening.

CHIP
Hoosier Healthwise covers children up to 250 percent of federal poverty guidelines under a low-cost CHIP plan. Expansion to 300 percent of federal poverty guidelines has been enacted.

State-Only Programs
High-Risk Pool: The Indiana Comprehensive Health Insurance Association (ICHIA) offers coverage for those who have applied for and been denied coverage under Medicaid in the last 60 days, are not eligible and have been rejected for coverage that meets Indiana minimum standards, or have federal eligibility through HIPAA or TAA. Premiums are reduced for those up to 350 percent of federal poverty guidelines. The program is funded by premiums, state general funds and insurance carrier assessments.

Other Programs
County Program: Wishard Advantage is a Marion County (Indianapolis) managed care program for uninsured residents up to 200 percent of federal poverty guidelines who are not eligible for another plan. Those up to 150 percent of federal poverty guidelines receive free care, while those from 150 percent to 200 percent of federal poverty guidelines pay coinsurance on a sliding scale.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Iowa

Medicaid
In addition to meeting minimum federal Medicaid standards, Iowa Medicaid Enterprise covers pregnant women and infants under age 1 up to 300 percent of federal poverty guidelines and all children under 21 up to 133 percent of federal poverty guidelines.

IowaCare, created by a Section 1115 waiver, covers uninsured adults up to 200 percent of federal poverty guidelines with a limited benefit plan; maximum cost is 5 percent of income. This program is limited to two provider networks located in Polk County (Des Moines) and the University of Iowa Hospital in Iowa City.

Private/Public Partnership: The Health Insurance Premium Payment (HIPP) program allows Medicaid-qualified individuals to apply Medicaid funding toward employer-sponsored insurance if it is cost effective.

CHIP
Hawk-i covers children under 19 up to 300 percent of federal poverty guidelines.

State-Only Programs
High-Risk Pool: The Health Insurance Plan of Iowa (HIPIowa) covers those who have been rejected for coverage in the past nine months, have been offered a plan with greatly reduced coverage due to a rider or at a rate exceeding the comparable HIPIowa cost, have been involuntarily terminated from coverage, are not eligible for group coverage, suffer from a specific qualifying condition, or have federal eligibility under HIPAA or TAA. Funding comes from premiums and insurance carrier assessments.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Kansas

Medicaid
In addition to meeting minimum federal Medicaid standards, Kansas Healthwave covers infants under age 1 and pregnant women up to 150 percent of federal poverty guidelines. Pending implementation, coverage for pregnant women will increase to 200 percent of federal poverty guidelines.

CHIP
Kansas Healthwave covers children up to 200 percent of federal poverty guidelines. Legislation was passed in 2008 that expands coverage up to 250 percent of federal poverty guidelines.

Private/Public Partnership: As part of the CHIP expansion, the state will pay for the employee portion of dependant coverage for eligible children in employer-sponsored insurance.

State-Only Programs
High-Risk Pool: The Kansas Health Insurance Association (KHIA) covers those who have been rejected by two different carriers for a health condition, have been offered a plan with a rate higher than that of KHIA, have been offered a plan excluding coverage for a preexisting condition, have been involuntarily terminated from previous insurance for a reason other than fraud or non-payment, or have federal eligibility due to HIPAA or TAA. The program is funded by premiums, grants and insurance carrier assessments.

Private/Public Partnership: The Employer Health Insurance Contribution Credit provides a refundable tax credit to qualifying small businesses that begin offering health insurance to their employees; the credit decreases over time.

Other Programs
County Program: Project Access coordinates donated care in Sedgwick County (Wichita) to individuals up to 200 percent of federal poverty guidelines, with limited county subsidies for prescription costs.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Kentucky

Medicaid
In addition to meeting minimum federal Medicaid standardsKentucky Medicaid covers pregnant women and infants under age 1 up to 185 percent of federal poverty guidelines and children up to 150 percent of federal poverty guidelines.

Private/Public Partnership: Enrollees also can receive credit toward an employer-sponsored option, provided it meets state employee plan coverage standards and is cost efficient.

CHIP
Kentucky Children's Health Insurance Program (KCHIP) covers children up to 200 percent of federal poverty guidelines.

State-Only Programs
High-Risk Pool: Kentucky Access provides coverage for those who have a qualifying high-cost medical condition, have been rejected for equivalent coverage, have been offered coverage at higher cost than Kentucky Access, are eligible for the state's Guaranteed Acceptance Program (GAP) that deals with high-cost conditions, or have federal eligibility under HIPAA. The program is funded by premiums, insurance carrier assessments and tobacco settlement funds.

Private/Public Partnership: The Insurance Coverage, Affordability and Relief to Employers (ICARE) program provides a subsidy (decreasing each year in the program) of $40 to $60 per employee per month to small businesses (two to 25 employees) that pay at least 50 percent of the premium, have been uninsured for 12 months and have average employee wages below 300 percent of federal poverty guidelines.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Louisiana

Medicaid
In addition to meeting minimum federal Medicaid standards, LaMOMS covers pregnant women up to 200 percent of federal poverty guidelines.

Private/Public Partnership: LaHIPP allows Medicaid to pay toward employer-provided health insurance for a Medicaid-qualified individual if it is cost effective.

CHIP
LaCHIP covers all children up to 200 percent of federal poverty guidelines at no cost and up to 250 percent of federal poverty guidelines at reduced cost. Coverage up to 300 percent of federal poverty guidelines has been enacted but has not been implemented pending federal approval.

State-Only Programs
High-Risk Pool: The Louisiana Health Plan (LHP) covers those who are not eligible for any other health insurance coverage and those with federal eligibility through HIPAA and TAA. The program is funded through these premiums, general fund money in the case of high-risk individuals, and insurance carrier assessments for those with federal eligibility.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Maine

Medicaid
In addition to meeting minimum federal Medicaid standards, MaineCare covers parents, pregnant women and infants under age 1 up to 200 percent of federal poverty guidelines and children under age 21 up to 150 percent of federal poverty guidelines. A HIFA waiver allows coverage of childless adults up to 125 percent of federal poverty guidelines, but budget limitations have capped coverage at 100 percent of federal poverty guidelines. Limited benefits and limited enrollment are available for childless adults under MaineCare.

CHIP
For a small premium, MaineCare covers all children under age 19 up to 200 percent of federal poverty guidelines who are not covered by Medicaid.

State-Only Programs
Private/Public Partnership: DirigoChoice, part of the Dirigo Health Reform Act, covers small businesses and self-employed and other people. Small business employers and self-employed people must contribute 60 percent of the premium cost to access discounted care. Individuals are subsidized up to 300 percent of federal poverty guidelines on a sliding scale; at publication, however, enrollment is closed to all except small businesses and unsubsidized self-employed people.

High-Risk Pool: Maine does not have a high-risk pool because it mandates guaranteed issue using community rating.

Maine RxPlus is a subsidized prescription discount plan for those up to 350 percent of federal poverty guidelines. Additional discounts are available for the elderly and disabled up to 185 percent of federal poverty guidelines.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Maryland

Medicaid
In addition to meeting minimum federal Medicaid standards, Maryland HealthChoice covers pregnant women up to 250 percent of federal poverty guidelines.

The Maryland Primary Adult Care program, authorized by a Section 1115 waiver, covers all adults up to 116 percent of federal poverty guidelines with a limited benefit plan.

CHIP
Maryland Children's Health Program (MCHP) fully covers the cost for children up to 200 percent of federal poverty guidelines and allows children between 200 percent and 300 percent of federal poverty guidelines to enroll with a premium.

State-Only Programs
Private/Public Partnership: The Working Families and Small Business Health Coverage Act offers subsidies to small businesses (two to nine employees) of up to 50 percent of premium cost and expands Medical Assistance for families up to 116 percent of federal poverty guidelines.

High-Risk Pool: The Maryland Health Insurance Plan (MHIP) covers those who have been refused health insurance, have been offered restricted coverage or a rate greater than that offered by MHIP due to a condition, have a qualifying medical condition, or have federal eligibility under HIPAA or TAA. The program is funded through premiums and assessments on hospitals.

The Maryland Medbank Program provides free or discounted prescriptions to anyone who pays for some of their prescriptions out-of-pocket.

Other Programs
County Program: The Primary Care Coalition of Montgomery County runs several programs to provide health care services to low-income, uninsured people. In addition to private funding, the program receives some federal and county funds.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Massachusetts

Medicaid
In addition to meeting minimum federal Medicaid standards, MassHealth Standard covers pregnant women and infants under age 1 up to 200 percent of federal poverty guidelines, children up to 150 percent of federal poverty guidelines, and parents up to 133 percent of federal poverty guidelines.

Private/Public Partnership: The Insurance Partnership provides premium assistance for small businesses (two to 50 employees) that have not offered insurance in the past six months, will have employer contribution of at least 50 percent, and have at least one employee who earns below 300 percent of federal poverty guidelines. The program is supported through a Section 1115 waiver.

CHIP
MassHealth Family Assistance covers children through CHIP up to 300 percent of federal poverty guidelines. CHIP funds also support dependent coverage through The Insurance Partnership.

State-Only Programs
Private/Public Partnership: Massachusetts passed a major reform package in 2006. Commonwealth Care, offered through the Commonwealth Connector, covers uninsured adults by providing a premium subsidy for private insurance. The entire premium is covered for those up to 100 percent of federal poverty guidelines; those up to 300 percent of federal poverty guidelines receive a sliding scale premium subsidy.

High-Risk Pool: Because Massachusetts requires guaranteed issue with community rating, it does not offer a high-risk pool.

For those receiving unemployment benefits, the Medical Security Program offers direct coverage or premium assistance of up to 80 percent towards continuation (COBRA) coverage premiums for those who meet eligibility standards.

Other Programs
The Commonwealth Connector also offers Commonwealth Choice for those who do not qualify for MassHealth or Commonwealth Care. Although it is not a subsidized program, Commonwealth Choice identifies private health plans that receive a "seal of approval" for meeting quality and cost criteria. The Connector also pools individual participants to access better prices. A pilot program allows small employers to buy coverage through the Connector for employees using defined contributions.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Michigan

Medicaid
In addition to meeting minimum federal Medicaid standards, Healthy Kids covers pregnant women and infants under age 1 up to 185 percent of federal poverty guidelines and all other children up to 150 percent of federal poverty guidelines.

CHIP
MIChild covers children up to 200 percent of federal poverty guidelines. A HIFA waiver allows for coverage of childless adults up to 35 percent of federal poverty guidelines with limited benefits using CHIP funds. This waiver created a county health plan infrastructure that many counties use to provide additional coverage for uninsured adults using financial support provided through hospitals with which counties have signed indigent care agreements.

Other Programs
County Program: Access Health provides low-cost coverage for small businesses in Muskegon and Northern Ottawa counties that currently do not offer insurance to their employees. The program combines employer and employee contributions with some public funding and cost savings through managed care.

County Program: The Kent Health Plan provides coverage for low-income people and has multiple plan options, including a limited benefit plan for those up to 150 percent of federal poverty guidelines, prescription assistance up to 200 percent of federal poverty guidelines, and small business premium assistance. In addition to private support, the plan receives some funding from Kent County.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Minnesota

Medicaid
In addition to meeting minimum federal Medicaid standards, Medical Assistance covers pregnant women up to 275 percent of federal poverty guidelines, infants under age 2 up to 280 percent of federal poverty guidelines, children ages 2 through 18 up to 150 percent of federal poverty guidelines, children ages 19 and 20 up to 100 percent of federal poverty guidelines, and parents with children under age 19 up to 100 percent of federal poverty guidelines. Those eligible for Medical Assistance also can apply the subsidy toward cost-effective private insurance.

CHIP
MinnesotaCare covers children under age 21 and their parents or guardians up to 275 percent of federal poverty guidelines and childless adults up to 200 percent of federal poverty guidelines. MinnesotaCare and some Medical Assistance coverage are supported by a pair of Section 1115 waivers, sliding-scale premiums, and a tax on hospitals and other care providers. Those with access to employer-provided coverage are not eligible for MinnesotaCare if the employer pays at least 50 percent of the premium.

State-Only Programs
General Assistance Medical Care covers adults who are not eligible for federal programs up to 75 percent of federal poverty guidelines with full medical care and from 75 percent to 175 percent of federal poverty guidelines with limited hospitalization coverage. The program is due to end in March 2010, with enrollees transfering into MinnesotaCare.

High-Risk Pool: The Minnesota Comprehensive Health Association (MCHA) covers those who have been rejected for coverage by a private insurer, have a qualifying condition, are over age 65 but are not eligible for Medicare, or have federal eligibility under HIPAA or TAA. The program is funded by premiums and insurance carrier assessments.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Mississippi

Medicaid
In addition to meeting minimum federal Medicaid standards, Mississippi Medicaid covers pregnant women and infants under age 1 up to 185 percent of federal poverty guidelines.

CHIP
The Mississippi Children's Health Insurance Plan covers children up to 200 percent of federal poverty guidelines.

State-Only Programs
High-Risk Pool: The Comprehensive Health Insurance Risk Pool Association covers those who have been rejected for similar coverage by another insurer or have federal eligibility under HIPAA. The program is funded by premiums and insurance carrier assessments.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Missouri

Medicaid
In addition to meeting minimum federal Medicaid standards, MOHealthNet covers pregnant women and infants under age 1 up to 185 percent of federal poverty guidelines and all other children up to 150 percent of federal poverty guidelines.

CHIP
Through a Section 1115 waiver, MOHealthNet covers children up to 300 percent of federal poverty guidelines.

State-Only Programs
High-Risk Pool: The Missouri Health Insurance Pool (MHIP) covers those without existing insurance who have experienced a lack of availability or a denial of insurance in the standard market or those with federal eligibility under HIPAA or TAA. The program is funded by premiums and insurance carrier assessments.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Montana

Medicaid
In addition to meeting minimum federal Medicaid standards, Montana Medicaid covers pregnant women and infants under age 1 up to 150 percent of federal poverty guidelines and children age 6 through age 18 up to 133 percent of federal poverty guidelines. A Section 1115 waiver allows a reduction in optional benefits provided to non-disabled, categorically eligible adults.

Initiative 155, passed in November 2008, authorized Medicaid coverage of all children up to 185 percent of federal poverty guidelines; however, current implementation only expands coverage up to 133 percent of federal poverty guidelines, due to budget constraints. The initiative also provides for premium assistance to add a child to employer-sponsored insurance.

CHIP
Montana CHIP covers children up to 250 percent of federal poverty guidelines.

State-Only Programs
High-Risk Pool: The Montana Comprehensive Health Association Plan covers those who have received notice from two insurers in the past six months rejecting insurance coverage or providing for a preexisting condition restriction or rider, have a qualifying medical condition, have or are offered coverage at higher than 150 percent of the average rate used to determine plan premiums, or have federal eligibility under HIPAA or TAA. A premium assistance option is available for those up to 150 percent of federal poverty guidelines. The program is funded by premiums and insurance carrier assessments.

Private/Public Partnership: Insure Montana helps small businesses (two to nine employees) provide health insurance to their employees. Using tobacco tax funds, the state provides a tax credit for employers that already provide health insurance or subsidizes entry into a purchasing pool with premium assistance for those that want to provide insurance. To be eligible for Insure Montana, a business can have no employees who earn more than $75,000, other than the owner.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Nebraska

Medicaid
In addition to meeting minimum federal Medicaid standards, Nebraska Medicaid covers pregnant women up to 185 percent of federal poverty guidelines and women with cancer up to 225 percent of federal poverty guidelines.

CHIP
Kids Connection covers children up to 200 percent of federal poverty guidelines.

State-Only Programs
High-Risk Pool: The Nebraska Comprehensive Health Insurance Pool (NECHIP) provides health insurance for those who have a qualifying medical condition, have been rejected for coverage, offered restricted coverage, offered equivalent coverage at a higher rate than NECHIP, or have federal eligibility under HIPAA or TAA. The program is funded through premiums and from the pool's distributive fund.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Nevada

Medicaid
In addition to meeting minimum federal Medicaid standards, Nevada Medicaid covers pregnant women and infants under age 1 up to 185 percent of federal poverty guidelines through a HIFA waiver.

CHIP
Nevada Check Up covers children up to 200 percent of federal poverty guidelines.

Private/Public Partnership: Through a HIFA waiver, Nevada Check Up Plus provides premium assistance to parents or guardians, up to 200 percent of federal poverty guidelines or those whose children are eligible for Medicaid or Check Up, who work for a small business with an employer contribution for health care of at least 50 percent of the premium.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

New Hampshire

Medicaid
In addition to meeting minimum federal Medicaid standards, New Hampshire covers pregnant women up to 185 percent of federal poverty guidelines and Healthy Kids covers children ages 1 through 18 up to 185 percent of federal poverty guidelines and infants under age 1 up to 300 percent of federal poverty guidelines.

Private/Public Partnership: The Health Insurance Premium Payment (HIPP) program allows Medicaid funds for eligible individuals to be applied to other insurance programs when it is cost effective.

CHIP
Healthy Kids covers children ages 1 through 18 up to 300 percent of federal poverty guidelines with a small premium based on income level or up to 400 percent of federal poverty guidelines through a full buy-in option. Under newly enacted legislation, adults under age 26 up to 300 percent of federal poverty guidelines can enroll in Healthy Kids through a buy-in option.

State-Only Programs
High-Risk Pool: New Hampshire Health Plan (NHHP) covers those with a qualifying medical condition, who have been denied coverage, offered coverage with restrictions, offered coverage at higher than the NHHP rate, or have federal eligibility under HIPAA or TAA. The program is funded by premiums and insurance carrier assessments.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

New Jersey

Medicaid
In addition to meeting minimum federal Medicaid standards, New Jersey Medicaid covers pregnant women and infants under age 1 up to 185 percent of federal poverty guidelines. NJFamilyCare covers parents up to 133 percent of federal poverty guidelines.

CHIP
NJFamilyCare covers children on a sliding scale up to 350 percent of federal poverty guidelines. New Jersey received a Section 1115 waiver to use CHIP funds to cover parents and pregnant women up to 200 percent of federal poverty guidelines.

State-Only Programs
High-Risk Pool: New Jersey does not have a high-risk pool because it requires guaranteed issue with community rating in the individual insurance market.

The Catastrophic Illness in Children Relief Fund program provides reimbursement for a child's uncovered medical expenses if eligible expenses under the program exceed 10 percent of family income and 15 percent of income exceeding $100,000.

Work First New Jersey/General Assistance (WFNJ/GA) provides cash and medical assistance for childless adults who have very low income (below 25 percent of federal poverty guidelines, depending on eligibility status).

Other Programs
NJ Family Care Advantage is a low-cost, unsubsidized insurance option for uninsured children over 350 percent of federal poverty guidelines.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

New Mexico

Medicaid
In addition to meeting minimum federal Medicaid standards, Medical Assistance for Women and Children covers pregnant women and children up to 185 percent of federal poverty guidelines.

CHIP
New Mexikids covers children up to 235 percent of federal poverty guidelines; some additional copayments are required based on income.

Private/Public Partnership: State Coverage Insurance (SCI) provides premium assistance on a sliding scale for adults up to 200 percent of federal poverty guidelines through a small business or as individuals. A HIFA waiver authorizes the use of CHIP funds for this coverage.

State-Only Programs
Private/Public Partnership: Premium Assistance for Kids (PAK) provides 50 percent premium assistance toward participating plans for uninsured children under age 12 and siblings up to age 18 who are not eligible for Medicaid or CHIP. Premium Assistance for Maternity (PAM) provides pre- and post-natal coverage to pregnant women who are not eligible for Medicaid and lack pregnancy coverage for a one-time premium. The programs are supported by state general funds and do not have income eligibility requirements.

High-Risk Pool: The New Mexico Medical Insurance Pool covers those who have a qualifying medical condition, have been rejected for similar coverage, are offered restricted coverage, are offered similar coverage at a higher rate, have been involuntarily terminated because the carrier ceased doing business in the state, or have federal eligibility under HIPAA. Those up to 200 percent of federal poverty guidelines qualify for a 75 percent premium discount, and those up to 400 percent of federal poverty guidelines qualify for a 50 percent premium discount. This program is funded by premiums, tax credits and insurance carrier assessments.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

New York

Medicaid
In addition to meeting minimum federal Medicaid standards, Children's Medicaid covers infants under age 1 and pregnant women up to 200 percent of federal poverty guidelines. A Section 1115 waiver allows the Family Health Plus managed plan to cover childless adults up to 100 percent of federal poverty guidelines and parents up to 150 percent of federal poverty guidelines.

CHIP
Child Health Plus covers children up to 400 percent of federal poverty guidelines on a sliding premium scale, and above that with full buy-in. Coverage above 250 percent of federal poverty guidelines is provided by state-only funding.

State-Only Programs
Private/Public Partnership: In 2007, legislation passed allowing employers to buy into Family Health Plus coverage as a low-cost option for their employees. Qualifying low-income employees can receive premium assistance for up to 40 percent of the premium.

High-Risk Pool: New York has guaranteed issue and community rating mandates, so it does not offer a high-risk pool.

Private/Public Partnership: Healthy NY, a subsidized reinsurance pool, provides lower cost health insurance for those up to 250 percent of federal poverty guidelines and for small businesses that meet specific eligibility criteria regarding low-income employees. The additional burden on the pool from high-cost individuals is offset to achieve the reduced cost.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

North Carolina

Medicaid
In addition to meeting minimum federal Medicaid standards, North Carolina Medicaid covers pregnant women up to 185 percent of federal poverty guidelines and children under age 6 up to 200 percent of federal poverty guidelines.

CHIP
Health Choice for Children covers children ages 6 through 18 up to 200 percent of federal poverty guidelines. An expansion to 250 percent of federal poverty guidelines has been enacted.

State-Only Programs
High-Risk Pool: Inclusive Health covers those with a qualifying medical condition, those who have been denied coverage, offered coverage with restrictions, offered coverage at higher than Inclusive Health rate, or have federal eligibility under HIPAA or TAA. The program is funded by premiums, state premium tax revenue, the NC State Health Plan, and the Health and Wellness Trust.

NC Health Net builds upon existing county indigent care programs, such as the one described below, using state funding to coordinate free and low-cost health care services and indigent care programs.

Other Programs
County Program: Project Access for Buncombe County organizes donated care from area providers for individuals up to 200 percent of federal poverty guidelines. The county subsidizes prescription costs.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

North Dakota

Medicaid
North Dakota Medicaid meets federal Medicaid standards.

CHIP
Healthy Steps covers all children up to 160 percent of federal poverty guidelines.

State-Only Programs
High-Risk Pool: The Comprehensive Health Association of North Dakota (CHAND) covers those with a qualifying medical condition, who have been denied coverage, offered coverage with restrictions, offered coverage at higher than the CHAND rate or have federal eligibility under HIPAA or TAA. CHAND offers some coverage to those eligible for Medicare under certain conditions. The program is funded through premiums and insurance carrier assessments.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Ohio

Medicaid
In addition to meeting minimum federal Medicaid standards, Healthy Families covers parents up to 90 percent of federal poverty guidelines.

CHIP
Healthy Start covers children and pregnant women up to 200 percent of federal poverty guidelines. Expansion up to 300 percent of federal poverty guidelines has been enacted.

State-Only Programs
The Children's Buy-In (CBI) program allows uninsured children who are above 300 percent of federal poverty guidelines to receive coverage through a state program for a sliding-scale premium. To qualify, the child must be unable to attain creditable coverage due to a preexisting condition, have lost coverage due to exhausting the maximum lifetime benefit, be denied coverage cheaper than 200 percent of the CBI rate, or participate in the Program for Mentally Handicapped Children.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Oklahoma

Medicaid
In addition to meeting minimum federal Medicaid standards, SoonerCare Choice covers pregnant women up to 185 percent of federal poverty guidelines.

Private/Public Partnership: Insure Oklahoma uses Medicaid funds, through a HIFA waiver, to provide premium assistance for adults employed by a small business (two to 99 employees) up to 200 percent of federal poverty guidelines. Depending on program demand, eligibility for businesses with up to 250 employees will be phased in. Self-employed or unemployed people, and full time college students age 19 through 22, up to 200 percent of federal poverty guidelines can qualify for the individual plan. Pending federal approval, coverage will expand to 250 percent of federal poverty guidelines.

CHIP
SoonerCare Choice covers children up to 185 percent of federal poverty guidelines. Legislation has passed calling for coverage to expand to up to 300 percent of federal poverty guidelines by 2011.

State-Only Programs
High-Risk Pool: Oklahoma Health Insurance High Risk Pool (OHRP) covers those who have been rejected for coverage by two carriers, have been offered insurance only at a rate higher than the OHRP rate, have been offered restricted coverage, or have federal eligibility under HIPAA or TAA. The program is funded by premiums and insurance carrier assessments.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Oregon

Medicaid
In addition to meeting minimum federal Medicaid standards, the Oregon Health Plan Plus covers pregnant women up to 185 percent of federal poverty guidelines. The Oregon Health Plan Standard covers adults up to 100 percent of federal poverty guidelines under the limited benefit, cost-sharing plan. Presently, however, enrollment in the standard plan is closed.

Private/Public Partnership: The Family Health Insurance Assistance Program (FHIAP) provides premium assistance of 50 percent to 95 percent toward employer-sponsored or individual health insurance for adults and children up to 185 percent of federal poverty guidelines. The program is supported by the state general fund with federal matching funds authorized by a HIFA waiver. Due to federal funding limits, however, at publication the program is closed to new enrollees and there is an 18-month to two-year wait list to receive an application.

CHIP
Oregon Health Plan Plus covers children up to 200 percent of federal poverty guidelines. CHIP matching funds are used for children participating in FHIAP who are eligible for CHIP. Beginning in January 2010, children up to 300 percent of federal poverty guidelines will receive premium assistance towards employer-sponsored insurance or entry into a subsidized state plan.

State-only Programs
High-Risk Pool: The Oregon Medical Insurance Pool (OMIP) covers those who have been denied coverage due to a preexisting health condition, have a qualifying medical condition, have been offered restricted coverage, have federal eligibility under HIPAA but lack access to a commercial portability plan, or have federal eligibility under TAA. The program is supported by premiums and insurance carrier assessments.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Pennsylvania

Medicaid
In addition to meeting minimum federal Medicaid standards, Pennsylvania's Medical Assistance covers pregnant women and infants under age 1 up to 185 percent of federal poverty guidelines.

Private/Public Partnership: The Health Insurance Premium Payment (HIPP) program allows Medicaid to reimburse beneficiary premiums in employer-sponsored insurance where it is cost effective to do so.

CHIP
Pennsylvania's CHIP provides free coverage to children up to 200 percent of federal poverty guidelines, subsidized coverage up to 300 percent of federal poverty guidelines, and buy-in access to all children above 300 percent of federal poverty guidelines. The state share of the program is funded by general funds, including a dedicated portion of the cigarette tax.

State-Only Programs
AdultBasic provides subsidized coverage to uninsured adults up to 200 percent of federal poverty guidelines using tobacco settlement funds and a funding agreement with charitable Blue Cross/Blue Shield health insurers. Entry is limited based on budget constraints, and there is a wait list for enrollment. Enrollees can buy-in to coverage while on the wait list for subsidized coverage.

General Assistance provides coverage for low-income adults age 21 through 64 who have a physical or mental disability lasting less than one year, are undergoing drug treatment or have been the victim of domestic violence. Coverage also is available through a "spend down" program for parents of children under age 21, adults age 59 through 64, or childless adults age 21 through 58 who meet certain employment criteria and have high medical expenses.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Rhode Island

Medicaid
In addition to meeting minimum federal Medicaid standards, RIte Care covers pregnant women up to 185 percent of federal poverty guidelines, parents up to 100 percent of federal poverty guidelines, and children ages 6 through 18 up to 110 percent of federal poverty guidelines.

Private/Public Partnership: RIte Share provides full or partial premium assistance toward employer-sponsored health insurance for those who qualify for Medicaid or CHIP. In addition to premium assistance, some can receive additional Medicaid services that are not covered under the employer plan.

CHIP
Through a Section 1115 waiver, RIte Care uses CHIP funds to cover children and pregnant women up to 250 percent of federal poverty guidelines and parents up to 175 percent of federal poverty guidelines.

Other Programs
The HEALTHpact plan is a low-cost small-business plan with incentives for employees that promotes wellness and chronic disease management.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

South Carolina

Medicaid
In addition to meeting minimum federal Medicaid standardsHealthy Connections covers pregnant women and infants under age 1 up to 185 percent of federal poverty guidelines. Partners for Healthy Children covers all other children up to 150 percent of federal poverty guidelines.

CHIP
Healthy Connections Kids covers children up to 200 percent of federal poverty guidelines.

State-Only Programs
High-Risk Pool: The South Carolina Health Insurance Pool covers those who have been refused insurance for health reasons, are offered only reduced coverage, are offered coverage at more than 50 percent higher than the pool rate, or have federal eligibility under HIPAA or TAA. The program is funded by premiums and insurance carrier assessments.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

South Dakota

Medicaid
In addition to meeting minimum federal Medicaid standards, South Dakota Medicaid covers children up to 140 percent of federal poverty guidelines.

CHIP
South Dakota CHIP covers children up to 200 percent of federal poverty guidelines.

State-Only Programs
High-Risk Pool: The South Dakota Risk Pool covers those who have federal eligibility under HIPAA, though only 12 months of continuous coverage is required. Limited spots in the pool are available for individuals in plans more than twice the pool's rate that no longer are marketed in the state. The program is funded by premiums, the state general fund and insurance carrier assessments, and a CMS grant.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Tennessee

Medicaid
In addition to meeting minimum federal Medicaid standards, TennCare, authorized by a Section 1115 waiver, covers pregnant women and infants under age 1 up to 185 percent of federal poverty guidelines and parents up to 140 percent of federal poverty guidelines.

CHIP
CoverKids provides comprehensive coverage to children and maternity coverage to pregnant women up to 250 percent of federal poverty guidelines. Children over 250 percent of federal poverty guidelines can buy in to coverage at full premium rate.

State-Only Programs
Private/Public Partnership: Cover Tennessee provides limited benefit coverage for small businesses and individuals. For small business coverage, the employer, employee and state each pay one-third of the premium. Individuals pay two-thirds and the state pays one-third for coverage. Eligible uninsured spouses pay two-thirds of the premium.

High-Risk Pool: Access Tennessee covers those who have a qualifying medical condition, have been denied coverage by two carriers for a condition, are qualified through a contracted underwriting process and have been uninsured for six months, or have exhausted COBRA coverage and have no access to other insurance. This program is funded by premiums, state funds and, in the event of losses, insurance carrier assessments. Those under 350 percent of federal poverty guidelines can qualify for premium assistance; however, enrollment in the assistance program is limited.

Other Programs
County Program: The Knoxville Area Project Access program provides select health care services free of cost to residents of Knox and Blount counties up to 200 percent of federal poverty guidelines.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Texas

Medicaid
In addition to meeting minimum federal Medicaid standards, Texas Medicaid covers pregnant women and infants under age 1 up to 185 percent of federal poverty guidelines.

Private/Public Partnership: The Health Insurance Premium Payment (HIPP) program allows Medicaid to reimburse beneficiary premiums in employer-sponsored insurance where it is cost effective to do so.

CHIP
Texas's CHIP program is available to children up to 200 percent of federal poverty guidelines. CHIP Perinatal provides prenatal care for pregnant women up to 200 percent of federal poverty guidelines.

State-Only Programs
The State Kids Insurance Program (SKIP) provides premium subsidy for dependent coverage through the Texas Employees' Group Benefits Program for the children of state employees who meet CHIP eligibility requirements.

High-Risk Pool: The Texas Health Insurance Risk Pool covers those who have been rejected for similar coverage due to health reasons, offered reduced coverage, have a qualifying medical condition, or have federal eligibility under HIPAA or TAA. The program is funded by premiums and insurance carrier assessments.

County Program: The County Indigent Health Care Program, operated by counties, hospital districts and public hospitals, provides free basic health care services for those who are not eligible for comprehensive Medicaid coverage up to 21 percent of federal poverty guidelines. Counties can choose to cover up to 50 percent of federal poverty guidelines and offer some optional services. State funding covers expenses that exceed 8 percent of the county general revenue tax levy.

County Program: TexHealth is three-share program in selected communities combining contributions from small businesses (2 to 50 employees), employees and a community subsidy fund to provide health insurance. This program is supported by a Texas Health and Human Services Commission grant.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Utah

Medicaid
In addition to meeting minimum federal Medicaid standards, Utah offers the Primary Care Network (PCN), a limited benefit coverage for adults up to 150 percent of federal poverty guidelines. At publication, however, the program is closed to new applicants. The program is authorized through a Section 1115 waiver.

CHIP
Utah's CHIP program covers children up to 200 percent of federal poverty guidelines.

Private/Public Partnership: Utah's Premium Partnership for Health Care (UPP) provides monthly premium assistance of $150 per adult up to 150 percent of federal poverty guidelines and $100 per child up to 200 percent of federal poverty guidelines toward employer-sponsored health insurance where premiums exceed 5 percent of income. Through the PCN section 1115 waiver, the program uses CHIP funding to cover children and Medicaid funding to cover adults.

State-Only Programs
High-Risk Pool: The Utah Comprehensive Health Insurance Pool (HIPUtah) covers those who meet the HIPUtah underwriting criteria, apply for coverage within 30 days of denial of private coverage, are moving from another state's high-risk pool, or have Medicaid spend-down requirements that exceed the pool's premium. The program is funded by premiums and state general funds. Some premium assistance is available, based on income.

Private/Public Partnership: Starting in 2009, those who pay for health insurance premiums with money that is not eligible for pre-tax treatment are eligible for a nonrefundable state income tax credit. The credit is for 5 percent of the eligible expenses, subject to limits of $300 (single), $600 (couple) or $900 (family).

Other Programs
The Utah Health Exchange is an internet-based state portal, comparing insurance options and providing greater transparency of insurance plan benefits, serving the individual and small group markets. The exchange allows employees to couple defined contributions from one or more employer and pre-tax personal contributions to purchase insurance that is also portable. Part of this reform was the creation of NetCare, a low-cost mandate-free insurance option for insurers to offer to the individual and small-business markets and for those eligible for COBRA, mini-COBRA or conversion coverage.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Vermont

Medicaid
Green Mountain Care is the umbrella program for Vermont's public health expansion plans. Many of the programs are authorized through the Global Commitment to Health Section 1115 waiver. The Vermont Health Access Plan covers childless adults up to 150 percent of federal poverty guidelines and parents up to 185 percent of federal poverty guidelines. Dr. Dynasaur covers children under 21 and pregnant women under Medicaid up to 185 percent of federal poverty guidelines with no cost-sharing, and children up to 225 percent of federal poverty guidelines with a minimal premium.

Private/Public Partnership: Catamount Health is a state-sponsored, private, comprehensive health plan for uninsured adults who do not have access to employer-sponsored insurance. Premium assistance is available on a sliding scale for individuals up to 300 percent of federal poverty guidelines, and unsubsidized access is available for those over 300 percent of federal poverty guidelines. Premium assistance also is offered toward employer-sponsored coverage for individuals up to 300 percent of federal poverty guidelines. The program is supported by premiums, an assessment on employers that do not contribute toward employee premiums, tobacco taxes, and a federal match through the Global Commitment waiver for coverage up to 200 percent of federal poverty guidelines.

CHIP
Dr. Dynasaur covers CHIP-eligible children up to 300 percent of federal poverty guidelines and pregnant women up to 200 percent of federal poverty guidelines. State-only funds are used to cover children under 19 who do not meet CHIP eligibility standards up to 300 percent of federal poverty guidelines.

State-Only Programs
Healthy Vermonters provides a discount on prescription medication for those up to 350 percent of federal poverty guidelines who have no prescription coverage or have exhausted coverage benefits.

High-Risk Pool: Because Vermont requires guaranteed issue, it does not offer a high-risk pool.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Virginia

Medicaid
In addition to meeting minimum federal Medicaid standards, Virginia Medicaid covers children ages 6 through 18 up to 133 percent of federal poverty guidelines.

CHIP
FAMIS, Virginia's CHIP program, covers children up to 200 percent of federal poverty guidelines. Virginia received a Section 1115 waiver to expand coverage of pregnant women up to 200 percent of federal poverty guidelines through CHIP funds in the FAMIS MOMS program. The actual coverage level is determined by availability of state funding.

Private/Public Partnership: FAMIS Select provides premium assistance of $100 per child per month toward a parent's employer-sponsored insurance for children up to 200 percent of federal poverty guidelines. It is supported by the FAMIS Section 1115 waiver.

State-Only Programs
The Indigent Health Care Trust Fund uses state general funds to offset the cost of uncompensated care at hospitals incurred by individuals up to 100 percent of federal poverty guidelines.

The State and Local Hospitalization (SLH) program covers claims from individuals up to 100 percent of federal poverty guidelines for services received at hospitals. Each locality has a limited pool of funds to use in this program.

Other Programs
Local Program: The Access Partnership's Access To Health program covers select medical services for uninsured patients at participating clinics who have been diagnosed with a chronic disease and are under 200 percent of federal poverty guidelines.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Washington

Medicaid
In addition to meeting minimum federal Medicaid standards, Washington Medicaid covers children up to 200 percent of federal poverty guidelines and pregnant women up to 185 percent of federal poverty guidelines.

CHIP
Apple Health for Kids covers children up to 300 percent of federal poverty guidelines.

State-Only Programs
High-Risk Pool: The Washington State Health Insurance Pool (WSHIP) covers those who have been rejected for coverage in the individual or Medicare supplement markets. The program is funded by premiums and insurance carrier assessments.

Private/Public Partnership: Basic Health provides premium subsides on a sliding scale for individuals up to 200 percent of federal poverty guidelines for use toward private health insurance plan membership. Basic Health has programs for adults, children and pregnant women.

Private/Public Partnership: The Health Insurance Partnership (HIP) combines contributions from small employers, employees and the state to make small group coverage more affordable for employees. Program implementation is pending due to a budget constraints.

Other Programs
County Program: Project Access organizes donated care for uninsured people up to 200 percent of federal poverty guidelines in Spokane County. The county provides funds for prescription costs.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

West Virginia

Medicaid
In addition to meeting minimum federal Medicaid standards, West Virginia Medicaid covers pregnant women and infants under age 1 up to 150 percent of federal poverty guidelines. As of July 2006, an enhanced Medicaid plan, Mountain Health Choices, is available to those who sign a membership agreement pledging to attempt to meet wellness goals, with rewards for fulfillment of goals. According to a report by the Institute for Health Policy Research at West Virginia University, approximately 10 to 13 percent of eligible individuals enrolled in the enhanced plan, with the rest falling in the reduced, basic plan.

CHIP
West Virginia CHIP covers children up to 220 percent of federal poverty guidelines, increasing to 250 percent of federal poverty guidelines in January 2009. Some premiums or copayments can apply, based on income level. Legislation allows for coverage expansion up to 300 percent of federal poverty guidelines.

State-Only Programs
High-Risk Pool: AccessWV covers those who have been refused similar coverage for health reasons, have been offered coverage only at a rate higher than the AccessWV rate, have a qualifying medical condition, or have federal eligibility under HIPAA or TAA. The program is funded by premiums and an assessment on hospitals.

Other Programs
Private/Public Partnership: The West Virginia Small Business Plan allows eligible small businesses access to a Blue Cross/Blue Shield plan using Public Employees Insurance Agency (PEIA) reimbursement rates, which results in lower premiums.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Wisconsin

Medicaid
Beginning February 2008, BadgerCare Plus replaced the Wisconsin MA and CHIP programs previously referred to as Family MA and BadgerCare. In addition to meeting minimum federal Medicaid standards, BadgerCare Plus covers parents up to 130 percent of federal poverty guidelines. It also covers childless adults up to 200 percent of the federal poverty guidelines with a limited benefit plan. An expansion to assist small businesses is planned in the future. The program is authorized by a Section 1115 waiver.

CHIP
BadgerCare Plus covers all uninsured children with a sliding scale for premiums and copayments, with coverage over 250 percent of federal poverty guidelines provided with state-only funding. It also covers pregnant women up to 300 percent of federal poverty guidelines, and parents up to 200 percent of federal poverty guidelines. Eligible children and pregnant women over 200 percent of federal poverty guidelines are enrolled in a plan that has fewer benefits and higher copayments than the standard plan. Pregnant women over 300 percent of federal poverty guidelines can receive coverage with a deductible.

State-Only Programs
High-Risk Pool: The Health Insurance Risk-Sharing Plan (HIRSP) covers those who are eligible for Medicare due to disability; have tested positive for HIV; have federal eligibility; or have received notice in the past nine months of a denial of coverage from two insurers, involuntary cancellation, significant reduction in coverage, an increase of premium greater than 50 percent, or two offers for coverage at a rate more than 50 percent higher than the charge for a standard individual policy. The program is funded by premiums and insurance carrier assessments. HIRSP receives discounted rates from providers. Those with household incomes below $33,000 qualify for reduced premiums on a sliding scale.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

Wyoming

Medicaid
Wyoming's Medicaid program, EqualityCare, meets minimum federal Medicaid standards.

CHIP
KidCareCHIP covers children up to 200 percent of federal poverty guidelines.

State-Only Programs
High-Risk Pool: The Wyoming Health Insurance Pool (WHIP) covers those who have been refused coverage for health reasons, have restricted coverage, have coverage exceeding the pool's rate, or have federal eligibility under HIPAA. The program is funded by premiums, the state general fund and insurance carrier assessments.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.

District of Columbia

Medicaid
In addition to meeting minimum federal Medicaid standards, a Section 1115 waiver allows the District of Columbia to cover childless adults age 50 through 64 up to 50 percent of federal poverty guidelines who do not qualify for other programs.

CHIP
The DC Healthy Families Insurance Program covers all children and pregnant women up to 300 percent of federal poverty guidelines. Parents also are covered up to 200 percent of federal poverty guidelines.

District-Only Programs
The DC HealthCare Alliance provides free health coverage, using managed care, for childless adults up to 200 percent of federal poverty guidelines. A pending HIFA waiver seeks federal matching funds for this program, which presently is funded entirely by the District.

The Healthy DC Act, passed in 2008, is intended to provide coverage similar to the Alliance program for those up to 400 percent of federal poverty guidelines with a subsidized premium, capping enrollee payment at 3 percent of income. At time of publication, implementation is expected to begin in fiscal year 2010.

Disparities in Health
For more information on state efforts to reduce health disparities, click here.

Primary Care
For more information on state primary care programs, click here.


 

Additional NCSL Resources on Access

Access to Health Care | Access to Health Care Bill Tracking | Small Business Subsidies | Using Medicaid to Cover the Uninsured | Community Health Center | Health Disparities Page | Medicaid | CHIP | Children's Health ReformState Pharmaceutical Assistance Programs | Dependent Coverage | Comprehensive Reform Page

Special Thanks To Support From

Colorado Trust | Denver Health Foundation | Caring for Colorado | Rose Foundation | Bureau of Primary Health Care

Program Definitions

Federal standards for Medicaid establish minimum coverage levels as follows:

  • Parent/guardian below Aid to Families with Dependent Children (AFDC) levels in 1996 (national average of approximately 40 percent of federal poverty guidelines).

  • People who receive Supplemental Security Income (SSI) due to a disability.

  • Pregnant women up to 133 percent of federal poverty guidelines.

  • Infants under age one are covered if their mother is on Medicaid at the time of birth or up to 133 percent of federal poverty guidelines; children ages 1 through 5 are covered up to 133 percent; and children ages 6 through 18 are covered up to 100 percent.

  • Children who are adopted or in foster care are covered.

  • Low-income recipients of Medicare are eligible.

In addition to these mandatory coverage classes, several optional populations can be covered with federal matching funds:

  • Infants and pregnant women up to 185 percent of federal poverty guidelines.

  • Parents of eligible children.

  • Medicare recipients at higher income levels than required.

  • Those who have high medical expenses relative to their income.

  • Those with disabilities but who would lose eligibility based on income.

  • Low-income, uninsured women diagnosed with breast or cervical cancer by the National Breast and Cervical Cancer Early Detection Program can be covered for cancer-related treatment.

  • Through the Children's Health Insurance Program (CHIP), children can be covered, through Medicaid, up to 200 percent of federal poverty guidelines.

The Children's Health Insurance Program reauthorization along with the rescinding of a CMS directive will lead to multiple changes in the coming months. States are now free to use CHIP funding to provide coverage for children under 19 and pregnant women, who are citizens or legal residents, up to 300 percent of the federal poverty level within the state's allotment of funds. Coverage above that level receives the reduced Medicaid match rate. Coverage for childless adults under CHIP will be phased out at the end of 2009 while coverage of parents will be phased out at the end of FY2011. Procedures for implementing premium assistance programs using CHIP funding have been streamlined.

States can submit a Section 1115 or Health Insurance Flexibility and Accountability (HIFA) waiver proposal to the Centers for Medicare and Medicaid Services (CMS) to apply federal matching funds for groups that are not covered by mandatory or optional designation, such as childless adults, or at higher eligibility levels. Waivers can also allow for coverage of services below mandated levels for nonmandatory populations. Under the Deficit Reduction Act of 2005, states have increased flexibility to design their Medicaid programs, allowing greater premium and/or cost-sharing provisions for individuals over 100 percent of federal poverty guidelines and for variety in benefit packages. It also requires that those applying for Medicaid show proof of citizenship. This report focuses on coverage offered through Medicaid and CHIP beyond mandatory levels for non-elderly, non-disabled people.

Private/public partnership highlights cooperation between states and private entities to expand coverage. This can involve state provision of premium assistance or tax credits to help individuals or small businesses obtain private insurance. It also can include providing small businesses access to a public insurance pool. These programs are targeted toward small businesses and individual markets where affordability and coverage are most often lacking. Presently, 27 states offer some form of premium assistance including 13 targeted towards small businesses.

County or local programs apply to one or several counties or localities in a state. They can either be state initiatives or local efforts. Inclusion of county and local programs is not exhaustive and is intended only to illustrate the kinds of programs that exist.

High-risk pools are common state programs that usually provide coverage for those with particular medical conditions that are more expensive under individual or small group coverage. These programs also frequently provide coverage for those who have special status through federal Health Insurance Portability and Accountability Act (HIPAA) and Trade Adjustment Act (TAA) mandates. Thirty-four states have active high-risk pools and 13 of these states offer premium subsidies for low-income enrollees. Five states require guaranteed issue and 4 have open enrollment requirements as alternative ways of addressing high-risk populations.

HIPAA requires access to guaranteed issue coverage without preexisting condition exclusions for those who meet the following criteria:

  • Have had 18 months of creditable coverage, most recently under an employer, government or church group plan;

  • Have had no gaps of 63 or more days without coverage during or after the 18-month period;

  • Have exhausted all COBRA eligibility;

  • Are not eligible for another group or governmental plan;

  • Have no other health coverage; and

  • Prior coverage was not cancelled for fraud or nonpayment of premium.

The TAA created the Health Coverage Tax Credit that provides for 65 percent of the premium cost for certain early retirees who receive pension payments from the Pension Benefit Guaranty Corporation or for those who have lost employment due to foreign trade. Some states that do not offer a high-risk pool can meet these needs by requiring private insurers to offer guaranteed issue, community rating, or open enrollment.

Glossary

Aid to Families with Dependent Children (AFDC):  AFDC was a federal assistance program created by the Social Security Act of 1935 and replaced by the Temporary Assistance for Needy Families (TANF) program in 1996. Parents who meet the 1996 AFDC eligibility standards—which vary by state but average approximately 40 percent of federal poverty guidelines—are a categorically eligible group for Medicaid.

Buy-In Option: A buy-in option allows those who do not meet eligibility guidelines for subsidized access to a public health insurance program to receive program benefits by paying the full cost.

Carrier Assessments: Carrier assessments are fees paid by health insurance carriers or health care providers and can be determined based on market share, per capita or other methods. These assessments are frequently used to fund state high-risk pools or health safety net services.

Centers for Medicare and Medicaid Services (CMS): The Centers for Medicare and Medicaid Services is the federal agency, within the Department of Health and Human Services, that oversees the Medicare program and Medicaid and CHIP matching funding to the states. The CMS establishes rules for state Medicaid programs and approves Section 1115 and HIFA demonstration waiver projects.

Children's Health Insurance Program (CHIP): CHIP is a state-federal program created by Title XXI of the Social Security Act to provide health insurance to low-income, uninsured children who are not eligible for Medicaid. CHIP can either function within a state's existing Medicaid program or be a separate program. Waivers have allowed some states to apply CHIP matching funds to adults.

Consolidated Omnibus Budget Reconciliation Act (COBRA): The Consolidated Omnibus Budget Reconciliation Act of 1985 addresses a variety of issues. In the area of health insurance, COBRA ties employer tax incentives to coverage, providing that employees and family members be allowed to continue their employer-sponsored health insurance coverage for a time after eligibility ceases due to termination, reduction of hours, death, divorce, or, in the case of dependent children, age or education status.

Community Rating: Community rating rules restrict medical underwriting by preventing an insurer from charging different premiums for the same coverage based on an applicant's medical history or other factors.

Cost-Sharing: Cost-sharing applies to medical costs borne by insured individuals beyond premiums, typically incorporated as an incentive against overuse of medical services. Cost-sharing mechanisms include copayment; a flat fee for service; or coinsurance, a percentage of service cost.

Crowd-Out Effect: The crowd-out effect in health insurance occurs when someone who is insured in the private market drops that coverage to join a subsidized public plan, raising public costs without helping to reduce the uninsured population usually targeted by those plans. To avoid this effect, most public plans require a person to be uninsured for a certain length of time before he or she can attain public coverage.

Deficit Reduction Act of 2005: The Deficit Reduction Act was intended to slow the growth of federal spending, including Medicare and Medicaid spending. It provides greater flexibility to states for Medicaid program design, allowing higher premiums, higher cost-sharing and reduced benefit packages for those on Medicaid over 100 percent of federal poverty guidelines.

Disproportionate Share: The Medicaid disproportionate share program provides direct payment to hospitals based on the amount of uncompensated care they provide. This reduces the financial burden to hospitals for, and encourages service to, uninsured and low-income people.

Employer-Sponsored Health Insurance: Employer-sponsored health insurance refers to group plans that employees and their family members have access to, often with some employer contribution toward premium cost.

Employment Retirement Income Security Act (ERISA): The Employment Retirement Income Security Act of 1974 is federal legislation that provides standards and rules related to employee benefit packages, including health insurance benefits.

Federal Eligibility: The Social Security Act mandates specific eligibility categories for Medicaid and mandatory medical benefits. Optional populations and benefits also are identified and can be included by states. Coverage beyond this often requires a waiver from the CMS.

Federal Poverty Guidelines: The federal poverty guidelines, often referred to as federal poverty level, are annually adjusted standards for many programs targeted toward low-income people. In 2008, the FPL for a single-member household in the contiguous states was $10,400. The guidelines are higher in Alaska and Hawaii or based on household size. Many programs use variations of federal poverty guidelines such as 200 percent of federal poverty guidelines, which is double the federal poverty guideline.

Guaranteed Issue: Guaranteed issue rules require insurers to offer coverage to anyone, regardless of medical risk. Open enrollment is a form of guaranteed issue in which enrollees are accepted without regard to medical risk during a set period of time or on a first-come, first-serve basis up to a set enrollment limit.

Health Insurance Flexibility and Accountability (HIFA) Waiver: HIFA waivers allow states to reorganize current Medicaid and CHIP funds to cover additional uninsured people, particularly those under 200 percent of federal poverty guidelines. This form of Section 1115 waiver features a more streamlined application process.

Health Insurance Portability and Accountability Act (HIPAA): HIPAA is a federal law enacted by Congress in 1996 to address many aspects of health care. Among other things, HIPAA limits the ability of health insurance plans to exclude coverage of preexisting conditions, and prevents exclusion of coverage for those conditions for people who have had 18 months of continuous coverage (no gap exceeding 63 days), with most recent coverage under a group or governmental plan. HIPAA also provides for efficiency improvements in the health care system through identification of health plans and care providers as well as privacy requirements for medical information. Many states accommodate those eligible under HIPAA through their high-risk pool.

Health Insurance Premium Payment (HIPP): The HIPP Program is a Medicaid program that allows states to apply a Medicaid-eligible person's financial allotment toward private insurance, through an employer or private plan, when it is cost effective to do so. This often involves a wrap-around provision for coverage of services under Medicaid that are not covered by the private plan. Only select states currently participate in this program.

Health Savings Account (HSA): Health savings accounts allow individuals to save tax-free income for use toward medical expenses or insurance premiums. Standard HSAs allow funds to be rolled over from year to year.

High-Risk Pool: High-risk pools are common state programs that usually provide coverage for those with medical conditions that make private insurance unavailable or unaffordable. These programs also frequently provide coverage for those who have special status through federal Health Insurance Portability and Accountability Act (HIPAA) and Trade Adjustment Act (TAA) mandates.

Limited Benefit Plan: Limited benefit plans do not offer the full benefit package of traditional comprehensive plans. A limited benefit plan can cover routine and preventive care and not provide coverage of catastrophic injuries, or could be a benefit package that excludes state-mandated services—this type of plan is often referred to as a mandate-lite plan.

Managed Care: Managed Care insurance plans, such as those featured in health maintenance organizations (HMOs), attempt to restrict costs by providing medical services through a restricted network of providers and by requiring referrals from a primary care physician for most specialized medical services.

Medicaid: Medicaid is a state-federal entitlement program created by federal statute in Title XIX of the Social Security Act to provide needy people with health care services. Medicaid programs are state-run, with federal matching funds and some federal mandates. They typically cover low-income children and parents and foster children and provide additional benefits for disabled or elderly people on Medicare. Medicaid is the largest source of funding for medical services in the nation and is the largest source of federal funding to the states.

Medical Underwriting: Medical underwriting is an insurance practice that uses demographic and medical information to determine whether to offer health insurance coverage and to determine premiums. This process makes health insurance more expensive for those who have a higher risk of requiring medical treatment. Guaranteed issue and community rating requirements limit this practice.

Medicare: Medicare is a federal program that provides health insurance for those who are over age 64 or are disabled.

National Breast and Cervical Cancer Early Detection Program (NBCCEDP): The NBCCEDP is a program through the Centers for Disease Control and Prevention (CDC) that offers free or discounted cancer screenings for low-income, uninsured or underserved women. Some Medicaid programs cover cancer treatment for women diagnosed through NBCCEDP.

Preexisting Condition: A preexisting condition is a medically diagnosed condition identified before enrollment in a health insurance plan.

Premium Cap: A premium cap, a restriction on traditional underwriting, usually is set as a percentage of the average premium for a given benefit package. Premium caps fundamental to high-risk pools, use a subsidy to keep premiums lower for those with high medical costs.

Purchasing Alliance: A purchasing alliance gathers a set of individuals or smaller groups into a larger pool for insurance purposes. By spreading risk across a larger population, premiums tend to be lower.

Reinsurance: Reinsurance pools use subsidies to pay for costs of pool members that exceed a set threshold. This provides greater predictability in pool costs and reduces pool premiums. For example, the Healthy NY program pools low-income individuals and qualifying small businesses that might otherwise face high premiums; the state covers losses sustained by the pool.

Resource Limits: Resource limits are the restrictions on income level or the amount of assets someone can hold in order to be eligible for a program.

Section 1115 Waiver: Section 1115 waivers allow states to exempt Medicaid or CHIP law as part of a demonstration project designed to promote the objectives of the programs. These waivers cover a wide range of modifications, but are required to be budget-neutral with federal funding.

Sliding Scale: Sliding scales are used to increase premiums or cost-sharing responsibilities as a person's income increases. Sliding scales can help expand coverage with less of a crowd-out effect on private insurance and can provide a more gradual transition as people's income increases.

Spend-Down Program: A spend-down program allows someone to count medical expenses against their income to meet income and asset eligibility requirements for a program. Many states also exempt a portion of income in order to broaden eligibility.

Supplemental Security Income (SSI): SSI is a federal assistance program for low-income people with disabilities. Those who meet SSI eligibility also can be eligible for Medicare and Medicaid health coverage.

Trade Adjustment Act (TAA): The TAA created the Health Coverage Tax Credit, providing for 65 percent of the premium cost for certain early retirees who receive pension payments from the Pension Benefit Guaranty Corporation or for those who have lost employment due to foreign trade. Many states accommodate those eligible under TAA through their high-risk pool.

Wrap-Around Coverage: Wrap-around coverage allows Medicaid-eligible people who have another insurer to receive services covered by Medicaid—but not covered by the primary insurance—through Medicaid.

Sources (including web links)

CMS Medicaid Waivers and Demonstrations List | CMS CHIP State Plan Information | Communities Joined In Action | Insure Kids NowNational Association of State Comprehensive Health Insurance Plans | State and Local Initiatives to Enhance Health Coverage for the Working Uninsured | State Coverage Initiatives | State Health Facts

NOTE: NCSL provides links to other Web sites from time to time for information purposes only. Providing these links does not necessarily indicate NCSL's support or endorsement of the site.


We make every attempt to keep this guide up to date, however, if you notice an error or omission in the guide, please let us know.

 

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