Child Health Coverage Faces New Limits

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Many children who attempt to enroll in a popular children's health insurance program will have to be uninsured for at least a year before they'll be allowed to participate, the Bush administration has informed state health officials.

The administration has repeatedly voiced concerns that some states were expanding their Children's Health Insurance Programs to the point that families were dropping private coverage for public coverage. Its latest directive is designed to prevent what it calls "crowd out" from occurring.

In a letter to state health officials, Dennis Smith, the administration's point man for the SCHIP program, laid out certain criteria that states must meet before they expand insurance coverage to those families above 250 percent of the poverty level — or $42,900 for a family of three.

For example, states must establish that a child has been without insurance for a minimum of one year before the child can get coverage through SCHIP. States will also have to assure the federal government that at least 95 percent of the children eligible for the program or for Medicaid are enrolled in either of those two programs.

But, currently, no state can make such an assurance for their participation rates. The best that any state is doing is Vermont, with about 92 percent participation. So, essentially, eligibility for states' SCHIP programs would be capped at 250 percent of poverty, said health officials who examined the administration's new policy. The policy went out in the form of a letter to state health officials late Friday.

Since many families above that threshold still can't afford private insurance, "the effect of this policy is to have more uninsured kids," said Rachel Klein, deputy director of health policy for Families USA, an advocacy group.

Some 19 states, including the District of Columbia, provide health insurance coverage to children in families with incomes above 250 percent of the poverty level, or are in the process of doing so.

Some states seeking to expand coverage have raised the income limits of families eligible for SCHIP, and consequently have placed certain systems in place (such as databases to ensure applicants were not covered under private plans), but the letter from the Centers for Medicare & Medicaid Services (CMS), a division of the Department of Health and Human Services, would make mandatory certain provisions, for example:

  • Waiting Periods: A minimum one-year period of "uninsurance" for individuals prior to receiving SCHIP coverage;
  • Verification: States must monitor health insurance status at time of application, and must include information regarding coverage eligibility through a non-custodial parent;
  • Cost Sharing: Imposing cost sharing in approximation to the cost of private coverage;
  • Dependency Policies: States must prevent employers from changing dependent coverage policies that would favor a shift to public coverage;
  • Reporting: States must report on a monthly basis data relating to the crowd-out requirements.
One of the stated aims of the new requirements is to prevent "higher income populations" from replacing their private health insurance (such as group health plans) with SCHIP coverage. "We expect affected States to amend their SCHIP state plan" within 12 months, the letter states, "or CMS may pursue corrective action."

The new guidelines could have a dramatic impact on those states as well as any other that wanted to follow in their steps, said Cindy Mann, executive director of the Georgetown University Center for Children and Families.

"It's a pretty radical departure in policy that has been in existence for 10 years," Mann said. "It attempts to stop in their tracks those states that have already or want to expand coverage."

Both chambers of Congress recently passed bills that would dramatically increase funding for SCHIP. The Bush administration opposes both measures, claiming that the increased funding sought by the two chambers is unwarranted and would result in less private coverage and more public coverage for children.

The letter from Smith said the new guidelines would not affect current enrollees.

"We appreciate your efforts and share your goal of providing health care to low-income, uninsured children," Smith told state officials.

About 6.6 million people participate in SCHIP. The program subsidizes insurance for those families with incomes too high to participate in Medicaid but not enough to afford private insurance.

The administration wants to spend about $30 billion on the program over the next five years. The Senate has called for spending about $60 billion. The House called for spending of about $75 billion. Negotiators have yet been appointed to work out the differences in the two bills.