ACYF
Administration on Children, Youth and Families |
U.S. DEPARTMENT
OF HEALTH AND HUMAN SERVICES
Administration for Children and Families |
| 1. Log No. ACYF-IM-HS-98-15 |
2. Issuance Date: 11/03/98 |
| 3. Originating Office: Head Start Bureau |
| 4. Key Word: Child Health Insurance Program (CHIP) |
INFORMATION MEMORANDUM
TO: All Head Start and Early Head Start Grantee and Delegate Agencies
SUBJECT: Children's Health Insurance Program (CHIP)
PURPOSE: The purpose of this memorandum is to provide information to Head Start and Early Head Start programs about the Children's Health Insurance Program (CHIP) and to present CHIP outreach strategies.
BACKGROUND:
The Balanced Budget Act of 1997 (BBA) created title XXI of the Social Security Act, also referred to as the State Children's Health Insurance Program (CHIP). CHIP offers new opportunities for low-income families to obtain health insurance for their children. Its primary focus is to initiate and expand health insurance coverage for low-income uninsured children. The program allows States to expand health insurance coverage for children in one of three ways: through a separate children's health insurance program, through the Medicaid program, or through a combination of these programs.
To be eligible for funds, States must submit and obtain approval for a Child Health Plan from the Department of Health and Human Services' (DHHS), Health Care Financing Administration (HCFA). The Plan must describe standards and methods used to establish and continue eligibility and enrollment for targeted low-income children. It must also describe procedures for outreach that inform families of the availability of, and assist in, enrollment in CHIP and Medicaid.
Under CHIP, States may either cover children in families whose incomes are above the Medicaid eligibility threshold but less than 200 per cent of the federal poverty guidelines, or within 50 percentage points over the state's current Medicaid income limit for children as of March 1997. For example, if the State's Medicaid program on March 31, 1997 covered children in families with incomes up to 185 percent of the poverty level, it could choose to use CHIP funds to cover children in families with incomes as high as 235 per cent above the poverty level.
If a State implements CHIP as a separate, non-Medicaid program, the State Child Health Plan must include a description of the amount of premiums, deductibles, co-insurance and other cost sharing imposed under CHIP. States may vary premiums, deductibles and other cost sharing mechanisms based on family income, provided that lower income families pay less than higher income families. However, States are prohibited from imposing deductibles, co-insurance, or other cost sharing on well-baby and well-child care, including immunizations.
States choosing to expand Medicaid must offer full Medicaid benefits, meet all Medicaid rules, and comply with Medicaid cost-sharing rules. Children eligible for Medicaid must be enrolled in that program rather than in a separate state insurance program. American Indian and Alaskan Native children are eligible for CHIP on the same basis as other children in their State. Eligibility for CHIP is not affected by the fact that they may also be eligible for or are recipients of health care services funded by the Indian Health Service.
Other Important Legislative Changes Under BBA
The BBA also included two additional Medicaid provisions giving States the option to increase children's health care coverage through the Medicaid program: 1) presumptive eligibility for low income children, and 2) the option to provide 12-month continuous eligibility.
Presumptive Eligibility Option. Certain "qualified entities" may enroll children under 19 years of age in Medicaid on a temporary basis if they appear to be eligible based on their ages and family income. Qualified entities may include children's traditional health care providers, such as pediatricians and health professionals who deliver services in community health centers, Women, Infants and Children (WIC) programs, Head Start programs, and State and local agencies that determine eligibility for subsidized child care under the Child Care and Development Block Grant.
Twelve-Month Continuous Eligibility Option. States can guarantee up to 12 months of coverage to children enrolled in Medicaid even if the child experiences changes in family income or other circumstances that would make the child ineligible for Medicaid during the 12-month period.
Although there is no explicit provision for presumptive eligibility under title XXI, a State may craft an equivalent procedure in a non-Medicaid CHIP program as a health initiative. As such, expenditures provided during the presumptive eligibility period are initially subject to the ten percent limit for administration, outreach, health services and other child health assistance and are counted against the State's title XXI allotment.
INFORMATION:
It is estimated that over ten million children in America are uninsured. Nearly 90 percent of these children have parents who work, but do not have access to or cannot afford health insurance. The General Accounting Office estimates that over 3 million children eligible for Medicaid are not enrolled. To ensure that both Medicaid and CHIP fulfill their potential, early this year, the President called for a nationwide children's health insurance outreach initiative involving both the public and private sectors. Eight Federal agencies with jurisdiction over children's programs, including the Administration for Children and Families (ACF) within DHHS, have established a multi-agency effort to increase enrollment of uninsured children in Medicaid and CHIP.
While Head Start and Medicaid have a long history of working together to improve the health of young children, the passage of the BBA offers new opportunities for Head Start programs to work with Medicaid and CHIP agencies to increase enrollment in Medicaid for both Head Start children and their siblings. (See Appendix A, Interagency Agreement Between ACF and HCFA.)
There are various outreach activities which Head Start programs can perform to bring potentially eligible children into the CHIP and Medicaid systems. Specific strategies for outreach that can be conducted by Head Start programs include:
I. Eligibility and Enrollment
- Informing Families about Medicaid and CHIP. Head Start programs, as a
part of their enrollment process, have discussions with families
about their income and health insurance status. During this time,
staff determines whether a family has health insurance. If they do
not, staff should provide families with information about Medicaid
and CHIP.
- Providing a Link to Eligibility Offices. When Head Start programs take
applications for enrollment in Head Start, there are some children
who meet eligibility requirements but, due to limited program
resources, cannot participate in Head Start at that time. These
children are placed on a waiting list and many of them are often
eligible for Medicaid. With the family's consent the Head Start
program could provide information to the local eligibility office
to initiate the application process for these children.
- Presumptive Eligibility. The BBA allows states, under their Medicaid
program, to offer presumptive eligibility to low-income children
enrolled in other Federal programs, such as Head Start or WIC.
Head Start programs can contact their State Medicaid office to see
if their state has chosen to offer presumptive eligibility to
children enrolled in Head Start.
- Joint Application. Some states have developed a joint application
for Medicaid and CHIP. Head Start programs can contact their local
and/or state Medicaid office and their state CHIP agency to see if
a joint application has been developed, and can assist families in
completing the application.
- Outstationing Medicaid Workers. In some States, Medicaid eligibility workers are co-located or outstationed in other offices with Head Start, WIC, or Federally Qualified Health Centers to assist with the initial processing of applications. Head Start programs can work with their Medicaid partners to explore if this is feasible in their community. Another consideration is to encourage the local Medicaid agency to outstation workers at community health fairs, or Head Start health fairs, etc.
II. Community Outreach
- Health Services Advisory Committee. The Health Services Advisory Committee
(HSAC) can not only assist Head Start programs in developing
outreach strategies for Medicaid and CHIP, but can also share
information about Medicaid and CHIP back to their own agencies.
They can help reach families not enrolled in Head Start, but who
may still be eligible for Medicaid or CHIP.
- Linkages with Community Partners. Head Start programs work with many
community partners who are also involved in Medicaid and CHIP
outreach activities, such as WIC, title V programs, Immunization
Outreach Efforts, JOBS, Child Support Enforcement and Child Care.
Head Start programs may want to meet with these community partners
to share ideas about how to coordinate outreach activities, they
can develop informational materials about Medicaid and CHIP that
can be distributed in a variety of community settings, or finally
they can discuss lessons learned from previous outreach campaigns.
In many communities, state and local CHIP planning and
implementation committees are being formed. Head Start Programs
should participate on these committees, and share their
experiences in getting information to hard-to-reach families. Many
states are developing Outreach Campaigns and would benefit from
Head Start's experience.
- Community Education Activities. Head Start programs, along with other community partners such as child care and WIC, can conduct joint community education activities about Medicaid and CHIP. For example, representatives from these programs can speak to parents and staff at community health fairs, and can offer information about how to enroll in these programs. Head Start programs can conduct parent workshops and can invite non Head Start parents, WIC and child care parents to learn about Medicaid and CHIP.
III. Planning and Advocacy
- Health Services Advisory Committee. A program's HSAC can be instrumental in
advising staff about issues related to Medicaid and CHIP. Head
Start programs may want to consider inviting a representative from
Medicaid or CHIP to become members of their HSAC. The HSAC may
provide assistance to staff in understanding changes in health
services delivery in the community due to changes in Medicaid or
the implementation of managed care or CHIP.
- Managed Care Organizations. Head Start programs can be a valuable resource
to community managed care organizations who are required to enroll
children and families in Medicaid and/or CHIP, but may not know
how to reach these families. Head Start programs may also want to
invite representatives from managed care organizations in the
community to participate on their HSAC.
- State Plan.
Head Start programs may wish to contact those individuals at the
State who are responsible for developing and/or amending the State
Plan and inform them of ways that Head Start programs can assist
them in outreach. Head Start State Collaboration Offices should be
working with State CHIP planning committees in early discussions
about outreach strategies and enrollment plans for children and
families to ensure Head Start is included as a participant in the
State planning or plan modification process.
- Data. Head Start programs collect information about families individually as well as on an aggregate level for program management purposes. Programs have information about the number of families with or without health insurance and Medicaid enrollments as well as the health needs and the health status of children. This program information can be useful to states as they amend their State Child Health Plan.
Reimbursement for Outreach Activities
Currently, the Federal government matches State Medicaid expenditures for outreach activities such as informing families about Medicaid through brochures or other promotional activities; assisting families in completing Medicaid applications; and providing the necessary forms and packaging for Medicaid eligibility determinations.
Under CHIP, ten percent of Federal and State expenditures may be used for total costs of outreach, administration, direct services to children, and other child health assistance. The Secretary of the Department of Health and Human Services may waive the ten percent limit for coverage that is cost-effective and is provided through a community-based health delivery system.
Attached to this memorandum is a list of where to get information on Medicaid and CHIP in each State. (Attachment B). Other sources of information about Medicaid and CHIP are the ACF Home Page and the HCFA Home Page. The Head Start State Collaboration Offices and the Head Start Quality Improvement Centers are also resources for Head Start programs wanting specific information about their state Medicaid and/or CHIP program.
/S/
Helen H. Taylor
Associate Commissioner
Head Start Bureau
ATTACHMENT A: ACF-HCFA Interagency Agreement
ATTACHMENT B: Medicaid and CHIP Information
