Coordination Between the Child Support and Children's Health Insurance Programs in Order to Obtain Health Insurance Coverage for Children

Nov 01, 1997  |  Paula Roberts

Under the Child Health Insurance Program (CHIP) recently enacted by Congress, states will be able to make health insurance coverage available to a large number of uninsured children. Once they have designed their approach and established their eligibility criteria, states will conduct CHIP outreach/enrollment efforts. As detailed below, a logical and cost-effective-but frequently ignored-- agency to involve in these outreach efforts is the state's child support enforcement program. Not only does this agency have records about which children do not have coverage through private insurance or Medicaid, but also it has financial information about parents which would be useful in screening for CHIP eligibility. Moreover, the child support agency could assist the state in collecting from noncustodial parents any CHIP premiums the state decides to impose, and could move children to private insurance if and when it becomes available to them through their noncustodial parents. This allows the state to keep within its fiscal constraints while making sure that children have continuous access to health insurance.

Why this is so and how the proper linkages might be made are discussed below.

THE CHILD SUPPORT SYSTEM

Under Title IVD of the Social Security Act, every state offers a program to assist single parent families to obtain child support and health care coverage for their children. Three groups of families use this system: 1) those receiving assistance funded under Title IVA of the Social Security Act, who are required to use these services and to cooperate with the IVD agency in obtaining cash support; 2) those receiving Medicaid benefits, who are required to use these services and to cooperate with the IVD agency in obtaining any private health insurance coverage which may be available to their children; and 3) those who apply for child support enforcement services.⁽¹⁾ The vast majority of users of the IVD system (85%) have incomes below 200 percent of the federal poverty line.⁽²⁾

In recent years, the role of these state IVD programs-- especially in the area of obtaining health care coverage-- has greatly expanded. Under current law, IVD agencies are required to address medical support issues in all orders they are responsible for enforcing.⁽³⁾ As a practical matter, this means that every new or modified IVD order must address the issue of medical support. If the non-custodial parent has access to group health insurance for his/her dependants (i.e., coverage is available through employment, a union, or some other organization,) the child support order must require that the children be enrolled in this group insurance plan.⁽⁴⁾ If private health insurance is not available, then the order must require the parent to obtain such coverage when and if it does become available through his/her current or future job.⁽⁵⁾

In order to carry out this function, the IVD agency needs information about which employers operating in the state provide dependants coverage. To this end, state IVD agencies must have the legal authority to obtain information about employee benefits from all public and private employers in the state.⁽⁶⁾

This information may be supplemented by information from the noncustodial parents themselves as they are required to keep the IVD agency informed about any change in their health care coverage⁽⁷⁾. If the IVD agency finds--through information provided by the employer or a parent-- that dependents' coverage has become available to the noncustodial parent, it should seek to have the children placed on the policy.⁽⁸⁾

If the state's IVD agency is not successful in obtaining or enforcing private insurance, the child may be eligible for Medicaid. At that point, the state's Medicaid agency becomes involved on two levels. First, the Medicaid agency is interested in having the IVD agency continue to monitor the situation and move to obtain private health insurance for the children as soon as it becomes available .⁽¹⁰⁾ Second, because Medicaid recipients are subject to a medical support cooperation obligation, there is an interface between the two agencies in enforcing that obligation.⁽¹¹⁾

In other words, as part of their mission, state child support (IVD) agencies:

• identify children who can obtain private health insurance coverage through their noncustodial parent.


• check periodically to see if health insurance coverage not previously available has become available and enroll the children if it has.


• know which children do not have access to private health insurance and what the income of those childrens' families is.


• interact with the state Medicaid agency around health insurance coverage and cooperation issues.

THE NEW CHILDREN'S HEALTH INSURANCE PROGRAM

Children who are ineligible for Medicaid and do not have access to private insurance frequently do not get the health care that they need. Recently enacted federal legislation-- the Children's Health Insurance Program (CHIP)-- offers a way to provide these children access to health insurance.⁽¹²⁾

As of October 1, 1997, enhanced federal funding⁽¹³⁾ is available to states to provide health insurance coverage to "optional targeted low-income children." These are children who 1) are not eligible for Medicaid or other health insurance coverage; and 2) live in families with incomes below either 200 percent of the federal poverty line for a family of comparable size or 50 percent above the state's Medicaid eligibility level, whichever is higher.⁽¹⁴⁾ States wishing to draw down the federal money must 1) submit a state plan which meets certain defined standards;⁽¹⁵⁾ 2) put up a "state match";⁽¹⁶⁾ 3) maintain Medicaid eligibility at levels that are not more restrictive than those in effect on June 1, 1997;⁽¹⁷⁾ and 4) fulfill certain reporting requirements.⁽¹⁸⁾

States can use the funds to expand their Medicaid programs, create new state child health insurance programs, or do both. ⁽¹⁹⁾ If they choose a non-Medicaid approach, the benefits package offered must meet certain minimum standards.⁽²⁰⁾ These are:

• Benchmark coverage-- The benefits package must be equivalent to either the standard Blue Cross/Blue Shield Preferred Provider option offered to federal employees; or the plan available to state employees; or the benefit package available through the commercial HMO in the state serving the largest number of non-Medicaid participants.


• Benchmark-equivalent coverage-- The benefit package must have an aggregate actuarial value at least equivalent to the benchmark package and include certain specified services.


• HHS approved coverage--The Secretary of HHS could approve another appropriate package if requested by a state to do so.⁽²¹⁾

If states choose one of these approaches they may impose cost-sharing on CHIP participants.⁽²²⁾ The one exception to this is for well-baby and well-child services.⁽²³⁾ For other services, allowable charges vary be income:

• for those with income at or below 150 percent of poverty, a sliding scale premium may be charged. ⁽²⁴⁾The maximum monthly premium (per family) is $19 for a family of 1 or 2, $16 for a family of 3 or 4, and $15 for a family of 5 or more. Such families may also be asked to pay nominal copayments of up to $3 for any service costing more than $50.⁽²⁵⁾


• for eligible families with incomes above that level, premiums can be charged on a sliding scale so long as aggregate charges ( premiums, copayments and deductibles) for all children in the family don't exceed 5 percent of family income.⁽²⁶⁾

To draw down the federal money, each state has to have an approved state plan . Among the elements of such a plan, the state must address:⁽²⁷⁾

• outreach efforts to families of children likely to be eligible for CHIP and how the state plans to inform them about the CHIP program and assist them to enroll.


• coordination with other private and public insurance programs.


• how the state will ensure that CHIP does not substitute for other group coverage available to children.

By March 31, 2000, each state must submit an evaluation of its program. Among other things the evaluation must address the state's effectiveness in increasing the number of children with health insurance coverage and the state's efforts at coordination with other public and private programs for children.⁽²⁸⁾

 

HOW THE PROGRAMS FIT TOGETHER

Outreach

The CHIP program requires states to identify uninsured children, inform those children about the new program, and assist eligible children to enroll. As noted above, the IVD agency has records about children who lack access to health insurance through private means . The IVD program also has access to financial information about the family. Thus, the IVD agency is a natural place to include in the states efforts to identify and enroll eligible children in the state's CHIP program.

A major advantage of this approach is that the cost would be minimal and could be built into existing IVD/ Medicaid interface efforts. Since there is a cap on the amount of CHIP funds that can be used for outreach,⁽²⁹⁾ an inexpensive approach is desirable.

There are two levels on which this outreach effort can be done. First, is looking at the current IVD caseload to identify families which appear to be income eligible and whose children do not have access to Medicaid or private health insurance. These families could be provided with CHIP information and assisted to enroll.This is a one-time outreach effort. Second, is a continuous outreach component. In this component, every time the child support agency establishes or modifies a child support order for a family which is income-eligible for CHIP and it finds that the noncustodial parent does not have access to private health insurance, it could offer CHIP information to the family. The agency could then include payment of any CHIP premiums in the support order. (See discussion below.) The parents could either share the cost, or the noncustodial parent could be ordered to pay the premiums and the money could be incorporated into any income withholding order and the amount deducted from earnings.

 

Coordination with Other Health Insurance Coverage

States must also coordinate CHIP with other coverage so that the program is not covering children who have access to private insurance. As noted above, the IVD agency is charged with identifying potential private insurance coverage and making it available to children in the IVD caseload. Almost of necessity, then, the Medicaid agency will need to interact with the IVD agency in order to meet this program requirement.

 

Collection of premiums

If a state chooses a non-Medicaid approach for some or all of the CHIP eligible children, the law allows fees to be imposed. Some states will use this authority to charge sliding scale premiums to families, especially those at the higher income eligibility range. In cases where health insurance coverage has been ordered, the IVD program has the ability to require employers to deduct any applicable premiums and remit them to the insurer. The IVD program could help to insure that CHIP premiums were actually paid by using this power in cases where the coverage was through CHIP.

 

DEVELOPING AN ACTION PLAN

Unfortunately, in its initial guidance to states, HHS failed to address the potential CHIP/IVD interface. Instead, it identified income-tested, health-related programs (e.g., WIC, public health clinics) as places for outreach.⁽³⁰⁾While these sites are necessary to an adequate outreach approach, they are not sufficient. Such efforts will only touch families which are trying to get health care for their children. They will not reach families who have given up (and whose children are not seeking the services they need) or those whose children are currently well (so they are not contacting any agency for help). Moreover, outreach efforts which are limited to programs known to be limited to those with poverty and near-poverty level incomes will miss working class families, especially those with income between 150 and 200 percent of poverty.

Advocates and state officials wanting to have a broader outreach campaign will want to point out the advantages of incorporating the IVD system into outreach efforts. Moreover, given the potential fiscal benefits- in financing the outreach, coordinating with private coverage, and collecting premiums- it should not be difficult to convince thoughtful state officials of the wisdom of such a coordinated approach.

To make sure this happens:

1. HCFA should amend its Draft Guidance to include mention of the potential advantages of a IVD/CHIP interface.
   
   
2. Advocates for the CHIP program should educate appropriate state IVD and Medicaid officials about the potential benefits of a IVD/CHIP interface.
   
   
3. State officials from both the IVD and the Medicaid agencies should meet and discuss how they could coordinate the two programs so that -through both one-time and continuous outreach to families in the IVD caseload who do not have access to private health insurance-- they can reach a broad audience of eligible children. For example, the IVD agency might include outreach materials in a targeted mailing, or it might do periodic outreach mailings to all cases in which its records show that the family does not have private health insurance or Medicaid coverage. Or the IVD agency might provide CHIP information to all new IVD applicants and recipients. Or, in appropriate cases, it might build CHIP enrollment into the process every time it obtains or modifies a support order.
   
   The Medicaid and IVD agencies will also need to discuss how eligible children will be enrolled. A variety of approaches is possible including out- stationing CHIP eligibility workers in IVD offices, and building a CHIP assistance component into an existing IVD information hot line or web site. In addition, both agencies will want to discuss how to improve existing efforts to identify and enroll children in private health insurance when it becomes available.
   
4. In states where advisory committees are still meeting to draw up CHIP plans, those committees should be informed about the potential advantages of a CHIP/IVD interface and encouraged to build such an interface into whatever plans they develop for the CHIP funds. In some states, this will be more productive than going to the IVD or Medicaid agency first.

 

Appendix

1. 42 USC Section 654(4).

2. About half the IVD caseload receives benefits under Title IVA and is therefore, by definition, low income. Of the remaining 50 percent of the IVD caseload, in 1991, approximately 65 percent had incomes below 200 percent of the poverty line. Due to changes in Title IVA, it is likely that an even larger percentage of low income non-IVA parents are using the IVD system today. See, Statement of Jane Ross, Director Income Security Issues, Health, Education and Human Services Division, U.S. General Accounting Office, before the Subcommittee on Human Resources of the Committee on Ways and Means, 104^th Cong. 1^st. Sess. , June 13, 1995, GAO/T HES-95-181.

3. 42 USC Section 666(a)(19).

4. 42 USC Section 652(f). See, also 45 CFR Section 303.31.

5. Id. Section 303.31(b)(2) and 303.31(c)(2).

6. 42 USC Section 666(a)(2)(c)(1)(C). This same information about out-of-state employers will soon be accessible through the Federal Parent Locate Service. Id.

Section 653(a)(2).

7. 45 CFR Section 303.100(a)(10).

8. IVD agencies can also issue notices to employers and actually enroll children when their noncustodial parents fail to do so and require employers to deduct any required health insurance premiums from the noncustodial parents wages. 42 USC Sections⁽⁹⁾

9. Id. Section 1396g-1(a)(3)(D). -

10. Even if the private insurance provides fewer benefits than Medicaid, the Medicaid agency

could still seek reimbursement for those things the private insurance does cover.

11. 42 USC Section 1396k(a)(1).See also, 45 CFR Section 433.138(b).

12. Pub. L. 105-33, Title 4, Subtitle J, which establishes a new Title 21 in the Social Security Act.

13. Each states allotment and how it was determined was published at 62 Fed. Reg. 48098-48105 (Sept. 12, 1997).

14. Section 2110(b)(1)of the Social Security Act as created by the Balanced Budget Act of 1997. Using this formula, several states (e.g., Connecticut, Missouri, Oklahoma, Rhode island) are planning to cover children in families with income greater than 200 percent of the poverty line.

15. Id. Sections 2101(b) and 2102.

16. Id. Section 2105.

17. Id. Section 2105(d).

18. Id. Section 2108.

19. Id. Section 2101(a). According to an October 10, 1997 memo from the Children's Defense Fund, Arkansas, Massachusetts, Missouri, New Mexico, Ohio, Oklahoma, Rhode Island, South Carolina, and Wisconsin plan to expand their Medicaid programs; California, Connecticut and New Jersey are combining Medicaid and a new program; while Colorado, Michigan, Nevada, Pennsylvania, and Utah have or are developing new programs. Other states ( Alabama, Idaho, Kansas, Louisiana, Montana, Nevada, North Carolina, Texas, Virginia and West Virginia) have established task forces or advisory groups to decide what to do.

20. Id. Section 2103.

21. Id. Sections 2103(a)and 2103(d) also provide an option to Florida, New York, and Pennsylvania to convert existing state health care programs into CHIP-funded programs.

22. Id. Section 2103(e)(1).

23. Id. Section 21039e)(2).

24. Id. Section 2103(e)(3)(A).

25. Questions and Answers issued by the Health Care Financing Agency (HCFA) on the State Children's Health Insurance Program, October 3, 1997, Question 28.

26. Id. Section 2103(e)(3)(B).

27. Id. Section 2102. See also, Instructions for completing the Draft Model Template for State Child Health Plan Under Title XXI of the Social Security Act State Children's Health Insurance Program dated September 12, 1997, Sections 4.4.3, and 5.1.

28. Section 2108(b) of the Social Security Act as added by the Balanced Budget Act of 1997.

29. Id. Section 2105(c)(2). For states opting for the non-Medicaid approach, the statute places a 10 percent limit on the amount of funds that can be used for other child-related health service initiatives, administrative costs and outreach.

30. See note 26, supra. States are also told they may discuss efforts involving day care centers and schools, as well as "traditional safety net providers".