CaliforniaKids is a non-profit organization sponsored by private donations that was founded July 30, 1992. The program was initially based in Los Angeles, and has since expanded to twenty-four other counties. CaliforniaKids offers children a limited health insurance product that focuses on preventive care. The program coordinates with MediCal, the state Medicaid program, to obtain care for children who need inpatient treatment or other serious care that CaliforniaKids does not provide. CaliforniaKids partners with community organizations to identify and enroll eligible children. Children enrolled in CaliforniaKids pay no monthly premiums, but are responsible for small copayments for their care. CaliforniaKids has provided coverage for 14,000 children since its inception in 1992.

Uninsured children ages 2-18 who are unmarried, ineligible for coverage under any federal or state health benefit program, not currently enrolled under a private health care contract, and enrolled and attending school (if school-age) are eligible for CaliforniaKids if their family income is below 200% of the poverty level. In August 1997, a pilot program was begun in San Diego that will expand the income eligibility level up to 300% of the poverty level in that county.

Benefits covered by CaliforniaKids include health screenings, immunizations, and hearing screening and aids without co-payment, emergency treatment with a $25 co-payment, outpatient care and doctor visits with a $5 co-payment each, and prescriptions, dental care and eye glasses with a $10 co-payment each.

CaliforniaKids utilizes a managed care, capitated system to maintain cost-effectiveness, minimize risk and unnecessary administrative expense due to excessive claims processing, and provide a "medical home" for the child. The network maintains choice and is sensitive to access, culture, language, gender, and age of child. Over 15,000 health care providers are contracted to provide services throughout the State and a 24-hour nurse hotline is available to all members to provide health care information and re-direct care from the emergency room to a lower cost, appropriate alternative. Plans donate their direct administrative expenses. CaliforniaKids partners with medical groups and IPAs, which offer wellness education to its members. Services are administered by Blue Cross of California, Delta Dental, Vision Service Plan, Wellpoint Pharmacy, and Access Health.

CaliforniaKids is financed through private donations. CaliforniaKids does not collect premiums, but charges nominal copayments for care. Costs are kept low by offering a limited benefit package and minimizing administrative costs.

HISTORY:

The Colorado Children's Health Plan (CCHP) was established in 1992 as a community-based health care reimbursement program for low-income children. CCHP operates as a health maintenance organization that is administered by the University of Colorado Health Sciences Center. The program initially targeted rural counties with a low number of safety net providers, and built its own network of physicians. Recent legislation established the Children's Basic Health Plan (CBHP), a program which will expand eligibility under CCHP up to age 18 and extend the network into every county in the state. CBHP will be a full benefit program administered by private HMOs. The CBHP will be funded in part by the Title XXI block grant.

The target population of CCHP is children age twelve and under with incomes up to 185% of the poverty level who are not eligible for Medicaid. Under CBHP, the target population will expand to include children up to age eighteen. Enrollment in FY1996 was 4,893 children. In FY1997 the target is 6,217 children, and in FY1998 the target is 12,041 children.

The benefit package was modeled after the Blue Cross/Blue Shield Caring Programs. Benefits include most preventive services, but do not include inpatient hospital care, eyeglasses, hearing aids or dental care. There is a maximum annual benefit of $10,000 per child. The program expansion will include inpatient and mental health care.

CCHP is administered by the state of Colorado through the University of Colorado Health Sciences Center. The program has a statewide network of pediatric physicians. Primary care physicians are reimbursed on a capitated basis and bear risk. Medical specialists are reimbursed on a fee-for-service basis.

Funding is obtained for CCHP through a combination of state appropriations and private donations. Funding comes from several sources: General Fund; public funds consisting of a portion of the Medicaid teaching adjustment paid to University Hospital; cash reserves and interest paid on those reserves; private donations; and enrollment fees. The enrollment fee is a $25 per child yearly payment in lieu of premium contributions. Copayments are required on doctor visits, health screenings, and prescriptions. Blue Cross/Blue Shield HMO donates all claims processing services.

The Florida Healthy Kids Corporation was established in November 1990 to create a comprehensive insurance product for school children using Florida school districts as a grouping mechanism. A HCFA(now known as CMS)-funded demonstration project of Healthy Kids was initiated in Volusia County in 1992 and was completed in 1995. In late 1993, Healthy Kids began expanding into additional counties utilizing both state and local government funds. Healthy Kids currently serves 19 of Florida's 67 counties, which contain approximately half the state's uninsured children. The program is designed to provide affordable access to health insurance for all Florida children. Children who are not on the school lunch program pay the entire cost of their insurance, while children who are on the school lunch program have access to subsidized insurance. Participation by Florida counties in the Healthy Kids program is strictly voluntary.

Once a school district elects to participate in the program, qualified children become eligible for Healthy Kids. Children must be between the ages of 5 and 19, uninsured (i.e. not enrolled in Medicaid or private insurance), and enrolled in school up to the 12th grade. Counties may expand eligibility to allow children of other age groups the ability to participate (e.g. children who are less than school age whose families are enrolled in Healthy Kids).

Program benefits are extensive, including inpatient care, surgery, emergency services and transportation, eyeglasses, hearing aids, physical therapy, mental health services, pre-natal care and delivery, and organ transplants. Copayments are required for certain benefits. Counties may add additional services such as dental care to the package. Healthy Kids has a $1,000,000 lifetime cap on services received.

Eight managed care networks serve Healthy Kids enrollees. Insurers are selected on the basis of five variables: price, benefits, provider network, reporting capabilities, and general criteria such as accreditation and solvency. Healthy Kids aggregates state, local and family funds to pay premiums to commercial health plans that assume the insurance risk.

All individuals enrolled in the Healthy Kids program are required to pay some portion of the cost of their insurance. Sliding-scale premiums are based on reported family income required for participation in the school lunch program. The three cost-sharing levels are "Free Lunch", "Reduced Lunch", and "Not on Lunch Program". Premium levels vary by county. Funding for the demonstration project in Volusia county came from a HCFA(now known as CMS) waiver. All subsequent funding has been granted through a combination of state, local and family contributions.

Authorizing legislation for the Children's Medical Security Plan (CMSP) was passed in 1993 to provide access to preventive and primary care services for Massachusetts' uninsured children. The plan originally covered uninsured children age 12 or younger. The impetus for the program was initially the national attention to health care reform and access to health care for all individuals. The passage of the Health Access Law in July 1996 expanded CMSP program eligibility to include adolescents up to age 18. In 1997 administration of the plan was transferred to the state Department of Public Health.

The target population for CMSP is uninsured children under the age of 19 who are residents of Massachusetts and who are not eligible for Medicaid. The number of projected children eligible for CMSP is 76,000.

The Children's Medical Security Plan offers a range of benefits designed to cover the services most frequently used by children. Routine well-child check-ups, immunizations, and smoking prevention services are covered without co-payment. All other covered benefits require a co-payment of are $1, $3 or $5 based on family income guidelines. Limited coverage is offered for emergency care, prescription drugs, durable medical equipment, and outpatient mental health services. CMSP does not pay for OTC drugs, ambulance transport, inpatient care, dental care, or early intervention. However, children enrolled in CMSP may be eligible to receive inpatient care in any of the state hospitals or community health clinics through the state free care pool.

The Community Health Plan (CHP) and John Hancock administer the health insurance program. The Community Health Plan serves three rural counties with approximately 3,000 participants. John Hancock serves the remainder of the state, with roughly 34,000 enrollees. John Hancock reimburses its providers on a fee-for-service basis, while CHP reimburses both through capitation and fee-for-service arrangements.

There are three sources of funding for the program: tobacco taxes, general funds, and family premium contributions. Families earning 200% or less of the federal poverty level receive the insurance free of charge. Those families earning below 400% of the poverty level are charged a reduced premium rate of $10.50 per child per month, with a $32.50 maximum per family per month. Families with income over 400% of poverty are charged the full premium, which is currently set at $52.50 per month.

HISTORY:

MinnesotaCare began in 1993 as part of a package of legislation aimed at reducing the number of uninsured in the state of Minnesota. With the advent of the MinnesotaCare demonstration project, all Minnesotan enrollees, including all AFDC-related families and poverty-related pregnant women and children, were moved to mandatory managed care. Phase I of the demonstration extended Medicaid coverage to families with children under 275% FPL and no employer coverage. Phase II extended Medicaid coverage to all uninsured low-income adults without dependent children. Under the demonstration, children and pregnant women receive all benefits available to traditional Medicaid enrollees. In May 1997, a bill was approved to expand MinnesotaCare eligibility to adults without children and cut the taxes that support the program due to a surplus of funds. The legislation reduced provider taxes and created a federal contingency fund in the event that a change in the Medicaid program results in gaps in coverage of current enrollees. The legislation also provided for increases in the income threshold from 135% FPL to 175% FPL for families without children and added nonpreventive dental coverage for adults in families below 175% FPL for adults without children. The Senior Drug Program is not funded by MinnesotaCare.

MinnesotaCare is available to families with children who earn 275% or less than the poverty level and individuals who earn 175% or less than the poverty level. To become eligible for MinnesotaCare, one must have been uninsured for at least four months or have been receiving less than a 50% subsidy on health insurance from an employer for 18 months or more. Applicants to MinnesotaCare are also subject to an assets test. Families cannot have more than $30,000 in assets, and individuals cannot have more than $15,000 in assets to be eligible for the plan. The asset test will be implemented when the amended demonstration waiver is approved by HCFA(now known as CMS).

The program offers a comprehensive benefit package including inpatient hospital benefits. However, inpatient benefits are capped at $10,000 annually for adults without children and for parents with incomes greater than 175% FPL.

Enrollees have the opportunity to choose a health plan upon enrollment into the program. Provider reimbursement was originally structured on a fee-for-service basis but now is a capitated payment system.

MinnesotaCare was originally funded through a cigarette tax, a provider tax, and family contributions. The cigarette tax is no longer used for MinnesotaCare support; it was only applied from July 1992 through January 1994. In July 1995, the state 1115 demonstration waiver was implemented, and the federal match was added to the funding mix. In 1997 a reduction was made in the provider taxes due to a surplus in MinnesotaCare funds.

The Child Health Plus program was passed by the New York State legislature in 1990, and by August of 1991, children began receiving coverage under the program. New York's Child Health Plus is the largest of 13 non-Medicaid, taxpayer-funded child health insurance programs in the country. As of July 1, 1997, the program was providing coverage to over 135,000 children. The program has estimated target enrollment over the next few years to total 250,000; this number may increase significantly due to recent federal legislation. The overall intent of the Child Health Plus Program is the following:

• To improve the health status of children participating in the program by providing a "medical home"
• To provide primary, preventive, outpatient and inpatient health insurance coverage to low income children by removing financial barriers to purchasing such coverage through an individual subsidy program
• To increase children's access to primary comprehensive, preventive and inpatient health care services
• To reduce and more effectively target bad debt and charity care expenditures in the state of New York

Children considered eligible for the program must be either uninsured or underinsured, residents of New York State, under the age of 19, and not eligible for state Medicaid benefits. Children under age 19 in families with an income below 222% FPL are eligible for an income-variable premium subsidy. Children in families above 222% FPL are permitted to buy into the program without any premium subsidy.

The program began providing coverage to children in August of 1991, initially providing subsidized primary and preventive outpatient care to children under age 13. In 1997, the program extended benefits to include inpatient care (excluding inpatient services for mental health and substance abuse) and extended coverage to include children through age 18.

The provider network currently consists of 15 insurance plans contracted to provide health services to enrollees, of which 11 are MCOs and 4 are traditional indemnity plans. As of October 1, 1997, 24 insurance plans, with almost all providing a managed care product, will participate in Child Health Plus. Additionally, a marketing and outreach organization has been contracted to promote the plan throughout the state. This will be complemented by an in-house statewide marketing effort.

The program is financed through a provider surcharge established under the New York Health Care Reform Act of 1996. The premium contribution from families participating in the program is an additional funding source.

A 1992 Penn State University study on uninsured children in Pennsylvania precipitated the interest in creating a state-subsidized health insurance program for children. The Pennsylvania Children's Health Insurance Program was enacted in November 1992 and implementation began in May 1993. The state-sponsored program was initially designed to cover 29,000 uninsured children ages 1-6 whose families were below 100% of the poverty level. In May 1994 the program was expanded to cover children ages 1-13 up to 185% of the poverty level due to excess funds. The Children's Health Insurance Program is currently capped at 53,879 children. There are approximately 3,000 children on the waiting list.

The target population of the Children's Health Insurance Program is children up to age 16 whose families are below 185% of the poverty level. These children receive free coverage. Children under age 6 up to 235% of the poverty level are eligible for subsidized coverage. Applicants must be residents of Pennsylvania for at least 30 days (except newborns) and cannot have access to any other private insurance or the Medicaid program.

The focus of the Children's Health Insurance Program is on preventive and primary care services. Primary care, vision and hearing screening, emergency care, outpatient care, mental health treatment and dental care are provided through the benefit package. Inpatient care is covered through the program with a limit of 90 days in-hospitalization.

The Department of Insurance Office of Special Projects contacts with five HMOs, and each plan insures a different region of the state. Plans are selected through a competitive bidding process. Three of the HMOs are Caring Foundations set up by Pennsylvania Blue Cross/Blue Shield. The State Department of Health approves provider networks, and children have their choice of providers from within the plan.

The Pennsylvania Children's Health Insurance Program is supported by a $0.02/pack state cigarette tax, which generates approximately $21.5 million annually. In the 1996 session, the program asked the state legislature to appropriate another $0.01 of the cigarette tax to the program. The cigarette tax fell through, but the legislature appropriated an additional $10 million in general funds to the program.

TennCare is a Medicaid 1115 Waiver program that began January 1, 1994. On that date, about 700,000 Tennesseans who had been enrolled in Medicaid were shifted into one of twelve managed care organizations throughout the state. Also on that date, the state began offering TennCare coverage to the estimated 750,000 uninsured Tennesseans, regardless of income or employment status. Tennessee residents were eligible for TennCare under the uninsured category if they did not have insurance on March 1, 1993. TennCare's scope is broader than virtually any other state's 1115 waiver demonstration project. A sliding scale is used to determine premiums and patient cost-sharing for enrollees above 100% of poverty. Persons within 100-200% of the FPL have increased co-payments up to 10% of the total cost of treatment. Categorical and asset test restrictions were removed from Medicaid eligibility with the onset of TennCare. On January 1, 1995, the state closed enrollment for the uninsured population, but remained open to those who are uninsurable. However, on April 1, 1997, enrollment into TennCare was opened up to all children under age 18. There is no intention of closing enrollment to children at any time in the future.

Enrollment in TennCare is currently open to persons eligible for Medicaid, the "uninsurable" population, displaced workers, and all children under age 18 who do not have access to insurance. Children under eighteen are eligible for benefits on the day of their enrollment.

Program benefits are very comprehensive, and include inpatient hospital care, hospice care, dental services, home health care, durable medical equipment, medical supplies, ambulance transportation, transportation, rehabilitation, chiropractic services, private duty nursing, speech therapy, sitter services, convalescent care, and organ transplants.

To implement TennCare, the state was divided into twelve Community Service Agencies through which each contracting managed care organization operates and guarantees access to services through provider networks. TennCare determined the terms and conditions of its managed care plan and invited plans to participate. Plans that could prove that they could provide the services were granted contracts with TennCare. Initially twelve MCOs contracted with TennCare. For the first three years, Tennessee allowed the plans to operate as PPOs. By January 1, 1997, they had to be converted to HMOs. Currently there are ten MCOs servicing the TennCare population.

TennCare was financed by pooling federal, state and local expenditures for indigent health care, including $2.2 billion of federal dollars. Pooled resources total $3.455 billion, of which $2.245 billion is used to fund the current year of the TennCare program. The remainder is used to fund long-term care programs, Home and Community Based Services Waiver programs, Medicare crossovers through the Medicaid system, Medicare premiums, and administration for the total program. No new taxes were established to pay for TennCare.

In 1993, Washington State created the Basic Health Plus program for children under 200% of the federal poverty level through a Medicaid expansion. These children were previously eligible for health insurance through the full state-subsidized Basic Health Plan established in 1988, under which adults below 200% of the federal poverty level still receive coverage. The Basic Health Plus program was established to take advantage of the federal funding available through Medicaid. Children covered under the program receive a comprehensive benefit package at no cost to their family. Provider networks are aligned between the Basic Health Plus program and the Basic Health Plan so that families can visit the same physicians.

Children ages 0-19 whose families earn less than 200% of the poverty level are the target population of Basic Health Plus.

The Washington Basic Health Plus program has the same rich benefit package traditionally provided under the state Medicaid program. This includes all preventive services, plus benefits such as inpatient care, dental care, eyeglasses and hearing aids. Basic Health Plus provides routine screenings of up to $125 per child per calendar year without co-payment (this does not apply to well-baby care). Immunizations and well-child visit are covered up to a maximum of $400 per calendar year for children ages 1-4. Children receive a 50% discount on glasses and a 25% discount on contact lenses. There is an unlimited inpatient stay, but care must be authorized within 48 hours of admission.

There are currently fourteen managed care plans contracting with Basic Health Plus. There is almost a complete overlap between the provider network utilized by Basic Health Plus and that used by the Basic Health Plan.

The program is funded through a combination of state and federal funds through the Medicaid match. State funds are obtained primarily through state taxes on cigarettes and alcohol.