Snapshot of Governors' Views on Extending CHIP
*Chart updated February 18, 2015
Policymakers in Congress are considering the role of the Children’s Health Insurance Program (CHIP) in the context of health coverage options available under the Affordable Care Act (ACA). Federal funding for CHIP is due to end in September, 2015 without Congressional action. To help inform these federal legislative discussions, the leadership of the House Committee on Energy and Commerce and the Senate Finance Committee sent a request to all governors seeking state input about the future of CHIP in July 2014. The chart below shares the governors’ responses to key questions in the Congressional request. Click on the state name below to read each state’s letter.
Most of the governors offered specific recommendations that federal CHIP funding be extended and all noted the success of the CHIP program. The letters also contain information about states’ CHIP programs and note recent changes as a result of ACA implementation, highlight differences in how benefits and cost sharing in CHIP compare to qualified health plans (QHPs), as well as surface policy recommendations that could help improve health outcomes and coverage for children into the future.
Know of something we should add to this compilation? Your feedback is central to our ongoing, real-time analytical process, so tell us in a comment below the chart, or email a NASHP staff member with your suggestion. You can reach Anita Cardwell at acardwell@oldsite.nashp.org.
Most of the governors offered specific recommendations that federal CHIP funding be extended and all noted the success of the CHIP program. The letters also contain information about states’ CHIP programs and note recent changes as a result of ACA implementation, highlight differences in how benefits and cost sharing in CHIP compare to qualified health plans (QHPs), as well as surface policy recommendations that could help improve health outcomes and coverage for children into the future.
Know of something we should add to this compilation? Your feedback is central to our ongoing, real-time analytical process, so tell us in a comment below the chart, or email a NASHP staff member with your suggestion. You can reach Anita Cardwell at acardwell@oldsite.nashp.org.
| State | Support Extending CHIP Funding? | Benefits and Cost Sharing in CHIP | Number of Uninsured Children if CHIP Funding Ends | Family Glitch Noted as an Issue? | Changes to CHIP Program as Result of ACA | Policy Recommendations & Other Issues |
|---|---|---|---|---|---|---|
| Congressional letter requested governors to comment on whether CHIP funding should be extended, if so for how long, and how quickly Congress should act [1] | Congressional letter requested information about how states’ CHIP programs’ benefits and cost sharing compares to coverage available through QHPs or employer sponsored insurance (ESI) [2] | Congressional letter requested estimates of the number of children that could become uninsured if CHIP funding ends [3] | Some governors’ letters mentioned the issue of the family glitch [4] | Description of how ACA implementation has affected administration of CHIP programs, such as implementing Modified Adjusted Gross Income (MAGI) eligibility rules or moving children from CHIP to Medicaid due to changes in eligibility levels [5] | State recommendations for any federal policy changes to improve enrollment of eligible children, reduce the number of uninsured, and improve health outcomes for children | |
| AL | Yes, 4 years; Congress should act soon, state has started budgeting for FY2016 | Unique benefits in CHIP, such as nutritional counseling and extra primary care visits for obese children; also generally lower copays in CHIP than other insurance | No precise estimates on number of children that might become uninsured if CHIP ends, but anticipate it would be a large number, because employer or marketplace coverage could be unaffordable | Yes | Moved about 23,000 children to Medicaid 1/1/14; new eligibility system based on MAGI; removed 3 month waiting period | Extending CHIP may help uninsured rate for children could continue to decline especially if the 23% increase in CHIP federal match is implemented |
| AK | Yes, 4 years, to align w/MOE | EPSDT is available to all children in AK’s CHIP program, and so more comprehensive than marketplace coverage; letter also notes other CHIP services that might not be available in private coverage. Also, unlike marketplace coverage, AK’s CHIP program has no cost sharing. | N/A, Medicaid expansion CHIP program only | No | MAGI implementation | Recommend continued federal support of the Express Lane Eligibility option, and implementing efforts to standardize basic eligibility requirements across programs. Also recommend continuation of quality improvement work. |
| AZ | Not explicitly mentioned, though letter mentions the program has been successful | Full Medicaid benefit package is provided to KidsCare enrollees. The state employee benefit package is the benchmark for marketplace coverage, and it aligns fairly closely to Medicaid, with the exception of non-emergency medical transportation, and some family supports and other behavioral health services that may not be available in QHPs. | Not mentioned; letter notes that AZ led the nation in the percentage of children who enrolled in QHPs | No | No changes needed in administering CHIP | State has had enrollment success through public-private partnerships that allow community groups to be part of the application assistance team. Letter notes that while there may be differences in terms of cost sharing between CHIP and QHPs, it could be possible to structure a marketplace option to meet the needs of children. |
| AR | Not explicitly mentioned, though letter mentions the program has worked well and that the success has led to a reduction in the number of uninsured children | CHIP provides vision and dental services, which historically are not covered in most ESI plans; in the marketplace, pediatric dental services are not required to be offered in the package if a stand-alone dental plan is available on the marketplace | Not mentioned | No | MAGI implementation; moving children from CHIP to Medicaid | Issue of ensuring access to coverage for children is critical, whether coverage is provided through CHIP or an alternate mechanism |
| CA | Yes, but no specific time period noted; maintaining CHIP funding is critical for achieving affordable and comprehensive coverage for low-income children. Fiscal barriers for the state if CHIP funding ends, both in terms of coverage ending for pregnant women and children in county programs and the lower federal match. Recommends early action by Congress. | Enrollees receive Medi-Cal benefits, including EPSDT, which offers a more comprehensive coverage package at a lower cost than private coverage. CHIP funding provides services to pregnant women. CHIP premiums range from zero to miminal, and no copays; QHP cost sharing varies but that even minimum coverage plans typically include deductibles, coinsurance and/or copays. | N/A, Medicaid expansion CHIP program only | No | Transitioned separate CHIP programs for children and pregnant women to Department of Health Care Services administration in 2013. Also AB1296 required development of standardized application form and renewal procedures. Streamlined eligibility and administrative processes, including the health plan contracting process. | The 23% increase in CHIP federal match is important. |
| CO | Yes, 4 years, to align w/MOE, and because ending funding in any less time would create financial hardship for families; also allows states time to analyze data and develop long-term strategies | CHIP and private market individual coverage have similar benefits, but significant differences in cost sharing, and that out-of-pocket maximums are much higher in QHPs. | Not mentioned | No | MAGI implementation; 12 month continuous eligibility beginning 3/1/14 to help reduce churn | Recommend alignment in eligibility and enrollment processes across social service programs to reduce administrative burden and better serve families. State goal to continue reducing the number of uninsured children. |
| CT | Yes, and CHIP funding should be made permanent | CHIP offers a much broader range of behavioral health benefits than those offered in ESI and QHPs. Also CHIP covers dental services and has very good access to care; in marketplace families need to buy stand-alone dental plans and usually in ESI dental coverage is limited. CHIP has no premiums and cost sharing is minimal, much less than QHPs | Not mentioned | Yes | MAGI implementation; also eliminated waiting period | Performance bonuses have been helpful; need to better understand number of those affected by family glitch and address the issue; also review cost effectiveness, network adequacy and scope of coverage of QHPs, and continue support of ACA in-person enrollment assistance |
| DE | Yes, 4 years, to align w/MOE and because of the financial burden for families to seek marketplace coverage | CHIP cost sharing is very minimal; EPSDT services are available to CHIP population, which provides access to specialized services that might not be available on the exchange | Not mentioned | Yes | MAGI implementation; moving children from CHIP to Medicaid | Recommend alignment in eligibility policies across social service programs to better serve families. CHIP serves an important role currently between Medicaid and the marketplace, a need that may decrease over time; it is necessary to assess the roles and value of each program, with the goal of greater integration and alignment. |
| GA | Yes, 2 years of additional funding consistent w/MACPAC recommendation, to ensure continued access for children who might otherwise become uninsured due to higher marketplace cost sharing, allow for time to assess comparability of QHPs, and provide states enough time to prepare for CHIP program ending and assist w/transitioning families; an early decision by Congress is needed | State has not conducted a comparison, but national studies show CHIP coverage is more affordable and provides a broader set of benefits than those offered in QHPs | An estimate of the number of uninsured children is currently difficult to determine, but approx. 170,000 children would lose coverage because of cost issues | Yes | MAGI implementation; lowered premiums due to income/federal poverty level conversions; implemented streamlined application process w/new time completion standards; removed requirement for backpay of premiums; moving children from CHIP to Medicaid; coverage of dependents of public employees | Cost of family coverage should be the defining criteria for accessing subsidized exchange coverage; permit federal exchange subsidies for anyone under 400% FPL, regardless of ESI offer. Change Vaccines for Children rules to match Medicaid rules. Consider expanding premium assistance models for families to purchase ESI as an alternative to CHIP to keep families on same coverage. If Congress ends CHIP, requirement for Medicaid to cover children up to 138% FPL should be removed or enhanced federal match for these children should be continued. |
| HI | Yes, for no less than 2 years, and preferably 10 years | CHIP in HI provides full Medicaid benefits, including EPSDT; also CHIP has no cost sharing | N/A, Medicaid expansion CHIP program only | No | New eligibility system and application, and other changes such as provider enrollment and screening | Provide full funding to states for outreach, and increase funding for public health agencies to incorporate health coverage tracking for younger children. Extend the enhanced provider reimbursement in Medicaid, expand provider eligibility to other provider types, and apply these initiatives to all CHIP programs, regardless of program type. |
| ID | Yes, 4 years, as a transition period to allow for issues related to the affordability and adequacy of QHP coverage for children to be addressed | CHIP enrollees in ID receive the same benefits as children in Medicaid, including EPSDT and other benefits typically not available in QHPs or ESI (e.g. case management for children w/special health care needs, dental care, hospice, and enabling services, etc.); CHIP cost sharing is much lower than QHPs or ESI. | No estimates available | No | MAGI implementation; moving children from CHIP to Medicaid; also extensive changes to eligibility system | CHIP should be designed to “look like an insurance plan (rather than an entitlement plan) by removing entitlement assurances like EPSDT and non-emergency medical transportation.” Parents should have option of choosing between premium subsidies on the exchange or subsidies for ESI, to improve continuity of care and keep families on the same plan. |
| IL | Yes, 5 years, because likely that a significant number of families would forgo coverage if CHIP is eliminated | CHIP offers more robust benefits, and more affordable cost sharing than QHPs; fundamental difference in services is the offering of EPSDT in CHIP; letter outlines differences in cost sharing between CHIP and QHPs | References that it would likely be a significant number because of higher costs in QHPs and ESI | Yes | MAGI implementation | Allow use of CHIP funds to cover undocumented children |
| IN | Not explicitly mentioned, but state supports efforts to ensure children have access to affordable coverage and CHIP has served as an important source of coverage for children. Recommend timely action to avoid coverage gaps; but extension of CHIP funding should be considered in the context of addressing current ACA barriers to family coverage. | CHIP has monthly premiums and a small set of copays; children in the Medicaid expansion program receive Medicaid benefits, and those in the separate CHIP program have access to slightly fewer services; no detailed comparison of QHP to separate CHIP program, but Medicaid expansion CHIP provides services beyond the standard QHP plan | Not mentioned | Yes | Changes to CHIP mirror the overall Medicaid program changes required by the ACA; MAGI implementation and slight modifications to already established streamlined application process | Congress should work with states to assess alternative private coverage sources to determine the need for and design of CHIP moving forward. State is exploring premium assistance options to keep parents and children on the same plan using CHIP funds. If CHIP funding is extended, more flexibility should be given to states to administer the program, ease coordinatation with the marketplace, and target CHIP to the lowest income children. Request MOE be lifted to provide more flexibility related to eligibility levels. Call for ACA repeal and replaced with legislation giving families more private market coverage options. |
| IA | Yes, at least 2 years until alternative policy options can be fully considered; while an alternative for CHIP enrollees could be subsidized marketplace coverage, policy changes such as addressing the family glitch will need to occur. | Benefits in IA’s separate CHIP program are roughly comparable to QHP coverage, although benefits in the Medicaid expansion program would be superior to QHPs as it would include EPSDT. In both programs the cost sharing would be much lower than in QHPs | Not mentioned | Yes | MAGI implementation | Streamline and simplify federal eligibility policies of various programs, which currently make it difficult for families to maintain coverage through one source. Value of CHIP “can be less clear” with new ACA coverage options, which introduced inefficiencies due to families being on different plans. MOE requirements should be modified to allow state flexibility. Accountable care models show promise in improving health outcomes, and IA’s State Innovation Model test is intended to expand across greater segments of the population, including CHIP. Also, enhancing partnerships with public health could help promote healthy behaviors among families. |
| KS | Yes, 5 years, for budgeting and planning purposes and because of higher cost and less robust benefits for families in QHPs or ESI | KS’ CHIP only charges premiums for higher income families, and has no deductibles or copays; benefit coverage is same in both Medicaid and CHIP, including EPSDT, so it is a very rich coverage package that could not be matched by commercial insurance | Can be assumed that most of the non-premium paying children may become uninsured if CHIP is not extended | No | MAGI implementation; moving children from CHIP to Medicaid; now applying 3 month maximum non-payment penalty; reduced waiting period from 8 to 3 months | Recommend giving states more flexibility in program design, streamline waiver process, encourage flexibility in program development; enact federal policy addressing beneficiary overpayments and allow options for repayment of overpayment |
| KY | Yes, until all KY families’ income no longer necessitates need for assistance (no time frame specified) | Kynect adopted KCHIP vision and dental package, so packages are more comparable; however KCHIP cost sharing is very minimal compared to QHPs, only copays | Estimate about 50,000 children would lose coverage if CHIP not extended | Yes | MAGI implementation; removed five-year waiting period for lawfully residing immigrant children; added substance abuse treatment services; amended cost sharing requirements; eliminated 6 month waiting period | Recommends fixing family glitch |
| MD | Yes, strongly recommend extension of CHIP funding (no time frame specified); mentions that it would be very helpful to know about the extension of funding by 7/1/15 | MD’s CHIP program has no cost sharing, and enrollees also receive EPSDT | N/A, Medicaid expansion CHIP program only | No | MAGI implementation; new ways for families to apply for coverage | Bonus payments have been helpful and should be continued, along w/Express Lane Eligibility; recommend Congress maintain enhanced federal matching funds but adjust allotment formula so there is a stable and predictable funding source for states. Significantly higher levels of state funding will be needed if federal funding for CHIP ends and state will need to continue covering enrollees through Medicaid at a reduced match rate. |
| MA | Yes, indefinite extension of CHIP funding; letter also notes that MOE demonstrates legislative intent to continue CHIP funding until at least 2019 | Premiums capped for families and are much lower than those in private plans; also there is no cost sharing for CHIP services in contrast to QHPs. Also scope of benefits in CHIP designed to meet children’s needs and some of these are not generally available in QHPs, such as early intervention services, behavioral health, special education evaluation services. Also CHIP has full dental benefits, whereas in exchange families must buy stand-alone dental plans and cost may be prohibitive. | No specific estimates, but mention that if federal funding ends anticipate many children would become uninsured because of the cost differences between CHIP and QHPs | Yes | MAGI implementation; updated waiting period rules for children with unpaid premiums; extended hospital presumptive eligibility to individuals eligible under CHIP unborn child option; eliminated 6 month waiting period for children 200-300% FPL; also CHIP unborn child option previously only provided pregnancy related services, but now receive full MassHealth Standard benefits | Federal funding to support outreach efforts are very helpful; recommend additional administrative simplification policies and also continuing the performance bonus program, but allow for bonuses to be given to states with smaller percentages of growth in coverage. Support continued emphasis on care quality. Letter also notes that in MA, CHIP provides premium assistance to allow families to enroll children in ESI, and CHIP children are exempted from premiums if they have a parent enrolled in a QHP who is receiving tax credits. |
| MI | Yes, for at least 5 years to allow for continuity of coverage for children; would prefer action within next few months due to state budgeting needs | MI CHIP benefits are based on employer coverage, and are comparable to large employer or QHP coverage, with the exception of one key difference, that on the exchange families must purchase a stand-alone dental plan, which they may not opt to do. Substantial differences in cost sharing, which could be significant for children w/special health care needs | Not mentioned | Yes | No changes needed in administering CHIP; focused on coordination between programs, using CHIP online application as a model | No specific recommendations but would consider suggestions to improve health outcomes for children |
| MN | Yes (no time frame specified) | Benefits and services are modeled after Medicaid; no cost sharing | Not mentioned, just noted that extending CHIP will help avoid increasing uninsurance for children | No | MAGI implementation, electronic application processing | Recommend lifting or raising the cap on special health initiatives and other forms of child health assistance (currently limited to 10% of CHIP program expenditures) |
| NV | Yes, at least 4 years, to align w/MOE and to allow states time to plan for addressing children’s needs; letter also notes the increased state costs in the Medicaid expansion program if CHIP funding ends | NV implements the Medicaid benefit plan, which includes behavioral health rehabilitative supports, dental and vision care, and long term services and supports. Cost sharing in CHIP is much lower than in QHPs. | Approx. 15,000 children would be at risk of losing coverage | No | Consolidated eligibility process into one division, aligned Medicaid and CHIP policies where possible, which included eliminating 6 month waiting period | Any changes to simplify enrollment should be aligned with federal eligibility audits. Letter notes that there should be a focus on developing the health care workforce, federal support for states to expand health outcome data gathering. |
| NH | Yes, until at least 2019 to align w/MOE; letter mentions the increased state cost of having to continue to cover children under Medicaid at a reduced match rate; recommends Congress address issue as soon as possible due to state budgeting issues | Benefits and services are modeled after Medicaid, with no cost sharing; families would face higher out of pocket costs in the marketplace, especially for children with special health care needs; also certain services in CHIP are limited or not covered in the marketplace, such as dental, audiology, non-emergency medical transportation and EPSDT | N/A, Medicaid expansion CHIP program only | Yes | MAGI implementation | Focus on ACA issues such as the family glitch, and on issues related to the affordability, accessibility and appropriateness of QHPs for children. An analysis should be done of the impact on health outcomes if children are moved to the marketplace. |
| NM | Not explicitly mentioned, but notes that until marketplace has time to mature to ensure a streamlined process for families to access coverage, CHIP and the accompanying federal funding will remain an important coverage option. Letter also notes that the MOE should not apply if federal funding is reduced or eliminated. | CHIP in NM is an extension of Medicaid, and benefits include EPSDT; differences compared to QHPs are most notable in terms of dental, vision, and psychiatric care. Copays in CHIP are minimal and much lower than in QHPs | N/A, Medicaid expansion CHIP program only | No | MAGI implementation and streamlined application and renewal processes; also creation of category of CHIP for children who lose Medicaid coverage due to MAGI | Encourage Congress to be innovative and flexible in developing any strategies; NM has implemented a range of enrollment simplification measures (such as presumptive eligibility, continous eligibility). Congress should assess and streamline the range of coverage options for families. |
| NY | Yes, 4 years, to allow for exchange to operate for a time | CHIP has monthly premiums based on income, but no deductibles or copays; child-only plans on marketplace are considerably more costly (letter does not mention differences in benefits) | No specific estimates, anticipates many children would become uninsured if CHIP ends because of the cost differences between CHIP and QHP | No | MAGI implementation and some changes to more closely align with Medicaid eligibility rules; also eligibility determinations now conducted by state marketplace | Performance bonuses have been helpful and should be continued. If decision is made to not continue CHIP, states should receive at least 12 months lead time in order to plan and avoid children becoming uninsured. |
| NC | Yes (no time frame specified) | NC mandates that separate CHIP program benefits be equivalent to Medicaid benefits (with a few exceptions); minimal cost sharing; letter includes a table comparing CHIP cost sharing to ESI and a silver marketplace plan to highlight differences | Estimate that based on enrollment statistics, 80,000 children would become uninsured | No | MAGI implementation; children moving from CHIP to Medicaid | Increased state flexibility in overall design and implementation of health care delivery systems and federal funding streams. While there might be comparable benefits in the marketplace, out of pocket expenses likely would be prohibitively expensive for families in QHPs; funding CHIP would be an important investment in children’s health. |
| ND | Not explicitly mentioned, though 2015-17 state budget request assumes continued federal CHIP funding; funding decision as soon as possible would be appreciated; notes the success of the program and how it has been supported by policymakers | Letter indicates information is not available | Letter indicates no estimates available | No | MAGI implementation and covering children losing eligibility for Medicaid due to MAGI in CHIP. Also, no longer allowing three-year average of income for self-employed and removal of 6 month waiting period | Alignment of federal policies could strengthen enrollment efforts, such as consistent guidelines across economic assistance programs for determining family/household income |
| OH | Not explicitly mentioned, but notes states need clarity about funding soon for budgeting; lower Medicaid match rate has significant budget effect for state | CHIP children have access to all Medicaid benefits including vision, dental, behavioral health services, and EPSDT; also no cost sharing | N/A, Medicaid expansion CHIP program only | No | No changes needed in administering CHIP | Not mentioned |
| OK | Yes, 4 years, to address issues such as the family glitch and provide continuity of coverage; Congress should take immediate action due to state budgeting and planning purposes | Majority of SoonerCare CHIP children are enrolled in Medicaid/CHIP combination program and receive comprehensive benefits including non-emergency medical transportation, dental and vision care, offered within Medicaid cost sharing limits. In contrast, premiums for child-only plan on exchange (without dental and vision) range from $192-$252/month. | Not mentioned | Yes | MAGI implementation resulting in significant modifications to enrollment system; overall determination process is more complex; also moving children from CHIP to Medicaid | Flexibility for state innovation and reward efforts through incentive programs like the performance bonus program; support quality measurement and improvement; reduce the burden on states by extending use of CHIP allotments to cover previously Medicaid-eligible children and create program efficiencies by establishing and maintaining a contingency fund |
| OR | Yes, at least for 4 years, to address affordability and adequacy of coverage issues | Services in CHIP that are not available in QHPs and usually not typical in ESI are: dental, vision (in CHIP, these services are not limited), hearing exams and aids, physical and speech therapies (QHPs have more limits), non-emergency medical transportation (not available through QHPs), and enabling services (e.g. sign language or translation); also no cost sharing in CHIP and families would probably not be able to afford QHP costs or overcome transportation barriers | No precise estimates on number of children that might become uninsured if CHIP ends, but estimate that as many as half of kids in CHIP would become uninsured | Yes | A few indirectly related changes have been made; transitioning the CHIP premium assistance commercial insurance option for children 200-300% FPL to direct coverage; moving children from CHIP to Medicaid | OR’s success in reducing the number of uninsured children is due to expansion of income eligibility, use of Supplemental Nutrition Assistance Program data, use of 12 month continuous eligibility, and use of premium subsidies. Also efforts to better integrate and coordinate care have helped to improve health outcomes, and so encourage Congress to allow these kinds of flexibilities. |
| PA | Yes, 4 years, to align w/MOE; Congress should act promptly, because both states and families need certainty | Graduated CHIP cost sharing is limited; marketplace premiums and cost sharing would likely be substantially above the 5% CHIP cap; CHIP covers 79% of child-specific services, while QHPs only cover 50%; it is difficult to compare between benefits between CHIP and QHPs, if child in CHIP is approaching a benefit limit, the child would likely be eligible for Medicaid through a special medical assistance program for children w/special health care needs | More than 157,200 children would need to find other coverage | No | MAGI implementation, combined rules engine w/Medicaid; preparations for moving children from CHIP to Medicaid; new application and renewal form; coordinating w/federal marketplace to transfer account info; transitioning to income tax rules was challenging for a means tested program; state is also evaluating how the program is administered through contractors; also not clear if the buy-in program constitutes minimum essential coverage. | Policy changes should align with Healthy Pennsylvania program and focus on affordability, improving access, and quality. Recommend that there should be options for providing additional premium assistance for ESI, allowing states to develop affordable premium structures that have consumer engagement policies and focus on healthy behaviors; also there should be a focus on retaining providers, such as through loan forgiveness programs. |
| RI | Yes, at least 4 years, to align w/MOE; Congress should act as soon as possible to allow states to maintain coverage and in consideration of state budget cycles | No QHPs currently available provide comparable coverage to CHIP, in terms of both scope of benefits and cost sharing; CHIP enrollees have no cost sharing. Differences in benefits are most notable in terms of dental services and EPSDT being offered in CHIP. | Not mentioned | No | Loss of state authority to claim CHIP funds for coverage provided to families under 133% FPL, resulting in lowering eligibility levels for parents and shifting them to marketplace; MAGI rules and streamlined application process; enhanced consumer support services; eliminated premiums Jan. 2014 to reduce likelihood of premium stacking and provide incentives for parents of RIte care eligible children to enroll in QHPs | Allocating more resources to states to expand services in high demand (e.g. dental) and/or consider providing states with additional flexibility to tailor benefit packages and develop new delivery and payment approaches. Significantly higher levels of state funding will be needed if CHIP ends and state required to continue covering them through lower Medicaid match rate. The 23% increase in CHIP federal match should be maintained. |
| SC | Yes, at least 4 years to align w/MOE | Integrated Medicaid/CHIP program: Medicaid and CHIP eligible children receive seamless coverage, same benefits (including EPSDT) and provider networks. | N/A, Medicaid expansion CHIP program only | No | MAGI implementation | If CHIP funding not extended, losing enhanced match would have significant budget effects; state successfully reduces number of uninsured children crediting integrated Medicaid/CHIP program and Express Lane Eligibility; recommends improved coordination and standardization between federal needs-based programs to promote efficiency. |
| SD | Yes, should be extended indefinitely, and Congress should act as soon as possible. Having to cover children in the Medicaid expansion program at a reduced federal match rate would involve significant cost to the state and loss of CHIP funding would have a state general fund impact in terms of administrative costs for eligibility determination staff. Also concerned about children in separate CHIP program losing coverage. | CHIP acts as a Medicaid look-alike program, and includes EPSDT; also SD’s CHIP program has no cost sharing and QHP coverage could be unaffordable in comparision | Not mentioned | Yes | MAGI implementation and transition to modernized application process | Ability of federal marketplace to verify Medicaid and CHIP eligibility must be resolved to avoid children being “stuck” in determination process. State has seen a large shift of children from CHIP to Medicaid, and this decreased CHIP enrollment has resulted in a cost shift to the state. Facing administrative burden related to exchanging application info w/federal marketplace. |
| TN | Yes, for at least 2 years until alternative policy options can be fully considered; and if current level of federal funding ends, MOE requirement should end; extension of CHIP should be carefully considered within the context of coverage options | Children will have access to alternative coverage options that offer comparable services in the future, but do not yet; CHIP benefits are roughly comparable to those offered by QHPs. However cost sharing is lower in CHIP than in QHPs; no premiums or deductibles in CHIP and copays are modest; actuarial value of CHIP plan is 90-95%, which is slightly higher than platinum plan | Not mentioned | Yes | Eliminated buy in program for families above 250% FPL as of 1/1/14; also eliminated three month waiting period | Policies should be targeted to streamlining and simplifying eligibility policies; currently there is duplication of programs and coverage silos; overall federal health policy and program eligibility must be simplified. If comparable, affordable QHP coverage is available, it should be considered as an option if CHIP is not continued. |
| TX | Yes (no time frame specified), since currently no other viable option for covering CHIP enrollees; Congress should act soon to allow for more predictability and stability for states | Letter does not compare benefits or cost sharing to QHPs or ESI, but briefly describes CHIP benefits and cost sharing | Not mentioned | No | Notes that a significant number of children moved from CHIP to Medicaid | Letter notes unique characteristics of CHIP, such as that it functions similarly to a block grant and states have more flexibility than in Medicaid in terms of program design; Congress should consider implementing effective CHIP initiatives in Medicaid. Also letter states that the ACA results in greater overall costs to operate Medicaid and current state and federal Medicaid expenditures are unsustainable. |
| UT | Yes, for at least 2 years, preferably 4 years, to allow time to address marketplace issues and availability of subsidies for families; Congress should act soon because state budget decisions need to be made by mid-March 2015, and states need time to transition families, adjust data systems and ensure continuity of care for children | UT’s CHIP benefits are benchmarked against largest HMO and therefore are similar to benefits offered in silver QHP plans with a few exceptions. CHIP families will experience greater costs in the marketplace and for families facing severe medical issues, QHP out of pockets costs could easily exceed CHIP’s cost sharing limits | No specific estimates, but mention that if federal funding ends anticipate many children would become uninsured | Yes | Eligibility levels in Medicaid changed (CHIP Plan A was eliminated, which was for children 0-100% FPL) along with the removal of the Medicaid asset test; this resulted in a significant reduction in the number of children in CHIP. Since the children transferred to Medicaid are eligible for enhanced federal matching funds, this results in a more complex tracking process; ACA also removed flexibility in eligibility determination | Increased flexibility for states, better options to address churn, possibly by use of CHIP funding to provide premium subsidies to keep families in marketplace and allow families to be on the same plan and minimize disruption in services. Issues to address: 1) interface w/federal marketplace 2) resolution of family glitch 3) CHIP needs ongoing funding or MOE must be modified for flexibility; 4) allow states to use the commercial market w/premium subsidies as the primary service delivery system for CHIP. State administers benefits through contracts w/private entities that will be significantly impacted by any change. At a minimum, states should know about any funding or program changes at least 6 months in advance. |
| VT | Yes, 4 years; in absence of federal funding, state would not be able to supplement the full loss of the enhanced CHIP match; also increased financial burden on state could result in the elimination of services for state-funded programs outside of CHIP | Letter notes that benefits offered through the state’s exchange are comparable to the CHIP benefit. However there are much higher out of pocket costs for QHP coverage compared to CHIP, which could result in financial hardship for families if CHIP is eliminated | Potential for over 7,000 to become uninsured | No | MAGI implementation and transition to modernized application process; also moved administration of CHIP under the Medicaid state plan; benefits through CHIP continue to be same as those in Medicaid | Incentives and funding for outreach are important. Recommends incentives for increasing evidence-based practices in primary care for children; support for analyzing pediatric quality measures and linking quality measures to clinical decision support. Also recommends federal policy requiring universal coverage of children; VT is moving in the direction of universal coverage and should receive some federal support for these reform efforts. |
| VA | Yes, 4 years, at the enhanced 23% increase in CHIP federal match (have already budgeted for this); 4 years allows time to evaluate marketplace coverage for children; will not be able to continue separate CHIP program with state funds only and concerned about funding Medicaid expansion program; also concerned that marketplace does not have child-specific benefit plans, the exclusion of the cost of stand-alone dental in calculation of subsidies, and overall OOP costs in marketplace as well as the family glitch | Benefits modeled after state employee health insurance benefits, but tailored to needs of children and include comprehensive dental including medically necessary orthodontia, early intervention services, school health services, substance abuse treatment services and non-traditional behavioral and psychiatric services; CHIP has no premiums and copays are very affordable and cost sharing would be much higher in QHPs | Approx. 104,000 children would be at risk of becoming uninsured | Yes | Early adopter of MAGI, when launched new eligibility and enrollment system in October 2013; also in July 2014 removed the four month waiting period; also in process of submitting a SPA to allow for dependents of state employees to enroll in CHIP beginning 1/1/15 | Guarantee 12 month continuous coverage, eliminate substitution requirements, allow for coverage of dependents of public employees without additional steps. Improve alignment with marketplace so there are no coverage gaps, improve electronic verification systems, allow coverage of medically-necessary Institutions for Mental Diseases placements, and allow enhanced federal matching funds for production of outreach materials in languages other than English. Concerns about children in separate CHIP becoming uninsured if CHIP funding ends and about funding for the Medicaid expansion CHIP program at the lower Medicaid match rate. |
| WA | Yes, for at least 2 years as recommended by the Medicaid and CHIP Payment and Access Commission, although additional two year extension to 2019 would give more time for exchanges and health networks to mature; urge Congress to act no later than March 2015 for the state to avoid costs associated with eliminating the program | CHIP benefit package is same as offered under Medicaid, with an actuarial value of 100%–more than 25% higher than silver level plan in exchange. CHIP has no cost sharing other than a $20-$30 monthly premium; also richer benefits including EPSDT, health homes, personal care services, tobacco cessation counseling, targeted case management, nursing facility/long term care, intermediate care, and facilities for the developmentally disabled | Letter mentions that if CHIP funding is not continued, 12,000 unborn children/year would not be covered | No | Successful state exchange, where families can apply for full range of IAP options; real time MAGI eligibility decisions have improved access to care | Support establishment of a unified set of pediatric quality measures; could encourage states to pursue improved health outcomes by providing enhanced federal funding (similar to enrollment performance bonuses). Also support continuation of grant funds for pediatric institutions to focus on research related to improved health outcomes. |
| WV | Yes, 4 years, to allow for further marketplace development and stabilization and potentially more affordable choices; Congress should act early in 2015 to allow time to close CHIP enrollment 6 months in advance | WVCHIP has modest cost sharing; letter provides comparison of costs in QHPs and notes the QHP deductibles as a barrier for families, especially for dental services. QHPs would also not offer the same services as CHIP and QHPs were not designed to be pediatric-centered | Estimate that more than half of enrollees would drop enrollment due to QHP affordability issues | Yes, but only in section discussing challenge of determining future state costs due to number of uninsured if CHIP ends | MAGI implementation | Express Lane Eligibility a permanent option or incentivizing renewal at time of Supplemental Nutrition Assistance Program enrollment to promote administrative efficiency, continuity of care, and lower caseloads. Incentives should be aligned with continued lowering of the children’s uninsured rate. In spring 2014 WV surveyed CHIP households and found more than half of respondents indicated they could only pay $50/month in premiums, much less than QHPs. Ultimate goal is to achieve a better marketplace/public coverage fit for families through whatever means is best. Continued funding to support state efforts to improve quality measurement. |
| WI | Yes, at least for 4 years, to align w/MOE; states need predictable funding levels in the coming years | CHIP benefits are more generous in particular for dental, prescription drugs, mental health, transportation, and long term care; also much lower cost sharing requirements in CHIP than QHPs or any other commercial coverage | Not mentioned | No | MAGI implementation; also as of 4/1/14, state began providing Medicaid Standard Plan benefits to all adults and children in the Medicaid and BadgerPlus program, including CHIP funded children; also state is processing CHIP applications from the federal marketplace | Recommend providing states with flexibility in program design |
| WY | Yes (no time frame specified), since majority of CHIP children would not have appropriate options in the marketplace and likely would not be eligible for subsidized coverage due to family glitch | No premiums or deductibles in CHIP and only minimal cost sharing, as compared to marketplace where there is significant cost sharing; CHIP also includes dental, which is only available in the marketplace through stand-alone dental plans | No specific estimates, but mention that if federal funding ends anticipate a significant number of children would become uninsured | Yes | MAGI implementation and children moving to Medicaid; new integrated eligibility system and new verification requirements; also administration of eligibility and enrollment processes shifted from in-house to customer service center | No policy recommendations related to improving enrollment of eligible children |
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Notes:
[1] A large number of states requested that Congress should extend federal CHIP funding for four years to align with the ACA’s maintenance of effort (MOE) provision for children. The MOE provision as it relates to children’s coverage requires states to maintain Medicaid and CHIP eligibility levels for children that were in place as of March 23, 2010 through September 30, 2019.
[2] Each state has the option to cover its CHIP population within its Medicaid program, design and structure a separate CHIP program, or establish a combination program using both options. States that operate Medicaid expansion CHIP programs must follow Medicaid rules, including providing all Medicaid covered benefits to enrolled children. In separate CHIP programs, states have substantial flexibility in designing CHIP benefit packages within broad federal guidelines. Some states offer Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services in their CHIP programs; the EPSDT benefit includes preventive and screening services, along with vision, dental and hearing services, and also includes additional services deemed medically necessary.
[3] Responses to this question vary by state in large part due to how the state’s CHIP program is structured. As a result of MOE, if federal CHIP funding runs out, states that operate Medicaid expansion CHIP programs must continue to provide coverage for these children with Medicaid funds, at the lower federal Medicaid match rate. However individuals enrolled in separate CHIP programs will likely need to seek coverage through health insurance marketplaces if federal CHIP funds are not available. Also, in FY2016, the federal match rate for CHIP will increase by 23 percentage points, which will affect the rate at which states exhaust their federal CHIP funding. For further information, see this NASHP fact sheet.
[4] According to IRS regulations, if an employee has access to individual employer sponsored insurance that is less than 9.5% of the employee’s household income it is deemed affordable and the household is ineligible for exchange subsidies. This is true even if coverage for the employee’s dependents or family is higher than 9.5% of the household income because only the costs for the employee are considered. This is sometimes referred to as the “family glitch.” Due to this provision, families with low- to moderate-income may not be able to afford either the employer sponsored insurance or exchange coverage without the subsidy.
[5] Prior to the ACA states could choose to cover children ages 6-19 with family income below 133% of the FPL in separate CHIP programs. The ACA contains a provision that expands Medicaid eligibility levels for all children up to 133% FPL, and as a result some states were required to move children from CHIP to Medicaid. For more information, see this brief from the Kaiser Family Foundation.
This chart was compiled with support from the David and Lucile Packard Foundation.
Chart produced by Anita Cardwell
[2] Each state has the option to cover its CHIP population within its Medicaid program, design and structure a separate CHIP program, or establish a combination program using both options. States that operate Medicaid expansion CHIP programs must follow Medicaid rules, including providing all Medicaid covered benefits to enrolled children. In separate CHIP programs, states have substantial flexibility in designing CHIP benefit packages within broad federal guidelines. Some states offer Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services in their CHIP programs; the EPSDT benefit includes preventive and screening services, along with vision, dental and hearing services, and also includes additional services deemed medically necessary.
[3] Responses to this question vary by state in large part due to how the state’s CHIP program is structured. As a result of MOE, if federal CHIP funding runs out, states that operate Medicaid expansion CHIP programs must continue to provide coverage for these children with Medicaid funds, at the lower federal Medicaid match rate. However individuals enrolled in separate CHIP programs will likely need to seek coverage through health insurance marketplaces if federal CHIP funds are not available. Also, in FY2016, the federal match rate for CHIP will increase by 23 percentage points, which will affect the rate at which states exhaust their federal CHIP funding. For further information, see this NASHP fact sheet.
[4] According to IRS regulations, if an employee has access to individual employer sponsored insurance that is less than 9.5% of the employee’s household income it is deemed affordable and the household is ineligible for exchange subsidies. This is true even if coverage for the employee’s dependents or family is higher than 9.5% of the household income because only the costs for the employee are considered. This is sometimes referred to as the “family glitch.” Due to this provision, families with low- to moderate-income may not be able to afford either the employer sponsored insurance or exchange coverage without the subsidy.
[5] Prior to the ACA states could choose to cover children ages 6-19 with family income below 133% of the FPL in separate CHIP programs. The ACA contains a provision that expands Medicaid eligibility levels for all children up to 133% FPL, and as a result some states were required to move children from CHIP to Medicaid. For more information, see this brief from the Kaiser Family Foundation.
This chart was compiled with support from the David and Lucile Packard Foundation.
Chart produced by Anita Cardwell
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For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
