Medicaid, SCHIP, and Federal Authority³

HIFA Waiver - In November 2004, the Centers for Medicare and Medicaid Services (CMS) approved Idaho's Health Insurance Flexibility and Accountability (HIFA) waiver application to create the Idaho Access Card-a program intended to increase private health insurance affordability for low-income individuals. To accomplish this, Idaho Medicaid offers premium assistance to cover children in families whose gross annual income is above mandatory Medicaid levels but below 185 percent FPL.

Idaho officials also submitted a Title XXI state plan amendment to create a separate State Children's Health Insurance Program-CHIP-B-in conjunction with its HIFA waiver proposal. The CHIP-B program was approved in June and implemented in July 2004, and is available to children whose parents earn incomes ranging from 150 to 185 percent FPL. Under the Idaho Access Card program, parents of children who qualify for SCHIP-funded coverage have a choice between enrolling their children in SCHIP or the premium-assistance program. The latter allows parents to add their eligible dependents to their existing employer-based insurance plan (or to an individual insurance policy) and have the state pay up to $100 toward the amount of the dependent's premium.

The Idaho Access Card program also offers premium assistance to adults whose gross annual income is below 185 percent FPL and who are employed by an Idaho small business, or who are the spouse of an employee. The program is capped at 1,000 adults; it began enrollment in July 2005. As of fall 2006, approximately 300 adults were enrolled in the program.

In 2006, Idaho undertook a Medicaid reform initiative. Idaho 's separate SCHIP program became a Medicaid look-alike and three Benchmark Benefit packages were approved by CMS under authority of the Deficit Reduction Act (DRA) of 2005. This allowed the state to split the Medicaid and SCHIP populations into three major benefit plans:

• Low-income children and working-age adults: the Medicaid Basic Plan
• Individuals with disabilities or special health needs: the Medicaid Enhanced Plan
• Elders or those otherwise dually eligible for Medicaid and Medicare who are enrolled in certain Medicare Advantage plans: the Medicare-Medicaid Coordinated Plan

Upon enrollment or annual re-enrollment into Medicaid or SCHIP, enrollees are placed into the Plan that best fits their health needs. Enrollees are given a health screening and placed into a primary care case management system (PCCM). Idaho has three different systems of triggers that move an individual into the Enhanced Plan: physician diagnosis of special health needs; utilization of mental health services up to the limits in the Basic Plan; or receiving certain other forms of assistance from the Idaho Department of Health and Welfare. Any one of these three triggers would move the enrollee into the Enhanced Plan. Both of these benefit packages (Medicaid Basic Plan and Medicaid Enhanced Plan) remain fee for service.

The final benefit plan and enrollment category is for persons eligible for both Medicare and Medicaid who are enrolled in participating Medicare Advantage plans. In an effort to coordinate services with Medicare Part D, Idaho has created a partially capitated system with major insurance carriers that provide Part D services. Idaho will pay a capitated rate per enrollee to carriers for integrated services in addition to Medicare-excluded drugs, and will also provide fee for service "wrap-around" benefits. The new coordinated plan will begin in Spring 2007.

Reinsurance

The state of Idaho operates reinsurance pools for both the small group and the nongroup (individual) markets. In the small group market, the insurer is responsible for the first $13,000 worth of claims as well as 10 percent of the next $12,000 in the basic plan, $87,000 in the standard plan, and $130,000 in the catastrophic plan. Above those amounts, the pool pays claims up to maximums of $25,000 for the basic plan, $100,000 for the standard plan and $200,000 for the catastrophic plan. Carriers determine whether they want to reinsure individuals, dependents, or small groups but all carriers participating in the health insurance market are assessed to cover loses incurred by the pool so, in essence, all carriers participate.

In the nongroup (individual) market, the state operates the Individual High-Risk Reinsurance Pool that reinsures five guaranteed issue products and sets premiums for the guaranteed issue products. The primary insurer is responsible for the first $5,000 in claims and 10 percent of the next $25,000. All claims exceeding $25,000 are covered by the reinsurance pool, up to the lifetime maximums of the guaranteed issue products.

High-Risk Pool  

The Idaho Individual High-Risk Reinsurance Pool became operational in 2001 and currently has an enrollment of approximately 1,400 individuals. In the nongroup (individual) market, the state operates the Individual High-Risk Reinsurance Pool that reinsures five guaranteed issue products and sets premiums for the guaranteed issue products. The primary insurer is responsible for the first $5,000 in claims, 10 percent of the next $25,000. All claims exceeding $25,000 are covered by the reinsurance pool, up to the lifetime maximums of the guaranteed issue products.

The pool is funded through premiums, a portion of the state premium tax, and, if necessary, an assessment on insurers. The premiums for the guaranteed issue products are between 125 percent and 150 percent of the rates applicable to standard risks. The Idaho High-Risk Pool functions differently than most state high-risk pools. Under Idaho 's program, all carriers who offer individual health insurance must also offer the Idaho Individual High-Risk Reinsurance Pool plans, as well as notify persons applying for individual coverage of these high-risk pool plans. Also see the description of the Reinsurance Pool in Reinsurance strategies.

Dependent Coverage

In March 2007, Idaho Governor C.L. "Butch" Otter (R) signed into law Senate Bill 1105 which expands the definition of 'dependent.' Under the new law, unmarried non-students can remain on their parents' insurance until the age of 21 and unmarried, financially dependent, full-time students can remain on parental insurance until the age of 25. Finally, unmarried children designated as disabled can remain a dependent for insurance purposes up until any age.

	Notes and Sources

Information presented in the profile was summarized in December 2006 from a review of state Web sites and reports, and through contacts with state officials. In most cases the profiles were reviewed by state officials; however, it is possible that states have implemented strategies that are not reflected in this profile.

¹ This overview provides a general description of state coverage levels under their Medicaid and SCHIP programs, including coverage through waivers, as of October 2006. Health Management Associates researched eligibility information from state web sites, data from state reports, and verified through contacts with state officials during the fall of 2006. This does not reflect the specific eligibility categories or requirements. This is not intended to be a substitute for eligibility information provided by each state. Individuals interested in applying for these programs should contact the state directly for specific eligibility requirements.

² As part of Idaho 's HIFA waiver, t he Idaho Access Card program also offers premium assistance to adults whose gross annual income is below 185 percent FPL and who are employed by an Idaho small business, or who are the spouse of an employee. The program is capped at 1,000 adults.

⁴ Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2005 and 2006 Current Population Survey.