Medicaid and SCHIP
States' Premium and Cost Sharing Requirements for Beneficiaries Gao ID: GAO-04-491 March 31, 2004Over 50 million low-income adults and children receive health insurance coverage through Medicaid and the State Children's Health Insurance Program (SCHIP). Federal law allows states to require beneficiary contributions, such as premiums and cost sharing (coinsurance, copayments, and deductibles), for at least some Medicaid and SCHIP beneficiaries. GAO was asked to (1) identify and compare states' Medicaid and SCHIP beneficiary contribution requirements for children, (2) identify states' Medicaid beneficiary contribution requirements for adults, and (3) determine the extent to which states' Medicaid and SCHIP beneficiary contribution requirements have changed since 2001. GAO surveyed Medicaid and SCHIP program offices in the 50 states and the District of Columbia about their beneficiary contribution requirements as of August 2003, including their requirements for specific population groups and for six selected services, such as inpatient hospital, physician services, and prescription drugs. For each population group covered, states were asked to indicate the portion of the group charged beneficiary contributions by selecting "all," "most," "some," or "none." GAO also interviewed officials of the Centers for Medicare & Medicaid Services (CMS) regarding the Medicaid and SCHIP statutory requirements for beneficiary contributions.
GAO's survey found that children were more likely to be subject to beneficiary contributions, specifically premiums and cost sharing, in SCHIP than in Medicaid. Overall, 26 states reported charging premiums for a portion of children--"some," "most," or "all"--in SCHIP, compared to 9 states in Medicaid. Twenty-five states charged cost sharing for some portion of children in SCHIP, compared to 6 states for Medicaid. States used copayments as the primary form of cost sharing for children. Most states that reported charging cost sharing applied copayment requirements to the six health care services. Most states reported requiring beneficiary contributions from adults enrolled in Medicaid. Twenty-five states charged premiums, generally charging portions of certain populations, such as adults with disabilities. Over 40 states charged cost sharing to most, if not all, adults, including those with disabilities, noninstitutionalized elderly persons, and parents. Copayments were the predominate form of cost sharing. States most frequently reported copayments for prescription drugs and physician services. From the beginning of their 2001 state fiscal years through August 1, 2003, 34 states reported increasing and 10 states reported decreasing the amount of beneficiary contributions required in Medicaid, SCHIP, or both. For the 33 states that provided information on the amount of increases, premium increases to existing requirements ranged from $2 a month to $39 a month. Other states added new premium requirements, some of which were as much as several hundred dollars a month. In most instances, reported copayment increases were generally limited to $5 or less. GAO asked CMS officials to provide technical comments on the statutory and regulatory information on Medicaid and SCHIP beneficiary contributions, which were incorporated as appropriate.
GAO-04-491, Medicaid and SCHIP: States' Premium and Cost Sharing Requirements for Beneficiaries
This is the accessible text file for GAO report number GAO-04-491
entitled 'Medicaid and SCHIP: States' Premium and Cost Sharing
Requirements for Beneficiaries' which was released on April 30, 2004.
This text file was formatted by the U.S. General Accounting Office
(GAO) to be accessible to users with visual impairments, as part of a
longer term project to improve GAO products' accessibility. Every
attempt has been made to maintain the structural and data integrity of
the original printed product. Accessibility features, such as text
descriptions of tables, consecutively numbered footnotes placed at the
end of the file, and the text of agency comment letters, are provided
but may not exactly duplicate the presentation or format of the printed
version. The portable document format (PDF) file is an exact electronic
replica of the printed version. We welcome your feedback. Please E-mail
your comments regarding the contents or accessibility features of this
document to Webmaster@gao.gov.
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed
in its entirety without further permission from GAO. Because this work
may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this
material separately.
Report to Congressional Requesters:
United States General Accounting Office:
GAO:
March 2004:
Medicaid and SCHIP:
States' Premium and Cost Sharing Requirements for Beneficiaries:
GAO-04-491:
GAO Highlights:
Highlights of GAO-04-491, a report to congressional requesters
Why GAO Did This Study:
Over 50 million low-income adults and children receive health insurance
coverage through Medicaid and the State Children‘s Health Insurance
Program (SCHIP). Federal law allows states to require beneficiary
contributions, such as premiums and cost sharing (coinsurance,
copayments, and deductibles), for at least some Medicaid and SCHIP
beneficiaries. GAO was asked to (1) identify and compare states‘
Medicaid and SCHIP beneficiary contribution requirements for children,
(2) identify states‘ Medicaid beneficiary contribution requirements for
adults, and (3) determine the extent to which states‘ Medicaid and
SCHIP beneficiary contribution requirements have changed since 2001.
GAO surveyed Medicaid and SCHIP program offices in the 50 states and
the District of Columbia about their beneficiary contribution
requirements as of August 2003, including their requirements for
specific population groups and for six selected services, such as
inpatient hospital, physician services, and prescription drugs. For
each population group covered, states were asked to indicate the
portion of the group charged beneficiary contributions by selecting
’all,“ ’most,“ ’some,“ or ’none.“ GAO also interviewed officials of the
Centers for Medicare & Medicaid Services (CMS) regarding the Medicaid
and SCHIP statutory requirements for beneficiary contributions.
What GAO Found:
GAO‘s survey found that children were more likely to be subject to
beneficiary contributions, specifically premiums and cost sharing, in
SCHIP than in Medicaid. Overall, 26 states reported charging premiums
for a portion of children”’some,“ ’most,“ or ’all“”in SCHIP, compared
to 9 states in Medicaid. Twenty-five states charged cost sharing for
some portion of children in SCHIP, compared to 6 states for Medicaid.
States used copayments as the primary form of cost sharing for
children. Most states that reported charging cost sharing applied
copayment requirements to the six health care services.
Most states reported requiring beneficiary contributions from adults
enrolled in Medicaid. Twenty-five states charged premiums, generally
charging portions of certain populations, such as adults with
disabilities. Over 40 states charged cost sharing to most, if not all,
adults, including those with disabilities, noninstitutionalized elderly
persons, and parents. Copayments were the predominate form of cost
sharing. States most frequently reported copayments for prescription
drugs and physician services.
States with Copayments for Selected Services and Populations, as of
August 1, 2003:
[See PDF for image]
[End of table]
From the beginning of their 2001 state fiscal years through August 1,
2003, 34 states reported increasing and 10 states reported decreasing
the amount of beneficiary contributions required in Medicaid, SCHIP, or
both. For the 33 states that provided information on the amount of
increases, premium increases to existing requirements ranged from $2 a
month to $39 a month. Other states added new premium requirements, some
of which were as much as several hundred dollars a month. In most
instances, reported copayment increases were generally limited to $5 or
less.
GAO asked CMS officials to provide technical comments on the statutory
and regulatory information on Medicaid and SCHIP beneficiary
contributions, which were incorporated as appropriate.
What GAO Recommends:
www.gao.gov/cgi-bin/getrpt?GAO-04-491.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Kathryn G. Allen at (202)
512-7118.
[End of section]
Contents:
Letter1:
Results in Brief:
Background:
Children Were More Likely to Be Subject to Beneficiary Contributions in
SCHIP than in Medicaid:
For Adults in Medicaid, Nearly Half the States Assessed Premiums and a
Majority Required Cost Sharing:
Thirty-Four States Increased and Ten States Decreased the Amount of
Beneficiary Contributions:
Agency Comments:
Appendix I: Service Utilization Rates for Low-Income Individuals:
Appendix II: Premium Requirements for Children in Medicaid and SCHIP,
by State, as of August 1, 2003:
Appendix III; Premium Amounts for Children in Medicaid and SCHIP, by
State, as of August 1, 2003:
Appendix IV: Copayment Requirements for Children in Medicaid and SCHIP,
by State, as of August 1, 2003:
Appendix V: Cost Sharing Amounts for Children in Medicaid and SCHIP, by
State, as of August 1, 2003:
Appendix VI: Premiums for Adult Populations in Medicaid, by State, as
of August 1, 2003:
Appendix VII: Premium Amounts for Adults in Medicaid, by State, as of
August 1, 2003:
Appendix VIII: Copayment Requirements for Adults in Medicaid, by State,
as of August 1, 2003:
Appendix IX: Cost Sharing Amounts for Adults in Medicaid, by State, as of
August 1, 2003:
Appendix XGAO Contact and Staff Acknowledgments:
GAO Contact:
Acknowledgments:
Tables:
Table 1: Common Health Care Cost Sharing Arrangements:
Table 2: Examples of Exceptions to Prohibitions on Premiums in
Medicaid, by Population Group:
Table 3: Medicaid Cost Sharing Limits:
Table 4: Federal Limits on Separate SCHIP Programs' Premium and Cost
Sharing for Children in Families with Income at or Below 150 Percent of
the Federal Poverty Level:
Table 5: States' Use of Premiums for Children in Medicaid and SCHIP, as
of August 1, 2003:
Table 6: States' Premium Charges for Children in Medicaid and SCHIP, as
of August 1, 2003:
Table 7: States' Use of Copayments for Children in Medicaid and SCHIP,
as of August 1, 2003:
Table 8: States' Use of Cost Sharing for Children for Six Services, by
Program and Service, as of August 1, 2003:
Table 9: States' Use of Cost Sharing Charges for Children in Medicaid
and SCHIP, as of August 1, 2003:
Table 10: States' Use of Premiums for Adults in Medicaid, by Population
Group, as of August 1, 2003:
Table 11: States' Premium Charges for Adults in Medicaid, as of August
1, 2003:
Table 12: States' Use of Copayments for Adults in Medicaid, as of
August 1, 2003:
Table 13: States' Use of Copayments for Adults for Six Services, by
Population Group, as of August 1, 2003:
Table 14: Changes in States' Premiums for Children in Medicaid and
SCHIP, State Fiscal Year 2001 through August 1, 2003:
Table 15: Changes in States' Copayments for Children in Medicaid and
SCHIP, State Fiscal Year 2001 through August 1, 2003:
Table 16: States' Changes to Premiums for Adults in Medicaid, State
Fiscal Year 2001 through August 1, 2003:
Table 17: States' Changes to Cost Sharing for Adults in Medicaid, State
Fiscal Year 2001 through August 1, 2003:
Table 18: Percentage of the Population Below 200 Percent of the FPL Who
Used Selected Services during 2000:
Table 19: Average Utilization Rates for Individuals Below 200 Percent
of the FPL Who Used Selected Services during 2000, by Population:
Figures:
Figure 1: States' Use of Premiums and Cost Sharing for Adults in
Medicaid, as of August 1, 2003:
Figure 2: States' Use of Cost Sharing for Adults in Medicaid, as of
August 1, 2003:
Abbreviations:
ADL: activity of daily living:
AHRQ: Agency for Healthcare Research and Quality:
CMS: Centers for Medicare & Medicaid Services:
ER: emergency room:
FPL: federal poverty level:
IADL; instrumental activity of daily living:
HHS: Department of Health and Human Services:
MEPS: Medical Expenditures Panel Survey:
SCHIP: State Children's Health Insurance Program:
United States General Accounting Office:
Washington, DC 20548:
March 31, 2004:
The Honorable John D. Dingell:
Ranking Minority Member:
Committee on Energy and Commerce:
House of Representatives:
The Honorable Sherrod Brown:
Ranking Minority Member:
Subcommittee on Health:
Committee on Energy and Commerce:
House of Representatives:
The Honorable Henry A. Waxman:
Ranking Minority Member:
Committee on Government Reform:
House of Representatives:
Over 50 million low-income adults and children receive health insurance
coverage largely through two federal-state programs--Medicaid and the
State Children's Health Insurance Program (SCHIP). Medicaid generally
covers low-income families and individuals who are aged or disabled,
while SCHIP provides health care coverage to children in families whose
incomes, while low, are above Medicaid's eligibility requirements.
Health insurance often includes beneficiary contribution requirements
of some type, which require the insured individual to pay some portion
of medical expenses. The most common types of beneficiary contribution
requirements are premiums--a payment required for insurance coverage
for a given period of time--and cost sharing--an out-of-pocket payment
for part of the cost of services used by a beneficiary. Medicaid and
SCHIP limit the use of beneficiary contribution requirements. The
Medicaid statute limits the amount of the premiums that can be charged
and prohibits states from instituting cost sharing provisions for
certain categories of individuals, such as children under age 18 and
pregnant women. Under SCHIP, federal law caps the amount of beneficiary
contributions that can be charged for certain children and exempts
preventive services for certain children from any cost sharing. States
must seek authority from the federal government to waive these
requirements to implement beneficiary contributions beyond Medicaid and
SCHIP limits.
Opinions differ over the extent to which beneficiary contributions are
appropriate and useful tools for managing health care utilization among
low-income populations. Premiums are sometimes viewed as promoting
personal responsibility by having the beneficiary participate in the
cost of coverage. Proponents of cost sharing believe that copayments
can make individuals more price-conscious consumers of health care
services, which may reduce the use of unnecessary services. Others
believe that cost sharing requirements may limit service use, such as
physician visits, causing individuals to defer necessary treatment,
resulting in more severe conditions and potentially higher expenses.
Concerns have been expressed that, as states seek to increase the use
of beneficiary contributions for Medicaid, SCHIP, or both programs,
eligible individuals may reduce their program participation or use of
services.
You asked us to (1) identify and compare states' Medicaid and SCHIP
beneficiary contribution requirements for children, (2) identify
states' Medicaid beneficiary contribution requirements for adults, and
(3) determine the extent to which states' Medicaid and SCHIP
beneficiary contribution requirements have changed since 2001.
To identify the beneficiary contribution requirements in states'
Medicaid and SCHIP programs, we surveyed offices of each program in the
50 states and the District of Columbia.[Footnote 1] The survey asked
which beneficiary contribution requirements existed in the state as of
August 1, 2003, the populations subject to each requirement, and
changes made to the requirements since the beginning of the state's
2001 fiscal year.[Footnote 2] For Medicaid, states were asked to report
on requirements for nine population groups--children, children with
special needs, pregnant women, individuals in nursing homes and
institutions, noninstitutionalized elderly persons, adults with
disabilities, medically needy,[Footnote 3] parents, and any other
populations defined by the state. We divided these categories into two
groups--children and adults.[Footnote 4] For SCHIP, states were asked
to report on requirements for children, children with special needs,
and any other populations defined by the state. For each population
group covered, such as children or individuals in nursing homes, the
state was asked to indicate the portion of the group charged each of
the four types of beneficiary contributions (premiums, copayments,
coinsurance, and deductibles) by selecting "all," "most," "some," or
"none." States were also asked to indicate if their Medicaid or SCHIP
program did not cover a specific population. The survey asked states
about their cost sharing requirements for six selected services
(inpatient hospital, outpatient hospital, physician services,
prescription drugs, nonemergency use of the emergency room (ER), and
dental). In addition to their survey responses, states submitted
documentation of the amounts of their beneficiary contribution
requirements. We corroborated survey responses with documentation
provided by states and other available data on states' Medicaid and
SCHIP programs. We also contacted officials from the Centers for
Medicare & Medicaid Services (CMS), the agency within the Department of
Health and Human Services (HHS) that oversees states' Medicaid and
SCHIP programs, regarding the Medicaid and SCHIP statutory requirements
for beneficiary contributions. We performed our work from July 2003
through March 2004 in accordance with generally accepted government
auditing standards.
Results in Brief:
Our state survey showed that children were more likely to be subject to
beneficiary contributions, specifically premiums and cost sharing, in
SCHIP than in Medicaid. Overall, 26 states reported charging premiums
for some portion of children--either "some," "most," or "all"--in SCHIP
compared to 9 states in Medicaid. Twenty-five states charged cost
sharing for some portion of children in SCHIP, while 6 states had cost
sharing requirements for some portion of children in Medicaid. States
used copayments as the primary form of cost sharing for children. Most
states that reported charging cost sharing applied copayment
requirements to the six health care services that we considered. The
amount of beneficiary contributions required for children varied on the
basis of factors such as family income. For example, two states'
Medicaid programs limited yearly premium amounts to a percentage of
annual family income; SCHIP copayments for most services in one state
were $2 or $5 depending on family income.
Nearly half of the states reported assessing premiums for some adults
enrolled in Medicaid and the majority of the states required cost
sharing for some portion of adults, primarily in the form of copayments
for services. Twenty-five states charged premiums, generally limiting
the charges to portions of certain population groups, such as working
adults with disabilities. Over 40 states charged cost sharing to most,
if not all, adults, including adults with disabilities,
noninstitutionalized elderly persons, and parents. Copayments were the
predominate form of cost sharing. The services for which states most
frequently required copayments were physician services and prescription
drugs. Copayment amounts varied depending on the service and the state.
For example, across states, copayments ranged from $.50 to $25 for
physician services and prescription drugs.
Thirty-four states reported increasing the amount of beneficiary
contributions required in Medicaid, SCHIP, or both programs, while 10
states reported decreasing such requirements during states' fiscal
years 2001 through August 1, 2003. Amounts of beneficiary contributions
for children increased in 18 states--3 states in Medicaid, 12 states in
SCHIP, and 3 states in both programs--and increased for adults in
Medicaid in 30 states. The requirement most often increased was the
copayment requirement, and the increases generally were targeted to
noninstitutionalized elderly persons, adults with disabilities, and
parents. Across the 33 states that provided us information on the
amount of beneficiary contribution increases, premium increases to
existing requirements ranged from $2 a month to $39 a month. Other
states added new premium requirements, some of which were as much as
several hundred dollars a month. Copayment increases were generally
limited to $5 or less; in a small number of instances, increases were
higher. For the 10 states that decreased beneficiary contribution
requirements during the time period we reviewed, 5 states decreased
requirements for some portion of children in SCHIP and 5 states
decreased requirements for some portion of adults in Medicaid.
Officials in CMS provided technical comments on the statutory and
regulatory information on Medicaid and SCHIP beneficiary contributions,
which we incorporated as appropriate.
Background:
Health insurance coverage often includes beneficiary contributions,
which require an insured individual to pay some portion of medical
expenses. The medical expenses charged to an individual--particularly
for certain types of beneficiary contributions--can vary depending on
the amount and type of services used. The two most common forms of
beneficiary contribution requirements--health insurance premiums and
cost sharing--differ in the method and frequency with which they are
applied. Premiums are charged at regular intervals, such as monthly,
and generally the same amount is charged each time. In contrast, cost
sharing charges can vary depending on the amount and type of services
used. There are three types of cost sharing arrangements: coinsurance,
copayments, and deductibles (see table 1).
Table 1: Common Health Care Cost Sharing Arrangements:
Type of cost sharing: Coinsurance;
Definition: A percentage of the cost of health care services, such as
physician visits and prescriptions filled.
Type of cost sharing: Copayment;
Definition: A fixed amount for each service paid at the time of
service. Examples include payments for each physician visit and for
each prescription filled.
Type of cost sharing: Deductible;
Definition: An amount that must be paid by the insured before the
insurer will begin paying. For example, a covered individual with a $50
deductible would have to pay the first $50 of health care charges,
after which the insurer would begin paying.
Source: Slee, Vergil N. et al., Slee's Health Care Terms: Third
Comprehensive Edition (St. Paul, Minn.: Tringa Press, 1996).
[End of table]
Among low-income populations, approximately 40 percent of children and
nondisabled adults had at least one nonpreventive physician visit
during 2000.[Footnote 5] Among these individuals, children averaged
close to three nonpreventive physician visits per year, while
nondisabled adults averaged fewer than five visits per year. Similarly,
for individuals who filled at least one prescription, the average
number of filled prescriptions ranged from approximately 4 per year for
children to over 32 per year for adults with disabilities.[Footnote 6]
(See app. I for more information on beneficiary service utilization.):
Medicaid and SCHIP generally limit the use of beneficiary contribution
requirements. The following sections contain specific information about
the programs and the federal laws pertaining to their use of
beneficiary contributions.
Medicaid:
Established in 1965, Medicaid is a joint federal-state entitlement
program that finances health care coverage for certain low-income
families, children, pregnant women, and individuals who are aged or
disabled. In fiscal year 2001, there were more than 46 million Medicaid
enrollees, over half of whom were children, and federal and state
expenditures totaled $228 billion. Medicaid eligibility is based in
part on family income and assets; states set their eligibility criteria
within broad federal guidelines. Eligibility criteria for each state's
Medicaid program are outlined in a CMS-approved state plan.
Medicaid allows states to require certain beneficiaries to contribute
to the cost of their coverage by charging premiums and requiring cost
sharing.[Footnote 7] The populations that can be required to make
beneficiary contributions under federal law differ depending on the
type of beneficiary contribution--premiums or cost sharing--and the law
places limits on the amounts of the contributions states can require.
Federal law generally bars states from requiring beneficiary
contributions of certain populations, but exceptions do exist.
Additionally, states may seek federal approval to waive certain
provisions regarding beneficiary contributions.
Federal Law Governing Premiums in Medicaid:
States are prohibited from requiring premiums from certain low-income
individuals within certain groups, including children, pregnant women,
individuals in families with dependent children, individuals with
disabilities, and elderly persons, but exceptions exist.[Footnote 8]
Specifically, in Medicaid, the law allows states to require premiums
from certain populations, such as certain working individuals with
disabilities and families.[Footnote 9] (See table 2 for examples of
these exceptions.) Additionally, states are allowed to charge premiums
to medically needy individuals--generally, people who fall into one of
the eligibility coverage groups indicated above, but who incur medical
expenses such that their income, less these expenses, makes them
eligible for Medicaid.[Footnote 10] If states require premiums for
medically needy individuals, the regulations specify that the premiums
be assessed on a sliding scale, from $1 to $19 per person per month, on
the basis of their family's total gross income.
Table 2: Examples of Exceptions to Prohibitions on Premiums in Medicaid, by Population Group:
Population: Children;
Exception:
* Children under age 1 in families with incomes equal to or exceeding
150 percent of the federal poverty level (FPL)[A] may be charged
premiums at states' discretion.[B] Premiums may not exceed 10 percent
of family income that is above 150 percent of the FPL.[C]
Population: Pregnant women;
Exception:
* Pregnant women whose incomes are equal to or exceed 150 percent of
the FPL may be charged premiums at states' discretion.[B] Premiums may
not exceed 10 percent of their income that is above 150 percent of the
FPL.[C]
Population: Individuals in families with dependent children;
Exception:
* Under "transitional Medicaid assistance," families moving from cash
assistance to employment may maintain health insurance coverage under
Medicaid for up to 1 year.[D] Premiums may be charged for the final 6
months of coverage for families above a certain level of income but may
not exceed 3 percent of the family's average gross monthly earnings
(less the average monthly costs for child care necessary to enable the
caretaker relative to engage in employment).
Population: Individuals with disabilities;
Exception:
* Under the Balanced Budget Act of 1997, states may cover working
individuals with disabilities who have family incomes exceeding 250
percent FPL and there is no limit to the amount of premiums states can
charge;
* Under the Ticket to Work and Work Incentives Improvement Act of 1999
(Ticket to Work Act), states may require premiums of up to 7.5 percent
of income from working individuals with disabilities whose annual
incomes do not exceed 450 percent of the FPL.
Source: GAO analysis of federal law, as of March 2004.
[A] In 2003, the FPL for an individual equated to $8,980 per year and
$15,260 for a family of three in the 48 contiguous states and the
District of Columbia.
[B] Population group is covered under an optional categorically needy
group in states that, as of December 19, 1989, had established, or
passed legislation authorizing or appropriating funds for, a minimum
income eligibility level for Medicaid greater than 133 percent of the
FPL.
[C] If the minimum income eligibility level in the state for the
optional categorically needy group exceeds 150 percent of the FPL,
premiums may not exceed 10 percent of the family income that exceeds
that minimum.
[D] Authorized by section 1925 of the Social Security Act (codified at
42 U.S.C. 1396r-6 (2000)).
[End of table]
Federal Law Governing Cost Sharing in Medicaid:
Federal law prohibits states from applying cost sharing requirements
for certain individuals and certain services. Specifically, cost
sharing may not be charged for categorically and medically needy
children under 18 years of age,[Footnote 11] and pregnant women, for
services related to the pregnancy or to conditions that could
complicate the pregnancy. Additionally, cost sharing may not be charged
for the categorically and medically needy for:
* services furnished to individuals residing in a nursing home or other
institution, who were required to spend most of their income for
medical care;[Footnote 12]
* services furnished to individuals receiving hospice care;
* emergency services; and:
* family planning services and supplies.
States may require nominal copayments, coinsurance, or deductibles
within federal limits from other beneficiaries or for other services
(see table 3). Beneficiaries may be charged only one type of cost
sharing per service. Providers may collect cost sharing amounts from
beneficiaries and generally are not to be reimbursed by the state if
they are unsuccessful in collecting cost sharing from beneficiaries.
Providers generally may not deny services if beneficiaries are unable
to pay cost sharing amounts.
Table 3: Medicaid Cost Sharing Limits:
Type of cost sharing: Coinsurance;
Limit[A]: Rates may not exceed 5 percent of the amount the state pays
to Medicaid providers for the services for noninstitutional care or be
more than 50 percent of the Medicaid payment for the first day of
institutional care per admission.
Type of cost sharing: Copayment;
Limit[A]: Amount is limited--from $0.50 to $3.00--for noninstitutional
care and may be no more than 50 percent of the Medicaid payment for the
first day of institutional care per admission.
Type of cost sharing: Deductible;
Limit[A]: Amount is limited to $2.00 per family per month for each
period of eligibility for noninstitutional care and to no more than 50
percent of the Medicaid payment for the first day of institutional care
per admission.
Source: GAO analysis, as of October 2003, of Medicaid regulations.
[A] States may seek authority from CMS to charge up to twice the cost
sharing limit for nonemergency services delivered in a hospital
emergency room provided that the state can demonstrate that alternative
sources of nonemergency, outpatient services are available and
accessible to beneficiaries. See Social Security Act sections
1916(a)(3) and 1916(b)(3) (codified at 42 U.S.C. 1396o(a)(3) and
(b)(3)).
[End of table]
Waivers of Premium and Cost Sharing Law in Medicaid:
States must seek permission from the federal government to charge
premiums or cost sharing beyond what is allowed under Medicaid. Under
section 1115 of the Social Security Act, the Secretary of Health and
Human Services has broad authority to approve demonstration projects
that he determines are likely to promote Medicaid objectives.[Footnote
13] The Secretary may waive certain provisions of the statute if the
Secretary finds it necessary for the performance of the experimental,
pilot, or demonstration projects. Section 1115 waivers have been used
to provide coverage to individuals not normally eligible for Medicaid-
-or to expand coverage to those who are eligible under Medicaid but are
not included in the scope of the state's plan. Beneficiary contribution
requirements for individuals who become eligible for Medicaid through
an 1115 waiver may be approved at the Secretary's discretion, subject
to some limitations. CMS reviews states' proposed beneficiary
contribution requirements for 1115 waivers as part of the waiver
approval process and specifies any terms and conditions that a state
must adhere to as a condition of the waiver approval.
According to CMS, because the provisions of Medicaid law related to
limitations on beneficiary contributions[Footnote 14] are applicable
only to persons eligible under the state plan, specific waivers of the
beneficiary contribution provisions are not always necessary. Waivers
are necessary when states want to charge premiums or cost sharing
amounts that are generally prohibited under federal law for individuals
who are already covered under the state's plan. As of February 2004,
two states--Arkansas and Vermont--have received approval to charge
individuals premiums and one state--Arizona--has received approval to
charge individuals both premiums and cost sharing.
For other populations, specific waivers of requirements regarding
beneficiary contributions are not necessary. In particular, states are
permitted to charge beneficiary contributions in excess of what would
otherwise be permitted for populations who, without a waiver, would not
be eligible for coverage under the state's Medicaid plan. For these
populations, states are permitted to end coverage for beneficiaries who
fail to pay premiums or deny services to those who fail to pay cost
sharing. As of February 2004, of the 22 states with statewide 1115
waivers, 21 states covered populations in their Medicaid program for
which the Medicaid statutory provisions regarding limits on beneficiary
contributions are not applicable.
SCHIP:
In 1997, Congress established SCHIP, which provides health care
coverage to low-income, uninsured children living in families whose
incomes exceed the states' eligibility limits for Medicaid. SCHIP
covered over 5.8 million children during fiscal year 2003,[Footnote 15]
and federal and state expenditures were approximately $6.1 billion.
States have three options in designing SCHIP--expand their Medicaid
program, develop a separate child health program that functions
independently of Medicaid, or combine these two approaches.
The approach that a state chooses affects its beneficiary contribution
policies. A state that uses its SCHIP allocation to expand Medicaid
must follow Medicaid rules--thus SCHIP beneficiaries are subject to the
state's Medicaid policies with regard to premiums and cost sharing. For
a state with a separate SCHIP program, federal law limits the premium
and cost sharing amounts it may charge. States with a separate SCHIP
program are prohibited from requiring premium or cost sharing
contributions together totaling more than 5 percent of family
income.[Footnote 16] States with separate SCHIP programs are also
prohibited from charging any cost sharing on preventive
services.[Footnote 17] In addition, for children in families with
income at or below 150 percent of the FPL, there are specific limits on
the amounts of premiums and cost sharing that states may charge in a
separate SCHIP program (see table 4). For these individuals, federal
regulation also prohibits states from requiring more than one type of
cost sharing charge on each service. Additionally, regardless of family
income or a state's SCHIP design, states are prohibited from charging
premiums or cost sharing to American Indians or Alaska
Natives.[Footnote 18]
Table 4: Federal Limits on Separate SCHIP Programs' Premium and Cost
Sharing for Children in Families with Income at or Below 150 Percent of
the Federal Poverty Level:
Type of beneficiary contribution: Premium;
Limits for children in families with income at or below 100 percent of
the federal poverty level (FPL):
* May not exceed the Medicaid premium schedule for the medically needy,
which operates on a sliding scale, with a maximum premium of $19 per
person per month;
Limits for children in families with income from 101 to 150 percent of
the FPL:
* Limits are the same as those for families with income at or below 100
percent of the FPL.
Type of beneficiary contribution: Coinsurance;
Limits for children in families with income at or below 100 percent of
the federal poverty level (FPL):
* May not exceed 5 percent of the state payment for non- institutional
services;
and;
* may not exceed 50 percent of the state payment for the first day of
institutional care per admission;
Limits for children in families with income from 101 to 150 percent of
the FPL:
* May not exceed 5 percent of the state payment for noninstitutional
services; and;
* may not exceed 50 percent of the state's Medicaid fee-for-service
payment for the first day of institutional care per admission.
Type of beneficiary contribution: Copayment;
Limits for children in families with income at or below 100 percent of
the federal poverty level (FPL):
* From $0.50 to $3 for noninstitutional services; and;
* may not exceed 50 percent of the state payment for the first day of
institutional care per admission;
Limits for children in families with income from 101 to 150 percent of
the FPL:
* From $1 to $5 for noninstitutional services provided under fee-for
service,
* may not exceed $5 per visit for noninstitutional services provided
under managed care,
* may not exceed 50 percent of the state's Medicaid fee- for-service
payment for the first day of institutional care per admission,
* may not exceed $5 for hospital emergency services; and;
* may not exceed $10 for nonemergency services furnished in an
emergency room.
Type of beneficiary contribution: Deductible;
Limits for children in families with income at or below 100 percent of
the federal poverty level (FPL):
* May not exceed $2 per family per month per period of eligibility for
noninstitutional services; and;
* may not exceed 50 percent of the state payment for the first day of
institutional care per admission;
Limits for children in families with income from 101 to 150 percent of
the FPL:
* May not exceed $3 per family per month per period of eligibility for
noninstitutional services; and;
* may not exceed 50 percent of the state's Medicaid fee-for-service
payment for the first day of institutional care per admission.
Source: GAO analysis of SCHIP regulations, March 2004.
[End of table]
Similar to Medicaid, to require premiums or cost sharing in SCHIP
beyond what is permissible under federal law, states must seek waivers
from the Secretary of Health and Human Services. In establishing SCHIP,
Congress extended the applicability of section 1115 of the Social
Security Act to SCHIP "in the same manner" as it applies to states
under Medicaid.[Footnote 19] According to CMS, six states with SCHIP
programs that are Medicaid expansions have received section 1115
waivers to require beneficiary contributions that would be allowable in
a separate SCHIP program.[Footnote 20] In some cases, 1115 waiver
approvals have allowed states to increase cost sharing in their premium
assistance programs--programs in which the state helps individuals gain
access to available employer-based insurance by using SCHIP funds to
pay for part of an individual's share of the cost of coverage.
Specifically, two states--Illinois and Oregon--have waivers to allow
for increased cost sharing for children in such premium assistance
programs.
Children Were More Likely to Be Subject to Beneficiary Contributions in
SCHIP than in Medicaid:
In response to our survey, states reported that children were more
likely to be subject to premiums and cost sharing in SCHIP than in
Medicaid. Overall, 26 states charged premiums for some portion of
children--"some," "most," or "all" in SCHIP, and 9 states charged
premiums, through the use of 1115 waivers, for some portion of children
in Medicaid. Twenty-five states charged cost sharing for children in
SCHIP compared to six states for Medicaid. Most states that reported
charging cost sharing applied copayment requirements to the six
services we reviewed.[Footnote 21] In addition, the amounts of
beneficiary contributions required for children varied on the basis of
factors such as family income.
Premiums:
Twenty-six states reported charging premiums for some portion of
children in SCHIP, compared to 9 states for Medicaid: 5 states charged
premiums for some portion of children in both Medicaid and SCHIP, 21
states charged premiums for SCHIP children only, and 4 states charged
premiums for Medicaid children only. (See table 5.):
Table 5: States' Use of Premiums for Children in Medicaid and SCHIP, as
of August 1, 2003:
Charge premiums in Medicaid? No;
Charge premiums in SCHIP? No;
Number of states: 21;
States: Alaska, Colorado, District of Columbia, Idaho, Kentucky,
Louisiana, Mississippi, Montana, Nebraska, New Mexico, North Carolina,
North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina,
South Dakota, Virginia, West Virginia, and Wyoming.
Charge premiums in Medicaid? No;
Charge premiums in SCHIP? Yes;
Number of states: 21;
States: Alabama, California, Connecticut, Delaware, Florida, Georgia,
Illinois, Indiana, Iowa, Kansas, Maine, Maryland, Michigan, Missouri,
Nevada, New Hampshire, New Jersey, New York, Texas, Utah, and
Washington.
Charge premiums in Medicaid? Yes;
Charge premiums in SCHIP? No;
Number of states: 4;
States: Arkansas,[A] Hawaii,[B] Minnesota,[C] and Tennessee[D].
Charge premiums in Medicaid? Yes;
Charge premiums in SCHIP? Yes;
Number of states: 5;
States: Arizona, Massachusetts, Rhode Island, Vermont, and Wisconsin.
Source: GAO analysis of state survey responses.
[A] Arkansas's 1115 waiver included premium charges for children who
are receiving medical care at home that otherwise would be provided in
an institution.
[B] Hawaii charged premiums for children in families with incomes above
200 percent of the FPL, which in 2003 equated to $20,660 per year for
an individual and $35,100 for a family of three.
[C] Minnesota allowed individuals the choice of participating in its
1115 waiver program, which includes premium charges, or its traditional
Medicaid program, which does not include premium charges for children.
[D] Tennessee did not have a SCHIP program.
[End of table]
Although federal law generally prohibits states from charging premiums
for children in Medicaid, some states reported having received waivers
from the Secretary of Health and Human Services granting them authority
to do so. Of the nine states charging premiums for children in
Medicaid, six states required premiums for children included in their
1115 waiver populations only. For example, Rhode Island charged
premiums only for children with incomes between 150 and 250 percent of
the FPL, all of whom became Medicaid eligible through its 1115 waiver.
The remaining three states--Arizona, Arkansas, and Vermont--also had
1115 waivers but had received approval to waive provisions related to
premium requirements. Thus, they were allowed to charge premiums for
children.
States generally are not allowed to charge premiums for children in
their SCHIP Medicaid expansion programs, as these programs follow the
law governing the Medicaid program. According to CMS, six states have
received SCHIP 1115 waivers to require beneficiary contributions for
children in their SCHIP Medicaid expansion programs. Three of those
states--Missouri, Rhode Island and Wisconsin--used their 1115 waiver to
implement premiums for some portion of their SCHIP beneficiaries. The
remaining three states--Arkansas, New Mexico and Ohio--did not charge
premiums for children in their SCHIP program.
Among states with premium requirements for children, SCHIP programs
often reported charging premiums for a larger proportion of their
children than did Medicaid programs (see app. II). Ten of the 26 states
charging premiums for children in SCHIP required them for all or most
of their SCHIP children. In contrast, all nine of the states with
premiums for children in Medicaid required them for only some of the
population.
The amount of premiums required for Medicaid and SCHIP children varied
across and within states. (See app. III for the range in premiums for
all states.) Some states reported varying premium amounts on the basis
of beneficiaries' family income, and some states reported capping the
amount of premiums a beneficiary could be subject to in a given year.
(See table 6.) The following are examples of the variation in states'
premium requirements.
* In Vermont, Medicaid premiums were assessed for eligible children in
families with incomes above 185 percent of the FPL, and amounts varied
from $25 to $35 a month depending on the family income.
* Medicaid programs in Rhode Island and Minnesota limited total yearly
premium amounts to 4 percent and 7.5 percent of annual family income,
respectively.
* In SCHIP, monthly premiums in Washington were $10 per child, with a
cap of $360 per family per year. In New York, monthly premiums for
families with incomes between 133 and 185 percent of the FPL were $9
per eligible child with a cap of $27 per family per month; families
with incomes above 185 were charged $15 per eligible child with a cap
of $45 per family per month.
Table 6: States' Premium Charges for Children in Medicaid and SCHIP, as
of August 1, 2003:
Characteristic: States charging premiums for children;
Number of states: Medicaid: 9;
Number of states: SCHIP: 26.
Characteristic: States varying premiums by income;
Number of states: Medicaid: 9;
Number of states: SCHIP: 20.
Characteristic: States capping premium charges;
Number of states: Medicaid: 4;
Number of states: SCHIP: 11.
Source: GAO analysis of state survey responses.
[End of table]
Cost Sharing:
In requiring cost sharing amounts, states reported relying on
copayments and generally did not report using the other two main types
of cost sharing requirements--coinsurance and deductibles. Twenty-five
states charged copayments for some portion of children in SCHIP, while
six states charged copayments for some portion of children in Medicaid.
(See table 7.) With regard to coinsurance, three states charged
coinsurance in Medicaid; Alaska and Missouri charged only children aged
18 or over, and Arkansas charged only children in its 1115 waiver
program. Additionally, four states charged coinsurance in SCHIP
(Alaska, Arkansas, Colorado, and Utah). None of the states reported
using deductibles as a form of cost sharing for children.
Table 7: States' Use of Copayments for Children in Medicaid and SCHIP,
as of August 1, 2003:
Charge copayments in Medicaid? No;
Charge copayments in SCHIP? No;
Number of states: 24;
States: District of Columbia, Georgia, Hawaii, Idaho, Kansas,
Louisiana, Maine, Maryland,[A] Massachusetts, Michigan, Minnesota,
Nebraska, Nevada, New York, Ohio, Oregon, Oklahoma, Pennsylvania, Rhode
Island, South Carolina, South Dakota, Vermont, Washington, and Wyoming.
Charge copayments in Medicaid? No;
Charge copayments in SCHIP? Yes;
Number of states: 21;
States: Alabama, Arizona, California, Colorado, Connecticut, Florida,
Illinois, Indiana, Iowa, Kentucky, Mississippi, Montana, New Hampshire,
New Jersey, New Mexico, North Carolina, North Dakota, Texas, Utah,
Virginia, and West Virginia.
Charge copayments in Medicaid? Yes;
Charge copayments in SCHIP? No;
Number of states: 2;
States: Delaware[B] and Tennessee[C].
Charge copayments in Medicaid? Yes;
Charge copayments in SCHIP? Yes;
Number of states: 4;
States: Alaska, Arkansas, Missouri, and Wisconsin.
Source: GAO analysis of state survey responses.
[A] Maryland did not charge copayments to children in Medicaid. In
SCHIP, the state did not charge copayments, but SCHIP beneficiaries
receiving coverage through the employer-sponsored insurance program may
be charged copayments by their health plan.
[B] Although Delaware did not require a copayment in SCHIP, the state
did have a fee for inappropriate use of the ER. In Medicaid, Delaware's
only copayment was for nonemergency transportation.
[C] Tennessee did not have a SCHIP program.
[End of table]
While federal law prohibits states from charging cost sharing for
children in Medicaid under age 18, some states require cost sharing to
the extent it is permissible under Medicaid provisions or through an
1115 waiver. For the six states that charged copayments for some
portion of Medicaid children, Alaska's, Missouri's, and Wisconsin's
copayment requirements applied to children age 18 or over, and Delaware
reported charging copayments for nonemergency transportation,
requirements that are permissible under federal law.[Footnote 22]
Arkansas charged copayments only to children in its state's 1115 waiver
population. Tennessee, whose entire Medicaid program operates under an
1115 waiver, charged copayments to children at or above the FPL.
With regard to cost sharing in SCHIP, six states obtained section 1115
waivers that allowed them to require beneficiary contributions from
children in their SCHIP Medicaid expansion programs.[Footnote 23] Four
of the states--Arkansas, Missouri, New Mexico and Wisconsin--used their
1115 waiver to implement copayments for some portion of their SCHIP
beneficiaries. The remaining two states--Ohio and Rhode Island--did not
charge copayments for children in their SCHIP programs. Among states
with copayment requirements for children, SCHIP programs were more
likely to charge a larger proportion of their population compared to
Medicaid (see app. IV).
Most states that reported charging cost sharing applied copayment
requirements to the six health care services that we considered. (See
table 8.) In addition, the amount of cost sharing that states charged
for the six selected services varied by service and state. For example,
in the Texas SCHIP program, copayments varied on the basis of family
income, ranging from $2 to $10 per physician visit, and from $25 to
$100 per inpatient hospitalization. Across states with copayments for
physician services, copayment amounts ranged from $1 per visit in
Missouri's Medicaid program and Wisconsin's Medicaid and SCHIP programs
to as high as $25 per visit in Tennessee's Medicaid program. (See app.
V.):
Table 8: States' Use of Cost Sharing for Children for Six Services, by Program and Service, as of August 1, 2003:
Service: Inpatient hospital;
Number of states: Copayment: Medicaid: 4;
Number of states: Copayment: SCHIP: 12;
Number of states: Coinsurance: Medicaid: 1;
Number of states: Coinsurance: SCHIP: 2;
Number of states: States using cost sharing for this service:
Medicaid: 5;
Number of states: States using cost sharing for this service:
SCHIP: 13[A].
Service: Outpatient hospital;
Number of states: Copayment: Medicaid: 3;
Number of states: Copayment: SCHIP: 17;
Number of states: Coinsurance: Medicaid: 1;
Number of states: Coinsurance: SCHIP: 2;
Number of states: States using cost sharing for this service:
Medicaid: 4;
Number of states: States using cost sharing for this service:
SCHIP: 18[A].
Service: Physician services;
Number of states: Copayment: Medicaid: 5;
Number of states: Copayment: SCHIP: 21;
Number of states: Coinsurance: Medicaid: 0;
Number of states: Coinsurance: SCHIP: 0;
Number of states: States using cost sharing for this service:
Medicaid: 5;
Number of states: States using cost sharing for this service:
SCHIP: 21.
Service: Prescription drugs;
Number of states: Copayment: Medicaid: 4;
Number of states: Copayment: SCHIP: 22;
Number of states: Coinsurance: Medicaid: 0;
Number of states: Coinsurance: SCHIP: 1;
Number of states: States using cost sharing for this service:
Medicaid: 4;
Number of states: States using cost sharing for this service:
SCHIP: 22[A].
Service: Nonemergency use of the emergency room;
Number of states: Copayment: Medicaid: 4;
Number of states: Copayment: SCHIP: 21;
Number of states: Coinsurance: Medicaid: 1;
Number of states: Coinsurance: SCHIP: 1;
Number of states: States using cost sharing for this service:
Medicaid: 5;
Number of states: States using cost sharing for this service:
SCHIP: 22.
Service: Dental;
Number of states: Copayment: Medicaid: 4;
Number of states: Copayment: SCHIP: 14;
Number of states: Coinsurance: Medicaid: 1;
Number of states: Coinsurance: SCHIP: 2;
Number of states: States using cost sharing for this service:
Medicaid: 4[B];
Number of states: States using cost sharing for this service:
SCHIP: 15[A].
Source: GAO analysis of state survey responses.
[A] Utah SCHIP charged a copayment for children with a family income at
or below 150% FPL and charged copayment or coinsurance for children in
a family with a higher income level.
[B] Missouri Medicaid charged a copayment or coinsurance, depending on
the dental service. Specifically, the state charged a coinsurance for
dentures and charged a copayment for all other dental services.
[End of table]
Some states varied cost sharing amounts for children on the basis of
family income. For example, in Virginia, SCHIP copayments for children
in families with income from 133 percent to below 150 percent of the
FPL were $2 per physician visit or per prescription and $5 for these
services for children in families with higher incomes. Of the six
states that charged cost sharing for children in Medicaid, only
Tennessee capped cost sharing amounts for children. In SCHIP, seven
states set specific caps for cost sharing amounts for a child in a
given year. (See table 9.) For example, SCHIP cost sharing was capped
at $650 a year in Connecticut and $750 a year in West Virginia.
Table 9: States' Use of Cost Sharing Charges for Children in Medicaid
and SCHIP, as of August 1, 2003:
Characteristics: States charging cost sharing for children;
Number of states: Medicaid: 6;
Number of states: SCHIP: 25.
Characteristics: States varying cost sharing by income;
Number of states: Medicaid: 1;
Number of states: SCHIP: 14.
Characteristics: States capping cost sharing charges;
Number of states: Medicaid: 1;
Number of states: SCHIP: 7.
Source: GAO analysis of state survey responses.
[End of table]
For Adults in Medicaid, Nearly Half the States Assessed Premiums and a
Majority Required Cost Sharing:
Nearly half the states (25) reported assessing premiums for some adults
enrolled in Medicaid, and a majority of the states (43) reported
requiring cost sharing for some portion of adults, primarily in the
form of copayments. Overall, 45 states required some portion of adults
to share in the cost of their care by charging premiums, cost sharing,
or both. (See fig. 1.) The states that required premiums generally did
so on a limited basis, targeting portions of particular population
groups, such as certain adults with disabilities. In contrast, the
states with cost sharing requirements for adults in Medicaid charged
several population groups and a larger portion of each group.
Figure 1: States' Use of Premiums and Cost Sharing for Adults in
Medicaid, as of August 1, 2003:
[See PDF for image]
[End of figure]
Premiums:
Twenty-five states reported assessing premiums for some portion of
their adult Medicaid populations. States mainly charged premiums to
adults with disabilities (23 states)[Footnote 24] and parents (9
states), but a few states charged premiums to other adults, such as
pregnant women (4 states) and noninstitutionalized elderly individuals
(2 states). (See table 10.) (App. VI contains details on the portion of
the populations charged premiums in each state.):
Table 10: States' Use of Premiums for Adults in Medicaid, by Population
Group, as of August 1, 2003:
Population[A]: Pregnant women;
Number of states charging all, most, or some of this population:
All: 0;
Number of states charging all, most, or some of this population:
Most: 0;
Number of states charging all, most, or some of this population:
Some: 4.
Population[A]: Individuals in nursing homes and institutions;
Number of states charging all, most, or some of this population:
All: 0;
Number of states charging all, most, or some of this population:
Most: 0;
Number of states charging all, most, or some of this population:
Some: 0.
Population[A]: Noninstitutionalized elderly;
Number of states charging all, most, or some of this population:
All: 0;
Number of states charging all, most, or some of this population:
Most: 0;
Number of states charging all, most, or some of this population:
Some: 2.
Population[A]: Adults with disabilities;
Number of states charging all, most, or some of this population:
All: 0;
Number of states charging all, most, or some of this population:
Most: 0;
Number of states charging all, most, or some of this population:
Some: 23.
Population[A]: Medically needy;
Number of states charging all, most, or some of this population:
All: 0;
Number of states charging all, most, or some of this population:
Most: 0;
Number of states charging all, most, or some of this population:
Some: 0.
Population[A]: Parents;
Number of states charging all, most, or some of this population:
All: 0;
Number of states charging all, most, or some of this population:
Most: 1;
Number of states charging all, most, or some of this population:
Some: 8.
Source: GAO analysis of state survey responses.
Note: In our survey, states were asked to indicate what portion of a
specific population group was charged premiums by selecting "all,"
"most," "some," or "none.":
[A] Five states reported charging premiums to other adult populations,
such as childless adults.
[End of table]
Generally, states are not permitted to require certain individuals to
pay premiums, including elderly persons, individuals with disabilities,
and pregnant women. However, certain exceptions exist, for example:
* Four states (Hawaii, Minnesota, Rhode Island, and Vermont) reported
charging premiums to pregnant women through their states' 1115 waiver
programs. Vermont had a waiver of the specific Medicaid provision
regarding premium requirements, while the other three states charged
pregnant women in their 1115 waiver programs. Hawaii, Rhode Island, and
Vermont charged premiums only to pregnant women with incomes exceeding
185 percent of the FPL. In the fourth state, Minnesota, pregnant women
with incomes at or below 275 percent of the FPL could choose whether to
enroll in the state's regular Medicaid program or the state's 1115
waiver program. Only those enrolled in the 1115 waiver program were
charged premiums, and failure to pay the required premiums did not
result in the women's disenrollment from the program.
* As allowed under federal law, states may charge premiums in Medicaid
to certain individuals with disabilities, primarily those who are
employed. For example, Connecticut reported charging premiums to
working individuals with disabilities with incomes above 200 percent of
the FPL. These individuals were required to pay a monthly premium
equivalent to 10 percent of their income that exceeded 200 percent of
the FPL, minus the amount the individuals or their spouses paid for any
other health insurance.
Premium amounts and requirements varied significantly across the 25
states. For example, in Massachusetts, monthly premiums ranged from $15
for families with incomes at the poverty level to over $928 for
families with incomes over 1,000 percent of the FPL. Maine charged
premiums equal to 3 percent of families' net incomes for eligible
parents with incomes above 150 percent of the FPL. (See app. VII for
the income thresholds and ranges in amounts for premiums charged to
adults in each state.) Twelve states capped the amount of premiums that
beneficiaries could be subject to in a given year. For example,
premiums for working individuals with disabilities in Mississippi were
capped at 5 percent of annual income, and in Maine, premiums for some
adults were capped at 3 percent of annual income. (See table 11.):
Table 11: States' Premium Charges for Adults in Medicaid, as of August
1, 2003:
Characteristic: States charging premiums;
Number of states: 25.
Characteristic: States varying premiums by income;
Number of states: 25.
Characteristic: States capping premium charges;
Number of states: 12[A].
Source: GAO analysis of state survey responses.
[A] Three of these states reported that premium charges were capped for
some beneficiaries.
[End of table]
Cost Sharing:
Forty-three states reported requiring adult populations to share in the
cost of their care by charging copayments, coinsurance, or deductibles.
(See fig. 2.) All 43 states charged copayments for selected services to
some portion of adults. Nine of these states also charged coinsurance
to some portion of adults.[Footnote 25] Two of the 43 states--South
Carolina and Wisconsin--required a deductible for elderly individuals
who received pharmacy--but no other--benefits from the states' Medicaid
program. For example, all participants in South Carolina's Medicaid
pharmacy program were required to pay a $500 deductible for
prescription drugs.
Figure 2: States' Use of Cost Sharing for Adults in Medicaid, as of
August 1, 2003:
[See PDF for image]
[End of figure]
Copayments were the predominate form of cost sharing for adults, with
states most frequently reporting copayments for adults with
disabilities, noninstitutionalized elderly persons, and parents. (See
table 12 and app. VIII.) Three states required copayments for pregnant
women (Delaware, Virginia, and Wisconsin) for services unrelated to the
pregnancy.[Footnote 26] While states generally are prohibited from
charging cost sharing, including copayments, for medical services for
individuals residing in institutions, Delaware considers nonemergency
transportation to be an administrative cost and thus was allowed to
charge a $1 copayment.
Table 12: States' Use of Copayments for Adults in Medicaid, as of
August 1, 2003:
Population[A]: Pregnant women[B];
Number of states and portion of population charged: All: 1;
Number of states and portion of population charged: Most: 0;
Number of states and portion of population charged: Some: 2.
Population[A]: Individuals in nursing homes and institutions[C];
Number of states and portion of population charged: All: 1;
Number of states and portion of population charged: Most: 0;
Number of states and portion of population charged: Some: 0.
Population[A]: Noninstitutionalized elderly persons;
Number of states and portion of population charged: All: 21;
Number of states and portion of population charged: Most: 8;
Number of states and portion of population charged: Some: 11.
Population[A]: Adults with disabilities;
Number of states and portion of population charged: All: 21;
Number of states and portion of population charged: Most: 9;
Number of states and portion of population charged: Some: 11.
Population[A]: Medically needy;
Number of states and portion of population charged: All: 14;
Number of states and portion of population charged: Most: 7;
Number of states and portion of population charged: Some: 8.
Population[A]: Parents;
Number of states and portion of population charged: All: 16;
Number of states and portion of population charged: Most: 11;
Number of states and portion of population charged: Some: 9.
Source: GAO analysis of state survey responses.
Note: In our survey, states were asked to indicate what portion of the
population were charged copayments by selecting "all," "most," "some,"
or "none." They were also asked to designate if a population was not
covered by their state's Medicaid program.
[A] Ten states reported charging copayments to other adult populations,
such as childless adults.
[B] Three states required copayments for services unrelated to the
pregnancy.
[C] One state charged individuals in institutions for nonemergency
transportation.
[End of table]
The services for which states most frequently reported charging
copayments were physician services and prescription drugs. (See table
13.) Copayment amounts varied depending on the service and the state.
Across states, copayments ranged from $.50 to $25 for physician
services and prescription drugs. Across the services, most states that
required copayments for inpatient hospital services charged higher
copayment amounts for this service compared to the other five services.
For example, Montana's copayment requirement for inpatient hospital
services was $100 per stay, whereas its copayment requirements for the
five remaining services we reviewed were $1 to $5. (See app. IX for
details on the cost sharing amounts, including copayments, for adults,
by state.):
Table 13: States' Use of Copayments for Adults for Six Services, by
Population Group, as of August 1, 2003:
Population[A]: Pregnant women;
Number of states charging copayment: Inpatient hospital: 2;
Number of states charging copayment: Outpatient hospital: 2;
Number of states charging copayment: Physician services: 2;
Number of states charging copayment: Prescription drugs: 2;
Number of states charging copayment: Nonemergency use of the ER: 0;
Number of states charging copayment: Dental: 1.
Population[A]: Noninstitutionalized elderly persons;
Number of states charging copayment: Inpatient hospital: 18;
Number of states charging copayment: Outpatient hospital: 21;
Number of states charging copayment: Physician services: 25;
Number of states charging copayment: Prescription drugs: 35;
Number of states charging copayment: Nonemergency use of the ER: 16;
Number of states charging copayment: Dental: 13.
Population[A]: Adults with disabilities;
Number of states charging copayment: Inpatient hospital: 19;
Number of states charging copayment: Outpatient hospital: 22;
Number of states charging copayment: Physician services: 26;
Number of states charging copayment: Prescription drugs: 36;
Number of states charging copayment: Nonemergency use of the ER: 16;
Number of states charging copayment: Dental: 14.
Population[A]: Medically needy;
Number of states charging copayment: Inpatient hospital: 11;
Number of states charging copayment: Outpatient hospital: 13;
Number of states charging copayment: Physician services: 16;
Number of states charging copayment: Prescription drugs: 25;
Number of states charging copayment: Nonemergency use of the ER: 8;
Number of states charging copayment: Dental: 9.
Population[A]: Parents;
Number of states charging copayment: Inpatient hospital: 16;
Number of states charging copayment: Outpatient hospital: 19;
Number of states charging copayment: Physician services: 22;
Number of states charging copayment: Prescription drugs: 31;
Number of states charging copayment: Nonemergency use of the ER: 12;
Number of states charging copayment: Dental: 14.
Source: GAO analysis of state survey responses.
[A] No states required copayments for individuals in nursing homes and
institutions for any of the six services; thus, this population is
excluded from the table.
[End of table]
In five states, the amount of cost sharing charged varied by income for
some portion of adults. For example, copayment amounts for physician
services in Utah varied from $3 or $5 per visit depending on income.
Six states reported placing a cap on the amount of cost sharing an
individual could be subject to in a given year. For example, in
Pennsylvania cost sharing expenses were capped at $90 per beneficiary
every 6 months, and in New Mexico cost sharing amounts for working
individuals with disabilities were capped at 3 to 5 percent a year
depending on income.
Thirty-Four States Increased and Ten States Decreased the Amount of
Beneficiary Contributions:
From the beginning of their 2001 state fiscal years through August 1,
2003, 34 states reported increasing and 10 states reported decreasing
the amount of beneficiary contributions they required in Medicaid,
SCHIP, or both.[Footnote 27] We considered states to have increased
beneficiary contribution requirements if they either raised the amount
of existing contributions or instituted new contribution requirements
for certain populations or services. For children, 18 states increased
the amount of beneficiary contributions required in Medicaid, SCHIP, or
both. For adults in Medicaid, 30 states increased the amount of
beneficiary contributions. For the states that provided us information
on the amount of beneficiary contribution increases,[Footnote 28]
premium increases to existing requirements ranged from $2 a month to
$39 a month. Other states added new premium requirements, some of which
were as much as several hundred dollars a month. In contrast, states
primarily increased copayment requirements by $5 or less. For a small
number of states, however, copayment increases were more significant.
New Hampshire SCHIP, for example, increased copayments for ER visits
from $25 to $50 per visit. While no states reported decreasing their
beneficiary contribution requirements for children in Medicaid, five
states decreased these requirements (premiums, cost sharing, or both)
for some portion of children in SCHIP, and five other states decreased
cost sharing requirements for some portion of adults in Medicaid.
Eighteen States Increased and Five States Decreased Beneficiary
Contributions for Children:
From the beginning of their 2001 state fiscal years through August 1,
2003, 18 states reported increasing the amount of beneficiary
contributions required for children in Medicaid, SCHIP, or both.
Beneficiary contribution requirements were increased solely in Medicaid
by 3 states, solely in SCHIP by 12 states, and in both Medicaid and
SCHIP by 3 states. During the same period, 5 states decreased the
amount of beneficiary contributions required for children, with all
decreases occurring in states' SCHIP programs.
Premiums:
Of the 9 states charging premiums for children in Medicaid, 5 reported
increases in premiums. Eleven of the 26 states charging premiums for
children in SCHIP also reported increased premium amounts. (See table
14.) Some states increased existing premiums, while other states added
new premiums, as shown in the following examples.
* Vermont increased its existing Medicaid monthly premiums by $5 or $9
per household depending on income;[Footnote 29] it increased its SCHIP
monthly premiums by $20 per household.[Footnote 30]
* Premiums for newly covered populations of children were added in
Arizona's Medicaid program and Maryland's SCHIP program.[Footnote 31]
Table 14: Changes in States' Premiums for Children in Medicaid and
SCHIP, State Fiscal Year 2001 through August 1, 2003:
Premium changes: States that increased;
Number of states: Medicaid[A]: 5 (Arizona, Arkansas, Massachusetts,
Rhode Island, and Vermont);
Number of states: SCHIP: 11 (Florida, Georgia, Kansas, Massachusetts,
Maryland, Missouri, New Jersey, New Hampshire, Rhode Island, Utah, and
Vermont).
Premium changes: States that decreased;
Number of states: Medicaid[A]: 0;
Number of states: SCHIP: 2 (Kansas and Utah).
Premium changes: States with no changes;
Number of states: Medicaid[A]: 3 (Hawaii, Minnesota, and Wisconsin);
Number of states: SCHIP: 15;
(Alabama, Arizona, California, Connecticut, Delaware, Iowa, Illinois,
Indiana, Maine, Michigan, Nevada, New York, Texas, Washington, and
Wisconsin).
Source: GAO analysis of state survey responses.
[A] One of the states charging premiums for some portion of children in
Medicaid, Tennessee, did not report whether changes were made to the
state's premium requirements.
[End of table]
While no states decreased their premiums for children in Medicaid, two
states--Kansas and Utah--decreased SCHIP premium amounts. For example,
in February 2003, Kansas increased its monthly premium amounts by $20
or $30, depending on family income, and then decreased them by $10 or
$15 dollars a few months later.
Cost Sharing:
Delaware was the only state of the 6 states charging copayments for
children in Medicaid that reported increasing copayment amounts,
compared to 6 of the 25 states charging copayments for children in
SCHIP that reported increasing copayment amounts. (See table 15.)
Delaware added a copayment in Medicaid for nonemergency transportation
services in 2002. As described in the following, of the six states that
reported increasing SCHIP copayment requirements, two increased
existing copayments, and four both increased existing copayments and
added new copayment requirements.
* Missouri and New Hampshire increased existing copayments. For
example, New Hampshire increased copayments for nonemergency use of the
ER from $25 per visit to $50 per visit and increased copayments for
physician visits from $5 to $10.
* Kentucky, Texas, Utah, and West Virginia made multiple changes to
their copayment requirements. For example, Utah added a copayment for
dental services for children in families with incomes at or below 150
percent of the FPL and increased copayment amounts for children in
families with incomes above 150 percent of the FPL.
Table 15: Changes in States' Copayments for Children in Medicaid and
SCHIP, State Fiscal Year 2001 through August 1, 2003:
Copayment changes: States that increased;
Medicaid[A]: 1 (Delaware);
SCHIP: 6 (Kentucky, Missouri, New Hampshire, Texas, Utah, and West
Virginia).
Copayment changes: States that decreased;
Medicaid[A]: 0;
SCHIP: 4 (Colorado, Texas, Utah, and Virginia).
Copayment changes: States with no changes;
Medicaid[A]: 4 (Alaska, Arkansas, Missouri, Wisconsin);
SCHIP: 17 (Alabama, Alaska, Arizona, Arkansas, California, Connecticut,
Florida, Illinois, Indiana, Iowa, Mississippi, Montana, New Jersey, New
Mexico, North Carolina, North Dakota, Wisconsin).
Source: GAO analysis of state survey responses.
[A] One of the states charging copayments for some portion of children
in Medicaid, Tennessee, did not report whether changes were made to the
state's copayment requirements.
[End of table]
While no states reported decreasing copayment amounts for children in
Medicaid, four states did so for SCHIP. Colorado decreased the SCHIP
copayment for nonemergency use of the ER from $5 to $3, and Virginia
decreased copayments for vision exams from $25 to either $2 or $5,
depending on family income. In addition to decreasing copayment
amounts, the remaining two states, Texas and Utah, also increased
copayments during the same period. Texas' changes to copayments varied
by service and family income. For example, the state decreased the
copayment for generic prescription drugs by $1 or $2 for certain SCHIP
beneficiaries, while increasing the copayment for brand name
prescription drugs by between $3 and $10 for these and other
beneficiaries. Copayment increases for other services in Texas ranged
from $3 to $50. Utah decreased SCHIP copayment amounts for children in
families with incomes at or below 150 percent of the FPL by $2 for
physician services, inpatient and outpatient hospital services, and ER
services. The state also increased copayments by $5 for physician and
ER services, and $1 for certain prescription drugs for children in
families with incomes above 150 percent of the FPL.
While none of the states changed coinsurance requirements for children
in Medicaid,[Footnote 32] one of the four states (Alaska, Arkansas,
Colorado, and Utah) that charged coinsurance in SCHIP (Colorado)
increased its coinsurance requirements.
Thirty States Increased and Five States Decreased Beneficiary
Contributions for Adults:
Thirty states reported increasing the amount of beneficiary
contributions charged to some portion of adults in Medicaid. Most of
these states (24) increased copayment amounts; fewer states increased
premiums (12) and coinsurance amounts (2). Five states decreased
beneficiary contribution requirements, specifically with respect to
cost sharing.
Premiums:
From the beginning of their 2001 state fiscal years through August 1,
2003, 12 states reported increasing premiums for some portion of adults
in Medicaid. Half of these states increased the amount of existing
premium requirements.[Footnote 33] For example, Rhode Island increased
monthly premiums from approximately 3 percent of a family's income to
approximately 4 percent,[Footnote 34] and Vermont increased premiums
for certain working individuals with disabilities by $25 to $36 a
month, depending on the individual's income and whether he or she had
other insurance. The other half of these states added new premium
requirements.[Footnote 35] For example, in January 2003, Arizona began
covering working individuals with disabilities, requiring the new
beneficiaries to pay monthly premiums of $15 or $25, depending on their
income. In 2002, Washington added a premium for certain families
covered under transitional Medicaid assistance.[Footnote 36] While a
few states increased premiums for pregnant women, adults with
disabilities, and parents, no states increased premiums for
noninstitutionalized elderly beneficiaries. (See table 16.) No states
decreased premium amounts for adults during this period.
Table 16: States' Changes to Premiums for Adults in Medicaid, State
Fiscal Year 2001 through August 1, 2003:
Population: Pregnant women;
Number of states: Increased premiums: 2;
Number of states: Decreased premiums: 0;
Number of states: No change: 2.
Population: Individuals in nursing homes and institutions;
Number of states: Increased premiums: 0;
Number of states: Decreased premiums: 0;
Number of states: No change: 0.
Population: Noninstitutionalized elderly;
Number of states: Increased premiums: 0;
Number of states: Decreased premiums: 0;
Number of states: No change: 2.
Population: Adults with disabilities;
Number of states: Increased premiums: 10;
Number of states: Decreased premiums: 0;
Number of states: No change: 13.
Population: Medically needy;
Number of states: Increased premiums: 0;
Number of states: Decreased premiums: 0;
Number of states: No change: 0.
Population: Parents;
Number of states: Increased premiums: 3;
Number of states: Decreased premiums: 0;
Number of states: No change: 6.
Source: GAO analysis of state survey responses.
[End of table]
Cost Sharing:
With regard to cost sharing, 25 states reported increasing requirements
for some portion of Medicaid adults. Twenty-two of these states
increased only copayment requirements, one state increased only
coinsurance requirements, and two states increased a combination of
cost sharing requirements.[Footnote 37] States' cost sharing increases
were generally targeted to noninstitutionalized elderly persons, adults
with disabilities, parents and medically needy individuals. (See table
17.) Some states increased the amount of existing cost sharing
requirements, while other states added cost sharing requirements for
new services, as shown in the following examples:
* Both Nebraska and South Carolina increased prescription drug
copayments by $1, and Utah increased copayments for drugs by $2.
* In North Dakota, copayments for inpatient hospitalization increased
from $50 to $75 per stay, and copayments for nonemergency visits to the
ER increased from $3 to $6 per visit.
* Washington implemented a $3 copayment for nonemergency visits to the
ER in July 2002, while Oklahoma added $1 to $3 copayments for certain
services, such as outpatient hospital services.
Table 17: States' Changes to Cost Sharing for Adults in Medicaid, State
Fiscal Year 2001 through August 1, 2003:
Population: Pregnant women;
Number of states: Copayment: Increased: 2;
Number of states: Copayment: Decreased: 0;
Number of states: Copayment: No change: 1;
Number of states: Coinsurance: Increased: 0;
Number of states: Coinsurance: Decreased: 0;
Number of states: Coinsurance: No change: 1.
Population: Individuals in nursing homes and institutions;
Number of states: Copayment: Increased: 1;
Number of states: Copayment: Decreased: 0;
Number of states: Copayment: No change: 0;
Number of states: Coinsurance: Increased: 0;
Number of states: Coinsurance: Decreased: 0;
Number of states: Coinsurance: No change: 0.
Population: Noninstitutionalized elderly persons;
Number of states: Copayment: Increased: 24;
Number of states: Copayment: Decreased: 4;
Number of states: Copayment: No change: 15;
Number of states: Coinsurance: Increased: 2;
Number of states: Coinsurance: Decreased: 1;
Number of states: Coinsurance: No change: 4.
Population: Adults with disabilities;
Number of states: Copayment: Increased: 24;
Number of states: Copayment: Decreased: 4;
Number of states: Copayment: No change: 16;
Number of states: Coinsurance: Increased: 2;
Number of states: Coinsurance: Decreased: 1;
Number of states: Coinsurance: No change: 4.
Population: Medically needy;
Number of states: Copayment: Increased: 17;
Number of states: Copayment: Decreased: 4;
Number of states: Copayment: No change: 11;
Number of states: Coinsurance: Increased: 2;
Number of states: Coinsurance: Decreased: 1;
Number of states: Coinsurance: No change: 2.
Population: Parents;
Number of states: Copayment: Increased: 21;
Number of states: Copayment: Decreased: 3;
Number of states: Copayment: No change: 14;
Number of states: Coinsurance: Increased: 2;
Number of states: Coinsurance: Decreased: 1;
Number of states: Coinsurance: No change: 4.
Source: GAO analysis of state survey responses.
[End of table]
During this same time period, five states reported decreasing copayment
or coinsurance requirements for portions of their adult population.
Specifically, Illinois, Indiana, Maryland, and Montana decreased
copayment amounts for some portion of adults. For example, both
Illinois and Maryland eliminated their $1 copayments for generic
prescription drugs.[Footnote 38] Only Arkansas decreased coinsurance
requirements for adults. In November 2001, the state decreased the
coinsurance amount for inpatient hospitalization for most adults by 12
percent, from 22 percent of the cost of the first day of
hospitalization to 10 percent.[Footnote 39]
Agency Comments:
We asked CMS officials to verify the technical accuracy of the
statutory and regulatory information on Medicaid and SCHIP beneficiary
contributions presented in the background section of this report. These
officials provided technical comments, which we have incorporated as
appropriate. Because we did not evaluate CMS's management of the
Medicaid and SCHIP programs, we did not ask CMS to comment on other
sections of this report.
As agreed with your offices, we plan no further distribution of this
report until 30 days from its date of issue, unless you publicly
announce its contents. At that time, we will send copies of this report
to the Administrator of the Centers for Medicare & Medicaid Services.
We will also make copies available to others upon request. In addition,
the report will be available at no charge on the GAO Web site at http:/
/www.gao.gov.
Please call me on (202) 512-7118 or Carolyn Yocom on (202) 512-4931 if
you have questions about this report. Major contributors to this report
are listed in appendix X.
Signed by:
Kathryn G. Allen:
Director, Health Care--Medicaid and Private Health Insurance Issues:
[End of section]
Appendix I: Service Utilization Rates for Low-Income Individuals:
The medical expenses charged to an individual--particularly for cost
sharing provisions--can vary depending on the amount and type of
services used. The Medical Expenditure Panel Survey (MEPS) provides
data on individuals' annual utilization of medical services. MEPS,
conducted by the Agency for Healthcare Research and Quality (AHRQ),
consists of four surveys, including the Household Component, which
provides nationally representative data and expenditures for the U.S.
civilian noninstitutionalized population. The MEPS Household Component
is a survey of individuals regarding their demographic characteristics,
health insurance coverage, and health care use. At the time of our
analysis, the 2000 version of the MEPS household component was the most
recent version with all of the necessary data available.
To determine service utilization for low-income populations, we
included individuals with incomes below 200 percent of the
FPL.[Footnote 40] For this cohort, we analyzed data for the following
five population groups: (1) children (defined as individuals under age
18), (2) pregnant women aged 18 and over, (3) elderly persons--
individuals aged 65 and over, (4) adults aged 18 to 64 with
disabilities,[Footnote 41] and (5) nondisabled adults aged 18 to 64.
For each of these population groups, we calculated the proportion of
the population that used the following five services--(1) inpatient
hospital, (2) outpatient hospital, (3) physician, (4) prescription
drug, and (5) dental--at least once during the year (see table
18).[Footnote 42] For example, approximately 38 percent of children had
a nonpreventive physician visit during the year, and almost 79 percent
of adults with disabilities visited the physician for nonpreventive
care.
Table 18: Percentage of the Population Below 200 Percent of the FPL Who
Used Selected Services during 2000:
Services: Inpatient hospital (discharges);
Children: 3.9;
Pregnant women: 50.5;
Noninstitutionalized elderly: 19.3;
Adults with disabilities: 26.8;
Nondisabled adults: 6.4.
Services: Outpatient hospital (visits);
Children: 4.8;
Pregnant women: 29.5;
Noninstitutionalized elderly: 27.2;
Adults with disabilities: 28.1;
Nondisabled adults: 9.2.
Services: Office-based physician visits;
Nonpreventive;
Children: 38.1;
Pregnant women: 60.5;
Noninstitutionalized elderly: 68.7;
Adults with disabilities: 78.7;
Nondisabled adults: 39.7.
Services: Office-based physician visits;
Nonemergency;
Children: 56.0;
Pregnant women: 89.7;
Noninstitutionalized elderly: 87.3;
Adults with disabilities: 86.8;
Nondisabled adults: 51.2.
Services: Prescription drugs (prescriptions filled);
Children: 44.8;
Pregnant women: 83.2;
Noninstitutionalized elderly: 89.4;
Adults with disabilities: 96.0;
Nondisabled adults: 54.2.
Services: Dental (visits);
Nonpreventive;
Children: 4.6;
Pregnant women: 11.9;
Noninstitutionalized elderly: 14.2;
Adults with disabilities: 13.1;
Nondisabled adults: 9.2.
Services: Dental (visits);
Nonemergency;
Children: 25.9;
Pregnant women: 25.0;
Noninstitutionalized elderly: 27.3;
Adults with disabilities: 28.4;
Nondisabled adults: 23.1.
Source: GAO analysis of AHRQ's MEPS household component, 2000.
Note: For each service, the data represent the percentage of the
population below 200 percent of the FPL who used that particular
service at least once during the year.
[End of table]
For the individuals in each population group who used a service, we
calculated their average utilization rates for each of the selected
services. The utilization rates for each service, displayed in table
19, represent the average use among individuals who used that
particular service at least once during the year. Additionally, since
federal law generally does not allow states to charge Medicaid cost
sharing for emergency services, we calculated the utilization rates for
nonemergency physician and dental visits by excluding visits classified
in MEPS as emergencies. Similarly, since SCHIP generally does not allow
states with separate SCHIP programs to require cost sharing for
preventive medical or dental visits, we excluded certain types of
visits we considered as preventive, such as well-child exams and dental
visits for teeth cleaning.
Table 19: Average Utilization Rates for Individuals Below 200 Percent
of the FPL Who Used Selected Services during 2000, by Population:
Service: Inpatient hospital (discharges);
Children: 1.18;
Pregnant women: 1.17;
Noninstitutionalized elderly: 1.43;
Adults with disabilities: 1.86;
Nondisabled adults: 1.26.
Service: Outpatient hospital (visits);
Children: 1.99;
Pregnant women: 3.21;
Noninstitutionalized elderly: 5.73;
Adults with disabilities: 7.79;
Nondisabled adults: 3.51.
Service: Office-based physician visits;
Nonpreventive;
Children: 2.94;
Pregnant women: 6.58;
Noninstitutionalized elderly: 5.39;
Adults with disabilities: 8.42;
Nondisabled adults: 4.55.
Service: Office-based physician visits;
Nonemergency;
Children: 3.17;
Pregnant women: 8.91;
Noninstitutionalized elderly: 7.11;
Adults with disabilities: 9.37;
Nondisabled adults: 4.63.
Service: Prescription drugs (prescriptions filled);
Children: 4.22;
Pregnant women: 15.68;
Noninstitutionalized elderly: 25.71;
Adults with disabilities: 32.69;
Nondisabled adults: 11.85.
Service: Dental (visits);
Service: Dental (visits);
Nonpreventive;
Children: 1.58;
Pregnant women: 2.31;
Noninstitutionalized elderly: 2.26;
Adults with disabilities: 2.62;
Nondisabled adults: 2.73.
Service: Dental (visits);
Nonemergency;
Children: 1.60;
Pregnant women: 2.43;
Noninstitutionalized elderly: 2.61;
Adults with disabilities: 2.58;
Nondisabled adults: 2.28.
Source: GAO's analysis of AHRQ's MEPS household component, 2000.
Note: For each service, the data represent the average utilization of
individuals who used that particular service at least once during the
year. For example, among the children who had at least one outpatient
hospital visit during the year, the average was 1.99 visits during the
year.
[End of table]
[End of section]
Appendix II: Premium Requirements for Children in Medicaid and SCHIP,
by State, as of August 1, 2003:
[See PDF for image]
Note: In our survey, states were asked to indicate what portion of the
population was charged premiums by selecting "all," "most," "some," or
"none.":
[A] State only charged premiums to some portion of children with
special needs.
[B] State did not charge premiums, but had an enrollment fee.
[C] Tennessee, which operates its entire Medicaid program under an 1115
waiver, charged premiums for some children in families with incomes at
or above the FPL.
[D] Tennessee did not have a SCHIP program.
[E] Texas also had an enrollment fee.
[End of figure]
[End of section]
Appendix III: Premium Amounts for Children in Medicaid and SCHIP, by
State, as of August 1, 2003:
Medicaid:
State: Arizona;
Lowest percentage of the FPL at which state charged premiums[A]: 100;
Lowest percentage of the FPL at which state charged premiums[A]: $15 or
$25;
Unit charged[C]: Individual.
State: Arkansas;
Lowest percentage of the FPL at which state charged premiums[A]:
Varied[D];
Lowest percentage of the FPL at which state charged premiums[A]: $21 to
$458[E];
Unit charged[C]: Family.
State: Hawaii;
Lowest percentage of the FPL at which state charged premiums[A]: >200;
Lowest percentage of the FPL at which state charged premiums[A]: $60;
Unit charged[C]: Individual.
State: Massachusetts;
Lowest percentage of the FPL at which state charged premiums[A]: >150;
Lowest percentage of the FPL at which state charged premiums[A]: $12
per child with $36 family maximum;
or $15 to over $928;
or 60% to 85% of full premium[F];
Unit charged[C]: Individual and family.
State: Minnesota;
Lowest percentage of the FPL at which state charged premiums[A]: [G];
Lowest percentage of the FPL at which state charged premiums[A]: $4 to
$300 per individual;
$8 to $900 per family[H];
Unit charged[C]: Individual or family.
State: Rhode Island;
Lowest percentage of the FPL at which state charged premiums[A]: 150;
Lowest percentage of the FPL at which state charged premiums[A]: $61 to
$92;
Unit charged[C]: Family.
State: Tennessee;
Lowest percentage of the FPL at which state charged premiums[A]: 100;
Lowest percentage of the FPL at which state charged premiums[A]: $20 to
$550 for an individual;
$40 to $1,375 for a family[I];
Unit charged[C]: Individual or family.
State: Vermont;
Lowest percentage of the FPL at which state charged premiums[A]: 185;
Lowest percentage of the FPL at which state charged premiums[A]: $25 or
$35;
Unit charged[C]: Household.
State: Wisconsin;
Lowest percentage of the FPL at which state charged premiums[A]: >150;
Lowest percentage of the FPL at which state charged premiums[A]: $30 to
over $360[J];
Unit charged[C]: Individual.
SCHIP:
State: Alabama;
Lowest percentage of the FPL at which state charged premiums[A]: >150;
Range of premium amounts[B]: $50 annual premium per child with a $150
family maximum;
Unit charged[C]: Individual and family.
State: Arizona;
Lowest percentage of the FPL at which state charged premiums[A]: >150;
Range of premium amounts[B]: $10 per child;
$15 for more than 1 child;
Unit charged[C]: Family.
State: California;
Lowest percentage of the FPL at which state charged premiums[A]:
>100[K];
Range of premium amounts[B]: $4 or $9;
Unit charged[C]: Individual.
State: Connecticut;
Lowest percentage of the FPL at which state charged premiums[A]: >235;
Range of premium amounts[B]: $30 per child, with a $50 per family
maximum;
Unit charged[C]: Individual and family.
State: Delaware;
Lowest percentage of the FPL at which state charged premiums[A]: 101;
Range of premium amounts[B]: $10 or $25;
Unit charged[C]: Family.
State: Florida;
Lowest percentage of the FPL at which state charged premiums[A]: 100;
Range of premium amounts[B]: $10 to $20;
Unit charged[C]: Household.
State: Illinois;
Lowest percentage of the FPL at which state charged premiums[A]: 150;
Range of premium amounts[B]: $15 to $30;
Unit charged[C]: Individual.
State: Indiana;
Lowest percentage of the FPL at which state charged premiums[A]: >150;
Range of premium amounts[B]: $11 to $25;
Unit charged[C]: Family.
State: Iowa;
Lowest percentage of the FPL at which state charged premiums[A]: >150;
Range of premium amounts[B]: $10 per child with a $20 family maximum;
Unit charged[C]: Individual and family.
State: Kansas;
Lowest percentage of the FPL at which state charged premiums[A]: 151;
Range of premium amounts[B]: $10 or $15;
Unit charged[C]: Family.
State: Maine;
Lowest percentage of the FPL at which state charged premiums[A]: >150;
Range of premium amounts[B]: $5 to $20 for 1 child;
$10 to $40 for more than 1 child;
Unit charged[C]: Individual or household.
State: Maryland;
Lowest percentage of the FPL at which state charged premiums[A]: >185;
Range of premium amounts[B]: $37 to $50;
Unit charged[C]: Family.
State: Massachusetts;
Lowest percentage of the FPL at which state charged premiums[A]: >150;
Range of premium amounts[B]: $12 per child with a $36 family maximum;
or $15 to $35;
or 60% of full premium;
Unit charged[C]: Individual or family.
State: Michigan;
Lowest percentage of the FPL at which state charged premiums[A]: >150;
Range of premium amounts[B]: $5;
Unit charged[C]: Family.
State: Missouri;
Lowest percentage of the FPL at which state charged premiums[A]: 226;
Range of premium amounts[B]: $59 to $225[L];
Unit charged[C]: Family.
State: Nevada;
Lowest percentage of the FPL at which state charged premiums[A]: 100;
Range of premium amounts[B]: $10 to $50;
Unit charged[C]: Household.
State: New Hampshire;
Lowest percentage of the FPL at which state charged premiums[A]: 185;
Range of premium amounts[B]: $25 to $100;
Unit charged[C]: Individual.
State: New Jersey;
Lowest percentage of the FPL at which state charged premiums[A]: 200;
Range of premium amounts[B]: $16.50 to $110;
Unit charged[C]: Family.
State: New York;
Lowest percentage of the FPL at which state charged premiums[A]: 133;
Range of premium amounts[B]: $9 or $15 per individual;
$27 or $45 per family;
Unit charged[C]: Individual or family.
State: Rhode Island;
Lowest percentage of the FPL at which state charged premiums[A]: 150;
Range of premium amounts[B]: $61 to $92;
Unit charged[C]: Family.
State: Texas;
Lowest percentage of the FPL at which state charged premiums[A]: 151;
Range of premium amounts[B]: $15 to $18;
Unit charged[C]: Family.
State: Utah;
Lowest percentage of the FPL at which state charged premiums[A]: 225;
Range of premium amounts[B]: $70;
Unit charged[C]: Household.
State: Washington;
Lowest percentage of the FPL at which state charged premiums[A]:
>200[M];
Range of premium amounts[B]: $10 per individual with $30 family
maximum;
Unit charged[C]: Individual or family.
State: Wisconsin;
Lowest percentage of the FPL at which state charged premiums[A]: >150;
Range of premium amounts[B]: $30 to $360[J];
Unit charged[C]: Family.
Source: GAO analysis of state survey responses and documentation
provided by states.
[A] In 2003, the FPL for an individual equated to $8,980 per year and
$15,260 for a family of three in the 48 contiguous states and the
District of Columbia.
[B] Premiums were paid on a monthly basis unless otherwise noted.
[C] In Medicaid and SCHIP, states determine premium charges for an
individual, family unit, or household (individuals living in the same
house).
[D] Arkansas charged premiums to children in a family of any size with
an income above $25,000. The estimated equivalent percentage of FPL at
which the state began charging children could have ranged from 120
percent for a family of five to 300 percent based on a family size of 1.
[E] In Arkansas, the highest premium amount, $458 per month, would be
charged to a child from a family whose income exceeded $200,000 per
year.
[F] In Massachusetts, premiums of $928 or more per month would be
charged to a child from a family whose income exceeded 1,000 percent of
the FPL, which equated to approximately $153,000 per year for a family
of three. Other individuals with other health insurance coverage can be
charged a percentage of premiums in order to obtain supplemental
coverage.
[G] In Minnesota, families could choose to enroll their children in
either the state's regular Medicaid program or its 1115 waiver program -
both of which covered children from families with incomes up to 275
percent of the FPL. Children in families that chose to enroll in the
1115 waiver program were charged premiums regardless of their family
income. Thus, families with incomes less than 1 percent of the FPL
could choose to pay premiums.
[H] In Minnesota, the highest premium amount, $900 per family per
month, would be charged to a family whose income was at least 275
percent of the FPL, which equates to approximately $42,000 per year for
a family of three.
[I] In Tennessee, the highest premium amount, $1,375 per month, would
be charged to a family of three whose income was at least 600 percent
of the FPL, which equated to approximately $91,600 per year.
[J] In Wisconsin, monthly premiums of $360 and above would be charged
to a child from a family whose annual income was at least $144,000.
[K] The percentage represents an estimated equivalent for the monthly
income figures that California provided based on one family member in
2003.
[L] In Missouri, the highest premium amount, $225 per month, would be
charged to a family of six or more whose income exceeds $61,700 per
year.
[M] The percentage represents an estimated equivalent for the monthly
income figures that Washington provided based on one family member in
2003.
[End of table]
[End of section]
Appendix IV: Copayment Requirements for Children in Medicaid and SCHIP,
by State, as of August 1, 2003:
[See PDF for image]
Note: In our survey, states were asked to indicate what portion of the
population was charged copayments by selecting "all," "most," "some,"
or "none.":
[A] Arkansas charged copayments to all children in its 1115 waiver
program, but did not charge copayments to other children.
[B] Delaware's only copayment, which the state charged to all
populations in its Medicaid program, was for nonemergency
transportation services.
[C] Although Delaware did not charge copayments to children in SCHIP,
the state did charge a fee for inappropriate use of the emergency room.
[D] Maryland's SCHIP program did not charge copayments, but SCHIP
beneficiaries receiving coverage through Maryland's employer-sponsored
insurance program may be charged copayments by their health plan.
[E] Tennessee, which operates its entire Medicaid program under an 1115
waiver, charged copayments for some children in families with incomes
at or above the FPL.
[F] Tennessee did not have a SCHIP program.
[End of figure]
[End of section]
Appendix V: Cost Sharing Amounts for Children in Medicaid and SCHIP, by
State, as of August 1, 2003:
Medicaid:
State: Alaska;
Inpatient hospital[A]: $50 per day (maximum of $200 per discharge);
Outpatient hospital[A]: 5% of allowable charges;
Physician services[A]: $3;
Prescription drugs[B]: $2;
Nonemergency use of emergency room[A]: 5% of allowable charges;
Dental services[A]: NA.
State: Arkansas;
Inpatient hospital[A]: 20% of the cost of the first day;
Outpatient hospital[A]: $10;
Physician services[A]: $10;
Prescription drugs[B]: $5;
Nonemergency use of emergency room[A]: $10;
Dental services[A]: $10.
State: Delaware[C];
Inpatient hospital[A]: NA;
Outpatient hospital[A]: NA;
Physician services[A]: NA;
Prescription drugs[B]: NA;
Nonemergency use of emergency room[A]: NA;
Dental services[A]: NA.
State: Missouri;
Inpatient hospital[A]: $10;
Outpatient hospital[A]: $2;
Physician services[A]: $1;
Prescription drugs[B]: [D];
Nonemergency use of emergency room[A]: $1 or $2;
Dental services[A]: 5% for dentures;
$0.50 to $3 for other services.
State: Tennessee;
Inpatient hospital[A]: $100 or $200;
Outpatient hospital[A]: NA;
Physician services[A]: $5 to $25;
Prescription drugs[B]: $5 or $10;
Nonemergency use of emergency room[A]: $25 or $50;
Dental services[A]: $15 or $25.
State: Wisconsin;
Inpatient hospital[A]: $3;
Outpatient hospital[A]: $3;
Physician services[A]: $1 to $3;
Prescription drugs[B]: $0.50 or $1;
Nonemergency use of emergency room[A]: $3;
Dental services[A]: $0.50 to $3.
SCHIP:
State: Alabama;
Inpatient hospital[A]: $5;
Outpatient hospital[A]: $5;
Physician services[A]: $5;
Prescription drugs[B]: $1 or $3;
Nonemergency use of emergency room[A]: $5;
Dental services[A]: $5.
State: Arizona;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: NA;
Physician services[A]: NA;
Prescription drugs[B]: NA;
Nonemergency use of emergency room[A]: $5;
Dental services[A]: NA.
State: Alaska;
Inpatient hospital[A]: $50 per day (maximum of $200 per discharge);
Outpatient hospital[A]: 5% of allowable charges;
Physician services[A]: $3;
Prescription drugs[B]: $2;
Nonemergency use of emergency room[A]: 5% of allowable charges;
Dental services[A]: NA.
State: Arkansas;
Inpatient hospital[A]: 20% of the cost of the first day;
Outpatient hospital[A]: $10;
Physician services[A]: $10;
Prescription drugs[B]: $5;
Nonemergency use of emergency room[A]: $10;
Dental services[A]: $10.
State: California;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: $5;
Physician services[A]: $5;
Prescription drugs[B]: $5;
Nonemergency use of emergency room[A]: $5[E];
Dental services[A]: $5 per service.
State: Colorado;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: $2 or $5;
Physician services[A]: $2 or $5;
Prescription drugs[B]: $1 to $5;
Nonemergency use of emergency room[A]: $3 or $15;
Dental services[A]: coinsurance not to exceed $5 per non-routine
service.
State: Connecticut;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: $5;
Physician services[A]: $5;
Prescription drugs[B]: $3 to $6;
Nonemergency use of emergency room[A]: $25;
Dental services[A]: $5.
State: Florida;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: $3;
Physician services[A]: $3;
Prescription drugs[B]: $3;
Nonemergency use of emergency room[A]: $10;
Dental services[A]: NA.
State: Illinois;
Inpatient hospital[A]: $2 or $5;
Outpatient hospital[A]: $2 or $5;
Physician services[A]: $2 or $5;
Prescription drugs[B]: $2 to $5;
Nonemergency use of emergency room[A]: $25;
Dental services[A]: $2 or $5.
State: Indiana;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: NA;
Physician services[A]: NA;
Prescription drugs[B]: $3 or $10;
Nonemergency use of emergency room[A]: NA;
Dental services[A]: NA.
State: Iowa;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: NA;
Physician services[A]: NA;
Prescription drugs[B]: NA;
Nonemergency use of emergency room[A]: $25;
Dental services[A]: NA.
State: Kentucky;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: NA;
Physician services[A]: $2;
Prescription drugs[B]: $1;
Nonemergency use of emergency room[A]: NA;
Dental services[A]: $2.
State: Mississippi;
Inpatient hospital[A]: $5;
Outpatient hospital[A]: $5;
Physician services[A]: $5;
Prescription drugs[B]: NA;
Nonemergency use of emergency room[A]: $15;
Dental services[A]: $5.
State: Missouri;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: $5 or $10;
Physician services[A]: $5 or $10;
Prescription drugs[B]: $9;
Nonemergency use of emergency room[A]: $5 or $10;
Dental services[A]: $5 or $10.
State: Montana;
Inpatient hospital[A]: $25;
Outpatient hospital[A]: $5;
Physician services[A]: $3;
Prescription drugs[B]: $3 or $5;
Nonemergency use of emergency room[A]: $5;
Dental services[A]: NA.
State: New Hampshire;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: NA;
Physician services[A]: $10;
Prescription drugs[B]: $5 or $10;
Nonemergency use of emergency room[A]: $50;
Dental services[A]: NA.
State: New Jersey;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: $5;
Physician services[A]: $5 or $10;
Prescription drugs[B]: $1 to $10;
Nonemergency use of emergency room[A]: $1 to $10;
Dental services[A]: NA.
State: New Mexico;
Inpatient hospital[A]: $25;
Outpatient hospital[A]: $5;
Physician services[A]: $5;
Prescription drugs[B]: $2;
Nonemergency use of emergency room[A]: $15;
Dental services[A]: $5.
State: North Carolina;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: $5;
Physician services[A]: $5;
Prescription drugs[B]: $6;
Nonemergency use of emergency room[A]: $20;
Dental services[A]: $5.
State: North Dakota;
Inpatient hospital[A]: $50;
Outpatient hospital[A]: NA;
Physician services[A]: NA;
Prescription drugs[B]: $2;
Nonemergency use of emergency room[A]: $5;
Dental services[A]: NA.
State: Texas;
Inpatient hospital[A]: $100;
Outpatient hospital[A]: NA;
Physician services[A]: $10;
Prescription drugs[B]: $3 to $20;
Nonemergency use of emergency room[A]: $3 to $50;
Dental services[A]: NA.
State: Utah;
Inpatient hospital[A]: $3 or 10% of allowable charges[F];
Outpatient hospital[A]: $3 or 10% of allowable charges[F];
Physician services[A]: $3 or $15[F];
Prescription drugs[B]: $1 to $5 or 50% of allowable charges[F];
Nonemergency use of emergency room[A]: $3 or $35[F];
Dental services[A]: $3 or 20% of allowable charges[F].
State: Virginia;
Inpatient hospital[A]: $15 or $25;
Outpatient hospital[A]: $2 or $5;
Physician services[A]: $2 or $5;
Prescription drugs[B]: $2 or $5;
Nonemergency use of emergency room[A]: $10 or $25;
Dental services[A]: $5.
State: West Virginia;
Inpatient hospital[A]: $25;
Outpatient hospital[A]: $25 per procedure;
Physician services[A]: $15;
Prescription drugs[B]: $5 to $15;
Nonemergency use of emergency room[A]: $35;
Dental services[A]: NA.
State: Wisconsin;
Inpatient hospital[A]: $3;
Outpatient hospital[A]: $3;
Physician services[A]: $1 to $3;
Prescription drugs[B]: $0.50 to $1;
Nonemergency use of emergency room[A]: $3;
Dental services[A]: $0.50 to $3.
Source: GAO analysis of state survey responses and documentation
provided by states.
NA = Not applicable. The state did not charge cost sharing for this
service.
Note: This appendix reflects cost sharing amounts charged by states for
the portion of the Medicaid and SCHIP populations subject to cost
sharing charges. The amount of cost sharing and the services subject to
cost sharing may vary within a state by population. See Appendix IV for
details on the portion of children subject to copayment requirements in
Medicaid and SCHIP.
[A] Cost sharing amount is on a per visit or per admission basis unless
otherwise noted.
[B] Cost sharing amount is on a per prescription basis unless otherwise
noted.
[C] Delaware charged a $1 copayment for nonemergency transportation.
[D] Missouri did not have a copayment for prescription drugs in
Medicaid, but some children were charged a dispensing fee for
prescriptions.
[E] California charged a $5 copayment for emergency services, which is
waived if the beneficiary is hospitalized. However, the state did not
cover nonemergency services provided in the emergency room.
[F] Utah SCHIP charged a copayment for children with a family income at
or below 150 percent FPL and charged copayment or coinsurance for
children in a family with a higher income level.
[End of table]
[End of section]
Appendix VI: Premiums for Adult Populations in Medicaid, by State, as
of August 1, 2003:
[See PDF for image]
Notes: In our survey, states were asked to indicate what portion of the
population was charged premiums by selecting "all," "most," "some," or
"none." They were also asked to designate if Medicaid did not cover a
population in their state.
The following states did not charge premiums to any adults in Medicaid:
Alabama, Arkansas, Colorado, Delaware, District of Columbia, Florida,
Georgia, Idaho, Kentucky, Louisiana, Maryland, Michigan, Montana,
Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota,
Ohio, Oklahoma, South Carolina, South Dakota, Texas, Virginia, and West
Virginia.
[A] This population includes working adults with disabilities. States
may require premiums from certain working adults with disabilities who
received Medicaid coverage under the Balanced Budget Act of 1997 or the
Ticket to Work and Work Incentives Improvement Act of 1999.
[B] Population not covered in the state's Medicaid program.
[C] State charged premiums to all working individuals with
disabilities, but did not charge premiums to other adults with
disabilities.
[D] State charged premiums to some portion of childless adults.
[E] Maine charged premiums to individuals in the state's HIV/AIDS
waiver program.
[F] Tennessee, which operates its entire Medicaid program under an 1115
waiver, charged premiums to some adults enrolled in the state's 1115
waiver program who had incomes at or above the poverty level.
[G] Not applicable: Tennessee did not report information based on these
population groups.
[H] Utah charged an enrollment fee to all adults enrolled in the
state's primary care waiver program.
[I] Vermont charged premiums to some adults enrolled in the state's
1115 waiver program.
[End of figure]
[End of section]
Appendix VII: Premium Amounts for Adults in Medicaid, by State, as of
August 1, 2003:
State: Alaska;
Lowest percentage of the FPL at which state charged premiums[A]: 100;
Range of premium amounts[B]: Formula based on family income;
Unit charged: Individual.
State: Arizona;
Lowest percentage of the FPL at which state charged premiums[A]: 100;
Range of premium amounts[B]: $15 or $25;
Unit charged: Individual.
State: California;
Lowest percentage of the FPL at which state charged premiums[A]: [C];
Range of premium amounts[B]: $20 to $250 for an individual;
$30 to $375 for a couple;
Unit charged: Individual or couple.
State: Connecticut;
Lowest percentage of the FPL at which state charged premiums[A]: >200;
Range of premium amounts[B]: 10% of monthly income exceeding 200% of
the FPL;
Unit charged: Individual and spouse.
State: Hawaii;
Lowest percentage of the FPL at which state charged premiums[A]: [C];
Range of premium amounts[B]: $30, $60, or amount varied[D];
Unit charged: Individual.
State: Illinois;
Lowest percentage of the FPL at which state charged premiums[A]: >250;
Range of premium amounts[B]: $6 to $100;
Unit charged: Individual.
State: Indiana;
Lowest percentage of the FPL at which state charged premiums[A]: 150;
Range of premium amounts[B]: $48 to $187 for an individual;
$65 to $254 for a couple;
Unit charged: Individual or couple.
State: Iowa;
Lowest percentage of the FPL at which state charged premiums[A]: >150;
Range of premium amounts[B]: $20 to $201;
Unit charged: Individual.
State: Kansas;
Lowest percentage of the FPL at which state charged premiums[A]: 100;
Range of premium amounts[B]: $55 to $152 for an individual;
$74 to $205 for a couple;
Unit charged: Individual or couple.
State: Maine;
Lowest percentage of the FPL at which state charged premiums[A]:
150[E];
Range of premium amounts[B]: $10 to $40;
3% of family income[E];
Unit charged: Individual or family.
State: Massachusetts;
Lowest percentage of the FPL at which state charged premiums[A]: >100[E];
Range of premium amounts[B]: $15 to over $928;
60 to 85% of full premium[F];
Unit charged: Individual or family.
State: Minnesota;
Lowest percentage of the FPL at which state charged premiums[A]: [C];
Range of premium amounts[B]: $4 to $900[G];
Unit charged: Individual, family, or household.
State: Mississippi;
Lowest percentage of the FPL at which state charged premiums[A]: 150;
Range of premium amounts[B]: $55 to $91 for an individual;
$75 to $122 for a couple;
Unit charged: Individual or couple.
State: Missouri;
Lowest percentage of the FPL at which state charged premiums[A]: >150;
Range of premium amounts[B]: Formula based on income;
Unit charged: Individual.
State: Nebraska;
Lowest percentage of the FPL at which state charged premiums[A]: 100[E];
Range of premium amounts[B]: $31 to $183 for an individual;
$41 to $247 for a couple;
$22 to $139 for a household;
Unit charged: Individual, couple, or household.
State: New Hampshire;
Lowest percentage of the FPL at which state charged premiums[A]: 150;
Range of premium amounts[B]: $80 to $220;
Unit charged: Individual.
State: Oregon;
Lowest percentage of the FPL at which state charged premiums[A]: [C];
Range of premium amounts[B]: $6 to $20;
Unit charged: Individual.
State: Pennsylvania;
Lowest percentage of the FPL at which state charged premiums[A]: [H];
Range of premium amounts[B]: 5% of income;
Unit charged: Individual.
State: Rhode Island;
Lowest percentage of the FPL at which state charged premiums[A]: 150[E];
Range of premium amounts[B]: $61 to $92;
Unit charged: Family.
State: Tennessee;
Lowest percentage of the FPL at which state charged premiums[A]: 100;
Range of premium amounts[B]: $20 to $550 for an individual;
$40 to $1,375 for a family[I];
Unit charged: Individual or family.
State: Utah;
Lowest percentage of the FPL at which state charged premiums[A]: 100;
Range of premium amounts[B]: 15% of income;
Unit charged: Individual.
State: Vermont;
Lowest percentage of the FPL at which state charged premiums[A]: >50[E];
Range of premium amounts[B]: $10 semi-annually to $75 per month;
Unit charged: Individual or household.
State: Washington;
Lowest percentage of the FPL at which state charged premiums[A]: 11[E];
Range of premium amounts[B]: Formula based on income;
Unit charged: Individual or household.
State: Wisconsin;
Lowest percentage of the FPL at which state charged premiums[A]: >150;
Range of premium amounts[B]: $25 to $1000[J] ;
$30 to $300;
Unit charged: Individual or family.
State: Wyoming;
Lowest percentage of the FPL at which state charged premiums[A]: 100;
Range of premium amounts[B]: Formula based on income;
Unit charged: Individual.
Source: GAO analysis of state survey responses and documentation
provided by states.
Notes: The following states did not charge premiums to any adults in
Medicaid: Alabama, Arkansas, Colorado, Delaware, District of Columbia,
Florida, Georgia, Idaho, Kentucky, Louisiana, Maryland, Michigan,
Montana, Nevada, New Jersey, New Mexico, New York, North Carolina,
North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Texas,
Virginia, and West Virginia.
This appendix reflects the range in premiums states charged across
their entire adult population.
[A] In 2003, the FPL for an individual equated to $8,980 per year and
$15,260 for a family of three in the 48 contiguous states and the
District of Columbia.
[B] Unless otherwise noted, premiums were paid on a monthly basis.
Additionally, states have discretion in defining income for purposes of
eligibility determination.
[C] The lowest income level at which an adult could be charged premiums
in this state's Medicaid program equated to less than one percent of
the FPL. However, for certain populations, there were higher income
thresholds at which the state began charging premiums.
[D] In Hawaii, the premium amount for certain individuals varied based
on the individual's age, gender, geographic location and health plan.
[E] Represents the lowest income level at which an adult could be
charged premiums in this state's Medicaid program. However, for certain
populations there were higher income thresholds at which the state
began charging premiums.
[F] In Massachusetts, premiums of $928 or more per month would be
charged to a child from a family whose income exceeded 1,000 percent of
the FPL, which equated to approximately $153,000 per year for a family
of three. Other individuals with other health insurance coverage can be
charged a percentage of premiums in order to obtain supplemental
coverage.
[G] In Minnesota, the highest premium amount, $900 per family per
month, would be charged to a family whose income was at least 275
percent of the FPL, which equated to approximately $42,000 per year for
a family of three.
[H] Pennsylvania charged premiums only for working individuals with
disabilities whose incomes were below 250 percent of the FPL.
[I] The highest premium amount, $1,375 per month, would be charged to a
family whose income was at least 600 percent of the FPL, which equated
to approximately $91,600 per year.
[J] The highest premium amounts were for certain working individuals
with disabilities. The premium amount charged was approximately three
percent of the individual's earned income and all of the individual's
unearned income after disregarding certain living and medical expenses.
[End of table]
[End of section]
Appendix VIII: Copayment Requirements for Adults in Medicaid, by State,
as of August 1, 2003:
[See PDF for image]
Notes: In our survey, states were asked to indicate what portion of the
population was charged cost sharing by selecting "all," "most," "some,"
or "none." They were also asked to designate if a population was not
covered by their states' Medicaid program.
The following states did not charge copayments to any adults in
Medicaid: Hawaii, Idaho, Michigan, Nevada, New Jersey, Ohio, Rhode
Island, and Texas.
[A] Population not covered in the state's Medicaid program.
[B] Alaska also charged copayments to all individuals qualifying for
transitional Medicaid assistance.
[C] Delaware's only copayment, which the state charged to all
populations in its Medicaid program, was for nonemergency
transportation services.
[D] Maine also charged copayments to all individuals enrolled in its
HIV/AIDs waiver program and all individuals in its comprehensive 1115
waiver program.
[E] In addition, individuals participating in the Missouri's 1115
waiver program, which extends 12 months of additional coverage to
working parents or caretakers, were also charged copayments. As of
January 2004, this program had approximately 2,400 beneficiaries.
[F] Nebraska also charged copayments to most individuals in its refugee
resettlement program.
[G] Oregon also charged copayments to most childless adults.
[H] Pennsylvania also charged copayments to most adults in its general
assistance program.
[I] State also charged copayments to all individuals in its state's
Medicaid pharmacy program.
[J] Tennessee, which operates its entire Medicaid program under an 1115
waiver, charged copayments to some adults enrolled in the state's 1115
waiver program who had incomes at or above the poverty level.
[K] Not applicable: Tennessee did not report information based on these
population groups.
[L] Utah also charged copayments to all individuals enrolled in its
primary care waiver program.
[M] Vermont also charged copayments to all individuals enrolled in its
1115 waiver program.
[End of figure]
[End of section]
Appendix IX: Cost Sharing Amounts for Adults in Medicaid, by State, as
of August 1, 2003:
State: Alabama;
Inpatient hospital[A]: $50;
Outpatient hospital[A]: $3;
Physician services[A]: $1;
Prescription drugs[B]: $0.50 to $3;
Nonemergency use of the emergency room[A]: $3;
Dental services[A]: NA.
State: Alaska;
Inpatient hospital[A]: $50 per day ($200 maximum per discharge);
Outpatient hospital[A]: 5% of allowable charges;
Physician services[A]: $3;
Prescription drugs[B]: $2;
Nonemergency use of the emergency room[A]: 5% of allowable charges;
Dental services[A]: NA.
State: Arizona;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: NA;
Physician services[A]: $1;
Prescription drugs[B]: NA;
Nonemergency use of the emergency room[A]: $5;
Dental services[A]: NA.
State: Arkansas;
Inpatient hospital[A]: 10% to 25% of per diem amount;
Outpatient hospital[A]: $10;
Physician services[A]: $10;
Prescription drugs[B]: $0.50 to $15;
Nonemergency use of the emergency room[A]: $10;
Dental services[A]: $10.
State: California;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: $1;
Physician services[A]: $1;
Prescription drugs[B]: $1;
Nonemergency use of the emergency room[A]: $5;
Dental services[A]: NA.
State: Colorado;
Inpatient hospital[A]: $15;
Outpatient hospital[A]: $3;
Physician services[A]: $2;
Prescription drugs[B]: $0.75 or $3;
Nonemergency use of the emergency room[A]: $3;
Dental services[A]: NA.
State: Connecticut;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: NA;
Physician services[A]: NA;
Prescription drugs[B]: $1;
Nonemergency use of the emergency room[A]: NA;
Dental services[A]: NA.
State: Delaware[C];
Inpatient hospital[A]: NA;
Outpatient hospital[A]: NA;
Physician services[A]: NA;
Prescription drugs[B]: NA;
Nonemergency use of the emergency room[A]: NA;
Dental services[A]: NA.
State: District of Columbia;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: NA;
Physician services[A]: NA;
Prescription drugs[B]: $1;
Nonemergency use of the emergency room[A]: NA;
Dental services[A]: NA.
State: Florida;
Inpatient hospital[A]: $3;
Outpatient hospital[A]: $3;
Physician services[A]: $2 per day per provider;
Prescription drugs[B]: NA;
Nonemergency use of the emergency room[A]: NA;
Dental services[A]: 5% of charges.
State: Georgia;
Inpatient hospital[A]: $12.50;
Outpatient hospital[A]: $3;
Physician services[A]: $2;
Prescription drugs[B]: $0.50;
Nonemergency use of the emergency room[A]: $3;
Dental services[A]: NA.
State: Illinois;
Inpatient hospital[A]: $2 or $3 per day[D];
Outpatient hospital[A]: NA;
Physician services[A]: $2;
Prescription drugs[B]: $1 to $3;
Nonemergency use of the emergency room[A]: NA;
Dental services[A]: NA.
State: Indiana;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: NA;
Physician services[A]: NA;
Prescription drugs[B]: $0.50 to $3;
Nonemergency use of the emergency room[A]: $1 to $2;
Dental services[A]: NA.
State: Iowa;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: NA;
Physician services[A]: $3;
Prescription drugs[B]: $0.50 to $3;
Nonemergency use of the emergency room[A]: NA;
Dental services[A]: $3.
State: Kansas;
Inpatient hospital[A]: $48;
Outpatient hospital[A]: $3;
Physician services[A]: $2;
Prescription drugs[B]: $3;
Nonemergency use of the emergency room[A]: NA;
Dental services[A]: $3.
State: Kentucky;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: NA;
Physician services[A]: $2;
Prescription drugs[B]: $1;
Nonemergency use of the emergency room[A]: NA;
Dental services[A]: $2.
State: Louisiana;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: NA;
Physician services[A]: NA;
Prescription drugs[B]: $0.50 to $3;
Nonemergency use of the emergency room[A]: NA;
Dental services[A]: NA.
State: Maine;
Inpatient hospital[A]: $0.50 to $3[E];
Outpatient hospital[A]: $0.50 to $3[E];
Physician services[A]: $0.50 to $3[E];
Prescription drugs[B]: $2.50 to $10;
Nonemergency use of the emergency room[A]: NA;
Dental services[A]: NA.
State: Maryland;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: NA;
Physician services[A]: NA;
Prescription drugs[B]: $2 to $7.50;
Nonemergency use of the emergency room[A]: NA;
Dental services[A]: NA.
State: Massachusetts;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: NA;
Physician services[A]: NA;
Prescription drugs[B]: $2;
Nonemergency use of the emergency room[A]: NA;
Dental services[A]: NA.
State: Minnesota;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: NA;
Physician services[A]: NA;
Prescription drugs[B]: $3;
Nonemergency use of the emergency room[A]: NA;
Dental services[A]: 50% of payment rate.
State: Mississippi;
Inpatient hospital[A]: $10 per day (maximum of one- half of first day
per diem);
Outpatient hospital[A]: $3;
Physician services[A]: $3;
Prescription drugs[B]: $1 or $3;
Nonemergency use of the emergency room[A]: $3;
Dental services[A]: $3.
State: Missouri;
Inpatient hospital[A]: $10;
Outpatient hospital[A]: $2 or $10[F];
Physician services[A]: $1[G] or $10f;
Prescription drugs[B]: $0.50 to $2 or $5[F];
Nonemergency use of the emergency room[A]: $1 or $2;
Dental services[A]: $0.50 to $3 or 5% of charges or $10[F].
State: Montana;
Inpatient hospital[A]: $100;
Outpatient hospital[A]: $5;
Physician services[A]: $4;
Prescription drugs[B]: $1 to $5;
Nonemergency use of the emergency room[A]: $5;
Dental services[A]: $3.
State: Nebraska;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: $3;
Physician services[A]: $2;
Prescription drugs[B]: $2 per person;
Nonemergency use of the emergency room[A]: NA;
Dental services[A]: $3 per service.
State: New Hampshire;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: NA;
Physician services[A]: NA;
Prescription drugs[B]: $0.50 or $1;
Nonemergency use of the emergency room[A]: NA;
Dental services[A]: NA.
State: New Mexico;
Inpatient hospital[A]: $25;
Outpatient hospital[A]: $5;
Physician services[A]: $5;
Prescription drugs[B]: $2;
Nonemergency use of the emergency room[A]: $15;
Dental services[A]: $5.
State: New York;
Inpatient hospital[A]: $25 per visit with an overnight stay;
Outpatient hospital[A]: $3;
Physician services[A]: NA;
Prescription drugs[B]: $0.50 or $2;
Nonemergency use of the emergency room[A]: $3;
Dental services[A]: NA.
State: North Carolina;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: $3;
Physician services[A]: $3;
Prescription drugs[B]: $1 or $3;
Nonemergency use of the emergency room[A]: NA;
Dental services[A]: $3 per service.
State: North Dakota;
Inpatient hospital[A]: $50;
Outpatient hospital[A]: $1 or $2;
Physician services[A]: $2;
Prescription drugs[B]: $3 (brand name only);
Nonemergency use of the emergency room[A]: $3;
Dental services[A]: $2.
State: Oklahoma;
Inpatient hospital[A]: $3 per day;
Outpatient hospital[A]: $3 per day;
Physician services[A]: $1 per service;
Prescription drugs[B]: $1 or $2;
Nonemergency use of the emergency room[A]: NA;
Dental services[A]: NA.
State: Oregon;
Inpatient hospital[A]: $250;
Outpatient hospital[A]: $3 to $20;
Physician services[A]: $3 to $5;
Prescription drugs[B]: $2 to $15;
Nonemergency use of the emergency room[A]: $50;
Dental services[A]: $10 to $100.
State: Pennsylvania;
Inpatient hospital[A]: $3 per day;
maximum of $21 per admission;
Outpatient hospital[A]: $0.50 to $3;
Physician services[A]: $0.50 to $3;
Prescription drugs[B]: $1;
Nonemergency use of the emergency room[A]: $1 to $6;
Dental services[A]: $0.50 to $3.
State: South Carolina;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: NA;
Physician services[A]: NA;
Prescription drugs[B]: $3 to $21[H];
Nonemergency use of the emergency room[A]: NA;
Dental services[A]: NA.
State: South Dakota;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: 5% of payment;
maximum of $50;
Physician services[A]: $2;
Prescription drugs[B]: $2;
Nonemergency use of the emergency room[A]: 5% of payment;
maximum of $50;
Dental services[A]: $1.
State: Tennessee;
Inpatient hospital[A]: $100 or $200;
Outpatient hospital[A]: NA;
Physician services[A]: $5 to $25;
Prescription drugs[B]: $5 or $10;
Nonemergency use of the emergency room[A]: $25 or $50;
Dental services[A]: $15 or $25.
State: Utah;
Inpatient hospital[A]: $220;
Outpatient hospital[A]: $2 or $3;
Physician services[A]: $3 or $5;
Prescription drugs[B]: $2 to $5 or 25% of cost;
Nonemergency use of the emergency room[A]: $6 or $30;
Dental services[A]: 10% of allowable Medicaid payment.
State: Vermont;
Inpatient hospital[A]: $50 or $75;
Outpatient hospital[A]: $3 or $25 per day;
Physician services[A]: $7;
Prescription drugs[B]: $1 to $10 or 50% to 60%;
Nonemergency use of the emergency room[A]: $60;
Dental services[A]: $3.
State: Virginia;
Inpatient hospital[A]: $100;
Outpatient hospital[A]: $3;
Physician services[A]: $1;
Prescription drugs[B]: $1;
Nonemergency use of the emergency room[A]: NA;
Dental services[A]: NA.
State: Washington;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: NA;
Physician services[A]: NA;
Prescription drugs[B]: NA;
Nonemergency use of the emergency room[A]: $3;
Dental services[A]: NA.
State: West Virginia;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: NA;
Physician services[A]: NA;
Prescription drugs[B]: $0.50 to $3;
Nonemergency use of the emergency room[A]: NA;
Dental services[A]: NA.
State: Wisconsin;
Inpatient hospital[A]: $3 per day;
maximium of $75;
Outpatient hospital[A]: $3;
Physician services[A]: $1 to $3;
Prescription drugs[B]: $.50 to $15[I];
Nonemergency use of the emergency room[A]: $3;
Dental services[A]: $.50 to $3.
State: Wyoming;
Inpatient hospital[A]: NA;
Outpatient hospital[A]: $6;
Physician services[A]: $2;
Prescription drugs[B]: $2 to $25;
Nonemergency use of the emergency room[A]: $6;
Dental services[A]: NA.
Source: GAO analysis of state survey responses and documentation
provided by states.
NA = Not applicable. The state did not charge cost sharing for this
service.
Notes: The following states did not charge cost sharing to any adults
in Medicaid: Hawaii, Idaho, Michigan, Nevada, New Jersey, Ohio, Rhode
Island, and Texas.
This appendix reflects cost sharing amounts charged by states for the
services and portions of the Medicaid adult populations subject to cost
sharing charges. The amount of cost sharing and the services subject to
cost sharing may vary within a state by population. See Appendix VIII
for details on the adult populations subject to copayment requirements
in Medicaid.
[A] Cost sharing amount is on a per visit or per admission basis unless
otherwise noted.
[B] Cost sharing amount is on a per prescription basis unless otherwise
noted.
[C] Delaware's only cost sharing was a $1 copayment for nonemergency
transportation.
[D] llinois did not require cost sharing for all procedures within this
service.
[E] Maine had a $3 daily limit and a $30 monthly limit for these
services.
[F] Copayment is for individuals participating in the Missouri's 1115
waiver program, which extends 12 months of additional coverage to
working parents or caretakers. As of January 2004, this program had
approximately 2,400 beneficiaries.
[G] Missouri's copayment for physician services is only for services
rendered in a hospital outpatient clinic or emergency room.
[H] South Carolina had a $500 deductible for elderly individuals
enrolled in the state's pharmacy waiver.
[I] Wisconsin also had a deductible--either $500 or $850, depending on
income levels--for elderly individuals enrolled in the state's pharmacy
waiver program.
[End of table]
[End of section]
Appendix X: GAO Contact and Staff Acknowledgments:
GAO Contact:
Carolyn Yocom, (202) 512-4931:
Acknowledgments:
Major contributors included Catina Bradley, Janice Raynor, Michelle
Rosenberg, Kevin Milne, and Elizabeth T. Morrison.
FOOTNOTES
[1] Throughout this report, the term "states" refers to the 50 states
and the District of Columbia.
[2] The time periods for states' fiscal years were different: most used
a fiscal year that began July 1 and others used either the federal
fiscal year (Oct. 1 through Sept. 30) or another time period.
[3] Medically needy individuals are generally people who fall into one
of the eligibility categories that are composed of broad groups--
children, individuals with disabilities, or the elderly--and who incur
medical expenses such that their income, less these expenses, makes
them eligible for Medicaid.
[4] The adult population group can include both children and adults.
For example, a child (aged 18 or younger) may be placed in a nursing
home or institution, be pregnant, or be considered medically needy.
However, since the majority of the individuals in this group were
likely to be over the age of 18, we categorized pregnant women,
individuals in nursing homes and institutions, and medically needy
population groups as adults for purposes of our report.
[5] The Medical Expenditure Panel Survey (MEPS) provides national data
on individuals' annual utilization of medical services. MEPS, conducted
by the Agency for Healthcare Research and Quality (AHRQ), consists of
four surveys, including the Household Component, which provides
nationally representative data and expenditures for the U.S. civilian
noninstitutionalized population.
[6] MEPS data showed that approximately 45 percent of low-income
children had a prescription filled during a year, compared to
approximately 96 percent of disabled adults.
[7] Social Security Act section 1902(a)(14) (codified at 42 U.S.C.
1396a(a)(14)).
[8] Medicaid classifies certain individuals as categorically needy.
Categorically needy persons are those within certain eligibility
categories, including persons who are disabled, elderly, pregnant,
children, beneficiaries of cash assistance programs, and whose income
and resources do not exceed specified levels.
[9] Social Security Act section 1916 (codified at 42 U.S.C. 1396o).
[10] Medically needy coverage is also termed "spend-down" coverage; as
of November 2002, 36 states opted to cover Medicaid beneficiaries under
the medically needy or spend-down category.
[11] States may require cost sharing for individuals aged 18 to 21 even
if they are considered children by the state.
[12] States may not charge cost sharing on medical services furnished
to a person who is an inpatient in a hospital, long-term care facility,
or other medical institution if, as a condition of receiving those
services, the person was required to spend almost all of his or her
income in order to qualify for Medicaid. See 42 CFR 447.53(b)(3)
(2003).
[13] For purposes of this report, we will refer to demonstration
projects approved under section 1115 as 1115 waiver programs.
[14] See section 1916 of the Social Security Act.
[15] This number represents an unduplicated count of all beneficiaries
enrolled at any time in fiscal year 2003.
[16] 42 CFR 457.560 (2003).
[17] Regarding preventive services, federal regulations prohibit these
states from charging cost sharing for well-baby and well-child
services, including routine physical examinations, associated
laboratory tests, immunizations, and routine preventive and diagnostic
dental services. See 42 CFR 457.520 (2003).
[18] 42 CFR 457.125, 457.535 (2003).
[19] Social Security Act section 2107(e)(2)(A) (codified at 42 U.S.C.
1397gg(e)(2)(A)(2000)).
[20] The six states that received section 1115 waivers are Arkansas,
Missouri, New Mexico, Ohio, Rhode Island, and Wisconsin. As of March
2004, Ohio had not implemented its waiver.
[21] Our survey asked states about their cost sharing requirements for
six services: inpatient hospital, outpatient hospital, physician
services, prescription drugs, nonemergency use of the ER, and dental.
[22] In Medicaid, nonemergency transportation can be considered either
a service or an administrative cost. Delaware treats nonemergency
transportation as an administrative cost and thus was allowed to charge
a copayment for this service.
[23] Section 2107(e)(2)(A) of the Social Security Act extends the
Secretary's authority under section 1115 to the SCHIP statute.
[24] In many cases, these states only charged working individuals with
disabilities. In 2003, the following states provided Medicaid coverage
to working individuals with disabilities: Alaska, Arizona, Arkansas,
California, Connecticut, Illinois, Indiana, Iowa, Kansas, Maine,
Massachusetts, Minnesota, Mississippi, Missouri, Nebraska, New
Hampshire, New Jersey, New Mexico, Oregon, Pennsylvania, South
Carolina, Utah, Vermont, Washington, Wisconsin, and Wyoming. See U.S.
General Accounting Office, Medicaid and Ticket to Work: States' Early
Efforts to Cover Working Individuals with Disabilities, GAO-03-587
(Washington, D.C.: June 13, 2003) and Jennifer Hess and Karen Tritz,
Ticket to Work and Work Incentives Improvement Act of 1999:
Implementation Status (Washington, D.C.: Congressional Research
Service, June 3, 2003).
[25] The nine states are Alaska, Arkansas, Florida, Minnesota,
Missouri, Montana, South Dakota, Utah, and Vermont.
[26] Delaware charged a copayment for nonemergency transportation and
Wisconsin charged a copayment for dental services. Virginia charged a
copayment for inpatient hospital services, outpatient hospital
services, physician services, and prescription drugs when the services
were unrelated to the pregnancy.
[27] The time periods for states' fiscal years were different: most
used a fiscal year that began July 1 and others used either the federal
fiscal year (Oct. 1 through Sept. 30) or another time period.
[28] Thirty-three of the 34 states that increased beneficiary
contributions in Medicaid, SCHIP or both provided us with information
on the amount of increases.
[29] In some states, such as Vermont, premiums are charged for a
household--individuals living together in the same house.
[30] In Vermont, monthly premiums for Medicaid increased from $20 to
$25 for children in households with income from 185 percent through 225
percent of the FPL and from $24 to $35 for children in households with
higher income. In SCHIP, monthly premiums increased by $20--from $50 to
$70.
[31] Since state fiscal year 2001, Arizona has implemented a program
under the Ticket to Work Act that provides Medicaid coverage to certain
working individuals with disabilities, including some children aged 18.
Maryland implemented a separate SCHIP program in July 2001, which
raised the state's SCHIP income eligibility level from 200 percent to
300 percent of the FPL. Both states' new programs included a premium
requirement.
[32] The three states that charged coinsurance to children in Medicaid
were Alaska, Arkansas, and Missouri.
[33] The six states were Massachusetts, Mississippi, New Hampshire,
Oregon, Rhode Island, and Vermont.
[34] In Rhode Island, monthly premiums for certain parents with incomes
from 150 percent through 185 percent of the FPL increased from $43 to
$61. Monthly premiums for pregnant women increased from $53 to $77 for
those with incomes from 185 percent through 200 percent of the FPL, and
from $53 to $92 for those with incomes at or above 200 percent of the
FPL.
[35] The six states were Arizona, Illinois, Kansas, Minnesota,
Missouri, and Washington.
[36] The premium was equal to 1 percent of income after deducting
certain child care expenses.
[37] For the two states increasing charges in more than one cost
sharing category, one state (Utah) increased both copayment and
coinsurance requirements, while the other state (South Carolina)
increased both copayment and deductible requirements.
[38] Maryland eliminated its generic prescription drug copayment in
November 2002, and Illinois made its change in July 2003. Both states
still required some portion of adults to pay copayments for brand-name
prescriptions.
[39] In Arkansas, the cost sharing requirements for working individuals
with disabilities were different from those of other Medicaid adults.
The state did not change cost sharing requirements for working
individuals with disabilities during the period under review.
[40] In 2000, the FPL for an individual equated to $8,350 per year and
$14,150 for a family of three in the 48 contiguous states and the
District of Columbia.
[41] MEPS defines individuals with disabilities as individuals who
identified needing assistance with at least one activity of daily
living (ADL) or instrumental activity of daily living (IADL). MEPS
identifies ADLs as basic physical activities such as bathing, dressing,
or getting around the house and IADLs as cognitive or social functions
such as using the telephone, paying bills, taking medications,
preparing light meals, doing laundry, or going shopping. MEPS offers a
relatively expansive definition of disability in that it does not
distinguish the number of ADLs or IADLs with which an individual may
require assistance.
[42] For physician services, we did not include services provided by
non-physician practitioners. We excluded orthodontia from our analysis
of dental services, and nonemergency use of the emergency room because
there was no MEPS category for these services.
GAO's Mission:
The General Accounting Office, the investigative arm of Congress,
exists to support Congress in meeting its constitutional
responsibilities and to help improve the performance and accountability
of the federal government for the American people. GAO examines the use
of public funds; evaluates federal programs and policies; and provides
analyses, recommendations, and other assistance to help Congress make
informed oversight, policy, and funding decisions. GAO's commitment to
good government is reflected in its core values of accountability,
integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony:
The fastest and easiest way to obtain copies of GAO documents at no
cost is through the Internet. GAO's Web site ( www.gao.gov ) contains
abstracts and full-text files of current reports and testimony and an
expanding archive of older products. The Web site features a search
engine to help you locate documents using key words and phrases. You
can print these documents in their entirety, including charts and other
graphics.
Each day, GAO issues a list of newly released reports, testimony, and
correspondence. GAO posts this list, known as "Today's Reports," on its
Web site daily. The list contains links to the full-text document
files. To have GAO e-mail this list to you every afternoon, go to
www.gao.gov and select "Subscribe to e-mail alerts" under the "Order
GAO Products" heading.
Order by Mail or Phone:
The first copy of each printed report is free. Additional copies are $2
each. A check or money order should be made out to the Superintendent
of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or
more copies mailed to a single address are discounted 25 percent.
Orders should be sent to:
U.S. General Accounting Office
441 G Street NW,
Room LM Washington,
D.C. 20548:
To order by Phone:
Voice: (202) 512-6000:
TDD: (202) 512-2537:
Fax: (202) 512-6061:
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: www.gao.gov/fraudnet/fraudnet.htm E-mail: fraudnet@gao.gov
Automated answering system: (800) 424-5454 or (202) 512-7470:
Public Affairs:
Jeff Nelligan, managing director, NelliganJ@gao.gov (202) 512-4800 U.S.
General Accounting Office, 441 G Street NW, Room 7149 Washington, D.C.
20548:
