Medicaid and CHIP
Enrollment, Benefits, Expenditures, and Other Characteristics of State Premium Assistance Programs Gao ID: GAO-10-258R January 19, 2010Fiscal pressures, rising health care costs, and increases in the number of uninsured may lead states to look toward public-private partnerships to help finance health insurance coverage. Through Medicaid and the State Children's Health Insurance Program (CHIP), states have had long-standing authority to operate premium assistance programs that subsidize the purchase of private health insurance. Enacted in February 2009, the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA), which reauthorized CHIP and made changes to Medicaid, provided states with additional options for operating premium assistance programs. As of November 2009, states had not implemented premium assistance programs under the new authorities provided by CHIPRA, but, as allowed by CHIPRA, states were continuing to operate their programs under preexisting authorities. Through premium assistance programs, states use Medicaid funds, CHIP funds, or both to subsidize the cost of private health insurance--such as employer-sponsored insurance (ESI)--for eligible individuals. As such, premium assistance programs contrast with direct coverage, where states provide Medicaid or CHIP benefits to enrollees by paying doctors and other providers directly or contracting with managed care organizations. Previous reports on premium assistance programs have described the programs' potential benefits, as well as potential issues that have been raised about them. One potential benefit reported is that premium assistance programs could generate cost savings for Medicaid and CHIP by leveraging private financial resources for health insurance coverage--such as employer contributions--and decreasing enrollment in direct coverage. Additional potential benefits include helping families make the transition to private health insurance, expanding coverage to family members who are not themselves eligible for coverage under Medicaid or CHIP, and supporting the private insurance market. In contrast, a reported issue with premium assistance programs is that there may be disparities in the benefits and cost-sharing protections offered to enrollees in such programs compared with those in direct coverage. Reports also note that premium assistance programs may not be cost-effective--that is, premium assistance may be more expensive than providing direct coverage through states' Medicaid and CHIP programs. Finally, reports have raised the possibility that premium assistance programs may create incentives for families to reduce their contributions toward the cost of health insurance coverage, thus shifting the costs of coverage to public funds. CHIPRA required GAO to study cost and coverage issues related to state premium assistance programs receiving Medicaid and CHIP funds. In this report, GAO describes states' premium assistance programs, including the (1) funding source, operating authority, and type of private health insurance coverage subsidized; (2) policies regarding eligibility and enrollment; (3) benefits, premiums, and cost sharing; (4) expenditures and cost-effectiveness policies; and (5) challenges program officials reported in implementing and operating such programs, as well as the effect that CHIPRA may have on these challenges.
1) Based on GAO's survey results from 45 of the 47 premium assistance programs, 30 premium assistance programs were funded solely by Medicaid, 6 programs were funded solely by CHIP, and 9 programs were funded by both Medicaid and CHIP. 2) Twenty-five of the 37 premium assistance programs that provided eligibility information covered only low-income individuals--which the Census Bureau defines as those with family incomes at or below 200 percent of the Federal Poverty Level (FPL). 3) Officials from almost three-quarters of the state premium assistance programs (33) reported that the program has minimum requirements that private health insurance benefit packages must meet in order to qualify for a state subsidy. The most commonly reported requirements were requiring coverage of certain services specified by the state (20 programs)--such as inpatient and outpatient hospital and physician services--and meeting state health insurance regulations (16 programs). Twelve programs did not have any requirements for the private health insurance benefit package. 4) Among the 42 premium assistance programs that provided expenditure data, annual expenditures for premium assistance totaled at least $222 million. Actual expenditures, however, were higher, because 32 of the 42 programs did not provide data for all program activities. For example, 19 of the 42 programs did not report the amount of expenditures for program administration. Furthermore, 3 premium assistance programs did not provide any data on program expenditures. (5) Program officials who responded to our survey identified several challenges to premium assistance program implementation and operation. The two most frequently identified challenges were a limited number of individuals with access to private health insurance (18 programs), and difficulty identifying individuals with access to private health insurance (17 programs).
GAO-10-258R, Medicaid and CHIP: Enrollment, Benefits, Expenditures, and Other Characteristics of State Premium Assistance Programs
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GAO-10-258R:
United States Government Accountability Office:
Washington, DC 20548:
January 19, 2010:
The Honorable Max Baucus:
Chairman:
The Honorable Charles E. Grassley:
Ranking Member:
Committee on Finance:
United States Senate:
The Honorable Henry A. Waxman:
Chairman:
The Honorable Joe Barton:
Ranking Member:
Committee on Energy and Commerce:
House of Representatives:
Subject: Medicaid and CHIP: Enrollment, Benefits, Expenditures, and
Other Characteristics of State Premium Assistance Programs:
Fiscal pressures, rising health care costs, and increases in the
number of uninsured may lead states to look toward public-private
partnerships to help finance health insurance coverage. Through
Medicaid and the State Children's Health Insurance Program (CHIP),
states have had long-standing authority to operate premium assistance
programs that subsidize the purchase of private health insurance.
[Footnote 1] Enacted in February 2009, the Children's Health Insurance
Program Reauthorization Act of 2009 (CHIPRA), which reauthorized CHIP
and made changes to Medicaid, provided states with additional options
for operating premium assistance programs. As of November 2009, states
had not implemented premium assistance programs under the new
authorities provided by CHIPRA, but, as allowed by CHIPRA, states were
continuing to operate their programs under preexisting authorities.
Through premium assistance programs, states use Medicaid funds, CHIP
funds, or both to subsidize the cost of private health insurance--such
as employer-sponsored insurance (ESI)--for eligible individuals. As
such, premium assistance programs contrast with direct coverage, where
states provide Medicaid or CHIP benefits to enrollees by paying
doctors and other providers directly or contracting with managed care
organizations. Previous reports on premium assistance programs have
described the programs' potential benefits, as well as potential
issues that have been raised about them.[Footnote 2] One potential
benefit reported is that premium assistance programs could generate
cost savings for Medicaid and CHIP by leveraging private financial
resources for health insurance coverage--such as employer
contributions--and decreasing enrollment in direct coverage.
Additional potential benefits include helping families make the
transition to private health insurance, expanding coverage to family
members who are not themselves eligible for coverage under Medicaid or
CHIP, and supporting the private insurance market. In contrast, a
reported issue with premium assistance programs is that there may be
disparities in the benefits and cost-sharing protections offered to
enrollees in such programs compared with those in direct coverage.
Reports also note that premium assistance programs may not be cost-
effective--that is, premium assistance may be more expensive than
providing direct coverage through states' Medicaid and CHIP programs.
Finally, reports have raised the possibility that premium assistance
programs may create incentives for families to reduce their
contributions toward the cost for health insurance coverage, thus
shifting the costs of coverage to public funds.
CHIPRA required GAO to study cost and coverage issues related to state
premium assistance programs receiving Medicaid and CHIP funds.
[Footnote 3] In this report, we describe states' premium assistance
programs, including the (1) funding source, operating authority, and
type of private health insurance coverage subsidized; (2) policies
regarding eligibility and enrollment; (3) benefits, premiums, and cost
sharing; (4) expenditures and cost-effectiveness policies; and (5)
challenges program officials reported in implementing and operating
such programs, as well as the effect that CHIPRA may have on these
challenges.
To describe these programs, we administered a Web-based survey to
officials from the states that had premium assistance programs funded
by Medicaid, CHIP, or both. To identify which states had premium
assistance programs funded by Medicaid or CHIP, we asked Medicaid and
CHIP officials in each state and the District of Columbia if the state
used Medicaid or CHIP funds to subsidize the purchase of private
health insurance.[Footnote 4] We compared the information we received
from state officials with information in published reports and with
information received from the Centers for Medicare & Medicaid Services
(CMS)--the agency within the Department of Health and Human Services
(HHS) that oversees states' Medicaid and CHIP programs--about which
states have authority to operate premium assistance programs. On this
basis, we identified 47 premium assistance programs in 39 states.
[Footnote 5] Officials in 8 of the 39 states reported having 2 premium
assistance programs; states with more than one program may have
separate programs for different populations or one program funded by
Medicaid and another funded by CHIP. From August through October 2009,
we administered a survey to officials representing the 47 premium
assistance programs we identified.[Footnote 6] To ensure the clarity
and precision of our survey questions, we pretested the survey with
officials from 3 states and with a researcher who has extensively
studied premium assistance programs. The survey requested information
about several dimensions of a state's premium assistance program,
including funding sources, operating authorities, type of private
health insurance subsidized, eligibility, enrollment, covered
benefits, premiums, cost sharing, expenditures, and cost-
effectiveness. The survey also asked respondents about any challenges
faced in implementing and operating their premium assistance programs,
as well as for their views on the effect that CHIPRA may have on those
challenges. Of the 47 Medicaid-or CHIP-funded premium assistance
programs we identified, we received survey responses from officials
representing 45 programs in 37 states, although not every official
responded to every question.[Footnote 7] We relied on the data as
reported by the state officials who were identified as the primary
contact for the premium assistance program and did not independently
verify these data or ask CMS to verify them. However, we reviewed all
responses for reasonableness and internal consistency, and followed up
with state officials for clarification where necessary. Based on these
activities, we determined these data were sufficiently reliable for
the purpose of our report.
We conducted our work from June 2009 through January 2010 in
accordance with all sections of GAO's Quality Assurance Framework that
are relevant to our objectives. This framework requires that we plan
and perform the engagement to obtain sufficient and appropriate
evidence to meet our stated objectives and to discuss any limitations
in our work. We believe that the information and data obtained, and
the analysis conducted, provide a reasonable basis for any findings
and conclusions in this product.
Background:
Before the enactment of CHIPRA, states had the authority to operate
premium assistance programs under Medicaid and CHIP. CHIPRA provides
states with additional options for operating premium assistance
programs.
Premium Assistance Authorities that Preceded CHIPRA:
The Medicaid and CHIP statutes authorize states to obtain federal
funding for the operation of state premium assistance programs. A key
authority to operate a Medicaid-funded premium assistance program was
provided through section 1906 of the Social Security Act (SSA),
[Footnote 8] which authorizes states to use Medicaid funds to purchase
group health plan coverage for eligible individuals.[Footnote 9]
Programs operated under section 1906 of the SSA are commonly referred
to as Health Insurance Premium Payment programs. The authority to
operate CHIP-funded premium assistance programs was first provided in
section 2105(c)(3) of the SSA, which permits states to provide
coverage to CHIP-eligible children and their families by subsidizing
premiums for group health plan and nongroup coverage.[Footnote 10]
Table 1 compares requirements for premium assistance programs under
these two authorities, both of which existed prior to the enactment of
CHIPRA.
Table 1: Requirements under Two Premium Assistance Operating
Authorities that Existed Prior to CHIPRA:
Category: Eligibility;
Section 1906 of the SSA: Individuals eligible for Medicaid or for CHIP
Medicaid expansion programs[A];
Section 2105(c)(3) of the SSA: Individuals eligible for separate child
health programs.[A]
Category: Type of coverage subsidized;
Section 1906 of the SSA: Group health coverage, such as employer-
sponsored insurance;
Section 2105(c)(3) of the SSA: Group health coverage, such as employer-
sponsored insurance, and nongroup coverage.
Category: Enrollees' existing or prior insurance coverage;
Section 1906 of the SSA: Enrollees' existing insurance coverage does
not affect eligibility;
Section 2105(c)(3) of the SSA: Enrollees must not have had group
health coverage for at least 6 months prior to enrollment in the
premium assistance program;
reasonable exceptions are permitted.[B]
Category: Mandatory enrollment;
Section 1906 of the SSA: Can be mandatory at state option[C];
Section 2105(c)(3) of the SSA: Can be mandatory at state option.[D]
Category: Benefits;
Section 1906 of the SSA: States must ensure that enrollees have access
to the full range of Medicaid benefits[E] either through the group
health coverage or wraparound coverage[F];
Section 2105(c)(3) of the SSA: States must ensure that children
receive benefits meeting requirements for CHIP benchmark coverage,
benchmark-equivalent coverage,[G] or Secretary-approved coverage,
either through the group health coverage or wraparound coverage.[F]
Category: Premiums and cost sharing[H];
Section 1906 of the SSA: Same as for direct coverage in Medicaid.[I]
Premiums are prohibited for individuals with incomes at or below 150
percent of the federal poverty level (FPL) and for pregnant women and
certain children at higher incomes. Cost sharing is prohibited for
some services and groups[J] and is otherwise limited to nominal
amounts for individuals with incomes below 100 percent of the FPL but
is allowed to be as much as 20 percent of service costs for
individuals with higher incomes. Total premiums and cost sharing for
eligible individuals in the family cannot exceed 5 percent of family
income;
Section 2105(c)(3) of the SSA: Same as for direct coverage in CHIP.[I]
Specific limits on premiums and cost sharing exist for families with
incomes at or below 150 percent of the FPL. Cost sharing is prohibited
for preventive care. Total premiums and cost sharing for eligible
individuals in the family cannot exceed 5 percent of family income.
Category: Cost-effectiveness;
Section 1906 of the SSA: States may enroll eligible individuals as
long as the cost, including premiums and cost sharing under the group
health plan and any additional administrative costs, is likely to be
less than the cost of an equivalent set of Medicaid services.[K] Cost-
effectiveness can be measured on an individual or aggregate basis;
Section 2105(c)(3) of the SSA: States may enroll eligible individuals
in health coverage as long as the cost is not greater than the cost of
direct coverage.[I] Cost-effectiveness can be measured on an
individual or aggregate basis.
Category: Covering noneligibles;
Section 1906 of the SSA: States may pay premiums to enroll noneligible
family members in a group health plan if cost-effective and needed to
obtain coverage for the Medicaid-eligible family members. Federal
matching funds are not available to pay cost sharing for noneligibles;
Section 2105(c)(3) of the SSA: States can purchase coverage for
noneligible family members, provided the family includes at least one
CHIP-eligible child. Coverage for the family must cost no more than
direct coverage for the eligible children.[I]
Category: Employer contribution;
Section 1906 of the SSA: No minimum contribution specified;
Section 2105(c)(3) of the SSA: States must identify a minimum
contribution representative of the employer-sponsored market in their
state and evaluate whether substitution of public for private coverage
is occurring.
Source: GAO analysis of Medicaid and CHIP statutes and regulations,
and interviews with CMS officials.
[A] Individuals eligible for Medicaid include certain mandatory
populations, such as low-income pregnant women and children. Other
populations, including those with higher incomes, can be covered at
state option. CHIP was designed to provide health care coverage to
children in families whose incomes, while low, are above Medicaid's
eligibility requirements. States may use one of three basic options
for structuring their CHIP programs: (1) a Medicaid expansion program,
(2) a separate child health program, or (3) a combination program that
includes both a Medicaid expansion and a separate child health
program. States operating CHIP Medicaid expansion programs must follow
Medicaid rules, while states operating separate child health programs
follow CHIP rules.
[B] See 42 C.F.R. §457.810 (2009). Requiring enrollees to be without
coverage for at least 6 months is intended to discourage crowd-out--
the substitution of public health insurance for private insurance.
Separate CHIP programs are required to monitor the extent to which
crowd-out may be occurring among enrollees in direct coverage, and
programs with eligibility thresholds above 200 percent of the FPL may
be required to implement policies to minimize crowd-out. For more
information on state efforts to monitor crowd-out, see GAO, State
Children's Health Insurance Program: CMS Should Improve Efforts to
Assess whether SCHIP Is Substituting for Private Insurance, GAO-09-252
(Washington, D.C.: Feb. 20, 2009).
[C] Eligible children cannot be denied direct coverage if their parent
fails to enroll them in the group health plan.
[D] States must offer individuals the option, at initial enrollment
and at redetermination of eligibility, of enrolling in direct coverage
if their group health plan does not provide certain enrollee
protections specified in the CHIP regulations, including the
opportunity for external review of delays or denials of health
services.
[E] Medicaid requires certain mandatory benefits, such as physician
and hospital services, and states can also cover optional benefits
such as dental services and prescription drugs.
[F] Benefits wraparound coverage refers to states' direct coverage of
any services to which premium assistance enrollees are entitled but
which are not covered under their private health insurance plan.
[G] A benchmark benefits package is a package substantially equivalent
to the benefits provided by the Federal Employee Health Benefits
Program's Blue Cross/Blue Shield Standard Option, a health benefits
plan offered by the state to its own employees, or a plan offered by
the HMO with the largest commercial enrollment in the state. A
benchmark equivalent package has the same actuarial value as one of
the benchmark plans.
[H] Premiums are payments required for insurance coverage for a given
period of time. Cost sharing is an out-of-pocket payment for part of
the cost of services used by an enrollee and can include coinsurance,
copayments, and deductibles.
[I] Direct coverage refers to the coverage provided to Medicaid or
CHIP enrollees who are not in premium assistance. For example, in
Medicaid, direct coverage includes all mandatory benefits and any
optional benefits that the state has chosen to provide.
[J] Cost sharing is largely prohibited for children in mandatory
coverage groups; for any preventive services for children, regardless
of income; and for pregnancy-related services.
[K] Cost-effectiveness is defined in section 1906(e)(2) of the SSA and
further explained in Section 3910 of the State Medicaid Manual.
[End of table]
Under certain circumstances, a state may operate a premium assistance
program that does not follow the Medicaid or CHIP statutory
requirements that usually apply. To do so, states must obtain a waiver
under section 1115 of the SSA. Section 1115 of the SSA allows the
Secretary of HHS to waive certain statutory requirements in the case
of experimental, pilot, or demonstration projects that are likely to
promote program objectives.[Footnote 11] According to CMS officials,
section 1115 waivers have been used to permit states to provide
premium assistance to populations not otherwise eligible for coverage
and to subsidize the cost of nongroup health coverage. Additionally,
premium assistance programs operated under section 1115 waivers may
not have to comply with all of the benefits, premiums, cost sharing,
and cost-effectiveness requirements outlined in table 1 above.
Additional Options for Premium Assistance Available under CHIPRA:
When CHIPRA was enacted in February 2009, it created additional
options for premium assistance in Medicaid and CHIP, including
allowing states to subsidize ESI for Medicaid-and CHIP-eligible
children and their parents if the employer's contribution is at least
40 percent of the total premium cost, enrollment in the program is
voluntary, and the ESI meets certain criteria.[Footnote 12] CHIPRA
requires states that operate premium assistance programs under these
new options to provide the full range of Medicaid or CHIP benefits
through benefits wraparound coverage, where states directly cover any
services to which premium assistance enrollees are entitled but which
are not covered under their private health insurance. Additionally,
CHIPRA specifies limits on the amount of enrollee cost sharing.
Premium assistance programs that operate under the new Medicaid option
created through CHIPRA do not have to meet a cost-effectiveness
requirement.
CHIPRA also amended the Employee Retirement Income Security Act
(ERISA) of 1974, the Internal Revenue Code of 1986, and the Public
Health Service Act to make eligibility for Medicaid or CHIP a basis
for enrollment in a group health plan for which the Medicaid or CHIP
enrollees are otherwise eligible to enroll. As a result of this
change, new Medicaid or CHIP enrollees may not be required to wait for
an open enrollment period to enroll in a group health plan and
participate in the state's premium assistance program because Medicaid
or CHIP eligibility would be considered a qualifying event. CHIPRA
also requires health plan administrators to provide information about
plan benefit packages when requested by states, and requires employers
to provide written notice to employees about the availability of
premium assistance if their state operates a program.
Results In Brief:
Funding Source, Operating Authority, and Type of Insurance Coverage
Subsidized:
* Based on our survey results from 45 of the 47 premium assistance
programs, 30 premium assistance programs were funded solely by
Medicaid, 6 programs were funded solely by CHIP, and 9 programs were
funded by both Medicaid and CHIP.
* According to our survey results, most premium assistance programs
operated under the authority of section 1906 of the SSA (29), while 16
programs operated under section 1115 waivers, 1 program operated under
section 2105(c)(3) of the SSA, and 9 programs operated under other
authorities. These other authorities include section 1902(a)(10)(F) of
the SSA which allows states to use Medicaid funds to pay premiums for
COBRA continuation coverage for certain low-income individuals and
section 1905(a) of the SSA which allows states to use Medicaid funds
to subsidize private health insurance premiums. In some cases, states'
premium assistance programs operated under multiple authorities.
* All but two premium assistance programs operated statewide. The two
exceptions were Florida's program, which operated in five counties,
and Colorado's CHP+ at Work program, which operated only in the
metropolitan Denver area.
* Based on our survey results, all 45 of the premium assistance
programs subsidized premiums for some type of group coverage, with 32
of the programs subsidizing premiums for multiple types of group
coverage. More specifically, 43 programs subsidized coverage for ESI,
32 subsidized COBRA coverage, and 17 subsidized other group health
coverage. Of the 43 premium assistance programs that subsidized ESI,
- 8 required that employers contribute a minimum amount toward the
cost of enrollees' premiums, with the required minimum contribution
ranging from 25 to 50 percent;
- 5 limited participation to employers with a certain number of
employees, typically fewer than 100; and:
- 8 had data on the number of participating employers; among those 8
programs, the number of participating employers ranged from less than
30 to nearly 4,800.
* Twenty-one of the 45 premium assistance programs subsidized nongroup
coverage, namely policies purchased from the individual market.
Enclosure I provides additional information on the funding source,
operating authority, and type of insurance coverage subsidized for
states' premium assistance programs.
Eligibility and Enrollment Policies:
* Twenty-five of the 37 premium assistance programs that provided
eligibility information covered only low-income individuals--which the
Census Bureau defines as those with family incomes at or below 200
percent of the FPL. The remaining 12 programs covered at least some
individuals with family incomes above 200 percent of the FPL, but only
2 of the 12 covered any individuals with incomes above 300 percent of
the FPL.
* Most of the 37 programs that provided eligibility information
covered children (32 programs), parents (29 programs), or pregnant
women (27 programs).[Footnote 13] Fewer covered childless adults (13
programs) or other groups (12 programs).[Footnote 14]
* Thirty-three of the 45 premium assistance programs subsidized
premiums for noneligible family members under certain circumstances--
for example, if the noneligible family member had to be enrolled in
the health plan for the eligible family member to obtain coverage.
* At least 8 programs targeted premium assistance to individuals with
high health care costs, such as pregnant women, premature or low birth
weight infants, or individuals with human immunodeficiency virus/
acquired immunodeficiency syndrome (HIV/AIDS), diabetes, or cancer.
* According to our survey results, fewer than half of the premium
assistance programs (20) mandated enrollment for any eligible
individuals. Programs with mandatory enrollment required individuals
to enroll in the premium assistance program if they had access to
private health insurance and met the program's eligibility
requirements; individuals who chose not to enroll in premium
assistance would not be eligible for direct coverage from the state.
[Footnote 15] Of the 20 programs with mandatory enrollment, 19
required all eligible individuals to enroll, while the remaining
program required only certain individuals to enroll.
* Eleven programs, 10 of which were at least partially funded by CHIP,
imposed waiting periods, requiring individuals to be without group
health insurance for some period of time--typically either 3 or 6
months--before they could enroll in the premium assistance program.
* All 45 programs collected documentation of individuals' enrollment
in private health insurance. Most also reported collecting a
description of benefits offered by that insurance plan (38 programs),
as well as documentation of premiums (35 programs).
* Reported premium assistance program enrollment--generally as of June
30, 2009--ranged from fewer than 10 individuals in 5 programs to more
than 10,000 individuals in 4 programs--including 1 program with more
than 30,600 individuals. Over half of the programs (25) had fewer than
1,000 enrollees.
Enclosure II provides additional information about eligibility and
enrollment policies for states' premium assistance programs.
Benefits, Premiums, and Cost Sharing:
* Officials from almost three-quarters of the state premium assistance
programs (33) reported that the program has minimum requirements that
private health insurance benefit packages must meet in order to
qualify for a state subsidy. The most commonly reported requirements
were requiring coverage of certain services specified by the state (20
programs)--such as inpatient and outpatient hospital and physician
services--and meeting state health insurance regulations (16
programs). Twelve programs did not have any requirements for the
private health insurance benefit package.
* Thirty-three premium assistance programs provided complete benefits
wraparound coverage to some or all eligible individuals, meaning the
state supplemented private insurance benefits up to the level
individuals would receive under direct coverage.[Footnote 16] Of the
remaining 12 programs, 3 programs provided partial benefits wraparound
coverage to some or all eligible individuals[Footnote 17] and 9
programs provided no benefits wraparound coverage.[Footnote 18]
* Officials from 34 premium assistance programs reported that they did
not monitor access to care or utilization of services for individuals
enrolled in the premium assistance program. Of the remaining 11
programs, 7 programs monitored utilization of services, 3 programs
monitored both utilization of services and access to care, and 1
program did not report whether it conducted either type of monitoring.
Programs' monitoring efforts typically involved examining enrollees'
private insurance claims, often in the process of determining whether
their enrollment in premium assistance was cost-effective for the
state.
* According to our survey results, at least 26 programs paid 100
percent of the enrollee's share of the premium. Officials from a few
other programs indicated that the program may pay 100 percent of the
enrollee's share of the premium under certain circumstances. Other
programs varied in the extent to which they subsidized premiums. For
example, some programs paid a specified dollar amount and some paid a
percentage that was less than 100 percent of the enrollee's share of
the premium. Officials from 2 programs did not provide information on
the way in which the program subsidizes enrollees' premiums.
* Officials from most programs (34) reported that the programs paid
some or all cost sharing for at least some eligible individuals; cost
sharing refers to out-of-pocket costs other than premiums, such as
copayments.[Footnote 19] The remaining 11 programs did not pay cost
sharing for any eligible individuals.[Footnote 20]
* At least 5 programs limited the amount of out-of-pocket costs, such
as premiums and cost sharing, which an individual enrolled in the
premium assistance program would have to pay in a year.
Enclosure III provides additional information about benefits,
premiums, and cost sharing in states' premium assistance programs.
Expenditures and Cost-Effectiveness Policies:
* Among the 42 premium assistance programs that provided expenditure
data, annual expenditures for premium assistance totaled at least $222
million.[Footnote 21] Actual expenditures, however, were higher,
because 32 of the 42 programs did not provide data for all program
activities. For example, 19 of the 42 programs did not report the
amount of expenditures for program administration.[Footnote 22]
Furthermore, 3 premium assistance programs did not provide any data on
program expenditures.
* Thirty-eight programs required premium assistance to be cost-
effective, meaning that the cost for Medicaid or CHIP to provide
premium assistance is likely less than the cost to provide direct
coverage. Of those 38 programs, 32 assessed cost-effectiveness on an
individual or family level, while the remaining 6 assessed cost-
effectiveness on an aggregate (or programwide) level. To calculate
cost-effectiveness, 18 of the 38 programs reported using the method
outlined in the State Medicaid Manual--referred to as the Secretary's
method--and 20 used another method.[Footnote 23]
* Officials from 18 programs reported having conducted an analysis to
assess whether any cost savings were realized as a result of their
state's premium assistance program. Twelve programs submitted
documentation that showed cost savings relative to direct coverage,
but we could not calculate average savings due to differences in the
types of documentation provided.
Enclosure IV provides additional information about expenditures for
and cost-effectiveness policies in states' premium assistance programs.
Challenges Officials Reported to Program Implementation and Operation,
and the Effect of CHIPRA:
* Program officials who responded to our survey identified several
challenges to premium assistance program implementation and operation.
The two most frequently identified challenges were a limited number of
individuals with access to private health insurance (18 programs), and
difficulty identifying individuals with access to private health
insurance (17 programs).
* Officials from 13 programs reported that the provisions in CHIPRA
would have an effect on the challenges they identified to premium
assistance program implementation or operation. For example, officials
from 9 of the 13 programs specifically noted that the CHIPRA provision
making eligibility for premium assistance a qualifying event for
enrollment in a group health plan would have an effect on the
challenges; officials from some of the programs noted that this
provision will make it easier to enroll individuals in the premium
assistance program.
* Officials from 11 programs reported that they were planning or
considering premium assistance program changes due to CHIPRA. For
example, officials from 5 of these programs reported that as a result
of CHIPRA the state may expand their existing programs--by including
new populations, such as CHIP-eligible individuals, or expanding
benefits, such as adding benefits wraparound coverage for dental
services.
Enclosure V provides additional information about challenges states
reported about implementing and operating their premium assistance
programs.
Agency Comments:
We provided a draft of this report to HHS for comment, which in turn
provided us with written comments from CMS (see enclosure VI).
Overall, CMS commended GAO's data collection efforts and noted that
the data will provide a useful baseline to inform Congress and other
stakeholders about Medicaid-and CHIP-funded premium assistance
programs. CMS noted that while it did due diligence to verify the
accuracy of the information we presented in the report, the agency was
unable to verify all of the data reported by the state officials who
responded to our Web-based survey. As we explained in the description
of our methodology, this report presents information provided to us by
the state officials identified as primary contacts for each premium
assistance program; we did not ask CMS to verify states' responses.
Finally, in its comments, CMS summarized some of the findings from our
draft report, including information on state premium assistance
program operating authorities and the extent to which programs
provided benefits wraparound coverage. We have updated these data in
our final report based upon further clarification we received from
state officials. CMS also provided technical comments, which we
incorporated as appropriate.
We are sending copies of this report to the Administrator of CMS and
other interested parties. In addition, the report is available at no
charge on the GAO Web site at [hyperlink, http://www.gao.gov].
If you or your staff have any questions about this report, please
contact me at (202) 512-7114 or yocomc@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. GAO staff who made major contributions
to this report are listed in enclosure VII.
Signed by:
Carolyn L. Yocom:
Acting Director, Health Care:
Enclosures - 7:
[End of section]
Enclosure I: States' Premium Assistance Programs' Funding Source,
Operating Authority, and Type of Insurance Coverage Subsidized:
Table 2: Program Name, Implementation Year, and Source of Federal
Funds, by State Premium Assistance Program, 2009:
State: Alabama;
Program name: Health Insurance Premium Program;
Implementation year: 1993;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: Alaska;
Program name: Health Insurance Premium Payments;
Implementation year: 2006;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: Federal funding source used.
State: Arizona;
Program name: Employer Sponsored Insurance Program;
Implementation year: 2008;
Federal funding source: Medicaid: [Empty];
Federal funding source: CHIP: Federal funding source used.
State: California;
Program name: Health Insurance Premium Payment;
Implementation year: 1989;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: Colorado-1;
Program name: CHP+ at Work;
Implementation year: 2007;
Federal funding source: Medicaid: [Empty];
Federal funding source: CHIP: Federal funding source used.
State: Colorado-2;
Program name: Health Insurance Buy-In;
Implementation year: 1992;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: Florida;
Program name: Medicaid Reform Opt Out Program;
Implementation year: 2006;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: Georgia;
Program name: Medicaid Health Insurance Premium Payment Program;
Implementation year: 1994;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: Idaho-1;
Program name: Children's Access Card;
Implementation year: 2004;
Federal funding source: Medicaid: [Empty];
Federal funding source: CHIP: Federal funding source used.
State: Idaho-2;
Program name: Access to Health Insurance;
Implementation year: 2005;
Federal funding source: Medicaid: [Empty];
Federal funding source: CHIP: Federal funding source used.
State: Illinois;
Program name: Health Insurance Premium Payment Program;
Implementation year: 1994;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: Iowa;
Program name: Health Insurance Premium Payment Program;
Implementation year: 1991;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: Kansas;
Program name: Health Insurance Premium Payment System;
Implementation year: 1991;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: Kentucky;
Program name: Health Insurance Premium Payment Program;
Implementation year: 1994;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: Louisiana;
Program name: Health Insurance Premium Assistance Program;
Implementation year: 1991;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: Federal funding source used.
State: Maine;
Program name: Private Health Insurance Premium;
Implementation year: 1992;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: Massachusetts-1;
Program name: MassHealth Premium Assistance;
Implementation year: 1997;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: Federal funding source used.
State: Massachusetts-2;
Program name: Medical Security Program;
Implementation year: 1997;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: Minnesota;
Program name: Cost-effective health insurance reviews for Medical
Assistance;
Implementation year: 1990;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: Missouri;
Program name: Health Insurance Premium Payment Program;
Implementation year: 1992;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: Montana;
Program name: Health Insurance Premium Payment;
Implementation year: 1992;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: Nebraska;
Program name: Health Insurance Premium Payment Program;
Implementation year: 1994;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: Nevada-1;
Program name: Check Up Plus;
Implementation year: 2006;
Federal funding source: Medicaid: [Empty];
Federal funding source: CHIP: Federal funding source used.
State: Nevada-2;
Program name: Health Insurance Premium Program;
Implementation year: 1992;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: New Hampshire;
Program name: Health Insurance Premium Payment Program;
Implementation year: 1991;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: New Jersey-1;
Program name: Payment of Premiums Program;
Implementation year: 1993;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: New Jersey-2;
Program name: Premium Support Program;
Implementation year: 2001;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: Federal funding source used.
State: New York;
Program name: Employer Sponsored Health Insurance Initiative;
Implementation year: 2008;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: North Dakota;
Program name: Cost Effective Employer-Based Group Health Plans;
Implementation year: 1993;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: Federal funding source used.
State: Oklahoma;
Program name: Insure Oklahoma/Oklahoma Employer and Employee
Partnership for Insurance Coverage (O-EPIC);
Implementation year: 2006;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: Oregon-1;
Program name: Family Health Insurance Assistance Program (FHIAP);
Implementation year: 2002;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: Federal funding source used.
State: Oregon-2;
Program name: Health Insurance Premium Payment/Private Health
Insurance Premium Payment;
Implementation year: 1992;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: Pennsylvania;
Program name: Health Insurance Premium Payment Program;
Implementation year: 1994;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: Rhode Island;
Program name: RIte Share;
Implementation year: 2001;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: Federal funding source used.
State: South Carolina;
Program name: Health Insurance Premium Payment;
Implementation year: 1994;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: South Dakota;
Program name: Private Health Insurance Premium Payment;
Implementation year: 2000;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: Texas;
Program name: Health Insurance Premium Payment Program;
Implementation year: 1994;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: Utah-1;
Program name: Premium Partnership for Health Insurance;
Implementation year: 2003;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: Federal funding source used.
State: Utah-2;
Program name: Medicaid Operations Buyout Program;
Implementation year: 1990;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: Vermont;
Program name: Catamount Health & Employer-sponsored premium assistance;
Implementation year: 2007;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: Virginia-1;
Program name: Family Access to Medical Insurance Security (FAMIS)
Select;
Implementation year: 2005;
Federal funding source: Medicaid: [Empty];
Federal funding source: CHIP: Federal funding source used.
State: Virginia-2;
Program name: Health Insurance Premium Payment;
Implementation year: 1993;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: Washington;
Program name: Premium Payment Program;
Implementation year: 1988;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: Wisconsin;
Program name: BadgerCare Health Insurance Premium Program;
Implementation year: 2001;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: Federal funding source used.
State: Wyoming;
Program name: Health Insurance Premium Payment Program;
Implementation year: 1993;
Federal funding source: Medicaid: Federal funding source used;
Federal funding source: CHIP: [Empty].
State: Total;
Program name: [Empty];
Implementation year: [Empty];
Federal funding source: Medicaid: 39;
Federal funding source: CHIP: 15.
Source: GAO Web-based survey administered to states' premium
assistance programs.
Note: Data were obtained from surveys administered from August through
October 2009 to officials in 39 states representing 47 premium
assistance programs funded by Medicaid, State Children's Health
Insurance Program (CHIP), or both. We received responses from
officials representing 45 programs in 37 states; officials from 2
states with premium assistance programs, North Carolina and West
Virginia, did not respond to the survey.
[End of table]
Table 3: Operating Authority, by State Premium Assistance Program,
2009:
State[A]: Alabama;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Alaska;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Arizona;
Section 1906 of the SSA[B]: [Empty];
Section 1115 waiver: Operating authority used;
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: California;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Colorado-1;
Section 1906 of the SSA[B]: [Empty];
Section 1115 waiver: Operating authority used;
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Colorado-2;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: Operating authority used[D].
State[A]: Florida;
Section 1906 of the SSA[B]: [Empty];
Section 1115 waiver: Operating authority used;
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Georgia;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Idaho-1;
Section 1906 of the SSA[B]: [Empty];
Section 1115 waiver: Operating authority used;
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Idaho-2;
Section 1906 of the SSA[B]: [Empty];
Section 1115 waiver: Operating authority used;
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Illinois;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Iowa;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: Operating authority used[E].
State[A]: Kansas;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Kentucky;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Louisiana;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Maine;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Massachusetts-1;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: Operating authority used;
Section 2105(c)(3) of the SSA[C]: Operating authority used;
Other: [Empty].
State[A]: Massachusetts-2;
Section 1906 of the SSA[B]: [Empty];
Section 1115 waiver: Operating authority used;
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Minnesota;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: Operating authority used[E].
State[A]: Missouri;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Montana;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Nebraska;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Nevada-1;
Section 1906 of the SSA[B]: [Empty];
Section 1115 waiver: Operating authority used;
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Nevada-2;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: New Hampshire;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: New Jersey-1;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: Operating authority used[E].
State[A]: New Jersey-2;
Section 1906 of the SSA[B]: [Empty];
Section 1115 waiver: Operating authority used;
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: New York;
Section 1906 of the SSA[B]: [Empty];
Section 1115 waiver: Operating authority used;
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: North Dakota;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: Operating authority used[D,E].
State[A]: Oklahoma;
Section 1906 of the SSA[B]: [Empty];
Section 1115 waiver: Operating authority used;
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Oregon-1;
Section 1906 of the SSA[B]: [Empty];
Section 1115 waiver: Operating authority used;
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Oregon-2;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Pennsylvania;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Rhode Island;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: South Carolina;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: Operating authority used[D].
State[A]: South Dakota;
Section 1906 of the SSA[B]: [Empty];
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: Operating authority used[F].
State[A]: Texas;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Utah-1;
Section 1906 of the SSA[B]: [Empty];
Section 1115 waiver: Operating authority used;
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Utah-2;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: Operating authority used[E].
State[A]: Vermont;
Section 1906 of the SSA[B]: [Empty];
Section 1115 waiver: Operating authority used;
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Virginia-1;
Section 1906 of the SSA[B]: [Empty];
Section 1115 waiver: Operating authority used;
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Virginia-2;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Washington;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: Operating authority used[D,E].
State[A]: Wisconsin;
Section 1906 of the SSA[B]: [Empty];
Section 1115 waiver: Operating authority used;
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Wyoming;
Section 1906 of the SSA[B]: Operating authority used;
Section 1115 waiver: [Empty];
Section 2105(c)(3) of the SSA[C]: [Empty];
Other: [Empty].
State[A]: Total;
Section 1906 of the SSA[B]: 29;
Section 1115 waiver: 16;
Section 2105(c)(3) of the SSA[C]: 1;
Other: 9.
Source: GAO Web-based survey administered to states' premium
assistance programs.
Note: Data were obtained from surveys administered from August through
October 2009 to officials in 39 states representing 47 premium
assistance programs funded by Medicaid, CHIP, or both. We received
responses from officials representing 45 programs in 37 states;
officials from 2 states with premium assistance programs, North
Carolina and West Virginia, did not respond to the survey.
[A] Some states operated two premium assistance programs. For program
names, see table 2.
[B] SSA is an abbreviation for the Social Security Act.
[C] Section 2105(c)(3) of the SSA permits payment to a state for
family coverage under a group health plan or health insurance
coverage. Regulations at 42 C.F.R. §457.1010 implement the provisions
of the statute related to family coverage. 42 C.F.R § 457.10
implements requirements related to premium assistance programs in
connection with group health plan coverage. For this report, we
consider programs operated under either authority to be premium
assistance programs.
[D] These programs also operated under the authority of section
1902(a)(10)(F) of the SSA, which allows states to use Medicaid funds
to pay premiums for COBRA continuation coverage. COBRA, an acronym for
the Consolidated Omnibus Budget Reconciliation Act of 1985, allows
employees the opportunity to remain in their employer's group coverage
when they would otherwise lose coverage.
[E] Officials representing this program also reported that the program
operated under the authority of section 1905(a) of the SSA, which
allows states to use Medicaid funds for the cost of insurance premiums
for certain Medicaid-eligible individuals.
[F] According to state officials, this program operated under the
authority of section 1903(a)(7) of the SSA, which allows for federal
funding for the proper and efficient administration of states'
Medicaid programs.
[End of table]
Table 4: Type of Private Health Insurance Coverage Subsidized, by
State Premium Assistance Program, 2009:
State[A]: Alabama;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: Coverage
subsidized;
Nongroup coverage: [Empty].
State[A]: Alaska;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: [Empty];
Group health insurance coverage: Other group coverage: Coverage
subsidized;
Nongroup coverage: [Empty].
State[A]: Arizona;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: [Empty];
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: [Empty].
State[A]: California;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: Coverage subsidized.
State[A]: Colorado-1;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: [Empty];
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: [Empty].
State[A]: Colorado-2;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: Coverage
subsidized;
Nongroup coverage: Coverage subsidized.
State[A]: Florida;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: [Empty].
State[A]: Georgia;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: Coverage
subsidized;
Nongroup coverage: Coverage subsidized.
State[A]: Idaho-1;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: [Empty];
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: Coverage subsidized.
State[A]: Idaho-2;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: [Empty];
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: [Empty].
State[A]: Illinois;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: Coverage
subsidized;
Nongroup coverage: Coverage subsidized.
State[A]: Iowa;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: Coverage subsidized.
State[A]: Kansas;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: [Empty].
State[A]: Kentucky;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: [Empty];
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: [Empty].
State[A]: Louisiana;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: [Empty].
State[A]: Maine;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: Coverage subsidized.
State[A]: Massachusetts-1;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: [Empty].
State[A]: Massachusetts-2;
Group health insurance coverage: Employer-sponsored: [Empty];
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: Coverage subsidized.
State[A]: Minnesota;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: Coverage
subsidized;
Nongroup coverage: Coverage subsidized.
State[A]: Missouri;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: Coverage
subsidized;
Nongroup coverage: Coverage subsidized.
State[A]: Montana;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: Coverage
subsidized;
Nongroup coverage: Coverage subsidized.
State[A]: Nebraska;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: Coverage
subsidized;
Nongroup coverage: Coverage subsidized.
State[A]: Nevada-1;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: [Empty];
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: [Empty].
State[A]: Nevada-2;
Group health insurance coverage: Employer-sponsored: [Empty];
Group health insurance coverage: COBRA[B]: [Empty];
Group health insurance coverage: Other group coverage: Coverage
subsidized;
Nongroup coverage: [Empty].
State[A]: New Hampshire;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: Coverage
subsidized;
Nongroup coverage: Coverage subsidized.
State[A]: New Jersey-1;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: Coverage subsidized.
State[A]: New Jersey-2;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: [Empty];
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: [Empty].
State[A]: New York;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: [Empty].
State[A]: North Dakota;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: Coverage
subsidized;
Nongroup coverage: Coverage subsidized.
State[A]: Oklahoma;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: [Empty];
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: [Empty].
State[A]: Oregon-1;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: Coverage
subsidized;
Nongroup coverage: Coverage subsidized.
State[A]: Oregon-2;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: [Empty].
State[A]: Pennsylvania;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: [Empty].
State[A]: Rhode Island;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: Coverage
subsidized;
Nongroup coverage: [Empty].
State[A]: South Carolina;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: Coverage subsidized.
State[A]: South Dakota;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: Coverage subsidized.
State[A]: Texas;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: [Empty].
State[A]: Utah-1;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: [Empty];
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: [Empty].
State[A]: Utah-2;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: Coverage
subsidized;
Nongroup coverage: Coverage subsidized.
State[A]: Vermont[C];
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: [Empty].
State[A]: Virginia-1;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: Coverage
subsidized;
Nongroup coverage: Coverage subsidized.
State[A]: Virginia-2;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: [Empty].
State[A]: Washington;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: Coverage subsidized;
Group health insurance coverage: Other group coverage: Coverage
subsidized;
Nongroup coverage: Coverage subsidized.
State[A]: Wisconsin;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: [Empty];
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: [Empty].
State[A]: Wyoming;
Group health insurance coverage: Employer-sponsored: Coverage
subsidized;
Group health insurance coverage: COBRA[B]: [Empty];
Group health insurance coverage: Other group coverage: [Empty];
Nongroup coverage: [Empty].
State[A]: Total;
Group health insurance coverage: Employer-sponsored: 43;
Group health insurance coverage: COBRA[B]: 32;
Group health insurance coverage: Other group coverage: 17;
Nongroup coverage: 21.
Source: GAO Web-based survey administered to states' premium
assistance programs.
Note: Data were obtained from surveys administered from August through
October 2009 to officials in 39 states representing 47 premium
assistance programs funded by Medicaid, CHIP, or both. We received
responses from officials representing 45 programs in 37 states;
officials from 2 states with premium assistance programs, North
Carolina and West Virginia, did not respond to the survey.
[A] Some states operated two premium assistance programs. For program
names, see table 2.
[B] COBRA, an acronym for the Consolidated Omnibus Budget
Reconciliation Act of 1985, allows employees the opportunity to remain
in their employer's group coverage when they would otherwise lose
coverage.
[C] Officials representing this program indicated that the program
also subsidized premiums for "Catamount Health," a state-sponsored
program in the nongroup market.
[End of table]
Table 5: State Premium Assistance Programs with Employer Contribution
or Size Requirements, 2009:
State[A]: Arizona;
Minimum employer contribution: 30 percent;
Limits on participation based on employer size: No requirement.
State[A]: Colorado-1;
Minimum employer contribution: 50 percent;
Limits on participation based on employer size: No requirement.
State[A]: Idaho-2;
Minimum employer contribution: 50 percent[B];
Limits on participation based on employer size: 2 to 50 employees.
State[A]: Massachusetts-1;
Minimum employer contribution: 50 percent[C];
Limits on participation based on employer size: No requirement.
State[A]: Nevada-1;
Minimum employer contribution: 50 percent[B];
Limits on participation based on employer size: 2 to 50 employees.
State[A]: New Jersey-2;
Minimum employer contribution: 50 percent;
Limits on participation based on employer size: 2 or more employees.
State[A]: Oklahoma;
Minimum employer contribution: 25 percent[B];
Limits on participation based on employer size: Less than 100
employees.
State[A]: South Dakota;
Minimum employer contribution: No requirement;
Limits on participation based on employer size: [D].
State[A]: Utah-1;
Minimum employer contribution: 50 percent[B];
Limits on participation based on employer size: No requirement.
Source: GAO Web-based survey administered to states' premium
assistance programs.
Note: Data were obtained from surveys administered from August through
October 2009 to officials in 39 states representing 47 premium
assistance programs funded by Medicaid, CHIP, or both. We received
responses from officials representing 45 programs in 37 states;
officials from 2 states with premium assistance programs, North
Carolina and West Virginia, did not respond to the survey.
[A] Some states operated two premium assistance programs. For program
names, see table 2.
[B] The survey response indicated that the minimum employer
contribution applied to the premium for the employee, while other
responses did not make this distinction.
[C] The employer contribution requirement pertained only to certain
groups covered by Massachusetts' premium assistance program,
specifically children and childless adults.
[D] Officials from this program indicated that the program had a
requirement on employer size, but did not indicate the limit on the
size of employers.
[End of table]
Table 6: State Premium Assistance Programs with Data on the Number of
Employers Participating, June 30, 2009:
State[A]: Colorado-1;
Employer size: Fewer than 50 employees: Response not provided;
Employer size: 50 to 199 employees: Response not provided;
Employer size: 200 or more employees: 1;
Total employers: 1.
State[A]: Florida;
Employer size: Fewer than 50 employees: 1;
Employer size: 50 to 199 employees: Response not provided;
Employer size: 200 or more employees: Response not provided;
Total employers: Response not provided.
State[A]: Idaho-2;
Employer size: Fewer than 50 employees: 121;
Employer size: 50 to 199 employees: NA;
Employer size: 200 or more employees: NA;
Total employers: 121.
State[A]: Nevada-1;
Employer size: Fewer than 50 employees: 27;
Employer size: 50 to 199 employees: NA;
Employer size: 200 or more employees: NA;
Total employers: 27.
State[A]: Oklahoma;
Employer size: Fewer than 50 employees: 4,529;
Employer size: 50 to 199 employees: 223;
Employer size: 200 or more employees: NA;
Total employers: 4,752.
State[A]: Texas;
Employer size: Fewer than 50 employees: [B];
Employer size: 50 to 199 employees: [B];
Employer size: 200 or more employees: [B];
Total employers: 3,500[C].
State[A]: Washington;
Employer size: Fewer than 50 employees: [B];
Employer size: 50 to 199 employees: [B];
Employer size: 200 or more employees: [B];
Total employers: 782[D].
State[A]: Wisconsin;
Employer size: Fewer than 50 employees: [B];
Employer size: 50 to 199 employees: [B];
Employer size: 200 or more employees: [B];
Total employers: 172[E].
Source: GAO Web-based survey administered to states' premium
assistance programs.
NA = not applicable. The program does not allow participation by
employers of this size.
Note: Data were obtained from surveys administered from August through
October 2009 to officials in 39 states representing 47 premium
assistance programs funded by Medicaid, CHIP, or both. We received
responses from officials representing 45 programs in 37 states;
officials from 2 states with premium assistance programs, North
Carolina and West Virginia, did not respond to the survey.
[A] Some states operated two premium assistance programs. For program
names, see table 2.
[B] Officials with these programs reported that data by employer size
were not available.
[C] Program officials reported the total number of employers as of
August 24, 2009.
[D] Program officials reported the total number of employers as of
June 26, 2009.
[E] Program officials reported the total number of employers as of
June 30, 2008.
[End of table]
[End of Enclosure I]
Enclosure II: States' Premium Assistance Programs' Policies Regarding
Eligibility and Enrollment:
Table 7: Income Eligibility Standards as a Percentage of the Federal
Poverty Level (FPL) and State Subsidy of Premiums for Noneligible
Family Members, by State Premium Assistance Program, June 30, 2009:
State[A]: Alabama;
Children: Under age 1 year: 0-133;
Children: Ages 1 through 5 years: 0-133;
Children: Ages 6 through 18 years: 0-100;
Children: Pregnant women/unborn children[B]: 0-133;
Children: Parents/legal guardians: 0-11;
Children: Childless adults: Population not covered;
Children: Other individuals[C]: Population not covered;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: Alaska;
Children: Under age 1 year: 150-185;
Children: Ages 1 through 5 years: 150-185;
Children: Ages 6 through 18 years: 150-185;
Children: Pregnant women/unborn children[B]: 150-185;
Children: Parents/legal guardians: 150-185;
Children: Childless adults: 150-185;
Children: Other individuals[C]: 100-250;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: Arizona;
Children: Under age 1 year: 140-200;
Children: Ages 1 through 5 years: 133-200;
Children: Ages 6 through 18 years: 100-200;
Children: Pregnant women/unborn children[B]: Population not covered;
Children: Parents/legal guardians: Population not covered;
Children: Childless adults: Population not covered;
Children: Other individuals[C]: Population not covered;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: California;
Children: Under age 1 year: response not provided;
Children: Ages 1 through 5 years: response not provided;
Children: Ages 6 through 18 years: response not provided;
Children: Pregnant women/unborn children[B]: response not provided;
Children: Parents/legal guardians: response not provided;
Children: Childless adults: response not provided;
Children: Other individuals[C]: response not provided;
Subsidize premiums for noneligible family members[D]: No.
State[A]: Colorado-1;
Children: Under age 1 year: 134-205;
Children: Ages 1 through 5 years: 134-205;
Children: Ages 6 through 18 years: 100-205;
Children: Pregnant women/unborn children[B]: 134-205;
Children: Parents/legal guardians: Population not covered;
Children: Childless adults: Population not covered;
Children: Other individuals[C]: Population not covered;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: Colorado-2;
Children: Under age 1 year: 0-133;
Children: Ages 1 through 5 years: 0-133;
Children: Ages 6 through 18 years: 0-100;
Children: Pregnant women/unborn children[B]: 0-133;
Children: Parents/legal guardians: 0-60;
Children: Childless adults: Population not covered;
Children: Other individuals[C]: Population not covered;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: Florida;
Children: Under age 1 year: response not provided;
Children: Ages 1 through 5 years: response not provided;
Children: Ages 6 through 18 years: response not provided;
Children: Pregnant women/unborn children[B]: response not provided;
Children: Parents/legal guardians: response not provided;
Children: Childless adults: response not provided;
Children: Other individuals[C]: response not provided;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: Georgia;
Children: Under age 1 year: response not provided;
Children: Ages 1 through 5 years: response not provided;
Children: Ages 6 through 18 years: response not provided;
Children: Pregnant women/unborn children[B]: response not provided;
Children: Parents/legal guardians: response not provided;
Children: Childless adults: response not provided;
Children: Other individuals[C]: response not provided;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: Idaho-1;
Children: Under age 1 year: 133-185;
Children: Ages 1 through 5 years: 133-185;
Children: Ages 6 through 18 years: 100-185;
Children: Pregnant women/unborn children[B]: Population not covered;
Children: Parents/legal guardians: Population not covered;
Children: Childless adults: Population not covered;
Children: Other individuals[C]: Population not covered;
Subsidize premiums for noneligible family members[D]: No.
State[A]: Idaho-2;
Children: Under age 1 year: Population not covered;
Children: Ages 1 through 5 years: Population not covered;
Children: Ages 6 through 18 years: Population not covered;
Children: Pregnant women/unborn children[B]: 133-185;
Children: Parents/legal guardians: 25-185;
Children: Childless adults: 0-185;
Children: Other individuals[C]: Population not covered;
Subsidize premiums for noneligible family members[D]: No.
State[A]: Illinois;
Children: Under age 1 year: 0-200;
Children: Ages 1 through 5 years: 0-133;
Children: Ages 6 through 18 years: 0-133;
Children: Pregnant women/unborn children[B]: 0-200;
Children: Parents/legal guardians: 0-133;
Children: Childless adults: Population not covered;
Children: Other individuals[C]: 0-100;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: Iowa;
Children: Under age 1 year: 0-200;
Children: Ages 1 through 5 years: 0-133;
Children: Ages 6 through 18 years: 0-133;
Children: Pregnant women/unborn children[B]: 0-200;
Children: Parents/legal guardians: 0-133;
Children: Childless adults: 0-133;
Children: Other individuals[C]: 0-250;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: Kansas;
Children: Under age 1 year: 100-150;
Children: Ages 1 through 5 years: 100-149;
Children: Ages 6 through 18 years: 100-132;
Children: Pregnant women/unborn children[B]: Population not covered;
Children: Parents/legal guardians: Population not covered;
Children: Childless adults: Population not covered;
Children: Other individuals[C]: Population not covered;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: Kentucky;
Children: Under age 1 year: response not provided;
Children: Ages 1 through 5 years: response not provided;
Children: Ages 6 through 18 years: response not provided;
Children: Pregnant women/unborn children[B]: response not provided;
Children: Parents/legal guardians: response not provided;
Children: Childless adults: response not provided;
Children: Other individuals[C]: response not provided;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: Louisiana;
Children: Under age 1 year: 0-250;
Children: Ages 1 through 5 years: 0-250;
Children: Ages 6 through 18 years: 0-250;
Children: Pregnant women/unborn children[B]: 0-200;
Children: Parents/legal guardians: 0-250;
Children: Childless adults: Population not covered;
Children: Other individuals[C]: Population not covered;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: Maine;
Children: Under age 1 year: 0-185;
Children: Ages 1 through 5 years: 0-150;
Children: Ages 6 through 18 years: 0-150;
Children: Pregnant women/unborn children[B]: 0-200;
Children: Parents/legal guardians: 0-200;
Children: Childless adults: 0-100;
Children: Other individuals[C]: Population not covered;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: Massachusetts-1;
Children: Under age 1 year: 0-300;
Children: Ages 1 through 5 years: 0-300;
Children: Ages 6 through 18 years: 0-300;
Children: Pregnant women/unborn children[B]: 0-200;
Children: Parents/legal guardians: 0-133;
Children: Childless adults: 0-200;
Children: Other individuals[C]: Population not covered;
Subsidize premiums for noneligible family members[D]: No.
State[A]: Massachusetts-2;
Children: Under age 1 year: Population not covered;
Children: Ages 1 through 5 years: Population not covered;
Children: Ages 6 through 18 years: Population not covered;
Children: Pregnant women/unborn children[B]: Population not covered;
Children: Parents/legal guardians: Population not covered;
Children: Childless adults: Population not covered;
Children: Other individuals[C]: 0-400;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: Minnesota;
Children: Under age 1 year: 0-275;
Children: Ages 1 through 5 years: 0-150;
Children: Ages 6 through 18 years: 0-150;
Children: Pregnant women/unborn children[B]: 0-275;
Children: Parents/legal guardians: 0-100;
Children: Childless adults: Population not covered;
Children: Other individuals[C]: 0-100;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: Missouri;
Children: Under age 1 year: 0-299;
Children: Ages 1 through 5 years: 0-299;
Children: Ages 6 through 18 years: 0-299;
Children: Pregnant women/unborn children[B]: 0-185;
Children: Parents/legal guardians: response not provided;
Children: Childless adults: Population not covered;
Children: Other individuals[C]: 0-85;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: Montana;
Children: Under age 1 year: 0-133;
Children: Ages 1 through 5 years: 0-133;
Children: Ages 6 through 18 years: 0-100;
Children: Pregnant women/unborn children[B]: 0-150;
Children: Parents/legal guardians: 0-40;
Children: Childless adults: Population not covered;
Children: Other individuals[C]: 0-58;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: Nebraska;
Children: Under age 1 year: response not provided;
Children: Ages 1 through 5 years: response not provided;
Children: Ages 6 through 18 years: response not provided;
Children: Pregnant women/unborn children[B]: response not provided;
Children: Parents/legal guardians: response not provided;
Children: Childless adults: response not provided;
Children: Other individuals[C]: response not provided;
Subsidize premiums for noneligible family members[D]: No.
State[A]: Nevada-1;
Children: Under age 1 year: 133-200;
Children: Ages 1 through 5 years: 133-200;
Children: Ages 6 through 18 years: 100-200;
Children: Pregnant women/unborn children[B]: Population not covered;
Children: Parents/legal guardians: 100-200;
Children: Childless adults: Population not covered;
Children: Other individuals[C]: 100-200;
Subsidize premiums for noneligible family members[D]: No.
State[A]: Nevada-2;
Children: Under age 1 year: 0-133;
Children: Ages 1 through 5 years: 0-133;
Children: Ages 6 through 18 years: 0-100;
Children: Pregnant women/unborn children[B]: 0-185;
Children: Parents/legal guardians: 0-130;
Children: Childless adults: Population not covered;
Children: Other individuals[C]: 133-185;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: New Hampshire;
Children: Under age 1 year: 0-185;
Children: Ages 1 through 5 years: 0-185;
Children: Ages 6 through 18 years: 0-185;
Children: Pregnant women/unborn children[B]: 133-185;
Children: Parents/legal guardians: Population not covered;
Children: Childless adults: Population not covered;
Children: Other individuals[C]: Population not covered;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: New Jersey-1;
Children: Under age 1 year: response not provided;
Children: Ages 1 through 5 years: response not provided;
Children: Ages 6 through 18 years: response not provided;
Children: Pregnant women/unborn children[B]: response not provided;
Children: Parents/legal guardians: response not provided;
Children: Childless adults: response not provided;
Children: Other individuals[C]: response not provided;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: New Jersey-2;
Children: Under age 1 year: 0-350;
Children: Ages 1 through 5 years: 0-350;
Children: Ages 6 through 18 years: 0-350;
Children: Pregnant women/unborn children[B]: Population not covered;
Children: Parents/legal guardians: 0-200;
Children: Childless adults: Population not covered;
Children: Other individuals[C]: Population not covered;
Subsidize premiums for noneligible family members[D]: No.
State[A]: New York;
Children: Under age 1 year: Population not covered;
Children: Ages 1 through 5 years: Population not covered;
Children: Ages 6 through 18 years: Population not covered;
Children: Pregnant women/unborn children[B]: Population not covered;
Children: Parents/legal guardians: 0-150;
Children: Childless adults: 0-100;
Children: Other individuals[C]: 0-150;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: North Dakota;
Children: Under age 1 year: 0-133;
Children: Ages 1 through 5 years: 0-133;
Children: Ages 6 through 18 years: 0-100;
Children: Pregnant women/unborn children[B]: 0-133;
Children: Parents/legal guardians: 0-83;
Children: Childless adults: Population not covered;
Children: Other individuals[C]: 0-225;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: Oklahoma;
Children: Under age 1 year: Population not covered;
Children: Ages 1 through 5 years: Population not covered;
Children: Ages 6 through 18 years: Population not covered;
Children: Pregnant women/unborn children[B]: 0-200;
Children: Parents/legal guardians: 0-200;
Children: Childless adults: 0-200;
Children: Other individuals[C]: Population not covered;
Subsidize premiums for noneligible family members[D]: No.
State[A]: Oregon-1;
Children: Under age 1 year: 0-185;
Children: Ages 1 through 5 years: 0-185;
Children: Ages 6 through 18 years: 0-185;
Children: Pregnant women/unborn children[B]: 0-185;
Children: Parents/legal guardians: 0-185;
Children: Childless adults: 0-185;
Children: Other individuals[C]: Population not covered;
Subsidize premiums for noneligible family members[D]: No.
State[A]: Oregon-2;
Children: Under age 1 year: 0-185;
Children: Ages 1 through 5 years: 0-133;
Children: Ages 6 through 18 years: 0-100;
Children: Pregnant women/unborn children[B]: 0-185;
Children: Parents/legal guardians: 0-41;
Children: Childless adults: Population not covered;
Children: Other individuals[C]: Population not covered;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: Pennsylvania;
Children: Under age 1 year: response not provided;
Children: Ages 1 through 5 years: response not provided;
Children: Ages 6 through 18 years: response not provided;
Children: Pregnant women/unborn children[B]: response not provided;
Children: Parents/legal guardians: response not provided;
Children: Childless adults: response not provided;
Children: Other individuals[C]: response not provided;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: Rhode Island;
Children: Under age 1 year: 0-250;
Children: Ages 1 through 5 years: 0-250;
Children: Ages 6 through 18 years: 0-250;
Children: Pregnant women/unborn children[B]: 0-250;
Children: Parents/legal guardians: 0-185;
Children: Childless adults: Population not covered;
Children: Other individuals[C]: Population not covered;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: South Carolina;
Children: Under age 1 year: response not provided;
Children: Ages 1 through 5 years: response not provided;
Children: Ages 6 through 18 years: response not provided;
Children: Pregnant women/unborn children[B]: response not provided;
Children: Parents/legal guardians: response not provided;
Children: Childless adults: response not provided;
Children: Other individuals[C]: response not provided;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: South Dakota;
Children: Under age 1 year: 0-140;
Children: Ages 1 through 5 years: 0-140;
Children: Ages 6 through 18 years: 0-140;
Children: Pregnant women/unborn children[B]: 0-133;
Children: Parents/legal guardians: 0-52;
Children: Childless adults: Population not covered;
Children: Other individuals[C]: Population not covered;
Subsidize premiums for noneligible family members[D]: No.
State[A]: Texas;
Children: Under age 1 year: 0-185;
Children: Ages 1 through 5 years: 0-133;
Children: Ages 6 through 18 years: 0-100;
Children: Pregnant women/unborn children[B]: 0-185;
Children: Parents/legal guardians: 0-13;
Children: Childless adults: Population not covered;
Children: Other individuals[C]: Population not covered;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: Utah-1;
Children: Under age 1 year: 133-200;
Children: Ages 1 through 5 years: 133-200;
Children: Ages 6 through 18 years: 0-200;
Children: Pregnant women/unborn children[B]: Population not covered;
Children: Parents/legal guardians: 0-150;
Children: Childless adults: 0-150;
Children: Other individuals[C]: Population not covered;
Subsidize premiums for noneligible family members[D]: No.
State[A]: Utah-2;
Children: Under age 1 year: 0-133;
Children: Ages 1 through 5 years: 0-133;
Children: Ages 6 through 18 years: 0-100;
Children: Pregnant women/unborn children[B]: 0-133;
Children: Parents/legal guardians: 0-42;
Children: Childless adults: 0-150;
Children: Other individuals[C]: 0-185;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: Vermont;
Children: Under age 1 year: Population not covered;
Children: Ages 1 through 5 years: Population not covered;
Children: Ages 6 through 18 years: Population not covered;
Children: Pregnant women/unborn children[B]: Population not covered;
Children: Parents/legal guardians: 0-200;
Children: Childless adults: 0-200;
Children: Other individuals[C]: Population not covered;
Subsidize premiums for noneligible family members[D]: No.
State[A]: Virginia-1;
Children: Under age 1 year: 134-200;
Children: Ages 1 through 5 years: 134-200;
Children: Ages 6 through 18 years: 134-200;
Children: Pregnant women/unborn children[B]: Population not covered;
Children: Parents/legal guardians: Population not covered;
Children: Childless adults: Population not covered;
Children: Other individuals[C]: Population not covered;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: Virginia-2;
Children: Under age 1 year: 0-133;
Children: Ages 1 through 5 years: 0-133;
Children: Ages 6 through 18 years: 0-133;
Children: Pregnant women/unborn children[B]: 0-133;
Children: Parents/legal guardians: 0-30;
Children: Childless adults: Population not covered;
Children: Other individuals[C]: Population not covered;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: Washington;
Children: Under age 1 year: 0-200;
Children: Ages 1 through 5 years: 0-200;
Children: Ages 6 through 18 years: 0-200;
Children: Pregnant women/unborn children[B]: 0-185;
Children: Parents/legal guardians: 0-79;
Children: Childless adults: 0-100;
Children: Other individuals[C]: Population not covered;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: Wisconsin;
Children: Under age 1 year: 0-250;
Children: Ages 1 through 5 years: 0-250;
Children: Ages 6 through 18 years: 0-250;
Children: Pregnant women/unborn children[B]: 0-300;
Children: Parents/legal guardians: 0-200;
Children: Childless adults: 0-200;
Children: Other individuals[C]: Population not covered;
Subsidize premiums for noneligible family members[D]: Yes.
State[A]: Wyoming;
Children: Under age 1 year: 0-133;
Children: Ages 1 through 5 years: 0-133;
Children: Ages 6 through 18 years: 0-100;
Children: Pregnant women/unborn children[B]: 0-133;
Children: Parents/legal guardians: 0-36;
Children: Childless adults: Population not covered;
Children: Other individuals[C]: Population not covered;
Subsidize premiums for noneligible family members[D]: Yes.
Source: GAO Web-based survey administered to states' premium
assistance programs.
Note: Data were obtained from surveys administered from August through
October 2009 to officials in 39 states representing 47 premium
assistance programs funded by Medicaid, State Children's Health
Insurance Program (CHIP), or both. We received responses from
officials representing 45 programs in 37 states; officials from 2
states with premium assistance programs, North Carolina and West
Virginia, did not respond to the survey.
The FPL is updated annually to reflect changes in the cost of living
and varies according to family size.
[A] Some states operated two premium assistance programs. For program
names, see table 2.
[B] Under CHIP, states may choose to extend eligibility to unborn
children and provide prenatal care and delivery. See 67 Fed. Reg.
61956 (Oct. 2, 2002).
[C] Individuals commonly included in this group were certain
unemployed individuals, aged or disabled individuals, or individuals
receiving Supplemental Security Income benefits.
[D] Programs may subsidize premiums (provide incidental coverage) for
noneligible family members under certain circumstances--for example,
if the noneligible family member must be enrolled in the health plan
for the eligible family member to obtain coverage.
[End of table]
Figure 1: Number of State Premium Assistance Programs that Set Maximum
Family Income Eligibility Thresholds within Selected Ranges, Expressed
as Percentages of the FPL, by Coverage Group, June 30, 2009:
[Refer to PDF for image: illustrated table]
Maximum threshold between 301 and 400 percent of the FPL:
Children under age 1: 1 program;
Children ages 1 through 5 years: 1 program;
Children ages 6 through 18 years: 1 program;
Pregnant women/unborn children[A]: 0;
Parents/legal guardians: 0;
Childless adults: 0;
Other individuals[B]: 1 program.
Maximum threshold between 201 and 300 percent of the FPL:
Children under age 1: 7 programs;
Children ages 1 through 5 years: 6 programs;
Children ages 6 through 18 years: 6 programs;
Pregnant women/unborn children[A]: 4 programs;
Parents/legal guardians: 1 program;
Childless adults: 0;
Other individuals[B]: 3 programs.
Maximum threshold between 101 and 200 percent of the FPL:
Children under age 1: 24 programs;
Children ages 1 through 5 years: 25 programs;
Children ages 6 through 18 years: 16 programs;
Pregnant women/unborn children[A]: 23 programs;
Parents/legal guardians: 16 programs;
Childless adults: 10 programs;
Other individuals[B]: 4 programs.
Maximum threshold at or below 100 percent of the FPL:
Children under age 1: 0;
Children ages 1 through 5 years: 0;
Children ages 6 through 18 years: 9 programs;
Pregnant women/unborn children[A]: 0;
Parents/legal guardians: 12 programs;
Childless adults: 3 programs;
Other individuals[B]: 4 programs.
Source: GAO Web-based survey administered to states' premium
assistance programs.
Note: Data were obtained from surveys administered from August through
October 2009 to officials in 39 states representing 47 premium
assistance programs funded by Medicaid, CHIP, or both. We received
responses from officials representing 45 programs in 37 states;
officials from 2 states with premium assistance programs, North
Carolina and West Virginia, did not respond to the survey. Officials
of 8 premium assistance programs did not provide information on income
eligibility thresholds.
The FPL is updated annually to reflect changes in the cost of living
and varies according to family size.
[A] Under CHIP, states may choose to extend eligibility to unborn
children and provide prenatal care and delivery. See 67 Fed. Reg.
61956 (Oct. 2, 2002).
[B] Individuals commonly included in this group were certain
unemployed individuals, aged or disabled individuals, or individuals
receiving Supplemental Security Income benefits.
[End of figure]
Table 8: Enrollment Policies, by State Premium Assistance Program,
2009:
State[A]: Alabama;
Mandatory enrollment[B]: Yes, for all individuals: [Empty];
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: Enrollment policy used;
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: Alaska;
Mandatory enrollment[B]: Yes, for all individuals: [Empty];
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: Enrollment policy used;
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: Arizona;
Mandatory enrollment[B]: Yes, for all individuals: [Empty];
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: Enrollment policy used;
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: 3.
State[A]: California;
Mandatory enrollment[B]: Yes, for all individuals: [Empty];
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: Enrollment policy used;
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: Colorado-1;
Mandatory enrollment[B]: Yes, for all individuals: [Empty];
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: Enrollment policy used;
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: Colorado-2;
Mandatory enrollment[B]: Yes, for all individuals: [Empty];
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: Enrollment policy used;
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: Florida;
Mandatory enrollment[B]: Yes, for all individuals: [Empty];
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: Enrollment policy used;
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: Georgia;
Mandatory enrollment[B]: Yes, for all individuals: [Empty];
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: Enrollment policy used;
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: Idaho-1;
Mandatory enrollment[B]: Yes, for all individuals: [Empty];
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: Enrollment policy used;
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: 6.
State[A]: Idaho-2;
Mandatory enrollment[B]: Yes, for all individuals: [Empty];
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: Enrollment policy used;
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: 6.
State[A]: Illinois;
Mandatory enrollment[B]: Yes, for all individuals: [Empty];
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: Enrollment policy used;
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: Iowa;
Mandatory enrollment[B]: Yes, for all individuals: Enrollment policy
used;
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: [Empty];
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: Kansas;
Mandatory enrollment[B]: Yes, for all individuals: Enrollment policy
used;
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: [Empty];
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: Kentucky;
Mandatory enrollment[B]: Yes, for all individuals: Enrollment policy
used;
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: [Empty];
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: Louisiana;
Mandatory enrollment[B]: Yes, for all individuals: Enrollment policy
used;
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: [Empty];
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: Maine;
Mandatory enrollment[B]: Yes, for all individuals: [Empty];
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: Enrollment policy used;
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: Massachusetts-1;
Mandatory enrollment[B]: Yes, for all individuals: Enrollment policy
used;
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: [Empty];
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: 6[E].
State[A]: Massachusetts-2;
Mandatory enrollment[B]: Yes, for all individuals: Enrollment policy
used;
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: [Empty];
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: Minnesota;
Mandatory enrollment[B]: Yes, for all individuals: Enrollment policy
used;
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: [Empty];
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: Missouri;
Mandatory enrollment[B]: Yes, for all individuals: Enrollment policy
used;
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: [Empty];
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: Montana;
Mandatory enrollment[B]: Yes, for all individuals: Enrollment policy
used;
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: [Empty];
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: Nebraska;
Mandatory enrollment[B]: Yes, for all individuals: [Empty];
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: Enrollment policy used;
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: Nevada-1;
Mandatory enrollment[B]: Yes, for all individuals: Enrollment policy
used;
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: [Empty];
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: 6.
State[A]: Nevada-2;
Mandatory enrollment[B]: Yes, for all individuals: Enrollment policy
used;
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: [Empty];
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: New Hampshire;
Mandatory enrollment[B]: Yes, for all individuals: [Empty];
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: Enrollment policy used;
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: New Jersey-1;
Mandatory enrollment[B]: Yes, for all individuals: Enrollment policy
used;
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: [Empty];
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: New Jersey-2;
Mandatory enrollment[B]: Yes, for all individuals: [Empty];
Mandatory enrollment[B]: Yes, for some individuals: Enrollment policy
used[F];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: [Empty];
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: 3.
State[A]: New York;
Mandatory enrollment[B]: Yes, for all individuals: [Empty];
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: Enrollment policy used;
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: North Dakota;
Mandatory enrollment[B]: Yes, for all individuals: Enrollment policy
used;
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: [Empty];
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: Oklahoma;
Mandatory enrollment[B]: Yes, for all individuals: [Empty];
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: Enrollment policy used;
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: Oregon-1;
Mandatory enrollment[B]: Yes, for all individuals: [Empty];
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: Enrollment policy used;
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: 6.
State[A]: Oregon-2;
Mandatory enrollment[B]: Yes, for all individuals: Enrollment policy
used;
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: [Empty];
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: Pennsylvania;
Mandatory enrollment[B]: Yes, for all individuals: Enrollment policy
used;
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: [Empty];
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: Rhode Island;
Mandatory enrollment[B]: Yes, for all individuals: Enrollment policy
used;
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: [Empty];
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: South Carolina;
Mandatory enrollment[B]: Yes, for all individuals: [Empty];
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: Enrollment policy used;
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: South Dakota;
Mandatory enrollment[B]: Yes, for all individuals: [Empty];
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: Enrollment policy used;
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: Texas;
Mandatory enrollment[B]: Yes, for all individuals: [Empty];
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: Enrollment policy used;
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: Utah-1;
Mandatory enrollment[B]: Yes, for all individuals: [Empty];
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: Enrollment policy used;
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: 3.
State[A]: Utah-2;
Mandatory enrollment[B]: Yes, for all individuals: [Empty];
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: Enrollment policy used;
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [D].
State[A]: Vermont;
Mandatory enrollment[B]: Yes, for all individuals: Enrollment policy
used;
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: [Empty];
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: 12.
State[A]: Virginia-1;
Mandatory enrollment[B]: Yes, for all individuals: [Empty];
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: Enrollment policy used;
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: 4.
State[A]: Virginia-2;
Mandatory enrollment[B]: Yes, for all individuals: [Empty];
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: Enrollment policy used;
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: d.
State[A]: Washington;
Mandatory enrollment[B]: Yes, for all individuals: [Empty];
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: Enrollment policy used;
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: d.
State[A]: Wisconsin;
Mandatory enrollment[B]: Yes, for all individuals: Enrollment policy
used;
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: [Empty];
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: 3[G].
State[A]: Wyoming;
Mandatory enrollment[B]: Yes, for all individuals: Enrollment policy
used;
Mandatory enrollment[B]: Yes, for some individuals: [Empty];
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: [Empty];
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: Response not
provided.
State[A]: Total;
Mandatory enrollment[B]: Yes, for all individuals: 19;
Mandatory enrollment[B]: Yes, for some individuals: 1;
Mandatory enrollment[B]: No, enrollment is voluntary for all
individuals: 25;
Months individuals are required to be without group health insurance
before enrollment in premium assistance is permitted[C]: [Empty].
Source: GAO Web-based survey administered to states' premium
assistance programs.
Note: Data were obtained from surveys administered from August through
October 2009 to officials in 39 states representing 47 premium
assistance programs funded by Medicaid, CHIP, or both. We received
responses from officials representing 45 programs in 37 states;
officials from 2 states with premium assistance programs, North
Carolina and West Virginia, did not respond to the survey.
[A] Some states operated two premium assistance programs. For program
names, see table 2.
[B] Enrollment was considered to be mandatory if individuals who met
the program's eligibility requirements--which may have included having
access to cost-effective private health insurance--were required to
enroll in the premium assistance program in order to get Medicaid or
CHIP benefits. Although a premium assistance program may have
mandatory enrollment for all eligible individuals, under section 1906
of the Social Security Act (SSA), eligible children cannot be denied
direct coverage if their parent fails to enroll them in a group health
plan.
[C] Programs may permit reasonable exceptions.
[D] This program does not require individuals to be uninsured for any
period of time before enrolling in premium assistance.
[E] Officials from this program reported that only children receiving
premium assistance through CHIP were required to be uninsured for the
6 months prior to enrollment in premium assistance.
[F] Officials from this program reported that the program did not have
mandatory enrollment for individuals with incomes less than 134
percent of the FPL.
[G] Officials from this program reported that childless adults were
required to be uninsured for the 12 months prior to enrollment in
premium assistance.
[End of table]
Table 9: Number of Individuals and Families Covered, by State Premium
Assistance Program, June 30, 2009:
State[A]: Alabama;
Number of Medicaid-or CHIP-eligible individuals[B]: 6;
Number of noneligible family members[B]: 0;
Total number of individuals[B]: 6;
Number of families[C]: 0.
State[A]: Alaska;
Number of Medicaid-or CHIP-eligible individuals[B]: 16;
Number of noneligible family members[B]: 29;
Total number of individuals[B]: 71[D];
Number of families[C]: 14.
State[A]: Arizona;
Number of Medicaid-or CHIP-eligible individuals[B]: 3;
Number of noneligible family members[B]: Response not provided;
Total number of individuals[B]: 3;
Number of families[C]: 1.
State[A]: California;
Number of Medicaid-or CHIP-eligible individuals[B]: 1,033;
Number of noneligible family members[B]: [E];
Total number of individuals[B]: [F];
Number of families[C]: [E].
State[A]: Colorado-1;
Number of Medicaid-or CHIP-eligible individuals[B]: 103;
Number of noneligible family members[B]: 61;
Total number of individuals[B]: 164;
Number of families[C]: 42.
State[A]: Colorado-2;
Number of Medicaid-or CHIP-eligible individuals[B]: 432;
Number of noneligible family members[B]: [E];
Total number of individuals[B]: 432;
Number of families[C]: 403.
State[A]: Florida;
Number of Medicaid-or CHIP-eligible individuals[B]: 21;
Number of noneligible family members[B]: [E];
Total number of individuals[B]: [F];
Number of families[C]: 13.
State[A]: Georgia;
Number of Medicaid-or CHIP-eligible individuals[B]: 937;
Number of noneligible family members[B]: [E];
Total number of individuals[B]: [F];
Number of families[C]: 882.
State[A]: Idaho-1;
Number of Medicaid-or CHIP-eligible individuals[B]: 133;
Number of noneligible family members[B]: 0;
Total number of individuals[B]: 133;
Number of families[C]: 0.
State[A]: Idaho-2;
Number of Medicaid-or CHIP-eligible individuals[B]: 347;
Number of noneligible family members[B]: 0;
Total number of individuals[B]: 347;
Number of families[C]: [E].
State[A]: Illinois;
Number of Medicaid-or CHIP-eligible individuals[B]: 145;
Number of noneligible family members[B]: e;
Total number of individuals[B]: [F];
Number of families[C]: 67.
State[A]: Iowa;
Number of Medicaid-or CHIP-eligible individuals[B]: 3,019;
Number of noneligible family members[B]: 4,319;
Total number of individuals[B]: 8,086[D];
Number of families[C]: 1,949.
State[A]: Kansas;
Number of Medicaid-or CHIP-eligible individuals[B]: [E];
Number of noneligible family members[B]: [E];
Total number of individuals[B]: [E];
Number of families[C]: [E].
State[A]: Kentucky;
Number of Medicaid-or CHIP-eligible individuals[B]: 6;
Number of noneligible family members[B]: Response not provided;
Total number of individuals[B]: [F];
Number of families[C]: 6.
State[A]: Louisiana;
Number of Medicaid-or CHIP-eligible individuals[B]: 2,621;
Number of noneligible family members[B]: 831;
Total number of individuals[B]: 3,452;
Number of families[C]: 743.
State[A]: Maine;
Number of Medicaid-or CHIP-eligible individuals[B]: 869;
Number of noneligible family members[B]: 172;
Total number of individuals[B]: 1,041;
Number of families[C]: 314.
State[A]: Massachusetts-1;
Number of Medicaid-or CHIP-eligible individuals[B]: 30,653;
Number of noneligible family members[B]: 0;
Total number of individuals[B]: 30,653;
Number of families[C]: 18,397.
State[A]: Massachusetts-2;
Number of Medicaid-or CHIP-eligible individuals[B]: 3,500;
Number of noneligible family members[B]: 2,034;
Total number of individuals[B]: 5,534;
Number of families[C]: 3,500.
State[A]: Minnesota;
Number of Medicaid-or CHIP-eligible individuals[B]: 20,276;
Number of noneligible family members[B]: Response not provided;
Total number of individuals[B]: 20,276;
Number of families[C]: 6,569.
State[A]: Missouri;
Number of Medicaid-or CHIP-eligible individuals[B]: 1,549;
Number of noneligible family members[B]: 1,297;
Total number of individuals[B]: 2,846;
Number of families[C]: 781.
State[A]: Montana;
Number of Medicaid-or CHIP-eligible individuals[B]: 747;
Number of noneligible family members[B]: [E];
Total number of individuals[B]: 747;
Number of families[C]: 267.
State[A]: Nebraska;
Number of Medicaid-or CHIP-eligible individuals[B]: 320;
Number of noneligible family members[B]: 750;
Total number of individuals[B]: 1,070;
Number of families[C]: 285.
State[A]: Nevada-1;
Number of Medicaid-or CHIP-eligible individuals[B]: 4;
Number of noneligible family members[B]: 0;
Total number of individuals[B]: 4;
Number of families[C]: 4.
State[A]: Nevada-2;
Number of Medicaid-or CHIP-eligible individuals[B]: 48;
Number of noneligible family members[B]: 110;
Total number of individuals[B]: 158;
Number of families[C]: e.
State[A]: New Hampshire;
Number of Medicaid-or CHIP-eligible individuals[B]: 127;
Number of noneligible family members[B]: 98;
Total number of individuals[B]: 229[D];
Number of families[C]: 94.
State[A]: New Jersey-1;
Number of Medicaid-or CHIP-eligible individuals[B]: 73;
Number of noneligible family members[B]: 58;
Total number of individuals[B]: 131;
Number of families[C]: 64.
State[A]: New Jersey-2;
Number of Medicaid-or CHIP-eligible individuals[B]: 300;
Number of noneligible family members[B]: 0;
Total number of individuals[B]: 300;
Number of families[C]: 95.
State[A]: New York;
Number of Medicaid-or CHIP-eligible individuals[B]: 1,380;
Number of noneligible family members[B]: Response not provided;
Total number of individuals[B]: [F];
Number of families[C]: 255.
State[A]: North Dakota;
Number of Medicaid-or CHIP-eligible individuals[B]: 54;
Number of noneligible family members[B]: 24;
Total number of individuals[B]: 78;
Number of families[C]: [E].
State[A]: Oklahoma;
Number of Medicaid-or CHIP-eligible individuals[B]: 14,217;
Number of noneligible family members[B]: e;
Total number of individuals[B]: 14,217;
Number of families[C]: [E].
State[A]: Oregon-1;
Number of Medicaid-or CHIP-eligible individuals[B]: 6,692;
Number of noneligible family members[B]: 0;
Total number of individuals[B]: 6,692;
Number of families[C]: 3,506.
State[A]: Oregon-2;
Number of Medicaid-or CHIP-eligible individuals[B]: 658;
Number of noneligible family members[B]: 205;
Total number of individuals[B]: 863;
Number of families[C]: [E].
State[A]: Pennsylvania;
Number of Medicaid-or CHIP-eligible individuals[B]: 26,693;
Number of noneligible family members[B]: [E];
Total number of individuals[B]: [F];
Number of families[C]: 12,462.
State[A]: Rhode Island;
Number of Medicaid-or CHIP-eligible individuals[B]: 8,493;
Number of noneligible family members[B]: [E];
Total number of individuals[B]: 8,493;
Number of families[C]: [E].
State[A]: South Carolina;
Number of Medicaid-or CHIP-eligible individuals[B]: 215;
Number of noneligible family members[B]: 40;
Total number of individuals[B]: 255;
Number of families[C]: 211.
State[A]: South Dakota;
Number of Medicaid-or CHIP-eligible individuals[B]: 70;
Number of noneligible family members[B]: [E];
Total number of individuals[B]: [F];
Number of families[C]: [E].
State[A]: Texas;
Number of Medicaid-or CHIP-eligible individuals[B]: 7,822;
Number of noneligible family members[B]: 849;
Total number of individuals[B]: 8,671;
Number of families[C]: 1,351.
State[A]: Utah-1;
Number of Medicaid-or CHIP-eligible individuals[B]: 728;
Number of noneligible family members[B]: 0;
Total number of individuals[B]: 728;
Number of families[C]: 331.
State[A]: Utah-2;
Number of Medicaid-or CHIP-eligible individuals[B]: 200;
Number of noneligible family members[B]: 5;
Total number of individuals[B]: 205;
Number of families[C]: 200.
State[A]: Vermont;
Number of Medicaid-or CHIP-eligible individuals[B]: 6,989;
Number of noneligible family members[B]: 0;
Total number of individuals[B]: 6,989;
Number of families[C]: 0.
State[A]: Virginia-1;
Number of Medicaid-or CHIP-eligible individuals[B]: 449;
Number of noneligible family members[B]: 342;
Total number of individuals[B]: 791;
Number of families[C]: 147.
State[A]: Virginia-2;
Number of Medicaid-or CHIP-eligible individuals[B]: 2,199;
Number of noneligible family members[B]: [E];
Total number of individuals[B]: [F];
Number of families[C]: 1,489.
State[A]: Washington;
Number of Medicaid-or CHIP-eligible individuals[B]: [E];
Number of noneligible family members[B]: [E];
Total number of individuals[B]: 6,041;
Number of families[C]: 3,393.
State[A]: Wisconsin;
Number of Medicaid-or CHIP-eligible individuals[B]: 1,110;
Number of noneligible family members[B]: [E];
Total number of individuals[B]: [F];
Number of families[C]: 304.
State[A]: Wyoming;
Number of Medicaid-or CHIP-eligible individuals[B]: 8;
Number of noneligible family members[B]: Response not provided;
Total number of individuals[B]: 8;
Number of families[C]: 5.
Source: GAO Web-based survey administered to states' premium
assistance programs.
Note: Data were obtained from surveys administered from August through
October 2009 to officials in 39 states representing 47 premium
assistance programs funded by Medicaid, CHIP, or both. We received
responses from officials representing 45 programs in 37 states;
officials from 2 states with premium assistance programs, North
Carolina and West Virginia, did not respond to the survey.
[A] Some states operated two premium assistance programs. For program
names, see table 2.
[B] The data on the number of individuals enrolled in states' premium
assistance programs were generally as of June 30, 2009. However, the
following programs provided data as of a different date: Arizona -
April 1, 2009; Georgia - July 31, 2009; Maine - August 19, 2009;
Minnesota - January 1, 2009; Nevada-2 - August 14, 2009; New Hampshire
- July 17, 2009; Texas - August 24, 2009; Utah-1 - August 1, 2009;
Washington - June 26, 2009; and Wisconsin - June 30, 2008.
[C] The data on the number of families enrolled in states' premium
assistance programs were generally as of June 30, 2009. However, the
following programs provided data as of a different date: Alaska - July
31, 2009; Arizona - April 1, 2009; Georgia - July 31, 2009;
Minnesota - January 1, 2009; New Hampshire - July 17, 2009; Texas -
August 24, 2009; Utah-1 - August 1, 2009; Virginia-1 - July 1, 2009;
Washington - June 26, 2009; and Wisconsin - June 30, 2008.
[D] We have reported the data as they were reported to us in states'
survey responses even though the data on the number of individuals and
noneligible family members enrolled in these states' premium
assistance programs did not equal the data provided on the total
number of individuals enrolled in the programs.
[E] According to program officials, data on enrollment were not
available for the specified category.
[F] These programs provided data on the number of eligible individuals
enrolled in premium assistance, but either indicated that data were
not available on the total number of individuals enrolled in premium
assistance programs or did not provide data on the total number of
individuals enrolled in premium assistance programs.
[End of table]
[End of Enclosure II]
Enclosure III: States' Premium Assistance Programs' Benefits,
Premiums, and Cost Sharing:
Table 10: Minimum Requirements Programs Have for Private Health
Insurance Benefit Packages to Qualify for a State Subsidy, by State
Premium Assistance Program, 2009:
State[A]: Alabama;
No requirement: [Empty];
Must cover certain services[B]: [Empty];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Check][C].
State[A]: Alaska;
No requirement: [Empty];
Must cover certain services[B]: [Empty];
Must meet state insurance regulations: [Check];
Must meet other requirements: [Empty].
State[A]: Arizona;
No requirement: [Empty];
Must cover certain services[B]: [Check];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Empty].
State[A]: California;
No requirement: [Empty];
Must cover certain services[B]: [Empty];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Check][D].
State[A]: Colorado-1;
No requirement: [Empty];
Must cover certain services[B]: [Check];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Empty].
State[A]: Colorado-2;
No requirement: [Empty];
Must cover certain services[B]: [Check];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Empty].
State[A]: Florida;
No requirement: [Empty];
Must cover certain services[B]: [Empty];
Must meet state insurance regulations: [Check];
Must meet other requirements: [Empty].
State[A]: Georgia;
No requirement: [Empty];
Must cover certain services[B]: [Check];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Empty].
State[A]: Idaho-1;
No requirement: [Empty];
Must cover certain services[B]: [Check];
Must meet state insurance regulations: [Check];
Must meet other requirements: [Empty].
State[A]: Idaho-2;
No requirement: [Empty];
Must cover certain services[B]: [Check];
Must meet state insurance regulations: [Check];
Must meet other requirements: [Empty].
State[A]: Illinois;
No requirement: [Check];
Must cover certain services[B]: [Empty];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Empty].
State[A]: Iowa;
No requirement: [Empty];
Must cover certain services[B]: [Check];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Empty].
State[A]: Kansas;
No requirement: [Empty];
Must cover certain services[B]: [Check];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Empty].
State[A]: Kentucky;
No requirement: [Empty];
Must cover certain services[B]: [Empty];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Empty].
State[A]: Louisiana;
No requirement: [Empty];
Must cover certain services[B]: [Check];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Empty].
State[A]: Maine;
No requirement: [Empty];
Must cover certain services[B]: [Empty];
Must meet state insurance regulations: [Check];
Must meet other requirements: [Empty].
State[A]: Massachusetts-1;
No requirement: [Empty];
Must cover certain services[B]: [Check];
Must meet state insurance regulations: [Check];
Must meet other requirements: [Check][E].
State[A]: Massachusetts-2;
No requirement: [Empty];
Must cover certain services[B]: [Empty];
Must meet state insurance regulations: [Check];
Must meet other requirements: [Empty].
State[A]: Minnesota;
No requirement: [Check];
Must cover certain services[B]: [Empty];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Empty].
State[A]: Missouri;
No requirement: [Check];
Must cover certain services[B]: [Empty];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Empty].
State[A]: Montana;
No requirement: [Check];
Must cover certain services[B]: [Empty];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Empty].
State[A]: Nebraska;
No requirement: [Empty];
Must cover certain services[B]: [Empty];
Must meet state insurance regulations: [Check];
Must meet other requirements: [Empty].
State[A]: Nevada-1;
No requirement: [Empty];
Must cover certain services[B]: [Empty];
Must meet state insurance regulations: [Check];
Must meet other requirements: [Empty].
State[A]: Nevada-2;
No requirement: [Empty];
Must cover certain services[B]: [Check];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Empty].
State[A]: New Hampshire;
No requirement: [Empty];
Must cover certain services[B]: [Empty];
Must meet state insurance regulations: [Check];
Must meet other requirements: [Empty].
State[A]: New Jersey-1;
No requirement: [Empty];
Must cover certain services[B]: [Empty];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Check][F].
State[A]: New Jersey-2;
No requirement: [Empty];
Must cover certain services[B]: [Empty];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Check][E].
State[A]: New York;
No requirement: [Empty];
Must cover certain services[B]: [Check];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Empty].
State[A]: North Dakota;
No requirement: [Check];
Must cover certain services[B]: [Empty];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Empty].
State[A]: Oklahoma;
No requirement: [Empty];
Must cover certain services[B]: [Check];
Must meet state insurance regulations: [Check];
Must meet other requirements: [Check].
State[A]: Oregon-1;
No requirement: [Empty];
Must cover certain services[B]: [Check];
Must meet state insurance regulations: [Check];
Must meet other requirements: [Check][G].
State[A]: Oregon-2;
No requirement: [Empty];
Must cover certain services[B]: [Empty];
Must meet state insurance regulations: [Check];
Must meet other requirements: [Empty].
State[A]: Pennsylvania;
No requirement: [Check];
Must cover certain services[B]: [Empty];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Empty].
State[A]: Rhode Island;
No requirement: [Empty];
Must cover certain services[B]: [Empty];
Must meet state insurance regulations: [Check];
Must meet other requirements: [Check][H].
State[A]: South Carolina;
No requirement: [Check];
Must cover certain services[B]: [Empty];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Empty].
State[A]: South Dakota;
No requirement: [Check];
Must cover certain services[B]: [Empty];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Empty].
State[A]: Texas;
No requirement: [Empty];
Must cover certain services[B]: [Check];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Check][I].
State[A]: Utah-1;
No requirement: [Empty];
Must cover certain services[B]: [Check];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Check][I].
State[A]: Utah-2;
No requirement: [Empty];
Must cover certain services[B]: [Check];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Check][H].
State[A]: Vermont;
No requirement: [Empty];
Must cover certain services[B]: [Check];
Must meet state insurance regulations: [Check];
Must meet other requirements: [Check][J].
State[A]: Virginia-1;
No requirement: [Check];
Must cover certain services[B]: [Empty];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Empty].
State[A]: Virginia-2;
No requirement: [Empty];
Must cover certain services[B]: [Check];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Empty].
State[A]: Washington;
No requirement: [Check];
Must cover certain services[B]: [Empty];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Empty].
State[A]: Wisconsin;
No requirement: [Empty];
Must cover certain services[B]: [Check];
Must meet state insurance regulations: [Check];
Must meet other requirements: [Empty].
State[A]: Wyoming;
No requirement: [Check];
Must cover certain services[B]: [Empty];
Must meet state insurance regulations: [Empty];
Must meet other requirements: [Empty].
State[A]: Total;
No requirement: 12;
Must cover certain services[B]: 20;
Must meet state insurance regulations: 16;
Must meet other requirements: 12.
Source: GAO Web-based survey administered to states' premium
assistance programs.
Legend:
[Check] = Requirement.
Note: Data were obtained from surveys administered from August through
October 2009 to officials in 39 states representing 47 premium
assistance programs funded by Medicaid, State Children's Health
Insurance Program (CHIP), or both. We received responses from
officials representing 45 programs in 37 states; officials from 2
states with premium assistance programs, North Carolina and West
Virginia, did not respond to the survey.
[A] Some states operated two premium assistance programs. For program
names, see table 2.
[B] See table 13 for a list of services required.
[C] In order to qualify for a state subsidy, the private insurance
benefit package was required to cover the services needed to treat the
premium assistance program applicant's high-cost condition.
[D] In order to qualify for a state subsidy, the private insurance
benefit package was required to cover the premium assistance program
applicant's high-cost medical condition and be a comprehensive health
coverage policy.
[E] In order to qualify for a state subsidy, the private insurance
benefit package was required to meet one of the CHIP benchmarks for
benefit packages.
[F] At a minimum, the plan was required to cover the services most
utilized by a client.
[G] In order to qualify for a state subsidy, the private insurance
benefit package was required to be actuarially equivalent to federally
mandated Medicaid benefits.
[H] In order to qualify for a state subsidy, the private insurance
benefit package was required to be actuarially equivalent to the
benefit package eligible individuals would receive under direct
coverage.
[I] In order to qualify for a state subsidy, the private insurance
benefit package was required to offer a lifetime maximum benefit at or
above a certain amount.
[J] In order to qualify for a state subsidy, the private insurance
benefit package must have a deductible of $500 or less.
[End of table]
Table 11: Services Programs Require Private Health Insurance Benefit
Packages to Cover in Order to Qualify for a State Subsidy, by State
Premium Assistance Program, 2009:
State[A]: Arizona;
Inpatient hospital: Service required;
Physician services: Service required;
Outpatient hospital: Service required;
Pharmacy or prescription drugs: Service required;
Mental health: Service required;
Well-baby and well-child care: Service required;
Immunizations: Service required;
Other services: [Empty].
State[A]: Colorado-1;
Inpatient hospital: Service required;
Physician services: Service required;
Outpatient hospital: [Empty];
Pharmacy or prescription drugs: [Empty];
Mental health: [Empty];
Well-baby and well-child care: Service required;
Immunizations: Service required;
Other services: [Empty].
State[A]: Colorado-2;
Inpatient hospital: Service required;
Physician services: Service required;
Outpatient hospital: Service required;
Pharmacy or prescription drugs: Service required;
Mental health: [Empty];
Well-baby and well-child care: [Empty];
Immunizations: [Empty];
Other services: Service required.
State[A]: Georgia;
Inpatient hospital: Service required;
Physician services: Service required;
Outpatient hospital: Service required;
Pharmacy or prescription drugs: Service required;
Mental health: Service required;
Well-baby and well-child care: [Empty];
Immunizations: [Empty];
Other services: [Empty].
State[A]: Idaho-1;
Inpatient hospital: Service required;
Physician services: Service required;
Outpatient hospital: Service required;
Pharmacy or prescription drugs: [Empty];
Mental health: [Empty];
Well-baby and well-child care: [Empty];
Immunizations: [Empty];
Other services: [Empty].
State[A]: Idaho-2;
Inpatient hospital: Service required;
Physician services: Service required;
Outpatient hospital: Service required;
Pharmacy or prescription drugs: Service required;
Mental health: Service required;
Well-baby and well-child care: Service required;
Immunizations: [Empty];
Other services: Service required.
State[A]: Iowa;
Inpatient hospital: Service required;
Physician services: Service required;
Outpatient hospital: Service required;
Pharmacy or prescription drugs: [Empty];
Mental health: [Empty];
Well-baby and well-child care: [Empty];
Immunizations: [Empty];
Other services: [Empty].
State[A]: Kansas;
Inpatient hospital: Service required;
Physician services: Service required;
Outpatient hospital: Service required;
Pharmacy or prescription drugs: Service required;
Mental health: [Empty];
Well-baby and well-child care: [Empty];
Immunizations: [Empty];
Other services: [Empty].
State[A]: Louisiana;
Inpatient hospital: Service required;
Physician services: Service required;
Outpatient hospital: Service required;
Pharmacy or prescription drugs: Service required;
Mental health: [Empty];
Well-baby and well-child care: [Empty];
Immunizations: [Empty];
Other services: [Empty].
State[A]: Massachusetts-1;
Inpatient hospital: Service required;
Physician services: Service required;
Outpatient hospital: Service required;
Pharmacy or prescription drugs: Service required;
Mental health: Service required;
Well-baby and well-child care: Service required;
Immunizations: Service required;
Other services: [Empty].
State[A]: Nevada-2;
Inpatient hospital: Service required;
Physician services: Service required;
Outpatient hospital: Service required;
Pharmacy or prescription drugs: Service required;
Mental health: Service required;
Well-baby and well-child care: Service required;
Immunizations: Service required;
Other services: Service required.
State[A]: New York;
Inpatient hospital: Service required;
Physician services: Service required;
Outpatient hospital: Service required;
Pharmacy or prescription drugs: [Empty];
Mental health: Service required;
Well-baby and well-child care: Service required;
Immunizations: Service required;
Other services: Service required.
State[A]: Oklahoma;
Inpatient hospital: Service required;
Physician services: Service required;
Outpatient hospital: Service required;
Pharmacy or prescription drugs: Service required;
Mental health: Service required;
Well-baby and well-child care: [Empty];
Immunizations: [Empty];
Other services: Service required.
State[A]: Oregon-1;
Inpatient hospital: Service required;
Physician services: Service required;
Outpatient hospital: Service required;
Pharmacy or prescription drugs: Service required;
Mental health: Service required;
Well-baby and well-child care: Service required;
Immunizations: Service required;
Other services: Service required.
State[A]: Texas;
Inpatient hospital: Service required;
Physician services: Service required;
Outpatient hospital: Service required;
Pharmacy or prescription drugs: Service required;
Mental health: [Empty];
Well-baby and well-child care: [Empty];
Immunizations: [Empty];
Other services: Service required.
State[A]: Utah-1;
Inpatient hospital: Service required;
Physician services: Service required;
Outpatient hospital: [Empty];
Pharmacy or prescription drugs: Service required;
Mental health: [Empty];
Well-baby and well-child care: Service required;
Immunizations: Service required;
Other services: [Empty].
State[A]: Utah-2;
Inpatient hospital: Service required;
Physician services: Service required;
Outpatient hospital: Service required;
Pharmacy or prescription drugs: Service required;
Mental health: Service required;
Well-baby and well-child care: Service required;
Immunizations: Service required;
Other services: [Empty].
State[A]: Vermont;
Inpatient hospital: Service required;
Physician services: Service required;
Outpatient hospital: Service required;
Pharmacy or prescription drugs: Service required;
Mental health: Service required;
Well-baby and well-child care: [Empty];
Immunizations: [Empty];
Other services: Service required.
State[A]: Virginia-2;
Inpatient hospital: Service required;
Physician services: Service required;
Outpatient hospital: Service required;
Pharmacy or prescription drugs: Service required;
Mental health: [Empty];
Well-baby and well-child care: [Empty];
Immunizations: Service required;
Other services: [Empty].
State[A]: Wisconsin;
Inpatient hospital: Service required;
Physician services: Service required;
Outpatient hospital: Service required;
Pharmacy or prescription drugs: [Empty];
Mental health: [Empty];
Well-baby and well-child care: [Empty];
Immunizations: [Empty];
Other services: [Empty].
State[A]: Total;
Inpatient hospital: 20;
Physician services: 20;
Outpatient hospital: 18;
Pharmacy or prescription drugs: 15;
Mental health: 10;
Well-baby and well-child care: 9;
Immunizations: 9;
Other services: 8.
Source: GAO Web-based survey administered to states' premium
assistance programs.
Note: Data were obtained from surveys administered from August through
October 2009 to officials in 39 states representing 47 premium
assistance programs funded by Medicaid, CHIP, or both. We received
responses from officials representing 45 programs in 37 states;
officials from 2 states with premium assistance programs, North
Carolina and West Virginia, did not respond to the survey.
Table includes only state premium assistance programs which reported a
requirement that the private health insurance benefit package cover
certain services specified by the program to qualify for the state
subsidy (see table 10). States may cover directly any services to
which eligible individuals are entitled that are not covered by the
private health insurance plan; see table 12 for more information.
[A] Some states operated two premium assistance programs. For program
names, see table 2.
[End of table]
Table 12: Level of Benefits Wraparound Provided to Eligible
Individuals, by State Premium Assistance Program, 2009:
State[A]: Alabama;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Alaska;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Arizona;
Complete benefits wraparound provided[B]: No individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: California;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Colorado-1;
Complete benefits wraparound provided[B]: No individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Colorado-2;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Florida;
Complete benefits wraparound provided[B]: No individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Georgia;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Idaho-1;
Complete benefits wraparound provided[B]: No individuals;
Partial benefits wraparound provided[C]: All individuals.
State[A]: Idaho-2;
Complete benefits wraparound provided[B]: No individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Illinois;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Iowa;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Kansas;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Kentucky;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Louisiana;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Maine[D];
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Massachusetts-1;
Complete benefits wraparound provided[B]: Some individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Massachusetts-2;
Complete benefits wraparound provided[B]: No individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Minnesota;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Missouri;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Montana;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Nebraska;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Nevada-1;
Complete benefits wraparound provided[B]: No individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Nevada-2;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: New Hampshire;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: New Jersey-1;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: New Jersey-2;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: New York;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: North Dakota[D];
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Oklahoma;
Complete benefits wraparound provided[B]: No individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Oregon-1;
Complete benefits wraparound provided[B]: No individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Oregon-2;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Pennsylvania;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Rhode Island;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: South Carolina;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: South Dakota;
Complete benefits wraparound provided[B]: No individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Texas;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Utah-1;
Complete benefits wraparound provided[B]: No individuals;
Partial benefits wraparound provided[C]: Some individuals.
State[A]: Utah-2;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Vermont[E];
Complete benefits wraparound provided[B]: Some individuals;
Partial benefits wraparound provided[C]: Some individuals.
State[A]: Virginia-1;
Complete benefits wraparound provided[B]: No individuals;
Partial benefits wraparound provided[C]: All individuals.
State[A]: Virginia-2;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Washington;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Wisconsin;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
State[A]: Wyoming;
Complete benefits wraparound provided[B]: All individuals;
Partial benefits wraparound provided[C]: No individuals.
Source: GAO Web-based survey administered to states' premium
assistance programs.
Note: Data were obtained from surveys administered from August through
October 2009 to officials in 39 states representing 47 premium
assistance programs funded by Medicaid, CHIP, or both. We received
responses from officials representing 45 programs in 37 states;
officials from 2 states with premium assistance programs, North
Carolina and West Virginia, did not respond to the survey.
[A] Some states operated two premium assistance programs. For program
names, see table 2.
[B] States that offer complete benefits wraparound coverage supplement
private insurance benefits up to the level an individual would receive
under direct coverage.
[C] States that offer partial benefits wraparound coverage supplement
private insurance benefits, but not to the level an individual would
receive under direct coverage. For example, states may supplement only
certain benefits, such as dental care, mental health care, or
immunizations.
[D] State also provided benefits wraparound coverage to noneligible
family members.
[E] Individuals eligible for the state's Vermont Health Access Program
and receiving subsidized employer-sponsored insurance (ESI) through
the premium assistance program received complete benefits wraparound
coverage. Individuals receiving subsidized ESI but not eligible for
the Vermont Health Access Plan receive a benefits wraparound coverage
for prevention and maintenance of specified chronic conditions.
[End of table]
Table 13: Monitoring of Enrollees' Access to Care and Utilization of
Services, by State Premium Assistance Program, 2009:
State[A]: Alabama;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Alaska;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Arizona;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: California;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Colorado-1;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Colorado-2;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Florida;
State monitors access to care: Response not provided;
State monitors utilization of services: Response not provided.
State[A]: Georgia;
State monitors access to care: [Empty];
State monitors utilization of services: [Check].
State[A]: Idaho-1;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Idaho-2;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Illinois;
State monitors access to care: [Empty];
State monitors utilization of services: [Check].
State[A]: Iowa;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Kansas;
State monitors access to care: [Check];
State monitors utilization of services: [Check].
State[A]: Kentucky;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Louisiana;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Maine;
State monitors access to care: [Empty];
State monitors utilization of services: [Check].
State[A]: Massachusetts-1;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Massachusetts-2;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Minnesota;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Missouri;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Montana;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Nebraska;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Nevada-1;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Nevada-2;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: New Hampshire;
State monitors access to care: [Empty];
State monitors utilization of services: [Check].
State[A]: New Jersey-1;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: New Jersey-2;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: New York;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: North Dakota;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Oklahoma;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Oregon-1;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Oregon-2;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Pennsylvania;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Rhode Island;
State monitors access to care: [Check];
State monitors utilization of services: [Check].
State[A]: South Carolina;
State monitors access to care: [Empty];
State monitors utilization of services: [Check].
State[A]: South Dakota;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Texas;
State monitors access to care: [Check];
State monitors utilization of services: [Check].
State[A]: Utah-1;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Utah-2;
State monitors access to care: [Empty];
State monitors utilization of services: [Check].
State[A]: Vermont;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Virginia-1;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Virginia-2;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Washington;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Wisconsin;
State monitors access to care: [Empty];
State monitors utilization of services: [Check].
State[A]: Wyoming;
State monitors access to care: [Empty];
State monitors utilization of services: [Empty].
State[A]: Total;
State monitors access to care: 3;
State monitors utilization of services: 10.
Source: GAO Web-based survey administered to states' premium
assistance programs.
Legend:
[Check] = State monitors.
Note: Data were obtained from surveys administered from August through
October 2009 to officials in 39 states representing 47 premium
assistance programs funded by Medicaid, CHIP, or both. We received
responses from officials representing 45 programs in 37 states;
officials from 2 states with premium assistance programs, North
Carolina and West Virginia, did not respond to the survey.
[A] Some states operated two premium assistance programs. For program
names, see table 2.
[End of table]
Table 14: Description of Monthly Premium Subsidy Provided, by State
Premium Assistance Program, 2009:
State[A]: Alabama;
Premium subsidy: 100 percent of enrollee's share of premium.
State[A]: Alaska;
Premium subsidy: 100 percent of enrollee's share of premium.
State[A]: Arizona;
Premium subsidy: Up to $100 per eligible child.
State[A]: California;
Premium subsidy: 100 percent of enrollee's share of premium.
State[A]: Colorado-1;
Premium subsidy: Up to $100 per eligible enrollee.
State[A]: Colorado-2;
Premium subsidy: Portion of premium that covers eligible enrollee
(amount policyholder would save if eligible enrollee were not covered).
State[A]: Florida;
Premium subsidy: Pays up to amount state would pay if individual were
in a Medicaid Reform Plan which varies between individuals[B].
State[A]: Georgia;
Premium subsidy: 100 percent of policyholder's share of premium.
State[A]: Idaho-1;
Premium subsidy: Up to $100 per enrollee with $300 family cap.
State[A]: Idaho-2;
Premium subsidy: Up to $100 per member.
State[A]: Illinois;
Premium subsidy: 100 percent of enrollee's share of premium.
State[A]: Iowa;
Premium subsidy: Response not provided.
State[A]: Kansas;
Premium subsidy: 100 percent of enrollee's and policyholder's share of
premium.
State[A]: Kentucky;
Premium subsidy: 100 percent of enrollee's share of premium.
State[A]: Louisiana;
Premium subsidy: 100 percent of enrollee's share of premium, up to
$200.
State[A]: Maine;
Premium subsidy: 100 percent of enrollee's share of premium.
State[A]: Massachusetts-1;
Premium subsidy: Portion of enrollee's premium.
State[A]: Massachusetts-2;
Premium subsidy: 80 percent of enrollee's share of premium, up to $450
per individual or $1,110 per family.
State[A]: Minnesota;
Premium subsidy: 100 percent of enrollee's share of premium.
State[A]: Missouri;
Premium subsidy: 100 percent of policyholder's share of premium.
State[A]: Montana;
Premium subsidy: 100 percent of enrollee's share of the premium.
State[A]: Nebraska;
Premium subsidy: 100 percent of the enrollee's share of premium.
State[A]: Nevada-1;
Premium subsidy: 50 percent of employee's coverage cost, up to $100
per enrollee.
State[A]: Nevada-2;
Premium subsidy: 100 percent of enrollee's share of premium.
State[A]: New Hampshire;
Premium subsidy: 100 percent of enrollee's share of premium.
State[A]: New Jersey-1;
Premium subsidy: 100 percent of enrollee's share of premium.
State[A]: New Jersey-2;
Premium subsidy: 100 percent of employee's share of premium.
State[A]: New York;
Premium subsidy: 100 percent of employee's share of premium.
State[A]: North Dakota;
Premium subsidy:
* 100 percent of individual/family's share of premium;
* If an individual has to spend down assets to qualify for Medicaid,
then the premium subsidy is reduced by that amount.
State[A]: Oklahoma;
Premium subsidy:
* At least 60 percent of the cost of covering the employee and 85
percent of cost of covering the spouse;
* Employee's premium contributions are limited to 3 percent of gross
income.
State[A]: Oregon-1;
Premium subsidy: 50 to 95 percent of eligible family member's premium.
State[A]: Oregon-2;
Premium subsidy: 100 percent of enrollee's share of premium.
State[A]: Pennsylvania;
Premium subsidy: Response not provided.
State[A]: Rhode Island;
Premium subsidy: 100 percent of enrollee's share of premium.
State[A]: South Carolina;
Premium subsidy:
* 100 percent of enrollee's share of premium;
* If necessary to cover enrollee, program will pay the policyholder's
share of premium.
State[A]: South Dakota;
Premium subsidy: 100 percent of enrollee's share of premium.
State[A]: Texas;
Premium subsidy: 100 percent of policyholder's share of premium.
State[A]: Utah-1;
Premium subsidy:
* Up to $150 for covered adults;
* $120 for children whose insurance covers dental services and $100
for children whose insurance does not cover dental services.
State[A]: Utah-2;
Premium subsidy: Up to 100 percent of enrollee's share of premium[C].
State[A]: Vermont;
Premium subsidy: Percentage of enrollee's share of premium based on
enrollee's income.
State[A]: Virginia-1;
Premium subsidy: Up to $100 per month towards enrollee's share of
premium.
State[A]: Virginia-2;
Premium subsidy: The lesser of the cost-effective rate for each
Medicaid-eligible individual or the employee's share of premium[D].
State[A]: Washington;
Premium subsidy: 100 percent of enrollee's share of premium.
State[A]: Wisconsin;
Premium subsidy: 100 percent of enrollee's share of premium.
State[A]: Wyoming;
Premium subsidy: 100 percent of enrollee's share of premium.
Source: GAO Web-based survey administered to states' premium
assistance programs.
Note: Data were obtained from surveys administered from August through
October 2009 to officials in 39 states representing 47 premium
assistance programs funded by Medicaid, CHIP, or both. We received
responses from officials representing 45 programs in 37 states;
officials from 2 states with premium assistance programs, North
Carolina and West Virginia, did not respond to the survey.
[A] Some states operated two premium assistance programs. For program
names, see table 2.
[B] A Medicaid Reform plan is a managed care health plan--chosen by
Medicaid-eligible individuals--which provides them with health
coverage.
[C] Officials from this premium assistance program indicated that,
depending on the cost-effectiveness calculation, the state's premium
subsidy may be negotiated with the enrollee to be an amount less than
100 percent of the enrollee's share of the premium.
[D] Officials from this premium assistance program indicated that the
cost-effective rate was based on several factors including age,
gender, and region of the state where the eligible individual lived.
[End of table]
Table 15: Extent to Which the State Paid for Cost Sharing Expenses
(Excluding Premiums), by Coverage Group and State Premium Assistance
Program, 2009:
State[A]: Alabama[B]; Coverage groups: Children: State pays some cost
sharing;
Coverage groups: Pregnant women/unborn children: State pays some cost
sharing;
Coverage groups: Parents: State pays some cost sharing;
Coverage groups: Childless adults: NA;
Coverage groups: Other individuals: State pays some cost sharing[C].
State[A]: Alaska;
Coverage groups: Children: State pays all cost sharing;
Coverage groups: Pregnant women/unborn children: State pays all cost
sharing;
Coverage groups: Parents: State pays all cost sharing;
Coverage groups: Childless adults: State pays all cost sharing;
Coverage groups: Other individuals: State pays all cost sharing.
State[A]: Arizona;
Coverage groups: Children: State pays no cost sharing;
Coverage groups: Pregnant women/unborn children: State pays no cost
sharing;
Coverage groups: Parents: State pays no cost sharing;
Coverage groups: Childless adults: State pays no cost sharing;
Coverage groups: Other individuals: State pays no cost sharing.
State[A]: California[D];
Coverage groups: Children: State pays some cost sharing;
Coverage groups: Pregnant women/unborn children: State pays some cost
sharing;
Coverage groups: Parents: State pays some cost sharing;
Coverage groups: Childless adults: State pays some cost sharing;
Coverage groups: Other individuals: State pays some cost sharing.
State[A]: Colorado-1;
Coverage groups: Children: State pays no cost sharing;
Coverage groups: Pregnant women/unborn children: State pays no cost
sharing;
Coverage groups: Parents: NA;
Coverage groups: Childless adults: NA;
Coverage groups: Other individuals: NA.
State[A]: Colorado-2;
Coverage groups: Children: State pays all cost sharing;
Coverage groups: Pregnant women/unborn children: State pays all cost
sharing;
Coverage groups: Parents: State pays all cost sharing;
Coverage groups: Childless adults: State pays all cost sharing;
Coverage groups: Other individuals: State pays all cost sharing.
State[A]: Florida;
Coverage groups: Children: State pays no cost sharing;
Coverage groups: Pregnant women/unborn children: State pays no cost
sharing;
Coverage groups: Parents: State pays no cost sharing;
Coverage groups: Childless adults: State pays no cost sharing;
Coverage groups: Other individuals: Response not provided.
State[A]: Georgia;
Coverage groups: Children: State pays all cost sharing;
Coverage groups: Pregnant women/unborn children: State pays all cost
sharing;
Coverage groups: Parents: State pays all cost sharing;
Coverage groups: Childless adults: State pays all cost sharing;
Coverage groups: Other individuals: Response not provided.
State[A]: Idaho-1;
Coverage groups: Children: State pays no cost sharing;
Coverage groups: Pregnant women/unborn children: NA;
Coverage groups: Parents: NA;
Coverage groups: Childless adults: NA;
Coverage groups: Other individuals: NA.
State[A]: Idaho-2;
Coverage groups: Children: NA;
Coverage groups: Pregnant women/unborn children: State pays no cost
sharing;
Coverage groups: Parents: State pays no cost sharing;
Coverage groups: Childless adults: State pays no cost sharing;
Coverage groups: Other individuals: NA.
State[A]: Illinois[B];
Coverage groups: Children: State pays some cost sharing;
Coverage groups: Pregnant women/unborn children: State pays some cost
sharing;
Coverage groups: Parents: State pays some cost sharing;
Coverage groups: Childless adults: State pays no cost sharing;
Coverage groups: Other individuals: State pays some cost sharing.
State[A]: Iowa;
Coverage groups: Children: State pays all cost sharing;
Coverage groups: Pregnant women/unborn children: State pays all cost
sharing;
Coverage groups: Parents: State pays all cost sharing;
Coverage groups: Childless adults: State pays all cost sharing;
Coverage groups: Other individuals: Response not provided.
State[A]: Kansas;
Coverage groups: Children: State pays all cost sharing;
Coverage groups: Pregnant women/unborn children: State pays all cost
sharing;
Coverage groups: Parents: State pays all cost sharing;
Coverage groups: Childless adults: State pays all cost sharing;
Coverage groups: Other individuals: State pays all cost sharing.
State[A]: Kentucky;
Coverage groups: Children: State pays all cost sharing;
Coverage groups: Pregnant women/unborn children: State pays all cost
sharing;
Coverage groups: Parents: State pays all cost sharing;
Coverage groups: Childless adults: State pays all cost sharing;
Coverage groups: Other individuals: Response not provided.
State[A]: Louisiana;
Coverage groups: Children: State pays all cost sharing;
Coverage groups: Pregnant women/unborn children: State pays all cost
sharing;
Coverage groups: Parents: State pays all cost sharing;
Coverage groups: Childless adults: NA;
Coverage groups: Other individuals: NA.
State[A]: Maine;
Coverage groups: Children: State pays all cost sharing;
Coverage groups: Pregnant women/unborn children: State pays all cost
sharing;
Coverage groups: Parents: State pays all cost sharing;
Coverage groups: Childless adults: State pays all cost sharing;
Coverage groups: Other individuals: State pays no cost sharing.
State[A]: Massachusetts-1;
Coverage groups: Children: State pays all cost sharing;
Coverage groups: Pregnant women/unborn children: State pays all cost
sharing;
Coverage groups: Parents: State pays all cost sharing;
Coverage groups: Childless adults: State pays no cost sharing;
Coverage groups: Other individuals: State pays no cost sharing.
State[A]: Massachusetts-2;
Coverage groups: Children: NA;
Coverage groups: Pregnant women/unborn children: NA;
Coverage groups: Parents: NA;
Coverage groups: Childless adults: NA;
Coverage groups: Other individuals: State pays no cost sharing.
State[A]: Minnesota;
Coverage groups: Children: State pays all cost sharing;
Coverage groups: Pregnant women/unborn children: State pays all cost
sharing;
Coverage groups: Parents: State pays all cost sharing;
Coverage groups: Childless adults: NA;
Coverage groups: Other individuals: State pays all cost sharing[E].
State[A]: Missouri[F];
Coverage groups: Children: State pays some cost sharing;
Coverage groups: Pregnant women/unborn children: State pays some cost
sharing;
Coverage groups: Parents: State pays some cost sharing;
Coverage groups: Childless adults: Response not provided;
Coverage groups: Other individuals: State pays some cost sharing[G].
State[A]: Montana;
Coverage groups: Children: State pays all cost sharing;
Coverage groups: Pregnant women/unborn children: State pays all cost
sharing;
Coverage groups: Parents: State pays all cost sharing;
Coverage groups: Childless adults: State pays all cost sharing;
Coverage groups: Other individuals: Response not provided.
State[A]: Nebraska;
Coverage groups: Children: State pays some cost sharing;
Coverage groups: Pregnant women/unborn children: State pays some cost
sharing;
Coverage groups: Parents: State pays some cost sharing;
Coverage groups: Childless adults: State pays some cost sharing;
Coverage groups: Other individuals: NA.
State[A]: Nevada-1;
Coverage groups: Children: State pays no cost sharing;
Coverage groups: Pregnant women/unborn children: NA;
Coverage groups: Parents: State pays no cost sharing;
Coverage groups: Childless adults: NA;
Coverage groups: Other individuals: State pays no cost sharing.
State[A]: Nevada-2;
Coverage groups: Children: State pays all cost sharing;
Coverage groups: Pregnant women/unborn children: State pays all cost
sharing;
Coverage groups: Parents: State pays all cost sharing;
Coverage groups: Childless adults: State pays all cost sharing;
Coverage groups: Other individuals: Response not provided.
State[A]: New Hampshire[B];
Coverage groups: Children: State pays some cost sharing;
Coverage groups: Pregnant women/unborn children: State pays some cost
sharing;
Coverage groups: Parents: NA;
Coverage groups: Childless adults: NA;
Coverage groups: Other individuals: State pays some cost sharing[H].
State[A]: New Jersey-1[F];
Coverage groups: Children: State pays some cost sharing;
Coverage groups: Pregnant women/unborn children: NA;
Coverage groups: Parents: State pays some cost sharing;
Coverage groups: Childless adults: State pays some cost sharing;
Coverage groups: Other individuals: Response not provided.
State[A]: New Jersey-2;
Coverage groups: Children: State pays all cost sharing;
Coverage groups: Pregnant women/unborn children: NA;
Coverage groups: Parents: State pays all cost sharing;
Coverage groups: Childless adults: NA;
Coverage groups: Other individuals: Response not provided.
State[A]: New York;
Coverage groups: Children: NA;
Coverage groups: Pregnant women/unborn children: State pays all cost
sharing;
Coverage groups: Parents: State pays all cost sharing;
Coverage groups: Childless adults: State pays all cost sharing;
Coverage groups: Other individuals: Response not provided.
State[A]: North Dakota;
Coverage groups: Children: State pays all cost sharing;
Coverage groups: Pregnant women/unborn children: State pays all cost
sharing;
Coverage groups: Parents: State pays all cost sharing;
Coverage groups: Childless adults: NA;
Coverage groups: Other individuals: State pays all cost sharing[I].
State[A]: Oklahoma[J];
Coverage groups: Children: NA;
Coverage groups: Pregnant women/unborn children: State pays some cost
sharing;
Coverage groups: Parents: State pays some cost sharing;
Coverage groups: Childless adults: State pays some cost sharing;
Coverage groups: Other individuals: Response not provided.
State[A]: Oregon-1;
Coverage groups: Children: State pays no cost sharing;
Coverage groups: Pregnant women/unborn children: State pays no cost
sharing;
Coverage groups: Parents: State pays no cost sharing;
Coverage groups: Childless adults: State pays no cost sharing;
Coverage groups: Other individuals: NA.
State[A]: Oregon-2[F];
Coverage groups: Children: State pays some cost sharing;
Coverage groups: Pregnant women/unborn children: State pays some cost
sharing;
Coverage groups: Parents: State pays some cost sharing;
Coverage groups: Childless adults: NA;
Coverage groups: Other individuals: Response not provided.
State[A]: Pennsylvania;
Coverage groups: Children: State pays all cost sharing;
Coverage groups: Pregnant women/unborn children: State pays all cost
sharing;
Coverage groups: Parents: State pays all cost sharing;
Coverage groups: Childless adults: State pays all cost sharing;
Coverage groups: Other individuals: State pays all cost sharing.
State[A]: Rhode Island;
Coverage groups: Children: State pays all cost sharing;
Coverage groups: Pregnant women/unborn children: State pays all cost
sharing;
Coverage groups: Parents: State pays all cost sharing;
Coverage groups: Childless adults: NA;
Coverage groups: Other individuals: Response not provided.
State[A]: South Carolina;
Coverage groups: Children: State pays some cost sharing;
Coverage groups: Pregnant women/unborn children: State pays some cost
sharing;
Coverage groups: Parents: State pays some cost sharing;
Coverage groups: Childless adults: State pays some cost sharing;
Coverage groups: Other individuals: Response not provided.
State[A]: South Dakota;
Coverage groups: Children: State pays no cost sharing;
Coverage groups: Pregnant women/unborn children: State pays no cost
sharing;
Coverage groups: Parents: State pays no cost sharing;
Coverage groups: Childless adults: State pays no cost sharing;
Coverage groups: Other individuals: State pays no cost sharing.
State[A]: Texas;
Coverage groups: Children: State pays all cost sharing;
Coverage groups: Pregnant women/unborn children: State pays all cost
sharing;
Coverage groups: Parents: State pays all cost sharing;
Coverage groups: Childless adults: NA;
Coverage groups: Other individuals: NA.
State[A]: Utah-1;
Coverage groups: Children: State pays no cost sharing;
Coverage groups: Pregnant women/unborn children: NA;
Coverage groups: Parents: State pays no cost sharing;
Coverage groups: Childless adults: State pays no cost sharing;
Coverage groups: Other individuals: NA.
State[A]: Utah-2;
Coverage groups: Children: State pays some cost sharing;
Coverage groups: Pregnant women/unborn children: State pays some cost
sharing;
Coverage groups: Parents: State pays some cost sharing;
Coverage groups: Childless adults: State pays some cost sharing;
Coverage groups: Other individuals: Response not provided.
State[A]: Vermont;
Coverage groups: Children: NA;
Coverage groups: Pregnant women/unborn children: NA;
Coverage groups: Parents: State pays some cost sharing[K];
Coverage groups: Childless adults: State pays some cost sharing[K];
Coverage groups: Other individuals: Response not provided.
State[A]: Virginia-1;
Coverage groups: Children: State pays no cost sharing;
Coverage groups: Pregnant women/unborn children: NA;
Coverage groups: Parents: NA;
Coverage groups: Childless adults: NA;
Coverage groups: Other individuals: NA.
State[A]: Virginia-2;
Coverage groups: Children: State pays all cost sharing;
Coverage groups: Pregnant women/unborn children: State pays all cost
sharing;
Coverage groups: Parents: State pays all cost sharing;
Coverage groups: Childless adults: NA;
Coverage groups: Other individuals: NA.
State[A]: Washington;
Coverage groups: Children: State pays all cost sharing;
Coverage groups: Pregnant women/unborn children: State pays all cost
sharing;
Coverage groups: Parents: State pays all cost sharing;
Coverage groups: Childless adults: State pays all cost sharing;
Coverage groups: Other individuals: Response not provided.
State[A]: Wisconsin;
Coverage groups: Children: State pays all cost sharing;
Coverage groups: Pregnant women/unborn children: State pays all cost
sharing;
Coverage groups: Parents: State pays all cost sharing;
Coverage groups: Childless adults: State pays all cost sharing;
Coverage groups: Other individuals: NA.
State[A]: Wyoming;
Coverage groups: Children: State pays all cost sharing;
Coverage groups: Pregnant women/unborn children: State pays all cost
sharing;
Coverage groups: Parents: State pays all cost sharing;
Coverage groups: Childless adults: NA;
Coverage groups: Other individuals: NA.
Source: GAO Web-based survey administered to states' premium
assistance programs.
NA = Not applicable, the coverage group is not eligible for the
premium assistance program.
Note: Data were obtained from surveys administered from August through
October 2009 to officials in 39 states representing 47 premium
assistance programs funded by Medicaid, CHIP, or both. We received
responses from officials representing 45 programs in 37 states;
officials from 2 states with premium assistance programs, North
Carolina and West Virginia, did not respond to the survey.
[A] Some states operated two premium assistance programs. For program
names, see table 2.
[B] Officials representing these programs indicated that the state
paid cost sharing up to the Medicaid allowed payment for a particular
service if the enrollee received that service from a Medicaid
participating provider. The officials noted that if the enrollee sees
a provider that does not participate in Medicaid, the state did not
pay cost sharing.
[C] This program paid some cost sharing for individuals eligible for
Supplemental Security Income program.
[D] Officials representing this program indicated that the state paid
cost sharing up to the Medicaid allowed payment for a particular
service if the enrollee received that service from a Medicaid
participating provider. The officials noted that if the enrollee sees
a provider that does not participate in Medicaid, the state did not
pay cost sharing. Additionally, if the enrollee were required to spend
down income to qualify for Medicaid, then the state did not pay for
cost sharing until the enrollee contributed his or her spend-down
amount.
[E] Officials representing this program indicated that the state paid
cost sharing for elderly and disabled individuals.
[F] Officials representing these programs indicated that the state
paid cost sharing for Medicaid covered services only.
[G] Officials representing this program indicated that the state paid
some cost sharing for individuals who are aged, blind, or permanently
disabled.
[H] Officials representing this program indicated that the state paid
cost sharing for individuals who are blind, disabled, or in foster
care.
[I] Officials representing this program indicated that the state paid
some cost sharing for individuals who are aged or disabled.
[J] Officials representing this program indicated that the state paid
up to $900 for cost sharing if the household's out-of-pocket expenses
had exceeded 5 percent of their gross income.
[K] Officials representing this program indicated that the state paid
all cost sharing for parents with incomes below 185 percent of the
federal poverty level (FPL) and childless adults with incomes below
150 percent of the FPL.
[End of table]
[End of Enclosure III]
Enclosure IV: States' Premium Assistance Programs' Expenditures and
Cost-Effectiveness Policies:
Table 16: Program Expenditures, by Type of Expenditure and State
Premium Assistance Program, July 1, 2008 through June 30, 2009:
State[A]: Alabama;
Premium subsidies: 17,051;
Benefits wraparound: 31,176;
Cost sharing: 0;
Administration: 0;
Total: 48,227[B].
State[A]: Alaska;
Premium subsidies: 34,498;
Benefits wraparound: Response not provided;
Cost sharing: Response not provided;
Administration: Response not provided;
Total: 34,498[B].
State[A]: Arizona;
Premium subsidies: 900;
Benefits wraparound: NA;
Cost sharing: NA;
Administration: 0;
Total: 900[B].
State[A]: California;
Premium subsidies: 5,845,615;
Benefits wraparound: [C];
Cost sharing: [C];
Administration: 590,606;
Total: 6,436,221[B].
State[A]: Colorado-1;
Premium subsidies: 63,018;
Benefits wraparound: NA;
Cost sharing: NA;
Administration: Response not provided;
Total: 63,018[B].
State[A]: Colorado-2;
Premium subsidies: 935,864;
Benefits wraparound: [C];
Cost sharing: 7,246;
Administration: [C];
Total: 943,110[B].
State[A]: Florida;
Premium subsidies: 10,023;
Benefits wraparound: NA;
Cost sharing: NA;
Administration: 23,400;
Total: 33,423.
State[A]: Georgia;
Premium subsidies: 2,915,713;
Benefits wraparound: Response not provided;
Cost sharing: Response not provided;
Administration: Response not provided;
Total: 2,915,713[B].
State[A]: Idaho-1;
Premium subsidies: 130,258;
Benefits wraparound: 0;
Cost sharing: NA;
Administration: 18,795;
Total: 149,053[B].
State[A]: Idaho-2;
Premium subsidies: 305,151;
Benefits wraparound: NA;
Cost sharing: NA;
Administration: 41,348;
Total: 346,499.
State[A]: Illinois;
Premium subsidies: 391,744;
Benefits wraparound: [C];
Cost sharing: 0;
Administration: [C];
Total: 391,744[B].
State[A]: Iowa;
Premium subsidies: 6,498,885;
Benefits wraparound: [C];
Cost sharing: [C];
Administration: 1,140,909;
Total: 7,639,794[B].
State[A]: Kansas;
Premium subsidies: [C];
Benefits wraparound: [C];
Cost sharing: [C];
Administration: [C];
Total: 736,763[B].
State[A]: Kentucky;
Premium subsidies: 1,073;
Benefits wraparound: [C];
Cost sharing: [C];
Administration: [C];
Total: 1,073[B].
State[A]: Louisiana;
Premium subsidies: 2,037,783;
Benefits wraparound: 5,553,673;
Cost sharing: 0;
Administration: 382,875;
Total: 7,974,331.
State[A]: Maine;
Premium subsidies: 885,834;
Benefits wraparound: [C];
Cost sharing: [C];
Administration: 410,000;
Total: 1,295,834[B].
State[A]: Massachusetts-1;
Premium subsidies: 49,000,000;
Benefits wraparound: [C];
Cost sharing: [C];
Administration: [C];
Total: 49,000,000[B].
State[A]: Massachusetts-2;
Premium subsidies: 19,792,990;
Benefits wraparound: NA;
Cost sharing: NA;
Administration: 737,046;
Total: 20,530,036.
State[A]: Minnesota;
Premium subsidies: 14,712,740;
Benefits wraparound: [C];
Cost sharing: Response not provided;
Administration: [C];
Total: 14,712,740[B].
State[A]: Missouri;
Premium subsidies: 3,495,089;
Benefits wraparound: [C];
Cost sharing: 30,179;
Administration: [C];
Total: 3,525,268[B].
State[A]: Montana;
Premium subsidies: 990,551;
Benefits wraparound: [C];
Cost sharing: [C];
Administration: 44,935;
Total: 1,035,486[B].
State[A]: Nebraska;
Premium subsidies: 1,035,560;
Benefits wraparound: NA;
Cost sharing: [C];
Administration: 62,501;
Total: 1,098,061[B].
State[A]: Nevada-1;
Premium subsidies: 3,574;
Benefits wraparound: NA;
Cost sharing: NA;
Administration: 39,388;
Total: 42,962.
State[A]: Nevada-2;
Premium subsidies: 173,940;
Benefits wraparound: 407,931;
Cost sharing: Response not provided;
Administration: Response not provided;
Total: 591,219[B,D].
State[A]: New Hampshire;
Premium subsidies: 911,581;
Benefits wraparound: 0;
Cost sharing: 0;
Administration: 82,686;
Total: 994,267[B].
State[A]: New Jersey-1;
Premium subsidies: 584,943;
Benefits wraparound: [C];
Cost sharing: 16,638;
Administration: [C];
Total: 601,581[B].
State[A]: New Jersey-2;
Premium subsidies: 206,980;
Benefits wraparound: [C];
Cost sharing: 32,408;
Administration: [C];
Total: 239,388[B].
State[A]: New York;
Premium subsidies: [C];
Benefits wraparound: [C];
Cost sharing: [C];
Administration: [C];
Total: [C].
State[A]: North Dakota;
Premium subsidies: 140,590;
Benefits wraparound: [C];
Cost sharing: [C];
Administration: [C];
Total: 140,590[B].
State[A]: Oklahoma;
Premium subsidies: [C];
Benefits wraparound: NA;
Cost sharing: [C];
Administration: [C];
Total: [C].
State[A]: Oregon-1;
Premium subsidies: 20,792,412;
Benefits wraparound: NA;
Cost sharing: NA;
Administration: 3,824,058;
Total: 24,616,470.
State[A]: Oregon-2;
Premium subsidies: 724,360;
Benefits wraparound: [C];
Cost sharing: [C];
Administration: [C];
Total: 724,360[B].
State[A]: Pennsylvania;
Premium subsidies: Response not provided;
Benefits wraparound: Response not provided;
Cost sharing: Response not provided;
Administration: Response not provided;
Total: Response not provided.
State[A]: Rhode Island;
Premium subsidies: 8,174,977;
Benefits wraparound: 1,793,526;
Cost sharing: Response not provided;
Administration: c;
Total: 9,968,503[B].
State[A]: South Carolina;
Premium subsidies: 493,659;
Benefits wraparound: [C];
Cost sharing: [C];
Administration: 119,042;
Total: 612,701[B].
State[A]: South Dakota;
Premium subsidies: 268,568;
Benefits wraparound: NA;
Cost sharing: NA;
Administration: 50,000;
Total: 318,568.
State[A]: Texas;
Premium subsidies: 17,478,158;
Benefits wraparound: 4,330,790;
Cost sharing: [C];
Administration: 917,042;
Total: 22,725,990[B].
State[A]: Utah-1;
Premium subsidies: 609,042;
Benefits wraparound: 19,200;
Cost sharing: NA;
Administration: 64,235;
Total: 823,155[E].
State[A]: Utah-2;
Premium subsidies: Response not provided;
Benefits wraparound: [C];
Cost sharing: [C];
Administration: [C];
Total: 520,000[B].
State[A]: Vermont;
Premium subsidies: 23,697,720;
Benefits wraparound: 454,787;
Cost sharing: Response not provided;
Administration: 1,278,217;
Total: 25,430,724.
State[A]: Virginia-1;
Premium subsidies: 448,288;
Benefits wraparound: 1,034;
Cost sharing: NA;
Administration: 83,617;
Total: 532,939.
State[A]: Virginia-2;
Premium subsidies: 4,968,135;
Benefits wraparound: [C];
Cost sharing: [C];
Administration: 342,367;
Total: 5,365,702[B,F].
State[A]: Washington;
Premium subsidies: 6,738,384;
Benefits wraparound: Response not provided;
Cost sharing: Response not provided;
Administration: 1,040,267;
Total: 7,778,651[B].
State[A]: Wisconsin;
Premium subsidies: 915,495;
Benefits wraparound: 764,977;
Cost sharing: [C];
Administration: [C];
Total: 1,680,472[B].
State[A]: Wyoming;
Premium subsidies: 50,758;
Benefits wraparound: Response not provided;
Cost sharing: Response not provided;
Administration: Response not provided;
Total: 50,758[B].
State[A]: Total;
Premium subsidies: 196,481,904;
Benefits wraparound: 13,357,094;
Cost sharing: 86,471;
Administration: 11,293,334;
Total: 222,670,792[G].
Source: GAO Web-based survey administered to states' premium
assistance programs.
NA = Not applicable; the premium assistance program did not pay for
this item.
Notes: Data were obtained from surveys administered from August
through October 2009 to officials in 39 states representing 47 premium
assistance programs funded by Medicaid, State Children's Health
Insurance Program (CHIP), or both. We received responses from
officials representing 45 programs in 37 states; officials from 2
states with premium assistance programs, North Carolina and West
Virginia, did not respond to the survey.
Amounts shown are combined federal and state expenditures.
Data on program expenditures were generally for the period of July 1,
2008, through June 30, 2009. However, the following programs provided
data for a different period: Idaho-1 and Idaho-2 - October 1, 2007,
through September 30, 2008; Rhode Island and Wisconsin - July 1, 2007,
through June 30, 2008; Texas - September 1, 2008, through August 31,
2009; Virginia-2 - 2007 for data on program administration and other
expenditures, including Medicaid Management Information System
enhancements.
[A] Some states operated two premium assistance programs. For program
names, see table 2.
[B] This figure is the total of all reported expenditures. However,
actual total expenditures for the program are likely higher because
the program did not provide data for all applicable types of
expenditures.
[C] Program officials reported that data were not available.
[D] This figure includes $9,349 in other reported expenditures.
[E] This figure includes $130,678 in other reported expenditures.
[F] This figure includes $55,200 in other reported expenditures.
[G] This figure includes $195,227 in other reported expenditures, as
well as $736,763 in total expenditures reported for the Kansas program
and $520,000 in total expenditures reported for the Utah-2 program.
Additionally, this figure is the total of all reported expenditures.
However, actual total expenditures for the programs are likely higher
because some programs did not provide data for all applicable types of
expenditures.
[End of table]
Table 17: Cost-effectiveness Requirements and Methods Used, by State
Premium Assistance Program, 2009:
State[A]: Alabama;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Empty];
Method used to calculate cost-effectiveness: Other method[C]: [Check].
State[A]: Alaska;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Check];
Method used to calculate cost-effectiveness: Other method[C]: [Empty].
State[A]: Arizona;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Empty];
Method used to calculate cost-effectiveness: Other method[C]: [Check].
State[A]: California;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Empty];
Method used to calculate cost-effectiveness: Other method[C]: [Check].
State[A]: Colorado-1;
Cost-effectiveness requirement: [Empty];
Level at which cost-effectiveness is assessed: Individual/family: NA;
Level at which cost-effectiveness is assessed: Aggregate: NA;
[Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]: NA;
Method used to calculate cost-effectiveness: Other method[C]: NA.
State[A]: Colorado-2;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Empty];
Method used to calculate cost-effectiveness: Other method[C]: [Check].
State[A]: Florida;
Cost-effectiveness requirement: [Empty];
Level at which cost-effectiveness is assessed: Individual/family: NA;
Level at which cost-effectiveness is assessed: Aggregate: NA;
Method used to calculate cost-effectiveness: Secretary's method[B]: NA;
Method used to calculate cost-effectiveness: Other method[C]: NA.
State[A]: Georgia;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Empty];
Method used to calculate cost-effectiveness: Other method[C]: [Check].
State[A]: Idaho-1;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Empty];
Level at which cost-effectiveness is assessed: Aggregate: [Check];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Empty];
Method used to calculate cost-effectiveness: Other method[C]: [Check].
State[A]: Idaho-2;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Empty];
Level at which cost-effectiveness is assessed: Aggregate: [Check];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Empty];
Method used to calculate cost-effectiveness: Other method[C]: [Check].
State[A]: Illinois;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Empty];
Method used to calculate cost-effectiveness: Other method[C]: [Check].
State[A]: Iowa;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Check];
Method used to calculate cost-effectiveness: Other method[C]: [Empty].
State[A]: Kansas;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Check];
Method used to calculate cost-effectiveness: Other method[C]: [Empty].
State[A]: Kentucky;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Check];
Method used to calculate cost-effectiveness: Other method[C]: [Empty].
State[A]: Louisiana;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Check];
Method used to calculate cost-effectiveness: Other method[C]: [Empty].
State[A]: Maine;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
[Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Check];
Method used to calculate cost-effectiveness: Other method[C]: [Empty].
State[A]: Massachusetts-1;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Check];
Method used to calculate cost-effectiveness: Other method[C]: [Empty].
State[A]: Massachusetts-2;
Cost-effectiveness requirement: [Empty];
Level at which cost-effectiveness is assessed: Individual/family: NA;
Level at which cost-effectiveness is assessed: Aggregate: NA;
Method used to calculate cost-effectiveness: Secretary's method[B]: NA;
Method used to calculate cost-effectiveness: Other method[C]: NA.
State[A]: Minnesota;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Empty];
Method used to calculate cost-effectiveness: Other method[C]: [Check].
State[A]: Missouri;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Check];
Method used to calculate cost-effectiveness: Other method[C]: [Empty].
State[A]: Montana;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Check];
Method used to calculate cost-effectiveness: Other method[C]: [Empty].
State[A]: Nebraska;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Empty];
Method used to calculate cost-effectiveness: Other method[C]: [Check].
State[A]: Nevada-1;
Cost-effectiveness requirement: [Empty];
Level at which cost-effectiveness is assessed: Individual/family: NA;
Level at which cost-effectiveness is assessed: Aggregate: NA;
Method used to calculate cost-effectiveness: Secretary's method[B]: NA;
Method used to calculate cost-effectiveness: Other method[C]: NA.
State[A]: Nevada-2;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Check];
Method used to calculate cost-effectiveness: Other method[C]: [Empty].
State[A]: New Hampshire;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Empty];
Method used to calculate cost-effectiveness: Other method[C]: [Check].
State[A]: New Jersey-1;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Check];
Method used to calculate cost-effectiveness: Other method[C]: [Empty].
State[A]: New Jersey-2;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
[Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Empty];
Method used to calculate cost-effectiveness: Other method[C]: [Check].
State[A]: New York;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Empty];
Level at which cost-effectiveness is assessed: Aggregate: [Check];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Empty];
Method used to calculate cost-effectiveness: Other method[C]: [Check].
State[A]: North Dakota;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
[Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Check];
Method used to calculate cost-effectiveness: Other method[C]: [Empty].
State[A]: Oklahoma;
Cost-effectiveness requirement: [Empty];
Level at which cost-effectiveness is assessed: Individual/family: NA;
Level at which cost-effectiveness is assessed: Aggregate: NA;
Method used to calculate cost-effectiveness: Secretary's method[B]: NA;
Method used to calculate cost-effectiveness: Other method[C]: NA.
State[A]: Oregon-1;
Cost-effectiveness requirement: [Empty];
Level at which cost-effectiveness is assessed: Individual/family: NA;
Level at which cost-effectiveness is assessed: Aggregate: NA;
[Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]: NA;
Method used to calculate cost-effectiveness: Other method[C]: NA.
State[A]: Oregon-2;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Empty];
Method used to calculate cost-effectiveness: Other method[C]: [Check].
State[A]: Pennsylvania;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Check];
Method used to calculate cost-effectiveness: Other method[C]: [Empty].
State[A]: Rhode Island;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Empty];
Level at which cost-effectiveness is assessed: Aggregate: [Check];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Check];
Method used to calculate cost-effectiveness: Other method[C]: [Empty].
State[A]: South Carolina;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
[Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Empty];
Method used to calculate cost-effectiveness: Other method[C]: [Check].
State[A]: South Dakota;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Empty];
Method used to calculate cost-effectiveness: Other method[C]: [Check].
State[A]: Texas;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Check];
Method used to calculate cost-effectiveness: Other method[C]: [Empty].
State[A]: Utah-1;
Cost-effectiveness requirement: [Empty];
Level at which cost-effectiveness is assessed: Individual/family: NA;
Level at which cost-effectiveness is assessed: Aggregate: NA;
[Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]: NA;
Method used to calculate cost-effectiveness: Other method[C]: NA.
State[A]: Utah-2;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Empty];
Level at which cost-effectiveness is assessed: Aggregate: [Check];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Empty];
Method used to calculate cost-effectiveness: Other method[C]: [Check].
State[A]: Vermont;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Empty];
Method used to calculate cost-effectiveness: Other method[C]: [Check].
State[A]: Virginia-1;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Empty];
Level at which cost-effectiveness is assessed: Aggregate: [Check];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Check];
Method used to calculate cost-effectiveness: Other method[C]: [Empty].
State[A]: Virginia-2;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Empty];
Method used to calculate cost-effectiveness: Other method[C]: [Check].
State[A]: Washington;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Check];
Method used to calculate cost-effectiveness: Other method[C]: [Empty].
State[A]: Wisconsin;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Empty];
Method used to calculate cost-effectiveness: Other method[C]: [Check].
State[A]: Wyoming;
Cost-effectiveness requirement: [Check];
Level at which cost-effectiveness is assessed: Individual/family:
[Check];
Level at which cost-effectiveness is assessed: Aggregate: [Empty];
Method used to calculate cost-effectiveness: Secretary's method[B]:
[Check];
Method used to calculate cost-effectiveness: Other method[C]: [Empty].
State[A]: Total;
Cost-effectiveness requirement: 38;
Level at which cost-effectiveness is assessed: Individual/family: 32;
Level at which cost-effectiveness is assessed: Aggregate: 6;
Method used to calculate cost-effectiveness: Secretary's method[B]: 18;
Method used to calculate cost-effectiveness: Other method[C]: 20.
Source: GAO Web-based survey administered to states' premium
assistance programs.
Legend:
[Check] = Requirement or method used.
NA = Not applicable, the program does not have a cost-effectiveness
requirement.
Note: Data were obtained from surveys administered from August through
October 2009 to officials in 39 states representing 47 premium
assistance programs funded by Medicaid, CHIP, or both. We received
responses from officials representing 45 programs in 37 states;
officials from 2 states with premium assistance programs, North
Carolina and West Virginia, did not respond to the survey.
[A] Some states operated two premium assistance programs. For program
names, see table 2.
[B] Section 3910 of the State Medicaid Manual states that an
individual's enrollment in premium assistance is cost-effective if the
amount paid for premiums, coinsurance, deductibles, other cost
sharing, as well as administrative costs, is likely to be less than
the Medicaid expenditures for an equivalent set of services. To
determine whether premium assistance is cost-effective, section 3910
of the State Medicaid Manual offers a calculation states can use. This
calculation--referred to as the Secretary's method--involves a seven-
step process that takes into account information on the group health
plan; average Medicaid costs; Medicaid cost for services included in
the group health plan; the group health plan cost for included
services; an adjustment for coinsurance and deductible amounts; and
additional administrative costs for processing the group health plan
information.
[C] Respondents who indicated "other method" used a method designed by
the state and approved by the Centers for Medicare & Medicaid Services.
[End of table]
[End of Enclosure IV]
Enclosure V: Challenges to States' Premium Assistance Programs'
Implementation and Operation:
Table 18: Challenges to Premium Assistance Program Implementation or
Operation, 2009:
Factor: Limited number of individuals with access to private health
insurance;
Number of programs where officials indicated that factor posed a
challenge: 18.
Factor: Difficulty identifying individuals with access to private
health insurance;
Number of programs where officials indicated that factor posed a
challenge: 17.
Factor: Difficulty enrolling individuals due to limits in the
enrollment periods for the private health insurance;
Number of programs where officials indicated that factor posed a
challenge: 16.
Factor: Difficulty getting necessary information from health plans or
employers;
Number of programs where officials indicated that factor posed a
challenge: 16.
Factor: Limited participation due to voluntary enrollment;
Number of programs where officials indicated that factor posed a
challenge: 16.
Factor: Difficulty meeting cost-effectiveness standards;
Number of programs where officials indicated that factor posed a
challenge: 13.
Factor: Program administrative costs too high;
Number of programs where officials indicated that factor posed a
challenge: 6.
Factor: Available private health plans often do not meet the minimum
benefit requirements;
Number of programs where officials indicated that factor posed a
challenge: 4.
Factor: Challenges providing benefits wraparound coverage;
Number of programs where officials indicated that factor posed a
challenge: 3.
Factor: State fiscal challenges and other budget constraints;
Number of programs where officials indicated that factor posed a
challenge: 3.
Source: GAO Web-based survey administered to states' premium
assistance programs.
Notes: Data were obtained from surveys administered from August
through October 2009 to officials in 39 states representing 47 premium
assistance programs funded by Medicaid, State Children's Health
Insurance Program (CHIP), or both. We received responses from
officials representing 45 programs in 37 states; officials from 2
states with premium assistance programs, North Carolina and West
Virginia, did not respond to the survey.
Responses from program officials (representing 45 premium assistance
programs) were included in this table if they indicated that the
factor posed either a great or moderate challenge to program
implementation or operation.
[End of table]
[End of Enclosure V]
Enclosure VI: Agency Comment Letter:
Department Of Health & Human Services:
Office Of The Secretary:
Assistant Secretary for Legislation:
Washington, DC 20201:
December 18, 2009:
Carolyn Yocom:
Acting Director, Health Care:
U.S. Government Accountability Office:
441 G Street N.W.
Washington, DC 20548:
Dear Ms. Yocom:
Enclosed are comments on the U.S. Government Accountability Office's
(GAO) report entitled: Medicaid and CHIP: Enrollment, Benefits,
Expenditures, and Other Characteristics of State Premium Assistance
Programs (GAO-10-258R).
The Department appreciates the opportunity to review this report
before its publication.
Sincerely,
Andrea Palm;
Acting Assistant Secretary for Legislation:
Enclosure:
Department Of Health & Human Services:
Center for Medicare and Medicaid Services:
Administrator:
Washington, DC 20201:
Date: December 17 2009:
To: Andrea Palm:
Acting Assistant Secretary for Legislation:
Office of the Secretary:
From: [Signed by] Charlene Frizzera:
Acting Administrator:
Subject: Government Accountability Office (GAO) Draft Report:
"Medicaid and CHIP: Enrollment, Benefits, Expenditures, and Other
Characteristics of State Premium Assistance Programs" (GAO-10-258R):
The Centers for Medicare & Medicaid Services (CMS) appreciates the
opportunity to review and comment on the subject GAO Draft Report. The
Children's Health Insurance Program Reauthorization Act (CHIPRA)
required the GAO to study cost and coverage issues related to State
premium assistance programs receiving Medicaid and Children's Health
Insurance Program (CHIP) funds. In this draft report, the GAO
describes States' premium assistance programs, including the--(1)
funding source, operating authority, and type of private health
insurance coverage subsidized; (2) policies regarding eligibility and
enrollment; (3) benefits, premiums, and cost sharing; (4) expenditures
and cost effectiveness policies; and (5) challenges program officials
reported in implementing and operating such programs, as well as the
effect that CHIPRA may have on these challenges.
From August through October 2009, the GAO administered a web-based
survey to officials from the States that had premium assistance
programs funded by Medicaid, CHIP, or both. The GAO identified 47
premium assistance programs in 39 States. The survey addressed all of
the dimensions identified above. Of the 47 Medicaid or CHIP funded
premium assistance programs identified, GAO received survey responses
from officials representing 45 programs in 37 States, although not
every official in the 37 States responded to each question. The GAO
did not include any recommendations for CMS in this report.
Key findings from the report include, but are not limited to:
* Thirty premium assistance programs were funded solely by Medicaid,
six programs were funded solely by CHIP, and nine programs were funded
by both Medicaid and CHIP;
* Most premium assistance programs operated under the authority of
section 1906 of the Social Security Act (the Act) (29), while 16
programs operated under section 1115 waivers, 1 program operated under
section 2105(c)(3) of the Act, and 10 programs operated under other
authorities;
* Reported premium assistance program enrollment ranged from fewer
than 10 individuals in five programs to more than 10,000 individuals
in four programs ” including one program with more than 36,600
individuals. Over half of the programs (25) had fewer than 1,000
enrollees;
* Forty-three programs subsidized coverage for employer-sponsored
insurance (ESI), 32 subsidized for Consolidated Omnibus Budget
Reconciliation Act (COBRA) coverage, and 17 subsidized other group
health coverage;
* Twenty-one of the 45 premium assistance programs subsidized non-
group coverage, namely policies purchased from the individual market;
* Fewer than half of the premium assistance programs (20) mandated
enrollment for any eligible individuals. Of those, 19 required all
eligible individuals to enroll, while the remaining program required
only certain individuals to enroll;
* Thirty premium assistance programs provided complete benefits
wraparound to some or all eligible individuals. Of the remaining 15
programs, four programs provided partial benefits wraparound, 10
programs provided no benefits wraparound coverage, and one program did
not indicate whether or not benefits wraparound coverage was provided;
* Thirty-eight programs required premium assistance to be cost-
effective, meaning that the cost for Medicaid or CHIP to provide
premium assistance is likely less than the cost to provide direct
coverage. Of the 38, 32 assessed cost-effectiveness on an individual
or family level, while the remaining six assessed cost-effectiveness
on an aggregate level. To calculate the cost-effectiveness, 18 of the
38 programs reported using the method outlined in the State Medicaid
Manual and 20 used another method;
* Officials from 34 premium assistance programs reported that they did
not monitor access to care or utilization of services for individuals
enrolled in the premium assistance program. Of the remaining 11
programs seven programs monitored utilization of services, three
programs monitored both utilization of services and access to care,
and one program did not report whether it conducted either type of
monitoring;
* The two most common challenges identified by program officials who
responded to the survey were a limited number of individuals with
access to private health insurance (18 programs) and difficulty
identifying individuals with access to private insurance (17
programs); and;
* Officials from nine of 13 programs specifically noted that the
CHIPRA provision making eligibility in premium assistance a qualifying
event would make it easier to enroll individuals in the premium
assistance program;
CMS Response:
We commend the GAO for its data collection efforts in examining the
various dimensions of how Medicaid and CHIP premium assistance
programs operate under title XIX and title XXI of the Act, and believe
these data will prove useful in serving as a baseline to inform
Congress and others stakeholders in this subject area.
We appreciate the fact that the report identifies that the GAO
utilized a web-based survey administered to States' premium assistance
program officials as the primary source of State-specific premium
assistance information however, we request that the GAO clarify in the
beginning of the report that while CMS did due diligence to verify the
accuracy of the information in the report, when possible, we were not
able to verify all of the data. We want to make clear that CMS is
unable to verify the majority of the State-reported information for a
variety of reasons, including the lack of specificity of whether the
data relate to the title XIX or title XXI component, the inclusion of
information (e.g., break out by type of employer sponsored coverage)
in the report that is not currently collected at the Federal level,
and the lack of CMS access to the detailed source information. GAO has
also indicated previously that it does not expect CMS to verify the
State-reported data.
We have provided some technical comments that we hope will be helpful
in refining your draft. CMS appreciates the opportunity to comment on
this draft report and we look forward to working with the GAO on this
and other issues.
[End of Enclosure VI]
Enclosure VII: GAO Contact and Staff Acknowledgments:
GAO Contact:
Carolyn L. Yocom, (202) 512-7114 or yocomc@gao.gov:
Acknowledgments:
In addition to the contact named above, Michelle Rosenberg, Assistant
Director; Christie Enders; Nancy Fasciano; Martha R. W. Kelly; Drew
Long; Kevin Milne; Dan Ries; Lillian Shields; Malissa G. Winograd; and
Suzanne Worth made key contributions to this report.
[End of Enclosure VII]
Footnotes:
[1] Medicaid and CHIP are joint federal-state programs that finance
health insurance coverage for certain categories of low-income adults
and children.
[2] See J. Alker, Choosing Premium Assistance: What Does State
Experience Tell Us? (Washington, D.C.: Henry J. Kaiser Family
Foundation, Kaiser Commission on Medicaid and the Uninsured, May
2008); D. Belnap and S. Schwartz, Premium Assistance, Pub. No. 2007-
109 (Portland, Maine: National Academy for State Health Policy,
October 2007); M. Herman, Premium Assistance Programs: Potential Help
for the Uninsured? (Washington, D.C.: Forum for State Health Policy
Leadership, National Conference of State Legislatures, 2004); C. Shirk
and J Ryan, Premium Assistance in Medicaid and SCHIP: Ace in the Hole
or House of Cards? Issue Brief no. 812 (Washington, D.C.: National
Health Policy Forum, The George Washington University, July 2006); and
C. Williams, A Snapshot of State Experience Implementing Premium
Assistance Programs (Portland, Maine: National Academy for State
Health Policy, April 2003).
[3] See Children's Health Insurance Program Reauthorization Act of
2009, Pub. L. No. 111-3, § 301(c), 123 Stat. 8, 11-15, 57-63.
[4] Our review of premium assistance programs did not include Medicaid
or CHIP-funded programs in which the states only subsidize premiums
for insurance packages they created, as opposed to private health
insurance packages created by employers or insurance companies. At
least three states--Arkansas, Massachusetts, and New Mexico--have such
programs.
[5] Officials from 11 states and the District of Columbia reported not
having a Medicaid-or CHIP-funded premium assistance program. An
official representing 1 of those states reported having a premium
assistance program in the past that was discontinued, and an official
representing another state reported plans for implementing a program
in the future.
[6] In states with more than one Medicaid-or CHIP-funded premium
assistance program, officials were asked to complete a separate survey
for each program.
[7] We did not receive completed surveys from North Carolina or West
Virginia and thus were unable to include information about these two
states' premium assistance programs.
[8] Section 1906 of the SSA was enacted in the Omnibus Budget
Reconciliation Act of 1990 and amended in the Balanced Budget Act of
1997. See Pub. L. No. 101-508, title IV, §4402(a)(2), 104 Stat. 1388-
161, as amended by Pub. L. No. 105-33, title IV, §4741(b), 111 Stat.
523.
[9] Other, less frequently used authorities through which states can
operate Medicaid-funded premium assistance programs are provided in
sections 1902 and 1905 of the SSA. Section 1902(a)(10)(F) of the SSA
allows states to use Medicaid funds to pay premiums for COBRA
continuation coverage for certain low-income individuals who are not
currently eligible for Medicaid but who are likely to become Medicaid
eligible in the future and have high health care costs. COBRA, an
acronym for the Consolidated Omnibus Budget Reconciliation Act of
1985, included provisions giving employees the opportunity to remain
in their employer's group coverage when they would otherwise lose
coverage. Section 1905(a) of the SSA allows states to use Medicaid
funds to subsidize premiums for group or nongroup health coverage. In
this report, we define nongroup health coverage as coverage purchased
from the individual market.
[10] States with CHIP Medicaid expansion programs can operate CHIP-
funded premium assistance programs through Medicaid authorities, such
as section 1906 of the SSA. States may use one of three basic options
for structuring their CHIP programs: (1) a Medicaid expansion program,
(2) a separate child health program, or (3) a combination program that
includes both a Medicaid expansion and a separate child health
program. States operating CHIP Medicaid expansion programs must follow
Medicaid rules, while states operating separate child health programs
follow CHIP rules. Section 2105(c)(3) of the SSA permits payment to a
state for family coverage under a group health plan or health
insurance coverage. Regulations at 42 C.F.R. §457.1010 implement the
provisions of the statute related to family coverage. 42 C.F.R §
457.10 implements requirements related to premium assistance programs
in connection with group health plan coverage. For this report, we
consider programs operated under either authority to be premium
assistance programs.
[11] Through a waiver under section 1115 of the SSA, the Secretary of
HHS could, for example, allow states to provide services or cover
individuals not normally eligible for Medicaid and CHIP and provide
federal funds for costs not otherwise eligible for payment.
[12] See Pub. L. No. 111-3, § 301, 123 Stat. at 57-63. While CHIPRA
provided additional options for states to operate premium assistance
programs, no state had implemented a program under these new options
as of November 2009.
[13] The "parents" coverage group includes legal guardians, and the
"pregnant women" coverage group includes unborn children. Under CHIP,
states may choose to extend eligibility to unborn children and provide
prenatal care and delivery. See 67 Fed. Reg. 61956 (Oct. 2, 2002).
[14] The "other" coverage groups most commonly reported were certain
unemployed individuals, aged or disabled individuals, or individuals
receiving Supplemental Security Income benefits.
[15] Certain exceptions may apply. For example, states that operate
their premium assistance programs under the authority of section 1906
of the SSA cannot deny direct coverage to eligible children if their
parent fails to enroll them in a group health plan.
[16] Two programs also provided at least some benefits wraparound
coverage to noneligible family members.
[17] In programs that provide partial benefits wraparound coverage,
the state supplements private health insurance benefits, but not to
the level an individual would receive under direct coverage. For
example, states may supplement only certain benefits, such as dental
care, mental health care, or immunizations.
[18] The authority under which a premium assistance program operates
determines whether or not the program has to provide benefits
wraparound coverage. For example, programs operating under section
1115 waivers may not have to provide benefits wraparound coverage. Of
the nine programs that provided no benefits wraparound coverage, two
had a mandatory enrollment policy for eligible individuals.
Additionally, three of the nine programs that provided no benefits
wraparound coverage subsidized premiums for nongroup coverage.
[19] Of the 34 programs that reported paying at least some cost
sharing, 21 reported paying all cost sharing for all eligible
individuals covered through premium assistance, 12 reported paying
some cost sharing for all eligible individuals, and 1 reported paying
all cost sharing for some eligible individuals and no cost sharing for
the other eligible individuals. Additionally, 1 program reported
paying some cost sharing for noneligible family members.
[20] Of those 11 programs that did not pay cost sharing for any groups
covered by premium assistance, 2 programs were mandatory programs, in
that individuals eligible for premium assistance were required to
enroll.
[21] Data were generally for the 12-month period from July 1, 2008,
through June 30, 2009, and included both the state and federal share.
[22] Additionally, 24 of the 35 programs that provided benefits
wraparound coverage did not report the amount of expenditures in this
category. Twenty-six of the 34 programs that paid some cost sharing
did not report the amount of expenditures in this category.
[23] Section 3910 of the State Medicaid Manual states that an
individual's enrollment in premium assistance is cost-effective if the
amount paid for premiums, coinsurance, deductibles, other cost
sharing, as well as administrative costs, is likely to be less than
the Medicaid expenditures for an equivalent set of services. To
determine whether premium assistance is cost-effective, section 3910
offers a calculation states can use. This calculation--referred to as
the Secretary's method--involves a seven-step process that takes into
account information on the group health plan; average Medicaid costs;
Medicaid cost for services included in the group health plan; the
group health plan cost for included services; an adjustment for
coinsurance and deductible amounts; and additional administrative
costs for processing the group health plan information. States that
use another method for determining cost-effectiveness must have their
methodology approved by CMS.
[End of section]
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