Frequently Asked Questions about the Children’s Health Initiative and Healthy Kids
– What is the Children’s Health Initiative?
– What is Healthy Kids?
– Who is eligible for Healthy Kids?
– Why create a 300% FPL ceiling?
– How do children qualify?
– How much does Healthy Kids cost?
– What’s the benefit to the community?
– Why is outreach important?
– How will we develop a new and expanded approach to outreach?
– Why is retention so important?
What is the Children’s Health Initiative?
The Santa Clara County Board of Supervisors, Working Partnerships USA and People Acting in Community Together (PACT) have established the goal that 100% of the children residing in Santa Clara County have access to quality health care through comprehensive health insurance. To meet this goal, the Children’s Health Initiative incorporates several major program components:
- Every child in Santa Clara County shall have real access to regular health care as a result of being insured;
- No uninsured child who is a resident of Santa Clara County, and whose parents have an income at or below 300% of the federal poverty level, shall be turned away from receiving health coverage.
- The Outreach Plan become a model ‘best practices’ program within the State of California, with program elements which include education of families on the appropriate use of their benefits and the health care system, and improvement of enrollment retention.
As currently designed, the Children’s Health Initiative seeks to reach all uninsured children in Santa Clara County whose families have incomes at or below 300% of the federal poverty level (FPL). Through an extensive outreach and enrollment project, workers and volunteers will discuss the benefits of health insurance for children with families, evaluate the families’ eligibility, and then assist the family in enrolling their child/children in the appropriate health insurance program (Medi-Cal, Healthy Families, or Healthy Kids).
The appropriate plan will depend upon the child’s age, residency status, family size, and income. Moreover, children within the same family may qualify for different programs. The following table demonstrates how these factors combine to determine eligibility in each program:
| Age | Income Limit as % of Federal Poverty Level (FPL) | Program Eligibility |
| < 1 Year | <200% 201-250% 0-300% |
Medi-Cal Healthy Families Healthy Kids* |
| 1-5 Years | <133% 134-250% 0-300% |
Medi-Cal Healthy Families Healthy Kids* |
| 6-18 Years | <100% 101-250% 0-300% |
Medi-Cal Healthy Families Healthy Kids* |
Healthy Kids is the essential component in helping reach the goal of making health insurance accessible to all children in the County. Created by a public-private partnership which was formed for this purpose, it is a new, locally funded health insurance product designed to fill in the gap for those who do not qualify for the existing programs and are financially unable to purchase coverage.
Healthy Kids will function like any other managed health care plan; it is regulated by the California Department of Managed Health Care and will offer benefits and provider networks that are the same as those available through the Family Health Plan from the State-managed Healthy Families program. Benefits include:
- Complete medical coverage including preventive check ups
- Specialist care
- Inpatient and outpatient hospital services
- Mental health care
- Alcohol & drug treatment
- Vision care
- Dental care
- Prescription coverage
- A 24-hour nurse advice line
- Health education and many other services
Who is eligible for Healthy Kids?
All children who are:
- under age 19
- uninsured
- residents of Santa Clara County
- families earn 300% FPL or less; and are
- ineligible for Medi-Cal or Healthy Families.
Why create a 300% FPL ceiling?
In the Santa Clara Valley the cost of living, particularly housing, is such that even 300% of poverty here is barely comparable to the 250% legislatively established for Healthy Families throughout the entire state. Moreover, it is believed that families earning over 300% FPL are more likely to have access to employer sponsored health insurance. As it is not the intent of this plan to replace health coverage currently being provided by employers for dependents, the 300% FPL ceiling seems reasonable.
In consideration of the aforementioned issues, Healthy Kids begins with an income limit of 300% of the federal poverty level. After experience and data has been gained, this income limit will be re-evaluated in light of the unique economic pressures within Silicon Valley. The high cost of living may well require that Santa Clara County establish its own “poverty level”. Further study of those children above the 300% FPL limit who continue to be uninsured will lead to better understanding of how to best meet their needs. (Note: For a family of four, 300% of the federal poverty level equals an annual income of $52,950.)
Application Specialists will help families complete the application form. The family will provide proof of income and county residency. Annual requalification will be required to maintain coverage.
Recognizing the variability in employment status, a variety of forms will be accepted as proof of income. For example, families may provide copies of recent pay stubs or tax returns to demonstrate income levels. Or, in cases where such documents are not available, the family may submit a letter from the employer or agency through which they find work. Residency can be determined by school enrollment forms, canceled mail or any other usually accepted documents. Spot checks will be conducted to validate this process. In addition, certified mail and/or returned mail can help verify residency.
Upon completion of the application, families with children deemed ineligible for Medi-Cal and Healthy Families will help applying for Healthy Kids. Should the child qualify for Healthy Families or Medi-Cal, the family will be assisted, automatically, in applying for the appropriate program.
How much does Healthy Kids cost?
The total cost of Healthy Kids is $87 per member per month for the initial fiscal year. Of that, the family’s share of the premium will be from $4 to $6 per child per month, with a maximum of from $12 to $18 monthly payment per family, depending upon income. (See chart, next page.) Families may pre-pay 3 months of their share of the premium and receive the fourth month free, or, pay for 9 months and receive the fourth quarter free.
Family Contribution Chart
|
Family Size
|
$4 per child up to maximum of$12 per family.
|
$6 per childup to maximum of $18 per family.
|
|
Maximum Monthly Family Income
|
Maximum Monthly Family Income
|
|
|
1
|
$1,123
|
$2,245
|
|
2
|
$1,515
|
$3,030
|
|
3
|
$1,908
|
$3,815
|
|
4
|
$2,300
|
$4,600
|
|
5
|
$2,693
|
$5,385
|
|
6
|
$3,085
|
$6,170
|
|
7
|
$3,498
|
$6,995
|
|
8
|
$3,870
|
$7,740
|
|
9
|
$4,263
|
$8,525
|
|
10
|
$4,655
|
$9,310
|
Income per Federal Poverty Level 4/1/03
In addition to the monthly family contribution to premium, there are co-payments for certain services (the same as Healthy Families):
|
CATEGORY
|
TYPES OF SERVICES
|
COPAYMENT
|
|
Health Facilities
|
All patient acute & Skilled Nursing (100 days) All Outpatient Services |
No co-payment |
|
Professional
|
Inpatient-based Office or home visit Visits for chemotherapy, dialysis, surgery, anesthesiology, radiation |
No co-payment $5 co-payment $5 co-payment |
|
Preventive Services
|
Visits for immunizations, periodic health exams, well-child visits, STD tests, cytology exams, family planning, vision and hearing tests, prenatal care, health education
|
No co-payment
|
|
Diagnostic x-ray and Laboratory Services
|
Therapeutic radiology services, ECG, EEG, mammography, other outpatient diagnostic laboratory and radiology tests
|
No co-payment
|
|
Prescriptions
|
Generic or name brand drugs Inpatient drugs and drug administration in a physician’s office, as well as FDA-approved contraception drugs and devices |
$5 co-payment
|
|
Mental Health |
Inpatient limited to 30 days/year Outpatient visits up to 20 visits per year |
No co-payment |
|
Drug and Alcohol
|
Inpatient detoxification Crisis intervention and abuse treatment |
$5 co-payment $5 co-payment |
|
Other Services
|
Othoses, prostheses, medical transportation Physical, occupational, and speech therapy |
No co-payment |
Experience with Healthy Families shows that some families have a difficult time paying monthly premiums for insurance coverage however small it may be. For those families for whom the monthly share of premium is a barrier to enrolling their children into Healthy Kids, a separately operated Premium Assistance Fund has been established. Families may request this assistance through the Santa Clara Family Health Plan, which will evaluate the application based on family size, income, and extraordinary circumstances.
Families qualifying for Premium Assistance will not be billed their monthly share of premium for the remainder of their enrollment year. Those funds will be transferred to Family Health Plan by the United Way, which will manage this account. The Premium Assistance Fund will cover only the family’s monthly share of premium payment.
Rather than disenrolling children automatically after two months of non-payment of the Family Contribution (current Healthy Families practice), Healthy Kids will “bill” the Premium Assistance Fund and try to contact the family to determine the reasons for non-payment. Should the family subsequently qualify for the Premium Assistance Fund, the payments will be made for the family. In those instances where non-payment is a choice, not the need for assistance, the children will be disenrolled from Healthy Kids.
What’s the benefit to the community?
Perhaps the benefit to the community is best stated by the Institute for Health Policy Solutions in its report to the Packard Foundation, “Background Data and Models for Expanding Health Insurance Coverage to Uninsured Children in Santa Clara County”
“Children’s access to health insurance and health care are important determinants of better health outcomes and readiness to learn. A regular source of care is particularly important for children in assuring that appropriate preventive services are provided, acute and chronic conditions are diagnosed and treated in a timely manner, and that children’s development is adequately monitored. Furthermore, children’s regular access to preventive services can decrease their need for emergency and specialized services.”
In other words, providing health coverage to children is the morally, medically and financially right thing to do.
Health care plans and benefits, and the health care delivery system in general, are complicated, intimidating, and are known primary barriers to parents seeking and obtaining health insurance for their children. As such, a goal of the Children’s Health
Initiative is to reduce parents’ fears and confusion by deploying a cadre of Application Specialists throughout the community who are highly trained and skilled in the arts of communication, information dissemination, and building trusted relationships with enrollees and the community-at-large.
How will we develop a new and expanded approach to outreach?
The Medi-Cal/Healthy Families Advisory Committee (Advisory Committee) is a collaborative of county-wide stakeholders that have conducted investigations and gathered information in the areas of outreach and enrollment best practices, barriers to enrollment, public awareness campaign strategies, retention of members, and training of personnel. Advisory Committee membership includes, but is not limited to, representatives from following agencies: Santa Clara Valley Health & Hospital System (SCVHHS), Santa Clara County Social Services Agency (SSA), Santa Clara Family Health Plan, Alum Rock Union School Districts, Working Partnerships, Community Health Partnership, People Acting in Community Together, Packard Foundation, and The Health Trust.
Successful identification and enrollment of all eligible children into a health insurance program will include 1) continuous communication and planning between SCVHHS Valley Community Outreach Services and the Social Services Agency, to ensure a fluid coordination of the County’s application process for enrollment, 2) developing a coordinated set of county-wide outreach activities to prospective enrollees, 3) providing comprehensive and dedicated assistance with the complex application process by trained professionals, including beneficiary education to promote appropriate health system utilization, and 4) creating a policy to streamline the processes necessary to provide continuous coverage for children as their family’s eligibility criteria changes over time.
In conjunction and partnership with our outreach efforts, the Social Services Agency will be performing an Agency-wide analysis of its existing Medi-Cal eligibility practices. There are a number of entry points within the application process that have proven to hold barriers for many eligible residents. Any opportunity to enroll an applicant into a program that becomes frustrating or unnecessarily burdensome is a potential missed opportunity to get a child enrolled for health care.
Why is retention so important?
The success of this outreach plan will ultimately be measured by the success of retaining its members and increasing utilization of care as outlined by the Children’s Health Initiative efforts. Santa Clara County Children’s Health Initiative will stand alone as a best practice model for achieving healthier communities by retaining our children and families within a health program once they are successfully enrolled. The uniqueness of our plan stems from 1) addressing the specific needs of the uninsured in our County, 2) providing the administrative continuity required to eliminate barriers to continuous coverage for each child, 3) educating enrollees on how to proactively utilize the health care delivery system, and 4) providing the commitment and resources necessary to deploy a highly trained and effective application assistance team.