Medicaid Trend Snapshots
Employer Sponsored Insurance Employer Sponsored Insurance
Declines in employer sponsored insurance between 2001 and 2005 were greatest among
poor and near-poor employees and those working in small businesses. During that same
four year period, the number of uninsured employees grew by 3.4 million, two-thirds of Iwhom were from low-income families. States are considering and implementing
programs for businesses that are unable to offer health insurance coverage to their
employees, as well as programs that employ partnerships between the state and private
employers. Other states are encouraging participation in employer-sponsored insurance
(ESI) plans when available as an alternative to Medicaid coverage.
Current State Activities
Arkansas Safety Net Benefit Program
Authorized through an 1115 HIFA waiver in March 2006, the program is targeted at
businesses with between two and 500 full time employees. For the purpose of this
program, employers are defined as a business entity if they have employees and a unique
Arkansas and/or federal tax identification number.
Employers will be eligible to participate in the program if they have not offered group
health insurance in the 12 months prior to participation in the program. Participating
employers will also be required to achieve 100 percent employee health insurance
coverage, regardless of income.
Funding for the program is provided by fees collected from participating employers, state
tobacco settlement funds, and federally matched funds.
Basic benefit package for adults:
? Six physician visits per year
? Seven inpatient hospital days per year
? Two outpatient hospital services per year
? Two prescription drugs per month
Individuals covered through the program will be required to cost share:
? $100 deductible
? 15 percent coinsurance for all services except pharmacy
? Premiums for individuals will not exceed $15 per month
I Clemans-Cope, L et al. Changes in Employees’ Health Insurance Coverage, 2001-2005. Kaiser Commission on
Medicaid and the Uninsured Issue Brief #7570, October 2006. Available at http://www.kff.org/uninsured/upload/7570.pdf.
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Medicaid Trend Snapshots
Florida Medicaid Reform – “Opt-Out”
In October 2005, CMS approved a section 1115 demonstration waiver for the state of
Florida. Two key principles of Florida Medicaid Reform are patient empowerment and
bridging public and private coverage. The new reform plan will allow Medicaid
beneficiaries with access to employer-sponsored health insurance to "opt-out" of the
Medicaid program and receive subsidies to pay premiums for the employer-sponsored
All individuals eligible for Medicaid Reform may voluntarily opt out. Coverage will still
be available for those individuals who have access to a quality ESI health plan, COBRA
coverage, and coverage through a private plan when the enrollee is self-employed.
The state will provide strong outreach and education through choice counselors to
increase awareness and understanding of the opt-out program. At a minimum, the choice
counselor will encourage the individual to seek information on:
? The available health insurance at work;
? When the individual can enroll;
? Cost sharing by the plan;
? Preexisting condition clauses; and
? Whether individual or family coverage is available.
The benefit package under the ESI plan may be more restrictive that Medicaid coverage.
However, because participation is voluntary, Medicaid will not provide wrap around
benefits. Enrollees electing to opt-out will be responsible for paying the cost sharing
requirements of the ESI plan, including deductibles and co-payments.
Idaho Access to Health Insurance Program & Access Card
The state of Idaho offers two "premium assistance" programs to support the purchase of
private health insurance: Access to Health Insurance and the Access Card. Each of these
programs is authorized through an 1115 HIFA waiver. Access to Health Insurance helps
employees of small businesses and their families enroll in employer-sponsored
insurance. The Access Card helps families buy health insurance for qualifying children.
The Access to Health Insurance Program is a program for small businesses and their
employees. Employers must meet the following guidelines to participate in this program:
? Operate an Idaho small business (2-50 employees)
? Currently not offer health insurance
? Be willing to pay at least 50 percent of the employee’s premium, or if the spouse
enrolls, 50 percent of the combined insurance premium for the employee and
? Have at least one employee who meets the income guidelines for premium
Employer Sponsored Insurance – Snapshot 1 2
Medicaid Trend Snapshots
? If the spouse enrolls, the employer must pay 50 percent of the combined premium
for the employee and spouse.
The Access Card is a premium assistance program that helps parents purchase health insurance for their children and is administered in partnership with Idaho insurance
carriers. An eligible child qualifies for up to $100 per month in premium assistance or up
to $300 per month for families whose income is between 150 percent and 185 percent of
federal poverty guidelines. Parents are responsible for premium payments, co-pays, and
Vermont Catamount Health Employer Sponsored Insurance Initiative
As part of the 2006 Health Care Affordability Act, uninsured Vermonters can receive
help with the cost of an employer-sponsored health insurance plan, funded with state
dollars. Vermont residents who are enrolled in or eligible for the Vermont Health Access
Plan (VHAP) and uninsured Vermont residents with incomes under 300 percent of the
federal poverty level are eligible to receive financial assistance for employer sponsored
Individuals enrolled in or applying for VHAP, health insurance for adults that are not
eligible for Medicaid, will be required to purchase their employer sponsored insurance
plan if the plan meets certain criteria:
? The employer’s plan is as good as the typical plan of four largest insurers in the
small group and association market.
? The state will review the plan to see if enrolling the individual in employer
sponsored insurance—rather than VHAP—is cost-effective to the state.
? The state will provide secondary benefit coverage, so the coverage will not
Individuals who are otherwise eligible for Catamount Health, the new comprehensive
insurance package that will be available to Vermonters that are ineligible for any other
programs in October 2007, may get assistance for purchasing an employer-sponsored
plan if the employer’s plan is:
? Equivalent to Catamount Health, although there is more flexibility on coverage
for chronic care by the plan before January 1, 2009
? The state will review the plan to see if enrolling the individual in ESI (rather than
Catamount Health) is cost-effective to the state.
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Medicaid Trend Snapshots
New Mexico State Coverage Insurance
State Coverage Insurance (SCI) is a public/private partnership that offers affordable
health care coverage to eligible low-income working adults, primarily through an
employer based system. It is available to uninsured adults ages 19 through 64, with
countable family incomes of up to 200 percent of the federal poverty level. Enrollment
may occur through employer groups or at the individual level. The program will be
authorized through an 1115 HIFA waiver.
The employer and employee pay part of the premium and state and federal funds pay the
remainder. If self-employed individuals wish to enroll, they pay the employer and
employee portion of the premium. Employees or individual enrollees cannot have
voluntarily cancelled health insurance in the past six months, and employers cannot have
voluntarily cancelled health insurance for their employees in the last twelve months.
Cost sharing requirements:
? Premiums - Individuals pay the employer share of $75 per month and the
employee share, $0 - $35 per month, depending on income.
? Co-payments and Limits - Each medical service has a co-payment on a sliding
scale based on family income.
Oklahoma O-EPIC Premium Assistance Program
In September 2005, the Centers for Medicare and Medicaid Services (CMS) approved a
Health Insurance Flexibility Act (HIFA) waiver under 1115 authority for the state of
The O-EPIC Premium Assistance Program will pay part of the health plan premiums for
eligible employees working for qualified Oklahoma small businesses. Participation in this
program is voluntary.
In order to participate in the O-EPIC program for small employers, the business must
meet the following eligibility criteria:
? The business must be located within Oklahoma.
? The business must have 25 or fewer full-time and part-time employees.
? The employer must contribute at minimum 25 percent of eligible employees'
? The insurance plan must be qualified by the Oklahoma Health Care Authority and
must cover a minimum of hospital, physician, and pharmacy services. In addition,
the out-of-pocket costs cannot exceed $3000, the office visit co-pay cannot
exceed $50, and the pharmacy annual deductible cannot exceed $500.
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Medicaid Trend Snapshots
The employer sponsored insurance is available for employees and their spouses, up to
185 percent of the federal poverty level. The employee is responsible for a 15 percent
contribution of the monthly premium. Employees may be eligible for reimbursement of
some out-of-pocket expenses, up to a certain amount, and will receive checks for those
expenses. Employers must renew their eligibility at the end of each twelve month period,
as well as when their health plan contract ends or when they choose to change health
plans. O-EPIC is voluntary and employers, employees, or spouses who no longer want to
participate may end their enrollment at any time.
Future State Plan
Several states intend to pursue programs to take advantage of employer sponsored
insurance in the near future. For example, Washington has recently launched a pilot to
enroll children in their parents’ employer-based insurance programs where it looks to be cost-beneficial. At least 19 states are actively considering programs to take advantage of
available employer sponsored insurance plans.
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