Sponsored by The Robert Wood Johnson Foundation's State Coverage Initiatives Program
Conducted by AcademyHealth

Q: In the BadgerCare HIPP program, will the state buy in to self-insured plans? How do you look at that benefit structure?

A: [Schneider] Actually, we did not include self-funded plans, but we did gather information about them. About 20 percent of employers in Wisconsin have self-funded plans so we are looking into that right now. Our hope is to start buying into them. My understanding is that it is feasible, but there may be resistance because some view this population group as an expensive one.

Q: In your presentation on BadgerCare, you said that you give enrollees the option about whether to reimburse the employee, the employer, or the plan directly. Which approach is most commonly taken?

A: [Schneider] We have had a pretty even split between reimbursing employees directly and having payments go to the employer. Some enrollees had concerns that they would not be able to come up with the money to pay the premiums (even though they would eventually be reimbursed). Those employees have preferred that their employer be reimbursed directly.

Q: How many people are currently enrolled in the Rhode Island RIte Share program?

A: [Brewster] We have 49 people enrolled and 33 employers participating thus far. We have marketed to about 200 to 250 employers since February/March but we have not done extensive marketing yet. Only a handful of the employers we have talked to have said "no way." Most employers are still considering joining.

Facilitator: Rhode Island is taking a different approach by doing the cost-effectiveness determinations on a program level rather than on a case-by-case basis. It is a very interesting approach and, as far as I know, unique among employer buy-in programs. But there are some adverse selection issues there in terms of the average family size that you will enroll in the buy-in program versus direct public program enrollment.

Q: In Rhode Island, have you run into privacy concerns with employees not wanting their family income to be disclosed and not wanting their employers to know that they are in a public program?

A: [Brewster] This has only been a problem, thus far, with undocumented parents. The concern from the advocacy community was that we would be communicating with employers who were employing undocumented residents and that the social security numbers would not match. There is a place on the application allowing the employee to approve that the state may contact his or her employer. There is another statement indicating that family income will not be disclosed, though the employer will have a general sense as a result of the relationship between the employer and the employee.

Q: How do you deal with open enrollment in Rhode Island?

A: [Brewster] Health Reform Rhode Island put into law that RIte Share eligibility approval would be a qualifying event. So, once someone is eligible, employers know that their employees can sign up immediately. If the employer has a waiting period, these employees either stay in the RIte Care program (if they are already in it) or are covered under fee-for-service for a few weeks.

Q: Have you been in operation long enough to encounter the problems that arise when an employee on RIte Share changes jobs? What systems do you have in place that take care of that?

A: [Brewster] This has not been a problem yet. RIte Care is always the safety net, so if they lose RIte Share eligibility, they are in RIte Care effective immediately. All of the enrollment facilitators know that if someone drops out of RIte Share, they are put into RiteCare immediately.

Q: When someone leaves group coverage and becomes eligible for COBRA or portability, does Rhode Island pay for that?

A: [Brewster] We have not encountered that situation so it has not been discussed yet. My guess is that if it is under $450/month that we would pay COBRA, but this issue is on our to-do list.

Q: Can you elaborate on what you said in your presentation about how more employers are starting to use cafeteria plans and how that affects RIte Share?

A: [Brewster] Sometimes employers that offer cafeteria plans will offer to pay their low-income employees $1,000/year (for example) that they can put toward other benefits if they do not take up the employer coverage that is offered. In this case, they might get covered through RIte Care. So, we are trying to pull people over and get them in the best situation and we are pushing against that effort of the employer. It is just not what we want to hear from an employer.

Q: Have you anticipated what would happen if you had a very sick child who was previously covered under RIte Care, who then moves into a small employer plan under RIte Share, and subsequently the premiums for that group goes up astronomically? Do you have back-up plans to deal with this issue?

A: [Brewster] This is certainly not my expertise, but market reforms did implement some rate bands that I think will control for some of what you are referring to. That is certainly a concern for employers, along with the general misconception that all Medicaid eligibles are sick. Education is also needed around that issue.

Q: I am very interested in New Jersey's experience with their 1115 waiver to add parents using SCHIP funds. You mentioned that you had 117,000 adults. I know that in addition to adding parents of SCHIP children that you are also covering childless adults. Of this 117,000, how many are childless adults?

A: [Doderer] Of the 117,000, the single adults and childless couples make up 23,000 to 25,000 of this total. We basically took what we had with the General Assistance program in New Jersey and incorporated them under our waiver.

Q: Now that you have parents in your SCHIP program, when you look at the cost-effectiveness of buying into an employer plan, will you be able to look at the cost of the parents and the children or can you only take into account the children's costs since Title XXI is a children's funding stream?

A: [Doderer] We do look at both the adults and children up to 200 percent FPL. For 200 percent to 350 percent, we only look at children, because adults are not eligible above 200 percent FPL.

Q: So you are using federal funds to subsidize parents as part of the base?

A: [Doderer] Yes, we are allowed to use SCHIP funds up to the limit of our allotment; over that, we have to use other funds, such as tobacco settlement money.

Comment from Questioner: I think this is an important point, because it may make employer buy-in programs more feasible. Understanding that that is permitted is really good news.

Q: Once someone goes into the Premium Assistance program and they become ineligible for group coverage, will they stay in private sector through COBRA or portability or will you bring them over to the public program?

A: [Doderer] We consciously decided not to keep anyone in premium support if they lost their coverage. Instead, they will revert to our NJ Family Care program. One problem that we ran into in the federal regulation of Medicaid was that if a person has been out of their managed care program for more than three consecutive months, you cannot automatically put them back in the same managed care plan. Instead, you have to offer them the choice of what plan they want. We had to create, in our system, a mechanism to carry these people temporarily. They stay in a fee-for-service status until they can re-enroll and choose a managed care company. That is part of our waiver and we are getting federal match on that. It can take anywhere from a few days to a month to re-enroll back into managed care.

Q: What is the enrollment thus far in the New Jersey Premium Assistance plan?

A: [Doderer] Our outreach just began in May. One family of three was enrolled on 7/1/01, the start of the program. There will be 12 enrolled as of 8/1/01. We have about 20 people enrolling in the next six months who are in large employers and we have to wait for their open enrollment. Our target is for 5,000 to 7,000 individuals by 6/30/02.

Q: If the goal is to dramatically reduce the number of uninsured in New Jersey and the premium support is the only option, what single obstacle would you most like to remove, regardless of the practicality of eliminating that obstacle?

A: [Doderer] We have found this to be a very labor-intensive process. We spoke with Massachusetts while developing our plan and they told us that it can take on average 60 to 120 days to process an application for these programs. You have to look at the employer, you have to seek out a lot of information from them, you have to look at one or more plans that the employer might offer, and you have to do cost-effectiveness tests. I would like to decrease the work involved and cut this window to 30 days.

Q: So is reducing federal regulations the answer?

A: [Doderer] Eliminating some federal regulations could help do this, but I do not live in a dream world.