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2000 SESSION

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HB 1489 Health insurance for children.

Introduced by: Jeannemarie Devolites | all patrons    ...    notes | add to my profiles | history

SUMMARY AS PASSED:

Health insurance for children. Revises and renames the Virginia Children's Medical Security Insurance Plan (CMSIP) as the Family Access to Medical Insurance Security (FAMIS) Plan. The FAMIS Plan coverage will be for individuals up to the age of 19, when such individuals (i) have family incomes at or below 200 percent of the federal poverty level; (ii) are not eligible for medical assistance services pursuant to Title XIX of the Social Security Act, as amended; (iii) are not covered under a group health plan or under health insurance coverage, as defined in § 2791 of the Public Health Service Act; (iv) have been without health insurance for at least six months or meet the exceptions as set forth in the Virginia Plan for Title XXI of the Social Security Act, as amended; and (v) meet both the requirements of Title XXI of the Social Security Act, as amended, and the FAMIS Plan. Those individuals who were enrolled on the date of federal approval of the FAMIS Plan in CMSIP will continue to be enrolled in FAMIS for so long as they continue to meet the eligibility requirements of CMSIP. Participants whose incomes are between 100 and 150 percent of the federal poverty level will participate in cost sharing only nominally, with the annual aggregate cost-sharing not exceeding 2.5 percent of the family's gross income. The annual aggregate cost-sharing for all eligible children in families at or above 150 percent of the federal poverty level will not exceed five percent of the family's gross income or as allowed by federal law and regulations. No cost sharing will be required for well-child and preventive services. In the event an application is denied, the applicant must be notified of any services available in the locality that can be accessed by contacting the local department of social services. The FAMIS Plan will provide comprehensive health care benefits, including medical, dental, vision, mental health, and substance abuse services and physical therapy, occupational therapy, speech language pathology, and skilled nursing services for special education students. FAMIS participants who have access to employer-sponsored health insurance coverage may, but will not be required to, enroll in an employer's health plan, with payments being made on their behalf if enrollment in the employer's plan is cost effective. Supplemental insurance equivalent to the comprehensive health care benefits provided to other participants will be provided for the benefits not included in the employer-sponsored health insurance benefit plan. Existing DMAS contracts and future contracts will be used to provide the benefits through health maintenance organizations and other providers and employer insurance plans. FAMIS will provide that, in addition to any centralized processing site for administration of the program, DMAS may contract with third-party administrators to provide additional administrative services, including providing and assisting with applications. Local social services agencies must provide and accept applications for the program and assist families in completing applications. Any centralized processing site will determine eligibility for either FAMIS or Medicaid and enroll the children accordingly. FAMIS must provide for coordinated implementation of publicity, enrollment, and service delivery with existing local programs. Employer-sponsored health insurance is defined as comprehensive health insurance offered by the employer when the employer contributes at least 50 percent toward the cost of dependent or family coverage, or as otherwise approved by Health Care Financing Administration (HCFA). The regulations for this program will include a comprehensive, statewide community-based outreach plan to enroll children in FAMIS or in Medicaid, as appropriate. The Outreach Plan must include specific strategies for improving outreach and enrollment in localities having less than the statewide average enrollment and enrolling uninsured children of former Temporary Assistance to Needy Families recipients. The Department will also maintain an Outreach Oversight Committee, composed of various interested parties and consumers, to make recommendations on state-level outreach activities, the coordination of regional and local outreach activities, and procedures for streamlining and simplifying the application process, brochures, other printed materials, forms, and applicant correspondence. DMAS will enroll applicants to the extent funds are available or as directed in the appropriation act. FAMIS is specifically noted as not being assistance or public assistance. The Medicaid fraud provisions will apply to FAMIS. The Board, or the Director, may adopt, promulgate and enforce regulations as may be necessary to implement and administer the FAMIS Plan. The provisions of the bill will not become effective until approved by HCFA; however, the Department is directed, as soon as possible after the enactment of this provision, to develop, submit, and seek approval of the FAMIS Plan. The Board is directed to promulgate emergency regulations. Certain outreach provisions of HB366 and eligibility provisions of HB1253 were incorporated into HB1489.

SUMMARY AS PASSED HOUSE:

Health insurance for children. Revises and renames the Virginia Children's Medical Security Insurance Plan (CMSIP) as the Family Access to Medical Insurance Security (FAMIS) Plan. The FAMIS Plan coverage will be for individuals up to the age of 19, when such individuals (i) have family incomes at or below 200 percent of the federal poverty level; (ii) are not eligible for medical assistance services pursuant to Title XIX of the Social Security Act, as amended; (iii) are not covered under a group health plan or under health insurance coverage, as defined in § 2791 of the Public Health Service Act (42 U.S.C. 300gg-91(a) and (b)(1)); (iv) have been without health insurance for at least 6 months or meet the exceptions as set forth in the Virginia Plan for Title XXI of the Social Security Act, as amended; and (v) meet both the requirements of Title XXI of the Social Security Act, as amended, and the FAMIS Plan. Those individuals who were enrolled on the date of federal approval of the FAMIS Plan in CMSIP will continue to be enrolled in FAMIS for so long as they continue to meet the eligibility requirements of CMSIP. All participants will participate in cost sharing to the extent allowed by federal law. No cost sharing will be required for well-child and preventive services. The FAMIS Plan will provide comprehensive health care benefits, including medical, dental, vision, mental health, and substance abuse services. FAMIS participants who have access to employer-sponsored health insurance coverage may, but will not be required to, enroll in an employer's health plan, with payments being made on their behalf if enrollment in the employer's plan is cost effective. Supplemental insurance equivalent to the comprehensive health care benefits provided to other participants will be provided for the benefits not included in the employer-sponsored health insurance benefit plan. Existing DMAS contracts and future contracts will be used to provide the benefits through health maintenance organizations and other providers and employer insurance plans. FAMIS will provide that, in addition to any centralized processing site for administration of the program, DMAS may contract with third-party administrators to provide additional administrative services, including providing and assisting with applications. Local social services agencies must provide and accept applications for the program and assist families in completing applications. Any centralized processing site will determine eligibility for either FAMIS or Medicaid and enroll the children accordingly. FAMIS must provide for coordinated implementation of publicity, enrollment, and service delivery with existing local programs. Employer-sponsored health insurance is defined as comprehensive health insurance offered by the employer when the employer contributes at least 50 percent towards the cost of dependent or family coverage, or as otherwise approved by Health Care Financing Administration (HCFA). The regulations for this program will include a comprehensive, statewide community-based outreach plan to enroll children in FAMIS or in Medicaid, as appropriate. The Department will also maintain an Outreach Oversight Committee, composed of various interested parties and consumers, to make recommendations on state-level outreach activities, the coordination of regional and local outreach activities, and procedures for streamlining and simplifying the application process, brochures, other printed materials, forms, and applicant correspondence. DMAS will enroll applicants to the extent funds are available or as directed in the appropriation act. FAMIS is specifically noted as not being assistance or public assistance. The Medicaid fraud provisions will apply to FAMIS. The Board, or the Director, may adopt, promulgate and enforce regulations as may be necessary to implement and administer the FAMIS Plan. The provisions of the bill will not become effective until approved by HCFA. The Board is directed to promulgate emergency regulations. Certain outreach provisions of HB366 and eligibility provisions of HB1253 were incorporated into HB1489.

SUMMARY AS INTRODUCED:

Health insurance for children. Amends the Virginia Children's Medical Security Insurance Plan and renames it the Family Access to Medical Insurance Security (FAMIS) Plan. FAMIS Plan coverage shall be for individuals up to the age of 19, when such individuals (i) have family incomes at or below 200 percent of the federal poverty level; (ii) are not eligible for medical assistance services pursuant to Title XIX of the Social Security Act, as amended; (iii) are not covered under a group health plan or under health insurance coverage, as defined in § 2791 of the Public Health Service Act (42 U.S.C. 300gg-91(a) and (b)(1)); (iv) have been without health insurance or meet the exceptions as set forth in the Virginia Plan for Title XXI of the Social Security Act, as amended; and (v) meet both the requirements of Title XXI of the Social Security Act, as amended, and the FAMIS Plan. The FAMIS Plan includes a provision for cost sharing, except for well-child and preventive services, and coverage through employer-sponsored health insurance plans if deemed cost effective. The annual aggregate cost sharing for all eligible children in a family at or above 150 percent of the federal poverty level shall not exceed five percent of the family's gross income, and cost sharing for all eligible children in a family between 100 and 150 percent of the federal poverty level shall not exceed 2.5 percent of the family's gross income, or as allowed by federal law and regulations. Children enrolled in the current Title XXI plan shall continue their eligibility in the FAMIS Plan and will be given reasonable notice of any changes to benefits.

Employer-sponsored health insurance is defined as comprehensive health insurance offered by the employer when the employer contributes 50 percent towards the cost of dependent or family coverage, or as otherwise approved by Health Care Financing Administration (HCFA), and shall be deemed cost effective by the Department of Medical Assistance Services (DMAS) if payment for such coverage is no greater than what would be spent on the FAMIS Plan. The FAMIS Plan will provide benefits not included in the employer-sponsored health insurance to the extent necessary to be at least equivalent to the comprehensive health care plan that is offered in FAMIS.

The bill also authorizes DMAS to contract with third-party administrators to perform enrollment, outreach, eligibility determination, data collection, premium payment and collection, and financial oversight and reporting. The fraud and abuse provisions applicable to Medicaid shall be applicable to the FAMIS Plan. The FAMIS Plan and any benefits provided thereunder shall not be public assistance.

DMAS shall enroll applicants to the extent funds are available, and, if funds are inadequate, the Board of Medical Assistance Services (Board) shall establish an appropriate income-eligibility threshold to allow for enrollment of eligible children to the extent funds are available. The Board, or the Director, may adopt, promulgate and enforce regulations as may be necessary to implement and administer the FAMIS Plan. The provisions of the bill will not become effective until approval from HCFA is granted, and the Board shall promulgate emergency regulations within 280 days of the enactment date.