Medicaid, SCHIP, & Federal Authority

Health Insurance Flexibility and Accountability (HIFA) Waiver - In 2001, Arizona obtained a waiver to use Title XXI funds to expand coverage to two populations: (1) adults over age 18 without dependent children and with adjusted net family income below 100 percent of the federal poverty level (FPL); and (2) individuals with adjusted net family income above 100 percent of the FPL and at or below 200 percent of the FPL who are parents of children enrolled in the Arizona Medicaid or State Children’s Health Insurance Program (SCHIP) programs, but who themselves are not eligible for either program. In 2007, Arizona requested and received an amendment to increase the eligibility level for pregnant women from 133 percent of the FPL to 150 percent of the FPL.

Health Insurance Flexibility and Accountability (HIFA) Waiver – On March 3, 2006, Arkansas received approval for their HIFA initiative, the Arkansas Safety Net Benefit Program, designed to increase health insurance coverage through a public/private partnership that will provide a ‘safety net’ benefit package to approximately 50,000 uninsured working individuals over 5 years. Recently renamed ARHealthNet, the program will provide coverage to adults who work for employers who agree to participate in the demonstration and meet participation requirements. Eligible are parents and spouses of Medicaid and State Children’s Health Insurance Program (SCHIP) children and childless adults aged 19-64 who do not have other insurance coverage, are ineligible for Medicaid or Medicare, and have family incomes at or below 200 percent of the federal poverty level (FPL). Employees with incomes above 200 percent of the FPL may also elect ARHealthNet coverage; however, such individuals do not receive subsidized premium assistance.  The demonstration will occur in two phases, with Phase I (years one and two) being capped at 15,000 parents and childless adults. Phase II will begin in year three and will target approximately 35,000 parents and childless adults.

Section 1115 Waiver - In 1997, Arkansas received approval for a Medicaid 1115 waiver for their ARKids B program. The waiver expanded eligibility to currently uninsured children through age 18 with family incomes at or below 200 percent of the FPL. ARKids B included a reduced benefit package, modeled on the Arkansas State Employee and State Teachers plans. The benefits have some limitations on Early Periodic Screening, Diagnosis, and Treatment (EPSDT) services, inpatient mental health services, transportation, and therapy services.

Section 1115 Waiver – In 2005, California received approval for its Medi-Cal Hospital Uninsured Care 1115 Waiver, allowing the state to continue its Selective Provider Contracting Program (SPCP) with a limited number of hospitals at a prospective per diem rate lower than the standard rate paid in the absence of the waiver.^[1] In return, the selected hospitals receive preferential or exclusive referrals of Medicaid patients in their geographic areas. The demonstration also created a Safety Net Care Pool (SNCP), with $766 million in Federal funds annually to assist providers with unreimbursed costs incurred in serving uninsured patients. For October 2007 through August 2010, $180 million of the annual Safety Net Pool allocation is diverted to expand coverage to uninsured individuals through the demonstration’s Healthcare Coverage Initiative. The State selected ten counties to cover an estimated 180,000 eligible low-income, uninsured adults ages 19-64 through this comprehensive healthcare coverage initiative. Cost sharing may be required and is based on income level. The ten counties will test innovative ways of providing health services while increasing the number of Californians with coverage, strengthening the local health care safety net system, and improving access to high-quality health care and health outcomes.   

Health Insurance Flexibility and Accountability (HIFA) Waiver – In 2002, Colorado received approval from the Centers for Medicare and Medicaid Services (CMS) for a HIFA demonstration to provide adult prenatal coverage under the State Children’s Health Insurance Program (SCHIP), CHP+. The waiver, amended in 2005 to increase eligibility, provides coverage to uninsured pregnant women with incomes between 134 percent and 200 percent of the federal poverty level (FPL) who are not otherwise eligible for Medicaid and SCHIP. Additionally, this waiver provides a premium assistance option for children with family incomes at or below 200 percent of the FPL with access to employer-sponsored insurance. Beneficiaries may opt out of the premium assistance program at any time and resume coverage through SCHIP.

SCHIP – Connecticut’s SCHIP program, called HUSKY B, allows uninsured children in families above 300 percent FPL the opportunity to buy-in to HUSKY B.   The cost of the Husky B buy-in is not subsidized by the state; the family buys into the plan at a negotiated group rate. Benefits under the HUSKY B program are similar to those available to state employees. The Husky Plus program provides supplemental coverage for children in families with incomes below 300 percent FPL enrolled in Husky B with intensive physical or behavioral needs.

Section 1115 Waiver – In 1995, Delaware received approval from the Centers for Medicare and Medicaid Services (CMS) to implement the Diamond State Health Plan waiver. Under this waiver, Delaware implemented a statewide mandatory Medicaid managed care program and expanded eligibility to low-income individuals with incomes up to 100 percent of the federal poverty level (FPL). The waiver was renewed in 2007.

Section 1115 Waiver –  In 2002, The District of Columbia received approval from the Centers for Medicare and Medicaid Services (CMS) to implement a Medicaid Section 1115 demonstration for District residents between the ages of 50 and 64, with incomes at or below 50 percent of the federal poverty level (FPL). This demonstration uses the same benefit package as the District’s current Medicaid managed care program delivery system. The waiver was approved for a five-year period, with an annual enrollment cap of 1,358 individuals.

Florida Medicaid Reform Waiver – In October 2005, Florida received approval for its Medicaid Reform waiver.  The waiver does not expand eligibility; however, it makes significant changes to the program. The Florida Medicaid Reform began in June 2006 in two counties and expanded to three additional counties in July 2007. The aim of the reform is to move the Medicaid program from being a defined benefit to a defined contribution program. The state provides a risk-adjusted payment to managed care plans. The increase in payments to the plans is capped at 8 percent per year. The program also created Enhanced Benefit Accounts, which reward beneficiaries for healthy behaviors (such as taking children to well-child checks or participating in a weight management program). The rewards can include up to $125 credit at a local pharmacy for health-related supplies such as bandaids or aspirin. In addition, beneficiaries can opt out of Medicaid and direct Medicaid premiums to employer-sponsored insurance. Individuals covered under the Medicaid Reform proposal have their choice of managed care plans and benefit packages.  As of February 2008, over 196,000 individuals were enrolled in Florida’s Medicaid Reform program.

Section 1115 Waiver – Hawaii’s QUEST Expanded (Quality care, ensuring Universal access, encouraging Efficient utilization, Stabilizing costs, and Transforming the way health care is provided to public clients) demonstration was originally approved by the Centers for Medicare & Medicaid Services (CMS) in 1993. Since that time, Hawaii has continued to enhance this coverage initiative to include additional populations and benefits. Under this section 1115 waiver program, the state uses a managed care delivery system to create efficiencies in the Medicaid program while extending coverage to individuals who would not otherwise be covered. Since 1994, the QUEST program has expanded coverage to pregnant women with incomes up to 185 percent of the federal poverty level (FPL); all children ages 0-19 with incomes up to 300 percent of the FPL; and adults with incomes at or below 100 percent of the FPL. This demonstration program works in partnership with the Hawaii Prepaid Health Care Act program (see below) in an unprecedented State public/private partnership that directly impacts the rate of uninsurance in the State.

HIFA Waiver – Through Idaho’s Health Insurance Flexibility and Accountability (HIFA) waiver program, the state offers two premium assistance programs to support the purchase of private insurance and to increase private health insurance affordability for low-income individuals: the Access Card and Access to Health Insurance (AHI). Under the Access Card program, children in Idaho’s separate State Children’s Health Insurance Program (SCHIP) may choose either the SCHIP benefit package or premium assistance of up to $100 per child toward monthly premiums of private insurance. This option is available to children whose parents earn incomes ranging from 133 percent to 185 percent of the federal poverty level (FPL).  

Idaho’s AHI program offers premium assistance to adults whose gross annual income is below 185 percent of the FPL and who are employed by an Idaho small business, or who are the spouse of such an employee. Through the AHI program, eligible individuals may receive up to $100 per month in premium assistance per individual with a maximum of $500 per month for each family. This program is capped at 1,000 adults; it began enrollment in July 2005. As of fall 2006, approximately300 adults wereenrolled in the program.

The Deficit Reduction Act of 2005 - In 2006, Idaho undertook a Medicaid reform initiative. Idaho’s separate SCHIP program became a Medicaid look-alike and three Benchmark Benefit packages were approved by the Centers for Medicare and Medicaid Services (CMS) under authority of the Deficit Reduction Act (DRA) of 2005. This allowed the state to split the Medicaid and SCHIP populations into three major benefit plans:

• Medicaid Basic Plan: Low-income children and working-age adults;
• Medicaid Enhanced Plan: Individuals with disabilities or special health needs;
• Medicare-Medicaid Coordinated Plan: Individuals dually eligible for Medicaid and Medicare who are enrolled in certain Medicare Advantage plans.

HIFA waiver – In 2002, Illinois received approval from the Centers for Medicare and Medicaid Services (CMS) for a Health Insurance Flexibility and Accountability (HIFA) waiver to provide FamilyCare coverage to parents and caregiver relatives of children eligible for the State Children’s Health Insurance Program (SCHIP) with incomes up to 185 percent of the federal poverty level (FPL). FamilyCare was fully phased-in over the course of several years, with the final HIFA waiver authorized expansion to 185 percent of the FPL taking effect January 1, 2006. Illinois also operated a premium assistance program, entitled All Kids/FamilyCare Rebate, under the HIFA waiver. This program allowed eligible children with family incomes between 134 percent and 200 percent of the FPL and parents or caregiver relatives with incomes between 134 percent and 185 percent of the FPL to enroll in employer-sponsored or private insurance and receive a monthly rebate ($75) from the State. The HIFA waiver expired in September 2007; Illinois no longer receives federal financial participation for these programs previously implemented under waiver authority.

In December 2007, Indiana received approval from the Centers for Medicare & Medicaid Services (CMS) to implement a section 1115 demonstration to operate two distinct health insurance products: Hoosier Healthwise Program for current Medicaid eligible individuals and the Healthy Indiana Plan (HIP) for uninsured adults with incomes up to 200 percent of the federal poverty level (FPL) who are otherwise not eligible for Medicaid. Individuals in Hoosier Healthwise receive Medicaid benefits through managed care. The HIP program provides a high deductible health plan and a Personal Wellness and Responsibility (POWER) Account (similar to a health savings account) valued at $1,100 per adult to pay for initial medical costs. Additionally, HIP provides $500 in “first-dollar” preventive benefits. Members make monthly contributions to the POWER Account based on income level.

Also included in the May 2007 legislation that enacted the HIP program were coverage expansions for pregnant women and children. Following are the details:

• Medicaid expansion for pregnant women to 200 percent FPL; up from 150 percent FPL. Pregnant women will now have presumptive eligibility.
   
• Expand SCHIP to children up to 300 percent FPL; up from 200 percent FPL. This was not implemented due to a restriction by CMS that prevents states from covering children above 250 percent FPL unless the state can meet certain benchmarks.) The State has since applied for a waiver to expand coverage to 250% FPL.

Section 1115 Waiver – The IowaCare program extends a limited set of Medicaid benefits to uninsured adults ages 19 through 64 with incomes at or below 200 percent of the federal poverty level (FPL), including parents of Medicaid or State Children’s Health Insurance Program (SCHIP)-eligible children. The program is a capped, non-entitlement program that converts uncompensated care funds into insurance coverage for adults. Benefits includehospital, physician, limited pharmacy, and limited dental services that are provided through a limited provider network. Under this 1115 waiver program, Iowa also provides additional home and community-based benefits to children with serious emotional disturbance (Children’s Mental Health Waiver) with net family income at or below 250 percent of FPL. 

In 2007, the Iowa legislature granted funding that would allow the State to serve an additional 300 children with serious emotional disturbance through the Children’s Mental Health Waiver and to eliminate premiums for enrollees with incomes at or below 100 percent of the FPL.

In September 2006, Kansas received approval from the Centers for Medicare and Medicaid Services (CMS) to establish a benchmark benefit for its Working Healthy Ticket to Work Medicaid Buy-In program. The benchmark benefit was approved as a state plan amendment under DRA authority. Working Healthy provides working individuals with disabilities who have incomes below 300 percent of the federal poverty level (FPL) the State Plan Medicaid coverage, in addition to the following benefits:  personal assistance services, which can be self-directed or agency directed, including a “Cash and Counseling” model; assessment to determine personal assistance and related service needs; independent living counseling; and assistive services.

The Deficit Reduction Act of 2005 (DRA)- While not a coverage expansion, Kentucky has recently undertaken a redesign of its Medicaid program. In May 2006, Kentucky received state plan amendment approval from the Centers for Medicare and Medicaid Services (CMS) to move forward on plans to redesign its Medicaid program using DRA flexibility. The new plan, KyHealth Choices, offers four different benefit packages tailored to specific populations, increases cost sharing, and expands access to community-based long-term care. The new targeted benefit plans replace the Medicaid benefit package with “Secretary-approved” coverage. The four plans are:

Global Choices: Global Choices is designed for pregnant women, working parents up to 68 percent of the federal poverty level (FPL), foster children, medically fragile children, Supplemental Security Income-related groups, and women with breast and cervical cancer. Global Choices covers basic medical services with new benefit limits and increased cost sharing. Long-term care services are excluded.

Family Choices: Family Choices is designed for most children, including children enrolled in Kentucky’s State Children’s Health Insurance Program (SCHIP) program. Family Choices offers the same benefit package as Global Choices except there are no prescription drug limits and there is a higher vision care maximum benefit.

Optimum Choices: For individuals with developmental disabilities and mental retardation in need of long-term care services, Optimum Choices covers all the benefits in Global Choices as well as three levels of long-term care services.

Comprehensive Choices: For the elderly and individuals with disabilities in need of nursing facility level care, Comprehensive Choices offers all the benefits of Global Choices plus two levels of long-term care, including services offered through the state’s current home and community-based services waivers.

Kentucky also implemented new cost sharing requirements in June 2006. There are no co-pays for preventive services. Pregnant women and mandatory children are exempt from cost sharing. KyHealth Choices includes new benefit limits; however, services beyond the benefit limits may be approved through a prior authorization process. KyHealth Choices also includes an employer-sponsored insurance option.

SCHIP - On February 28, 2008, the Centers for Medicare and Medicaid Services (CMS) announced their approval for an increase in the eligibility level for children in the Louisiana State Children’s Health Insurance Program (SCHIP) from 200 to 250 percent of the federal poverty level (FPL). The state will depart from the delivery model used for the current SCHIP population to serve the newly-covered children. The new program will be administered by the same group that coordinates the state employees’ benefit plan. The benefits will be benchmarked to the state employees plan and will use its network of providers. Parents will pay $50 per month to enroll their children, and they will be required to pay similar copayments and deductibles as state employees.

HIFA Waiver – In 2002, Maine received approval from the Centers for Medicare and Medicaid Services (CMS) for a Health Insurance Flexibility and Accountability (HIFA) waiver to expand health insurance coverage to childless adults with incomes at or below 125 percent of the federal poverty level (FPL). To fund the coverage initiative, Maine redirects a portion of its disproportionate share hospital allocation to cover this population. Coverage was to be expanded in 2 phases, with the first covering childless adults with incomes at or below 100 percent of the FPL and the second covering childless adults up to 125 percent of the FPL as part of the Dirigo Health Reform initiative. The second phase was never implemented as the program had reached its budget neutrality cap. The expansion was later repealed by the Maine legislature, and CMS removed the state’s authority to cover childless adults with incomes between 101 and 125 percent of the FPL. This waiver was renewed for an additional three years in 2007.

The Deficit Reduction Act of 2005 (DRA) - In January 2008, Maine received approval from CMS to implement a DRA cost-sharing state plan amendment, allowing the state to charge premiums for the Katie Beckett population. (The Katie Beckett population are children who can qualify for Medicaid even though their family has an income above the allowable limit. This eligibility is based on the fact that their medical condition would make them eligible for hospital or skilled nursing facility care.) Premiums, ranging from .005 to 2.5 percent of gross income, will be imposed on families with incomes exceeding 150 percent of the FPL. The state will determine monthly premiums with a sliding fee schedule based on income.

Section 1115 Waiver – In 1996, Maryland received approval from the Centers for Medicare and Medicaid Services (CMS) to implement a statewide mandatory managed care program, HealthChoice, under the authority of a section 1115 waiver. The main goals of the program are to control rising Medicaid costs and to improve care coordination. The HealthChoice waiver has undergone two renewals and numerous amendments.  HealthChoice expansion initiatives include: the Family Planning Program, Employed Individuals with Disabilities, and the Maryland Primary Adult Care program. The Employed Individuals with Disabilities program, implemented in April 2006, provides full Medicaid coverage to individuals with disabilities with incomes up to 300 percent of the federal poverty level (FPL). Program enrollment reached 160 individuals in November 2007.  Under the Maryland Primary Adult Care (PAC) program, adults over the age of 19 with incomes up to 116 percent of the FPL, who are ineligible for Medicaid and Medicare, receive primary care, outpatient mental health, and pharmacy services. The Maryland Primary Adult Care program began enrollment in July 2006.  As of December 2007, more than 28,000 adults were enrolled in PAC.

On November 19, 2007, Governor Martin O’Malley (D) signed the Working Families and Small Business Health Coverage Act that will expand Medicaid eligibility up to 116 percent of the Federal Poverty Level (FPL) for parent and caretaker relatives with a dependent child living at home. The legislation also called for a four year phase-in of Medicaid eligibility up to 116 percent FPL for childless adults. Enrollment may be capped and benefits may be limited based on available funding. The state of Maryland expects to seek approval from CMS for this expansion in the spring of 2008.

Section 1115 Waiver - In July 2006, Massachusetts received approval from the Centers for Medicare and Medicaid Services (CMS) for the revised Section 1115 MassHealth waiver.  The waiver was renewed on July 31, 2008. The MassHealth waiver program provides federal funding and support for key components of the state’s comprehensive health care reform initiative to achieve universal coverage.  To support state coverage programs which build upon private insurance and to stimulate employers to offer coverage to low-income workers, the MassHealth program provides premium assistance for low-income workers of qualified small employers.  The waiver makes revisions to the Insurance Partnership (IP) raising income guidelines from 200 percent to 300 percent of the FPL and coordinating coverage between IP and the Connector.  Beginning in 2006, the waiver program’s uncompensated care pool, now the Health Safety Net, incorporated a significant reform, shifting funds to include premium subsidies for the uninsured in addition to uncompensated care payments to facilities.

Massachusetts Health Safety Net – The Massachusetts legislature established the Uncompensated Care Pool in 1985 to help ensure access to needed health care services to individuals with income below 400% FPL and no other source of health care coverage. The health care reform act transitioned the Uncompensated Care Pool to the Health Safety Net on October 1, 2007.  The Health Safety Net makes payments to acute care hospitals and community health centers for eligible services provided to low-income uninsured and underinsured individuals.  Enrollment of eligible UCP individuals in Commonwealth Care began in October 2006.  As a result HSN usage has dropped 16% in the first year of health care reform. That drop is expected to continue and funds from the Health Safety Net will be shifted into premium subsidies for the uninsured. 

Insurance Partnership – Massachusetts operates the Insurance Partnership as part of its Medicaid program under an 1115 waiver.  The Partnership helps small employers (<50) offer insurance and helps low-income workers afford premiums.  Small employers can have part of their cost paid for premiums paid on behalf of qualified employees.  Workers with family income below 300 percent FPL qualify for premium assistance through the MassHealth program. 

Adult Medical Security Plan – The Medical Security Plan, run by the Division of Unemployment Assistance, helps laid-off workers and their families who receive unemployment insurance payments. Depending on the workers’ circumstances, the program either provides direct, state-based coverage or helps pay the cost of coverage available through former employers. This is a short-term program that serves a relatively healthy population and is available to families who have family incomes up to 400 percent FPL.  The state’s 1115 waiver provides federal Medicaid matching funds for all enrollees.

Health Insurance Flexibility and Accountability (HIFA) Waiver - In 2004, the state received approval from the Centers for Medicare and Medicaid Services (CMS) to expand health insurance coverage to childless adults with incomes at or below 35 percent of the federal poverty level (FPL) by utilizing unspent State Children’s Health Insurance Program (SCHIP) funds.  The Adults Benefits Waiver program was designed to provide new beneficiaries with a benefits package that is less broad than Michigan’s standard Medicaid or SCHIP coverage. In order to meet the HIFA requirements for coordinating with private insurance, Michigan is also offering to those beneficiaries with access to employer-sponsored insurance a voucher that is equal in value to the state’s cost of providing service. Enrollment in the employer-sponsored plan is in lieu of receiving benefits through the state program.

SCHIP Section 1115 Waiver – In 2001, Minnesota received approval under a Section 1115 waiver to use Title XXI funds to cover parents and caretaker relatives of Medicaid and State Children’s Health Insurance Program (SCHIP)-eligible children with family incomes between 100 percent and 200 percent of the federal poverty level (FPL). These individuals are subject to premiums established on a sliding scale.  This is a component of the state’s MinnesotaCare program.

 Medicaid Section 1115 Health Reform Demonstration – In 1995, Minnesota received approval to implement the Minnesota Prepaid Medical Assistance Project Plus (PMAP+) Section 1115 Health Reform Demonstration. Through this initiative, children and pregnant women with incomes up to 275 percent of the FPL who were previously covered under the state-funded MinnesotaCare program became part of a Medicaid waiver component of the MinnesotaCare program.  Under subsequent modifications of the waiver, Medicaid waiver coverage in MinnesotaCare is available to parents in families with gross incomes up to 275 percent of the FPL (but not above $50,000 per year).  These individuals are subject to premiums based on a sliding scale.  In Minnesota, individuals who are eligible for Medicaid may instead choose to join MinnesotaCare and pay a premium.

Section 1115 Waiver – In 2004, Mississippi received a waiver to provide Medicaid benefits to a select group of aged and disabled Mississippi residents.  There are two groups covered by this waiver 1) Aged and disabled residents with incomes below 135 percent of the federal poverty level (FPL) who do not qualify for Medicare and 2) Aged and disabled residents with incomes below 135 percent of FPL who DO qualify for Medicare and have the following conditions: patients on dialysis, patients with cancer who are receiving radiation or chemotherapy treatments, transplant patients on anti-rejection drugs and patients taking anti-psychotic medications. Coverage of the chronic conditions under the waiver ended in December 2005. Currently, about 4,400 people are served by this program in the non-Medicare waiver, and the program has a cap of 5,000. 

Mississippi received approval from the Centers for Medicare and Medicaid Services (CMS) for a State Children’s Health Insurance Program (SCHIP) employer buy-in program, but implementation has been put on hold indefinitely. 

In 2007, Missouri embarked upon a transformation of its Medicaid program into MO HealthNet, with the vision of creating a model for the provision of high-quality health care focused on wellness.  As part of this reform initiative, in October 2007, Missouri transitioned its comprehensive Section 1115 waiver program to a State Plan State Children’s Health Insurance Program (SCHIP) combination program with a separate SCHIP component. The combination program continues to provide benefits to eligible children up to age 19 with incomes up to 300 percent of the federal poverty level (FPL), primarily under a managed care delivery system. 

Through a new Section 1115 family planning waiver, the State continues to provide Women's Health services for up to one year to uninsured post-partum women ages 18 to 55 who are losing Medicaid eligibility 60 days after their child’s birth. Missouri will be modifying the 1115 Family Planning Waiver to include women 18 to 55 years of age with net income of less than 185% of the Federal Poverty Level. 

Section 1115 Waiver – In January 2004, the Centers for Medicare and Medicaid Services (CMS) approved a Medicaid Section 1115 waiver that would allow Montana to provide a limited Medicaid benefit package of optional services for Medicaid-eligible parents aged 21 through 64 who are not pregnant or disabled.  The optional services were excluded to align coverage with typical employer-sponsored insurance.  This waiver was based on a previous Montana waiver, which provided a limited Medicaid benefit package to adults who are neither disabled nor pregnant, under the authority of Montana’s welfare reform waiver in 1996.

Section 1115/Health Insurance Flexibility and Accountability (HIFA) Waiver – On November 2, 2006, the Centers for Medicare and Medicaid Services (CMS) approved Nevada’s Title XXI State Children’s Health Insurance Program (SCHIP) Section 1115/HIFA Waiver program.  This demonstration provides health care coverage to pregnant women with family incomes above 133 percent of the federal poverty level (FPL) up to and including 185 percent of the FPL.  Parents, caretaker relatives, and legal guardians with family incomes below 200 percent of the FPL can receive coverage through employer-sponsored insurance (ESI) premium assistance. 

Section 1115 Waiver – In 2001, the state received approval  from the Centers for Medicare and Medicaid Services (CMS) to implement a waiver demonstration that extended coverage to parents of Medicaid or State Children’s Health Insurance Program (SCHIP)-eligible children with incomes up to 200 percent of the federal poverty level (FPL) and pregnant women with incomes between 185 percent and 200 percent of the FPL. Under this waiver program, Medicaid covered parents with incomes up to 133 percent of the FPL, and SCHIP covered parents with incomes between 134 percent and 200 percent of the FPL. Although parent enrollment was capped as of June 14, 2002, parent enrollment up to 100 percent of the FPL was initiated again on September 1, 2005. This increased to 115 percent of the FPL on September 1, 2006, increased again to 133 percent of the FPL on September 1, 2007, and increased further to 200 percent of the FPL for 2008.

Health Insurance Flexibility and Accountability (HIFA) Demonstration Waiver - In 2003, New Jersey received approval from CMS to modify the SCHIP 1115 waiver. The waiver modification standardized coverage to uninsured parents and relative caretakers of children in the Medicaid and SCHIP programs whose incomes are at or below 133 percent of the FPL to that of the parents between 134 percent and 200 percent of the FPL, which was a standard commercial benefit package.

On July 8, 2008 Governor Corzine signed a health reform bill that will be effective one year after enactment.  This legislation includes a mandate that all children 18 years and younger must have health coverage.  It also increases the eligibility level for parents in the New Jersey Family Care program to 200 percent of FPL. 

Health Insurance Flexibility and Accountability (HIFA) Demonstration - In 2002, New Mexico received a HIFA waiver to expand coverage to low-income uninsured working adults with incomes up to 200 percent of the federal poverty level (FPL).  Under that program, coverage was purchased with a combination of state, federal, employer and employee funds. 

In July 2005, the state implemented the New Mexico State Coverage Insurance (SCI).  This is a public-private partnership resulting in the creation of a new employer-sponsored insurance program.  The state contracts with managed care organizations to provide the product.  The target population is low-income, uninsured, adults working for small employers with family income below 200 percent of the federal poverty level (FPL). An individual may enroll through his or her employer, as a self-employed individual, or as an individual without employer-sponsored insurance.  The premium is paid through contributions from the employer and employee in combination with state and federal funds.  Individuals and the self-employed must pay the employer as well as the employee portion of the premium. The benefit package is a comprehensive health care benefit with a claims benefit maximum.  The SCI plan features cost-sharing designed to ensure that low-income participants would have access to care. Enrollment in the program began in July 2005 and, as of November 2007, 11,489 participants were enrolled.

Section 1115 Waiver - In 1998, New Mexico received approval for a State Children’s Health Insurance Program (SCHIP) demonstration for implementation of co-payment requirements and a six-month period of SCHIP ineligibility in instances where an applicant’s health insurance was voluntarily dropped.  New Mexico SCHIP covers children up to age 19 in families with income between 185 percent and 235 percent of the FPL.

Section 1115 Waiver – In 1997, the Centers for Medicare and Medicaid Services (CMS) approved New York’s section 1115 Medicaid demonstration, the Partnership Plan, in which Medicaid beneficiaries began receiving benefits through  mandatory managed care.  In 2001, CMS approved New York’s Family Health Plus (FHPlus) amendment. FHPlus expanded health insurance to childless adults with incomes up to 100 percent of the federal poverty level (FPL) and expanded coverage to parents with incomes up to 150 percent of the FPL.  Prior to 2001, these populations were covered in the state’s Safety Net program.  FHPlus is delivered via managed care organizations and has a less comprehensive benefit package than traditional Medicaid.  In 2002, the waiver was amended to include a family planning demonstration which expands family planning services to individuals with net incomes at or below 200 percent of the FPL.  In 2007, New York further amended the waiver to include a premium assistance program in FHPlus. If an FHPlus enrollee has access to employer-sponsored health insurance, such coverage must be evaluated to determine if it is cost effective for the State to pay the employee’s share of the health insurance program as opposed to Medicaid.  Such analysis must include the cost provided to FHPlus enrollees of the wrap-around services.

Section 1115 Waiver – In 2006, New York was approved for a new Section 1115 Medicaid demonstration, the Federal-State Health Reform Partnership (FSHRP).  Under this demonstration, New York is undertaking significant reforms to promote the efficient operation of its healthcare system by reducing excess capacity in acute care hospitals, shifting emphasis in long-term health care to community settings, investing in health IT, and reorienting the healthcare system to a value-based outpatient and primary care driven system which rewards quality.  The federal government will provide federal financial participation for designated state-funded health programs which serve low-income and uninsured individuals, not otherwise eligible for federal matching funds. After incurring expenditures, the state may draw down federal match only as it is ready to expend state funds on the specified health reform initiatives.  Once the state meets required milestones, the federal government will provide up to $300 million per year to allow the state to invest in the agreed upon healthcare reforms.  Failure to meet a milestone will result in cessation of federal matching funds.  New York is required to generate $3 billion in gross Medicaid savings over the 5-year demonstration period. Additionally, the FSHRP demonstration transfers the authority from the Partnership Plan demonstration to enroll adults with disabilities, children with disabilities, and older adults in managed care.

Health Insurance Flexibility and Accountability (HIFA) Waiver - On September 30, 2005, the Centers for Medicare and Medicaid Services (CMS) approved the Oklahoma Premium Assistance Plan as a HIFA amendment to the existing section 1115 demonstration, SoonerCare. The Oklahoma Employer/Employee Partnership for Insurance Coverage (O-EPIC), rebranded in 2007 as Insure Oklahoma, was originally designed to cover an estimated additional 50,000 Oklahoma residents with incomes at or below 185 percent of the federal poverty level (FPL). Oklahoma increased eligibility for adults to 200 percent of the FPL as part of the section 1115 demonstration renewal in 2006. The increased coverage is funded by state general fund revenues generated by a tobacco tax, along with federal matching funds under Title XIX and employer and employee contributions. Insure Oklahoma has two different strategies for covering low-wage workers. The Employer Sponsored Insurance program helps low-wage workers in small Oklahoma firms purchase qualified insurance offered by their employer. The Individual Plan provides health insurance coverage for qualified individuals even if they are not able to obtain coverage through their employer.

Eligible Employer Sponsored Insurance program populations include adults who work for qualified small employers, with 50 or fewer employees, and have incomes above the Medicaid standard, but no more than 200 percent of the FPL and their spouses.  As of April 2008, the employer-sponsored product had 9,416 enrollees and the individual product had just under 2,500 people enrolled.  

Eligible Individual Plan populations include self-employed, unemployed currently seeking work, workers who are not eligible to participate in their employer’s small group health plan, and workers (and their spouses) whose employers do not offer a group health plan and have incomes above the Medicaid standard but no more than 200 percent of the FPL.  Working individuals with disabilities who have incomes above the Medicaid standard, but no more than 200 percent of the FPL are also eligible for the Individual Plan.

To learn more about Insure Oklahoma, read SCI’s Profile in Coverage. 

Section 1115 Waiver – Oregon initially received approval from the Centers for Medicare and Medicaid Services (CMS) to implement a waiver demonstration for the Oregon Health Plan (OHP) in 1993. This waiver was amended and expanded under Health Insurance Flexibility and Accountability (HIFA) authority in 2002, creating the OHP2. The OHP2 has undergone several amendments and was renewed for an additional three years in November 2007. A key feature of the direct coverage program is that benefits are structured using a prioritized list of conditions and treatments, which ranks health services based on the “comparative benefit to the population to be served.” The waiver also expands Medicaid coverage to most individuals with family incomes up to 185 percent of the federal poverty level (FPL) through three benefit packages or programs: OHP Plus, OHP Standard, and the Family Health Insurance Assistance Program (FHIAP).

• The OHP Plus benefit package provides a comprehensive array of services to Medicaid state plan and optional populations, including low-income older adults, individuals with disabilities, families meeting the eligibility criteria for Temporary Aid to Needy Families (TANF), children, and pregnant women.

• The OHP Standard program has a more limited benefit package and includes premiums for individuals with household income exceeding 10 percent of the FPL. The state may require enrollees to be current on their premium payment before they may apply for another six-month eligibility period.  This program serves the expansion population of uninsured, non-pregnant adults with incomes below 100 percent of the FPL, but has been closed to new applicants since August 2004. In 2008, the State reopened enrollment to a limited number of individuals randomly selected from the OHP Standard Reservation List who meet all financial and non-financial eligibility requirements.  The OHP Standard reservation list was open for one month and received 92,000 unduplicated names; approximately 10,000 people are expected to be enrolled through this process.

• FHIAP is a voluntary premium assistance program for individuals with incomes up to 185 percent of the FPL. Premium subsidies, which vary according to income, may be used for individual or employer-sponsored private health insurance. The FHIAP program was created in 1997 with state-only dollars to address the needs of families who do not qualify for Medicaid or Medicare.  In 2002, the program was included in the OHP2 Waiver and began to receive federal matching funds.  Members enroll in their employer’s group insurance if one is available; otherwise they enroll in an individual plan in the private market.  FHIAP provides a premium subsidy on a sliding scale to individuals (families and adults without children) with income below 185 percent of the FPL.  When employer-sponsored coverage is offered, the state pays a portion of the individual share of the premium.  For both individual and employer-based plans, the state pays between 50 and 95 percent of premiums. With the renewal of the waiver in November 2007, FHIAP was no longer allowed to use Title XXI matching funds for adults, but could use Title XIX funds instead. The use of Title XXI funds had been allowed under the prior waiver. This created a state General Fund shortfall which caused the program to close to new enrollments, starting in November 2007, and to provide 4,300 adults under 85% of the FPL an opportunity to transfer to OHP Standard or be terminated from the program, beginning June 1, 2008.

Section 1115 Waiver – After receiving approval from the Centers for Medicare and Medicaid Services (CMS) in 1993, the state originally implemented the Rhode Island RIte Care demonstration, providing families on the Family Independence Program and eligible uninsured pregnant women, parents, and children up to age 19 with comprehensive health coverage. RIte Care currently provides coverage to parents with incomes up to 185 percent of the federal poverty level (FPL) and to children and pregnant women up to 250 percent of the FPL using title XIX and XXI funds.

Under the demonstration, the state also operates a premium assistance program, RIte Share, which is available to those who qualify for Medicaid coverage. RIte Share helps families get health insurance coverage through their employer (or spouse’s employer). If a family qualifies, RIte Share will pay for all or part of the employee’s share of the health insurance premium. RIte Share also pays for co-payments in the employer’s health insurance plan.

As of April 2008, approximately 7,428 people were enrolled in RIte Share.  For every 1,000 people enrolled in RIte Share, the State of Rhode Island saves over $1 million in avoided costs.  RIte Share has been an effective tool to address concerns about “crowd out” (substituting public coverage for employer-sponsored insurance). 

The Centers for Medicare and Medicaid Services (CMS) approved South Carolina for a Deficit Reduction Act Health Opportunity Account (HOA) state plan amendment to offer enrollees the option of enrolling in a high deductible plan. The purpose of the program is to increase beneficiary involvement in their health care by creating awareness of the costs of care, reducing inappropriate use of services, and encouraging the utilization of preventive care services. The program covers Medicaid state plan services after an annual deductible has been met. The state will annually contribute $2,500 for each adult and $1,000 for each child to an HOA. Enrollees are not subject to cost sharing while using HOA funds. Once the HOA has been exhausted, however, enrollees are subject to 10 percent in cost sharing. If an enrollee loses Medicaid eligibility, account funds (up to 25 percent) may be used for health insurance, tuition, or job training up to three years after the loss of eligibility. The program operates under a fee-for-service model, and enrollees receive incentives for preventive health care services. Enrollment in the program is voluntary and will initially be limited to one county with a cap of 1,000 individuals. South Carolina is the first and only state, as of February 2008, to receive approval for an HOA amendment.

CMS also approved a DRA benchmark state plan amendment for the state in June 2007. The new program, entitled the State Employee High Deductible Health Plan, offers Medicaid beneficiaries the option to receive the same benefits that South Carolina state employees receive. Enrollees in the program are not subject to cost sharing until the annual deductible ($3,000 for an individual) has been met. Once the deductible is met, enrollees are subject to traditional state plan cost-sharing. Like the new HOA program, enrollment is voluntary and will initially be limited to 1,000 beneficiaries in one county. Individuals may opt out of the program and return to traditional Medicaid at any time.

Section 1115 Waiver – In 1994, Tennessee received approval from the Centers for Medicare and Medicaid Services (CMS) for a Section 1115 demonstration program, TennCare, to provide Medicaid benefits to an expanded population of uninsured residents with low incomes or with medical conditions which make them uninsurable. After several extensions, Tennessee began a new 1115 waiver program entitled TennCare II in 2002. TennCare II utilizes a managed care delivery model to provide most state plan benefits to enrollees. Due to budget deficits in 2005, the waiver was amended to reduce services for certain populations and close enrollment for medically needy adults and all expansion population adults and children.  Ultimately, 170,000 people were cut from the program.  The waiver was amended again in 2006 to transition individuals dually eligible for Medicare and Medicaid into the demonstration from the existing 1915(b) waiver program and to add a new demonstration population of medically needy adults.

CoverKids – Tennessee established a separate, stand-alone State Children’s Health Insurance Program (SCHIP) in 2006 for uninsured children under the age of 19.  The program, entitled CoverKids, combines state and Title XXI funds from the federal government to cover children and pregnant women with family incomes up to 250 percent of the federal poverty level (FPL). Eligibility is layered over current TennCare levels.  CoverKids also offers a buy-in program for children who do not qualify for the subsidized product. Enrollment reached 22,570 children in May 2008.

Section 115 Waiver – In March 2007, the Centers for Medicare and Medicaid Services (CMS) approved the state of Texas for a State Children’s Health Insurance Program (SCHIP) section 1115 demonstration, Texas SCHIP Cost Share 1115. This new program moves from a monthly premium to a semi-annual enrollment fee of $25 for those with incomes between 133 percent and 150 percent of the federal poverty level (FPL). The purpose of this waiver program is to promote continuous SCHIP coverage and to reduce the likelihood of disenrollment due to non-payment of monthly cost-sharing requirements. Unborn children will be exempt from this cost-sharing requirement.   

Section 1115 Waiver - Utah’s Primary Care Network is a statewide Section 1115 demonstration to expand Medicaid coverage. The demonstration uses increased flexibility with current state plan eligibles to fund a Medicaid expansion to 25,000 uninsured adults between the ages of 19 and 64 with incomes up to 150 percent of the federal poverty level (FPL).  The expansion provides primary care and preventive services to low-income adults who would otherwise lack health insurance. Utah’s State Children’s Health Insurance Program (SCHIP) covers children under age 19 with family incomes up to 200 percent of the FPL.

In November 2006, the Centers for Medicare and Medicaid Services (CMS) approved a Health Insurance Flexibility and Accountability (HIFA) amendment to this waiver, establishing Utah’s Premium Partnership for Health Insurance (UPP). The UPP is a public-private partnership to reduce the number of uninsured individuals in the state through an employer-sponsored insurance program.  Qualified low-income workers and their families may receive up to $150 per adult and $120 per child on a monthly basis to help defray the cost of employer-sponsored insurance premiums if these premiums represent more than 5 percent of their annual income. Employers are required to pay at least half of the employee’s premium. The program provides funding for up to 1,000 adults with incomes up to 150 percent of the FPL and children with family incomes up to 200 percent of the FPL. As of March 2008, 195 adults and 326 children were enrolled in the program. UPP replaces an earlier program, entitled Covered at Work, which offered a monthly premium subsidy of $50.

The demonstration was renewed for an additional three years in July 2007.

To learn more about the Utah Primary Care Network, read SCI's Profile in Coverage.

Section 1115 Waiver - In September of 2005, the Centers for Medicare and Medicaid Services (CMS) approved Vermont's new Section 1115 waiver program, the Global Commitment to Health. Vermont will manage its Medicaid program within a five-year, $4.7 billion budget. The state will be financially at risk to keep expenditures below this target.

Vermont has chosen to accept a capped federal contribution, with a 9 percent inflationary trend adjustment, in exchange for increased program flexibility, the authority to alter pieces of the benefit package, increased participant cost sharing, and flexibility to implement new cost-control strategies. To implement the demonstration, the Office of Vermont Health Access (OVHA) converted into a statewide public managed care organization and has the authority to use any additional funds to reduce the uninsured/underinsured rate; increase access to quality health care; support public health approaches to improve the health outcomes and the quality of life for Medicaid-eligible individuals in Vermont; and encourage the formation and maintenance of public-private partnerships in health care.

This waiver was amended in 2007 to include premium assistance for individuals without access to employer-sponsored insurance with incomes at or below 200 percent of the federal poverty level (FPL).²

Vermont Health Access Plan (VHAP) - In 1995, Vermont received Section 1115 authority to implement VHAP.  After various amendments, VHAP covered parents with incomes up to 185 percent of the FPL and childless adults up to 150 percent of the FPL. The VHAP population is now part of the “Global Commitment to Health” Section 1115 waiver approved in September 2005.

Dr. Dynasaur -  Vermont uses the Dr. Dynasaur brand to represent all Medicaid coverage programs for children up to age 18.  These include traditional Medicaid and coverage up to 225 percent of the FPL, which were included in the 1995 Section 1115 waiver that created VHAP. Starting in 1998, Vermont has used SCHIP funds to cover children with family incomes between 225 percent and 300 percent of the FPL, as part of the Dr. Dynasaur program.

Section 1115/HIFA Waiver – In June 2005, Virginia received approval from the Centers for Medicare and Medicaid Services (CMS) for a demonstration waiver entitled FAMIS MOMS and FAMIS Select.  The waiver allows the state to claim Title XXI funding for pregnant women with incomes between 133 percent and 200 percent of the federal poverty level (FPL).  Virginia has been incrementally phasing in this expansion: first covering pregnant women with incomes between 133 percent and 150 percent of the FPL, followed by women with incomes between 150 percent and 165 percent of the FPL in August 2006.  Virginia expanded eligibility again in October 2007 to women with incomes between 165 and 185 percent of the FPL.  Virginia is currently scheduled to complete the FAMIS MOMS expansion to 200 percent of the FPL beginning July 1, 2009.  The expansion is subject to the availability of state funds.

The waiver also includes an employer-sponsored insurance premium assistance option, called FAMIS Select, for children with family incomes below 200 percent of the FPL.  Families with children who choose to enroll in FAMIS Select may receive up to $100 per FAMIS Select enrolled child per month to help pay their family premium. In fiscal year 2007, a total of 857 women were enrolled in FAMIS MOMS, and 857 children were enrolled in FAMIS Select.

The Deficit Reduction Act of 2005 (DRA) – In March 2007, CMS approved Virginia’s submission of a benchmark state plan amendment under the DRA to offer Medicaid and disease management services to beneficiaries with certain chronic medical conditions. The program, entitled Healthy Returns, is open to categorically eligible individuals who have asthma, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease, and/or diabetes.^[1]  Enrollment in the program is voluntary. In addition to state plan services, enrollees receive condition-specific education; access to a 24-hour hotline; care coordination; and regularly-scheduled telephonic care management. All traditional Medicaid services will be administered on a fee-for-service basis, and a prepaid ambulatory health plan will provide the disease management.

Additionally, the Virginia Department of Medical Assistance Services recently sought and received authorization, through the DRA, to establish an optional “alternative benefits package” for MEDICAID WORKS program enrollees that includes personal assistance services in addition to the standard health care services available through Medicaid.  MEDICAID WORKS is Virginia’s Medicaid Buy-In program, which enables workers with disabilities to earn higher income and retain more in savings than is typically allowed by Medicaid while ensuring continued health care coverage.  With the addition of personal assistance services, sometimes called attendant care, individuals with disabilities can receive non-medical support in the home or the workplace in order to continue to live at home, maintain employment and participate in community activities.

Deficit Reduction Act of 2005 (DRA) – In June 2007, the Centers for Medicare and Medicaid Services (CMS) approved Washington’s submission of a benchmark state plan amendment under the DRA to offer Medicaid and disease management services to beneficiaries with certain chronic medical conditions. The chronic care coordination program, identifies high-risk and high-cost individuals with multiple chronic care needs and seeks to improve access and health outcomes while controlling costs.    Enrollment in the program is voluntary.[1] The program has two components:  a statewide care management program and a local care program.  In addition to state plan services, all enrollees receive condition-specific education; access to a nurse call line; care coordination including feedback to the primary care physician; and regularly-scheduled telephonic care management. All traditional Medicaid services will be administered on a fee-for-service basis, and a prepaid ambulatory health plan will provide the disease management.  

During the 2007 legislative session, Washington passed legislation to provide access to coverage for all children in the state by 2010.  Starting July 2007, it funds intensive education, outreach, and administrative simplification efforts to enroll all currently eligible children, covering over one-half of Washington 's uninsured children. Beginning in January 2009, the legislation authorizes the state to expand the State Children's Health Insurance Program (SCHIP) to children who have family incomes up to 300 percent FPL; the current eligibility level is 250 percent FPL. The department is authorized to seek federal financial participation for the expansion population. In addition, children in families with incomes above 300 percent FPL will have access to SCHIP at full-cost. Premiums would apply to children above 200 percent FPL. The legislation also includes a premium assistance program, if cost-effective, for those families with access to employer-sponsored insurance.

The Deficit Reduction Act of 2005 (DRA) - In May 2006, West Virginia received approval from the Centers for Medicare and Medicaid Services (CMS) to move forward on plans to redesign its Medicaid program. Taking advantage of the flexibility outlined in the DRA, West Virginia utilized the state plan amendment process. A four-year, phased in implementation began in July 2006. The West Virginia reform streamlines eligibility and moves healthy children and parents into one of two plans:

• Basic Plan: The plan covers all mandatory and some optional services, but benefits are more limited than the state’s previous Medicaid benefits package. Children continue to receive services under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. Enrollees can access additional benefits covered by the Enhanced Plan by signing a member agreement.  
• Enhanced Plan: For individuals who have signed a member agreement, this plan covers all the services included in the Basic Plan plus mental health services, diabetes care, and prescription drugs above the four-drug limit in the Basic Plan. The Enhanced Plan is comparable to the state’s previous Medicaid benefits package.

The cornerstone of West Virginia’s plan is the member agreement and the Healthy Rewards pilot program. Enrollees who sign a member agreement, a ‘personal responsibility contract,’ are enrolled in the Enhanced Plan and receive a fixed amount of credits per quarter in a Healthy Rewards account. The credits can be used to cover medical and pharmaceutical co-pays and bonus credits are added for meeting health goals. Individuals who do not meet their responsibilities are moved to the more limited Basic Plan.

State Children’s Health Insurance (SCHIP) Expansion – In December 2006, West Virginia received approval from CMS to increase SCHIP eligibility from 200 percent of the FPL to 220 percent of the FPL. Children in the new eligibility level will have different cost-sharing requirements and benefits from children with family incomes at or below 200 percent of the FPL. For example, individuals in the expanded eligibility category will be required to pay monthly premiums and will not receive vision services.
 

Section 1115 Waiver - In 2008, Wisconsin transformed its Medicaid and State Children’s Health Insurance Program (SCHIP) program by implementing BadgerCare Plus.  Wisconsin built upon its previous section 1115 waiver program, Wisconsin BadgerCare program, to create a streamlined statewide coverage initiative.  BadgerCare Plus utilizes a managed care delivery system to provide easy access to health care for lower income adults and all children.  This initiative uses federal match from SCHIP and Medicaid to expand coverage to new populations.  The state seamlessly integrates state-only funded programs into the overall program to assure access.  Enrollees in BadgerCare Plus receive benefits either through the Standard Plan or the Benchmark Plan, depending on income level.  

As part of BadgerCare Plus, Wisconsin extended coverage to all children in the state beginning in February 2008.  Children in families with lower incomes are covered with Medicaid and SCHIP funding. Children in families whose income exceeds this amount are covered with state-only funds.  Under the section 1115 waiver program, Wisconsin has expanded eligibility levels for custodial parents of eligible children with net family incomes, and the uninsured spouses of such parents, up to 200 percent of the FPL.   

Deficit Reduction Act (DRA) of 2005As part of its overall transformation to BadgerCare Plus, Wisconsin increased eligibility for pregnant women up to 300 percent of the FPL (federal match is only up to 250 percent).  In conjunction with this eligibility expansion, Wisconsin received approval from the Centers for Medicare and Medicaid Services (CMS) to implement a Benchmark plan for pregnant women between 200 and 300 percent under the benefit flexibility provision of the DRA.  Wisconsin’s Benchmark plan for pregnant women is consistent with the benefits of the largest commercial plan offered in the State with some additional benefits, including mental health and substance abuse coverage comparable to that of the state’s employee health plan. To receive benefits under Medicaid, pregnant women between 200 percent and 300 percent of the FPL are required to enroll in the Benchmark plan. Children in families earning above 200 percent of FPL are also enrolled in the Benchmark Plan.  Children, parents and pregnant women below 200 percent of FPL are enrolled in the Standard Plan.

BadgerCare Core Plan for Childless Adults.  The state passed legislation to expand coverage to all childless adults up to 200 percent of FPL.  Due the downturn in the economy the coverage expansion will be implemented in phases.  During the first phase, the approximately 7,000 adults currently enrolled in the GAMP program (see below) will be enrolled in the BadgerCare Core plan on January 1, 2009.