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Medicaid, SCHIP, & Federal Authority

  • 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.
    Upon enrollment or annual re-enrollment into Medicaid or SCHIP, enrollees are placed into the Plan that best fits their health needs. Enrollees are given a health screening and placed into a primary care case management system (PCCM). Idaho has three different systems of triggers that move an individual into the Enhanced Plan: physician diagnosis of special health needs; utilization of mental health services up to the limits in the Basic Plan; or receiving certainother forms of assistance from the Idaho Department of Health and Welfare. Any one of these three triggers would move the enrollee into the Enhanced Plan. Both of these benefit packages (Medicaid Basic Plan and Medicaid Enhanced Plan) remain fee for service.
    The final benefit plan, the Medicare-Medicaid Coordinated Plan, is for persons eligible for both Medicare and Medicaid who are enrolled in participating Medicare Advantage plans. In an effort to coordinate services with Medicare Advantage, Idaho has created a partially capitated system with major insurance carriers that provide Medicare Part C and D services. Idaho implemented this plan in April 2007 to provide coordination of benefits and expanded coverage and selection of providers in the areas of vision, hearing, dental and prescription drug services. Idaho pays a capitated rate per enrollee to carriers for integrated services in addition to Medicare-excluded drugs. For Medicaid-only “wrap-around” benefits, reimbursement follows the Enhanced Benefits methodology.
    SCHIP - In 2007, Idaho incorporated an incentive program to reward families with children in SCHIP who assure their children receive all recommended wellness visits and can demonstrate all up-to-date immunizations. Each enrollee can earn points every three months for these activities through the Wellness Preventative Health Assistance (PHA) program. These points may then be used to offset children’s premium payments. 


  • The state of Idaho operates reinsurance pools for both the small group and the nongroup (individual) markets. In the small group market, the insurer is responsible for the first $13,000 worth of claims as well as 10 percent of the next $12,000 in the basic plan, $87,000 in the standard plan, and $130,000 in the catastrophic plan. Above those amounts, the pool pays claims up to maximums of $25,000 for the basic plan, $100,000 for the standard plan and $200,000 for the catastrophic plan. Carriers determine whether they want to reinsure individuals, dependents, or small groups but all carriers participating in the health insurance market are assessed to cover loses incurred by the pool so, in essence, all carriers participate.


High-Risk Pools

  • The Idaho Individual High-Risk Reinsurance Pool became operational in 2001 and currently has an enrollment of approximately 1,400 individuals. In the nongroup (individual) market, the state operates the Individual High-Risk Reinsurance Pool that reinsures fiveguaranteed issue products and sets premiums for the guaranteed issue products. The primary insurer is responsible for the first $5,000 in claims, 10 percent of the next $25,000. All claims exceeding $25,000 are covered by the reinsurance pool, up to the lifetime maximums of the guaranteed issue products.

    The pool is funded through premiums, a portion of the state premium tax, and, if necessary, an assessment on insurers. The premiums for the guaranteed issue products are between 125 percent and 150 percent of the rates applicable to standard risks. The Idaho High-Risk Pool functions differently than most state high-risk pools. Under Idaho’s program, all carriers who offer individual health insurance must also offer the Idaho Individual High-Risk Reinsurance Pool plans, as well as notify persons applying for individual coverage of these high-risk pool plans.


Dependent Coverage

  • In March 2007, Idaho Governor C.L. “Butch” Otter (R) signed into law Senate Bill 1105 which expands the definition of ‘dependent.’ Under the new law, unmarried non-students can remain on their parents’ insurance until the age of 21 and unmarried, financially dependent, full-time students can remain on parental insurance until the age of 25. Finally, unmarried children designated as disabled can remain a dependent for insurance purposes up until any age.