SCHIP Frequently Asked Questions
The topics on this page were taken from questions at past training sessions conducted by agency staff. The questions were asked by outreach workers, health care providers, client advocate groups, Community Service Office (CSO) staff and others. Below are topics of the most frequently asked questions. Select a topic to see the question and answer to it. |
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Covered Services
Does
SCHIP have the same benefits as Medicaid? Are mental health
services and substance abuse treatment
services covered under SCHIP? What if a patient or parent wants a non-covered service
(e.g., circumcision). Can the doctor (provider) bill the client for this
service?
Who pays the
hospital bill
when a patient is in the hospital and they change managed care plans? Will SCHIP cover medical bills that I had
before I became eligible for SCHIP? What medical application is used for SCHIP? Is it the same as Medicaid? Yes, it is the same as Medicaid. Clients can use the short Children’s Medical application form (DSHS form 14-380) or the Healthy Kids Now form (DSHS form 23-394(x), used by families applying for medical benefits for their children. The client can mail the form to their local Community Service Office (CSO). But, families do not need to visit a CSO to get their children on SCHIP. No in-person interview is necessary. Will SCHIP cover legal immigrants who arrived after August 22, 1996? What about aliens? The rules for aliens and immigrants under Medicaid also apply to the SCHIP program. it is the same as Medicaid. The immigration and naturalization service issued rules that immigrants or aliens receiving Medicaid will not be subject to the "Public Charge" provisions. Do these rules also apply to SCHIP enrollees? Yes, the same rules apply; immigrants and aliens can safely get medical coverage without any impact on public charge. For more information, we suggest you visit the U.S. Citizenship and Immigration Services website. Will HRSA expand SCHIP to include coverage for families? Not at this time. Will HRSA expand SCHIP to cover prenatal care for pregnant women over 18? Due to federal regulations, SCHIP cannot cover children over 19 years of age. However, a pregnant woman over 19 may be eligible for Medicaid. If a child is on Medically Needy (MN) spenddown, can the child become eligible for SCHIP? Eligibility workers and the Automated Client Eligibility System (ACES) first assess eligibility for Medicaid, then SCHIP, and then MN spenddown. Clarify the process for determining SCHIP eligibility. When a client submits an application to the Community Service Office (CSO), we review it for Medicaid eligibility. If the CSO determines a client not eligible for Medicaid, and the family income is between 200 and 250% of the Federal Poverty Level (FPL), we automatically pend the application. We then evaluate the child’s eligibility for SCHIP, and then the Medically Needy program. Clients ineligible for any program receive a denial letter. How long will it take to determine if the children are eligible for SCHIP? Or how long will the whole eligibility process take? For both SCHIP and Medicaid,
we adhere to a 45-day standard of promptness. Other health insurance What types of health insurance are considered "creditable coverage" or "employer sponsored dependent coverage"? When is the 4-month waiting period applied? The following table clarifies how various types of health coverage are defined and when the 4-month waiting period applies for the purposes of determining SCHIP eligibility.
What is the difference between coverage purchased through a group health plan or through an individual plan? When determining SCHIP eligibility, we use the following definitions: Group Health Plan or Group Plans: Only members of a specific group can purchase coverage through a group plan. The types of groups that often purchase group insurance include employers, unions, and chamber of commerce members. This term should not be confused with Group Health Cooperative of Puget Sound (GHC). GHC is a private corporation that provides direct medical services. Individual Coverage: This type of coverage is purchased for an individual and/or their family. It is usually purchased when group coverage is not available to an individual or their family. Examples of individual coverage include the Health Care Authority’s unsubsidized program, and the Washington State Health Insurance Pool (WSHIP). What if a family drops non-employer sponsored insurance, such as insurance offered through school districts? When assessing SCHIP eligibility, we will not ask whether a family has dropped "non" employer sponsored coverage. If a family dropped employer sponsored dependent coverage within four months of applying for SCHIP, they may need to serve a four month waiting period before they are eligible for SCHIP. There are many exceptions to the waiting period. As an outreach worker, I am trying to help a family apply for SCHIP. This family is buying individual health insurance at a cost of $150/month with a $2,500 deductible they never meet. Is this family eligible for SCHIP? No. If this family has "creditable coverage" at the time of application, the child is not eligible for SCHIP. "Creditable coverage" means coverage that "includes physician, hospital, x-ray and laboratory services." Federal law created this barrier to SCHIP eligibility as a way to prevent a family from dropping private insurance and signing up for public insurance (the term for this process is called "crowd-out") I am trying to help another family apply for SCHIP. This family is buying health coverage through COBRA, costing over $100/month for just the child. Is this family eligible for SCHIP? Is their present coverage going to disqualify them or would it be considered an exception because they are paying more than $50/month out-of-pocket? A family paying for health insurance under COBRA is considered to have both creditable coverage and employer sponsored dependent coverage. If the child had this coverage at the time of application, they would not be eligible for SCHIP. Since the family was paying more than $50 a month for this coverage, they would be exempt from the 4-month waiting period. If the family was paying less than $50 a month for the family’s coverage, and did not meet any of the other exemptions, the child would have to serve the 4-month waiting period. I am trying to help a family that is paying out-of-pocket for private health insurance. The coverage is really expensive and has high deductibles. What should I tell the client about dropping the private coverage to go on to SCHIP? The situation that you describe is a really a tough one, because federal law states that children who have coverage are not eligible for SCHIP. We don't know of any other states that have gotten around this limitation. No one should tell families to drop private or employer-based coverage because of the potential that the family would end up without any coverage at all. For example, what would happen if (for some reason) the family drops private coverage and the child: 1) Is not
Medicaid or SCHIP eligible? The first two situations could be a problem because federal law states that a child who is Medicaid eligible is not SCHIP eligible. The third situation above could be a problem because of the policies used by private insurers to manage pre-existing conditions. For more information on private coverage and pre-existing conditions, contact the Office of the Insurance Commissioner’s (OIC) Consumer Advocacy and Outreach staff at 1-800-562-6900 (in Washington only). The OIC website is http://www.insurance.wa.gov/. I heard that private insurers have a waiting period for pre-existing conditions. Does SCHIP have this same limitation? Will this limitation affect my SCHIP eligibility? Some public and private insurers have waiting periods for pre-existing conditions. SCHIP and Medicaid do not. Once a child is determined to be eligible for SCHIP, there is no waiting period to get treatment for covered conditions. If a family decides to drop SCHIP to go on private (e.g., self-pay), or employer coverage, there may be a waiting period for that coverage due to a pre-existing condition. For more information on private coverage and pre-existing conditions, contact the Office of the Insurance Commissioner’s (OIC) Consumer Advocacy and Outreach staff at 1-800-562-6900 (in Washington only). The OIC website is http://www.insurance.wa.gov/. I have a client who is covered by private insurance coverage and applied for SCHIP. They wrote on the application that their private coverage will end at the end of the current month. Is the application processed the day you receive it? If the child is SCHIP eligible, will SCHIP start the day after the private coverage was no longer in effect? DSHS processes SCHIP applications in the order received. If the child is covered by other insurance at this time, they are not eligible for SCHIP. If it is determined that a child had coverage at the time of application, but was made SCHIP eligible anyway, the child will be terminated from SCHIP on a prospective basis. If a family makes a decision to drop their private coverage, in order to become eligible for SCHIP, they need to give the date that their coverage will end on the Children's Medical Application. If this information is supplied on the application, we will follow Washington Administrative Code 388-416-0015 (Certification Periods) that states: For a child who has creditable coverage at the time of application, the SCHIP certification period begins on the first of the month after a child’s creditable coverage is no longer in effect, if: 1) All other SCHIP eligibility factors
are met; and What is Third Party Liability (TPL) and what happens if an SCHIP child is covered by another health insurance program? Third-Party Liability occurs when an individual is covered by two different insurance plans. For example, a person may have medical coverage through their employer and through Medicaid. When this happens the two insurers (i.e., the private company and Medicaid) need to coordinate payment for covered services. The Health and Recovery Services Administration is required by federal regulation to determine the liability of third-party resources that are available to its clients. All resources available to the client that are applicable to the costs of medical care must be used. Once the applicable resources are applied, HRSA may make payment on the balance if the third party payment is less than the allowed amount. To be eligible for HRSA programs, a client must sign his/her insurance rights to the state in conformance with federal requirements. Where does the department get third party information? From clients, employers, medical providers and special data matches. What are the Third Party Liability (TPL) policies for SCHIP? For SCHIP, a child cannot have other insurance at the time of application or at redetermination. A child may gain other coverage after they have been made eligible, or before their redetermination, without penalty. The policies used to coordinate benefits are the same for both SCHIP and Medicaid. An SCHIP child may be affected by these policies if their SCHIP managed care plan is with the same, or different, company as their other coverage. A summary of the SCHIP TPL
policies is below. If you need more detailed information on these policies,
contact TPL’s Coordination of Benefits section at
Managed Care and Fee for Service Will there be some providers who serve Medicaid but
not Yes. Fee-for-service providers who serve Medicaid clients also serve SCHIP clients (for covered services). This means that fee-for-service clients have the same choice of providers under SCHIP and Medicaid. Do SCHIP clients have the same enrollment policies as other Healthy Options clients? Yes. Enrollees have the right to change enrollment prospectively, from one Healthy Options/SCHIP plan to another each month. In counties with one managed care plan, the client must choose between a managed care plan or HRSA’s fee-for-service program. A client may request a change to fee-for-service or managed care at any time. However, the change is not effective until the following month. In counties with two or more managed care plans, the client must choose a managed care plan. Provider Training Is there a "trainer" available for community training?Yes, if you would like HRSA to provide training about SCHIP, please e-mail us at: Ask SCHIP. How much are SCHIP premiums and to whom are they paid? SCHIP premiums are paid to DSHS, not to providers. The premiums are $15 per child, with a family maximum of $45 per month. This means that a family with four or more children in SCHIP pay only $45 per month. What address do I send my premiums to? DSHS, FSA Yes. Can someone other than the child’s family pay the monthly premium? Yes, there can be financial sponsors other than the family. Will the state pay for the premiums for health insurance for children in SCHIP? No. The Department of Social and Health Services (DSHS) will not pay for a child’s SCHIP monthly premiums. Once on SCHIP, if a family tells us they have a change in circumstances and they cannot afford to pay SCHIP premiums we will evaluate their eligibility for Medicaid. If an SCHIP client fails to pay the premium to receive coverage, will they no longer be eligible for SCHIP? Yes, failure to pay the monthly premium can lead to termination of coverage. The bills sent for the monthly premiums will indicate how much has been owed for 30 and 60 days. If the client has not paid the premiums for three months, HRSA will terminate the client’s participation in the SCHIP program. A terminated client will be able to apply again, but will be required to wait three months and pay past due premiums in full. Where can I get applications for our office? SCHIP uses the Children’s Medical application
(DSHS form 14-380(X), or 22-394(X)). How can an individual or organization like Catholic Charities, Family Voices, schools and parishes assist in outreach? Questions about outreach contracting activities should be directed to Ask SCHIP. Other Client Resources Where can we refer clients who are not eligible for Medicaid, SCHIP or Basic Health? When a family submits an application to DSHS, we will assess their eligibility for all of our medical programs. If they are not eligible for any DSHS medical program, and the Health Care Authority has determined that they are not eligible for the Basic Health Plan, they should call SHIBA Helpline at 1.800.562.6900 or visit their website: http://www.insurance.wa.gov/consumers/shiba/default.asp. American Indians/Alaska Natives (AI/AN) What are the enrollment policies for American Indians and Alaska Natives (AI/AN)? American Indian and Alaska Natives have several choices: 1) enroll with an SCHIP managed care plan; 2) enroll with an SCHIP Indian or tribal primary case manger (PCCM) provider; or 3) use HRSA's fee for service. What are the cost sharing policies for American Indians and Alaska Natives? American Indians and Alaska Natives are exempt from paying SCHIP premiums. Are Indian Health Services considered "creditable coverage"? It is a payer of last resort on federal guidelines. All types of DSHS programs pay prime to Indian Health. All AI/AN are required by federal law to apply for an alternate insurance as Indian Health is not an insurance or an entitlement. According to federal law, Indian Health clinics are not considered "creditable coverage" when determining SCHIP eligibility. Miscellaneous Questions How can a financial worker check a client’s SCHIP status in ACES?
Who is a good contact for technical eligibility questions? Questions about SCHIP policies can be directed to: Ask SCHIP. How is the SCHIP program evaluated? What evaluation measures are used? The state must submit an annual report to CMS each year. The information included in the Annual Report includes an analysis of the: 1) Characteristics of the families
served under the program |
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