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This paper suggests methods of financing managed care for people with HIV or AIDS.
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Side-By-Side Comparison Of Proposed Federal Legislation For Consumer Protection In Managed Care Plans
Nicole Tapay, Karen Pollitz, Jalena Curtis
Institute for Health Care Research and Policy Georgetown University Medical Center
July 18, 1997
Issue Summary
Over the past decade, an increasing number of Americans have been receiving their health care coverage through HMOs, PPOs and other types of managed care entities. The growing influence of managed care, in turn, has led consumers and state and federal policy makers to raise questions about the appropriate roles and rights of consumers, providers, employers, purchasers, and insurers within this system. Areas of concern include: 1) whether plans provide sufficient access and choice for consumers; 2) what is the appropriate method to enable consumers to appeal plan decisions; and 3) what rights consumers have with respect to information about their health plans.
Most states have basic protections in place regulating HMOs and managed care plans that are subject to state law. In addition, there has been a surge of recent state legislative activity in this area which has augmented the sophistication and specificity of some of these laws. At the federal level, Medicare currently imposes certain requirements upon managed care plans contracting with the program. Federal standards for Medicaid managed care have been somewhat more general; as states move toward requiring managed care enrollment, federal legislation has been proposed to strengthen protections for Medicaid beneficiaries. Also at the federal level, ERISA, which governs self-funded employer plans, contains minimal requirements for such plans and virtually no protections specifically targeted at the managed care components of such plans.
In the 105th Congress, several bills of varying scope have been introduced to address an array of concerns relating to consumer and provider protections in health plans. In addition, Congressional Budget Reconciliation Bills suggest several changes in this area for Medicare and Medicaid. This document is a side-by-side comparison of many of the leading federal bills in these areas. It begins with the following brief description of the bills contained in the side-by-side comparison tables. The Medicare and Medicaid provisions of the House and Senate Budget Reconciliation Bills (House and Senate Budget Bills) are presented in Part I. The eight remaining bills discussed below, introduced in the House and/or Senate, are presented by topic in Part II.
Please note: This document includes certain acronyms; many of these are defined in the “Definitions” section at the end of the document.
H.R. 2015–House Budget Bill/Provisions Relating To Medicare Managed Care
The House Budget Bill would establish a new Medicare managed care program, MedicarePlus. Plan options include a variety of coordinated care plans. Importantly, this option does not preclude Medicare eligibles from choosing the traditional fee-for-service Medicare program. The House Budget Bill includes requirements relating to information disclosure, gag rules, grievance procedures, quality assurance, access to care, access to specialists, emergency services, continuity of care, privacy, provider protection, solvency standards for provider-sponsored organizations, and enforcement issues.
The House Budget Bill requires plans to disclose specified information to federal authorities and enrollees. It also includes a grievance/appeals system with internal and external mechanisms, including time limits and reviewer requirements for all grievances and appeals. Time frames are established for prior authorization determinations. Minimum requirements are established for internal quality assurance. The House Budget Bill requires plans to provide access to providers in service area within a reasonable time frame and to cover appropriate specialist treatment.
The House Budget Bill sets forth a process for provider-sponsored organizations (PSOs) to receive federal waivers from state laws that fall within specified categories. Solvency standards for PSOs will be set at the federal level. The House Budget Bill also sets forth open enrollment and information requirements to facilitate beneficiary choice and mobility among Medicare options.
Status: Passed by the House on June 25, 1997, and awaiting action by reconciliation conference committee. The House Budget Bill incorporates two separate proposals for Medicare, as passed by the committees of jurisdiction (Commerce and Ways and Means) with some slight variations.
S. 947–Senate Budget Bill/Provisions Relating To Medicare Managed Care
The Senate Budget Bill would establish a new Medicare managed care program, Medicare Choice. In general, the Senate Budget Bill is very similar to the House Budget Bill, with differences highlighted within the attached side-by-side chart. Plan options include a variety of coordinated care plans; Medicare eligibles can still choose the traditional fee-for-service program. The Senate Budget Bill includes requirements relating to information disclosure, gag rules, grievance procedures, quality assurance, access to care, access to specialists, emergency services, continuity of care, privacy, provider protection, solvency standards for provider-sponsored organizations, and enforcement issues.
The Senate Budget Bill requires plans to disclose specified information to federal authorities and enrollees. It also includes a grievance/appeals system with internal and external mechanisms, including time limits for all grievances and appeals and limited reviewer requirements. Time frames are established for prior authorization determinations. Minimum requirements are established for internal quality assurance. The Senate Budget Bill requires plans to provide access to providers in their service areas within a reasonable time frame and to cover appropriate specialist treatment.
The Senate Budget Bill sets forth a process for provider-sponsored organizations (PSOs) to receive waivers from state laws. Solvency standards for PSOs will be set at the federal level. The Senate Budget Bill also sets forth open enrollment and information requirements to facilitate beneficiary choice and mobility among Medicare options.
Status: Passed by the Senate on June 26, 1997, and awaiting action by reconciliation conference committee.
H.R. 2015–House Budget Bill/Provisions Relating To Medicaid Managed Care
The House Budget Bill incorporates selected consumer protection standards for Medicaid managed care enrollees. The House Budget Bill includes requirements relating to gag rules, grievance procedures, quality assurance, access to care, access to specialists, emergency services, and continuity of care. It requires plans to permit female enrollees access, without prior authorization, to obstetricians/gynecologists for routine care and to designate such physicians as their primary care providers. It requires plans to establish internal grievance procedures that meet federal standards, including timeliness of considerations. It requires plans to follow quality standards. The House Budget Bill also prohibits restrictions on medical communications between providers and patients.
Status: Passed by the House on June 25, 1997, and awaiting action by reconciliation conference committee.
S. 947–Senate Budget Bill/Provisions Relating To Medicaid Managed Care
The Senate Budget Bill sets forth protections for Medicaid beneficiaries enrolled in managed care plans. The Senate Budget Bill includes requirements relating to information disclosure, grievance procedures, quality assurance, utilization review, access to care, access to specialists, emergency services, protections relating to covered benefits, discrimination, continuity of care, and enforcement issues. It permits states to mandate enrollment in a managed care plan as a condition of receiving Medicaid coverage. Beneficiaries generally must be given a choice of at least two plans, though states may waive this rule in rural areas under certain circumstances. States may not mandate managed care enrollment for certain, more vulnerable Medicaid beneficiaries. The Senate Budget Bill establishes standards relating to information disclosure, access to care, access to specialists, and access to emergency services. It requires plans to establish grievance procedures, sets a general requirement of timeliness for prior authorization systems, and provides for quality assurance standards. It prohibits balance billing by plan contractors and subcontractors. It establishes standards for financial soundness of Medicaid managed care plans, and authorizes the Secretary to apply new sanctions against plans that do not comply with the Senate Budget Bill’s requirements.
Status: Passed by the Senate on June 26, 1997, and awaiting action by reconciliation conference committee.
S. 644–D’Amato/H.R. 1415–Norwood
This bill establishes consumer protection standards for managed care plans, both insured and self-insured. Standards address information disclosure, gag rules, grievance procedures, utilization review, quality assurance, access to care, access to specialists, emergency services, continuity of care, privacy, experimental therapies, provider protection, discrimination, minimum solvency, and enforcement issues. The bill requires plans to disclose specified information to enrollees, prospective enrollees, health professionals, and providers. Time limits and restrictions on reviewer qualifications are established for internal review of grievances and appeals; time limits are also specified for UR prior authorization determinations. The bill mandates internal quality improvement programs with specified components. Enrollees must have access to specialized treatment when necessary, and must receive continued coverage when provider changes could disrupt continuity of care. Plans must offer point-of-service options with fair and reasonable premiums. Emergency services must be covered and must be accessible at all times. States may impose more stringent requirements than those specified in the bill.
Status: Hearings were held in the Committee on Labor and Human Resources in May 1997. No committee or legislative actions have been taken; provisions similar to portions of this bill have been incorporated into the House and Senate Budget Bills. The House companion bill to S. 644 is H.R. 1415 (Norwood).
S. 373–Kennedy/ H.R. 820–Dingell
This bill sets forth consumer protection standards for managed care plans, both insured and self-insured. Standards address information disclosure, gag rules, grievance procedures, utilization review, quality assurance, access to care, access to specialists, emergency services, continuity of care, privacy, experimental therapies, provider protection, and enforcement issues. The bill requires plans to disclose specified information, updated monthly, to state authorities, enrollees, and the public. The bill also outlines a grievance/appeals system with internal and external mechanisms, including time limits and reviewer requirements for all grievances/appeals. Time frames are also established for UR prior authorization determinations. Minimum requirements for internal quality assurance are established, including a minimum uniform data set to be specified by the Secretary. The bill requires plans to cover treatment by specialists, and requires continuity of care for specified periods after providers are no longer participating. If emergency services are covered benefits, standards are set forth for coverage without prior authorization and without regard to whether the provider is participating. To assist consumers with coverage choice, filing complaints, and to investigate instances of poor treatment of enrollees, the bill requires the establishment of state health insurance Ombudsmen. States are permitted to impose more stringent requirements on plans than those outlined in the bill.
Status: Hearings on the subject of health care quality in commercial and public plans have been held by the Senate Labor and Human Resources Committee and the Senate Finance committee. No hearings have yet been held on this particular bill, nor has committee or legislative action been taken. A similar bill to S. 373 has been introduced in the House, H.R. 820 (Dingell). Unlike S. 373, H.R. 820 does not amend ERISA.
S. 346–Wellstone
This bill sets forth consumer protection standards for managed care plans, both insured and self-insured. Standards address information disclosure, gag rules, grievance procedures, utilization review, access to care, access to specialists, emergency services, privacy, provider protection, discrimination, minimum solvency, and enforcement issues. The bill requires plans to disclose specified information in standardized form to prospective covered individuals and UR information to state officials. The bill also establishes guidelines for internal, external/independent, and expedited reviews of grievances, which are to be further developed through federal regulation. Requirements for mandatory UR programs are described, and additional standards are to be developed for certification of UR programs. The bill sets forth standards for provider credentialing, and requires states to develop uniform credentialing requirements. “Meaningful” access to specialist treatment is required, and enrollees with chronic conditions must receive ongoing direct access to specialists as appropriate. Emergency services must be covered and must be accessible at all times. States are to establish Offices for Consumer Information, Counseling and Assistance with Health Care to educate and assist consumers with health insurance issues. States may pass laws with equal effect or stricter requirements than those in the bill.
Status: Hearings on the subject of health care quality in commercial and public plans have been held by the Senate Labor and Human Resources Committee and the Senate Finance committee. No hearings have yet been held on this particular bill, nor has committee or legislative action been taken.
S. 864–Chafee/Breaux
This bill sets forth protections for Medicaid beneficiaries enrolled in managed care plans. The bill permits states to mandate enrollment in a managed care plan as a condition of receiving Medicaid coverage. Beneficiaries generally must be given a choice of at least two plans, though states may waive this rule in rural areas under certain circumstances. States may not mandate managed care enrollment for certain, more vulnerable Medicaid beneficiaries. The bill establishes standards relating to information disclosure, access to care, access to specialists, and access to emergency services. It establishes specific standards for access to care provided by Ob-Gyns for women and care by specialists for patient with chronic conditions. The bill requires plans to establish grievance procedures, sets a general requirement of timeliness for prior authorization systems, and provides for external review of enrollee grievances and of quality assurance standards. It prohibits balance billing and restrictions on medical communications between providers and patients. It establishes standards for financial soundness of Medicaid managed care plans, and authorizes the Secretary to apply new sanctions against plans that do not comply with the bill’s requirements.
Status: Some portions of this bill appear in the Senate Budget Bill, and others appear in the House Budget Bill.
H.R. 586–Ganske
This bill establishes consumer protection standards in the area of medical communications for group and individual insurers, including group health plans. Standards address gag rules and enforcement issues. Although a similar bill, S. 449 (Kyl/Wyden), is not included as a separate bill in the side-by-side, the description of H.R. 586 highlights the main difference between H.R. 586 and S. 449. Both S. 449 and H.R. 586 prohibit plan restrictions on medical communications and establish monetary penalties for violation of this rule. In addition, H.R. 586 provides that while plans may not restrict such communications, entities operating plans may place limitations on services offered based on religious or moral convictions. S. 449 includes a somewhat different “conscience clause.”
Status: During the 104th Congress, hearings on this bill were held by the Health Subcommittee of the House Committee on Ways and Means. In addition, the Health and Environment Subcommittee of the House Commerce Committee also held a hearing which focused on the issue of gag rules in managed care plans and whether legislation was necessary to address the issue. In July 1996, the full Commerce Committee met in open markup session and ordered the bill reported to the House, as amended, by a voice vote. No further action was taken. During the 105th Congress, portions of this bill have been incorporated within the House Budget Reconciliation Bill. See above.
H.R. 815–Cardin
This bill establishes consumer protection standards in limited areas for group and individual insurers, group health plans, Medicare (HMOs and competitive medical plans), Medicaid, and Medicare Select plans. Standards address emergency services, information disclosure, and enforcement issues. The bill sets forth standards for coverage of emergency services without prior authorization and without regard to whether providers are participating. Time limits are established for authorization of post-stabilization care. States may establish standards relating to emergency services to the extent they do not prevent the application of requirements in the bill.
Status: No legislative or committee action. Similar provisions are incorporated within the House and Senate Budget Bills, as well as within S. 644, S. 373, and S. 346.
H.R.135–DeLauro
This bill establishes consumer protection standards in limited areas for group and individual insurers, including group health plans. Standards address protections relating to covered benefits, provider protection, and discrimination as they relate to treatment of breast cancer. The bill establishes minimum length of stay requirements for mastectomies and lymph node dissections for treatment of breast cancer if these services are covered benefits. In addition, the bill prohibits financial incentives to providers and enrollees for purposes of avoiding these requirements; however, doctors in conjunction with patients may decide upon shorter lengths of stay. States may pass laws requiring at least the same length of stay or requiring that length of stay decisions be left to doctors in consultation with patients.
Status: No legislative or committee action.
S. 795–Jeffords/Lieberman
This bill establishes consumer protection standards for federal health plan contractors, including the Federal Employees Health Benefits Program, Medicare, Medicaid, TRICARE, and Veterans Affairs. Standards developed pursuant to the bill address information disclosure, grievance procedures, quality assurance, and enforcement. The bill requires plans to disclose specified information in standardized form to prospective enrollees. The bill also establishes a Federal Health Plan Quality Council to evaluate plans, direct government participation in regional health care accountability initiatives, and advise the President and Congress on consumer protection and quality of participants’ health care. The Council must establish criteria for mandatory certification of plans by licensed certification entities, with minimum criteria requirements specified in the bill. The Council will pay plans to reward them for meeting or exceeding quality targets; to fund this program, all plans must allocate annual payments to the Council.
Status: Hearings on the subject of health care quality in commercial and public plans have been held by the Senate Labor and Human Resources Committee and the Senate Finance committee. No hearings have yet been held on this particular bill, nor has committee or legislative action been taken.
Side-By-Side Comparison Of Proposed Federal Legislation For Consumer Protection In Managed Care Plans:
Side-By-Side Part One Part Two Part Three Part Four
Children’s Health Insurance: 1997 Budget Reconciliation Provisions
(as of 07/14/1997)
Center of Health Policy Research and The George Washington University Medical Center
Current Law And StatusHouse BillSenate BillI.Status Recommendations transmitted 06/12/97 from Commerce Committee to Budget Committee. H.R. 2015 passed House 06/25/97. Recommendations transmitted 06/19/97 from Finance Cte to Budget Cte. H.R. 2015 (spending bill) and H.R. 2014 (tax bill) as passed by the Senate 06/25/97 and 06/27/97. II.General Approach No systematic approach to financing health coverage for children. Coverage is through employer-sponsored private insurance, publicly-subsidized private plans, and Medicaid.
In 1994 among children under age 18:
The percentage of uninsured children varied by income, with no coverage among:
Most uninsured children live in working families with incomes <250% FPL.
One third of uninsured children are eligible for Medicaid but not enrolled. Children’s Health Insurance
Child Health Assistance Program (CHAP) creates an entitlement in states, but not in individuals.
Entitles states to payments ($14 billion over five years) to cover uninsured, low income children using any or all of the following methods:
Requires states to submit to HHS a plan describing use of funds, with approval of the plan triggering state eligibility for payments.
Requires state plans to follow federal framework on eligibility, benefits, cost-sharing, and other matters.
Effective October 1, 1997.
Number of children covered under CHAP = 500,000 previously uninsured children (CBO estimate).
Medicaid
Permits states to speed up the current mandatory phase-in of Medicaid coverage for children born after September 30, 1983 who are under age 19 and whose family income is below 100% FPL. Children covered = 125,000 (CBO estimate).
Allows states the option to provide 1 year of continuous coverage under Medicaid for children under 19 ($0.7 billion over five years). Children covered = 130,000 (CBO estimate).
Permits states to provide Medicaid during a presumptive eligibility period for children under 19 years old ($0.5 billion over five years). Children covered = 110,000 (CBO estimate).
Total number of children covered = 865,000 previously uninsured children (CBO estimate). Children’s Health Insurance
Children’s Health Insurance Initiatives creates an entitlement in states, but not in individuals.
Entitles states to payments ($16-$24 billion over five years) to cover uninsured, low income children using one of two methods:
Requires states to carry out outreach activities to enroll children who are eligible for Medicaid and to encourage employers to provide health insurance coverage for children.
Requires states to submit to HHS a program outline identifying which one of the two options the state intends to use.
Effective October 1, 1997.
Medicaid
To qualify for new funds, states must speed up (by 2000) the current mandatory phasing-in of Medicaid coverage for children born after September 30, 1983 who have not reached the age of 19 and whose family income is below 100% FPL.
Allows states the option to provide 1 year of continuous coverage under Medicaid for children under age 19.
Total number of children covered = 1,670,000 previously uninsured children (CBO estimate). III.Coverage Rules Eligibility and coverage rules vary with type of plan (e.g., employer-based plan, Medicaid, state insurance program).
States have an option to extend Medicaid to all uninsured children. Five states cover children under age 18 or 19 in near-poor families with incomes up to 185% FPL or higher. Defines low income children as children who are under 19 years old and whose family income is below 300% FPL.
Further defines targeted low-income children as those who:
Prohibits discrimination on the basis of diagnosis or denial of eligibility on the basis of a preexisting medical condition, although group health plans may continue to exclude coverage of preexisting conditions as under current law.
Permits states to establish coverage standards based on age, income, resources, disability status, duration of eligibility and geographic area. Within each category, states must give priority to children with lower family incomes.
Requires state plans to include a description of:
Defines low income children as children who are under 19 years old and whose family income is below 200% FPL.
Permits states to establish coverage standards with priority to children with lower family incomes.
Requires program outlines to include a description of
IV.Premium Assistance Requires that, to the extent possible, states set individual premiums on a income-based, sliding scale, giving priority to children in lower income families.
Any state payments (in the form of cash or vouchers) would not be counted as income for purposes of determining eligibility for any means-tested federal or federally-assisted program (e.g., food stamps). Permits states to impose premiums on families with incomes above 150% FPL.
Imposes same limits on beneficiary costs as Medicaid for those below 150% FPL (i.e., no cost-sharing for mandated populations, but nominal cost-sharing for optional populations). V.Benefit Structure Medicaid’s EPSDT program covers comprehensive benefits for children, including: medical, dental, preventive, primary, hospital, specialty, developmental, and long term care services.
Employer plans vary in scope of benefits, with most including preventive, primary, and inpatient services and few covering developmental or long term care services.
Special state programs and private insurance plans for children vary in scope of benefits; most have preventive and primary care, but many do not include inpatient or long term care services. Requires states to cover at least four categories of services:
Requires states to specify:
Group plans are exempt from covering the minimum categories of benefits if they provide the same coverage to children eligible for assistance as provided to other individuals covered by the group plan.
Prohibits states from using funds to pay for abortions or to assist in the purchase of benefits that include coverage of abortion except in cases of rape, incest, or danger to the mother. Requires states using the grant program to provide benefits at least equivalent to the Blue Cross/Blue Shield standard PPO option under Federal Employee Health Benefit Plan (FEHBP), including dental, vision and hearing. The Secretary of HHS will certify that plans are equivalent or better than this standard FEHBP benefit package.
Requires parity in mental health coverage if insurers offer such coverage.
Prohibits states from using funds to pay for abortions or to assist in the purchase of benefits that include coverage of abortion except in cases of rape, incest, or danger to the mother. VI.Cost-Sharing Prohibits states from imposing cost-sharing on preventive services. Permits states to impose cost-sharing requirements on families with incomes above 150% FPL. Imposes same limits on beneficiary costs as Medicaid for those below 150% FPL. VII.Insurance Reforms Prohibits states from permitting the use of any preexisting condition exclusion for covered benefits.
Group plans are exempt from preexisting conditions requirements so long as they are in compliance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Not specified. VIII.Treatment of Medicaid Medicaid coverage mandated for:
Optional groups:
No cost-sharing for children’s services.
States have an option to extend Medicaid to all uninsured children. Five states cover children under age 18 or 19 in near-poor families with incomes up to 185% FPL or higher. Phase-In Of Poor Children
Permits states to speed up the current mandatory phase-in of Medicaid coverage for children born after September 30, 1983 who have reached age 6 and whose family income is below 100% FPL. (Under the current mandatory phase-in schedule, all poor children under 19 will be eligible for Medicaid by the year 2002).
Eligibility
Permits states to use new funds available under the child health assistance program with an enhanced federal match to expand Medicaid eligibility under the following conditions:
Outreach And Enrollment
Requires state plans to describe:
Continuous Coverage
Permits states to provide 12-month continuous coverage under Medicaid for children under 19.
Presumptive Eligibility
Permits states to provide Medicaid during a presumptive eligibility period for children under 19 years old; coverage financed through the state allotment for the child health assistance program.
Reductions In Federal Grant
Reduces federal grants to states based on costs related to presumptive eligibility. Phase-In Of Poor Children
To qualify for new funds, states must complete the phase-in of Medicaid to provide coverage for all children under age 19 whose family income is below 100% FPL by 2000. The phase-in can be staggered: under 17 by 1998 and under 19 by 2000.
Eligibility
Permits states to use new funds available under the child health assistance program to expand Medicaid with an enhanced federal match for children in eligibility expansion group.
Outreach And Enrollment
Funds set aside for states to carry out outreach activities, including:
Requires states to coordinate coverage with other programs (e.g., Medicaid).
Continuous Coverage
Permits states to provide 12-month continuous Medicaid coverage for children under age 19 for 1 year after eligibility is determined (option would trigger coverage of other Medicaid-eligible populations).
Maintenance Of Medicaid Effort
Requires state maintenance-of-effort according to which states must maintain:
Reductions In Federal Grant
Reduces federal grants to states based on costs related to three aspects of Medicaid expansion:
IX.Treatment of Employer-Based Coverage Permits states to deny benefits under the child health assistance program if other private coverage is available.
Exempts group plans from covering the minimum categories of benefits if they provide the same coverage to children eligible for assistance as provided to other individuals covered by the group plan. Permits group plans to impose preexisting condition exclusions so long as they are in compliance with HIPAA.
Requires HHS to establish rules for payment of family coverage under group plans. Permits payment if state demonstrates that purchase of that coverage is cost effective relative to the purchase of comparable coverage limited to targeted low income children. Provides FEHBP-equivalent coverage.
Requires states to avoid substitution of private coverage by the new assistance provided by the state. X.Children with Special Health Care Needs Requires states to ensure access to specialty care, including the use of a specialist as a primary care provider, for eligible children who have a chronic condition, a life-threatening condition, or a combination of conditions warranting such care. Provides for financial parity of mental health coverage if insurers offer such coverage. XI.State Role in Program Administration Multiple approaches to financing children’s health insurance.
States administer Medicaid. In general states determine the eligibility process, payment levels, providers, etc. State Medicaid programs use options and waivers to further modify program eligibility categories, benefits, payments, and provider types.
Over 30 states operate child health insurance initiatives including premium subsidy programs, insurance pools, and Medicaid optional expansions. States may choose to cover uninsured, low income children using any or all of the following methods:
Requires states to prepare a plan in compliance with federal requirements and to submit it to HHS for approval.
Gives states the flexibility to design a child health assistance program within broad federal guidelines.
Requires states to set up a process to involve the public in the design and implementation of the plan as well as to ensure ongoing public involvement.
Mandates state spending to match federal allocation.
Requires states to collect data, maintain records and furnish reports to HHS for monitoring of administration and compliance as well as evaluation and comparison of state plan effectiveness.
Requires states to submit an evaluation to HHS by March 31, 2000 that would include:
Denies payments to states in the following cases:
States may choose to cover uninsured, low income children using one of two methods:
Requires states to prepare a program outline in compliance with federal requirements and to submit it to HHS for approval.
Gives states the flexibility to design a grant program within broad federal guidelines.
Mandates state spending to match federal allocation.
Requires states to submit annual progress reports to HHS.
Denies payments to states in the following cases:
Requires maintenance-of-effort according to which states must maintain
XII.Allocation and Distribution of Funds to States Federal-state entitlement funding for Medicaid, in which a set federal contribution is made to states for each dollar spent – known as federal matching (FMAP).
Employers have tax deduction for contributing to employee health benefits. Typically, employees make a contribution to health benefit costs. Some employers “self-insure” under ERISA, (i.e. they assume the risk associated with health insurance rather than buying coverage from an insurance company). Federal Matching
For expanded coverage of children through Medicaid the Enhanced FMAP = FMAP + [30% x (100-FMAP)].
For expanded coverage of children through grant program, provides for quarterly payments by HHS not to exceed 80% of state expenditures.
Allocation Of Funds
Entitles each state to receive a yearly minimum allotment of $2 million (each territory: $100,000).
Ratio for allotments = (Number of uncovered low income children for a fiscal year in the state1 x State cost factor2)/(Sum of the products in numerator)
Reduces the allotment of states opting for the increased Medicaid matching option by the amount of additional payment made under Medicaid that is attributable to the increase in the federal medical assistance percentage.
Authorized Expenditures
Permits payments for:
Caps payments for health services initiatives to improve the health of children, outreach activities, and other reasonable costs incurred to administer the program at 15% of total program expenditures.
Gives states three years to expend the money under the child health assistance program.
Reductions In Federal Grant
Reduces federal grants to states based on costs related to presumptive eligibility. Federal Matching
Defines bonus amount as:
Allocation Of Funds
Entitles states to receive a base allotment.
Allotment percentage = (Number of low-income children in the base period in the state3)/(Total number of low income children in the base period in all states)
Creates two financing pools:
Permits HHS to adjust the 85/15 split annually.
Authorized Expenditures
Permits payments for:
Prohibits use of funds for:
Gives states three years to expend the money.
Reductions In Federal Grant
Reduces federal grants to states based on costs related to three aspects of Medicaid expansion:
XIII.Estimated Cost $16 billion over 5 years:
$16-$24 billion over 5 years for children’s health insurance initiatives, with $8 billion through 20 cents/pack increase in the cigarette tax. 1 Defined as the arithmetic average of the number of low income children (i.e., children whose family income is below 300% FPL) with no health insurance coverage as reported in the three most recent March supplements to the Current Population Survey before the beginning of the fiscal year.
2 Defined as (.15) + [(.85) x (annual average wages per employee for the state for a fiscal year/annual average wages per employee for the 50 states and D.C.)].
3 Defined as the average number of low income children in the state between 10/01/92 and 09/30/95 as reported in the March 1994, 1995, and 1996 supplements to the Current Population Survey.
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For more information on Medicare and Medicaid Provisions being reviewed by Congress, see:
Contraception in the 90’s: Which Methods Are Most Widely Used? And, Who Uses What?
A fact sheet and resource list on new contraceptive use data from the 1995 National Survey of Family Growth (NSFG) from a briefing on the topic held in New York City on June 20, 1997. Contraception In The 90s: Which Methods Are Most Widely Used?And, Who Uses What? was co-sponsored by the Kaiser Family Foundation, the National Press Foundation and The Alan Guttmacher Institute, as part of an ongoing briefing series for journalists on reproductive health issues: Emerging Issues in Reproductive Health. The NSFG is based on interviews with more than 10,000 women across the country, and is the nation’s most comprehensive source of information on women’s reproductive and sexual health behavior, including sexual activity, pregnancy, infertility and contraceptive use.
The June 1997 edition of the Kaiser Family Foundation/Harvard Health News Index includes questions about major health issues covered in the news,including questions about Late-Term Abortions, Sexual Activity among Teens and the Tobacco Industry. The survey is based on a national random sample of 1,202 Americans conducted from April 28 – June 8, 1997 which measures public knowledge of health stories covered in the news media during the previous month. The Health News Index is designed to help the news media and people in the health field gain a better understanding of which health stories in the news Americans are following and what they understand about those health issues. Every two months, Kaiser/Harvard issues a new index report.
A national random sample telephone survey of 700 regular ER viewers before and after the April 10th episode, featuring a date rape victim who learns that she still has contraceptive options to help prevent pregnancy, even after having unprotected sex. While in the emergency room, she learns that if she takes a heavy dose of regular birth control pills within three days of unprotected sex, she can reduce her chance of becoming pregnant by 75%. The survey was conducted to find out if watching the show made any difference in their awareness of emergency contraception.
1997 Kaiser Media Fellows Selected
For Immediate Release: June 5, 1997Contacts: Tina Hoff — (415) 854-9400 ext. 108
Menlo Park, California — Six journalists have been selected as 1997 Kaiser Media fellows, in the fifth year of an annual fellowship program for health reporters sponsored by the Kaiser Family Foundation. The journalists, whose selection was announced today, will start their fellowships projects in September 1997.
1997 Kaiser Media fellows:
Debra Gordon, medical writer, The Virginian-Pilot
Jon Hamilton, freelance health policy writer
Leslie Laurence, syndicated health columnist, and writer, Glamour magazine
Christopher Ringwald, demographics/mental health reporter, The (Albany) Times Union
Joanne Silberner, health policy correspondent, National Public Radio
Tammie Smith, health reporter, The Tennessean
The Kaiser Media Fellowships Program provides health journalists with a highly flexible range of opportunities to pursue in-depth projects related to health policy, healthcare financing and public health issues. There is no obligation to be based at an academic institution, and no bar on fellows continuing to report for publication or TV/radio production during their fellowship.
The Program gives fellows time and travel opportunities to research specific topics, to broaden their perspectives, and deepen understanding of health policy, health financing and public health issues. The purpose is to help journalists improve the quality of the work they do–to enhance their ability to explain the complex ethical, economic, medical and political aspects involved in their reporting on health issues.
In addition to working on their individual projects, fellows meet as a group five times during the year and participate in a series of program seminars and site visits, in part designed by the fellows. These vary widely in focus, location and in the range of participants. In January 1997, the current fellows met for a three-day program on computer-assisted health reporting at the Poynter Institute, followed by a four-day sitevisit to Miami with briefings on various immigration and public health issues. The next fellowship site visit in August 1997 to Portland, Oregon, will focus on longterm care and end-of life issues.
Fellows are awarded a basic stipend of $45,000 for a twelve-month period, plus travel expenses. In 1998, six fellowships will again be awarded to print, television, and radio health reporters, commentators, editors and producers. Applications for 1998 will be available shortly, for submission by March 1998. For further information, or to apply for the 1998 awards, contact Penny Duckham, executive director of the fellowships program, at the Henry J. Kaiser Family Foundation, 2400 Sand Hill Road, Menlo Park, CA 94025 (Tel: 415-854-9400; fax: 415-854-4800; e-mail: pduckham@kff.org).
The Kaiser Family Foundation is an independent health care foundation and is not affiliated with Kaiser Permanente or Kaiser Industries.
Kaiser Media Fellows
Fellows are selected by a national advisory committee:
Hale Champion (chair)
Paul Delaney
Anne Gudenkauf
Timothy Johnson, M.D.
Eileen Shanahan
1996 Media Fellows
Lisa Aliferis, producer, KPIX-TV (San Francisco)
Susan FitzGerald, medical writer, The Philadelphia Inquirer
Samuel Orozco, news/satellite director, Radio Bilingue
Eugene Richards, photo-journalist and author
Joseph P. Shapiro, senior editor, U.S. News & World Report
Mark Taylor, health reporter, Post-Tribune (Gary, Indiana)
1995 Media Fellows
Chris Adams, reporter, The Times-Picayune (New Orleans)
Leon Dash, reporter, The Washington Post
Jonathan Freedman, author, columnist; regular contributor, Los Angeles Times Commentary Page
Judith Graham, business writer, The Denver Post
Lani Luciano, staff writer, Money magazine
Patricia Neighmond, health policy correspondent, National Public Radio
1994 Media Fellows
Jeanne Blake, documentary producer and author
Janet Firshein, Editor, Medicine & Health
Carol Gentry, medical writer, St. Petersburg Times
Angela Mitchell, freelance writer and author
Rita Rubin, associate editor, U.S. News & World Report
Steve Sternberg, freelance health policy writer
1993 Media Fellows
Lisa Belkin, healthcare reporter, The New York Times
Mary Flannery, health/medical reporter, The Philadelphia Daily News
Julie Kosterlitz, Contributing Editor, The National Journal
Linda Roach Monroe, health and medicine reporter, The Miami Herald
Rebecca Perl, science desk, National Public Radio
Stuart Schear, health/science reporter, The MacNeil/Lehrer NewsHour
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