State Plan Extends Helping Hand to Thousands of Uninsured Kids

Now comes the children’s hour. California is beginning the biggest expansion of public health insurance programs since Medi-Cal was created a generation ago.

Working families of modest incomes without health insurance for their children became eligible July 1 for a new state program offering coverage for doctor visits, hospital care and prescription drugs.

The Healthy Families program aims at finding and covering many of the 400,000 uninsured children in the state.

“We want to provide low-wage families with access to comprehensive systems of care,” said Sandra Shewry, head of the state’s Managed Risk Medical Insurance Board, which runs the Healthy Families program. “We are trying to model this after the commercial insurance market in California,” she said.

The benefits are identical to those in the health insurance package offered to members of the state Legislature and to state government employees.

Healthy Families is California’s version of the legislation approved by Congress in 1997, providing $24 billion, a major expansion of federal health spending. Two-thirds of the money comes from Washington.

At the same time, the state will be trying to find more low-income families whose children qualify for Medi-Cal, a program for the poor.

A single application will help families enroll their kids in either Healthy Families or Medi-Cal.

Healthy Families is designed for children 18 or younger. They must be U.S. citizens or qualified legal immigrants who entered the U.S. before Aug. 22, 1996. (There are some exceptions for refugees.)

The cost will vary, depending on family income and the type of health plan selected. The payment can be as little as $4 a month for each child, and the maximum for any family, no matter how many children, would be $27 per month.

There is a co-payment of $5 for an office visit. There are no further charges once a family makes a total of $250 in co-payments for the year.

Applications are available through community organizations, schools, PTAs, day-care centers, county health programs, insurance agents, churches and synagogues, and state government offices. A drive to enroll all eligible children, called the 100% Campaign, is being run by the Children’s Defense Fund, a national Washington-based group; Children Now, based in Oakland; and the Children’s Partnership, based in Santa Monica.

The goal of Healthy Families is to find uninsured children whose families have incomes between 100% and 200% of the federal poverty level, which is $16,450 for a family of four. The income limit for participation in Healthy Families is 200% of that figure, or $32,900.

Typically, these children come from households in which parents work full time but don’t have health insurance through work. Many low-wage workers have no insurance at all. Others have coverage for the worker only.

Employers cannot use Healthy Families to reduce their own costs if they already provide health insurance for children to their workers. Under California law, it is an unfair business practice to cancel the coverage at work for children of workers whose income would qualify them for the public program.

Healthy Families essentially uses federal and state dollars to subsidize the cost of private insurance. The care will be provided through the same standard health organizations that provide coverage for millions of Californians through the private health care market.

In Los Angeles County, the participants are: American Family Care, Blue Cross (HMO), Blue Shield (HMO), Community Health Plan, Health Net, Kaiser Permanente, L.A. Care Health Plan, UHP Healthcare, and United Health Care.

Orange County choices are Blue Cross (HMO), Blue Shield (HMO), CalOptima Kids, Kaiser Permanente and UHP Health Care.

Health plans that have been successful in serving low-income families have been designated “community providers.” They will be allowed to offer the lowest premiums, $4 a month. Community Health Plan is listed as a community provider for Los Angeles County, and CalOptima Kids has the designation for Orange County.

For Riverside County, the community provider plan is Inland Empire Health Plan, and the other plans are Blue Cross-EPO, Blue Shield--HMO, Health Net, Kaiser Permanente, American Family Care, UHP Healthcare, United HealthCare and Universal Care. In San Bernardino County, the community provider plan is Inland Empire Health Plan, and the other plans are Blue Cross-EPO, Blue Shield-HMO, Health Net, Kaiser Permanente, American Family Care, UHP Healthcare, United HealthCare, and Universal Care.

Ventura County has Ventura County Health Care Plan as the community provider plan, and the other participants are Blue Cross-EPO, Blue Shield-HMO, Health Net, United HealthCare and Universal Care.

Families can fill out a single application to determine eligibility for Healthy Families and for Medi-Cal. If a family qualifies for both, there are certain times when Medi-Cal may be preferable, according to Patricia Freeman, a health policy analyst with Children Now:

* If a child has a serious drug or alcohol problem. Healthy Families has a limit of 20 outpatient visits a year for mental health or substance abuse. Medi-Cal permits whatever is deemed “medically necessary,” with no official limits on the number of visits.

* If transportation is difficult. Healthy Families covers only emergency transportation, while Medi-Cal covers routine as well as emergency transportation charges.

* If a family already has a child enrolled in Medi-Cal and wants to keep using the same doctor.

Kaiser Permanente is starting its own program to help families who cannot afford health coverage. The Kaiser Permanente Child Health Plan takes over where the Healthy Families income limit stops. Kaiser will allow participation with family incomes up to $45,000 a year for a family of four.

Depending on their income, parents will pay premiums of $25 to $35 a month per child, with a maximum payment of $105 for three children, regardless of the number of kids in the family. There is no charge for hospital care, but there will be $5 co-payments for doctor’s office visits, with a maximum of $250 a year for these co-payments.

Parents must be living within the Kaiser service area, have children 18 or younger who cannot qualify for a public program, and the children must have been uninsured for at least 90 days. The program will be run with participating public schools. Only children who attend the participating schools, or who have siblings at one of these schools, can enroll in the Kaiser program. Kaiser is enrolling children now, with coverage beginning Sept. 1.

Hoping to fill the remaining gaps in coverage is the California Kids Health Care Foundation, which has been providing coverage for children with financing from private foundations. Now that Healthy Families is in place, California Kids will focus on those who can’t qualify for the new public program. They might be families who make too much money for Healthy Families but still can’t afford insurance. Or families whose children are barred from the program because they do not have legal immigration status.

Now we turn to questions from our readers, who are wondering this month about COBRA. It’s not the snake, but an acronym for Consolidated Omnibus Budget Reconciliation Act, a federal law that gives you the right to continue group health insurance coverage after you leave a job.

Q: Can you tell me if businesses are required to offer health insurance to their employees? You say they are required to offer COBRA if they have 20 employees who are eligible for insurance. But if you don’t offer insurance, then you don’t have to offer COBRA? If you offer a policy that is paid for by the worker and not the employer, who covers the cost of COBRA? I would appreciate your help on this as we are a small family-owned company (19 employees).

A: Health insurance is strictly a voluntary benefit. Businesses offer it at their discretion. If a company does offer insurance, however, it is required to follow all federal and state laws and rules on the subject. The federal COBRA law requires a firm that has coverage for its workers to make the insurance available to a worker for up to 18 months after leaving the job. The worker has to pay both her share and the firm’s share of the cost, plus a 2% administrative fee. This applies to companies with 20 or more employees.

California has its own version, CAL-COBRA, which covers firms up to 19 workers, such as your business. If the company contributes to the coverage, a worker who leaves can keep the coverage, but must pay the full cost, his share and the firm’s share, plus a 10% administrative fee. However, if the company simply makes the insurance available through work, and does not share any of the costs, there is no requirement for continuation of insurance under CAL-COBRA, according to the California Department of Insurance.

Q: My daughter, who is 47 years old, divorced with two teenage sons, has excellent health insurance coverage under COBRA. Her coverage will expire Feb. 14, 1999, at which time she will have to get new coverage. She presently pays $503 a month for her own coverage, not including her sons’. She is mentally ill, diagnosed as bipolar manic-depressive. She has been told she can convert her COBRA policy to a new policy that has less coverage than she presently has. The most onerous change is that the new policy has a $100,000 lifetime limit, which is terribly inadequate for a 47-year-old woman with her condition. Is there any hope for her to find a source that will insure her with at least a $1-million lifetime maximum and without putting any restrictions on the coverage for her mental illness? Her net worth is such that she would not qualify for public assistance, unless there is some government program that helps those with a mental illness who cannot get insurance adequate to treat their illness.

A: Federal law, under the Health Insurance Portability and Accountability Act (HIPAA), makes it mandatory for companies to offer insurance for sale to someone who has exhausted COBRA coverage. Your daughter does not need to convert her COBRA to a new policy with just a $100,000 limit. Instead, she can get better coverage in the open market because of HIPAA. She can contact an insurance broker to get prices on HIPAA policies. All the companies selling individual policies in the state must make coverage available. Kaiser, Blue Cross, Blue Shield and PacifiCare are among the big firms serving this market. Prices will range from $200 to about $500 a month, and she can get coverage with a $1-million lifetime limit, say officials at the federal Health Care Financing Administration, which enforces HIPAA.

*

Tip of the Month: Medicare coverage was expanded July 1, and now pays for blood glucose monitors and testing strips for anyone who has diabetes. Medicare also pays for all diabetes education and training programs. Testing for bone-mass density, which helps determine whether a person has osteoporosis, is covered for the first time.

* This column appears every second Monday in Health. Send your questions and ideas to Benefits Bob Rosenblatt, Health, Los Angeles Times, Times Mirror Square, Los Angeles, CA 90053. Or e-mail: Bob.Rosenblatt@latimes.com.

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Your Guide to Kids’ Health Programs

Healthy Families

The income limits eligibility are:

$21,700 for a family of two;

$27,300 for a family of three;

$32,900 for a family of four;

$38,500 for a family of five;

Larger families also may qualify.

For general questions about the program, call (800) 880-5305, 8 a.m.-8 p.m. Monday-Friday. To receive an application packet, call (888) 747-1222. Information available in multiple languages.

The same application packet is used for both Healthy Families and Medi-Cal for children.

If you want to be a trainer to help families fill out applications, call (888) 237-6248.

Medi-Cal Eligibility

Child under age 1 in a family with income up to 200% of poverty level ($32,900 for family of four);

Child ages 1 to 5 in a family with income to 133% of poverty level ($21,900 for family of four);

Child 6 to 18 in a family with income to 100% of poverty level ($16,450 for family of four);

(Permissible income may actually be higher because Medi-Cal allows certain deductions.)

Kaiser Permanente Child Health Plan for Kids

If your income is too high for Healthy Families, you may qualify for Kaiser subsidized coverage (income for family of four can go up to $45,000). Coverage will begin Sept. 1. But children can enroll now. Call (800) 255-5053.

California Kids Foundation

Will help children whose family income is too high for Healthy Families or children who do not have legal immigrant status, and others who may be ineligible for public programs. Call (800) 374-4543.

Access for Mothers and Infants

For pregnant women and children up to age 2. Eligibility up to 200% of federal poverty level. Call (800) 433-2611.