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CMS Clarifies Position on SCHIP Eligibility

The Centers for Medicare & Medicaid Services (CMS) recently sent a letter to state Medicaid administrators clarifying their August 2007 directive regarding the State Children’s Health Insurance Program (SCHIP).  These changes could be significant for people with bleeding disorders and others seeking coverage under SCHIP programs, which go by a variety of names, depending on the state.

In September 2007, the National Hemophilia Foundation (NHF) reported that CMS had issued a new guidance placing additional burdens on states that had expanded SCHIP eligibility to include children in families with incomes above 250% of the federal poverty level (FPL).  These new requirements are designed to discourage individuals who have or are otherwise able to obtain private coverage from dropping that coverage and switching to government-sponsored programs (a practice called “crowd-out”). Among the changes was a requirement that states demonstrate that they had already enrolled at least 95% of all eligible children in families with incomes below 200% of the FPL.  Another stipulation requires states to prove that the percentage of low-income children in families with private insurance coverage has not declined by more than 2% in the preceding five years.  Finally, CMS directed states to impose additional cost sharing on these families, including a one-year waiting period during which they must go without coverage.  

The good news is that children continuously enrolled in the program, even if their family is more than 250% above the FPL, will not lose coverage.  In addition, states have been given some leeway in demonstrating that they are avoiding crowd-out.  States may even ask for exemptions for some categories of individuals with special needs, which might be applicable to children with bleeding disorders.  However, despite the serious objections raised by legislators, state policy makers and healthcare advocacy organizations including NHF, most of the existing provisions of the guidance will stand.

NHF is working with other healthcare advocacy organizations and supportive legislators to avoid the implementation of these directives. Our goal is to permanently expand the SCHIP program to cover more children.  We will continue to monitor this issue, inform the community, and take any appropriate actions to ensure that children and families who rely on this and other programs will be able to maintain access to adequate, reasonable coverage and high-quality care.  For more information, contact Ruthlyn Noel, NHF Manager of Public Policy: 212-328-3730 or


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