Medicaid Buy-in programs are particularly important for underinsured children and youth with disabilities because they allow families to purchase access to Medicaid benefits, specifically to cover services that are not covered or are covered inadequately by private insurance plans. A Medicaid Buy-in program can supplement other health insurance a child might have, such as insurance through a parent’s employer, or can be a child’s sole form of coverage. Note: Children who have private health insurance cannot buy in to the Children’s Health Insurance Program (CHIP) to supplement coverage. Only uninsured children are eligible for CHIP.
In Massachusetts, the Medicaid program is called MassHealth. Under the umbrella of MassHealth, Massachusetts has operated a Medicaid Buy-in program for individuals with disabilities, called MassHealth CommonHealth, since 1988. To be eligible, a child must be younger than 19, meet the Social Security Adminstration’s listing of impairments for children, and have household income that exceeds the state’s income eligibility limit for children’s coverage under Medicaid. Families pay a monthly premium, which is based on household income. Not every family who is eligible for the program enrolls their child. Because there is no income cap for the program and the cost of premiums rises along with income, families make a cost-benefit assessment to determine whether their out-of-pocket costs are greater than the cost of the premium.
The Family Opportunity Act (FOA) was passed as part of the Deficit Reduction Act of 2005 (PL No. 109-171, Section 6062). It includes a state option to create a Medicaid Buy-in program for children with disabilities whose family income is less than 300% of the Federal Poverty Level (FPL). As of 2017, five states have implemented an FOA Medicaid Buy-in program: Colorado, Iowa, Louisiana, North Dakota, and Texas.
Louisiana created a Family Opportunity Act Medicaid Program for children with disabilities with household income up to 300% FPL. Families with household income between 201% and 250% FPL, who also have private insurance pay a premium of $12 per month. If the Buy-in is a child’s only insurance, the premium is $30 per month. For household income between 251% and 300% FPL, if the child has other insurance, the premium is $15 per month. Without other insurance, the premium is $35 per month.
The Children with Disabilities Medicaid Coverage program is North Dakota’s FOA Medicaid Buy-in program for families of children with disabilities whose household income is less than 200% FPL. The premiums are set at 5% of the family’s adjusted gross income. The amount of any private insurance premium the family pays is deducted from their Buy-in premium.
Texas has a Medicaid Buy-In for Children (MBIC) with disabilities whose family income is over the current income eligibility limit for Medicaid and who need health insurance or who need to supplement existing health coverage. Depending on income, families have to pay part of the cost for their child’s doctor visits, hospital stays, medicine, therapy, other health services, and buy-in premiums until they reach a cost-share limit, which is assessed every 12 months. The cost-share limit is determined as a percent of the eligible child’s, or children’s household income, as there is only one cost-share limit per family unit. For families below 200% FPL, the cost-share is 5% of countable gross annual income. For families between 201% and 300% FPL, the cost-share limit is 7.5% of countable gross annual income. When the family meets the limit, they do not have to make additional monthly payments until their next benefit period.
Iowa does not assess premiums for children enrolled in its Medicaid for Kids with Special Health Care Needs, the state’s FOA Medicaid Buy-in.
The Colorado Medicaid Buy-in for Children with Disabilities helped reduce the wait lists for waiver services because families with income below 300% FPL can now buy-in to Medicaid for their children with disabilities.
Not every buy-in program is limited to children with disabilities. For example, Maine used its Children’s Health Insurance Program (CHIP) funding to expand MaineCare, which is the name of the state’s Medicaid program. This expansion is called the “Full Cost Purchase Option for Children under 19 Years of Age” for families with household income between 140% and 213% of the federal poverty level (FPL). The program is for families who may or may not have other health insurance. If they have other private health insurance, they can use the Buy-in as supplemental coverage, and because it is a Medicaid expansion, it includes the EPSDT benefit. The Buy-in is available to all children, except children of state employees. The cost to families depends on income; there is a sliding scale premium schedule.
- Catalyst Center Surveys Families about their Experiences with Medicaid Buy-in Programs
- TEFRA and FOA Medicaid Buy-in Programs: An Educational Worksheet from the Catalyst Center
- Case Study: Buying into a Medicaid Buy-in Program: The Texas Experience
- The Family Opportunity Act’s Medicaid Buy-in Option: What We’ve Learned
- Frequently Asked Questions about the Family Opportunity Act’s Medicaid Buy-In Option
- Reducing Under-Insurance for Children and Youth with Special Health Care Needs