Health and Recovery Services Administration, Department of Social and Health Services

SCHIP overview 


Milestones - Healthcare under the SCHIP
program began on February 1, 2000

Eligibility

  • Children under 19 in families with "countable" income between 200% and 300% of the federal poverty level (FPL)
    • This is a monthly income between $4,594 and $5,513 per month (effective 4/1/09) for a family of four
    • "Countable" income means we allow the same income deductions as the children’s Medicaid program
  • Children who are eligible for Medicaid are not eligible for SCHIP
  • Children cannot have other insurance that provides access to doctors, hospitals, laboratory services and radiology services
  • If the family dropped employer sponsored dependent coverage, the child must wait 4 months before enrolling in SCHIP.  Exceptions to this policy are listed below under "Exceptions to Waiting Period."
  • Children are covered for up to 6 months.  Coverage may end during the 6 months if the children move out of state, turn 19 years old, their income goes up, or monthly premiums are not paid.

Application Process
  • There is a single application for both Medicaid and SCHIP
  • When a family submits an application for benefits:
    • We need information on whether a child has other insurance coverage, or whether the family dropped employer sponsored dependent coverage

Scope of Services
  • Same as covered under Medicaid's Categorically Needy (CNP) program

Service Delivery
  • Services are covered from the beginning of the month in which the application was received
    • Fee-for-service (no health care plan) is used before managed care starts
  • Managed care
    • Clients are required to enroll in managed care if they live in counties with two or more plans.
    • Clients have voluntary managed care enrollment if they live in counties with only 1 plan 
    • Clients will get their care through fee-for-service in counties with no plans (Asotin county only)
  • American Indian/Alaska Natives have the same choice of health plans plus Primary Care Case Manager Indian clinics or fee-for-service (no health care plan)

Client Cost Sharing

      Clients are required to pay monthly premiums, unless they are an
     American Indian or Alaska Native.

    • $15 per child/per month, $45 family maximum per month
      •
    • Clients will be disenrolled if payments are not made for 3 months and must wait 3 months before they can become eligible again.

Exceptions to Waiting Period

If a family dropped employer-sponsored health care there is a 4-month waiting period to be eligible for SCHIP.  There is no waiting period if the family has one of the following exceptions:

  • The client or family member has a medical condition that, without treatment would be life-threatening or cause serious disability or loss of function; or

  • The loss of employer sponsored dependent coverage is due to any of the following;

    • Loss of employment;

    • Death of the employee;

    • The employer discontinues employer-sponsored dependent coverage;

    • The family's total out-of-pocket maximum for employer-sponsored dependent coverage is fifty dollars per month or more;

    • The plan terminates employer-sponsored dependent coverage for the client because the client reached the maximum lifetime coverage amount;

    • Coverage under a COBRA extension period expired;

    • Employer-sponsored dependent coverage is not reasonably available (e.g., client would have to travel to another city or state to access care); or

    • Domestic violence that leads to loss of coverage for the victim.

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Page modified: November 2009       

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