Chiloren's Health Initiative

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Health Insurancefor the Children ofSanta Clara County

Frequently Asked Questions about the
Children’s Health Initiative and Healthy Kids

What is the Children's Health Initiative?

The Santa Clara County Board of Supervisors, Working Partnership USA and People
Acting in Community Together(PACT)have established the goal that 100% ofthe
children residing in Santa Clara Coimty have access to quality health care through

comprehensive health insurance. To meet this goal, the Chil^en’s Health Initiative

incorporates several major program components:

Every child in Santa Clara County shall have real access to regular health
care as a result ofbeing insured;

No uninsured child who is a resident of Santa Clara Coimty, and whose
parents have an income at or below 300% ofthe federal poverty level, shall
be turned away from receiving health coverage.
The Outreach Plan become a model 'best practices' program within the State
of California, with program elements which include education offamilies on
the appropriate use oftheir benefits and the health care system, and
improvement of enrollment retention.
As currently designed, the Children’s Health Initiative seeks to reach all uninsured
children in Santa Clara County whose families have incomes at or below 300% of
the federal poverty level(FPL). Through an extensive outreach and enrollment
project, workers and volunteers will discuss the benefits of health insurance for

children with families, evaluate the families’ eligibility, and then assist the family in

enrolling their child/children in the appropriate health insurance program (Medi-Cal,

Healthy Families, or Healthy Kids).

The appropriate plan will depend upon on the child’s age, residency status, family
size, and income. Moreover,children within the same family may qualify for

different programs. The following table demonstrates how these factors combine to
determine eligibility in each program:

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Health Insurancefor the Children ofSanta Clara County

Children’s Eligibility for Medi-Cal, Healthy Families & Healthy Kids
Income Limit

as % of Federal

Age

Program
Eligibility

Poverty Level (FPL)

< 1 Year

1-5 Years

6-18 Years

<200%
201-250%

Medi-Cal

0-300%

Healthy Families
Healthy Kids*

<133%
134-250%
0-300%

Healthy Families
Healthy Kids*

<100%

Medi-Cal

101-250%

Healthy Families
Healthy Kids*

0-300%

Medi-Cal

* Children ineligible for Medi-Cal and Healthy Families ARE eligible for Healthy Kids
up to 300% of FPL.

What is Healthy Kids?

Healthy Kids is the essential component in helping reach the goal of making health
insurance accessible to all children in the County. Created by a public-private
partnership which was formed for this purpose, it is a new, locally funded health
insurance product designed to fill in the gap for those who do not qualify for the
existing programs and are financially unable to purchase coverage.
Healthy Kids will function like any other managed health care plan; it is regulated by

the California Department of Managed Health Care and will offer benefits and
provider networks that are the same as those available through the Family Health
Plan from the State-managed Healthy Families program. Benefits include:

■

Complete medical coverage including preventive check ups,

■
■

Specialist care,
Inpatient and outpatient hospital services

■

Mental health care.

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Health Insurancefor the Children ofSanta Clara County

Alcohol & drug treatment,
Vision care,
Dental care.

Prescription coverage
A 24-hour nurse advice line.
Health education and many other services.

Who is eligible for Healthy Kids?
All children who are:

n

under age 19;

n

uninsured

n
n
n

residents of Santa Clara County;
families earn 300% FPL or less; and are
ineligible for Medi-Cal or Healthy Families.

Why create a 300% FPL ceiling?

In the Santa Clara Valley the cost of living, particularly housing, is such that even
300% of poverty here is barely comparable to the 250% legislatively established for
Healthy Families throughout the entire state. Moreover, it is believed that families
earning over 300% FPL are more likely to have access to employer sponsored health
insurance. As it is not the intent of this plan to replace health coverage currently
being provided by employers for dependents, the 300% FPL ceiling seems
reasonable.

In consideration of the aforementioned issues. Healthy Kids begins with an income
limit of 300% of the federal poverty level. After experience and data has been
gained, this income limit will be re-evaluated in light of the unique economic
pressures within Silicon Valley. The high cost of living may well require that Santa
Clara County establish its own “poverty level”. Further study of those children above
the 300% FPL limit who continue to be uninsured will lead to better understanding
of how to best meet their needs. (Note: For a family offour, 300% of the federal
poverty level equals an annual income of $51,150.)

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Children's Health Initeative
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How do children qualify?

Application Specialists will help families complete the application form. The family
will provide proof ofincome and county residency. Annual requalification will be
required to maintain coverage.

Recognizing the variability in employment status, a variety offorms will be accepted
as proof of income. For example, families may provide copies of recent pay stubs or

tax returns to demonstrate income levels. Or, in cases where such documents are not

available, the family may submit a letter from the employer or agency through which

they find work. Residency can be determined by school enrollment forms, canceled
mail or any other usually accepted documents. Spot checks will be conducted to

validate this process. In addition, certified mail and/or returned mail can help verify

residency.

Upon completion of the application, families with children deemed ineligible for
Medi-Cal and Healthy Families will help applying for Healthy Kids. Should the
child qualify for Healthy Families or Medi-Cal, the family will be assisted,
automatically, in applying for the appropriate program.
How much does Health Kids cost?

The total cost of Healthy Kids is $87 per member per month for the initial fiscal
year. Of that, the family’s share of the premium will be from $4 to $6 per per child
per month, with a maximum of from $12 to $18 monthly payment per family,
depending upon income.(See chart, next page.) Families may pre-pay 3 months of
their share ofthe premium and receive the fourth month free, or, pay for 9 months
and receive the fourth quarter free.

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Children's Health Initiative
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FAMILY CONTRIBUTION CHART

$4 per child
up to maximum of
$12 per family.

$6 per child
up to maximum of

$18 per family.

Monthly Income
Up to 150% FPL*

150%-300% FPL*

Monthly Income

Family

Maximum

Maximum

Size

Amount

Amount

1

$1,044

$2,088

2

$1,407

$2,814

3

$1,770

$3,540

4

$2,132

$4,263

5

$2,495

$4,989

6

$2,857

$5,715

7

$3,219

$6,438

8

$3,582

$7,164

9

$3,945

$7,890

10

$4,307

$8,613

*FPL = Federal Poverty Level

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In addition to the monthly family contribution to premium, there are co-payments for
certain services (the same as Healthy Families):
CATEGORY

TYPES OF SERVICES

COPAYMENT

Health Facilities

All patient acute &
Skilled Nursing (100 days)
All Outpatient Services

No co-payment

Professional Services

Inpatient-based
Office or home visit

Visits for chemotherapy, dialysis,
surgery, anesthesiology, radiation
Preventive Services

Visits for immunizations,
periodic health exams, well-child
visits, STD tests, cytology exams,
family planning, vision and
hearing tests, prenatal care, health

$5 co-payment
No co-payment
$5 co-payment
$5 co-payment

No co-payment

education

Diagnostic x-ray and
Laboratory Services

Therapeutic radiology services,
EGG,EEG, mammography, other
outpatient diagnostic laboratory
and radiology tests

No co-payment

Prescriptions

Generic or name brand drags
Inpatient drags and drag
administration in a physician's
office, as well as FDA-approved
contraception drags and devices

$5 co-payment

Inpatient limited to 30 days/year
Outpatient visits up to 20 visits

No co-payment
$5 co-payment

Mental Health

No co-payment

per year

Drug and Alcohol

Inpatient detoxification
Crisis intervention and abuse

$5 co-payment
$5 co-payment

treatment

Other Services

Othoses, prostheses, medical
transportation
Physical, occupational, and

speech therapy

No co-payment
$5 co-payment

Experience with Healthy Families shows that some families have a difficult time

paying monthly premiums for insurance coverage however small it may be. For
those families for whom the monthly share of premium is a barrier to enrolling their
children into Healthy Kids, a separately operated Premium Assistance Fund has been
established. Families may request this assistance through the Santa Clara Family
Health Plan, which will evaluate the application based on family size, income, and
extraordinary circumstances.
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Families qualifying for the Premium Assistance will not be billed their monthly
share of premium for the remainder of their enrollment year. Those funds will be
transferred to Family Health Plan by the United Way, which will manage this
account. The Premium Assistance Fund will cover only the family’s monthly share
of premium payment.
Rather than disenrolling children automatically after two months of non-payment of
the Family Contribution (current Healthy Families practice), Healthy Kids will “bill”
the Premium Assistance Fund and try to contact the family to determine the reasons
for non-payment. Should the family subsequently qualify for the Premium
Assistance Fund, the payments will be made for the family. In those instances where
non-payment is a choice, not the need for assistance, the children will be disenrolled
from Healthy Kids.
How is Funding Already Received To Be Used?
The County’s tobacco settlement funds will be used primarily to pay premiums for
children. In the start-up phase of Healthy Kids, these funds also will cover
development costs that are critical to the creation of Healthy Klids. These would
include legal and consultant fees, information systems, design and printing costs, etc.

The Healthy Kids program will cost an estimated $14-18 million aimually. It is
expected that Santa Clara County, City of San Jose, and Propositio 10 funds already
received will leverage additional funds from private foundations, corporations, and
individuals.

’What happens when enrollment exceeds resources?

If the monthly reports on Healthy Kids’ finances and enrollment indicate that
enrollment will exceed resources, a waiting list will be created and enrollment closed
while efforts are undertaken to increase funding. As soon as additional funds are
secured, children can have their applications considered for enrollment in Healthy
Kids - on a first come, first served basis.

Who is going to administer Healthy Kids?
The Santa Clara Family Health Plan will administer the Healthy Kids program, as it
currently does for 63% of county residents enrolled in Medi-Cal(managed care) and
Healthy Families. Additionally, the Santa Clara Family Health Foundation, has
received a grant from the Packard Foundation to conduct the fundraising necessary
to obtain full on-going funding for the program.

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Children's Health Initiative
Health Insurancefor the Children ofSanta Clara County

The Santa Clara County Family Health Authority (d.b.a. Santa Clara Family Health
Plan) is a fully licensed Knox-Keene health plan and is a public agency, formed
pursuant to ordinance by the Santa Clara County Board of Supervisors on August 1,
1995. Family Health Plan is a public community health plan and offers the proven
ability to administer health insurance plans with low-cost administration. The plan is
subject to applicable Brown Act requirements.

Importantly, SCFHP has the ability to provide continuity of care as children move

back and forth in eligibility between health plans due to changes in parental incomes.
And as in the Healthy Families and Medi-Cal programs, all materials will be

available in English, Spanish and Vietnamese. Moreover, the Santa Clara Family

Health Plan’s staff and network of providers speak over 35 languages.

As the Healthy Kids administrator, SCFHP will conduct the following duties;
Application processing
Eligibility determination
Contracting with health care providers
Oversight and maintenance of provider networks
Claims and provider payments on behalf of enrollees
Contracting with dental plan
Contracting with vision plan
Contracting for outreach and education services
Funds administration

Premium billing
Family contribution collection

Notification of families offailure to pay premium/hardship process
Tracking hardship fund payments
Coordination of evaluation activities
Fraud detection and resolution.

Why choose the Santa Clara Family Health Plan?

The SCFHP met all of the criteria for administration ofthe Healthy Kids program as
stated in the Children’s Health Initiative concept paper, and approved of by the

Board of Supervisors on October 4, 2000:
Ability to administer

Ease of administration/core business functions being prepaid health care
Public accountability
Experience

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Health Insurancefor the Children ofSanta Clara County

n

Continuity of care between Healthy Families, Medi-Cal and Healthy Kids

n

Low cost of administration

n

Locally based

SCFHP has responsibility for managing revenue from the state and federal
government(through Medi-Cal and Healthy Families) and has its operations audited
annually by the California Department of Managed Care, the state Department of
Health Services, the federal Health Care Financing Administration, and the Board of
Supervisors’ external audit firm. Each has determined SCFHP’s sound fiscal
management. As a public entity, SCFHP is subject to the Brown Act, conducts its
business in public and has all of its records open for public inspection. Moreover,
the Board of Supervisors appoints each of the members of the SCFHP Board of
Directors - of which two are seats reserved for County Supervisors.

The Santa Clara Family Health Plan is a culturally competent provider of health
insurance services: The Healthy Kids network will be made up of more than 2,100
doctors and clinics, 9 hospitals and more than 170 pharmacies located throughout
Santa Clara County.

In addition, a Community Oversight Board will be created to help oversee and hold
SCFHP accountable to the public for the Children’s Health Initiative and Healthy
Kids product. This thirteen-member board will be created along with the start of
Healthy Kids. Membership will represent the community and contributors:
1 member of Working Partnerships USA

1 member ofPeople Acting in Community Together(PACT), a communitybased organization

1 representative from Santa Clara County (elected official, preferably)

1 representative from tbe Children & Families First Commission
1 representative from the City of San Jose
2 parents of consumers
1 representative of labor
1 medical professional

1 representative from the business community
1 representative from schools (superintendent)
1 clinic/hospital representative
1 expert in health care evaluation and research

How will Healthy Kids be implemented?

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Children's Health Initiative
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Enrollment for Healthy Kids began on January 2, 2001 and coverage on February 1.
Assumptions are that approximately 4,500 children will enroll during the remainder

of FY 2001, and in FY 2002, enrollment should increase to 5,700.

Because the SCFHP is a fully operational health plan, it is able to absorb the influx

of this new activity and means that Healthy Kids will ramp up very quickly. The
plan cannot start until approved by the State Department of Managed Health Care,
which has notified the SCFHP that it anticipates meeting the above schedule.
What’s the benefit to the community?

Perhaps the benefit to the community is best stated by the Institute for Health Policy
Solutions in its report to the Packard Foundation,''Background Data and Modelsfor

Expanding Health Insurance Coverage to Uninsured Children in Santa Clara
County"
“Children’s access to health insurance and health care are

important determinants of better health outcomes and readiness to

learn. A regular source of care is particularly important for
children in assuring that appropriate preventive services are
provided, acute and chronic conditions are diagnosed and treated in
a timely manner, and that children’s development is adequately
monitored. Furthermore, children’s regular access to preventive
services can decrease their need for emergency and specialized
services.”

In other words, providing health coverage to children is the morally, medically and
financially right thing to do.

What about governmental matching funds?

Once operational, and during the first 18 months, there will be an exploration of
available federal/state matching funds. Matching funds for premiums were not
pursued at the outset due to the aggressive start up time frame of this Initiative.
Matching funds for outreach are currently being used and will be actively sought on
a continual basis.

Why is outreach important?

Health care plans and benefits, and the health care delivery system in general, are
complicated, intimidating, and are known primary barriers to parents seeking and

obtaining health insurance for their children. As such, a goal of the Children’s Health
Initiative is to reduce parents' fears and confusion by deploying a cadre of
Application Specialists throughout the community who are highly trained and skilled

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in the arts ofcommunication, information dissemination, and building trusted
relationships with enrollees and the community-at-large.

A January 2,2001 timeline may be perceived by some as ambitious for launching

this comprehensive outreach effort. However, kids need coverage now, which is the
purpose of establishing an aggressive start date. Using existing and successful
practices currently utilized within the County, and calling on established trusted
relationships to move forward with Plan activities will enable us together to meet the
goals of the Children's Health Initiative.

How will we develop a new and expanded approach to outreach?

The Medi-Cal/Healthy Families Advisory Committee (Advisory Committee) is a
collaborative of county-wide stakeholders that have conducted investigations and
gathered information in the areas of outreach and enrollment best practices, barriers
to enrollment, public awareness campaign strategies, retention of members, and
training of personnel. Advisory Committee membership includes, but is not limited
to, representatives from following agencies: Santa Clara Valley Health & Hospital
System (SCVHHS), Santa Clara County Social Services Agency(SSA), Santa Clara

Family Health Plan, Alum Rock Union School Districts, Working Partnerships,
Community Health Partnership, People Acting in Community Together, Packard
Foundation, and The Health Trust.

Successful identification and enrollment of all eligible children into a health
insurance program will include 1) continuous communication and planning between
SCVHHS Valley Community Outreach Services and the Social Services Agency, to
ensure a fluid coordination of the County’s application process for enrollment, 2)
developing a coordinated set of county-wide outreach activities to prospective
enrollees, 3) providing comprehensive and dedicated assistance with the complex
application process by trained professionals, including beneficiary education to
promote appropriate health system utilization, and 4)creating a policy to streamline
the processes necessary to provide continuous coverage for children as their family's
eligibility criteria changes over time.

In conjunction and partnership with our outreach efforts, the Social Services Agency
will be performing an Agency-wide analysis of its existing Medi-Cal eligibility
practices. There are a number of entry points within the application process that have
proven to hold barriers for many eligible residents. Any opportunity to enroll an
applicant into a program that becomes frustrating or unnecessarily burdensome is a
potential missed opportunity to get a child enrolled for health care.
Keeping that in mind, a consultant effort is underway to conduct an overview of
Social Services Agency operations and data collection processes, to improve the

application process for applying through the SSA. The Social Services Agency, the

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Health and Hospital System, and the Santa Clara Family Health Plan are co
sponsoring the activities of the consultant, for the following purposes:
• To ensure that when Medi-Cal applicants are found ineligible, SSA staff will
refer will them to an Application Specialist for enrollment into one of several
available programs.
• To develop a basic pre-screening questiormaire for Medi-Cal eligibility, to be
used by Application Specialists, to maximize the use of everyone's time in
the application process.
• Develop a plan to implement new processes, including a timeline for systemwide changes.

While our outreach plans are being developed. Valley Community Outreach Services
program staff will:
• Ensure immediate efforts are coordinated with all other stakeholders;
• Establish and implement a core set of training materials and modules, as well
as a specialized set of trainings relative to job specification, including, but not
limited to areas of: managed care system, cultural competence, available
resources, understanding the various insurance programs, understanding the
SSA system, and understanding their assigned milieu, computer and various
technologies training, communication skill building;

• Be deployed to school sites, the safety net of community clinic providers,
and to Valley Medical Center and associated Health Centers;
• Serve as the 'single-point-of-contacf for prospective enrollees, to, screen and
assess enrollees, assist prospective enrollees with the application process,
triage and refer to appropriate program, provide education about application
materials, support enrollee in obtaining required documents, when
appropriate submit application, provide follow-up support for status of
application, provide information and resources for future contact with VCOS
program, staff the 1-800 telephone for inbound calls (and outbound when
needed).

• Track and monitor staff performance and enrollment outcomes including
implementing a centralized system to capture, track, analyze, and report
outreach and enrollment data.

What outreach efforts have already occurred?

Throughout Santa Clara County there currently are a variety of outreach and
enrollment efforts underway, performed by different agencies and stakeholders
targeting and enrolling children and families. In June of 2000, the Board of
Supervisors approved additional Valley Community Outreach Services(VCOS)

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staff, that are dedicated to performing countywide outreach and application
assistance activities. Those activities have included:

Community Clinics: Gardner Family Health Network, CompreCare, Indian
Health Center, Planned Parenthood, MayField Clinic, Mountain View.
Valley Health Centers: East Valley, San Martin, Bascom, Silver Creek, and
Fair Oaks.

Schools: Gavilan College, Head Start, Sherman Oaks, Columbia, Miller,
Burnett, Erikson, James Lick.

Social Services: Assistance Application Center, Gilroy Offices.
Community Centers: Mexican Heritage Corporation, Columbia
Neighborhood Center, Family Resource Center, Head Start of Gilroy.
Shopping Center: Mi Pueblo.

Faith-based Organizations: City Team Ministries, Sacred Heart Community
Center.

Why is retention so important?

The success of this outreach plan will ultimately be measured by the success of
retaining its members and increasing utilization of care as outlined by the Children's
Health Initiative efforts. Santa Clara County Children's Health Initiative will stand
alone as a best practice model for achieving healthier communities by retaining our
children and families within a health program once they are successfully emolled.
The uniqueness of our plan stems from 1) addressing the specific needs of the
uninsured in our County,2)providing the administrative continuity required to
eliminate barriers to continuous coverage for each child, 3)educating enrollees on
how to proactively utilize the health care delivery system, and 4)providing the
commitment and resources necessary to deploy a highly trained and effective
application assistance team.

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