Migrant and Seasonal Farmworker Access to
Health Care Services and Insurance Coverage:
Summary Report on Issues, Resources and
Potential Solutions.
1
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I. Executive Summary
The Health Care Safety Net Amendments of 2002, signed into law (Public Law No:
107-251) by President Bush, directs the Department of Health and Human Services
(DHHS) to conduct a “study” regarding barriers to participation of farmworkers1 in
health programs, specifically problems experienced by farmworkers and their family
members when accessing Medicaid and the State Children’s Health insurance Program
(SCHIP). The legislation calls for the study to examine the barriers to enrollment,
including a lack of outreach and outstationed eligibility workers; complicated
application and eligibility determination procedures; and linguistic and cultural barriers.
Additionally, the Secretary is instructed “to exam the lack of portability of Medicaid
and CHIP coverage for farmworkers eligible in one state, but who move to other states
on a seasonal basis.” Finally, the study is to identify solutions that will increase
enrollment and access to benefits for farmworkers as well as associated costs of each of
the following possible solutions:
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Use of Current Law Flexibility;
Demonstration Projects;
Interstate Compacts;
Public-Private Partnerships;
National Migrant Family Coverage; and
Other Possible Solutions
This paper provides a brief summary of the issues and associated literature and research
that document past and current efforts - both public and private - to identify health care
services access barriers for migrant and seasonal farmworkers (MSFW) and initiatives
to address those barriers. In addition, appendix 1 provides a chronological history of
health coverage for farmworkers and the key outcomes and lessons of each component.
Integral to this study, and as specified in the Act, is consultation with those individuals
and agencies who have, for much of their lives, been affected by or who have been
affecting change in regards to this topic. Appendix 2 identifies numerous individuals
and agencies for consultation on the study, including individuals who are:
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Farmworkers;
Experts in providing health care to farmworkers, including designees of national
and local organizations, migrant health centers and other providers;
Experts in health care financing;
Representatives from foundations and other non-profits that have conducted or
supported research on farmworker health care financial issues;
Representatives of federal agencies who are involved in the provision or
1
For the purposes of this paper, farmworker is defined as an individual whose principal employment is in
agriculture on a seasonal basis, who has so been employed in the last 24 months, and who establishes for of
the purposes of such employment a temporary abode. HRSA BPHC Program information Notice 2003-01.
2
National Association of Community Health Centers, Inc. 7200 Wisconsin Ave, Bethesda, MD 20814
(301) 347-0400 Fax (301) 347-0459
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financing of health care to farmworkers (including CMS and HRSA);
Representatives of state governments;
Agricultural industries; and
Labor.
Lastly, this paper identifies potential solutions and /or suggested directions for
consideration by DHHS. The potential solutions listed are a compilation of the
suggested potential solutions found in the literature and are intended solely as
references for DHHS.
The National Association of Community Health Centers, Inc. fully recognizes the need
for and importance of this study, and values the work and activity that have been
dedicated to this issue in the past. NACHC also values the leaders in the migrant health
field who have contributed to the focus on this important issue and who incrementally
over three decades, have continued to document the great need for expanded access
among migrant and seasonal farm workers to health care services, and for extending
coverage to them under the Medicaid and Child Health Insurance programs.
3
National Association of Community Health Centers, Inc. 7200 Wisconsin Ave, Bethesda, MD 20814
(301) 347-0400 Fax (301) 347-0459
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II. Introduction
It is well documented that there are many factors that contribute to the lack of access to
health care services by migrant and seasonal farmworkers (MSFW). These range from
social, cultural, and economic factors to issues related to enrollment in health care
programs, be they public benefits or private insurance. In the past 30 years, studies
have shown that low income, the need to travel from state to state for work purposes, an
inability to understand the language or navigate the health care system2, and often
immigration status, affect MSFW access to primary and preventive care as well as
continuity of health care. Studies also have shown that in spite of their eligibility for
Medicaid and SCHIP health care coverage, the State-based nature of the programs often
hinder enrollment for MSFW and their family members.
Those familiar with the provision of health services to MSFW and their family
members are aware that solutions range from an expansion of affordable culturally and
linguistically appropriate health care services (as early as 1962 the Migrant Health Act
establishing the migrant health centers program was enacted to address this problem)3,
to better enforcement of existing Medicaid and SCHIP program provisions (such as 45
CFR 233.40, issued in 1979, defining ‘resident’ for state Medicaid eligibility purposes
as including “anyone who is living in a State with a job commitment or seeking
employment in the State”4), to more recent recommendations for changes to Statedirected and designed Medicaid and SCHIP programs. As reflected in the legislative
directive to DHHS, the solutions are as complicated as the problems and call for serious
consideration of portability options, interstate compacts, reciprocity agreements,
demonstration projects, and public/private partnerships, etc.
Specific to enrollment of MSFW in Medicaid and subsequently SCHIP, as far back as
1993, the often-cited Mathematica report, “Feasibility Study to Develop a Medicaid
Reciprocity Program for Migrant And Seasonal Farmworkers” and, subsequently, a
second report issues in 1994, “Crossing State Lines: Making Medicaid work for
Farmworkers: Final Report of a Demonstration Feasibility Study,” both identified
issues associated with developing a Medicaid reciprocity program. In 1999, HRSA
held a series of meetings with agency heads from the Bureau of Primary Health Care
and the Health Care Financing Administration to revisit the Mathematica Policy
Research study recommendations5. In June 2000, both the National Health Policy
Forum at George Washington University and the Reforming States/Milbank group
convened advocates from across the country and representatives from federal agencies
2
Rosenbaum, Sara, “Options for expanding publicly financed helath coverage of migrant
farmworkers and their families” Memorandum prepared for the National Association of
Community Health Centers, Inc, October, 2000
3
Migrant Health Act; Public Law 87-692.
Rossenbaum, Sara, “Options for expanding publicly financed helath coverage of migrant farmworkers and
their families” Memorandum prepared for the National Association of Community Health Centers, Inc,
October, 2000
5
Gaston, Marilyn. “Reciprocity for Migrant Farmworkers” minutes with attachments from HCFA
Eligibility Technical Advisory Group meetings sent to Claude Earl Fox. May 17, 1999
4
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to address the policy options for serving migrant children and families under SCHIP
and Medicaid6. Building on these earlier efforts, both Sara Rosenbaum, of the George
Washington University’s School of Public Health and Health Services, and Mary S.
Kenneson, of the Center for Health Care Strategies, have suggested the need to develop
multi-faceted approaches including enforcement of current program provisions, usage
of Section 1115 waiver authority and public-private joint ventures, as well as purchase
of commercial indemnity insurance for MSFW7.
While it is evident that there is agreement among the many policy makers, health
professionals, policy analysts, advocates and others that a need exists to address the
health care access problems faced by farmworkers and their families8, there appears to
be neither consensus on the solutions, nor actions undertaken to implement solutions
that have been identified. The literature cited in this paper underscores the need for
bringing together experts with knowledge of farmworker health care needs and health
care services financing experts, as well as the need for public and private sector
collaboration to identify the problems, recommend solutions, and implement the
necessary changes.
The remainder of this report provides a summary, with related suggested literature, of
the health care services access barriers experienced by MSFW and their family
members, and a compilation of suggested potential solutions found in the literature that
will, in our opinion, enable DHHS to produce a comprehensive study that encompasses
the large body of work and expert resources in this area. Appendix 1 provides a
chronological history summary of health coverage for farmworkers and the key
outcomes and lessons of each component.
6
Moore, Judith, “Policy Options for Serving Migrant Children and families underMedicaid and SCHIP:
Observations based on a June 14, 2000 discussion convened by the National Health Policy Forum”, George
Washington University, Washington , DC, month not specified, 2000
7
Rosenbaum, Sara. ibid.
8
Rosenbaum, Sara. ibid.
5
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III. Health care services and coverage access barriers
A. Issues specific to Medicaid and SCHIP program
1. Migrant farmworker mobility and lack of Medicaid and SCHIP program
portability between states. This is largely due to the state based nature of the
programs; currently, the programs are state directed and defined.
The farmworker population is divided into those who find employment on a
seasonal basis and those who migrate to find employment. Migrant
farmworkers and dependents who are eligible for Medicaid often face many
challenges and difficulties in retaining their health coverage as they move from
state-to-state. Each state has configured their Medicaid programs differently
with varying income eligibility standards, assets tests, and enrollment
requirements. Because of these differences, migrant families must re-apply for
Medicaid and undergo the lengthy enrollment process every time they cross
state lines. For populations like farmworkers, who migrate and are likely
eligible for Medicaid coverage, portability of coverage would no doubt greatly
improve access to and proper use of health care.9 Health care access obviously
improves health outcomes while preventive care and screenings can reduce
future illnesses and debilitating diseases. The long-term effect of improving
access and preventing more severe conditions would be improved health
outcomes and decreased costs from avoidable hospital and emergency room use.
Solutions to portability problems are numerous, complex, and present the
biggest challenge both in terms of design and implementation.
a. Residency requirements – Federal regulations provide that individuals
are residents of the state in which they either intend to reside indefinitely
or in which they are present for work-related reasons. The work-related
residency standard was added to the rules in 1979 specifically to foster
improved coverage of migrant family members. Studies have found both
a lack of awareness of this provision by Medicaid eligibility workers and
variable implementation from state to state.
b. Income determination – Farmworker income fluctuates, often
dramatically, during the year. Certain methodologies utilized to calculate
annual income often grossly over-estimate farmworkers’ actual annual
income by basing projections on peak employment periods and earnings,
but failing to capture unemployment or low earnings periods.
9
Gallardo, E., Huang, V., (2002) “Expanding Immigrant Access to Health Care Services: A Policy Brief”,
California Primary Care Association
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c. Upper income limits and assets tests – Standards vary from state to
state, and often use key assets (such as vehicles or tools) needed by
farmworkers for the very nature of their work for exclusionary purposes.
d. Differences in categorical eligibility – States are required to cover
certain categorical groups in the Medicaid and SCHIP programs, but
often have flexibility and options to cover additional population groups.
For example, states vary tremendously in their coverage of legal
immigrants so that an immigrant farmworker eligible for Medicaid
coverage in California may not be eligible in Colorado, resulting in
barriers to retaining coverage.
2. State-Designed and Directed Program Structural Barriers
a. Complexity of the application process, application form, and length
of the determination period – Variations in the process, forms utilized,
and the eligibility determination period from state to state are
impediments that often discourage migrant farmworkers from seeking or
securing enrollment in Medicaid and SCHIP. Mobility intensifies
enrollment-related barriers. Families may lack the necessary documents
that some states require because they are on travel. Finally, farmworkers
often must move on before the eligibility determination process is
complete and assistance is made available.10
b. Proximity of enrollment sites – Medicaid enrollment sites may be
inaccessible in the remote areas in which migrant families may live and
work.11 Many farmworkers depend on others for transportation to work.
Often a visit to the Medicaid offices can mean loss of a day’s pay in
addition to the expense of getting there. As a result, health care is often
delayed until it is absolutely necessary and more likely results in costly
emergency room visits.
c. Lack of conformity between states in services provided – Some states
cover optional Medicaid benefits, like dental and mental health services.
The lack of conformity between states in services provided is a structural
barrier that is often cited as an impediment for establishing interstate
compacts and reciprocity agreements between states.
d. Categorical eligibility - The Medicaid program covers three major
eligibility groups: children and families, the disabled, and the elderly.
These eligibility groups do not correlate well with the demographic
10
Rosenbaum, Sara, “Options for expanding publicly financed health coverage of migrant farmworkers and
their families” Memorandum prepared for the National Association of Community Health Centers, Inc,
October, 2000
11
Rosenbaum, Sara. Ibid.
7
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characteristics of the farmworker population. For example, many
migrant farmworkers travel as single adults. Similarly, many
farmworkers leave their families in their country of origin or do not have
Medicaid eligible children because of immigration barriers. The result
leaves very few farmworkers able to access Medicaid coverage.
e. Language and cultural issues – Unique language and cultural needs
complicate understanding and navigating the application process and
require limited English proficiency assistance. The Office of Civil
Rights in the Department of Health and Human Services is charged with
enforcement of Title VI of the Civil Rights Act of 1964 including
provisions requiring meaningful access to limited English proficient
patient populations, such as farmworkers. Despite federal requirements,
there remain linguistic barriers for MSFW trying to access state services.
Many states have been sued for non-compliance with these provisions
and have adopted comprehensive language service programs as a
remedy. The Office of Civil Rights recently issued a guidance to assist
states with compliance.
f. Geographically designed managed care programs participating in
Medicaid – Increased participation of HMO’s in Medicaid managed
care has further exacerbated the issues associated with lack of coverage
portability. Given conventional managed care’s reliance on gatekeeper
functions, providers who render care without approval from designated
primary care gatekeepers are typically not reimbursed.
Suggested literature
California Primary Care Association, “Medicaid Portability for Migrant
Farmworkers: Cost-Benefit Analysis,” research conducted by the California Institute for
Rural Studies, 2002.
Wright, G., Fasciano, N., Frazer, H., Hill, I., Zimmerman, B., and Pindus, N.
“Feasibility Study to Develop a Medicaid Reciprocity Program for Migrant and Seasonal
Farmworkers: Background Paper,” submitted to the Department of Health & Human
Services, 1993.
Arendale, E., “Medicaid and State Children’s Health Insurance Program” produced
for the National Advisory Council on Migrant Health by the National Center for
Farmworker Health, Inc, Buda, TX October 2001
Kenesson, Mary S., “Improving Health Services Access for Medicaid-Eligible
Migrant Farmworkers” Study funded by the Center for Health Care Strategies, Inc,
September, 2000
Rosenbaum, Sara, “Options for expanding publicly financed health coverage of
migrant farmworkers and their families” Memorandum prepared for the National
Association of Community Health Centers, Inc, October, 2000
Moore, Judith, “Policy Options for Serving Migrant Children and families under
Medicaid and SCHIP: Observations based on a June 14, 2000 discussion convened by the
National Health Policy Forum”, George Washington University, Washington , DC, month
not specified, 2000
8
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(301) 347-0400 Fax (301) 347-0459
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Gaston, Marilyn. “Reciprocity for Migrant Farmworkers” minutes with
attachments from HCFA Eligibility Technical Advisory Group meetings sent to Claude
Earl Fox. May 17, 1999
Bohrer, Richard “Medicaid Reciprocity/Portability” minutes from HCFA
Eligibility Technical Advisory Group, June 24, 1999
Medicaid and SCHIP Enrollment for Migrant Workers: Issues and Options –
Migrant Health Branch Division of Community and Migrant Health, Bureau of Primary
Health Care, Health Resources and Services Administration, Department of Health
Administration
3. Immigrant Eligibility
Title IV of the Personal Responsibility and Work Opportunity Reconciliation
Act of 1996 (welfare reform) and the Illegal Immigration Reform and
Immigrant Responsibility Act of 1996 (immigration reform) created various
barriers to health care access for the immigrant population and therefore, the
farmworker population. For example, welfare law now grants states discretion
to preserve or deny non-emergency Medicaid and State Children's Health
Insurance Program (SCHIP) to most legal immigrants. Welfare reform created
new categories for the immigrant community. Welfare reform recognizes
“qualified “ immigrants, which includes lawful permanent residents who have
resided in the U.S. for at least 5 years; conditional entrants; parolees admitted
for at least 1 year; refugees; asylees; persons who have had their deportation
withheld; and certain battered immigrant women and immigrant parents of
battered children. All immigrant groups that do not fit in the "qualified"
category are considered “not qualified” immigrants and are ineligible for many
federal public health care benefits, including full coverage under Medicaid and
SCHIP.
Suggested literature
Pub. L. No. 104-193, 110 Stat. 2105 (1996), codified at 8 U.S.C. §1601 et seq.
Pub. L. No. 104-208, 110 Stat. 3009 (1996)
Gallardo, E., Huang, V., (2002) “Expanding Immigrant Access to Health Care
Services: A Policy Brief”, California Primary Care Association
National Immigration Law Center, (2002), Guide to Immigrant Eligibility for
Federal Programs, 4th edition.
Reardon-Anderson, J., Capps, R., Fix, M., (2002) “The Health and Well-Being
of Children in Immigrant Families”, Urban Institute
Fix, M., Passel, J. (2002) “The Scope and Impact of Welfare Reform's Immigrant
Provisions”, Urban Institute
Brown, R., Wyn, R., and Ojeda, V. (1999). “Access to Health Insurance and
Health Care for Children in Immigrant Families,” UCLA Center for Health Policy
Research.
Schlosberg, C. and Wiley, D. (1998). “The Impact of INS Public Charge
Determinations on Immigrant Access to Health Care,” National Health Law Program and
National Immigration Law Center.
National Immigration Law Center, (1998), Affidavits of Support and Sponsorship
Requirements: A Practitioner's Guide
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IV. Other Health Care Services Barriers – This section is provided to describe
additional barriers to health care services and insurance coverage beyond those that
relate specifically to Medicaid and SCHIP.
A. Lack of Employer Provided Health Care Insurance – By virtue of their work
in agriculture, most farmworkers lack employer provided health care insurance
and do not make enough to purchase individual private health insurance. Even in
the small number of cases where insurance is offered, MSFW lack sufficient
economic resources to afford their share of premiums, co-pays, and deductibles.
B. Lack of primary and preventive health care benefits for authorized
temporary foreign workers (H2A) - Guestworker employers are required to
provide state workmen’s compensation for authorized temporary foreign workers.
However, there is no provision in the statute requiring the provision of primary
and preventive health care services.
C. Rising costs of enabling services and services for the uninsured. – Community
and migrant health centers provide affordable comprehensive primary and
preventive health services. Health center patients are not required to provide
citizenship verification in order to receive care. Often, increasing numbers of
uninsured patients and decreasing Medicaid revenues result in fewer resources
targeted for enabling services such as outreach, interpreters, and transportation. In
addition to ensuring communication between providers and patients,
communication between government agencies and patients is indispensable to
ensure that limited English proficient (LEP) individuals have access to public
programs for which they are eligible, such as Medicaid, SCHIP, and Medicare. A
California survey of LEP parents found that 25% of all Spanish-speaking Latinos
had difficulty understanding California’s Medicaid and California’s SCHIP
application as compared to 14.2% of non-Latinos. As a result, Latino children are
more likely to be uninsured due to language barriers in completing the enrollment
process for health coverage.
10
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V. Potential Solutions
Conditions relating to eligibility, enrollment, and portability of coverage (or the lack
thereof) under Medicaid and SCHIP, which present often insurmountable barriers to
securing such coverage for MSFW have been the subject of a large volume of work
over the years, with recommendations for potential solutions that range from
enforcement of existing program regulations that could facilitate greater enrollment and
provision of services, to more complex options involving the use of interstate compacts
or reciprocal agreements. More recent literature suggests exploring further possibilities
including the use of third party administrators, purchase of commercial indemnity
insurance, and other legislative solutions.
Currently, numerous efforts are underway across the country to address these problems
and other related health services access issues. California, Oregon, and Washington
have been funded by the HRSA/BPHC to pilot reciprocal State Medicaid agreements.
The Texas Primary Care Association and the State Medicaid Agency have ongoing
discussions related to a third party administrator arrangement that would manage out of
state claims for MSFW. Since 1997 Wisconsin has accepted individuals with proof of
valid Medicaid coverage in other states, and has automatically enrolled them in its
Badger Care plan. Some migrant health centers have pursued out-of-state provider
billing agreements. The California Endowment funds research and initiatives that have
enabled researchers, public officials, state agencies and private non-profit organizations
to come together to identify the issues and potential solutions, and to implement
programs.
What follows below is a summary of potential solutions that can be implemented as
stand-alone actions or be combined in multi-faceted strategies. The potential solutions
listed are derived from suggestions found throughout the literature and are intended as
references for DHHS.
Suggested written literature
California Primary Care Association, “Policy Options,” analysis conducted for the
Medicaid Portability for Migrant Farmworkers Project, 2002.
Kenesson, M. “Improving Health Service Access for Medicaid-Eligible Migrant
Farmworkers,” Health Policy Crossroads for the Center for Health Care Strategies, 40
pages.
Moore, J. “Policy Options for Serving Migrant Children and Families under
Medicaid and SCHIP: Observations based on a June 14, 2000 discussion convened by the
National Health Policy Forum,” National Health Policy Forum, 3 pages, 2000.
Rosenbaum, S. Memorandum on Options for expanding publicly financed health
coverage of migrant farmworkers and their families. Dated October 20, 2000.
Wright, G. and Fasciano, N. “Feasibility Study for a Demonstration to Improve
Medicaid Coverage of Migrant Farmworkers and Their Families: Issues and
Recommended Approach,” Mathematica Policy Research Inc., August 2, 1994.
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A. Enforcement of current program provisions.
Efforts could be made to inform states of current federal regulations that
facilitate enrollment and provision of services. States could streamline
enrollment policies, including instituting presumptive eligibility, for the
farmworker population in order to reduce barriers to access. Federal regulations
address both minimum requirements and state options in the following areas:
1.
2.
3.
4.
5.
Residency requirements
Simplified application forms
Length of enrollment determination period
Presumptive eligibility
Out of state provider billing agreements
B. Uniform eligibility requirements
Uniform eligibility requirements for MSFW enrollment in Medicaid and SCHIP
across the programs or among several participating states (e.g. those with the
largest farmworker populations) would resolve many of the problems related to
residency, assets, and income requirements. As an interim step, a pilot project
could be established among two or more states.
C. Interstate compacts and reciprocity agreements.
Discussions related to lack of program coverage portability for MSFW have
centered on development of interstate compacts and reciprocity agreements
among participating states. Much discussion has been devoted to the issues
related to each model presented below. For a summary of issues for each
model, the reader is referred to the matrix of options developed by Mary S.
Kenneson in her report “ Improving Health Services Access for MedicaidEligible Migrant Farmworkers.”
1. Inter-State Eligibility Transfer – Farmworker’s would secure initial
annual Medicaid enrollment in any state, using that state’s policies and
process. Other states allow simple local enrollment, accepting the
initial state’s determination of basic eligibility criteria, for expedited
issuance of state-specific Medicaid card.
2. Reciprocal Eligibility Determination – States would fully recognize
other states’ eligibility determinations. Wisconsin has been accepting
Medicaid enrollments from other states since 1997 as part of its
Badger Care program
3. FQHC centered reciprocal eligibility model - FQHCs in all states
would accept other states’ Medicaid card. FQHC services (only)
would be billed to each FQHC’s own state as Medicaid encounter.
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D. Other Potential Demonstration Projects (Multi-state and Hybrid Models)
1. Central Eligibility Clearinghouse – Central to any interstate
compacts or reciprocity agreements is the development of a multi-state
migrant eligibility roster and database to facilitate re-enrollment in
each state and/or provider verification of eligibility.
2. Improved out-of-state claims processing - Current regulations
permit and contemplate reimbursements to out-of-state providers.
Some health centers have secured out of state provider billing
agreements, but this practice is not widespread. Greater participation
of out-of-state providers would be facilitated by encouraging states to
utilize more flexible, uniform policies for payment of-out-state claims.
3. Use of a Third Party Administrator to establish a claims
processing clearing house – A commercial insurer or TPA would
issue Medicaid cards and process claims for payment by the state
where the farmworker enrolled in Medicaid. Providers would
recognize the card as similar to commercial coverage, but payment
liability remains with the state of enrollment.
4. Purchase of commercial indemnity insurance – Each state that
enrolls a migrant farmworker would pay a fixed premium to the
insurance company, which would issue a card and pay all claims
regardless of the service delivery location.
5. Use of statewide or multi-state managed care systems – The rise of
statewide and multi-state, and even nationwide, managed care systems
in recent years, both for enrollment of commercial and of Medicaid
populations, could form the foundation for resolving the portability
issue. For example, one or more states could enroll eligible
farmworker populations in one or more managed care organization
(MCOs), which could arrange care through provider networks that
cross state lines. Special arrangements may be needed to ensure that
these networks include providers located along the migrant streams,
and ideally should include migrant health centers and other providers
with expertise in serving farmworkers.
E. Legislation to expand current or establish new coverage
1. Federal eligibility category created for farmworkers. Farmworkers who meet the eligibility requirements could receive
Medicaid coverage that could be recognized among several states.
The existing infrastructure of providers would remain the same and
states would continue paying their providers for services received by
migrant farmworkers with this coverage.
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2. Enhanced coverage for legal immigrants -- One partial, yet
important, solution is passage of the Immigrant Children’s Health
Improvement Act. This legislation would provide states with the
option of providing Medicaid coverage to legal immigrant children
and pregnant women within their first five years of arrival in the
United States. For states that take up this option, they would receive a
federal match for the provision of coverage to this population; thereby
providing incentives for states to provide Medicaid coverage for legal
immigrant children and pregnant women within their first five years of
arrival.
3. Universal coverage - Universal coverage options should be explored
as a mechanism for ensuring access to health care for farmworker
populations. A variety of options exist. On the federal level, the
National Association of Community Health Centers (NACHC) is
advocating for H.R. 1200 (McDermott), the American Health Security
Act of 2003 that would create a national single payer system. Also,
NACHC is supporting H.R. 1205/S. 588 (Stark/Rockefeller), the
MediKids Health Insurance Act of 2003 that would provide coverage
for children through a Medicare type system. In California, there is a
variety of universal coverage proposals which include coverage for
undocumented individuals. S.B. 921 (Kuehl) would create a single
payer system, and S.B. 2 (Burton), A.B. 1527 (Frommer), and A.B.
1528 (Cohn) are variations of “pay-or-play” proposals that would
create a requirement for employers to provide health coverage for
employees or pay into a state pool to do so.
4. Tax credits for employer provided health insurance – California is
currently exploring legislation to provide incentives for agricultural
employers to provide health insurance coverage. AB 923 (Wesson,
Chavez and Firebaugh) would repeal various existing tax credits and
exemptions, and instead authorize a credit for agricultural employers
who provide health care coverage for their agricultural employees.
Although the California version of this legislation does include the
repeal of some credits, this kind of model could simply offer the credit
without a repeal. If implemented, this model could result in many
uninsured farmworkers securing employment-based health insurance
coverage.
5. Inclusion of primary and prevention health care services
requirements in H2-A program – Inclusion of requirements that
employers provide primary and preventive health care services for H2A workers should be explored.
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Suggested Literature
California Health and Human Services Agency, “State Health Care Options
Project,” health care coverage reform options papers can be found on the website:
http://www.healthcareoptions.ca.gov/doclib.asp
H.R. 1200 (McDermott), the American Health Security Act of 2003, 108th
Congress.
H.R. 1205/S. 588 (Stark/Rockefeller), the MediKids Health Insurance Act of 2003,
108th Congress.
California State Legislature, Senate Bill 921 (Kuehl), Legislative Session 2003-04.
California State Legislature, Senate Bill 2 (Burton), Legislative Session 2003-04.
California State Legislature, Assembly Bill 1527 (Frommer), Legislative Session
2003-04.
California State Legislature, Assembly Bill 1528 (Cohn), Legislative Session
2003-04.
H.R. 1143/S. 582 “Immigrant Children’s Health Improvement Act” introduced by
Representative Lincoln Diaz-Balart and Senator Bob Graham in the 107th
Congress. Will be reintroduced in the 108th Congress.
F. Reimbursement for language assistance services
The Office of Civil Rights in the Department of Health and Human Services is
charged with enforcement of Title VI of the Civil Rights Act of 1964 including
provisions requiring meaningful access to limited English proficient patient
populations, such as farmworkers. Many states have been sued for noncompliance with these provisions and have adopted comprehensive language
service programs as a remedy. The Office of Civil Rights recently issued a
guidance to assist states with compliance.
Section 330 of the Public Health Service Act outlines health center services as
including those that enable individuals to use the services of the health center,
including employing appropriate personnel fluent in the language spoken by a
predominant number of limited English-speaking individuals. However, despite
the mission of health centers to provide these services, there is currently no
specific mechanism for health centers to be reimbursed for such services. In
order to improve access to language services, reimbursement for health care
providers is critical. One approach would be to ensure that language assistance
services are accurately and appropriately included in the process for establishing
prospective payment system rates and the process for calculating rates as a
result of changes in scope of services.
The Centers for Medicare and Medicaid Services should issue a clarifying Dear
State Medicaid Directors letter to outline the procedures for obtaining federal
reimbursement for language assistance services, especially through the
Medicaid and State Children’s Health Insurance Programs. To further support
and incentivize the provision of language assistance services, the federal
Medicaid/SCHIP matching rates should be increased to 90% for states that
provide language services. This provision is currently a component of the
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Hispanic Health Improvement Act.
The Department of Health and Human Services should promote other grant
funding opportunities for providing language services to underserved
populations.
Suggested literature
Asian & Pacific Islander American Health Forum, “Improving Access to Health
Care for Limited English Proficient Health Care Consumers: Options for Federal Funding
for Language Assistance Services,” Health in Brief, Volume 2, Issue 1, April 2003.
California Primary Care Association, “Providing Health Care to Limited English
Proficient Patients: A Manual of Promising Practices,” 117 pages, 2001.
Centers for Medicare and Medicaid Services, Dear State Medicaid Director Letter,
dated August 31, 2000.
Linguistic Access Grants provision in S. 1533, “Health Care Safety Net
Amendments Act of 2002” introduced by Senator Edward Kennedy. Became Public Law
No: 107-251.
Increased Federal Medicaid Match provision in H.R. 5449/S. 2990 “Hispanic
Health Improvement Act” introduced by Representative Ciro Rodriguez and Senator Jeff
Bingaman in 2002.
G. Potential benefits of technology and information systems –
Increased developments in information systems technology and usage provide
opportunities to address many of the barriers and solutions that have been
identified thus far. Recent HIPAA federal regulations that adopt national
standards for exchange of electronic health care data as well as current
initiatives at DHHS to implement common IT standards will facilitate electronic
information exchange as well as usage of a centralized database that are implicit
in many of the interstate compact and/or reciprocity models identified
previously. Areas that may be affected include:
1. Enrollment verification – Compatible information systems between
states facilitate enrollment verification and transfer of historical
eligibility information as well as assists with continuity of service.
2. Ability to streamline out of state provider reimbursements –
Information standards for claims processing facilitate out of state
provider reimbursements.
3. Use of a centralized database – the advent of the internet and
broadband technologies have enabled greater use of remote hosting
and connection to centralized databases for program administration. A
good example of this is in California, where the state has initiated an
internet-based Medicaid enrollment program that allows for eligibility
verification and enrollment from any location via laptop computer.
16
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VI. Recommended Experts and Consultants
Appendix 2 references suggested individuals and organizations that have expertise on
both farmworker health issues and/or familiarity with financing of health care services for
farmworkers.
17
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(301) 347-0400 Fax (301) 347-0459
www.nachc.com
Appendices and Attachments
18
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Appendix 1
Chronology of significant events – Farmworker Access to Health Care Services and Financing.
Summary
Historical milestones toward Medicaid and SCHIP coverage for
Migrant and Seasonal Farmworker (MSFW)s
Anne Kauffman Nolon, MPH
Hudson River Community Health
The Road Most Traveled– Historical Milestones in Medicaid and SCHIP Coverage for MSFWs
Date
1962
Sentinel Event/ Impetus
Migrant Health Act
PL 89-692
What did this action do?
• Established the Migrant Health
Center Program
Helen Johnston
July
1979
Federal Reg. Published
(45 CFR Part 233), Effective
10/15/79
James Laughlin
Midwest Migrant Consortium
E. Roberta Ryder
1980
to
1990
NACHC Farmworker Committee
established and meets regularly
Feb,
1994
Mathematica Policy Research
submits “Crossing State Lines:
Making Medicaid Work for
Migrant Farmworkers
• Establishes additional criteria for
determining state residency of
applicant for public assistance. •
Expands the definition of a resident
to include anyone who, at the time
of application, is living in the state.
Significance to MSFWs
Amended the Public Health
Service Act and authorized the
Surgeon General to make grants
for establishing and maintaining
MHCs
• This definition allows MSFWs
with families, who are denied
AFDC and Medicaid benefits
because they move state to state
for employment, to meet the
residency requirements for state
assistance, as well as benefits if
they are eligible.
• Kept coverage issue for MSFWs
in the forefront
• Helped to integrate views and
regulatory change into action
• Advocacy influences moved
players toward feasibility study
• Study recommended an
“Interstate Transfer Model”
Addresses the need to improve
Medicaid participation for
MSFWs and their families
• Recommended nationally
administered health care program
for MSFWs
• Creation of a cooperative
demonstration project sponsored
by CMS & BPHC to facilitate
reciprocity through use of an
‘interstate enrollment transfer
model.’
• Action promoted out-stationing of
county eligibility workers in high
impact areas, and the ease of a
simplified Medicaid application
process.
• First experiment using waiver
and reciprocity: acknowledged
the need for ‘relaxed’ and
proactive state eligibility
determination
• Led to implementation of
‘Badger Care’ Program for
uninsured children and parents
• Action augmented provision of
services by M/CHCs for
MSFWs
Sara Rosenbaum
E Roberta Ryder
NACHC Farmworker Committee members
Barriers/
Contradictions
George E. Wright
Nancy J. Fasciano
Mathematica Policy Consultants
1995
National Advisory Council on
Migrant Health issues report
“Losing Ground”
David Duran
Chair Advisory Council Members
1997
Wisconsin utilized a waiver
process to allow for Medicaid
reciprocity
David Duran
National Advisory Council
appeals to Secretary Shalala
regarding CHIP
• Urges Secretary to guide states in
developing CHIP regulations to
ensure that plans maximize services
to MSFWs
Good and Bad:
• State volume is low so
that cost implications
are minimized
• Not really ‘reciprocity’
when other states don’t
do it!
Raphael Martinez, PhD. Chair of Council;
NCFH; OMH
1998
July
Texas explores Medicaid
• Clarifies that federal Medicaid reg
• Increases access and improves
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1998
coverage for migrants traveling
out-of-state wishing to establish a
multi-state migrant health care
system
42 CFR 431.52(b) permits payment
for state residents who are traveling
out of state.
continuity of care for MSFWs
traveling out of state
• Explores billing/ payment
options for out-of-state migrant
care
• Highlights state flexibility to
simplify the CHIP and Medicaid
application and enrollment process.
• Clarified eligibility issues: SSNs
and non-applicant family members
• Augments eligibility
determination and enrollment for
MSFWs into CHIP and
Medicaid.
• NCFH staff worked with Mich. to
focus on simplification of
eligibility process for CHIP and
MA with presumptive eligibility
likely to be implemented.
• Texas legislature was moved to
action: NCFH used ‘Call for
Health’ case studies to urge, with
TACHC leadership, the creation of
a PPO for migrants in MA
• Migrant health advocates
began to differentiate between
portability and reciprocity
• Request for TA from
organizations at state level to
include farmworker access to
CHIP and Medicaid in their
agendas.
•Discussed a letter to all state MA
agencies, from HRSA and HCFA,
listing options and encouraging
implementation.
• Identified TX as a candidate for
pursuing reciprocity
• Included reciprocity/
portability on agenda for state
MA directors
J. Camacho, TACHC
Sara Rosenbaum
Sep
1998
HCFA Admin. Sally Richardson
issues clarification in the Jan. 23,
1998 letter to state health officials
regarding outreach to uninsured
children.
Sally Richardson
Marc
h
1999
NCFH initiates “Removing
Barriers to Farmworker
Participation in CHIP and
Medicaid” funded by the MCH,
HRSA which supported staff
assistance to states and
implementation of ‘Call for
Health’ program.
E Roberta Ryder, NCFH
May
1999
HCFA invites BPHC to lead
discussion on reciprocity at its
Eligibility Advisory Group.
S. Richardson
D. Cade
M. Svolos
L. Partridge
Dr. E. Fox
Dr. M. Gaston
R. Abrams
J. Rodgers
Aug .
1999
NACHC Farmworker Committee
Access Workgroup focuses on
categorizing info. and monitors
HCFA/HRSA.
• Initiated NACHC’s focus on
MSFWs Access to Care
Eligio White
Tina Castanares
John Ruiz
Aug .
1999
California Rural Demonstration
for Migrant/Seasonal Worker
Health Services initiated.
Elia Gallardo, CPCA
June
2000
National Health Policy Forum
sponsors meeting to discuss how
to better serve MSFW children
and families.
• CA utilized its SCHIP allocation
for administration, outreach and
health services initiatives.
• CA continues to focus on
portability of Medicaid w/in the
state as well as reciprocity among
CA, OR and WA for agricultural
workers.
• Suggested policy options and
identified limited, intermediate and
major comprehensive reform
approaches.
• CA Model focuses on
increasing access through
reciprocity among California,
Oregon & Washington
• Highlighted SCHIP addressing
issues of portability and mobility
and suggests expansion
Judy Moore, Robert Valdez,
RWJ Covering Kids
Aug .
2000
Access Workgroup modified
charge under new direction
Anne Nolon
Bobbi Ryder
John Ruiz
Sep.
2000
‘Improving Health Service
Access for MA-Eligible
Farmworkers’ published by Mary
Kenesson.
• New mandate to explore MSFW
access to MA and SCHIP at
national and state levels; provide
recommendations on policy or
legislative initiatives.
• Acknowledged barriers to the
reciprocity approach and
recommends portability as the
solution.
• Allows farmworkers to remain
insured as they travel with no
new application and same
coverage
• Fiscal implications of
serving additional
eligible but non-enrolled
patients
• Administrative
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coordination among
state Medicaid offices
• Providers enrollment
in multiple state
Medicaid programs
Mary Kenesson, Health Policy Consultant
for Health Care Strategies, In. funded by the
Robert Wood Johnson Fund.
Sep.
2000
Reforming States Group, HCFA,
HRSA, with assistance from
Millbank Fund, sponsors meeting
to discuss feasible future of MA
coverage for migrant workers
who cross state lines
HCFA
Tim Westmoreland
Oct.
2000
Sara Rosenbaum memo to Access
Workgroup
• Develop steps that would lead to
administrative or regulatory
mechanisms that would enable
portability of coverage.
• Immediate minor and major
changes in law or regulatory
process
• Presents options for expanding
publicly-financed health coverage
for MSFWs and families
Sara Rosenbaum
Jan.
2001
HCFA letter to State MA
Directors: Westmoreland
clarification on out stationing of
MA eligibility workers
• Requires states to provide
opportunities to apply for MA at
locations other than MA offices,
including FQHCs.
HCFA Administrator
Tim Westmoreland
Access Workgroup submits
‘Concept Paper’ to Farmworker
Committee
Rachel Gonzalez
Anne Nolon
Dan Hawkins
Velma Hendershott
Chris Koppen
Susan McNally
John Ruiz
Oct.
2001
MA and the State Children’s
Health Insurance Program’ by
Elizabeth Arendale of NCFH.
NCFH
E. Arendale
April
2002
TX Health & Human Services
Commission recommends the
establishment of a Migrant Care
Network with funding.
• Based on committee
recommendations, NACHC Board
of Directors supports inclusion of
the establishment of a commission
(later changed to ‘Study’) as part of
its legislative agenda; hence
inclusion in the C/MHC
Reauthorization Bill No. S1533.
• Published as part of the Advisory
Council Migrant Health monograph
series. • Reviewed evolution of key
concepts related to SCHIP and MA
and eligibility and enrollment.
• Focused on establishing MA
portability for TX migrants
traveling to selected pilot states
through a managed care model.
• Allows farmworkers to remain
insured as they travel
• Presumptive eligibility for all
MSFWs in MI, scheduled to begin
November 2002
Increase enrollment in Medicaid
and Mi Family
J. Camacho
TACHC
Oct.
2002
MI Migrant Health Plan
introduced by PCA coalition.
Proposed relationship with TX.
MPCA, NCFH, MHR, MHC Leaders
E. Kapeller
Oct.
2002
C/MHC consolidate
Reauthorization Bill signed by
President Bush
• Directs HHS Secretary to conduct
a study regarding barriers to
participation of MSFWs in health
programs.
Thanks to ALL NACHC Family
Nov.
2002
SCHIP/MA meeting, hosted by
NCFH at the Midwest Stream
Meeting
• Presentation on historical
milestones toward MA & SCHIP
coverage, TX, MI and CA models.
NCFH, E Roberta Ryder, E. Kapeller, Anne
Nolon, John Ruiz, Jose Camacho, Jana Blasi,
Olga Garcia, Carolee Besteman
Jan.
2003
NACHC Farmworker Committee
Chair, Juan Carlos Olivares,
• Workgroup charge: “to ensure
that NACHC and collaborators
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establishes workgroup.
exercise maximum influence on
report.”
Juan Carlos Olivares, Jerry Brasher, Eliz
Gallardo, Rachel Gonzalez, Velma
Hendershott, Vivian Huang, Anne Nolon,
Doug Smith, Bobbi Ryder, Eligio White,
NACHC Staff, John Ruiz
May
2003
Farmworker Study Workgroup
reports to Farmworker Committee
for recommendation to NACHC
Board
Juan Carlos Olivares, Jerry Brasher, Eliz
Gallardo, Rachel Gonzalez, Velma
Hendershott, Vivian Huang, Anne Nolon,
Doug Smith, Bobbi Ryder, Eligio White,
NACHC Staff, John Ruiz
• Reports on strategies to ensure
successful implementation of
Farmworker Study reflecting on
potential solutions. Names experts
and advisors.
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Appendix 2
Contact Chart:
Individuals Involved with Issues Facing
Migrant and Seasonal Farm Workers (MSFWs).
Contact
Name
Affiliation
Abrams, Rhoda
Health Resources and
Services
Administration
Arendale, E.
National Center for
Farmworker Health
Besteman Carol
National Center for
Farmworker Health
Blasi, Jana
National Center for
Farmworker Health
Brasher, Jerry
Plan de Salud del
Valle, Inc
Cade, David
HHS
Camacho, Jose
Texas Association of
Community Health
Centers, CEO
Castañares, Tina
NACHC Farmworker
Committee Access
Workgroup
Duran, David
National Advisory
Council, Chair;
Migrant Hispanic
Liaison
Contact Info.
HHS
Center for Managed Care
301-443-1550
rabrams@hrsa.gov
PO Box 150009
Buda TX, 78715
512-312-5453
Michigan Primary Care Association
Clinical Consultant
cbesteman@mpca.net
517.381.8000 x 204
TACHC Deputy Director
512-329-5959
jblasi@tachc.org
1115 Second Street
Fort Lupton, CO 80621
303-892-6401
F 303-892-1511
jbrasher@saludclinic.org
Office of the General Counsel
2301 S Capital of Texas H
Bldg H
Austin, TX 78746
T (512) 329-5959
F (512) 329-9189
jcamacho@tachc.org
La Clinica del Cariño Family Health
Care Center
Castañares Consulting
637 Highway 141
White Salmon, WA 98672
509 - 493-1600
tina.castanares@gorge.net
Wisconsin Department of Health and
Family Services
PO Box 7850
One West Wilson Street, Room 561
Madison, WI 53707durand@dhfs.state.wi.us
Area of
Expertise
Health Care
Financing
Medicaid and SCHIP
Michigan state based
model of coverage
Texas state based
model of coverage
Farmworker
Advocacy
Health Care Policy
Texas state based
model of coverage
Farmworker Medical
Provider
Wisconsin state
based model of
coverage;
Farmworker
Advocacy
23
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(301) 347-0400 Fax (301) 347-0459
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Phone: (608) 266-9372
Fax: (608) 267-2147
Fox, Dr. E.
HCFA
Former Administrator
Health Care
Financing
Gallardo, Elia
California Primary
Care Association,
Legislative Director
1215 K Street
Ste 700
Sacramento, CA 95814
T (916)440-8170 F (916)440-8172
egallardo@cpca.org
Farmworker Access
and California state
based models of
coverage
Gaston, Dr. M.
Bureau of Primary
Health Care
Former Director of BPHC
Health Care Policy
Gonzalez, Rachel
Uvalde County
Clinic, CEO;
NACHC Farmworker
Committee, past
chair; NACHC
Board, past chair;
201 South Evans
Uvalde, TX 78801
830-278-5604
raghanson.chdi@tachc.org
Farmworker
Advocacy
Hawkins, Dan
National Association
of Community Health
Centers, Vice
President
Division of Federal, State and Public
Affairs
7200 Wisconsin Ave., Suite 210
Bethesda, MD 20814
Phone: 301/347-0400
Fax: 301/347-0459
dhawkins@nachc.com
Health Care
Financing and Health
Policy
Hendershott, Velma
InterCare Community
Health Network,
CEO; NACHC
Board, past chair;
National Center for
Farmworker Health,
current Board
member
308 Charles Street
PO Box 130
Bangor MI 49013
616-427-7937velma@intercare.org
Farmworker
Advocacy
Huang, Vivian
California Primary
Care Association,
Senior Policy Analyst
Kenesson, Mary
Koppen, Chris
Health Care
Strategies, Inc Health Policy
Consultant
National Association
of Community Health
Centers, Director for
Health Care Financing
Policy
Laughlin, James
Community Health
Partnership of
Illinois, Inc., CEO;
NACHC Farmworker
Committee, past
chair; Midwest
Migrant Consortium
1215 K Street
Ste 700
Sacramento, CA 95814
T (916)440-8170 F (916)440-8172
vhuang@cpca.org
PO Box 371 Waterford VA 20197
540-882-4431
fax: 540-882-4416
masuke@erols.com
7200 Wisconsin Ave., Suite 210
Bethesda, MD 20814
Phone: 301/347-0400
Fax: 301/347-0459
ckoppen@nachc.com
203 North Wabash, Suite 300
Chicago, IL 6060
312-795-0000
jimchp@aol.com
Farmworker Access
and California state
based models of
coverage
Health Care
Financing
Health Care
Financing
Migrant Health
Voucher;
Health Policy
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National Association of Community Health Centers, Inc. 7200 Wisconsin Ave, Bethesda, MD 20814
(301) 347-0400 Fax (301) 347-0459
www.nachc.com
Martinez, Raphael –
PhD
Past Chair of
National Advisory
Council; National
Center for
Farmworker Health,
Board member
9601 Southbrook Drive, N103
Jacksonville, FL 32256
(904) 564 - 3737
Farmworker
Advocacy
Moore, Judy
HCFA
Former Director Medicaid Bureau
(ret.)
Medicaid
Nolon, Anne
Hudson River
Community Health,
CEO; National
Center for
Farmworker Health,
Past Chair, current
Board member;
NACHC Farmworker
Committee, past chair
HRHCare
1037 Main Street
Peekskill, NY 10566
914.734.8800
914.734.8745
anolon@hrhcare.org
Farmworker Health
Coverage History;
Health Policy,
Farmworker
Advocacy
Olivares, Juan Carlos
Yakima Valley Farm
Workers Clinic, Inc,
CEO; NACHC
Farmworker
Committee, chair;
Partridge, Lee
HCFA
Director, Health Policy Unit
American Public Human Services
Association
Health Access
Richardson, Sally
HCFA
Former Administrator, HCFA
Health Care
Financing
Rodgers, Jack
Pricewaterhouse
Coopers
Washington, D.C., office of
PricewaterhouseCoopers
(202) 414-1646
jack.rodgers@us.pwcglobal.com.
HMOs
Medicare
Rosenbaum, Sara;
Esquire
George Washington
University Medical
Center School of
Public Health and
Health Services
Ruiz, John
National Association
of Community Health
Centers, Assistant
Director
Ryder, Roberta
National Center for
Farmworker Health,
CEO; NACHC
Farmworker
Committee, past chair
518 West First Ave
PO Box 190
Toppenish, WA 98948
509-865-5898
F 509-865-4337
GWU
2021 K St. NW
Suite 800
Washington, DC 20006
sarar@gwu.edu
Department of Systems Development
and Policy,
7200 Wisconsin Ave., Suite 210
Bethesda, MD 20814
Phone: 301/347-0400
Fax: 301/347-0459
jruiz@nachc.com
PO Box 150009
Buda TX, 78715
512-312-5453
ryder@ncfh.org
Farmworker
Advocacy, Health
Policy
Health Care
Financing
Health Law & Policy
Farmworker Health
Farmworker Health
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(301) 347-0400 Fax (301) 347-0459
www.nachc.com
Smith, Doug
Svolos, Marty
Valdez, Robert
Greene County
Health Care, Inc,
CEO; NACHC
Farmworker
Committee
HCFA, Eligibility,
Enrollment and
Outreach Division,
Director
MCP Hahnemann
University
302 North Greene Street
Snow Hill, NC 28580-0658
252-747-8162
F 252-747-8163
dsmith@greenecountyhealthcare.com
Farmworker
Advocacy
7500 Security Blvd. Room S2-01-16
Baltimore MD 21244-1850
410-786-4582
Health Care
Coverage
Dean, School of Public Health MCP
Hahnemann University, Philadelphia
and RAND Health Sciences
Program, Santa Monica, CA
Health Care Poilcy
245 N. 15th Street, Mail Stop 660,
Philadelphia, PA 19102-1192
Westmoreland, Tim
HCFA Administrator
Former Administrator, HCFA
Health Care
Financing
White, Eligio
NACHC Farmworker
Committee, past
chair; NACHC
Farmworker
Committee Access
Workgroup
Community Health Centers, Inc.
4745 South 3200 West, Suite A
Salt Lake City, UT 84118
801-955-2338
F 801-963-1029
Health Policy
Wright, George E.
Mathematica Policy
Consultants
600 Maryland Ave., S.W.
Suite 550
Washington DC 20024
Medicaid
105 Manheim Avenue,
PO Box 597
Bridgeton, NJ 08302
(856) 451-4700
FAX: (856) 451-0029
Farmworker
Advocacy
Salud Para la Gente
204 E. Beech St.
Watsonville, CA 95076-4809
831-763-3401
F 831-728-8266
aviveros@saludparalagente.org
Farmworker Health
Walter, Gil
Viveros, Arcadios
Licy M. Do Canto
Community Health
Care, CEO; National
Center for
Farmworker Health,
Board member and
past Chair
Salud Para la Gente,
CEO; National
Advisory Council,
past member;
National Center for
Farmworker Health,
Board member
Assistant Director,
Health Care
Financing Policy
National Association of Community
Health Centers
2001 L Street, NW Suite 300
Washington, DC 20036202.296.1721
Direct
202.997.5963 Cell
ldocanto@nachc.com
Health Care
Financing
26
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Appendix 3
Medicaid Coverage for Migrant and Seasonal Farmworkers and their Families:
Relevant Provisions of Current Law and Issues that Arise in Their Application
Sara Rosenbaum J.D.
Prepared for the National Association of Community Health Centers
July 28, 2003
This taxonomy, which reflects several analyses of Medicaid coverage for farmworkers
and their families,12 identifies the major barriers to Medicaid coverage as well as the
relevant provisions of current federal law that could eliminate or mitigate these barriers
and their legal or implementation limitations.
This taxonomy considers the two basic models for addressing farmworker Medicaid
coverage that have emerged in the analyses and reports. The first model can be thought
of as a “state based” model. Under this model, eligible individuals and families enroll
in the program and secure coverage in the specific state in which they reside (at any given
time) for employment purposes. Under this model, the issuing state changes as
frequently as do job moves, and an application is completed and eligibility determined by
the state in which the applicant is working.
The second model can be thought of as the “portability” model. This model assumes
that eligible individuals will secure coverage in a “home state” and then carry that
coverage throughout their travels, essentially using their benefits on an “out of area”
basis, much the way that either Medicare beneficiaries or privately insured persons with
regional or nationwide coverage use their benefits.
In this model, the issuing state
remains static, and coverage is on an “out of area” basis.
Both models have possible permutations. For example, a hybrid of portable and statebased systems would be a multi-state card issued by multiple states which provides an
eligible individual with simultaneous coverage in more than one state, with the payer
state for any procedure being the state in which the procedure was performed. Another
hybrid would be a reciprocity system, with immediate enrollment in a work state’s
Medicaid program without a new application or eligibility determination, simply upon
showing a current and valid Medicaid card from another state.
Regardless of which of the two basic models (or their hybrids) is used, the models must
satisfy both basic eligibility standards as well as program administration requirements in
12
See, e.g., NHPF, Policy Options for Serving Migrant Children and Families under Medicaid and SCHIP
(GWU, Washington D.C., undated) California Policy Research Center, Si Se Puede (UCLA, Berkeley, CA
2000); Zaidi and Kambara, Medicaid Portability for Migrant Farmworkers Cost Benefit Analysis; George
Wright and Nancy Fasciano, Crossing State Lines: Making Medicaid Work for Migrant Farmworkers
(Mathematica Policy Research, Washington D.C. 1994) Mary Kenesson, Improving Health Service Access
for Medicaid Eligible Migrant Farmworkers (CHCS, Princeton NJ, 2000)
27
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order to be viable under current law. Basic eligibility standards are: categorical eligibility,
financial eligibility, state residency, and citizenship. While any model has its strength or
limitations, current law supports implementation of the two basic models, although with
important limitations. The two hybrids noted above raise additional issues. Certain
eligibility requirements have a greater impact on farmworkers as a distinct class than
others. For example, general limitations on categorical eligibility would affect any
Medicaid applicant, farmworker or otherwise. Other criteria such as residency are more
heavily associated with farmworkers. Even here however, residency is also an issue that
arises for itinerant workers of all types, as well as individuals with severe disabilities who
are institutionalized out of state.
The table that follows identifies (a) general eligibility barriers that would arise under any
model; (b) barriers that arise under the state based model; (c) barriers that arise under the
portability model; and (d) barriers that arise under either the multi-state or reciprocity
hybrids. In most cases, a comprehensive set of CMS guidelines devoted to coverage of
farmworkers and the innovative use of current law would make the options far more
attractive to states since there would be clear policy regarding what can be done within
the bounds of current law.
It should be noted that a farmworker demonstration also would focus on issues of health
quality. Certain issues would of course be equally applicable to any group of
beneficiaries who face health care access barriers. For example, language access and
payment for translation services would be a vital issue to address in a farmworker
demonstration, just as is the case for central city factory workers whose primary language
is not English.
It also should be noted that other issues raised in the context of farmworker health care
include innovations in state administration of claims payment for out of state care (such
as using a multi-state contractor) as well as the establishment of a “migrant health plan”
that is regional in nature and can participate in multiple state plans and manage crossstate coverage and claims payment. Both of these innovations appear to be lawful under
current Medicaid managed care and claims administration principles. Many MCOs do
regional business and the history of Medicaid is replete with examples of national claims
administration activities. Both of these approaches might be part of a broader effort to
make Medicaid “farmworker friendly.”
The bottom line is that 90% or better of what needs to be done in Medicaid to make it
amenable to farmworker families (at least those individuals who meet current eligibility
standards) can be done without any demonstration authority and as a basic state plan
option. What is clearly needed is a comprehensive set of guidelines that clarify for states
the steps they could take that would make the program work better for farmworker
families. There are a few BIG TICKET items such as legal status and categorical
exclusion of adults, which are enormous barriers for all poor people, not just
farmworkers. These issues should not be allowed in my view to cloud what can be done
under current law.
28
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Barriers identified in
studies and analyses
Relevant provisions of
current Medicaid law
Limitations of current
law/implementation issues
General Eligibility Considerations
(affects any applicant for Medicaid)
Categorical eligibility
None
This would need to be
restrictions that preclude
addressed through an §1115
coverage of non-disabled
demonstration or a new
childless working age
statute recognizing
adults
farmworkers as an optional
eligibility group. .
Financial eligibility
Sections 1931 and 1902
Comparability and
barriers created by low
(r)(2) authorize more liberal statewideness requirements
financial eligibility
standards and
would prohibit limiting
standards, restrictive
methodologies for
more liberal standards and
methods for calculating
determining applicants’
methods to one subgroup of
financial eligibility, short
income and
workers (as opposed to all
(as opposed to annualized) resources(including
workers falling in the
budgeting systems that
annualized income
group). Depending on how
create problems for persons calculation). States could
a state specifies the methods
with fluctuating income
establish more generous
standards the more liberal
financial calculation
treatment of certain types of
methods for income derived income and resources might
from itinerant or agricultural be OK as long as the more
labor as well as higher asset generous rule is fairly
standards for certain classes applied to all similarly
of employment where tools situated persons.
of the trade are necessary.
Permissible latitude could
be described in CMS
guidelines.
No special recognition of
No separate optional
Statutory recognition of new
farmworkers as a distinct
categorically need group
eligibility category would be
eligibility group.
known as “farmworkers.”
one means of addressing the
But §§1902(a) (1) and (10)
issue (e.g., breast and
(comparability and
cervical cancer patients).
statewideness) would appear Another would be CMS
to be satisfied by eligibility memo clarifying permissible
criteria that, while statewide flexibility that does not
and across all categorical
violate comparability or
groups, might tend to most
statewideness while still
benefit farmworkers.
targeting those eligibility
Examples, would be more
rules that tend to affect
liberal treatment of itinerant
29
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Barriers identified in
studies and analyses
The requisite legal status
necessary to be able to
qualify for full (as opposed
to only emergency)
coverage assuming other
conditions of eligibility are
met
Relevant provisions of
current Medicaid law
Limitations of current
law/implementation issues
labor income, tools for
farmwork, etc.
No current provision other
than emergency coverage
for otherwise eligible
persons who are in a
temporarily lawful status.
State Based Model
(rapid and repeated reenrollment as work-related residency state changes)
Enrollment delays resulting Current law sets reasonable The eligibility determination
from limited enrollment
promptness test.
time period is still long in
sites, limited assistance in a (§1902(a)(8)). Outstationed relation to farmworker
primary language, limited
enrollment a requirement at travels (45 days). While
access to application
all FQHCs (§1902(a)(55)
outstationed enrollment is
process, which in turn
and presumptive eligibility
mandatory, evidence
hinder enrollment by
permissible for women and
suggests only limited
individuals whose
children.
implementation.
residency is brief and based (e.g.,§1902(a)(47)).
Clarification is advisable on
on temporary employment Translation services can be
state options in presumptive
recognized as either medical eligibility in the context of
assistance or administration farmworkers and their
costs. Medicaid is already
families. Clarification may
required to follow LEP
also be helpful regarding
guidelines as a condition of payments for language
Title VI of the 1964 Civil
services.
Rights Act.
Misunderstanding and
mis-application of
Medicaid residency test
Failure to have a process
for rapid disenrollment and
re-enrollment as state of
residence changes
Eligibility verification
requirements related to
Current law clear on
New CMS guidance
residency linked to work or covering eligibility for
job seeking. 42 CFR 431.52. farmworkers and
permissible options might
help.
Current law bars more than Test methods for electronic
one state Medicaid
disenrollment as soon as
enrollment at a time. This
work state determines
prevents multiple cards
eligibility. Alternatively
develop a multi-state card,
identified as a hybrid option
for possible demonstration
Current law permits the
Remind states of option to
elimination of virtually all
limit verification
30
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Barriers identified in
studies and analyses
Relevant provisions of
current Medicaid law
Limitations of current
law/implementation issues
verification of income,
assets, age, residency,
family status, citizenship,
residency, etc., with each
application site.
required proof except
citizenship
requirements and use
affirmances, particularly if
accompanied by valid out of
state card.
Portability Model
(long term coverage through a home state with out of area coverage)
Brief enrollment periods
Current law may permit
Clarify CMS policy through
and frequent re-verification states to establish longer
guidance on comparability
that precludes long
enrollment time periods (up and budgeting periods for
duration enrollment
to 12 months) and budgeting itinerant laborers who travel
for persons who derive the
interstate.
majority of their incomes
from itinerant and interstate
employment.
Lack of clarity regarding
Current rules allow out of
Clarify that interstate travel
which services can be
state payment when the
makes out of state usage of
covered on an out of state
need is urgent or out of state pediatrics, prenatal and adult
basis and under what
usage is customary.
routine care customary
conditions
where the patient is an
itinerant laborer
Lack of access to out of
Current law requires states
Develop greater awareness
area providers willing to
to have procedures as
among out of state
accept out of state cards
required by the Secretary for providers. Work with states
providing medical
to develop prompt payment
assistance to absent state
and administratively
residents. (§1902(a)(16)).
simplified arrangements as a
This would include
means of attracting migrant
recognizing and paying for
providers. Deem all migrant
out of state providers.
health centers that are
Current law also uses
FQHCs as meeting the
urgency and custom to
provider qualification
guide out of state payment
standard of all state
policies.
Medicaid programs for
purposes of out of state
billing and without separate
application to each state.
Payment principles can be
modified to incorporate
payment for translation
services in accordance with
Title VI requirements.
Providers who do accept
Current law requires prompt Encourage high migrant
31
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Barriers identified in
studies and analyses
Relevant provisions of
current Medicaid law
Limitations of current
law/implementation issues
out of state cards but who
then encounter difficulties
in getting agreement from
the issuing state to pay the
bill
Managed care related
network issues for migrant
families enrolled in
network-style managed
care plans in their home
states.
payment of clean claims
(§1902(a)(37))
states to develop special
provider outreach programs
for out of state providers
who see traveling families
Current law (§1932)
Develop CMS guidelines
requires coverage of
clarifying out of area
emergency care, and states
coverage requirements for
are permitted to pay for out farmworkers who are out of
of area care when it is
area.
customary.
Multi-State Hybrid Model
(simultaneous enrollment in multiple states with multi-state card)
Inability to enroll quickly
None, since individuals can §1115 demonstration that
enough to make transition
be enrolled in only one state would allow uniform crossfrom one state enrollment
medical assistance program state eligibility standards
to another feasible
at a time.
for a subclass of individuals
(farmworker families),
enrollment in any one state,
and a card that is multi-state
and that provides for
payment by state in which
treatment is rendered.
Reciprocal Model
(In state card issued automatically and without reapplication upon proof of
enrollment in another state)
Inability to make use of an None, since federal law
Demonstration involving
out of state card because of requires application and
immediate issuance of inprovider non-acceptance
eligibility determination for state card by work related
medical assistance in a state. state of residence without a
separate application or
eligibility determination, as
long as the applicant has an
in-effect and valid card from
an issuing state.
32
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