IM-34 April 23, 2008,�� IM-99 October 2, 2007,��IM-67 July 13, 2004
To be eligible in any of the SCHIP groups a child must be uninsured. Uninsured children are defined as persons up to nineteen (19) years of age that do not have health insurance. Refer to Section 0920.020.05.10 for definition of health insurance. A child covered by health insurance at the time SCHIP eligibility is determined is ineligible, unless:
the insurance enrollment is already paid for by HIPP; oran eligible child has exceeded the annual or lifetime benefit maximums of his or her health plan for all healthcare services.
NOTE: Persons who have exceeded a lifetime maximum for all benefits under their plan are considered uninsured. In addition, persons who have insurance, but have exceeded the annual benefits of the plan for all healthcare services are considered uninsured. The applicant/participant must provide verification from his or her health plan that the child has reached the annual maximum for all plan benefits. The verification must provide a date when healthcare benefits will once again be available for the child. The eligibility specialist must set a reminder in FAMIS to re-determine case eligibility when healthcare benefits will be available for the child.
If the health insurance is dropped without “good cause” and the child is determined to not be eligible for the “special healthcare needs exception”, the Premium Group child is ineligible for six months from the month coverage ended. (Section 0920.020.05.20) Count the first full month of non-coverage as the first month of ineligibility when determining when the six month penalty expires.
NOTE: Children in the No-Cost Group (LOC 1 or CHIP0) are not subject to a penalty for dropped insurance.
EXAMPLE: Mr. Smith dropped coverage on son, Joey, on June 15, 2004. It was determined that Mr. Smith dropped coverage without good cause, that the family income puts Joey in an SCHIP Premium group, and that Joey does not have special healthcare needs. Joey’s first month of non-coverage begins July 1, 2004. Joey is ineligible for SCHIP coverage until January 1, 2005.
If an uninsured child income-eligible in the SCHIP Premium group has lost or discontinued health insurance coverage in the six months prior to application, explore “good cause” referenced in Section 0920.020.05.15. If the reason for dropping meets a “good cause” reason, a six month penalty is not imposed. If “good cause” does not exist, a six month penalty is imposed unless a child meets the “special healthcare needs exception” in Section 0920.020.05.20. The participant’s statement on insurance status or “good cause” will be accepted unless questionable. Special healthcare needs must be verified.