Family Healthcare (FAMIS) Manual

0920.020.05.20 Special Healthcare Needs Exception for CHIP

IM-99 October 2, 2007, IM-#130 November 4, 2005, IM-#67 July 13, 2004

Effective July 1, 2004, RSMo. 208.647 provided for the elimination of the following requirements for children with special healthcare needs who do not have access to affordable employer-subsidized health insurance.

  • The six month penalty for loss of health insurance coverage without good cause; and
  • The 30-day waiting period for children in the CHIP Full Premium Group (income above 225% FPL).

Special healthcare needs are defined as a medical condition which left untreated would result in the death of or serious physical injury to a child. Special healthcare needs are established based on a written statement from the child’s treating physician. The Physician’s Statement (IM-60MC) form has been produced as a means of obtaining verification of the special healthcare needs.

Evaluate the special healthcare needs exception to determine if the six month penalty should be imposed when:

  • health insurance coverage was discontinued within six months prior to the date of application without good cause,
  • the child(ren) has no access to affordable, employer sponsored healthcare coverage; and
  • the parent/caretaker has indicated there is a child with special healthcare needs.

Affordable employer sponsored healthcare is defined in Sections 0920.020.10.05 and 0920.020.10.10. Children in either of the premium groups (income above 150% FPL) are ineligible if they have access to any affordable health insurance, private or employer-sponsored. (Refer to Section 0920.020.10).

For CHIP Full Premium Group children (LOC 3 or CHIP75) who meet all other eligibility factors, the exception to the 30-day waiting period should be explored anytime a parent/caretaker has indicated a child has special healthcare needs.