Family Healthcare (FAMIS)

0920.020.10.10 Employer Sponsored Insurance

IM-69 November 21, 2014IM-01 January 4, 2012,  IM-73 September 25, 2009IM-34 April 23, 2008

Employer-sponsored health insurance causes ineligibility if:

  • the premium meets the affordable definition in Section 0920.020.10.05;
  • the coverage meets the definition of health insurance in Section 0920.020.05.10 and
  • it covers all of a child’s pre-existing conditions.NOTE:  Section 2110 of the Social Security Act states children who have a family member eligible for health benefits coverage under a State health benefits plan on the basis of the family member’s employment with the State are not eligible for the Children’s Health Insurance Program (CHIP).  Health insurance available to a state employee through a state agency is considered affordable regardless of cost.

    EXAMPLE:  The Missouri Department of Transportation (MODOT) is a state agency that does not participant in Missouri Consolidated Health Care Plan (MCHCP), however, provides health insurance to their employees.

    An applicant with two children applies for MO HealthNet (MHN) and works part-time for MODOT. The expense of purchasing the MODOT health insurance is $300.00 per month and therefore, the applicant chose not to purchase the insurance. The applicant’s household is uninsured. The applicant is a state employee who can purchase health insurance through their state employer.  The children are not eligible for CHIP level of care.

    EXAMPLE: Mrs. Maple applied for MO HealthNet for Kids for her daughter Ann. The Maple family income is over 150% of the federal poverty level (CHIP premium level). Ann does not have health insurance. Mr. Maple has employer sponsored insurance that would cover Ann if he elected to cover her, but it will not cover her asthma, a pre-existing condition. She also furnished Mr. Maple’s health insurance member handbook that verifies that pre-existing conditions are not covered. Since Ann is uninsured and Mr. Maple’s employer sponsored health insurance will not cover Ann’s asthma, Ann does not have access to affordable employer sponsored health insurance. Mrs. Maple must still furnish two private insurance quotes to evaluate her access to affordable private insurance. If the two private quotes do not meet the criteria in Section 0920.020.10.15, Ann is eligible if all other eligibility requirements are met.

    EXAMPLE: Mrs. Davis applied for MO HealthNet for Kids for her daughter Julie. Mr. Davis just purchased employer sponsored health insurance for Julie, and then learned that her asthma will not be covered because it is a pre-existing condition. The Davis family income is over 150% of the federal poverty level (CHIP premium level). Julie has health insurance, but it does not cover her pre-existing conditions. However, Julie’s health insurance still meets the definition of health insurance in Section 0920.020.05.10. Julie is not eligible for MO HealthNet for Kids, CHIP premium level of care, because she is an insured child.