Family Healthcare (FAMIS) Manual – Table of Contents

0920.020.10.15 Private Insurance

IM-#83 August 2, 2005,  IM-#67 July 13, 2004,  IM-#04 January 12, 2001

If affordable employer sponsored insurance is not available, evaluate access to affordable private insurance coverage. The family must provide quotes on the cost of health insurance for their children from two private insurance companies. Written verification from the insurance companies is not required, but the applicant must supply names of the insurance companies on the application.

If the private insurance quotes are above the affordable amount, the family does NOT have access to affordable insurance and the children are eligible on that factor.

If one or both of the private insurance quotes are less than the affordable amount, send the applicant the MC+ Insurance Company Quotes form for completion for each insurance plan that is affordable.

When sending the insurance company quotes form, instruct the applicant to ask the companies the questions on the form, write down the insurance company’s answers and return the form. Upon receipt of the completed forms, the worker will determine whether the insurance meets the definition for affordable.

A private insurance policy causes ineligibility if it:

  • covers all MC+ healthcare services (Medicaid), except non-emergency medical transportation;
  • has a premium that meets the affordable definition in Section 0920.020.10.05 ; and
  • covers all the children’s pre-existing medical conditions.

If an applicant with children in the premium group fails to provide an amount a private insurance company would charge to cover their children, reject the application the 30th day. Enter a reason code of 61 (Access to Affordable Insurance) in IMU5. The rejection letter should state “You failed to provide information concerning the amount a private insurance company would charge for health insurance for your children. This information is required as your monthly income exceeds ___________. (Chapter 208.RSMo, Section 208.640). Enter the 150% FPL income for the number of persons in the assistance group.