Family Healthcare (FAMIS) Manual

0920.020.15 Payment Of Premium

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Effective July 1, 2014, premiums range from a minimum of $14 to the maximum based on gross income and family size, not to exceed 5% of the family’s gross income. The MO HealthNet Division’s (MHD’s) Premium Payment Unit notifies the participant of the monthly premium amount and provides direction on how to make the payment. Premiums may change on July 1 of each year. Refer to the MO HealthNet for Kids – CHIP Premium Chart at Appendix E, Section 0900.000.00.

Families with income above 150% of poverty must pay a monthly premium for their children to be eligible for coverage. Premiums vary from $14 to a maximum based on gross income and family size.

Premiums are calculated as follows:

  • Families with gross income above 150% up to and including 185% of the FPL are responsible for a monthly premium equal to:
    • 4% of monthly income between 150% and 185% of the FPL for the family size.
  • Families with gross income above 185% up to and including 225% of the FPL are responsible for a monthly premium equal to:
    • 4% of monthly income between 150% and 185% of the FPL for the family size plus
    • 8% of monthly income between 185% and 225% of the FPL for the family size.
  • Families with gross income above 225% up to and including 300% of the FPL are responsible for a monthly premium equal to:
    • 4% of monthly income between 150% and 185% of the FPL for the family size plus
    • 8% of monthly income between 185% and 225% of the FPL for the family size plus
    • 14% of monthly income between 225% and 300% of the FPL for the family size, but
    • the total monthly premium is not to exceed 5% of the family’s gross income.

Approval in the CHIP Premium group does not mean a child will receive coverage. It means the family is eligible to buy medical coverage for their child(ren) through the MO HealthNet for Kids CHIP Program. Premium payments are required for the below groups and coverage begins as follows:

  • Reduced Premium Group (above 150% to 225% FPL) – LOC 2 on MXIX and MPNI, CHIP73 or CHIP74 in FAMIS:The eligibility start date begins either the date of application or the first of the month following application. There is no waiting period to begin eligibility. Once the child(ren) is approved LOC 2 (CHIP73 or CHIP74), an invoice is mailed. Coverage starts the date of receipt of the premium, not the eligibility start date.
  • Full Premium Group (above 225% and below 300% FPL) – LOC 3 on MXIX and MPNI, CHIP75 in FAMIS:RSMo Section 208.646 and State Regulation 13 CSR 70-4.080 require a 30-day waiting period from the date of application for coverage to begin for children whose family’s gross income is over 225% of the FPL (in the Full Premium group). The eligibility start date is 30 days from the date of application. If the premium is paid within 30 days from the date of application, coverage is effective on the 30th day after application. The day following the day of application is considered day one. If the premium is not paid within the 30-day period, coverage is effective the date of receipt of the premium. RSMo Section 208.647 makes an exception to the 30-day waiting period for children determined to have special healthcare needs (Section 0920.020.05.20). For children determined to have special healthcare needs, the eligibility start date is the date of application and coverage starts on the date the premium is paid, not the eligibility date.

The MCII screen displays coverage dates for the Premium groups. The enrollment date in a health plan (including Psuedo group) on MCII is the first date of any coverage in the Premium group. The MCII screen is also used to show a lock-in to a specific health plan in Managed Care counties. Premium group children in fee-for-service counties are assigned to a pseudo plan number. Premium group children in managed care regions are assigned to the pseudo plan until the effective date of their enrollment in a managed care health plan.

Example 1:

Mrs. Jones applies October 1 for her child. She meets all eligibility requirements for Premium Group coverage, Level of Care 2 (CHIP73 or CHIP74 in FAMIS). The eligibility specialist approves case October 10. Eligibility for MO HealthNet for Kids begins October 1.

An invoice is mailed to Mrs. Jones October 11. Mrs. Jones’ payment is received by the Premium Payment Unit on October 16. Her child’s coverage begins October 16.

The MXIX screen in Legacy and the Medicaid Category History (FM4L or MEDHIST) screen in FAMIS for her child display October 1 as the Start Date. This is the Start Date for eligibility only. Check the child’s MCII screen to find the date of coverage. The Enrollment Start Date for the Psuedo Health Plan is the first date of coverage; for Mrs. Jones’ child, the Start Date displays October 16.

Example 2:

Mr. Smith applies October 1 for his two children, Jane and Jack. He meets all eligibility requirements for Premium Group coverage, Level of Care 3 (CHIP75 in FAMIS). Mr. Smith also provides verification that Jack has special healthcare needs. In FAMIS, enter Jack’s special healthcare needs status on the Medical Condition screen (FMXZ or MEDCOND). Eligibility specialist approves the case October 15. Jack’s eligibility for MO HealthNet for Kids begins October 1; eligibility for Jane begins October 31.

An invoice is mailed to Mr. Smith on October 15, the date of approval. Mr. Smith’s payment is received by the Premium Payment Unit on October 20. Jack’s coverage begins October 20, Jane’s on October 31.

The MXIX and MEDHIST screens for Jack display October 1 as the eligibility Start Date; for Jane, the screens display the eligibility start date of October 31. The MCII screen for Jack displays October 20 as the coverage Start Date; for Jane, MCII displays October 31 as the coverage Start Date.