Family Healthcare (FAMIS) Manual

0920.045.00 NOTICES AND CLOSINGS FOR NON-PAYMENT OF PREMIUM

IM-21 March 5, 2008,  IM-#83 August 2, 2005

MO HealthNet Division’s (MHD) Premium Collections Unit is responsible for collecting the monthly premiums. MHD uses a series of notification letters and invoices for collecting the premium. The order the notifications are sent to participants is as follows:

  1. Initial Invoice;
  2. Recurring Invoice;
  3. Failure to Pay Notice (LOC 2 and LOC 3);
  4. Notice of Case Action; and
  5. Closing Letter (LOC 2 and LOC 3).

Initial and Recurring Invoices

Initial and Recurring Invoices are sent to MO HealthNet for Kids Premium participants. These notices inform the participant of the amount of their monthly premium and the due date.

Failure to Pay Notice

The Failure to Pay Notice (formerly referred to as Late Payment Notice) is sent to participants whose premium payment is not received by the due date noted on the Recurring Invoice. The Failure to Pay Notice states that premium payment is past due and gives the participant an additional 20 days for the payment to be received before coverage is ended.

The Failure to Pay Notice allows participants an opportunity to show that their income or household size has changed prior to ending coverage due to failure to pay a premium. Participants are informed that they must contact their Family Support Division (FSD) eligibility specialist (ES) within ten days of the date of the notice to report changes in income and/or household size. If a participant reports one or both of these changes, the eligibility specialist must take the following steps:

  • The ES must enter reported information into FAMIS immediately. If a change in income is reported enter the current budget month or following month if change is not effective until the next month. FAMIS will run an eligibility determination to determine if there is a change in level of care or premium amount.
  • The eligibility specialist informs the participant to contact the MO HealthNet Premium Collections Unit at 1-877-888-2811 regarding their outstanding invoice.

Example:

Mr. Thompson�s child Mike has been receiving SCHIP premium coverage, CHIP74. He fails to pay the Recurring Invoice for $52 sent April 1. Mr. Thompson is mailed a Failure to Pay Notice on April 15 stating he is being given an additional twenty (20) days to pay his premium, due now by May 5. Mr. Thompson notifies his FSD ES on April 18 that Mike�s child support income decreased by $50. The ES verifies the change in income through the FAMIS interface and enters the adjusted income with a budget month of April. The eligibility specialist informs the participant to contact the MO HealthNet Premium Collections Unit for information regarding the outstanding invoice.

Notice of Case Action

The Notice of Case Action is sent to participants whose premium payment is not received by the due date noted on the Failure to Pay Notices. This notice states that the participant�s premium payment has not been received, and that coverage will end in ten (10) days. Participants are informed that coverage may continue if a hearing is requested within ten (10) days.

Participants requesting hearings on termination of coverage and/or eligibility for a child(ren) receiving SCHIP Premium coverage due to non-payment of a premium may request a hearing through the Family Support Division office. DO NOT tell the participant that they must contact the MO HealthNet Division’s (MHD’s) Premium Collections Unit to request the hearing.

If a participant requests a hearing due to an SCHIP Premium child losing eligibility or coverage, the eligibility specialist must determine whether the reason for hearing request is due to a case action taken by FSD or due to non-payment of a premium. If the request appears to be due to non-payment of a premium, the FSD eligibility specialist must fax a copy of the IM-87 Hearing Request form to the MO HealthNet Hearings Unit at (573) 526-2471 on the date of the request. File the original IM-87 in the participant�s case record.

MHD’s Premium Collection Unit will continue to provide coverage for the child(ren) affected by the hearing request. There will be no affect to FSD eligibility. MHD will essentially be holding the close action for failure to pay a premium. If the participant loses the hearing, MHD will send the closing action to close coverage and/or eligibility. MHD will file the claim for any MO HealthNet benefits received that the participant’s child(ren) was not eligible to receive.

NOTE: Do not put a hold on the SCHIP case due to a hearing requested because of non-payment of premium.

Closing Letter

The Closing Letter is sent to participants who either:

  • have not requested a hearing by the due date noted on the Notice of Case Action;
  • whose premium payment has not been received by the hearing request due date; or,
  • have requested a hearing and subsequently either withdrew the request or have received notification that their hearing request did not affirm the participant.

The Closing Letter for families with income over 150% of federal poverty level (FPL) up to 225% FPL (CHIP 73 and CHIP 74 cases in FAMIS) states that coverage may start again when the premium payment is received, and contains an Initial Invoice. The Closing Letter for families with income over 225% FPL but less than 300% FPL (CHIP 75 cases in FAMIS) states that coverage ends and the child(ren) will not be eligible for coverage for six (6) months.

Both Closing Letters give the participant ninety (90) day appeal rights.

MHD will automatically stop coverage upon notification that the premium was not paid by the due date (date of Closing Letter). The ending eligibility date on MXIX or the Medicaid Category History screen (MEDHIST) will not reflect the actual date coverage ended. Check the MCII screen for the correct beginning and ending date of coverage for the Premium Groups, LOC �2� and �3� (CHIP73/74). The enrollment stop date is the last day of coverage.

If contacted by a participant who states they did pay the premium, FSD staff should refer the participant to the MHD Premium Payment Unit at 1-877-888-2811.