Employer-sponsored health insurance causes ineligibility if:
- the premium meets the affordable definition in 1840.010.15.05 Affordable Insurance Definition
- the coverage meets the definition of health insurance in 1840.010.10 Uninsured; and
- the insurance covers all of a child’s pre-existing conditions
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. Mrs. Maple provided a letter from Ann’s physician stating that Ann has asthma. 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. FSD staff processing the application must use the Affordability Calculator to determine if affordable insurance is available to this family. DO NOT require the family to provide insurance quotes unless they disagree with the Calculator determination. If that occurs, they may provide quotes verbally or in writing at an FSD office or through the FSD Information Center at 855-FSD-INFO (855-373-4636).
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. Because Mr. Davis’ employee insurance will not cover Julie’s pre-existing condition she is eligible for MO HealthNet for Kids, CHIP premium level of care, even though she is an insured child. Third Party Liability (TPL) information must be submitted to MO HealthNet Division regarding Mr. Davis’ insurance.
If an individual does not meet the workplace criteria to be eligible for employer insurance at the time of application, such as hours worked or length of time with the company, then the insurance is not available to that person. It is the participant’s responsibility to report any changes that could affect his or her eligibility within ten days of the change.