Family MO HealthNet (MAGI) Manual

1840.025.00 PAYMENT OF PREMIUM

IM-#153, November 30, 2017IM-#123 September 11, 2017IM-#112 August 10, 2017

Families with income above 150% of poverty must pay a monthly premium for their children to be eligible for coverage. The MO HealthNet Division’s (MHD’s) Stakeholder Services Unit (formerly the Premium Collections Unit) notifies the participant of the monthly premium amount and provides direction on how to make the payment. If payment is not received within 15 days, a second and final notice is sent by MHD requesting payment. If the initial premium is not paid, after 90 days MHD will notify the Family Support Division (FSD) to close the case.

NOTE: Children who are members of a federally-recognized American Indian or Native Alaskan tribe may not have to pay a premium for CHIP level health care coverage. To stop owing a premium, qualifying households should contact the MHD Stakeholder Services Unit at 800-392-2161 for more information.

Premiums may change on July 1 of each year. Refer to the MO HealthNet for Kids – CHIP Premium Chart at Appendix E, Section 1800.000.00.

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. Eligibility and coverage begin as follows:

  • Reduced Premium Group (above 150% to 225% FPL) – CHIP73 or CHIP74:There is no waiting period to begin eligibility. Once the child(ren) is determined eligible for CHIP73 or CHIP74, an invoice is mailed. Coverage begins the date the premium is received, not the eligibility start date.
  • Full Premium Group (above 225% and below 300% FPL) – CHIP75: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 (CHIP 75). 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 1820.020.05.20). 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.

The Managed Care Enrollment Inquiry (MCII) screen displays coverage dates for individuals in the Premium groups. The enrollment date in a health plan on MCII is the first date of any coverage in the Premium group. The MCII screen is also used to show enrollment in 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: Mrs. Jones applies October 1 for her child. She meets all eligibility requirements for Premium Group coverage, CHIP73 or CHIP74. The eligibility specialist approves her 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 MHD Stakeholder Services Unit on October 16. Her child’s coverage begins October 16.

The MO HealthNet Division Title XIX Cross Reference Eligibility (MXIX) screen in Legacy for her child displays 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 Pseudo Health Plan is the first date of coverage; for Mrs. Jones’ child, the Start Date displays October 16.

EXAMPLE: 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). Mr. Smith also provides verification that Jack has special healthcare needs. In MEDES, enter Jack’s special healthcare needs status in the application flow when the question is asked. Eligibility specialist approves the case October 15. Jack’s eligibility for CHIP75 eligibility 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 MHD Stakeholder Services Unit on October 20. Jack’s coverage begins October 20, Jane’s on October 31.

The MXIX screen for Jack displays 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.