Family MO HealthNet (MAGI) Manual

1865.020.00 Eligibility Requirements

IM-#95 September 21, 2021

All eligibility requirements in Chapters 1802.000.00 Applications and 1805.000.00 Eligibility and Verification must be met, in addition to the following:

  • Must be aged 19 to 64
  • Income at or below 133% of the Federal Poverty Level
  • Not pregnant
  • Not entitled to or enrolled in Medicare Part A or B
    • Note: SSDI recipients may be eligible for Adult Expansion Group (AEG) if NOT entitled to or enrolled in Medicare Part A or B. Upon approval of SSDI, some recipients may have a two (2) year waiting period for Part A or B
  • Not receiving SSI
  • Ineligible for all MO HealthNet (MHN) mandatory category programs listed below:
    • MO HealthNet for Pregnant Women (MPW)
    • MO HealthNet for Families (MHF)
    • MO HealthNet for the Aged, Blind, and Disabled (MHABD) Non-Spend Down, or
    • MHN coverage for former foster youth who have aged out of Missouri foster care up until age 26. In January 2023, ALL MHN coverage for former foster youth becomes mandatory

See Appendix K for a full list of mandatory MHN programs.

Note: Coverage listed on Appendix K as better level of care of the medical need should be treated as mandatory.

Participants who meet the eligibility criteria for AEG:

  • Are able to receive AEG coverage while they undergo a determination of eligibility by the Medical Review Team (MRT) for a non-MAGI program
  • Do not have to meet categorical requirements such as blindness, disability, or caring for a dependent child

If there is a child, under age 19 who does not have Minimum Essential Coverage (MEC) and is residing in the home of a parent or non-parent caretaker relative who assumes primary responsibility for the child, the adult applicant must apply for MHN coverage for the child and the child must be found eligible in order for the parent or non-parent caretaker to be eligible for the AEG. MEC is defined in 42 CFR 435.4. The parent or non-parent caretaker relative must attest that the child is enrolled in health care coverage that meets MEC requirements if the child is not eligible for MHN coverage.

Participants who are enrolled in AEG and report a pregnancy to the Family Support Division (FSD) must have eligibility explored under 1850.000.00 MPW and 1855.000.00 Show-Me Healthy Babies (SMHB). If eligible, FSD will take actions to change the program level to MPW or SMHB.

Examples of AEG Eligibility for Parent/Caretaker Relatives

John applies for MHN for himself. Included in John’s household are his wife and his two stepchildren. John refuses to apply for his stepchildren and his stepchildren are not enrolled in a health insurance plan that meets MEC requirements. John is found ineligible for AEG because he is the stepparent of children who reside in the home and the children are not enrolled in a health insurance plan that meets MEC requirements.

Note: If John’s stepchildren were enrolled in a health insurance plan that meets MEC requirements, John would be found eligible for AEG.

Mary (Mom), Bob (Dad), and Charlie (child in common) live in the same household. Mary and Bob are not married. Mary has income at 30% of FPL, but Bob has income that makes Charlie over income for all MHN programs. Charlie is not enrolled in a health insurance plan that meets MEC requirements. Mary is found ineligible for AEG because she is the parent of child who resides in the home who is not eligible for MHN and is not enrolled in a health insurance plan that meets MEC requirements.

Note: If Charlie was enrolled in a health insurance plan that meets MEC requirements, Mary would be found eligible for AEG.

Maggie (Mom) and Ben (child under one) apply for MHN coverage. Maggie meets most of the eligibility requirements for AEG except coverage for a dependent child. Ben still needs to provide proof of application for a Social Security Number (SSN) or the number. Maggie fails to provide verification of Ben’s SSN; therefore, Ben is denied MHN coverage. Ben does not have other health insurance that meets MEC requirements. Maggie is found ineligible for AEG because she is the parent of a child who resides in the home, who is not eligible for MHN and is not enrolled in other health insurance that meets MEC requirements.

Note: If Maggie had provided verification of Ben’s proof of application for SSN or the number within 10 days or within the cancel reject period, and Ben was found eligible for MHN then Maggie would be eligible for AEG.

Example of AEG Eligibility for Non-Citizens

Ahmed, 50 years old, is in need of healthcare coverage and applies for MHN. He reports on his application that he is a Lawful Permanent Resident of two years and is a refugee. He is claiming a disability, therefore, a concurrent eligibility determination is made for MAGI and Non-MAGI based methodology. He meets AEG eligibility but his class of admission needs to be confirmed. He provides verification of his immigration status and it is confirmed that he is a refugee, therefore, he does not have to meet the 5 year bar requirement (see 1805.020.10.10.05 Qualified Immigrants with No Waiting Period). Ahmed meets all eligibility requirements for AEG and is approved while his Non-MAGI determination is pending.

Note: Citizenship and immigration requirements are outlined in policy subsections of 1805.020.00 Citizenship and Immigrant Status.

Examples of AEG Eligibility for Homeless Youth

Joe, 19 years old, is in need of healthcare coverage and applies for MHN. He reports that he is homeless. He is not reporting a disability, receipt of SSI or SSDI and he is not enrolled in/entitled to Medicare so coverage is only explored for AEG. Joe meets all eligibility factors for AEG, therefore, he is approved for the program.

Kenny, 21 years old, is in need of healthcare coverage and applies for MHN. He reports that he is homeless with monthly income of $1650.00, which is over the income threshold of 133% FPL, plus the 5% disregard, for a household of one (1). He is not reporting a disability, SSI, or SSDI and he is not enrolled in/entitled to Medicare so coverage is only explored for AEG. Kenny meets all other eligibility factors for AEG, with the exception of income, therefore he is found to be ineligible and his request is rejected for excessive income.

Note: If a homeless youth (19-20 years of age) is found ineligible for AEG, a policy clearance for interpretation (IM-14) must be submitted using appropriate supervisory channels, prior to rejecting the applicant’s request.