| SUBJECT: |
| SPECIAL HEALTHCARE NEEDS SYSTEM CHANGES |
| DISCUSSION: |
| Effective November 15, 2004 the IMU5 system will require information on CHIP children who have dropped insurance and/or have a special healthcare need which exempts them from the waiting period. Refer to Memorandum IM-67 dated July 13, 2004. The system will allow entry of the exception to the 30-day waiting period for children in families above 225% federal poverty level (level of care 3). It will also track children exempted from the six month penalty for dropping insurance because of special healthcare needs or other good cause reasons. It is not longer necessary to fax a copy of the IM-60MC to the IM Policy Unit. CHANGES TO THE IMU5 SYSTEM WHEN APPROVING MC+ CHIP (LEVELS OF CARE 1, 2 AND 3): Field 13g2 will now require an entry when approving a child for MC+ CHIP (level of care 1, 2 or 3). The following new codes were developed to track whether or not the child had insurance in the six months prior to application.
Field 13g3 will require an entry when a “D” (Dropped without good cause) is entered for level of care 1 and 2. The field is required for level of care 3 regardless of the code entered in field 13g2. Appropriate codes are as follows:
Field 13g4 has been added to require entry of the last month of coverage if health insurance was dropped in the six months prior to application.. This is a four digit field (mmyy). This field is required for all CHIP levels of care with a D or G in field 13g2. The IMU5 Code Sheet has been revised to reflect these changes. ELIMINATION OF SIX MONTH PENALTY FOR DROPPING INSURANCE FOR SPECIAL HEALTHCARE NEEDS CHILD (LOC 1, 2 and 3) : If a CHIP child has had insurance in the six months prior to application, the date it was dropped must be entered along with whether or not they had good cause. The system will not allow a child with a “D” – Dropped insurance without good cause in field 13g2 unless there is a special health care needs indicator of “Y” in field 13g3. Other children in the family who do not have a special healthcare need will have the six month penalty imposed and are entered a level of care “Z”, included, on the case. The system will set a priority in Field 18 of “1” – lapse of six month penalty. The date of the priority will be in the sixth month after the last date of coverage shown in field 13g4. This alerts staff the six month penalty has lapsed and staff should add the remaining children’s eligibility effective with the first of the next month, if dropping insurance was the only reason they were ineligible. EXAMPLE #1: Mrs. A. applied for MC+ for her two children, Megan and Aaron, on. October 10, 2004. A budget was completed which resulted in eligibility at level of care 2. Mrs. A. indicated on the MC+ application that she had dropped private insurance in Sept. 2004 without good cause. The children do not have access to affordable employer subsidized health insurance. Mrs. A indicated Megan has special healthcare needs. The IM-60MC was obtained from her physician confirming the special healthcare need. Megan can be approved effective with the date of application while Aaron is not eligible until the six month penalty for dropping insurance has expired. To approve enter a “D” in field13g2 for Megan with a “Y” in field 13g3 and the last month of insurance coverage in field 13g4. Aaron is not eligible for coverage as he does not have a special healthcare needs. He will be a level of care Z (included status) on the IMU5. The system will assign a priority of 1 – lapse of six month penalty. Aaron can be added to coverage once the penalty has been exhausted, if dropping insurance was the only reason he was ineligible. EXAMPLE #2: Mrs. B. applied for MC+ for her two children, Seth and Devin. Income results in eligibility at LOC 1. Insurance coverage was dropped without good cause the month prior to applying for MC+. None of the children have special healthcare needs. This application should be rejected. ELIMINATION OF 30 DAYS WAITING PERIOD FOR PREMIUM LEVEL CHILDREN WITH SPECIAL HEALTHCARE NEEDS CHILD: Any child in the premium group (LOC 3) who is determined to have a special healthcare need is not subject to the 30 days waiting period and is eligible to purchase coverage from the date of application regardless of the entry in field 13g2. If a “Y” is entered in field 13g3, the system will allow the date of application as a beginning eligibility date in field 13e for the special healthcare need child. The remaining eligible children’s eligibility will start 30 days from the date of application. Coverage becomes effective the later of date the premium is paid or the date in field 13e. EXAMPLE #1: Mrs. C. applied for MC+ for her three children, Patty, Carol and Donna on November 1, 2004. Income results in eligibility at LOC 3. The children have never been insured. Donna has special healthcare needs as confirmed by IM-60MC. When entering the approval, Donna’s eligibility would start with date of application as she has special healthcare needs. The remaining children’s eligibility would start 30 days from the date of application (December 1,) as required by current policy. Mrs. C’s premium is received on November 25. Coverage for Donna is effective November 25, and on December 1 for the other children. EXAMPLE #2: Mrs. D. applied for MC+ for her two children on October 31, 2004. Income results in eligibility at LOC 3. Mrs. D. dropped insurance coverage for the children in Sept. 2004 for what was determined not to be good cause. Sara, the oldest child, is determined to have special healthcare needs. Approve Sara for LOC 3 effective with date of application and enter the remaining children as level of care “Z” (included) until the 6 month penalty has been exhausted. The system will set the priority to alert staff the penalty period has lapsed. |
| NECESSARY ACTION: |
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