SUBJECT:
ANSWERS TO COMMON QUESTIONS REGARDING MC+ CHIP CASES
DISCUSSION:
Following are some common questions regarding MC+ CHIP.
Questions Regarding Eligibility:
Q: A family's income increases, changing their MC+ level of care from 1 to 2. They have HIPP coverage. Are they considered uninsured, and is affordability of insurance an issue?
A: A family who is having their premiums paid by HIPP are considered uninsured. If the insurance being paid for by HIPP is employer-sponsored and falls within affordability requirements, the CHIP case must be closed/rejected for availability of affordable insurance.
If the insurance being paid by HIPP is not employer-sponsored, but the family has affordable employer-sponsored insurance available for their children (even if it is not until open enrollment), the family is not eligible for CHIP Premium Group coverage.
If affordable employer-sponsored insurance is not available, and HIPP is paying Private Insurance that meets all the CHIP requirements (affordability, coverage areas, and pre-existing illnesses), then private insurance is available to them and the family is not eligible for CHIP.
HIPP will close their eligibility upon receipt of information that the case was closed. They receive this information in a weekly report. If the client gets reimbursed for the expense, and the expense date is prior to the date HIPP closes their eligibility, the client will be reimbursed for that payment. If it is after the date HIPP closes their eligibility, the client will not be reimbursed. Payment by HIPP stops the day the HIPP case is closed, whether it is to the client, the employer, or the insurance company.
Q: The manual says for insurance to be considered affordable, the family's cost must be no more than $342 per month. Does this mean the cost for the whole family to be covered must be under this amount, or does this cost apply only to insurance for the children?
A: Insurance to cover only the children must not cost the family more than $342 per month. This is the out-of-pocket expense to the family; it does not include the cost subsidized by the employer or another entity. Some employers require the employed parent to be included on the health insurance policy in order to get the children insured. In these cases, if the total premium to the family would be over $342, then the insurance would be unaffordable. NOTE: Do not include coverage for the spouse in determining affordability.
Example: Mrs. Jacobs has a husband and two children. Mrs. Jacobs applies for MC+ for Kids, and it is determined that the family's income is 185% FPL, making them CHIP Premium Group LOC2. Mrs. Jacobs's employer offers health insurance plans to their employees, with the following employee cost break down:
| Employee only | $ 35.00 per month |
| Employee and one child | $ 100.00 per month |
| Employee and all children | $ 250.00 per month |
| Employee and family (includes Spouse) | $ 380.00 per month |
Insurance cost to the family to cover the children is $250.00 per month. Mrs. Jacobs has affordable insurance and is not eligible for CHIP.
Q: The family's gross income puts them in CHIP Premium Group 2. The family has access to affordable employer-sponsored insurance but states that one child has a pre-existing illness that will not be covered. Since this child has been determined to be a special healthcare needs child, can this one child be approved?
A: Special healthcare needs children must still meet the CHIP Premium Group eligibility requirements. Access to affordable employer-sponsored insurance that meets the definition of health insurance (see Manual Section 0920.020.05.10 Health Insurance Definition (MC+) is still a condition of eligibility. The definition states that the insurance does not have to cover pre-existing illnesses; therefore, the special healthcare needs child is not eligible for CHIP.
Q: The date on the MXIX/IXIX screens show a start date of 10-01-05 for CHIP 2, but my client states they cannot use their card. Why isn't MC+ active for the children?
A: The MXIX/IXIX screens show the date the child was determined eligible for CHIP 2, the date the worker entered on the individual screen in IMU5. Coverage does not begin until the premium is received by the Premium Collections Unit. Look at the individual child's MCII screen to see the start date for the Medicaid Pseudo Plan. This is the date TXIX coverage starts.
Q: The mother has access to employer-sponsored insurance that is affordable, but the coverage is not as extensive as Medicaid (there is no vision and dental). Doesn't both employer-sponsored insurance and private insurance have to cover everything Medicaid does in order for the family to be ineligible for CHIP Premium Groups?
A: Employer-sponsored insurance has to cover services noted under Manual Section 0920.020.05.10 Health Insurance Definition (MC+) which states, in part: Health insurance is defined as insurance that minimally provides coverage for physician's services and hospitalization. Dental, vision, and other services listed in the section are not required to be covered services.
Affordable private insurance, though, must cover all services that Medicaid covers, including dental and vision, to cause ineligibility for the CHIP Premium groups. See the attached MC+ FOR KIDS INSURANCE COMPANY QUOTES 
for services that private insurance must cover.
Q: At what point should a worker request quotes for private insurance?
A: If a worker has reason to believe that the family's income will be over 150% of the FPL, begin exploration of access to affordable insurance at the time of application. Workers must first determine whether a family has access to affordable employer sponsored insurance. If the applicant provides private insurance quotes of more than the affordable limit on the application, the family does not have access to affordable insurance and the children are eligible on that factor. If the applicant provides private insurance quotes that are considered affordable, the applicant must be sent the MC+ FOR KIDS INSURANCE COMPANY QUOTES form. The applicant is to contact the insurance companies, write down the information that is requested on the form, and mail it in to the caseworker. The worker may then evaluate if the private insurance meets the required elements.
If the application is made by mail and has incomplete information regarding private insurance, send the MC+ for Kids Insurance Company Quote form, requesting the needed information. If further review indicates that the family's income is under Premium Group income limits, do not delay approval if the private insurance quotes have not been received.
Access to affordable insurance (employer and private) must be evaluated at application and at reinvestigation. Also explore access to affordable employer-sponsored insurance if new employment is reported.
Budget Adjustments and On-Going Eligibility Questions:
Q: When an active CHIP Premium Group case reports an income increase that changes the level of care from 2 to 3, does an Adverse Action Notice (IM-80) need to be sent? Also, if a reported income change decreases a premium amount (regardless of the level of care), how should the worker notify the family of the reduction in premium?
A: Prior to September 1, 2005, when a CHIP Premium group (level of care 3) reported an increase in income which in turn increased the family's premium rate, an IM-80 was not needed. Since CHIP 2 and CHIP 3 cases are both Premium Groups as of September 1, 2005, an IM-80 will not be sent when a CHIP Premium Group case goes from loc 2 to loc 3, or vice versa. DMS sends an invoice the month following the budget adjustment for the new premium amount, informing the claimant that changes in income must be reported to their caseworker.
Example: Mr. Jones reports a change in income October 10. Worker makes the budget adjustment October 20 in the IMU5 system, changing the level of care for the children from CHIP 2 to CHIP 3, the TXIX date the same as the date of adjustment. DMS sends out an invoice November 1. Premium is due by November 30 to have coverage for the month of December.
If a family's income decreases, workers are to put in the correct budget information in the IMU5 system, changing the level of care for the children from CHIP 3 to CHIP 2, the TXIX date the same as the date of adjustment. The worker does not notify the family of the change in premium. DMS sets the premium and will send an invoice reflecting the lower premium the beginning of the month following the budget adjustment. The worker is not to inform the family that they can send in a premium lower than the amount stated on the invoice. If it is determined that worker error caused a family to be invoiced for an amount higher than correct, the worker may request a lower premium be accepted by contacting Income Maintenance Program and Policy.
Q: The family has been paying their invoices for CHIP coverage for the past six months. They requested the case be closed December 15, 2005. They tried to use their MC+ healthcare coverage for a prescription December 20 and were told they were no longer covered. The family thought they had coverage until the end of the month as they had already paid for that month. Why did their coverage end December 15, when they had paid through the month?
A: CHIP coverage is date-specific. The date the case is closed is the date coverage ends. DMS will automatically refund based on premium payments received and date of change in the level of care. A family whose case is closed during a pre-paid month receives a pro-rated refund.
Example: Mrs. Anderson has paid the CHIP Premium for her two children for six months. She paid her invoice for December coverage on November 12, 2005. On November 20, 2005, she requests that her case be closed as she now has available insurance. A refund is generated as follows:
- A pro-rated refund for November 20 through November 30 and;
- A full refund for December.
The refund will be mailed out to Mrs. Anderson approximately six weeks after the case is closed.
Note: The same process happens when a case goes from a premium level of care (CHIP 2 or 3) to a non-premium level of care (CHIP 1, Q, T).
Q: The head of household has a C7 and C8 case open, both are CHIP Premium cases. During the reinvestigation it is discovered that combining the two cases will result in a lower total premium payment. The family requests that the worker combine the cases. Is this okay to do?
A: Workers should check CHIP Premium cases to see if alternative assistance grouping could reduce premium payment amounts to the family. In some cases, it may be less expensive to the family to separate some or all of the children into separate cases or to combine existing cases. A discussion should occur with the family to let them know their options.
Example: Mrs. Jackson gets $1000/month SSA, her three children (all over age 10) each receive $1300 SSA due to a deceased father. The total household income is $4,900, which is over 300% FPL for CHIP 3, and no child is eligible for MC+. Look at other assistance grouping options.
AG option #1:
C7 with Mom and two children, total gross income = $3600, monthly premium payment = $151.
C8 with Mom and one child, total gross income = $2300, monthly premium payment = $59.
Total premium cost to family = $210
This generates invoices for the C7 and C8 cases, with each case/assistance group billed separately)
OR
AG option #2:
C7 with Mom and one child, total gross income = $2300, monthly premium = $59.
C8 with Mom and one child, total gross income = $2300, monthly premium = $59.
C9 with Mom and one child, total gross income = $2300, monthly premium = $59.
Total premium cost to family = $177
This generates invoices for the C7, C8 and C9 cases, with each case/assistance group billed separately)
In this example, AG option #2 would be the best (least expensive) scenario to enable coverage for all the children.
Q: The family has two different assistance group cases. The C7 case has one child on level of care Q, and the C8 case has a child on a Premium level of care. How do I give the 60 day transition period from a non-premium case to a premium case?
A: For Q children going to Premium cases, send the IM-80MCC giving the 60 day notice of transition when the Adverse Action time period ends. Leave the LOC Q child on the C7 case. When the 60-day time frame has expired, close the C7 case and add the child to LOC 2 on the C8 case. The Q LOC child is to be moved to the premium case to prevent closing of the premium child. Moving the premium child to the LOC Q case will result in a lapse of coverage for the premium child. If transferring to LOC 3, the Q child will have to be added on the C8 case as LOC Z (included) the day before, if the child was not previously on the case, and changed to LOC 3 the following day.
As long as the premiums are being paid on the C8 case, the child will show active in the FSD system and coverage will be transferred over to the DMS system the following day.
General Information Related to CHIP Cases:
Q: The family had automatic bank withdrawal to pay their CHIP premium. The case was closed for failure to cooperate with their reinvestigation. They have now been approved again for the CHIP Premium Group eligibility. Will the automatic withdrawal still be in effect?
A: Whenever a CHIP Premium case is closed, DMS discontinues the automatic bank withdrawal. The family will receive another form to sign up for the automatic withdrawal. If the client wishes to utilize automatic bank withdrawal for payment and cannot find their request form, they may contact the Premiums Collection Unit at 1-877-888-2811.
Q: Can a parent call in a payment to the Premiums Collection Unit?
A: No. Payments can be made by check, cashier's check or money order. Payments may also be paid through automatic bank withdrawal. Automatic bank withdrawals are all scheduled for withdrawal on the 15th of the month and cannot be changed.
Q: Are premium payments for CHIP and Spenddown payments for Medical Assistance sent to the same address?
A: Payments for each program are sent to different addresses. Addresses are included on the invoices sent clients each month. It is important that invoices be sent with the payment to ensure that the payment is applied to the correct case. Payments sent without invoices and with incorrect or incomplete identifying information (invoice number, DCN) may be sent back to the client or be unable to be identified (money orders sent with indistinguishable names and no other identifying information, with no return address on envelope, have been received).
CHIP payments are not to be accepted by the county office. The county offices are to return any payments to the client, and the client informed that the payment must be sent to the Premium Collections Unit. Clients with questions about their payment may contact the Division of Medical Services Premium Collections Unit at 1-877-888-2811.
CHIP Premium payments are mailed to:
Premium Payments
P.O. Box 104178
Jefferson City, MO 65110
DO NOT give this address out for Medical Assistance Spenddown payments, as they go elsewhere.
Q: What do we do if a client states that s/he has not received an invoice? We have verified that the address in our system is correct. Is there a way for us to resend the invoice or can the client send in her payment?
A: The system cannot resend an invoice. The worker may look at the MPNI screen to see the premium amount billed the client. The client can also call the Premium Collections Unit at 1-877-888-2811 to get information regarding the amount of the premium amount and where to send the payment. The client can send in his/her payment, but the DCN must be included. The address to send the CHIP premium payment is noted in the answer above.
NECESSARY ACTION:
- Review this memorandum with appropriate staff.