| TO: | ALL COUNTY OFFICES |
| FROM: | JANEL R. LUCK, DIRECTOR |
| SUBJECT: | AFFORDABLE INSURANCE STANDARDS CHANGE FOR MO HEALTHNET FOR KIDS SCHIP PREMIUM PROGRAM; |
DISCUSSION:
Effective July 1, 2008, the affordability standard for SCHIP Premium families is changed. Senate Bill 577 (2007) amended the affordability standard in Section 208.640 RSMo, basing the affordability standard upon a percentage of income for a family of three at 150%, 185%, or 225% of the Federal Poverty Level (FPL), depending upon the family's gross income. Effective July 1, 2008, families with income between 150% and 300% of the FPL with access to health insurance must meet the following affordability guidelines:
-
151% - 185% of the FPL (CHIP 73) = $66/month
-
186% - 225% of the FPL (CHIP 74) = $109/month
- 226% - 300% of the FPL (CHIP 75) = $165/month
Employer-Sponsored Health Insurance
If employer-sponsored insurance meets the definition of health insurance in Section 0920.020.05.10 and is available for the child(ren) below the affordable levels, the child(ren) is not eligible for MO HealthNet for Kids SCHIP Premium healthcare coverage due to access to affordable health insurance, unless the child(ren) has a pre-existing condition that will not be covered and verification of the pre-existing condition is obtained as explained in Section 0920.020.10.
EXAMPLE: Mrs. Gardener submits an application on 7/11/08 for MO HealthNet for Kids for her children, Rose and Lily. The Gardener family's gross income is at a CHIP 74 level of care, between 186% and 225% of FPL. Mrs. Gardener's employer offers insurance for the children at a monthly cost to Mrs. Gardener of $100. Rose has pre-existing conditions that cannot be covered under the employer insurance. Private insurance is explored and quotes are considered unaffordable as the cost is over $200 per month. All other eligibility conditions are met. Rose is eligible for CHIP 74, as the affordable insurance does not cover her pre-existing condition; Lily is not eligible as she has affordable insurance available and has no barrier to coverage.
Private Insurance
If private insurance is available for the child(ren) below the affordable levels, healthcare services provided by the private insurer must also cover all MO HealthNet for Kids healthcare services, with the exception of non-emergency medical transportation, and must cover all the child(ren)'s pre-existing medical conditions to cause ineligibility for MO HealthNet SCHIP Premium coverage. If private insurance is below the affordable limit, benefits are comparable to MO HealthNet for Kids, and it covers all pre-existing conditions, the child(ren) is not eligible for MO HealthNet for Kids SCHIP Premium healthcare coverage due to access to affordable health insurance.
EXAMPLE: Mr. Primrose applies for MO HealthNet for Kids for his children, Travis and Brianna on 7/3/08. The Primrose family's gross income is at a CHIP 75 level of care, between 226% and 300% of FPL. Mr. Primrose's employer does not offer insurance coverage for the children. Mr. Primrose provides quotes and coverage information from two private companies. The first company offers insurance coverage for the children at a monthly cost to Mr. Primrose of $120, but the benefits are not comparable to MO HealthNet for Kids healthcare as it does not cover dental or vision. The second company offers insurance coverage for the children at a monthly cost of $160. Brianna has pre-existing conditions that cannot be covered by the second private insurance company and the policy does not cover all benefits as MO HealthNet for Kids. Travis and Brianna are both eligible for CHIP 75, as they have no access to affordable insurance.
Applications and Interim Changes
The affordability standards will be applied by the FAMIS system to any pending applications and case actions for July 1, 2008, and ongoing.
NECESSARY ACTION:
- Apply the new affordability standards for July 2008 and later.
- Review this memorandum with appropriate staff.