MEMORANDUM

DISCUSSION:

The purpose of this memorandum is to introduce the Show-Me Healthy Babies (SMHB) program, Income Maintenance Manual section 1855.000.00 and the new Show-Me Healthy Babies Action Notice (IM-32 SMHB).  The Show-Me Healthy Babies Program is established under the authority of Title XXI of the Federal Social Security Act, the State Children's Health Insurance Program, as amended, and 42 CFR 457.1. The Revised Statutes of Missouri, Section 208.662 establishes within the Department of Social Services the Show-Me Healthy Babies Program as a separate CHIP program for any low-income unborn child.  It also establishes a presumptive eligibility process for the pregnant woman and unborn child (ren) with eligibility determined by Qualified Entities.  Presumptive Eligibility details may be viewed in the Income Maintenance Manual under Section 1900.000 Presumptive Eligibility Programs.

Eligibility

Eligibility requirements for unborn children enrolling in the Show-Me Healthy Babies program are:

• The pregnancy is verified by self-attestation;
• The pregnant woman must be a Missouri resident;
• The household size, for income eligibility, includes the unborn child (ren).  Income cannot exceed the income guideline of 300% FPL plus 5% disregard (305% FPL).  Use the tax-filing status of the pregnant woman in determining household size and what income is included;
• The pregnant woman must be uninsured and cannot have access to employer insurance which includes maternity benefits (prenatal, labor and delivery, and postpartum services);
• The pregnant woman must not have access to other affordable health insurance that covers the unborn child;  and

• The pregnant woman must not be eligible for any other MO HealthNet program that covers the pregnancy and does not require a premium or a spend down in exchange for coverage.

  NOTE:  Citizenship is based on the unborn child. Assume the child will be born in Missouri and will be a United States citizen.

  NOTE: A Social Security number is not a factor of eligibility for the pregnant mother or other household members.  While obtaining a social security number is not a factor of eligibility, the social security number should be requested as it may be necessary to verify income.

  NOTE: The Show Me Healthy Babies program does not require a premium.

Coverage

• Unborn child coverage will include the same services available through the MO HealthNet for Pregnant Women (MPW) program under 196% FPL + 5% disregard (201% FPL);
• There is no waiting period for coverage.
• Coverage can begin as early as the date of application if all eligibility factors are met.
• Coverage through labor and delivery will be provided under Managed Care for women residing in Managed Care counties.
• Mothers of unborn children, who were denied MPW for excessive income only, will continue to receive managed care in the post-partum period.
• MO HealthNet coverage will end at birth of the child for mothers who were denied MPW due to citizenship. 

Coverage for Show Me Healthy Babies children after birth:

• For children born to mothers who were denied MPW due to excessive income only, the child is deemed eligible for automatic coverage.

  • Within 10 days of the child's reported birth the income used at he time of the SMHB determination will be used to determine the child's appropriate Federal Poverty Level (FPL). This coverage will have a Federal Grant Indicator (FGI) of 8 and a zero dollar ($0) premium.

    EXAMPLE: A SMHB birth is reported to FSD. The ES uses the income provided at the SMHB determination, in this case 275% of FPL. The child will receive CHIP 75 coverage with an FGI indicator of 8 and will have a $0 premium through the first year of life. The appropriate coverage begins on the date of birth.

• For children born to mothers who were denied MPW due to citizenship,  a re-determination of child's continued eligibility is required at the time of birth.  Since the newborn does not qualify for "Automatic Newborn" coverage, the additional household member is considered a change in circumstance. The ES should make a re-determination using the most recent income verification available. Follow guidelines for verifying income in IM Manual section 1805.030.05 Verification of Income.
  • If household income is at or below 201% of FPL (196% plus 5% disregard), child is eligible for MHK Under One (ME 62 with FGI 8) coverage;
  • If household income is above 201% (196% plus 5% disregard) but at or below 305% (300% of FPL plus 5% disregard) of FPL, the child is in a CHIP premium category (ME 73, 74, or 75 with FGI 8); or

    NOTE: Regardless of the FPL, no premium will be due during the child's first year of life.  The child should be put on the appropriate level of care with a FGI of 8.  Due to system functionality, families may receive an invoice for $0 premium, but should disregard it.   

  • If household income is over the 305% (300% of FPL plus 5% disregard) of FPL guideline, the child is not eligible for any MO HealthNet coverage.  Send a pre-closing notice (IM-80PRE) to the household to allow for ex parte review.  If household does not respond within 10 days, send an adverse action notice.   After ten more days with no response, send Action Notice – SMHB (IM-32 SMHB)

    NOTE: During the ex-parte process the child should be given CHIP 0 (ME 71 with FGI 8) coverage from the DOB through the ex-parte process.

  • An ex parte review must be completed before the child turns age one (1).

  Processing Applications and Case Actions

  • Applications can be submitted by:
    • On-line at www.mydss.mo.gov;
    • Telephone at (855) 373-9994; or
    • Completing the Single Streamlined Application (IM-1SSL) and mailing, faxing, or dropping it off at a local FSD office.
  • Applications will be processed in MEDES using the DCN of the pregnant woman.
  • If the pregnant woman is not eligible for MPW and is denied based on income or citizenship, eligibility for SMHB should be explored.  
  • The ES denying MPW coverage must mail out an IM-31A Electronic form and  two MO HealthNet for Kids Insurance Company Quotes (IM-5) forms to the household, allowing ten days for response.
  • The ES processing SMHB application must review all documentation provided by the pregnant woman's household for self-attested insurance information. 
    • If employer sponsored insurance is available and affordable for the household, explore if all maternity services are covered.
      • If available and affordable, with all maternity services covered, SMHB application is denied.
      • If available and not affordable or all maternity services not covered, explore private insurance.
    • Review documentation to determine if private insurance quotes were provided.
      • If insurance quotes were provided and are above the affordability standard, no further information is needed for this requirement.  Continue with SMHB eligilbity processing.
      • If insurance quotes provided and one or both are below the affordability standard,  review if coverage provides full maternity services including prenatal, labor and delivery, and post-partum coverage.  If full maternity services are available, deny SMHB application.  If full maternity services are not available, proceed with processing SMHB application.
    • Income eligibility will be determined using the new SMHB calculator.
    • Notification of approval, denial, and re-determinations will use the new Action Notice – Show-Me Healthy Babies (IM-32 SMHB) form.
    • If determined eligible for SMHB, coverage for the pregnant woman will be entered by a selected processing center via a special bypass process. 

      NOTE:  Presumptive eligibility determinations received from qualified providers showing eligibility for Show Me Healthy Babies should be sent to FSD.MEDES@dss.mo.gov with the subject line: PE SMHB.

    • Coverage for child after date of birth will be determined and entered by a selected processing center via a special bypass process. 
    • The child will be assigned a DCN and appropriate coverage will be entered when the Family Support Division is notified of the birth.

    NECESSARY ACTION:

    • Review this memorandum with appropriate staff.

    ATTACHMENTS:

    • Action Notice – SMHB (IM-32 SMHB)
    • IM-31A Electronic
    • MO HealthNet for Kids Insurance Company Quotes (IM-5)
    • Flow Chart for Pregnant Women Applications

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