IM-87 07/23/98 MC+ ELIGIBILITY FOR CHILDREN
|MC+ ELIGIBILITY FOR CHILDREN|
|The Children's Health Initiative expands
healthcare coverage to uninsured children with gross family income up to
300% of the Federal Poverty Level (FPL). IM Memorandum #65 of June
22, 1998, announced the MC+ program as Missouri's Children's Health Insurance
Program (CHIP)and provided general information. Missouri's MC+ Program
not only includes the new groups of uninsured children, but also includes
the Medicaid for Children (MC) and Medicaid for Pregnant Women (MPW) programs.
Anyone applying for health care benefits for children or pregnant women
will be applying for MC+, as the MC+ program also replaces the MC and MPW
On July 1, 1998, we began accepting applications for uninsured children with family income above the current Medicaid for Children maximums. Services for these children will begin on September 1, 1998. After September 1, coverage for the new groups of children in families with income up to and including 225% FPL will be effective with the date of application. Eligibility for the new groups of children with family income above 225% FPL cannot begin prior to the 30th day after the date of application. This memorandum addresses policy and procedures for determining eligibility for the uninsured children.
NOTE: Although we began accepting applications on July 1, 1998, no approvals for the new groups of children can be entered until systems work has been completed. It is permissible to process rejections. Staff will be notified when approvals for the new groups may be processed. ALL APPLICATIONS SHOULD BE SCREENED TO DETERMINE IF ELIGIBILITY EXISTS UNDER THE OLD MEDICAID FOR CHILDREN PROGRAM. If eligible, approve the application according to existing procedures for the old Medicaid for Children program.
There are now four eligibility groups of
children who are eligible for the MC+ program:
To the public, the program for all health care benefits for children and pregnant women will be known as MC+. MC+ previously referred only to the managed care health plans and regions. Now it encompasses both managed care regions and fee-for-service counties. Applications for uninsured children will be registered and processed as C7 applications. The IM-1UA as revised in IM Memorandum #71 dated June 26, 1998, will be used for all applications for children and pregnant women. The worker will review the completed IM-1UA, Application for MC+, to determine what type of application or combination of applications should be registered. If the application is for a child, register a C7 application. If the application is for a pregnant woman, register a MPW application. Always explore eligibility for the current family Medicaid programs prior to determining eligibility for the new groups.
To qualify for MC+ under the Children's Health Initiative (income above the Non-CHIP Group, old Medicaid for Children Program, maximums) the following eligibility criteria must be met:
Uninsured children are defined as persons up to nineteen (19) years of age who do not have health insurance. Additionally, an uninsured child must not have had health insurance in the six months prior to application. The applicant's statement will be accepted unless questionable. If health insurance is dropped without "good cause", the child is ineligible for six (6) months from the month coverage ended.
Health insurance is defined as insurance that minimally provides coverage for physician's services and hospitalization.
The term "health insurance" does not
include short-term, accident, fixed indemnity, limited benefit or credit
insurance, coverage issued as a supplement to liability insurance, insurance
arising out of a workers' compensation or similar law, automobile medical-payment
insurance, or insurance under which benefits are payable with or without
regard to fault and which is statutorily required to be contained in any
liability insurance policy or equivalent self-insurance. Also, participation
in the Caring Foundation for Children program is not considered health
If it is determined the parents or guardian dropped health insurance for their children in the last six (6) months for "good cause", the six month ineligibility period will not apply. Good cause is defined as loss of insurance coverage resulting from no action taken by insured. Examples include:
HIPP / TPL Requirements: All Health Insurance Premium Payment (HIPP) requirements apply to the new groups of uninsured children. Those individuals insured simply because HIPP is paying the premium will be treated as though they were uninsured. The following procedures should be followed with regard to HIPP.
System Changes with Regard to Insurance: Because of the importance of information concerning health insurance coverage, field 13-O3 has been created in the IMU5 system to enter the following codes:
U -- uninsured,
It will be necessary to enter this information for all approvals. Data Processing (DP) will complete an initial match with the TPL system and enter the appropriate code according to information on file for each individual. Division of Medical Services (DMS) will alert staff if they obtain new information on health insurance for an individual so an appropriate code may be entered. An edit will be implemented to ensure that information is entered in Field 13-O3.
NO ACCESS TO AFFORDABLE HEALTH INSURANCE
Premium Group (income above 225% of FPL) children must not have access to affordable health insurance that is employer sponsored or available through a group membership. Examples of group memberships that could offer health insurance are a union, professional organization, or trade association. If the family fails to purchase the affordable health insurance, premium group children are ineligible as long as it is available. It is considered available even though there is a limited open enrollment period for which they need to wait.
Affordable refers to health insurance requiring a monthly premium of $86 or less per month per family. Affordable is defined as 133% of the current monthly average premium in the state's Missouri Consolidated Health Plan. Adjustments will be made to the premium amount each July 1st to reflect changes in Missouri Consolidated Health Plan premiums.
PAYMENT OF PREMIUM
Families with income above 225% of poverty must pay a $65 monthly premium for their children to be eligible for coverage. The premium is the same for families of all sizes. The premium will be collected by DMS s contracted designee.
Approval in the Premium group does not mean a child will receive benefits. It means the family is eligible to buy medical coverage for the child(ren) through MC+. Parent(s) or guardian(s) are asked to pay the monthly premium within 30 days from the date of application. If the premium is paid within this time, coverage will be effective on the 30th day after application. The day following the day of application is considered day one. If the premium is not paid within the 30 day period, coverage will be effective with the date of receipt of the premium.
The MCII screen will be used to show coverage dates for the Premium group. The enrollment date in a health plan on MCII will be the first date of any coverage in the Premium group. The MCII screen was previously only used to show a lock-in to a specific health plan. It will now also be used to show fee-for-service coverage for persons in the Premium group. Persons in fee-for-service counties will be assigned to a pseudo plan number. Premium group children in managed care regions will also be assigned to the pseudo plan until the effective date of their enrollment in a managed care health plan.
Failure to pay a premium any time after coverage begins will result in a six (6) month period of ineligibility. DMS will notify DFS through Data Processing when a case is ineligible due to non-payment of premium and the case must be closed. If the participant reapplies for coverage within the six month penalty period, and they remain eligible in the Premium group, the application must be rejected. Any time a premium group family reapplies for MC+ within six (6) months of a closing, the MCII screen should be viewed to determine if the case was previously closed for failure to pay the premium. An edit will occur in IMU5 if the caseworker attempts to approve an individual to the premium group during the penalty period.
If an individual (who was previously closed for failure to pay a premium) is eligible for benefits in the non-CHIP group, no cost sharing group, the co-pay group , or for another program, the penalty will not apply. If the individual is determined eligible in the premium group at a later date, the penalty period must have expired before they may be approved.
Failure to pay the premium at initial approval will not impose a penalty. The case will be closed for non-receipt of premium. A family must have been receiving coverage and stop paying the required premiums in order for the penalty to apply.
Eligibility for the new groups of children will be determined by comparing available gross monthly income to the appropriate percentage of poverty level. Medicaid for Children assistance grouping rules apply (1996, IM Memorandum #21). Gross income is determined following Medicaid for Children policy. There are no allowable deductions/disregards with the exception of overhead expenses for self-employment income. The IBCA will be revised to assist workers in determining eligibility for the new groups.
NOTE: An individual must be determined ineligible for the MPW program and the Non-CHIP group (old Medicaid for Children program) prior to completing an eligibility determination for the new CHIP groups. This includes children only eligible by excluding optional members from the assistance group.
The cover letter for the mail-out application requests the applicant submit pay stubs. However, if they are not provided, the application must be processed and may be approved without this type of verification. The applicant's declaration of income is acceptable unless questionable. This applies to all MC+ applications, not just the new groups of uninsured children.
Families must have a total net worth of $250,000 or less. Net worth is the value of all assets (real and personal property, liquid assets, etc.) minus indebtedness. There are no homestead, vehicle, or other exemptions. The applicant's statement is acceptable unless the information conflicts with other available information. This policy only applies to the new CHIP groups of eligible children.
Assignment and cooperation are the same as outlined in the Medicaid for Children section of the IM Manual, Chapter I, Section X, p. 2 (d - e).
The requirements have not changed. The procedures for collection of information and making these referrals have changed. The IM-1UA has been revised to include pertinent absent parent information. The client has met initial cooperation requirements if they supply the information requested on the IM-1UA.
A CSE-201 must be completed, but is not required prior to approval. Do not hold an application pending completion of the CSE-201. If the applicant is unavailable to sign the CSE-201 (mail-in application), mail them the CSE-201 with a self-addressed envelope. Include a notice that they have ten (10) days to return the completed CSE-201.
If the CSE-201 is not received by the date of approval, send another notice advising the applicant they have ten (10) days to provide the completed CSE-201. If the CSE-201 is not received during this ten (10) day time period, send an IM-80 to sanction the payee. DCSE should either receive the appropriately completed CSE-201 or an IM-16 notifying DCSE a sanction was imposed. STAFF SHOULD HAVE THE CSE-201 COMPLETED BY THE APPLICANT IF THE APPLICATION IS MADE IN PERSON.
The following eligibility criteria are the same as existing policy for Medicaid for Children:
SOCIAL SECURITY NUMBER
Coverage for the three new groups of uninsured children approved for MC+ will be the same as that received by children eligible for the current Medicaid for Children program, except:
Children in the Co-Pay Group (186 - 225% FPL) will have a $5 co-pay at the time of each provider visit. The co-pay will be collected by the provider at the time of service.
Children in the Premium Group (226-300% FPL) will have a $10 co-pay at the time of each provider visit and a $5 co-pay per prescription. This is in addition to the $65 monthly family premium. The co-pays will be collected by the provider at the time of service.SYSTEM CHANGES:
MC+ applications for uninsured children will be registered on IAPP immediately as C7 (Medicaid for Children) applications. It is important to update changes in worker and load assignments so the person responsible for the application can be determined. All C7 applications will now be due within 30 days. The application control report has not been changed to reflect the new time frames yet.
The new groups are distinguished from the Non-CHIP group (old Medicaid for Children program) by a different level of care on the IMU5 in Field 13G. The new groups will be coded with a "1", "2", or "3" level of care (LOC).
LOC "1" - indicates eligibility for the No Cost Sharing Group; net income above 100% and gross income at or below 185% for children ages 6 - 18, and net income above 133% and gross income at or below 185% for children ages 1 - 5.
LOC "2" - indicates eligibility for the Co-pay Group; gross income above 185%, and at or below 225%
LOC "3" - indicates eligibility for Premium Group; gross income above 225%, and below 300%
Determine eligibility for current programs prior to determining a child's eligibility for MC+ in one of the new groups.
The following edits are being added to IMU5 to ensure children are approved for the Non-CHIP Group, if eligible; and given the correct LOC if in one of the new groups:
1. If child under age 1 and net income is less than 185%, must be "Q" LOC
2. Child age 1 through 5 and net income is less than 133%, must be "Q" LOC
3. Child age 6 through 18 and net income less than 100%, must be "Q" LOC
4. Gross income between 100% and 185% -- No cost sharing group -- LOC must
5. Gross income between 186% and 225% -- Co-pay group -- LOC must be "2"
6. Gross income between 226% and 300% -- Premium group -- LOC must be "3"
7. Gross income 300% or over -- ineligible
8. LOC "1" and "2" -- date of eligibility cannot be prior to date of application
9. LOC "3" -- date of eligibility cannot be prior to thirty (30) days after applicationThree reason codes for closing/rejection have been added. They are as follows:
60 -- InsuredOther new edits include:
1. Required entry in Field 13-O3 (insurance coverage)
2. Ineligible -- six month penalty period for non-payment of premium (LOC "3" only)SPECIAL INSTRUCTIONS FOR PREMIUM GROUP:
The beginning eligibility date in Field 13E for the premium group (LOC 3) does not necessarily reflect eligibility for MC+ coverage. This date simply indicates the earliest date the individual can become eligible. These participants are not eligible until the premium is paid. These participants have thirty (30) days from the date of application to pay their premiums. If paid during the 30 day period, coverage will begin on the 30th day.
If the premium is not paid during this 30 day period following application, the parent(s) or guardian(s) will be notified to remit their premium within 20 calendar days from the date of the notice or their case will be closed. DMS will notify DFS if the premium is not received within this time period after allowing an additional 10 days. DFS will then take action to close the casefor non-payment of premium. An IM-80 is not required in this situation.
If the premium is paid, the MCII screen will be used to show coverage dates. Persons in fee-for-service areas will be assigned a pseudo plan number. To determine if the premium has been paid and the individual is actually eligible, refer to the MCII screen which shows if the individual is locked in. If no lock-in, they are not eligible to receive services.
DMS's designated contractor is responsible for collecting the monthly premiums. DMS Data Processing will notify our system to close the MC+ case when the premium has not been paid by the due date. DMS will maintain a record of the month of non-payment of premium, to track the six month penalty period. An edit will be implemented which will not allow an approval in the premium group during the six month penalty period. When the system indicates an individual is not eligible for this reason, reject the individual's application.
DMS will automatically stop coverage upon notification from the designated contractor that the premium was not paid by the due date. The ending eligibility date on IXIX will not reflect the actual date coverage ended. Check the MCII screen for the correct beginning and ending date of coverage for the Premium Group, LOC "3". The enrollment stop date is the last day of coverage.
If staff is contacted by a participant who states they did pay the premium, refer the participant to the DMS designated contractor (name and phone number of be provided later) or the DMS Recipient Services at 1-800-392-2161.
When a person's level of care changes to the premium group (3), enter the current date in field 13E as the begin date for that LOC. Our system will put an end date on the old LOC that is 60 days from the action date. This applies to both health plan regions and fee-for-service counties. This will allow the participant to have uninterrupted service. If they fail to pay the premium within the 30 day period, at the end of the 60 day period coverage in the old LOC will end.
When an application for MC+ is received, it may not be clear which type of assistance the family will be eligible to receive. Family members may be eligible for MPW or one of the 4 MC+ children s groups. It may be necessary to register both a MPW and a C7 application into IAPP. Always determine eligibility for the Non-CHIP group (level of care "Q") and MPW prior to approving a person in one of the new CHIP groups. Benefit packages are more restrictive for individuals approved in the new CHIP groups.
After determining ineligibility for the Non-CHIP group, determine if the child is insured. If insured, a child is ineligible for any of the CHIP groups. If uninsured and in the premium group, determine if affordable health insurance is available. If affordable health insurance is available, a child is ineligible.
The time frame for processing all MC+ applications; except MC+ for Pregnant Women, is now 30 days. Applications for pregnant women must be processed within 15 days. It is important to process all MC+ applications as quickly as possible. The reduced verification requirements should make it possible to approve many applications on the date of receipt or the following day. Title XIX beginning dates cannot be prior to 30 days from the date of application for the premium group. For children in the no cost-sharing and co-pay groups coverage cannot begin prior to the date of application.
The beginning date of eligibility for the Non-CHIP group (old Medicaid for Children) and MPW recipients continues to be the first day of the month of application if eligible. Prior quarter eligibility continues to apply to the Non-CHIP group and MPW recipients.
Changes on Active Cases
Changes in income and household composition may cause a family to change to a different eligibility group. The following are the procedures to use when a change in eligibility is reported or discovered.
Your household s gross income of ________exceeds the limit of ________ allowed to receive MC+ without paying a premium. To continue to be eligible for MC+ you will be required to pay a $65 monthly premium. Your first premium will be due 30 days after the expiration date shown above. You will receive information about the required premium. Legal Reference 208.185 RSMo.
Change the individual to the appropriate level or care. The Title XIX begin date will be the date the change is reported to Division of Family Services. Any refund of premiums will be determined by DMS or their appointed designee.
Notify the participant in writing any time there is a change in the level of care. An IM-80 is not required when the LOC changes from "Q" to "1" or "2", or from "1" to "2".You will be notified later of the date the system will be ready to accept approvals. At that time, additional information will be sent regarding the premium collection process, approval letters, and the MCII screen.