13 CSR 70-4.080 - State Children's Health Insurance Program
(1) Definitions.
(A) Children. Persons up to nineteen (19)
years of age.
(B) Health insurance.
Any hospital and medical expense incurred policy, nonprofit health care service
for benefits other than through an insurer, nonprofit health care service plan
contract, health maintenance organization subscriber contract, preferred
provider arrangement or contract, or any other similar contract or agreement
for the provision of health care benefits. 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.
(2) An uninsured child/children in
a family(ies) with gross income of more than one hundred fifty percent (150%)
of the federal poverty level shall not have had health insurance prior to
application pursuant to 208.631, RSMo.
(3) Parent(s) and guardian(s) of uninsured
children with gross income of more than one hundred fifty percent (150%) but
less than three hundred percent (300%) of the federal poverty level must
certify, as a part of the application process, that the child does not have
access to affordable employer-sponsored health care insurance or other
affordable health care coverage available to the parent(s) or guardian(s)
through their association with an identifiable group (for example, a trade
association, union, professional organization) or through the purchase of
individual health insurance coverage. Access to affordable employer-sponsored
health care insurance or other affordable health care coverage shall result in
the applicant not being eligible for the Health Care for Uninsured Children
program for the child/children in families with gross income of more than one
hundred fifty percent (150%) but less than three hundred percent (300%) of the
federal poverty level.
(A) For families with
gross income of more than two hundred twenty-five percent (225%) but less than
three hundred percent (300%) of the federal poverty level affordable
employer-sponsored health care insurance or other affordable health care
coverage is health insurance requiring a monthly dependent premium of five
percent (5%) of two hundred twenty-five percent (225%) of the federal poverty
level for a family of three (3).
(B) For families with gross income of more
than one hundred eighty-five percent (185%) but less than two hundred
twenty-six percent (226%) of the federal poverty level affordable
employer-sponsored health care insurance or other affordable health care
coverage is health insurance requiring a monthly dependent premium of four
percent (4%) of one hundred eighty-five percent (185%) of the federal poverty
level for a family of three (3).
(C) For families with gross income of more
than one hundred fifty percent (150%) but less than one hundred eighty-six
percent (186%) of the federal poverty level affordable employer-sponsored
health care insurance or other affordable health care coverage is health
insurance requiring a monthly dependent premium of three percent (3%) of one
hundred fifty percent (150%) of the federal poverty level for a family of three
(3).
(4) An uninsured
child/children with gross income of more than two hundred twenty-five percent
(225%) but less than three hundred percent (300%) of the federal poverty level
shall be eligible for service(s) thirty (30) calendar days after the
application is received if the required premium has been received. An uninsured
child/children with gross income of more than one hundred fifty percent (150%)
but less than two hundred twenty-six percent (226%) of the federal poverty
level shall be eligible for services once the required premium has been
received.
(A) Parent(s) or guardian(s) of
uninsured children with gross income of more than one hundred fifty percent
(150%) but less than one hundred eighty-six percent (186%) of the federal
poverty level are responsible for a monthly premium equal to four percent (4%)
of monthly income between one hundred fifty percent (150%) and one hundred
eighty-five percent (185%) of the federal poverty level for the family
size.
(B) Parent(s) or guardian(s)
of uninsured children with gross income of more than one hundred eighty-five
percent (185%) but less than two hundred twenty-six percent (226%) of the
federal poverty level are responsible for a monthly premium equal to four
percent (4%) of monthly income between one hundred fifty percent (150%) and one
hundred eighty-five percent (185%) of the federal poverty level for the family
size plus eight percent (8%) of monthly income between one hundred eighty-five
percent (185%) and two hundred twenty-five percent (225%) of the federal
poverty level for the family size.
(C) Parent(s) or guardian(s) of uninsured
children with gross income of more than two hundred twenty-five percent (225%)
but less than three hundred percent (300%) of the federal poverty level are
responsible for a monthly premium equal to four percent (4%) of monthly income
between one hundred fifty percent (150%) and one hundred eighty-five percent
(185%) of the federal poverty level for the family size plus eight percent (8%)
of monthly income between one hundred eighty-five percent (185%) and two
hundred twenty-five percent (225%) of the federal poverty level for the family
size plus fourteen percent (14%) of monthly income between two hundred
twenty-five percent (225%) and three hundred percent (300%) of the federal
poverty level for the family size.
(D) The monthly premium shall not exceed five
percent (5%) of the family's gross income.
(E) The premium must be paid prior to service
delivery.
(F) The premium notice
shall include information on what to do if there is a change in gross
income.
(G) No service(s) will be
covered prior to the effective date which is thirty (30) calendar days after
the date the application is received for uninsured children in families with an
income of more than two hundred twenty-five percent (225%) of the federal
poverty level.
(5) If the
parent(s) or guardian(s) who owes a premium fails to meet the premium payment
requirements, a past due notice shall be sent requesting remittance within
thirty (30) calendar days from the date of the past due letter.
(6) Premium adjustments shall be calculated
yearly in March with an effective date of July 1 of the same calendar year.
Individuals shall be notified of the change in premium amount at least thirty
(30) days prior to the effective date.
(7) The thirty- (30-) calendar-day delay in
service delivery is not applicable to a child/children already participating in
the program when the parent's or guardian's income changes. If the household
incurs a premium as the result of an annual review, regardless of whether it is
a new amount or the same amount, coverage shall be extended for sixty (60)
calendar days to allow for premium collection and to ensure continuity in
coverage. Coverage shall be discontinued for the child/children if the premium
payment is not made within the sixty- (60-) day extension period.
(8) Any child identified as having "special
health care needs," defined as a condition which left untreated would result in
the death or serious physical injury of a child, who does not have access to
affordable employer-subsidized health care insurance shall not be subject to
the thirty- (30-) day waiting period required under section
208.646, RSMo, and once
enrolled, shall not be required to be without health care coverage for any
period of time in order to be eligible for services under sections
208.631 to
208.657, RSMo, for the parent's
or guardian's failure to pay a premium, as long as the child meets all other
qualifications for eligibility for the remainder of the twelve- (12-) month
continuous eligibility period described in section (11) of this rule.
(9) The total aggregate premiums for a family
covered by this rule shall not exceed five percent (5%) of the family's gross
income for a twelve- (12-) month period of coverage beginning with the first
month of service eligibility. Waiver of premiums shall be made upon
notification and documentation from the family that payments for premiums have
been made up to five percent (5%) of their yearly gross income.
(10) For the purposes of this rule, a
child/children whose annual maximum benefits of a particular medical service
under their private insurance has been exhausted is not considered insured and
does not have access to affordable health insurance.
(11) When a household pays its first premium,
or pays the first premium due after a completed annual review, coverage for the
household's child(ren) shall extend for a twelve (12) month continuous
eligibility period from the month of application or the month of the last
completed annual review (whichever is later).
(A) If the household does not pay its first
premium due after a completed annual review, then the case will be
closed.
(12) A household
with children that is not required to pay a premium shall have continuous
coverage for the household's child(ren) for twelve (12) months from the month
of application or the month of the last completed annual review (whichever is
later).
Notes
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