PURPOSE: The Department of Health and Senior
Services (DHSS) provides low-protein formula, a special dietary product, to
individuals diagnosed as having phenylketonuria (PKU), maple syrup urine
disease (MSUD) and other metabolic conditions as approved by the Newborn
Screening Standing Committee, a subcommittee of the Missouri Genetic Advisory
Committee which makes recommendations to the department on newborn screening
issues. This rule establishes the criteria by which the Metabolic Formula
Program accepts clients for service.
(1) Conditions of eligibility for
the
Metabolic Formula Program (MFP) include:
(A)
An applicant must be diagnosed as having phenylketonuria (PKU), maple syrup
urine disease (MSUD) or other metabolic conditions as approved by the Newborn
Screening Standing Committee and recommended to the department. The diagnosis
must be made by a physician who practices at a metabolic treatment
center;
(B) An applicant must be a
resident of Missouri and cannot reside in a state facility. Proof of residency
will consist of submitting a copy of the previous month's utility bill with the
applicant's home address clearly printed;
(C) The physician treating the applicant must
submit the following information to the
department:
1. A letter requesting the applicant be
placed on the MFP;
2. The name and
address of the applicant; and
3. A
prescription, signed by the treating physician, stating the name of the
low-protein formula, a special dietary product the individual will be using;
and
(D) Financial
eligibility guidelines for enrollment in the MFP shall be based upon the
Poverty Income Guidelines as established by the United States
Department of
Health and Human Services. Determination of individual applicant eligibility
shall be based upon the following:
1.
Applicants five (5) years or under shall have no income qualification
requirements;
2. Applicants six (6)
through eighteen (18) years whose family income is below three hundred percent
(300%) of the federal poverty level shall be eligible for enrollment in the
MFP;
3. Applicants six (6) through
eighteen (18) years whose family income is at three hundred percent (300%) of
the federal poverty level or above shall be eligible based on a sliding fee
scale for enrollment in the MFP;
4.
Applicants nineteen (19) years and above whose income does not exceed one
hundred eighty-five percent (185%) of the federal poverty level shall be
eligible for enrollment in the MFP;
5. Size of family unit shall be the number of
persons in the household, including the responsible party(ies) and dependents
allowable by the Internal Revenue Service as federal income tax exemptions. The
family size may be increased by two (2) additional family members per affected
individual nineteen (19) years and above for the cost of low-protein formula;
and
6. Funding to eligible
applicants may be adjusted by the department based on available
funding.
(2) A
sliding fee scale shall be used to determine the amount of monthly premium and
assistance to be provided by the
department for those individuals six (6)
through eighteen (18) years having no insurance, Medicaid or Medicare and whose
adjusted gross income places the family at three hundred percent (300%) of the
federal poverty level or above. The
sliding fee scale shall be updated based on
changes in the federal poverty guidelines. The adjusted gross income line from
Internal Revenue Service recognized tax forms shall be the income used to
determine financial eligibility with adjustments for child support received or
paid. The table for establishing a sliding scale fee of premiums is provided
below.
Table: Sliding Fee Scale for those Applicants Age 6
through 18 Years Based on Family Adjusted Gross Income
|
Adjusted Gross Income
is:
|
Approximate Family Monthly Premium for
Formula*
|
|
299% of poverty or below
|
0
|
|
300% - 399% of poverty
|
25%
|
|
400 - 499% of poverty
|
40%
|
|
500% of poverty and above
|
50%
|
*Based upon DHSS cost of formula and subject to available
funding for the program.
(3)
Approved applicants having no insurance coverage for metabolic formula,
Medicaid benefits or other third party payor will have formula provided as
prescribed by the person's genetic disease physician or a general physician in
consultation with the genetic disease physician at the metabolic treatment
center.
Notes
19 CSR 40-7.050
AUTHORITY:
section 191.315, RSMo 2000 and sections
191.331 and
191.332, RSMo Supp. 2007.*
Emergency rule filed Sept. 7, 2007, effective Sept. 17, 2007, expired March 14,
2008. Original rule filed Nov. 1, 2007, effective May 30,
2008.
AUTHORITY: section
191.315, RSMo 2000 and sections
191.331 and
191.332, RSMo Supp. 2007.*
Emergency rule filed Sept. 7, 2007, effective Sept. 17, 2007, expired March 14,
2008. Original rule filed Nov. 1, 2007, effective May 30, 2008.
