To be eligible in any of the SCHIP groups a child must be uninsured. Uninsured children are defined as persons up to nineteen (19) years of age that do not have health insurance. Refer to Section 0920.020.05.10 for definition of health insurance. A child covered by health insurance at the time SCHIP eligibility is determined is ineligible, unless:
NOTE: Persons who have exceeded a lifetime maximum for all benefits under their plan are considered uninsured. In addition, persons who have insurance, but have exceeded the annual benefits of the plan for all healthcare services are considered uninsured. The applicant/participant must provide verification from his or her health plan that the child has reached the annual maximum for all plan benefits. The verification must provide a date when healthcare benefits will once again be available for the child. The eligibility specialist must set a reminder in FAMIS to re-determine case eligibility when healthcare benefits will be available for the child.
If the health insurance is dropped without “good cause” and the child is determined to not be eligible for the “special healthcare needs exception”, the Premium Group child is ineligible for six months from the month coverage ended. (Section 0920.020.05.20) Count the first full month of non-coverage as the first month of ineligibility when determining when the six month penalty expires.
NOTE: Children in the No-Cost Group (LOC 1 or CHIP0) are not subject to a penalty for dropped insurance.
EXAMPLE: Mr. Smith dropped coverage on son, Joey, on June 15, 2004. It was determined that Mr. Smith dropped coverage without good cause, that the family income puts Joey in an SCHIP Premium group, and that Joey does not have special healthcare needs. Joey's first month of non-coverage begins July 1, 2004. Joey is ineligible for SCHIP coverage until January 1, 2005.
If an uninsured child income-eligible in the SCHIP Premium group has lost or discontinued health insurance coverage in the six months prior to application, explore “good cause” referenced in Section 0920.020.05.15. If the reason for dropping meets a “good cause” reason, a six month penalty is not imposed. If “good cause” does not exist, a six month penalty is imposed unless a child meets the “special healthcare needs exception” in Section 0920.020.05.20. The participant’s statement on insurance status or “good cause” will be accepted unless questionable. Special healthcare needs must be verified.
Individuals insured simply because the Health Insurance Premium Payment (HIPP) program is paying the premium will be treated as though they were uninsured. If a child in the non-CHIP group has insurance through HIPP, and a change in income occurs which changes eligibility to one of the CHIP groups, the children continue to be eligible for MC+ as though uninsured.
If the HIPP Unit stops paying the premiums for CHIP eligible children because it is determined it is no longer cost-effective and the recipient does not pick up the coverage, we would allow ‘good cause’ and the six month penalty does not apply.� Families picking up the coverage pending an appeal concerning discontinuance of HIPP will be allowed ‘good cause’ for dropping coverage if Division of Medical Services is upheld and the insurance is dropped at that time.� This is because DMS will not continue payment of premiums pending the outcome of an appeal.� However, if the family chooses to continue the coverage after the appeal is upheld the child is considered insured.� If at some point in time later the family decides to drop the coverage, ‘good cause’ is not allowed and the six-month penalty applies.� If the family's income is above the non-CHIP limit, the child is ineligible.
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 insurance.
Health insurance does not have to cover all medical conditions (such as pre-existing conditions) to cause ineligibility for the SCHIP groups. Individuals who have insurance, but have exceeded a maximum benefit for a covered service are also considered insured.
NOTE: Persons who have exceeded a lifetime maximum for all benefits under their plan are considered uninsured. In addition, persons who have insurance, but have exceeded the annual benefits of the plan for all healthcare services are considered uninsured. The applicant/participant must provide verification from his or her health plan that the child has reached the annual maximum for all plan benefits. The verification must provide a date when healthcare benefits will once again be available for the child. The eligibility specialist must set a reminder in FAMIS to re-determine case eligibility when healthcare benefits will be available for the child.
If “good cause” exists for dropping health insurance, the six-month ineligibility period does not apply. Good cause is defined as loss of insurance coverage resulting from no action taken by insured. Good cause reasons are:
Health insurance being unaffordable is not a “good cause” reason for dropping coverage. However, there is an exception to the six month penalty for children with special healthcare needs who do not have access to affordable, employer sponsored healthcare coverage. Refer to Section 0920.020.05.20.
Effective July 1, 2004, RSMo. 208.647 provided for the elimination of the following requirements for children with special healthcare needs who do not have access to affordable employer-subsidized health insurance.
Special healthcare needs are defined as a medical condition which left untreated would result in the death of or serious physical injury to a child. Special healthcare needs are established based on a written statement from the child's treating physician. The Physician's Statement (IM-60MC) form has been produced as a means of obtaining verification of the special healthcare needs.
Evaluate the special healthcare needs exception to determine if the six month penalty should be imposed when:
Affordable employer sponsored healthcare is defined in Sections 0920.020.10.05 and 0920.020.10.10. Children in either of the premium groups (income above 150% FPL) are ineligible if they have access to any affordable health insurance, private or employer-sponsored. (Refer to Section 0920.020.10).
For CHIP Full Premium Group children (LOC 3 or CHIP75) who meet all other eligibility factors, the exception to the 30-day waiting period should be explored anytime a parent/caretaker has indicated a child has special healthcare needs.