In addition to being uninsured, Premium group (income above 150% of FPL) children cannot have access to affordable health insurance. Access to affordable insurance available through employment, a group membership, or from a private company causes ineligibility. 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.
EXAMPLE: Ms. Marks applies for MO HealthNet for Kids (MHK) for her children in July. Her gross income places coverage within the Premium Group. Ms. Marks became employed in February, and chose not to enroll her children in employer-sponsored insurance that is considered affordable. Her employer offers open enrollment every October with coverage beginning in January. Ms. Marks has access to affordable health insurance and is not eligible for MHK healthcare coverage.
Senate Bill 577 (2007) modified Section 208.640 RSMo to provide that employer sponsored health insurance and other health insurance that does not cover an eligible child’s pre-existing conditions are not considered affordable health insurance. The applicant/participant must provide verification from the health insurance plan that the plan does not cover the eligible child’s pre-existing condition and must provide verification from the child’s physician that the child has the pre-existing condition the health plan will not cover.
Additionally, Senate Bill 577 (2007) modified Section 208.640 RSMO to provide that an eligible child who has exceeded the annual benefits of his or her health plan for all healthcare services, is considered uninsured and does not have access to affordable health insurance.
House Bill 2014 (2008), signed by the Governor on April 22, 2008, provided funding to implement the provisions relating to pre-existing conditions and exceeding annual benefits for all healthcare services effective April 1, 2008.
NOTE: If the state employee is receiving premium assistance through the Health Insurance Premium Payment (HIPP) program, they still have access to affordable insurance and are ineligible for all CHIP levels of coverage. HIPP payment of the premium is only an eligibility consideration when reviewing the factor of Uninsured and not when considering the eligibility factor of Access to Affordable Health Insurance
Senate Bill 577 amended the affordability standard in Section 208.640 RSMo effective August 28, 2007. The new affordability standard is based upon a percentage of income for a family of three at 150%, 185%, or 225% of the FPL, depending upon the family's gross income.
Families with income between 150% and 300% of the FPL with access to insurance must meet the following affordability guidelines:
Effective April 1, 2015, families with income between 150% and 300% of the FPL with access to insurance must have monthly health insurance premiums for the children compared to the following affordability standards:
If insurance is available for the child(ren) at a cost below the affordability standards, the child(ren) is not eligible for the MO HealthNet for Kids SCHIP Premium healthcare coverage due to access to affordable health insurance. Refer to Section 0920.020.10 and Section 0920.020.10.10 if the child(ren) has a pre-existing condition that the health insurance plan does not cover, or if the child has exceeded annual benefits for all healthcare services.
Employer-sponsored health insurance causes ineligibility if:
NOTE: Section 2110 of the Social Security Act states children who have a family member eligible for health benefits coverage under a State health benefits plan on the basis of the family member’s employment with the State are not eligible for the Children’s Health Insurance Program (CHIP). Health insurance available to a state employee through a state agency is considered affordable regardless of cost.
EXAMPLE: The Missouri Department of Transportation (MODOT) is a state agency that does not participant in Missouri Consolidated Health Care Plan (MCHCP), however, provides health insurance to their employees.
An applicant with two children applies for MO HealthNet (MHN) and works part-time for MODOT. The expense of purchasing the MODOT health insurance is $300.00 per month and therefore, the applicant chose not to purchase the insurance. The applicant's household is uninsured. The applicant is a state employee who can purchase health insurance through their state employer. The children are not eligible for CHIP level of care.
EXAMPLE: Mrs. Maple applied for MO HealthNet for Kids for her daughter Ann. The Maple family income is over 150% of the federal poverty level (CHIP premium level). Ann does not have health insurance. Mr. Maple has employer sponsored insurance that would cover Ann if he elected to cover her, but it will not cover her asthma, a pre-existing condition. She also furnished Mr. Maple’s health insurance member handbook that verifies that pre-existing conditions are not covered. Since Ann is uninsured and Mr. Maple’s employer sponsored health insurance will not cover Ann’s asthma, Ann does not have access to affordable employer sponsored health insurance. Mrs. Maple must still furnish two private insurance quotes to evaluate her access to affordable private insurance. If the two private quotes do not meet the criteria in Section 0920.020.10.15, Ann is eligible if all other eligibility requirements are met.
EXAMPLE: Mrs. Davis applied for MO HealthNet for Kids for her daughter Julie. Mr. Davis just purchased employer sponsored health insurance for Julie, and then learned that her asthma will not be covered because it is a pre-existing condition. The Davis family income is over 150% of the federal poverty level (CHIP premium level). Julie has health insurance, but it does not cover her pre-existing conditions. However, Julie’s health insurance still meets the definition of health insurance in Section 0920.020.05.10. Julie is not eligible for MO HealthNet for Kids, CHIP premium level of care, because she is an insured child.
If affordable employer sponsored insurance is not available, evaluate access to affordable private insurance coverage. The family must provide quotes on the cost of health insurance for their children from two private insurance companies. Written verification from the insurance companies is not required, but the applicant must supply names of the insurance companies on the application.
If the private insurance quotes are above the affordable amount, the family does NOT have access to affordable insurance and the children are eligible on that factor.
If one or both of the private insurance quotes are less than the affordable amount, send the applicant the MC+ Insurance Company Quotes form for completion for each insurance plan that is affordable.
When sending the insurance company quotes form, instruct the applicant to ask the companies the questions on the form, write down the insurance company's answers and return the form. Upon receipt of the completed forms, the worker will determine whether the insurance meets the definition for affordable.
A private insurance policy causes ineligibility if it:
If an applicant with children in the premium group fails to provide an amount a private insurance company would charge to cover their children, reject the application the 30th day. Enter a reason code of 61 (Access to Affordable Insurance) in IMU5. The rejection letter should state “You failed to provide information concerning the amount a private insurance company would charge for health insurance for your children. This information is required as your monthly income exceeds ___________. (Chapter 208.RSMo, Section 208.640). Enter the 150% FPL income for the number of persons in the assistance group.