0920.020.10 Access To Affordable Health Insurance

IM-69 November 21, 2014, IM-01 January 4, 2012,  IM-34 April 23, 2008,  IM-#83 August 2, 2005

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

0920.020.10.05  Affordable Insurance Definition

IM-#23 April 26, 2016, IM-#20 March 19, 2015, IM-#16 March 20, 2014, IM-#27 March 11, 2013, IM-#18 March 13, 2012, IM-#17 March 14, 2011, IM-#14 March 5, 2009, IM-#48 June 25, 2008, IM-#71 August 1, 2007, IM-#64 June 15, 2006, IM-#83 August 2, 2005, IM-#64 June 9, 2005, IM-#56 June 9, 2004, IM-#72 June 4, 2002, IM-#59 May 30, 2002

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.

0920.020.10.10   Employer Sponsored Insurance

IM-69 November 21, 2014, IM-01 January 4, 2012,  IM-73 September 25, 2009, IM-34 April 23, 2008

Employer-sponsored health insurance causes ineligibility if:

0920.020.10.15  Private Insurance

IM-#83 August 2, 2005,  IM-#67 July 13, 2004,  IM-#04 January 12, 2001

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.