1600.000.00 GATEWAY TO BETTER HEALTH (GTBH)

The Gateway to Better Health (GTBH) program provides benefits for uninsured adults, age 19-64 who reside in St. Louis City or St. Louis County and who meet certain eligibility criteria. Coverage benefits include preventive, family, and well care and are provided at participating primary care centers. The application form for GTBH is the IM-1GW. The participating health clinic will assist the participant in filling out the IM-1GW application and return it to the St. Louis City, Chouteau office. Individuals may only apply at a participating health clinic. All applications will be processed at the Chouteau office.

1600.005.00 LEGAL BASIS

On July 28, 2010, Missouri's request for a section 1115 demonstration project, entitled "Gateway to Better Health," was approved. This demonstration project provides financial support to specified St. Louis Health Centers.

1600.010.00 ELIGIBILITY REQUIREMENTS (GTBH)

To qualify for GTBH the following eligibility criteria must be met:

• Not eligible for any other MO HealthNet program with the exception of UWHS and EWHS
• Age 19 – 64
• Income at or below 100% of FPL
• Resident of Missouri and St. Louis City or St. Louis County
• Primary Care Home at one of the participating health clinics
• Uninsured
• Citizenship / alien status, and
• Social Security Number.

The Citizenship/alien status and Social Security Number requirements are the same as for the MO HealthNet for Families (MHF) program 0905.010.30.

There are no resource limits for the Gateway to Better Health program.

1600.010.05 Ineligibility for Other MO HealthNet Programs

To qualify for Gateway to Better Health program the participant must be found ineligible for all other MO HealthNet programs. The only exception to this is the Uninsured Women's Health Services program (UWHS) and Extended Women's Health Services program. If the participant is eligible for Uninsured Women's Health Services (UWHS) program or is covered under the Extended Women's Health Services (EWHS) program she is eligible to receive Gateway Coverage as well.

1600.010.10 Age 19-64 (GTBH)

The participant must be age 19-64 to receive Gateway to Better Health program benefits.

1600.010.15 Need (GTBH)

To receive Gateway to Better Health program benefits, income must not exceed 100% FPL.

1600.010.15.05 Assistance Group (GTBH)

Although GTBH eligibility is determined on an individual basis, the income of certain household members is considered when establishing need.

Those whose income is to be considered are:

• the participant;
• the participant's spouse, if living together.

The income of other members of the household is not considered, however they are included in the assistance group when establishing need. Those whose income is not considered, but who are included when establishing need are:

• Dependent children under the age of 18.

1600.010.15.10 Income (GTBH)

In determining need, consider all income available during the period. To be considered available, the income must actually exist and be usable by the applicant or participant.

NOTE: When potential eligibility for SSDI, UC, or veteran's benefits exists, but the participant (or spouse) refuses to apply for these benefits, reject or close the case. Inform the family of their obligation to apply for benefits. The family must cooperate with the other agency's requirements in pursuing these benefits.

Division of Employment Security notifies FSD when an applicant or participant:

• Receives UC benefits,
• UC benefit amount changes, or
• UC benefits are terminated.

Determine eligibility based on need by projection. Projection is defined as the best estimate of the income and circumstances that will exist. This estimate is based on reasonable expectation and knowledge of the individual's current, past, or future circumstances.

In ESTIMATING THE AMOUNT OF INCOME, consider all factors that most accurately estimate and reflect the amount of income to be received.

Review any information available showing income and expenses during the past 30 days. Discuss with the household any changes expected or predicted in income and expenses by comparing information over the past 30 days. If income fluctuates to the extent that a 30-day period does not accurately indicate projected income, choose a method that accurately indicates future income.  Record the basis for the time period used.

During an application, budget income that will not continue as actual income for the month of receipt.

Budget income that starts while the application is pending using actual income in the month the income starts and project for future months.

Also use actual income in a month in which an entire pay period is missed but the employment situation is unchanged.

A claim cannot be established for the period of the projection unless one of the following apply:

• the participant failed to report income or circumstances he/she was aware of
• the eligibility specialist erred in making the decision, considering the information available.

1600.010.15.15 Sources of Earned and Unearned Income (GTBH):

Enter the income information on the Income (FMX0) and Income Amount (FMX3) screens. The income type code is EI (earned income) or UI (unearned income). The income source code follows each income in parenthesis. Refer to the FAMIS Income Code Chart for more information. Record a comment as outlined in the FAMIS Comments Quick Reference Chart.

13 CSR 40-2.050 defines earned income as income in cash or kind currently earned as wages, salary, commissions, or profits from any business in which the participant engages as a self-employed person or employee, with responsibilities that require his/her continuing activity. Possible sources of EARNED INCOME include but are not limited to:

• Wages(WA) (including the amount of any garnishment);
• Tips (TI);
• Boarders or lodgers(RB);
• Income or earnings from self-employment (SE), sale of plasma (BP), sale of business products, child care self employment (CC), and self employment from sale of farm or garden products(FA/FM);
• Compensation in lieu of wages (CL), such as working off the rent;
• Americorps*NCCC stipends (AE) (See Excluded Income for Americorps income excluded) ; and
• Rental property (RE);

Possible sources of UNEARNED INCOME include but are not limited to:

• Child Support or Alimony payments including the following:
  • child support (CS) - this is income to the child for whom the payment is made if the child is in the EU;
  • child support arrearages (CA) - this is income to the child for whom the payment is made if the child is in the EU;
  • child support payments paid for someone outside the home (CR);
  • alimony (AL); and
  • alimony arrearages (AR).
• Interest Income (IN);
• Property rental (RN);
• Income from stocks, bonds, investments (DI), trusts (TR);
• Benefits received under Social Security Programs, such as Social Security Disability or Social Security Retirement (SS) or SSI (SI);
• Veteran's benefits (VA), compensation, and allowances;
• Worker's compensation awards (WC);
• Retirement pensions from industry (UF);
• UC payments (UC or UO);
• Annuities (AN);
• Allowances and allotments from members of the armed forces (AA);
• Railroad retirement benefits (RR);
• Contributions from relatives, friends, churches, clubs, etc., MADE DIRECTLY TO THE FAMILY (CO);
• Real or personal property when sold on a time payment plan. The unpaid balance does not cause ineligibility. Consider the down payment (if any) as cash, but include time payments as income;
• Aliens with sponsors (AC). Income received from sponsors is to be counted in its entirety;
• Grants and scholarships for graduate students available for living expenses (grants and scholarships minus school expenses). This does not apply to undergraduate students. (Refer to Section 0905.012.75.25 );
• Allotments including:
  • Military Allotments (AA);
  • Community Spouse Allotments (A2);
  • Minor/Dependent Allotments (A3); and
  • Minor Living Outside Household Allotments (A4).
• Temporary Assistance (C1-C6);
• Blind Pension (B1);
• SAB (F1);
• Refugee Cash Assistance (RF);
• PTD State Supplemental Payment (E1);
• OAA State Supplemental Payment (A1);
• Supplemental Nursing Care (N1);
• Welfare payments from another state (WS);
• Agent Orange Veteran's benefits (AV);
• Black Lung benefits (BL);
• Payments held in trust by Secretary of Interior for Indians (PS);
• Vocational Rehabilitation payments for child care compensation (VF);
• Vocational Rehabilitation payments not for child care compensation (VR);
• Military Retirement (MR);
• Disability benefit (DB);
• Strike benefits (SB);
• Severance payments received from an employer when an employee's job is terminated (SV);
• Subsidized employment( SU);
• Foster Care payments (FC);
• Adoption Subsidy Payments (AS);
• Guardianship Subsidy payments(GS);
• Cash gifts (GF);
• Lottery/Gambling income (LO);
• Incentive payments to encourage activity (IP);
• Representative Payee payments not given to the beneficiary (RH);
• Reimbursements for living expenses (RL);
• Notes receivable (NR);
• Non Bona Fide Loans (NB); and
• Nursing home Insurance income (NI).

1600.010.15.20 Income Exclusions (GTBH)

Exclude, as income, any of the following:

1. Department of Mental Health Funds (DMH).
2. Compensation received under the Federal Older Americans Volunteer Program (OA) - Section 611 of Title VI of Public Law 93-29 dated May 3, 1973, (also called the "Foster Grandparent" and Older Americans Community Service Program) excludes any income received under this program by the individual volunteers, age 60 or over, from being considered on the budget.
3. Any payments for supportive services or reimbursement of out-of-pocket expenses made to individual volunteers, grandparents, senior health aides, or senior companions, and to persons serving in the Service Corps of Retired Executives (SCORE) and Active Corps of Executives (ACE) and any other programs under Title II and III of the Domestic Volunteer Services Act of 1973 (Public Law 93-113).
4. Vocational Rehabilitation Payments(VR/VF) - Payments made for maintenance, transportation, tuition, fees, etc., in connection with a participant participating in training or school attendance subsidized by the Division of Vocational Rehabilitation.
5. Loans or grants to an undergraduate student(NA, N4) for educational purposes made or insured under any program administered by the Commissioner of Education. This includes the Basic Educational Opportunity Grants Program (BEOG), Supplemental Educational Opportunity Grants (SEOG), National Direct Student Loans (NDSL) and Guaranteed Student Loans and PELL grants.
6. Veterans Education Assistance (VE/VC) - Exclude as income that portion of a Veterans Educational Assistance payment that is for the "student" and that is actually used for items such as tuition, books, fees, equipment, transportation for school purposes, child care services necessary for school attendance, etc.
7. Low-Income Home Energy Assistance(EA) payments made under the Low Income Home Energy Assistance Act of 1981, are not considered as income.
8. Certain Home Energy Assistance payments made on or after October 1, 1983, by energy suppliers or private nonprofit organizations are excluded. "Home energy assistance" is defined as any assistance that is related to home energy, except food or clothing.

   Exclude the payment as income if is made in cash or in-kind by:

   • a supplier of home heating gas or oil; or
   • a municipal utility providing home energy; or
   • an entity whose revenues are primarily derived on a rate-of-return basis regulated by a State of Federal governmental body;

   If the payment is made in-kind by a private nonprofit organization, exclude the payment as income. Consider cash payments made by private nonprofit organizations as income.

9. Agent Orange Settlement Payments (AV)
10. Missouri Family Trust Fund (PM) - Exclude payments from the Missouri Family Trust Fund made on behalf of a beneficiary who is an applicant/participant of GTBH.
11. Temporary Assistance cash grant (C1-C6)
12. Bona Fide Loans (BF) - refer to Section 0205.005.30.40 of the Temporary Assistance manual.
13. Ricky Ray Hemophilia Fund(RI) - refer to Section 0905.012.75.12 of the Family Healthcare manual.
14. PASS Account: Money SSI participants set aside under an approved plan for achieving self-support (PASS)(PA). SSA must approve the written plan.
15. The allowance provided to children of Vietnam veterans (including adult children) who were born with the congenital defect spina bifida (SP).
16. Supportive service payments, stipends (a payment received while participating in a training program), and needs related payments from WIA program(s) (J7).
17. WIA work experience payments(J2).
18. Any portion of a veteran's pension (VA)designated for Aid and Attendance. In FAMIS enter the full amount of the VA Pension including the Aid and Attendance Pension, as "UI – Unearned Income", source "VA – Veterans Administration" and enter the Aid and Attendance portion of the pension as income expense code "AA – VA Aid and Attendance Expenses". 
19. Any benefits designated for a veteran's dependent. In FAMIS enter the full amount of the VA Pension including the portion designated for the veteran's dependent , as "UI – Unearned Income", source "VA – Veterans Administration" and enter the portion of the pension designated for the veteran's dependent as income expense code "DX– VA Dependent Expenses".
20. Any portion of a veteran's pension (VA) paid for unusual medical expenses. In FAMIS enter the full amount of the VA Pension including the portion of the pension designated for unusual medical expenses, as "UI – Unearned Income", source "VA – Veterans Administration" and enter the portion of the pension designated for unusual medical expenses as income expense code "ME – VA Unusual Medical Expenses". 
21. VA homebound allowances. In FAMIS enter the full amount of the VA Pension(VA) including the homebound allowance, as "UI – Unearned Income", source "VA – Veterans Administration" and enter the homebound allowance portion of the pension as income expense code "HB – VA Home Bound Expenses".

1600.010.20 Residence (GTBH)

To be eligible for GTBH, the participant must be a Missouri resident and a resident of St. Louis City or County.

1600.010.25 Primary Care Home (GTBH TIER I ONLY)

To receive Gateway to Better Health Tier I benefits the participant must have a Primary Care Home at one of the participating Health Care Clinics. Participating Health Care Clinics are:

• Betty Jean Kerr People's Health Centers
• Family Care Health Centers
• Grace Hill  Health Centers
• Myrtle Hilliard Davis Comprehensive Health Centers
• Saint Louis County Department of Health

1600.010.30 Uninsured (GTBH)

To be eligible for Gateway to Better Health an individual must be uninsured.  Health insurance is defined as insurance that minimally provides coverage for physician's services and hospitalization.  There is no penalty or waiting period for dropping insurance.

Health insurance does not have to cover all medical conditions (such as pre-existing conditions) to cause ineligibility.

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 worker's 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.

An individual who has exceeded a lifetime maximum for all benefits under their health plan are considered uninsured. The applicant must provide documentation they have reached their lifetime maximum for all benefits.

1600.010.35 Need for Specialty Care Treatment (GTBH TIER II ONLY)

removed

1600.010.40 Citizenship/Alien Status (GTBH)

The requirement is the same as for MHF. Refer to Section 0905.010.30.

1600.010.45 Social Security Number (GTBH)

The requirement is the same as for MHF. Refer to Section 0905.010.05.

1600.015.00  GATEWAY TO BETTER HEALTH COVERAGE

Coverage under GTBH begins on the 1st day of the month of application, if all eligibility requirements are met. There is no prior quarter coverage. No coverage can begin prior to July 1, 2012.

Benefits: Preventative; well care; dental (diagnostic, periodontal, preventive, prosthodontics and the removal of erupted teeth); internal and family practice medicine; gynecology; generic prescriptions dispensed at primary care clinics.

1600.020.00 GATEWAY TO BETTER HEALTH COVERAGE END DATE ON CLOSINGS

Gateway to Better Health coverage is date-specific for GTBH participants at the time of closing.

1600.025.00 PROMPT DISPOSITION (GTBH)

Process GTBH applications without undue delay unless unusual or extreme circumstances exist. Complete the eligibility determination to ensure an applicant is mailed his/her notice of approval or denial within a period not to exceed 30 days. If the application cannot be completed promptly due to an extreme circumstance the eligibility specialist must enter the appropriate delay code in the Delay Code field on the Application Request (FM0G or REQUEST) screen in FAMIS.

If eligibility is not determined by the 30th day, record the reason for delay on the Eligibility Unit Member Role (EUMEMROL or FM3Z) screen.

An application may be rejected prior to the 30th day if the case is found to be ineligible on a specific eligibility factor.

Applications will be rejected on the 30th day if outstanding verification exists.

1600.030.00 INTERIM CONTACTS (GTBH)

The program begins effective July 1, 2012 and continues through December 31, 2013.

September 2013 Gateway 2.0 was extended through December 31, 2014. August 2014 Gateway was extended through December 31, 2015. December 2015 Gateway was extended through December 31, 2015.  An annual review of GTBH is required due to extensions granted in 2013, 2014, and 2015. Every change in circumstance requires appropriate action and recording. Types of interim contacts include:

• Address changes,
• Changes in income,
• Changes in primary care home,
• Voluntary closings,
• Adding a person.

A participant is required to report changes within ten days.  Obtain documentation necessary to process change within ten days.