MEMORANDUM
2004 Memorandums
IM-67      07/13/04
SUBJECT:
SPECIAL HEALTHCARE NEEDS EXCEPTION TO MC+ CHIP ELIGIBILITY REQUIREMENTS
FAMILY HEALTHCARE MANUAL REVISION #16: SECTIONS 0920.020.05, 0920.020.05.15, 0920.020.05.20, 0920.020.10.15, 0920.020.15, 0920.020.30, 0920.030.00, 0920.030.10
FORMS MANUAL REVISION #11: IM-60MC & INSTRUCTIONS
DISCUSSION:

Missouri House Bill 1453 (2004) provided for the elimination of the following CHIP eligibility requirements for children with special healthcare needs who do not have access to affordable employer-subsidized health insurance:

  • the 6-month penalty for dropping insurance without good cause; and
  • the 30-day waiting period for Premium group children (family income above 225% of the federal poverty level).
These changes are effective July 1, 2004.

Special health care needs are defined as a condition which left untreated would result in the death or serious physical injury of a child. Special healthcare needs will be established based on a written statement from the child’s physician. The attached Physician’s Statement ( IM-60MC pdf file) is being produced to obtain confirmation of special healthcare needs. Make copies of the attachment until an initial supply is received.

The MC+ Application form (IM-1UA) is being revised to address this change. Until a supply of the revised IM-1UA is received, staff must use the attached IM-1UA addendum pdf file with each MC+ application.

Programming has not been completed for the IMU5 system to allow for the exception to the 30-day waiting period or to track children with special healthcare needs where the 6-month penalty is not imposed. Until the programming is completed, fax a copy of the IM-60MC to the IM Policy Unit at 573-751-3677.

EXCEPTION TO THE SIX MONTH PENALTY FOR DROPPING INSURANCE:

The six month penalty for dropping insurance will not be imposed for any level of care (LOC) MC+ CHIP child if:

  • it was dropped for a good cause reason listed in Section 0920.020.05.15; or
  • the child has special healthcare needs and
  • the child does not have access to affordable, employer-subsidized healthcare insurance (Sections 0920.020.10.05 and 0920.020.10.10).

If health insurance coverage was discontinued in the six months prior to application, always explore "good cause" prior to special healthcare needs. "Good cause" applies to all children in the assistance group.

If "Good Cause" does not exist and the applicant indicated there is a child(ren) with special health care needs, send the IM-60MC to the applicant. Request that it be completed by the child’s treating physician and returned within 10 days. If the physician indicates there is no special healthcare need that meets the criteria, reject the child for dropping insurance. If the IM-60MC is not returned by the due date and the applicant does not request additional time, reject the child for dropping insurance.

The special healthcare needs exception to the six month penalty for dropping insurance coverage only applies to the child(ren) determined to have special healthcare needs. Other children in the assistance group will remain subject to the six month penalty (Family Healthcare Manual section 0920.020.05). Approve the special healthcare needs child in the IMU5 system, with the remaining children entered as LOC Z (included). Set a priority to add the penalized children at the end of the six month penalty time.

EXCEPTION TO THE 30-DAY WAITING PERIOD FOR PREMIUM GROUP CHILDREN:

When approving a MC+ case in the Premium group (LOC 3) and the applicant indicated there is a child(ren) with special health care needs, the 30-day waiting period may be waived. Use the IM-60MC to verify special healthcare needs. If eligible on all other factors, the 30-day waiting period will be waived for any child determined to have special healthcare needs.

NOTE: Premium group children with access to any affordable health insurance (employer sponsored or private) are ineligible, even if they have special healthcare needs.

Currently the IMU5 system will not allow a TXIX begin date prior to the 30th day after application for LOC 3 children. Until revised programming has been completed, approve MC+ CHIP LOC 3 special healthcare needs children using normal procedures. The faxed copy of the IM-60MC will be used to identify the special healthcare needs child(ren) so the beginning date of eligibility can be made effective with the date of application. Even though the 30-day waiting period is waived coverage does not become effective until the date the premium is paid. For LOC 3 determined to have special healthcare needs coverage will begin on the date of application or the date the premium is paid, whichever is later. The other children in the assistance group are still subject to the 30-day waiting period.

NOTIFICATION:

When approving a special healthcare needs child(ren) for MC+ CHIP in either non-premium group (LOC 1 or 2), send the IM-32MC approval notice. For other children in the assistance group that remain subject to the six month penalty for dropping insurance without good cause, send the IM-33MC denial notice. On the IM-33MC, state when the six month penalty expires for the remaining children.

When approving a special healthcare needs child(ren) for the MC+ CHIP Premium group (LOC 3), send the IM-32PRM approval notice. In the space where you are to enter the date coverage cannot begin until, write see below. Enter the effective date between the name and health insurance number for each child. The effective (eligibility) date for the special healthcare needs child(ren) will be the date of application.

 
NECESSARY ACTION:
  • Review this memorandum with all appropriate staff.
  • Begin exploring special healthcare needs when insurance has been dropped without good cause on a child in any CHIP group.
  • Begin exploring special healthcare needs for all children determined eligible in the CHIP premium group.
  • Copy the attached IM-60MC for use to determine special healthcare needs until the new supply is received.
LH/CW