Current through Register Vol. 50, No. 9, September 20, 2024
A. The Family Opportunity Act, signed into
law by Congress as part of the Deficit Reduction Act of 2005, allows states to
offer a Medicaid buy-in program to families with income up to 300 percent of
the federal poverty level (FPL) for children with disabilities who are not
eligible for Supplemental Security income (SSI) disability benefits due to
excess income or resources. The department hereby implements a Medicaid buy-in
program called the Family Opportunity Act Medicaid Program to provide Medicaid
coverage to children with disabilities.
B. Eligibility Requirements. Children born on
or after October 1, 1989, up to age 19, and who meet the following requirements
may receive health care coverage through the Family Opportunity Act Medicaid
Program.
1. The child must have a disability
which meets the Social Security administration's childhood disability
criteria.
2. Gross family income
must not be more than 300 percent of the federal poverty level using the income
methodologies of the SSI program.
a. For the
purpose of determining family income, the family unit shall consist of the
following members:
i. child(ren) with
disabilities;
ii. natural or legal
parent(s); and
iii. siblings under
age 19.
b. Step-parents
and step-siblings are excluded from the income determination.
3. The child may be uninsured or
underinsured.
a. Parents are required to
enroll in available employer-sponsored health plans when the employer
contributes at least 50 percent of the annual premium costs. Participation in
such employer-sponsored health plans is a condition of continuing Medicaid
coverage.
C.
Children determined eligible under the Family Opportunity Act Medicaid Program
shall receive coverage of medically necessary health care services provided
under the Medicaid state plan.
D.
Premium Payments. Families with gross income above 200 percent, but not more
than 300 percent of the FPL, are required to pay premiums for Medicaid
coverage. Families with gross income up to 200 percent of the FPL are not
required to pay premiums for Medicaid coverage.
1. The amounts paid for premiums for
Medicaid-required family coverage and other cost-sharing may not exceed 5
percent of a family's income for families with income up to 200 percent of the
FPL and 7.5 percent of a family's income for families with income above 200
percent of the FPL.
2. For families
with gross income above 200 percent, but not more than 300 percent of the FPL,
the premium amount for Medicaid is determined by whether the natural or legal
parent(s) living in the household is paying for other creditable health
insurance that covers the child(ren) with disabilities.
a. Families who have other creditable health
insurance that provides coverage to the child(ren) with disabilities will pay a
family Medicaid premium on a sliding scale as follows:
i. $12 per month for families with income
above 200 percent and up to 250 percent of the FPL;
ii. $15 per month for families with income
above 250 percent, but not more than 300 percent of the FPL.
b. Families who do not have other
creditable health insurance that provides coverage to the child(ren) with
disabilities will pay a family Medicaid premium on a sliding scale as follows:
i. no premium is required for families with
income from 0 percent and up to 200 percent of the FPL;
ii. $30 per month for families with income
above 200 percent and up to 250 percent of the FPL;
iii. $35 per month for families with income
above 250 percent, but not more than 300 percent of the FPL.
3. The first premium is
due the month following the month that eligibility is established. Prepayment
of premiums is not required. A child's eligibility for medical assistance will
not terminate on the basis of failure to pay a premium until the failure to pay
continues for at least 60 days from the date on which the premium was past
due.
4. The premium may be waived
in any case where it is determined that requiring a payment would create an
undue hardship for the family. Undue hardships exist when a family:
a. is homeless or displaced due to a flood,
fire, or natural disaster;
b.
resides in an area where there is a presidential-declared emergency in
effect;
c. presents a current
notice of eviction or foreclosure; or
d. has other reasons as determined by the
department.
5. Families
whose eligibility has been terminated for non-payment of premiums must pay any
outstanding premium balances for Medicaid-covered months before eligibility can
be re-established, unless:
a. the liability
has been canceled by the Bureau of Appeals or the Medicaid Recovery Unit;
or
b. there has been a lapse in
Medicaid coverage of at least 12 months.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
36:254 and Title XIX of the Social Security
Act.
