Current through Register Vol. 50, No. 9, September 20, 2024
A. For eligibility determinations effective
December 31, 2013 eligibility shall be determined by modified adjusted gross
income (MAGI) methodology in accordance with section 1004(a)(2) of the Patient
Protection and Affordable Care Act (ACA) of 2010 and section 36B(d)(2)(B) of
the Internal Revenue Code, for the following groups:
1. parents and caretaker relatives group
which includes adult individuals formerly considered for low income families
with children as parents or caretaker relatives;
2. pregnant women;
3. child related groups; and
4. other adult related groups including
breast and cervical cancer, tuberculosis (TB) and family planning.
B. A MAGI determination will be
necessary for each individual in the home for whom coverage is being requested.
The MAGI household resembles the tax household.
1. MAGI Household. The individuals
relationship to the tax filer and every other household member must be
established for budgeting purposes. The MAGI household is constructed based on
whether an individual is a:
a. tax
filer;
b. tax dependent;
or
c. non-filer (neither tax filer
or tax dependent.
2. For
the tax filer the MAGI household includes the tax filer and all claimed tax
dependents.
a. Whether claimed or not, the
tax filers spouse, who lives in the home, must be included.
b. If a child files taxes and is counted as a
tax dependent on his/her parents tax return, the child is classified as a tax
dependent not a tax filer.
3. When taxes are filed for the tax dependent
the MAGI household consists of the tax filer and all other tax dependents
unless one of the following exceptions is met:
a. being claimed as a tax dependent by a tax
filer other than a parent or spouse (for example, a grandchild, niece, or tax
filers parent);
b. children living
with two parents who do not expect to file a joint tax return (including
step-parents); or
c. children
claimed as a tax dependent by a noncustodial parent.
4. For individuals who do not file taxes nor
expect to be claimed as a tax dependent (non-filer), the MAGI household
consists of the following when they all live together:
a. for an adult:
i. the individuals spouse; and
ii. the individuals natural, adopted, and
stepchildren under age 19; and
b. for a minor:
i. the individuals natural, adoptive, or
stepparents; and
ii. the
individuals natural, adopted, and step-siblings under age 19.
C. Parents
and Caretaker Relatives Group
1. A caretaker
relative is a relative of a dependent child by blood, adoption, or marriage
with whom the child is living, and who assumes primary responsibility for the
childs care. A caretaker relative must be one of the following:
a. parent;
b. grandparent;
c. sibling;
d. brother-in-law;
e. sister-in-law;
f. step-parent;
g. step-sibling;
h. aunt;
i. uncle;
j. first cousin;
k.
niece; or
l. nephew.
2. The spouse of such parents or
caretaker relatives may be considered a caretaker relative even after the
marriage is terminated by death or divorce.
3. The assistance/benefit unit consists of
the parent and/or caretaker relative and the spouse of the parent and/or
caretaker relative, if living together, of child(ren) under age 18, or age 18
and a full-time student in high school or vocational/technical training.
Children are considered deprived if income eligibility is met for the parents
and caretaker relatives group. Children shall be certified in the appropriate
childrens category.
D.
Pregnant Women Group
1. Eligibility for the
pregnant women group may begin:
a. at any time
during a pregnancy; and
b. as early
as three months prior to the month of application.
2. Eligibility cannot begin before the first
month of pregnancy. The pregnant women group certification may extend through
the calendar month in which the 12-month postpartum period ends.
3. An applicant/enrollee whose pregnancy
terminated in the month of application or in one of the three months prior
without a surviving child shall be considered a pregnant woman for the purpose
of determining eligibility in the pregnant women group.
4. Certification shall be from the earliest
possible month of eligibility (up to three months prior to application) through
the month in which the 12-month postpartum period ends.
5. Retroactive eligibility shall be explored
regardless of current eligibility status.
a.
If the applicant/enrollee is eligible for any of the three prior months, she
remains eligible throughout the pregnancy and 12-month postpartum period. When
determining retroactive eligibility actual income received in the month of
determination shall be used.
b. If
application is made after the month her pregnancy ends, the period of
eligibility will be retroactive but shall not start more than three months
prior to the month of application. The start date of retroactive eligibility is
determined by counting back three months prior to the date of application. The
start date will be the first day of that month.
6. Coverage during the 12-month postpartum
period is only available to an individual who is eligible for medical
assistance under the state plan while pregnant, including during a period of
retroactive eligibility.
7.
Eligibility may not extend past the month in which the 12-month postpartum
period ends.
a. The 12-month postpartum period
begins on the last day of pregnancy.
b. The 12-month postpartum period ends the
last day of the month in which the 12-month postpartum period has
expired.
8. The
applicant/enrollee must be income eligible during the initial month of
eligibility only. Changes in income after the initial month will not affect
eligibility.
E. Child
Related Groups
1. Children Under Age 19CHAMP.
CHAMP children are under age 19 and meet income and non-financial eligibility
criteria. ACA expands mandatory coverage to all children under age 19 with
household income at or below 133 percent federal poverty level (FPL). Such
children are considered CHAMP children.
2. Children Under Age 19LaCHIP A child
covered under the Louisiana State Children's Health Insurance Program (LaCHIP)
shall:
a. be under age 19;
b. not be eligible for Medicaid under any
other optional or mandatory eligibility group or eligible as medically needy
(without spend-down liability);
c.
not be eligible for Medicaid under the policies in the state's Medicaid plan in
effect on April 15, 1997;
d. not
have health insurance; and
e. have
MAGI-based income at or below 212 percent (217 percent FPL with 5 percent
disregard) of the federal poverty level.
3. Children Under Age 19-LaCHIP Affordable
Plan. A child covered under the Louisiana State Children's Health Insurance
Program (LaCHIP) Affordable Plan shall:
a. be
under age 19;
b. not be income
eligible for regular LaCHIP;
c.
have MAGI-based income that does not exceed 250 percent FPL;
d. not have other insurance or access to the
State Employees Health Plan;
e.
have been determined eligible for child health assistance under the State Child
Health Insurance Plan; and
f. be a
child whose custodial parent has not voluntarily dropped the child(ren) from
employer sponsored insurance within the last three months without good cause.
Good cause exceptions to the three month period for dropping employer sponsored
insurance are:
i. the premium paid by the
family for coverage of the child under the group health plan exceeded 5 percent
of household income;
ii. the
child's parent is determined eligible for advance payment of the premium tax
credit for enrollment in a qualified health plan (QHP) through the marketplace
because the employer-sponsored insurance (ESI) in which the family was enrolled
is determined unaffordable in accordance with
26 CFR
1.36B-2(c)(3)(v);
iii. the cost of family coverage that
includes the child exceeded 9.5 percent of the household income;
iv. the employer stopped offering coverage of
dependents (or any coverage) under an employer-sponsored health insurance
plan;
v. a change in employment,
including involuntary separation, resulted in the child's loss of
employer-sponsored insurance (other than through full payment of the premium by
the parent under the Consolidated Omnibus Reconciliation Act of 1985
(COBRA));
vi. the child has special
health care needs;
vii. the child
lost coverage due to the death or divorce of a parent;
viii. involuntary termination of health
benefits due to a long-term disability or other medical condition;
ix. the child has exhausted coverage under
the COBRA continuation provision (i.e., COBRA expired); or
x. lifetime maximum has been
reached.
4.
Children Under Age 19-Phase IV LaCHIP (SCHIP). The State Child Health Insurance
Program (SCHIP) provides prenatal care services, from conception to birth, for
low income uninsured mothers who are not otherwise eligible for other Medicaid
programs, including CHAMP pregnant women benefits. This program, phase IV
LaCHIP, also covers non-citizen women who are not qualified for other Medicaid
programs due to citizenship status only.
F. Regular and Spend Down Medically Needy
MAGI. Regular and spend down medically needy shall use the MAGI determination
methodology.
G. Former Foster Care
Children. Former foster care children are applicants/enrollees under 26 years
of age, who were in foster care under the responsibility of the state at the
time of their eighteenth birthday, and are not eligible or enrolled in another
mandatory coverage category.
1. Former foster
care children may also be applicants/enrollees who:
a. have lost eligibility due to moving out of
state, but re-established Louisiana residency prior to reaching age
26.
b. Repealed.
2. Former foster care children
must:
a. be at least age 18, but under age
26;
b. currently live in
Louisiana;
c. have been a child in
foster care in any states custody upon reaching age 18; and
d. not be eligible for coverage in another
mandatory group.
AUTHORITY
NOTE: Promulgated in accordance with
R.S.
36:254 and Title XIX of the Social Security
Act.