Missouri Code of State Regulations
Title 13 - DEPARTMENT OF SOCIAL SERVICES
Division 70 - MO HealthNet Division
Chapter 4 - Conditions of Participant Participation, Rights and Responsibilities
Section 13 CSR 70-4.080 - State Children's Health Insurance Program

(1) Definitions.

(2) An uninsured child/children in a family(ies) with gross income of more than one hundred fifty percent (150%) of the federal poverty level shall not have had health insurance prior to application pursuant to 208.631, RSMo.

(3) Parent(s) and guardian(s) of uninsured children with gross income of more than one hundred fifty percent (150%) but less than three hundred percent (300%) of the federal poverty level must certify, as a part of the application process, that the child does not have access to affordable employer-sponsored health care insurance or other affordable health care coverage available to the parent(s) or guardian(s) through their association with an identifiable group (for example, a trade association, union, professional organization) or through the purchase of individual health insurance coverage. Access to affordable employer-sponsored health care insurance or other affordable health care coverage shall result in the applicant not being eligible for the Health Care for Uninsured Children program for the child/children in families with gross income of more than one hundred fifty percent (150%) but less than three hundred percent (300%) of the federal poverty level.

(4) An uninsured child/children with gross income of more than two hundred twenty-five percent (225%) but less than three hundred percent (300%) of the federal poverty level shall be eligible for service(s) thirty (30) calendar days after the application is received if the required premium has been received. An uninsured child/children with gross income of more than one hundred fifty percent (150%) but less than two hundred twenty-six percent (226%) of the federal poverty level shall be eligible for services once the required premium has been received.

(5) If the parent(s) or guardian(s) with an income of more than two hundred twenty-five percent (225%) of the federal poverty level fails to meet the premium payment requirements, a past due notice shall be sent requesting remittance within twenty (20) calendar days from date of the past due letter. Failure to make payment within this time period shall result in the child's ineligibility for coverage for ninety (90)-days.

(6) Premium adjustments shall be calculated yearly in March with an effective date of July 1 of the same calendar year. Individuals shall be notified of the change in premium amount at least thirty (30) days prior to the effective date.

(7) The thirty (30)-cal-endar-day delay in service delivery is not applicable to a child/children already participating in the program when the parent's or guardian's income changes. Coverage shall be extended for sixty (60) calendar days to allow for premium collection and to ensure continuity in coverage. Coverage shall be discontinued for the child/children if the premium payment is not made within the sixty- (60-) day extension.

(8) Any child identified as having "special health care needs," defined as a condition which left untreated would result in the death or serious physical injury of a child, who does not have access to affordable employer-subsidized health care insurance shall not be required to be without health care coverage in order to be eligible for services under sections 208.631 to 208.658, RSMo and shall not be subject to the thirty-(30-) day waiting period required under section 208.646, RSMo, as long as the child meets all other qualifications for eligibility.

(9) The total aggregate premiums for a family covered by this rule shall not exceed five percent (5%) of the family's gross income for a twelve- (12-) month period of coverage beginning with the first month of service eligibility. Waiver of premiums shall be made upon notification and documentation from the family that payments for premiums have been made up to five percent (5%) of their yearly gross income.

(10) For the purposes of this rule, a child/children whose annual maximum benefits of a particular medical service under their private insurance has been exhausted is not considered insured and does not have access to affordable health insurance.