Missouri Code of State Regulations
Title 19 - DEPARTMENT OF HEALTH AND SENIOR SERVICES
Division 40 - Division of Maternal, Child and Family Health
Chapter 7 - Metabolic Formula Program
Section 19 CSR 40-7.050 - Program Eligibility

Universal Citation: 19 MO Code of State Regs 40-7.050

Current through Register Vol. 49, No. 6, March 15, 2024

PURPOSE: The Department of Health and Senior Services (DHSS) provides low-protein formula, a special dietary product, to individuals diagnosed as having phenylketonuria (PKU), maple syrup urine disease (MSUD) and other metabolic conditions as approved by the Newborn Screening Standing Committee, a subcommittee of the Missouri Genetic Advisory Committee which makes recommendations to the department on newborn screening issues. This rule establishes the criteria by which the Metabolic Formula Program accepts clients for service.

(1) Conditions of eligibility for the Metabolic Formula Program (MFP) include:

(A) An applicant must be diagnosed as having phenylketonuria (PKU), maple syrup urine disease (MSUD) or other metabolic conditions as approved by the Newborn Screening Standing Committee and recommended to the department. The diagnosis must be made by a physician who practices at a metabolic treatment center;

(B) An applicant must be a resident of Missouri and cannot reside in a state facility. Proof of residency will consist of submitting a copy of the previous month's utility bill with the applicant's home address clearly printed;

(C) The physician treating the applicant must submit the following information to the department:
1. A letter requesting the applicant be placed on the MFP;

2. The name and address of the applicant; and

3. A prescription, signed by the treating physician, stating the name of the low-protein formula, a special dietary product the individual will be using; and

(D) Financial eligibility guidelines for enrollment in the MFP shall be based upon the Poverty Income Guidelines as established by the United States Department of Health and Human Services. Determination of individual applicant eligibility shall be based upon the following:
1. Applicants five (5) years or under shall have no income qualification requirements;

2. Applicants six (6) through eighteen (18) years whose family income is below three hundred percent (300%) of the federal poverty level shall be eligible for enrollment in the MFP;

3. Applicants six (6) through eighteen (18) years whose family income is at three hundred percent (300%) of the federal poverty level or above shall be eligible based on a sliding fee scale for enrollment in the MFP;

4. Applicants nineteen (19) years and above whose income does not exceed one hundred eighty-five percent (185%) of the federal poverty level shall be eligible for enrollment in the MFP;

5. Size of family unit shall be the number of persons in the household, including the responsible party(ies) and dependents allowable by the Internal Revenue Service as federal income tax exemptions. The family size may be increased by two (2) additional family members per affected individual nineteen (19) years and above for the cost of low-protein formula; and

6. Funding to eligible applicants may be adjusted by the department based on available funding.

(2) A sliding fee scale shall be used to determine the amount of monthly premium and assistance to be provided by the department for those individuals six (6) through eighteen (18) years having no insurance, Medicaid or Medicare and whose adjusted gross income places the family at three hundred percent (300%) of the federal poverty level or above. The sliding fee scale shall be updated based on changes in the federal poverty guidelines. The adjusted gross income line from Internal Revenue Service recognized tax forms shall be the income used to determine financial eligibility with adjustments for child support received or paid. The table for establishing a sliding scale fee of premiums is provided below.

Table: Sliding Fee Scale for those Applicants Age 6 through 18 Years Based on Family Adjusted Gross Income

Adjusted Gross Income is: Approximate Family Monthly Premium for Formula*
299% of poverty or below 0
300% - 399% of poverty 25%
400 - 499% of poverty 40%
500% of poverty and above 50%

*Based upon DHSS cost of formula and subject to available funding for the program.

(3) Approved applicants having no insurance coverage for metabolic formula, Medicaid benefits or other third party payor will have formula provided as prescribed by the person's genetic disease physician or a general physician in consultation with the genetic disease physician at the metabolic treatment center.

*Original authority: 191.315, RSMo 1985, amended 1993, 1995; 191.331, RSMo 1965, amended 1985, 1992, 1993, 1995, 1997, 2007; and 191.332, RSMo 2001, amended 2005.

Disclaimer: These regulations may not be the most recent version. Missouri may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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