PURPOSE: This rule defines the application procedures for Family MO HealthNet programs or the Children’s Health Insurance Program (CHIP).

1. (1) General application procedures for programs administered by the Family Support Division are found at 13 CSR 40-2.010. For anything in this section conflicting with the general application procedures, this regulation controls for the application procedures for Family MO HealthNet programs or the Children’s Health Insurance Program (CHIP).

2. (2) An application for Family MO HealthNet programs or the Children’s Health Insurance Program (CHIP) may be obtained by contacting one (1) of the following sources:

   1. (A) An insurance exchange, whether federally facilitated, state based, or operated on a partnership basis;
   2. (B) The Family Support Division Contact Center;
   3. (C) A Family Support Division office; or
   4. (D) Accessing the Department of Social Services website www.dss.mo.gov.
3. (3) An application for Family MO HealthNet program or the Children’s Health Insurance Program (CHIP) shall be accepted by mail, telephone, or in person at any Family Support office, or via the department’s Internet website found at www.dss.mo.gov. The division shall also accept applications through providers who the division contracts with in order to facilitate eligibility decisions.

4. (4) The following individuals may apply for Family MO HealthNet or the Children’s Health Insurance Program (CHIP) on behalf of a participant:

   1. (A) The participant, as defined under 13 CSR 40-7.010;
   2. (B) An adult who is in the participant’s household. For purposes of this subsection, “household” shall have the same definition as in 42 CFR section 435.603(f)(1);
   3. (C) A member of the participant’s family, as defined in 26 U.S.C section 36B(d)(1);
   4. (D) An authorized representative of the participant;
   5. (E) An individual with a valid power of attorney to act on behalf of the participant;

   6. (F) If the participant is an incapacitated person as defined under 475.010, RSMo—

      1. 1. A parent, spouse, and other close

adult relative;

1. 2. An authorized representative; or
2. 3. A guardian or conservator; or
3. 4. A public administrator; or
4. 5. Other person appointed by a court of

competent jurisdiction.

1. (G) If the participant is a minor under age eighteen (18), an application may be submitted by the following:

   1. 1. The minor on behalf of him/herself,

if any of the following conditions apply:

1. A. The minor is pregnant;
2. B. The minor has been lawfully mar-

ried;

1. C. The minor is a parent;
2. D. The minor is a victim of domestic

violence, as defined by section 455.010, RSMo, or meets all the criteria in section 431.056, RSMo;

1. E. Is a victim of trafficking offenses

under section 566.203, 566.206, 566.209, 566.210, or 566.211, RSMo; or

1. F. The minor is emancipated.
2. 2. For other minors not in the custody,

care, or control of a parent or guardian, someone acting responsibly for the applicant. This shall include a person age eighteen (18) or over who has the capacity to enter into a contract, has primary custody, care, or control of the minor and who—

1. A. Is related to the applicant by

blood, marriage, or adoption; or

1. B. Is a person who—

   1. (I) The division reasonably deter-

mines has sufficient knowledge of the applicant’s circumstances to accurately complete the application; and

1. (II) Has an obligation to act in the

best interests of the applicant as per 13 CSR 40-2.015.

1. (5) The applicant shall provide and attest to the following information when making an application for Family MO HealthNet benefits or CHIP benefits:

   1. (A) The name of each individual who resides with the participant;
   2. (B) The name of each individual who the participant claims or intends to claim on his or her federal income tax returns;
   3. (C) The name of any person who claims or intends to claim the participant as a dependent on his or her federal tax forms; and

   4. (D) For the participant, and each person listed in subsections (5)(A), (5)(B), or (5)(C), the applicant shall provide the following information:

      1. 1. Relationship to the applicant;
      2. 2. Physical Address;
      3. 3. Mailing address, if different from

physical address;

1. 4. Date of Birth;
2. 5. Gender;
3. 6. Social Security Number, in accor-

dance with section (6) of this rule;

1. 7. Intent to file taxes or be claimed as a

tax dependent on someone else’s taxes;

1. 8. Whether the participant is pregnant;
2. 9. Any physical, mental, or emotional

health condition that causes limitations in activities of daily living;

1. 10. Residence in a medical facility or

nursing home;

1. 11. Citizenship or immigration status;
2. 12. Race (optional);
3. 13. Employment status, employer name

and address, hours employed, and rate of pay;

1. 14. Any and all sources of income and

amounts;

1. 15. Any federal tax deductions entitled

for alimony paid or student loan interest;

1. 16. Enrollment in any health care cover-

age, name of insurer, policy number, and any limitations on the coverage;

1. 17. If he or she or anyone in their family

is American Indian or Alaska Native. If any person is, information about tribe affiliation, services, and income received from benefits must be disclosed;

1. 18. Details concerning any health cover-

age which is available to him or her through a job. This includes coverage that is offered through someone else’s job, such as a parent or spouse; and

1. 19. If a participant is a child, the name

and address of any parent living outside the home.

1. (6) Subject to the exceptions recognized in 42 CFR 435.910(h), Social Security numbers are requested of every person for whom coverage is being requested, pursuant to subsections (5)(A), (5)(B), or (5)(C).

   1. (A) If the person is a participant in MO HealthNet, the person’s Social Security number shall be included.
   2. (B) If the person is not a participant in MO HealthNet, the inclusion of the Social Security number is voluntary.
   3. (C) Social Security numbers are to be used only for the purpose of determining a participant’s eligibility for MO HealthNet or for a purpose directly connected to the administration of MO HealthNet.
2. (7) The applicant shall sign an assignment of rights to the MO HealthNet Division to pursue and recover money owed for medical expenses from any applicable insurance policies, legal settlements or judgments, or other liable or potentially liable third parties.
3. (8) The applicant shall sign an assignment of rights to pursue and obtain medical support from a parent or spouse who owes such a duty.
4. (9) The participant and applicant shall disclose all information which may impact eligibility for any MO HealthNet program. The participant and applicant have a continuing obligation to notify the division if any information specified in the application changes within ten (10) days of the change. The continuing duty includes, but is not limited to disclosing any changes in income of the participant or household member, changes in residence or mailing address, and the addition or removal of any individual from the household whose information is or was required to be submitted.
5. (10) The applications shall be signed under penalty of perjury, attesting to the information provided as true, accurate, and complete.

AUTHORITY: sections 207.022, 208.991, and 660.017, RSMo 2016.* Original rule filed July 31, 2013, effective Feb. 28, 2014. Amended: Filed April 18, 2018, effective Nov. 30, 2018.

*Original authority: 207.022, RSMo 2014; 208.991, RSMo 2013; and 660.017, RSMo 1995.