PURPOSE: This rule establishes components of the Children’s Health Insurance Program which will provide health care coverage to uninsured, low income children pursuant to Senate Bill 632 enacted by the 89th General Assembly, 1998.

1. (1) Definitions.

   1. (A) Children. Persons up to nineteen (19) years of age.
   2. (B) Health insurance. Any hospital and medical expense incurred policy, nonprofit health care service for benefits other than through an insurer, nonprofit health care service plan contract, health maintenance organization subscriber contract, preferred provider arrangement or contract, or any other similar contract or agreement for the provision of health care benefits. The term “health insurance” does not include short-term, accident, fixed indemnity, limited benefit or credit insurance, coverage issued as a supplement to liability insurance, insurance arising out of a workers’ compensation or similar law, automobile medical-payment insurance, or insurance under which benefits are payable with or without regard to fault and which is statutorily required to be contained in any liability insurance policy or equivalent self-insurance.
2. (2) An uninsured child/children shall not have had health insurance for six (6) months prior to the month of application pursuant to 208.185, RSMo.
3. (3) If a child/children had health insurance and such health insurance coverage was dropped, within six (6) months prior to the month of application, the child is not eligible for coverage under this rule until six (6) months after coverage was dropped.

4. (4) The six (6)-month period of ineligibility would not apply to children who lose health insurance due to—

   1. (A) A parent’s or guardian’s loss of employment due to factors other than voluntary termination;
   2. (B) A parent’s or guardian’s employment with a new employer that does not provide an option for dependent coverage;
   3. (C) Expiration of a parent’s or guardian’s dependent Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage period;
   4. (D) Lapse of a child’s (children’s) health insurance when maintained by an individual other than custodial parent or guardian; or
   5. (E) Lapse of a child’s (children’s) health insurance when the lifetime maximum benefits under their private health insurance have been exhausted.
5. (5) Parent(s) and guardian(s) of uninsured children with gross income above one hundred fifty percent (150%) and below 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 insurance or other affordable health insurance available to the parent(s) or guardian(s) through their association with an 13 CSR 70-4

identifiable group (for example, a trade association, union, professional organization) or through the purchase of individual health insurance coverage.

1. (A) Affordable access is calculated by comparing the health insurance monthly dependent premium to one hundred thirtythree percent (133%) of the monthly statewide weighted average child/children premium required by the Missouri Consolidated Health Care Plan. Adjustment to the monthly statewide weighted average, based on changes in the Missouri Consolidated Health Care Plan, shall be calculated yearly in March with an effective date of July 1 of the same calendar year.
2. (B) Health insurance premiums less than or equal to one hundred thirty-three percent (133%) of the monthly average dependent premium required by the Missouri Consolidated Health Care Plan are deemed affordable and shall result in ineligibility for the child/children.

1. (6) An uninsured child/children with gross income above one hundred fifty percent (150%) and below three hundred percent (300%) of the federal poverty level shall be eligible for services(s) thirty (30) calendar days after the application is received if the required premium has been received.

   1. (A) Parent(s) or guardians(s) of uninsured children with gross income above one hundred fifty percent (150%) and below one hundred eighty-six percent (186%) of the federal poverty level are responsible for a monthly premium equal to the statewide weighted average child/children premium required by the Missouri Consolidated Health Plan not to exceed one percent (1%) of the family’s gross income. Parent(s) or guardian(s) of uninsured children with gross income above one hundred eighty-five percent (185%) and below two hundred twenty-six percent (226%) of the federal poverty level are responsible for a monthly premium equal to the statewide weighted average child/children premium required by the Missouri Consolidated Health Care Plan not to exceed three percent (3%) of the family’s gross income. Parent(s) or guardian(s) of uninsured children with gross income above two hundred twenty-five percent (225%) and below three hundred percent (300%) of the federal poverty level are responsible for a monthly premium equal to the statewide weighted average child/children premium required by the Missouri Consolidated Health Care Plan not to exceed five percent (5%) of the family’s gross income.
   2. (B) The premium must be paid prior to service delivery.
   3. (C) The premium notice shall include information on what to do if there is a change in gross income.
   4. (D) No service(s) will be covered prior to the effective date which is thirty (30) calendar days after the date the application is received.
2. (7) If the parent or guardian discontinues payment of premiums, a past due notice shall be sent requesting remittance within twenty (20) calendar days from date of the letter. Failure to make payment shall result in the child’s ineligibility for coverage for the following six
3. (6) months.
4. (8) Premium adjustments, based on changes in the Missouri Consolidated Health Care Plan, 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
5. (30) days prior to the effective date.
6. (9) The six (6)-month waiting period and thirty (30)-calendar-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 thirty (30) calendar days to allow for premium collection and to ensure continuity in coverage. Eligibility shall be discontinued for the child/children if the premium payment is not made within the thirty (30)-day extension.
7. (10) 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 employersubsidized health care insurance shall not be required to be without health care coverage for six (6) months in order to be eligible for services under sections 208.631 to 208.657, 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.

8. (11) 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.

   1. (A) The total aggregate premiums for a family covered by this rule with gross income above one hundred fifty percent (150%) and below one hundred eighty-six percent (186%) of the federal poverty level shall not exceed one percent (1%) of the family’s gross income for a twelve (12)-month period of coverage beginning with the first month of service eligibility. When the total aggregate premiums have reached one percent (1%) of the family’s gross income all premiums shall be waived for the remainder of the twelve (12)-month period. Waiver of premiums shall be made upon notification and documentation from the family that payments for premiums have been made up to one percent (1%) of their yearly gross income.
   2. (B) The total aggregate premiums for a family covered by this rule with gross income above one hundred eighty-five percent (185%) and below two hundred twenty-six percent (226%) of the federal poverty level shall not exceed three percent (3%) of the family’s gross income for a twelve (12)- month period of coverage beginning with the first month of service eligibility. When the total aggregate premiums have reached three percent (3%) of the family’s gross income all premiums shall be waived for the remainder of the twelve (12)-month period. Waiver of premiums shall be made upon notification and documentation from the family that payments for premiums have been made up to three percent (3%) of their yearly gross income.
   3. (C) The total aggregate premiums for a family covered by this rule with gross income above two hundred twenty-five percent (225%) and below three hundred percent of (300%) of the federal poverty level 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. When the total aggregate premiums have reached five percent (5%) of the family’s gross income all premiums shall be waived for the remainder of the twelve (12)-month period. 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.
9. (12) Parents of uninsured children must certify that their total net worth does not exceed two hundred fifty thousand dollars ($250,000) to be eligible for health insurance under this rule.
10. (13) For the purposes of this rule, children participating in the Missouri Health Insurance Pool and child/children whose annual maximum benefits on a particular medical service under their private insurance have been exhausted are considered insured. Child/children whose parent(s) or guardian(s) drop Missouri Health Insurance Pool coverage in order to qualify under this rule shall not be eligible for six (6) months from the month coverage was terminated.

AUTHORITY: sections 208.633, 208.636, 208.640, 208.643, 208.646, 208.650, 208.655, 208.657 and 208.201, RSMo 2000 and 208.631 and 208.647, RSMo Supp. 2004.* Original rule filed July 15, 1998, effective Feb. 28, 1999. Emergency amendment filed Aug. 4, 2005, effective Sept. 1, 2005, expired Feb. 27, 2006. Amended: Filed April 29, 2005, effective Nov. 30, 2005.

*Original authority: 208.201, RSMo 1987; 208.631, RSMo 1998, 2002; 208.633, RSMo 1998; 208.636, RSMo 1998; 208.640, RSMo 1998; 208.643, RSMo 1998; 208.646, RSMo 1998; 208.647, RSMo 2004; 208.650, RSMo 1998; 208.655, RSMo 1998; and 208.657, RSMo 1998.