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) Available income. For the purpose of this rule available income shall be defined as the household’s total gross income compared to one hundred eighty-five percent (185%), two hundred twenty-five percent (225%) and three hundred percent (300%) of the federal poverty level for the household size.
   2. (B) Cost sharing. Payment of co-payments and premiums.
   3. (C) Children. Persons up to nineteen (19) years of age.
   4. (D) 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 available income above two hundred twenty-five percent (225%) 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 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.
6. (6) An uninsured child/children with available income less than two hundred twenty-six percent (226%) of the federal poverty level shall be eligible for service(s) from the date the application is received. No service(s) will be covered prior to the date the application is received or September 1, 1998, whichever is later.
7. (7) An uninsured child/children with available income above two hundred twenty-five percent (225%) and below three hundred percent (300%) of the federal poverty level shall 13 CSR 70-4

be eligible for service(s) thirty (30) calendar days after the application is received if the required premium has been received.

1. (A) Parent(s) or guardian(s) of uninsured children with available 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.
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 available 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.

1. (8) 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
2. (6) months.
3. (9) 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
4. (30) days prior to the effective date.
5. (10) 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.

6. (11) Parent(s) or guardian(s) of uninsured children with available income above two hundred twenty-five percent (225%) and below three hundred percent (300%) of the federal poverty level are responsible for a copayment at the time of professional service and for prescriptions.

   1. (A) The co-payment is equal to the co-payment required by the Missouri Consolidated Health Care Plan.
   2. (B) Co-payment 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.
   3. (C) Individuals shall be notified of change(s) in the co-payment amount(s) at least thirty (30) days prior to the effective date.
   4. (D) Providers may require payment of the co-payment prior to service delivery and service may be denied for failure to make copayment. No co-payments shall be required for well-baby and well-child care including age-appropriate immunizations.
7. (12) Parent(s) or guardian(s) of uninsured children with income above one hundred eighty-five percent (185%) and at or below two hundred twenty-five percent (225%) of the federal poverty level for the household size are responsible for a five-dollar ($5) copayment at the time of professional service. Providers may require payment of the co-payment prior to service delivery and may deny services for failure to make co-payment. No co-payments shall be required for well-baby and well-child care including age-appropriate immunizations.
8. (13) The total aggregate cost-sharing for a family covered by this rule shall not exceed five percent (5%) of the family’s available income for a twelve (12)-month period of coverage beginning with the first month of service eligibility. Families responsible for cost-sharing shall be notified of their maximum liability for the twelve (12)-month period following service eligibility. When the total aggregate cost-sharing has reached five percent (5%) of the family’s available income all co-payments and premiums shall be waived for the remainder of the twelve (12)- month period. Waiver in cost-sharing shall be made upon notification and documentation of co-payments from the family that payments have been made up to five percent (5%) of their yearly available income.
9. (14) 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. (15) 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 208.631, 208.633, 208.636, 208.640, 208.643, 208.646, 208.650, 208.655, 208.657 and 208.660, RSMo Supp. 1998 and 208.201, RSMo 1994.* Original rule filed July 15, 1998, effective Feb. 28, 1999.

*Original authority: 208.201, RSMo 1987; 208.631, RSMo 1998; 208.633, RSMo 1998; 208.636, RSMo 1998; 208.640, RSMo 1998; 208.643, RSMo 1998; 208.646, RSMo 1998; 208.650, RSMo 1998; 208.655, RSMo 1998; 208.657, RSMo 1998; and 208.660, RSMo 1998.