PURPOSE: This rule establishes the Uninsured Working Parents’ Health Insurance Program. This program will provide payment for health care coverage for uninsured, low income, working parents leaving welfare for work thereby reducing future dependence on welfare and reducing the possibility of a family’s future dependence on welfare as authorized pursuant to section 208.040, RSMo. The program is also authorized pursuant to the award of the Missouri State Medicaid Section 1115 Health Care Reform Demonstration Proposal approved by the Health Care Financing Administration.

1. (1) Definitions.

   1. (A) Health insurance. Any hospital and medical expense incurred policy, nonprofit heath 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. (B) Co-payment. A cost-sharing arrangement in which a covered person pays a specified charge for a specified service, such as ten dollars ($10) for a professional service.
   3. (C) Parents. For purposes of this regulations the term parents refers to biological or adoptive parent(s).

2. (2) The following uninsured individuals shall be eligible to receive medical services to the extent and in the manner provided in this regulation:

   1. (A) Individuals losing transitional medical assistance (TMA) who would not otherwise be insured or Medicaid eligible, with gross income below three hundred percent (300%) of the federal poverty level for the household size—

      1. 1. Eligibility for the Uninsured Parents’

Health Insurance Program for individuals losing TMA ends twenty-four (24) months after TMA eligibility ends; and

1. 2. After coverage ends, the individuals

with a child eligible for MC+ have the option of staying in the MC+ health plan, where managed care is available, if the parents pay the cost of the state’s cost for the time period covered by the Missouri Medicaid Section 1115 Health Care Reform Demonstration Proposal as approved by the Health Care Financing Administration;

1. (B) Uninsured non-custodial parents with income at or below one hundred twenty-five percent (125%) of the federal poverty level for the household size who are current in paying their child support—

   1. 1. Eligibility for the Uninsured Parents’

Health Insurance Program for uninsured non-custodial parents with income below one hundred twenty-five percent (125%) of the federal poverty level ends after twenty-four (24) total months, the months can be nonconsecutive; and

1. 2. Child support refers to a legally obli-

gated dollar amount established by court or administrative order;

1. (C) Uninsured non-custodial parents who are actively participating in Missouri’s Parents’ Fair Share Program;
2. (D) Uninsured custodial parents with family income at or below one hundred percent (100%) of the federal poverty level for the household size; and
3. (E) Uninsured women who do not qualify for other medical assistance benefits, and would lose their Medicaid eligibility sixty (60) days after the birth of their child or sixty (60) days after a miscarriage, will continue to be eligible for family planning and limited testing of sexually transmitted diseases (EWH), regardless of income, for twenty-four (24) consecutive months after the pregnancy ends.

1. (3) Uninsured parents identified in subsections (2)(B), (2)(C) or (2)(D) who had health insurance in the six (6) months prior to the month of application shall not be eligible for coverage under this rule until six (6) months after coverage was dropped.

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

   1. (A) Loss of employment due to factors other than voluntary termination;
   2. (B) Employment with a new employer that does not provide an option for coverage;
   3. (C) Expiration of the Consolidated Budget Reconciliation Act (COBRA) coverage period;
   4. (D) Lapse of health insurance when the lifetime maximum benefits under their private health insurance have been exhausted; or
   5. (E) Lapse of health insurance when maintained by an individual other than the parent, individual losing TMA, or women who qualify for EWH.
3. (5) Beneficiaries covered in section (2) of this rule shall be eligible for service(s) from the date their application is received. No service(s) will be covered prior to the date the application is received.

4. (6) The following services are covered for beneficiaries of the Uninsured Parents’ Health Insurance Program if they are medically necessary:

   1. (A) Inpatient hospital services;
   2. (B) Outpatient hospital services;
   3. (C) Emergency room services;
   4. (D) Ambulatory surgical center, birthing center;
   5. (E) Physician, advanced practice nurse, and certified nurse midwife services;
   6. (F) Maternity benefits for inpatient hospital and certified nurse midwife. The health plan shall provide coverage for a minimum of forty-eight (48) hours of inpatient hospital services following a vaginal delivery and a minimum of ninety-six (96) hours of inpatient hospital services following a cesarean section for a mother and her newly born child in a hospital or any other health care facility licensed to provide obstetrical care under the provision of Chapter 197, RSMo. A shorter length of hospital stay for services related to maternity and newborn care may be authorized if a shorter inpatient hospital stay meets with the approval of the attending physician after consulting with the mother and is in keeping with federal and state law. The health plan is to provide coverage for post-discharge care to the mother and her newborn. The physician’s approval to discharge shall be made in accordance with the most current version of the “Guidelines for Perinatal Care” prepared by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, or similar guidelines prepared by another nationally recognized medical organization and be documented in the patient’s medical record. The first post-discharge visit shall occur within twenty-four (24) to forty-eight (48) hours. Post-discharge care shall consist of a minimum of two (2) visits at least one (1) of which shall be in the home, in accordance with accepted maternal and neonatal physical assessments, by a registered professional nurse with experience in maternal and child health nursing or a physician. The location and schedule of the post-discharge visits shall be determined by the attending physician. Services provided by the registered professional nurse or physician shall include, but not be limited to, physician assessment of the newborn and mother, parent education, assistance and training in breast or bottle feeding, education and services for complete childhood immunizations, the performance of any necessary and appropriate clinical tests and submission of a metabolic specimen satisfactory to the state laboratory. Such services shall be in accordance with the medical criteria outlined in the most current version of the “Guidelines for Perinatal Care” prepared by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, or similar guidelines prepared by another nationally recognized medical organization. If the health plan intends to use another nationally recognized medical organization’s guidelines, the state agency must approve prior to implementation of its use;
   7. (G) Family planning services;
   8. (H) Pharmacy benefits;
   9. (I) Dental services to treat trauma or disease;
   10. (J) Laboratory, radiology and other diagnostic services;
   11. (K) Prenatal case management;
   12. (L) Hearing aids and related services;
   13. (M) Eye exams and services to treat trauma or disease (one (1) pair of glasses after cataract surgery only);
   14. (N) Home health services;
   15. (O) Emergent (ground or air) transportation;
   16. (P) Non-emergent transportation only for members in ME Code 78 Parents’ Fair Share;
   17. (Q) Mental health and substance abuse services, subject to limitation of thirty (30) inpatient days and twenty (20) outpatient visits. One (1) inpatient day may be traded for two

5. (2) outpatient visits;

   1. (R) Services of other providers when referred by the health plan’s primary care provider;
   2. (S) Hospice services;
   3. (T) Durable medical equipment (including but not limited to: orthotic and prosthetic devices, respiratory equipment and oxygen, enteral and parenteral nutrition, wheelchairs 13 CSR 70-4

and walkers, diabetes supplies and equipment);

1. (U) Diabetes self-management training for persons with gestational, Type I or Type II diabetes;

2. (V) Services provided by local health agencies (may be provided by the health plan or through an arrangement between the local health agency and the health plan)—

   1. 1. Screening, diagnosis, and treatment

of sexually transmitted diseases;

1. 2. HIV screening and diagnostic ser-

vices;

1. 3. Screening, diagnosis, and treatment

of tuberculosis; and

1. (W) Emergency medical services. Emergency medical services are defined as those health care items and services furnished or required to evaluate or stabilize a sudden and unforseen situation or occurrence or a sudden onset of a medical or mental health condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the failure to provide immediate medical attention could reasonably be expected by a prudent lay person, possessing average knowledge of health and medicine, to result in:

   1. 1. Placing the patient’s health (or with

respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; or

1. 2. Serious impairment of bodily func-

tions; or

1. 3. Serious dysfunction of any bodily

organ or part; or

1. 4. Serious harm to a member or others

due to an alcohol or drug abuse emergency; or

1. 5. Injury to self or bodily harm to oth-

ers; or

1. 6. With respect to a pregnant woman

who is having contractions: a) that there is inadequate time to effect a safe transfer to another hospital before delivery; or b) that transfer may pose a threat to the health or safety of the woman or the unborn child.

1. (7) Individuals losing TMA, uninsured noncustodial parent(s) with family income at or below one hundred twenty-five percent (125%) of the federal poverty level who are current in paying their child support and uninsured custodial parent(s) with family income at or below one hundred percent (100%) of the federal poverty level shall owe a ten dollar ($10) co-payment for certain professional services and a five dollar ($5) copayment in addition to the recipient portion of the professional dispensing fee for pharmacy services required by 13 CSR 70-4.051.

   1. (A) Providers may request payment of the mandatory co-payment(s) prior to or after service delivery.
   2. (B) The co-payment amount shall be deducted from the Medicaid maximum allowable amount for fee-for-service claims reimbursed by the Division of Medical Services.
   3. (C) Service(s) may not be denied for failure to pay the mandatory co-payment(s).

   4. (D) When a mandatory co-payment is not paid, the Medicaid provider will have the following options:

      1. 1. Forego the co-payment entirely;
      2. 2. Make arrangements for future pay-

ment with the recipient; or

1. 3. File a claim with the Division of

Medical Services to report the non-payment of the mandatory co-payment(s) and secure payment for the service from the Division of Medical Services.

1. (E) When the Division of Medical Services receives a claim from a Medicaid fee-for-service provider for non-payment of the mandatory co-payment, the division shall send a notice to the recipient—

   1. 1. Requesting that the recipient reim-

burse the Division of Medical Services for the mandatory co-payment made on their behalf;

1. 2. Requesting information from the

recipient to determine if the mandatory copayment was not made because there has been a change in the financial situation of the family; and

1. 3. Advising the recipient of the possible

loss of coverage for up to six (6) months if the recipient fails to pay three (3) co-payments in one (1) year.

1. (F) The recipient will be allowed fourteen

1. (14) calendar days to respond. If the recipient indicated there has been a change in the financial situation of the family, the state shall redetermine eligibility—

   1. 1. If the eligibility redetermination

places the recipient in a non-mandatory copayment category, there will be no co-payment due; or

1. 2. If the eligibility redetermination does

not place the recipient in a non-mandatory co-payment category another notice will be sent to the recipient about the mandatory copayment provision of the program which shall include the number of co-payments that have not been paid and how many may not be paid before a recipient is terminated from the program.

1. (G) Notice of non-payment of mandatory co-payment(s) sent to the recipient during the course of a year shall establish a pattern of not meeting the mandatory cost sharing requirement of the program. The process to terminate eligibility shall proceed with the third failure to pay a mandatory co-payment in any one (1) year or until one (1) or more of the three (3) delinquent mandatory co-payments is made. Coverage shall begin again only after payment of one (1) or more of the three (3) co-payments or passage of six (6) months time whichever occurs first. Health care coverage shall not be retroactive.

   1. 1. A year starts at the time a co-payment

is reported not paid to the Division of Medical Services;

1. 2. Payment of a delinquent co-payment

or co-payments will eliminate the failure to pay a mandatory co-payment or co-payments.

1. (H) Recipient(s) shall have access to a fair hearing process to appeal the disenrollment decision.
2. (I) If the recipient fails to pay the mandatory co-payments three (3) times within a year and is disenrolled from coverage the recipient shall not be eligible for coverage for six (6) months after the department provides notice to the recipient of disenrollment for failure to pay mandatory co-payments or until one (1) or more of the three (3) delinquent mandatory co-payments is paid. Coverage shall begin again only after payment of one

1. (1) or more of the three (3) co-payments or passage of six (6) months whichever occurs first. Coverage shall not be retroactive.
2. (8) Uninsured non-custodial parents who are actively participating in Missouri’s Parents’ Fair Share Program and uninsured women who do not qualify for other benefits, and would lose their Medicaid eligibility sixty
3. (60) days after the birth of their child or sixty
4. (60) days after a miscarriage are not required to pay a co-payment for services.
5. (9) The Department of Social Services, Division of Medical Services shall provide for granting an opportunity for a fair hearing to any applicant or recipient whose claim for benefits under the Missouri Medicaid Section 1115 Health Care Reform Demonstration Proposal is denied or disenrollment for failure to pay mandatory co-payments has been determined by the Division of Medical Services. There are established positions of state hearing officer within the Department of Social Services, Division of Legal Services in order to comply with all pertinent federal and state law and regulations. The state hearing officers shall have authority to conduct state level hearings of an appeal nature and shall serve as direct representative of the director of the Division of Medicaid Services.

AUTHORITY: sections 208.040 and 208.201, RSMo 1994 and 660.017, RSMo Supp. 1998.* Emergency rule filed Sept. 13, 1999, effective Sept. 23, 1999, terminated Oct. 15, 1999. Original rule filed Aug. 16, 1999, effective March 30, 2000. *Original authority: 208.040, RSMo 1939, amended 1941, 1949, 1951, 1953, 1955, 1957, 1973, 1977, 1982, 1983, 1984, 1987, 1994, 1999; 208.201, RSMo 1987; and 660.017, RSMo 1993, amended 1995.