PURPOSE: This rule establishes guide. lines for the health insurance premium payment program in accordance with

, section 1906 of the Social Security Act, P.L. 101.508 of Noumber 5, 1990, as amended. The Department of Social Seroices, Division of Medical Seruices shall pay for the cost of enrolling an eligible Medicaid recipient in a group health insuranceplan when theDiuision of Medical Seruices determines it is costeffective to do so. (1) Definitions. Group health insurance shall mean any plan of, or contributed to by, an employer (including a self-insured plan) to provide health care (directly or otherwise) to the employer’s employees, former employees, or the families of the employees or former employees. A group health plan must meet s&ion 5000(b)(l) ofthelnternalReoenue Code of 1986, as amended, and include continuation coverage pursuant to Title XXII of the Public Health Service Act, section 4980B of the Internal Reuenue Code of 1986, or Title VI of the Employee Retirement Income Security Act of 1974, as amended. Participation in a health insurance plan that is not group health insurance as defined in this section is not a condition of Medicaid eligibility. (2) Condition of Eligibility. An individual eligible for Medicaid, or a person acting on the recipient’s behalf, shall cooperate in pmviding information necessary for the Division of Medical Setices to establish availability and cost-effectiveness of group health insurance by completing the Application for Health Insurance Premium Payment (HIPP) Program, Form MOW%3179(6-94). As a condition of Medicaid eligibility, persons who are not enrolled in an available group health insurance plan which the division has determined is c&effective, and who are otherwise eligible for Medicaid, shall apply for enrollment in the Plan.

1. (A) The Department of Social Services, Division of Medical Services shall pay all enrollee premiums and deductibles, coinsw awe and other cost-sharing obligations for items and services otherwise covered under the Medicaid program. Payment of these items is considered a8 payment for medical assistance; the group health insurance is the primary

   MISSOURI (12/30/94) EEmtaly of state

payor to Medicaid. Only coverage of services not pmvided under the group health plan, but to which the individual is entitled under the Medicaid program, shall be pmvided under Medicaid as wrap-around coverage.

1. (B) When an applicant, recipient, parent, guardian or caretaker fails to provide information necessary to determine availability and cosLeffediveness of group health insurance, Medicaid benefita of the applicant, recipient, parent, guardian or caretaker shall be denied unless good cause for failure to cooperate is established. If an applicant, recipient, parent, guardian or caretaker fails to enroll in a group health insurance plan that has been determined costeffective, or disenmlls from a group health insurance plan the department has determined cost-effective Medicaid benefits of the applicant, recipient, parent, guardian or caretaker shall be terminated unless good cause for failwe to cooperate is established. Good cause for failure to cooperate shall be established when the applicant, recipient, parent, guardian or caretaker demonstrates one (1) or more of the following conditions exist:

   1. 1. There was a serious illness or death of

the applicant, recipient, parent, guardian or caretaker or a member of the applicant’s, recipient’s, parent’s, guardian’s or caretaker’s family;

1. 2. There was a family emergency or

household disaster such as a tie, flood or tornado;

1. 3. The applicant, recipient, parent, guard-

ian or caretaker offers a good cause beyond the applicant’s, recipient’s, parent’s, guardian’s or caretaker’s control; and

1. 4. There was a failure to receive the

department’s request for information or notication for a reason not attributable to the applicant, recipient, parent, guardian or caretaker. Lack of a forwarding address is attributable to the applicant, recipient, parent, guardian or caretaker.

1. (C) Medicaid benefits of a child shall not be denied or terminated due to the failure of the parent, guardian or caretaker to cooperate. Additionally, the Medicaid benefits of the spouse of the employed person shall not be denied or terminated due to the employed person’s failure to cooperate when the spouse cannot enroll in the plan independently of the employed person.

1. (3) Cost-effectiveness. Enrollment in a health insurance plan is considered cost-effective when the cost of paying the premiums, coinsurance, deductibles and other costsharing obligations, and additional administrative costs is likely to be less than the amount paid for an equivalent set of Medicaid services. when determining the cost-effwtive-

   -~

   13 CSR 70-97 ,

   m

ness of the health insurance plan, the following data shall be considered:

1. (A) The cost of the insurance premium, coinsurance and deductibles;
2. (B) The scope of services covered under the insurance plan, including exclusions for pm existing conditions, exchsions to enrollment and lifetime maximum benefits imposed;
3. (C) The average anticipated Medicaid utilization, by age, sex, geographic location and coverage group, for persons covered under the insurance plan;
4. (D) The specific health-related circumstances of the persons covered under the inmnince plan. The HIPP Medical History Questionnaire, Form MOW3178(6-94) shall be used to obtain this information; and
5. (E) Annual administrative expenditures of an amount determined by,the Division of Medical Services per Medicaid recipient covered under the health insurance policy.

1. (4) Coverage of Non-Medicaid-Eligible Family Members. When it is determined to be costeffective, the department shall pay for health insurance premiums for non-Medicaideligible family members if a non-Medicaid-eligible family member must be enrolled in the health plan in order to obtain coverage for the Medicaid-eligible family members. However, the needs of the non-Medicaid-eligible family members shall not be taken into consideration when determining cost-effectiveness, and payments for deductibles, coinsurances or other co&sharing obligations shall not be made on behalf of family members who are not Medicaid-eligible.

2. (5) Exceptions to Payment. Premiums shall not be paid for health insurance plans under any of the following circumstances:

   1. (A) The insurance plan is designed to provide coverage only for a temporary period of time (for example, thiiy to one hundred eighty (30-180) days);

   2. (B) The insurance plan is a school plan offered on the basis of attendance or enmllment at the school; (Cl The premium is used to meet a spenddown obligation when all persons in the household are eligible or potentially eligible only under the spenddown program. When some of the household members am eligible for full Medicaid benefits, the premium shall be paidifitisdeterminedtobecost-effective when considering only the persons receiving full Medicaid coverage. In those cases, the pre miom shall not be allowed as a deduction to meet the spenddown obligation for those persons in the household participating in the spenddown program;

      -- .--

m 13 CSR 70-97-SOCIAL SERVICES

1. (D) The insurance plan is an indemnity policy which supplements the policyholder’s income or pays only a predetermined amount for services covered under the policy (for example, tifty dollars ($50) per day for hospital services instead of eiehtv percent (80%) of the --. charge); or (Ei The mxsons covered under the dan are ” ~=.~~ not Medicmddeligible on the date the be&ion regarding eligibility for the HIPP program is made.

1. (6) Duplicate Policies. When more than one (1) health insurance plan or policy is available, the Department of Social Services, Division of Medical Services shall pay only for the most cost-effective plan. However, in situations where the department is buying-in to the cost of Medicare Part A or Part B for eligible Medicare beneficiaries, the cost of premiums for a Medicare supplemental insurance policy may also be paid if the department determines it is likely to be c&effective to do 80.
2. (7) Discontinuance of Premium Payments. When all Medicaid-eligible members covered under the health insurance plan lose Medicaid eligibility, premium payments shall be dis~ontinued as of the month of Medicaid ineligibil ity. When only some of the Medicaid-eligible members covered under the health insurance planloseMedicaid eligibility, a review shall be completed in order to ascertain whether payment of the health insurance premium continues to be cost-effective.

3. (8) Effective Date of Premium Payment. The effective date of premium payments for cost effective health insurance plans shall be determined as follows:

   1. (A) Premium payments for cost-effective health insurance plans shall begin with the month the HIPP program application is received by the department, or the effective date of eligibility, whichever is later. If the person is not currently enrolled in the cos& effective health insurance plan, premium payments shall begin in the month in which the first premium payment is due after enrollment occum; and
   2. (B) In no case shall payments be made for premiums which are used as a deduction to income when determining client participation in the Medicaid program.

4. (9) Method of Premium Payment. Payments of health insurance premiums will be made directly to the insurance carrier except as follows:

   1. (A) The department may arrange for pay ment to the employer to circumvent a paymll deduction;
5. (B) When the employer will not agree to accept premium payments from the depart ment in lieu of a payroll deduction to the employee’s wages, the department shall reimburse the policyholder directly for payroll deductions or for payments made directly to the employer for the payment of health insurance premiums;
6. (C) When premium payments occur through an automatic withdrawal from a bank account by the insurance carrier, the department may reimburse the policyholder for said withdrawals; and
7. (D) When the department is otherwise unable to make direct premium payments because the health insurance is offered through a contract that covers a group of persons identified as individuals by reference to their relationship to the entity, the department shall reimburse the policyholder for premium payments made to the entity.
8. (10) Reviews of Co&Effectiveness. Reviews of cost-effectiveness will be completed at least every six (6) months for employer-related group health plans and annually for nonemplayer-related group health plans. Additionally, redeterminations shall be completed whenever a predetermined premium rate, deductible, or coinsurance increases, mm8 of the persons covered under the policy lose full Medicaid eligibility, loss of employment when the insurance is through an employer, or there is a decrease in the services covered under the policy. F&pi&a shall report all changes concerning health insurance coverage to the local Division of Family Service’s office within ten (10) days of the change.
9. (11) Notices.

10. (A) Notice shall be provided to the house hold under the following circumstances:

    1. 1. To inform the household of the initial decision on cost-effwtiveness and premium payment (Form M0886-3180(6-94) or Form M0886.3181(6-94));
    2. 2. To inform the household that premium payments are being discontinued because Medicaid eligibility has been lost by all persons covered under the policy (Form MO8863182(694)); or
    3. 3. The policy is no longer available to the family (for example, the employer drops insurance coverage or the policy is terminated by the insurance company, Form MO8863182 (6.94)).

    4. (B) A timely notice shall be provided to the household informing them of a decision to discontinue payment of the health insurance premium because the department has determined the policy is no longer costeffective (Form M08863182(6-94)).

       CODEOFSTATEREGULATIDNS

    5. (C) Notice of appeal and hearing rights are 8s provided for in 208.080, RSMo.

11. (12) Fwnimn or Bate Refunds. The department shall be entitled to any premium refund due to overpayment of premium or payment of aninadivepolicyforanytimeperiodforwhich the department paid the premium. The department shall be entitled to any rate refund made when the health insurance carrier determines areturn of premiumsto thepolicyholderis due, because of lower than anticipated claims, for any time period for which the department paid the premium. Auth: sections 208.153, RSMo (Cum. Supp. 1991) and 208.201, RSMo (Supp. 1987).’ Original rule filed June 30,1994, effective Jan. 29,1995. ‘Original authority: 208.153, RSMo fZ967), amended 1973, 1989, 1990, 195’0, 1991 and 208.201, RSMo (1987/.

    (12/30/94) MISSOURI %craaR 0‘ state

    MISSOURI DEPARTMENT DIVISION OF MEDICAL SERVICES HEALTH INSURANCE MEDICAL HISTORY QUESTIONNAIRE

i

L

In orderforthe Department of Social Services, Division of Medical Services insurance premium is cost effective, please provide addressed, postage-paid envelope by confidentiality of all medical information for the HIPP Program.

1. 1. How maw prescriptions are filled each month for persons covered under the insurance policy? Average tidnthly 6x4 $ Does anyone covered under the insurance policy have any of the following conditions which require medical care? Check 2. all conditions that a~~lv and if yes is checked. needed to treat the condition. ’

   Condition

   Diabetes Blood Disorder C*nCi?r Mental Illness or Mental Retardation Pregnancy Heart Condition Asthma or other Respiratory Ailment Scoliosis or Back Injury Stroke or Head Injury Organ Transplant Seizure Disorder Kidney or Liver Disorder Alcoholism/Drug Addiction HIV Positive/AIDS Other Disease/Condition (list)

2. 3. Are any of the persons covered under the insurance policy periodically (mental health institution. nursing home, hospital, etc.)? If yes, list the name of the person and the reason they are institutionalized Is medical care of any of the conditions checked “Yes” above excluded 4. pre-existing condition? q YES ON0 If yes. list conditions not covered

Any questions or concerns you may have regarding this form should be referred to the HIPP worker listed above M0885.3118 (6-Sd) OF SOCIAL SERVICES

PREMIUM PAYMENT (HIPP) PROGRd

J

to determine whether payment of your health

the following information and return

provided on this form. This information iill only be used to determine eligibility

list the name of the person with this condition and how often medical care is

If yes, list name of person with this condition

lYES 3NO OYES ON0 OYES ON0 CIYES ON0 OYES iIN0 ( 3YES ON0 ‘ZIYES ON0 OYES ON0 BYES ON0 OYES ON0 i DYES ON0 I 3YES UN0 OYES ON0 OYES ON0 RYES ON0

I

instiUionalized

q YES ON0

from coverage under the health insurance plan as a

13 CSR70-97 @b

Notice Date: Case Number:

HIPP Worker: Phone Number:

this form in the enclosed seif-

The Department will maintain the

How often is medical care required?

or currently living in an institution 13 CSR70-97-SOCIALSERVICES

MISSOURI DEPARTMENT OF SOCIAL SERVICES DIVISION OF MEDICAL SERVICES APPLICATION FOR HEALTH INSURANCE PREMIUM PAYMENT (HIPP) PROGRAM

1. 1. DO YOU HAVE INSURANCE AVAILABLE THROUGH AN EMPLOYER OR FORMER EMPLOYER? If YES, complete the rest of the form. If NO, you must complete question 8 and sign and date the form at the bottom of the page.

2. 2. COMPLETE THE FOLLOWING ABOUT YOUR INSURANCE POLICY OR ABOUT AN INSURANCE POLICY THAT IS A”A,LABLE. I*S”*WCEW*ME:

   I

3. 4. Are you currently enrolled in this policy? q YES
4. 5. How much is your share of the premiums? $
5. 6. How often are the premiums paid?
6. 7. Is this policy through an employer or former employer?
7. 8. List employer or former employer’s name, address and telephone number: EMPLOIER NAME

My signature below guarantees that my answers on this form are correcf insurers or employers to release any information on myself or my dependent(s) needed to determine eligibility I

/ I / i / I !

IIN0 Are your dependents currently enrolled? 0 YES 0 NO

q YES ON0

true and complete q YES Cl NO

WLICYHOLOEII WE

q YES ON0 q YES ON0 I DYES ON0

to the best of my knowledge. I authorize for the HIPP program.

(12/30/94) MISSOURI SEmm Of state m

WHO MUST APPLY?

Applicants’, recipientz’, parents’, guardians’ or caretakers’ Medicaid benefits will be denied or cancelled ir the applicanf recipient. parent, guardian or caretaker does not provide information necessary to establish cost effectiveness or does not enroll in a health insurance plan that the Department determines is cost effective.

WHO CAN CHOOSE TO APPLY?

Cwestion 1.

Question 2.

Question 3.

Ctuesdon 4.

Question 5.

Question 6.

Question 7. Question 8. ,,.. Signature: 13 CSR 70-97-SOCIAL SERVICES

MISSOURI DEPARTMENT OF SOCIAL SERVICES DIVISION OF MEDICAL SERVICES APPROVAL NOTICE OF HEALTH INSURANCE

You have been approved to take part in the Health Insurance Premium Payment Services has determined that paying your health insurance premiums is cost effective. Cost effective means that paying your health insurance premiums will cost the Department less than paying for your medical care with Medicaid PREMIUMS WILL CONTlNUE AS LONG AS THE POLICY REMAINS COST-EFFECTIVE BELOW REMAIN ELIGIBLE FOR MEDICAID. Your case will be re-examined either every six months or every year for costeffectiveness. Additionally, your case will be re-examined if the premium amount changes, some of the persons covered under the policy lose full Medicaid ellglbalrty, or the policy changes. The decision to pay premiums the premium rates, the average medical care costs and the individual health related conditions of the Medicaid-eligible covered under the policy. Any questions or concerns you may have about this action should be referred to the HIPP worker listed above.

PAYMENT INFORMATION Effective Date of Premium Payment:

AmO”nt of Premium:

NAME AND ADDRESS OF INSURANCE CARRIER Policyholder: Policy No.:

MEDICAID RECIPIENTS COVERED UNDER THIS POLICY Birth Date

Name

PLEASEREADIMPORTANTNOTICEONENCLOSEDSHEET Laal office

copy to: PolicynoideriCarehead M0e.s31&z (6-W Division ‘IO-Division of Y&dial Services

PREMIUM PAYMENT

Notice Date: Case Number: County Number: Co Worker Name:

HIPP Worker: Phone Number:

(HIPP) program. The Department of Social

funds. PAYMENT OF YOUR

AND AS LONG AS THE PERSONS

is based upon a review of the policy, persons

Medicaid ID Number (DCN)

(12/30/94) MISSOURI sdLIMa111) of stat*

Please read the f&tin9 on the approval notice enclosed.

To be eligible for the HlPP program. some or all ofthe persons covered under the insurance policy must be eligible for Medicaid. eligibility ends. will w-examine

-

Repat all changes concerning your health insurance coverage chanqe (13 CSR 70-97.010). Changes

.

.

.

.

.

I

I If you are enrolled health insurance may still be available for the insurance coverage.

Under the Consolidated Omnibus Budget Reconciliation Act of 1985 (often referred continue to make health insurance available reduced (such as going from full-time to part-time). However. premiums. notice informing you of your tight COBRA COVERAGE UNTIL WE CAN DETERMINE WHETHER THE POLICY

HAS DETERMINED

MISSOURI (12/30/34) sdcmrj of stats insurance Premium Payment (HIPP) Program

information about taking pad in the HlPP program. Questions should be referred

Medicaid (Tide

!faJ of the persons covered under the policy lose Medicaid eligibility, HlPP payments If of the persons covered under the policy lose Medicaid eligibility, the Department of Social Services the policy to see r X is still cost effective to pay the premiums.

Reporting Changes

to your local Division of Family Sewice’s office within ten days. of the

that should be reported include, but are not limited to the following:

A change in the amount of the premium

A change in the amount of the deductible

A change in the beneflts or services covered by the policy.

Loss of employment when the insurance is through an employer.

A change in the number of persons in your household etc.,

lf You Lose Your Job or Your Hours of Employment

in a group heaith plan through your employer and you lose your job or you are working throuuh vow employer.

for a limited time to persons after employment ends or hour of work are

If you are eligible for insurance coverage under the COBRA provisions. your employer must give you a wiien to continue the coverage. DO NOT SIGN THE FORM SAYING YOU DON’T WANT

IF YOU VOLUNTARILY DROP HEALTH INSURANCE COVERAGE THAT THE DEPARTMENT TO SE COST EFFECTIVE, YOUR MEDICAID BENEFITS MAY BE CANCELLED

CODE OF STATE REGULAllONS

f9) Eligibility

(e.g. birth of a baby, the policyholder

If it is cost effective,

the employer may no longer share

IS COST EFFECTIVE. 13 CSR 70-97

‘139

to the HlPP worker listed

till stop as ofthe date

leaves the household,

are Reduced

fewer hours.

the HIPP program will continue to pay

to as COBRA), some employers must

in the cost of the

(13 CSR 70-97.010)

13 CSR 70-97-SOCIAL SERVICES

The Department eligible for the Health of the policy, premium the Medicaid-eligible program is:

Any questions MISSOURI DEPARTMENT DIVISION OF MEDICAL SERVICES DENIAL OF HEALTH INSURANCE

of Social Services, Division Insurance Premium Payment rates, average medical persons covered

or concerns regarding

SEE ENCLOSED SHEET FOR YOUR APPEAL RIGHTS

OF SOCIAL SERVICES

PREMIUM

of Medical Services has made (HIPP) program. care costs and the

under the policy. The reason

this action should be referred PAYMENT

Notice Date: Case Number: County Number: Co Worker Name:

HIPP Worker: Phone Number:

the decision that you are not

The decision is based upon a review individual health-related conditions of for denying ellglblllty for the HIPP

to the HIPP worker listed above.

MISSOURI

%cmlAun of S,,b

If you are dissatisfied with any action or failure you have the right Missouri Division Rights” (IM-4).

Before you request a hearing, supervisor to discuss hearing.....

.

.

.

FOLLOW THESE STEPS:

.

.

.

Detailed instructions oamphlet “Important

MISSOURI (E/30/94) bcrshrj Of state RIGHT TO APPEAL

to act with

to appeal. Your rights and procedures of Family Service’s pamphlet “Important

request a conference with the HIPP worker and his/her

the proposed action. If you still disagree with

The hearing is held locally either by speaker-telephone to you and the atmosphere is informal.

You may represent yourself or have a friend or relative do so.

You will not need a lawyer, but may have legal representation you do not have an attorney or cannot afford one, and legal aid or legal services office, you may be eligible

REQUEST A HEARING

PREPARE FOR THE HEARING BY GATHERING YOUR CASE

ATTEND THE HEARING

and information can be found in Missouri Division of Family Service’s Information About Your Hearing Rights”

CODEOFSTATE REGULATIONS

13 CSR 70-97

m

regard to your Medicaid assistance, for hearing are explained in the Information About your Hearing

the decision, request a

or in-person without cost

if you desire it. If

live in an area served by

for these services.

INFORMATION ABOUT

(IM-4).

m 13 CSR 70-97-SOCIAL SERVICES

Based on the code entered, section is free form

Department this time. (Regulation

You or a member of your household you are not eligible for Medicaid, about any elrgrbrlrty questions.

Payment of your health used as a deduction 97.010)

Payment of your health plan is no longer available WITHIN TEN DAYS AVAILABLE.

Payment of your health school plan offered on basis of attendance are not eligible DAYS IF YOU HAVE ANOTHER HEALTH (Regulation

Payment of your health indemnity policy. An indemnity pays $50/day instead of paying payment by the HIPP program. HAVE ANOTHER 97.010)

Department your failure 97.01 0)

Other various messages to enter anything.

REASONS FOR DENIAL

payment of your health 13 CSR 70-97.010

to participate

please contact your worker (Regulation

insurance

in meeting your spenddown

insurance or your policy

IF YOU HAVE ANOTHER HEALTH

(Regulation 13 CSR 70-97.010)

insurance

for payment by the HIPP program.

13 CSR 70-97.010)

insurance policy

to the policyholder for actual health care costs. PLEASE NOTIFY US WITHIN TEN DAYS HEALTH INSURANCE

payment of your health to provide necessary

COOEOFSTATE REGULATIONS

for denial will appear.

insurance )

are not currently

in the HIPP program. in the local Division 13 CSR 70-97.010)

premium cannot be made because

premium cannot be made because is discontinued.

premium cannot be made because or enrollment

INSURANCE

premium cannot be made because just supplements and not the caregiver

PLAN AVAILABLE.

insurance

information Division 704ivision

premiums would not be cost effective at

eligible If you believe you are eligible

obligation.

PLEASE NOTIFY US INSURANCE

at the school. School plans

PLEASE NOTIFY US WITHIN TEN PLAN AVAILABLE.

the policyholder’s for every day in the hospital)

Indemnity policies are not eligible

premium cannot be made because of requested. (Regulation The “Comments”

for Medicaid.

of Family Service’s office

your premium

(Regulation 13 CSR 70-

your

PLAN

the plan

the plan

(Regulation

13 CSR 70-

of Medical Services

Therefore,

is

insurance

is a

is an

income (e.g.

for

IF YOU 13 CSR 70-

MISSOURI

sccw+dry Of state

The Department payment of Your health program. The decision cancellation

Comments:

Any questions

MISSOURI (12/30/94) SocrmY 0, state Insurance Premium Payment (HIPP) Program

MISSOURI DEPARTMENT OF SOCIAL SERVICES DIVISION OF MEDICAL SERVICES CANCELLATION OF HEALTH INSURANCE

of Social Services, Division of Medical Services insurance premiums through the Health is based upon a review or re-examination

is:

or concerns regarding this action should be referred

SEE ENCLOSED SHEET FOR YOUR APPEAL RIGHTS

CODE OF STATE REGUIATIONS

13 CSR 70-97

m

PREMIUM PAYMENT

Notice Date: Case Number: County Number: Co Worker Name:

HIPP Worker: Phone Number:

has made the decisions to cancel Insurance Premium Payment (HIPP)

of your HIPP case. The reason for the

to the HIPP worker listed above.

m 13 CSR 70-97-SOCIAL SERVICES

If you are dissatisfied with any action or failure to act with regard to your Medicaid assistance, have the right to appeal. Your rights and procedures Division of Family Service’s pamphlet

Before you request a hearing, to discuss the proposed action.

l

l

l

FOLLOW THESE STEPS:

l

l

l

letailed instructions oamphlet “Important request a conference with the HIPP worker and his/her supervisor If you still disagree with the decision,

The hearing is held locally either by speaker-telephone to you and the atmosphere

You may represent yourself or have a friend or relative do so.

You will not need a lawyer, but may have legal representation do not have an attorney or cannot afford one, and live in an area served by legal aid or legal services office, you may be eligible

REQUEST A HEARING

PREPARE FOR THE HEARING BY GATHERING YOUR CASE

ATTEND THE HEARING

and information Information About Your Hearing Rights”

RIGHT TO APPEAL

you

for hearing are explained in the Missouri

“Important Information About your Hearing Rights” (IM-4).

request a hearing.....

or in-person without cost

is informal.

If you

if you desire.it.

for these services.

INFORMATION ABOUT

can be found in Missouri Division of Family Service’s (IM-4).

CODEOFSTATEREGUtATlONS MISSOURI secreury 0‘ state Based on the code entered, various messages section is free form to enter anything.

REASONS FOR CANCELLATION

Department payment of your health insurance Therefore, we will stop paying your premiums effective Your Medicaid eligibility and benefits are not affected by this determination. contact your insurance carrier immediately by making the payments yourself. (Regulation

You are no longer eligible for Medicaid. Please contact your if you wish to continue your insurance (Regulation 13 CSR 70-97.010)

Payment of your health insurance premium cannot be made because your premium as a deduction in meeting your spenddown obligation. Therefore, we will stop paying your premiums effective carrier immediately if you wish to continue payments yourself. (Regulation 13 CSR 70-97.010)

Your insurance plan is no longer available or your policy will stop paying your premiums effective NOTIFY US WITHIN TEN DAYS IF YOU HAVE ANOTHER HEALTH AVAILABLE. (Regulation 13 CSR 70-97.010)

0 Other

MISSOURI (12/30/94) CODEOFSTATEREGUlATlONS SecretarI 0‘ Stab 13 CSR 70-97

m

for cancellation will appe~ar. The “Comments”

premium is no longer cost effective.

Please

if you wish to continue your insurance coverage 13 CSR 70-97.010)

Therefore, we will stop paying your premiums insurance carrier immediately coverage by making the payments yourself.

is used

Please contact your insurance

your insurance coverage by making the

is discontinued. Therefore, we PLEASE INSURANCE PLAN