1840.010.15 Access to Affordable Health Insurance – DSS Manuals

IM-129 October 10, 2017

In addition to being uninsured, Premium group children (income above 150% of FPL) (CHIP73, CHIP74, and CHIP75) cannot have access to affordable health insurance. Access to affordable insurance available through employment, a group membership, or from a private company causes ineligibility. Examples of group memberships that could offer health insurance are a union, professional organization, or trade association.

NOTE : If an individual does not meet the workplace or group membership criteria to be eligible for employer-sponsored or group membership insurance at the time of application, such as hours worked or length of membership, then the insurance is not available to that person. It is the participant’s responsibility to report any changes that could affect his or her eligibility within ten days of the change.

If the household fails to purchase the affordable health insurance, premium group children are ineligible as long as it is available. It is considered available even though there is a limited open enrollment period for which they need to wait.

EXAMPLE: In July, Ms. Marks applies for MO HealthNet for Kids (MHK) for her children. Her gross income places coverage within the Premium Group. Ms. Marks has been employed since February and chose not to enroll her children in employer-sponsored insurance that is considered affordable. Her employer offers open enrollment every October with coverage beginning in January. Ms. Marks has access to affordable health insurance and is not eligible for MHK coverage.

Senate Bill 577 (2007) modified RSMo 208.640 to provide that employer-sponsored health insurance and other health insurance that does not cover an eligible child’s pre-existing conditions is not considered affordable health insurance. The applicant/participant must provide verification from:

the health insurance plan that the eligible child’s pre-existing condition is not covered; and

the child’s physician that the child has the pre-existing condition the health plan will not cover

Additionally, Senate Bill 577 (2007) modified RSMo 208.640 to provide that an eligible child who has exceeded the annual coverage of his or her health plan for all healthcare services, is considered uninsured and does not have access to affordable health insurance.