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Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 20D -

• Children in families with gross income above 150% of the FPL cannot have access to affordable employer sponsored or private health insurance. These children must pay a premium to be eligible (a cost sharing provision). The following is a description of the affordability test: • Three percent of 150% of the FPL for a family of three, for families with a gross income of more than 150% and up to 185% FPL • Four percent of 185% of the FPL for a family of three, for families with a gross income of more than 185% and up to 225% FPL • Five percent of 225% of the FPL for a family of three, for families with a gross income of more than 225% but less than 300% FPL. Non-Emergency Medical Transportation  Children in families with gross income below 150% will be covered. Service(s) furnished or proposed to be furnished that is (are) reasonable and medically necessary for the prevention, diagnosis, or treatment of a physical or mental illness or injury; to achieve age appropriate growth and development; to minimize the progression of a disability; or to attain, maintain, or regain functional capacity; in accordance with accepted standards of practice in the medical community of the area in which the physical or mental health services are rendered; and service(s) could not have been omitted without adversely affecting the recipient’s condition or the quality of medical care rendered; and service(s) is (are) furnished in the most appropriate setting. Services must be sufficient in amount, duration, and scope to reasonably achieve their purpose and may only be limited by medical necessity.  Children in families with gross income between 150% through 300% will not be covered. This benefit is so unheard of in any health insurance plan that its inclusion would serve as a significant incentive for the dropping of private coverage. Crowd out will be evaluated yearly to determine if additional protections are warranted. If crowd out does become a problem the State will develop additional anti-crowd out measures as warranted by the scope and nature of the problem. Additional options may include:  Adding an insurance availability test to preclude participation  Lengthening the look back period;  Implementing cost sharing provisions;  Moving to once yearly open enrollment periods for children with family income over 200% of gross FPL;  Other measures designed to efficiently deal with what the research finds.