SECTION 6  FAMILY MEDICAID  AND SCHIP PROGRAMS RELATED TO FEDERAL POVERTY GUIDELINES

03.01.500.  HEALTH CARE ASSISTANCE COVERAGE GROUPS RELATED TO THE FPG STANDARDS

03.01.501.  LOW INCOME CHILD

03.01.502.  LOW INCOME PREGNANT WOMAN

03.01.503.  PREGNANT WOMAN INELIGIBLE BECAUSE OF EXCESS INCOME

03.01.504.  PRESUMPTIVE ELIGIBILITY FOR PREGNANT WOMEN

03.01.505.  CHIP A

03.01.506.  CHIP B

03.01.507.  CHILDREN’S ACCESS CARD

03.01.508. – 03.01.599.  (RESERVED)

03.01.500. HEALTH CARE ASSISTANCE COVERAGE GROUPS RELATED TO THE FPG STANDARDS.

Pregnant women and children whose countable income is within the income ranges specified may be eligible for one of the FPG coverage groups.  The Title XIX Medicaid coverage groups related to the FPG are Low Income Child, Low Income Pregnant Women, and presumptively eligible pregnant women.  The Title XXI coverage groups related to the FPG are CHIP A, CHIP B and Children’s Access Card.  (7-1-04)T 

FPG COVERAGE GROUPS

CRITERIA

DESCRIPTION

Family Size

Count family members living with the child.

Family members include the child, parent(s), stepparent, minor siblings, minor half-siblings, minor step-siblings, and the child's children. Otherwise related and non-related minor children are optional members.

Count family members regardless of Medicaid ineligibility or disqualification.

Do not include persons receiving SSI or AABD payments.

For an individual Medicaid determination, only income and resources of persons financially responsible for the individual can make the individual ineligible for Medicaid.

Non-Financial Criteria

The child must meet the Medicaid non-financial eligibility criteria. These include:

 -Residency

 -Citizenship

 -Applying for and furnishing an SSN

Application

If a child gets Medicaid as a Newborn Child of a Medicaid Eligible Mother, and there are no other eligible participants in the case, an application for the child must be filed no later than his first (1st) birthday. If other members of the family receive Medicaid on the same case, there is no need to file a new application to continue Medicaid coverage for a newborn after the first birthday. The child's eligibility must be redetermined at the end of the family's annual eligibility period. If the certification period ends before the newborn's first birthday, the child remains eligible through the month of the first birthday, as long as he meets the requirements outlined in 03.01.601.

 A new application is not required after the child turns six (6).

Resources

The family's countable resources must be five thousand dollars ($5,000) or less for the child to be eligible. Resources are evaluated using the methods described in Section 3 of this Reference Guide, rules 310 through 329.

Income

Family income must be determined using the methods described in Section 3 of this Reference Guide, rules 349 through 386.

Handbook Table FPG Coverage Groups. (7-1-04) 

 For the current Federal Poverty Guidelines follow this link.

                                                                                    (7-1-04)

03.01.501. LOW INCOME CHILD.

A child may be Medicaid eligible if non-financial criteria and financial criteria are met. The child's birth date must be after September 30, 1983. The child's age determines the percentage of FPG used as an income limit and is listed in Subsections 501.01 and 501.02.  (7-1-97) 

01. Child Under Age Six (6). Family income must not exceed one hundred and thirty-three percent (133%) of the Federal Poverty Guideline for the family size. If the child is receiving Medicaid inpatient services when he turns six (6), eligibility continues through the month his inpatient stay ends.  (10-1-97) 

02. Child Age Six (6) and Over. Family income must not exceed one hundred percent (100%) of the Federal Poverty Guideline for the family size. If the child is receiving Medicaid inpatient services when he turns six (6) or nineteen (19), eligibility continues through the month his inpatient stay ends.  (10-1-97) 

 For the current Federal Poverty Guidelines follow this link

If family income exceeds 100% of the Federal Poverty Guideline when a child enrolled in PW turns 6, the child remains eligible for the balance of his 12 calendar months of continuous eligibility.                                                   (7-1-04)

03.01.502. LOW INCOME PREGNANT WOMAN.

A pregnant woman of any age is eligible for the Low Income Pregnant Woman coverage group if she meets all of the non-financial and financial criteria of the coverage group. Medical assistance for a participant in the Low Income Pregnant Woman coverage group is limited to pregnancy related and postpartum services. The Low Income Pregnant Woman medical assistance coverage extends through the sixty (60) day postpartum period if she applied for medical assistance while pregnant and was receiving medical assistance when the child was born.  An individual who applies for Low Income Pregnant Woman medical assistance after the child is born is not eligible for the sixty (60) day postpartum period.  (7-1-04)T 

Family Size For PW – (Low Income Pregnant Women and Children)

-Ineligible Aliens are counted in the family size and their income is counted (minus disregards).

-Disqualified parents are counted in the family size and their income is counted the same (minus disregards).

-If a parent is applying for themselves as well as their child, they are required to cooperate with Child Support. The parent can choose not to apply for PW. The child’s eligibility is not affected for their parent’s non-cooperation with child support.                                                                       (7-1-04)

01. Income Limit. The individual’s countable income which is calculated using income disregards must not exceed one hundred thirty-three percent (133%) of the FPG for her budget unit size in the application month.  (7-1-04)T 

 For the current Federal Poverty Guidelines follow this link

                                                                                    (7-1-04)

 02. Family Size. Family members include the pregnant woman and the unborn child. Family members also include the spouse, minor dependent children, and minor step-children, if living with the pregnant woman. Other related or non-related children may be included if they live with the pregnant woman. Count family members regardless of Medicaid ineligibility or disqualification. Do not include family members receiving SSI or AABD payments. For an individual Medicaid determination, only income and resources of persons financially responsible for the individual can make the individual ineligible for Medicaid.  (3-30-01) 

03. Income Disregards. Subtract allowable income exclusions and disregards to determine family income.  (3-30-01)

04. Continuing Eligibility. The pregnant woman remains eligible during the pregnancy regardless of changes in income. Changes in resources and non-financial criteria must be considered prospectively. The woman must report the end of pregnancy to the Department within ten (10) days.  (4-5-00) 

How to Key EPICS for a Miscarriage

Do not close an unborn on CLPA with a C01 because the notice generated to the participant says that a person who was on the case died.

Process cases with a pregnant mom whose unborn has died using the instructions below:

1.  Do not change the participation of the unborn or the mother will not receive her postpartum benefits.

2. When you know the date the miscarriage occurred, document in the narrative.

3. Set an alert to close the mom at the end of the post partum period.

Example:  If the mother’s postpartum eligibility ends 7/31/04, the unborn can be coded OU during July after the July benefit is paid.  Do not re-trigger eligibility for July once the unborn is coded as OU.

4. Out (OU) the unborn on CLPA. Use the C83 closure code with a start date beginning the first day of the next month. This generates the notice A333 “PW ends for female “MY”.

5. Do not under any circumstances change the unborn’s name from “Unborn” to Miscarriage or to any other name that implies something other than a live birth.  For live births, leave the name as “Unborn” until the mother gives you an actual name.                                       (7-1-04)

03.01.503. PREGNANT WOMAN INELIGIBLE BECAUSE OF EXCESS INCOME.

A pregnant woman in any Title XIX Medicaid coverage group, who becomes ineligible for that coverage group because of an increase in income, continues to receive coverage as a Low Income Pregnant Woman.  (7-1-04)T

03.01.504. PRESUMPTIVE ELIGIBILITY FOR PREGNANT WOMEN.

A pregnant woman can get limited ambulatory prenatal care as a presumptively eligible (PE) pregnant woman through the end of the month after the month the provider completes the PE determination.  PE coverage is designed to provide some prenatal care during the time between the pregnancy diagnosis and the eligibility determination. A qualified PE provider accepts written requests for these services and completes the eligibility determination. The PE provider must inform the participant how to complete the formal application process. Qualified providers are required to send the result of the PE decision and the completed application for Title XIX Medicaid to the Department within two (2) working days. Notice and hearing rights of the Title XIX Medicaid program do not apply to the PE decisions. An individual is eligible for only one period of PE coverage during each pregnancy.  (7-1-04)T 

If the Department finds the woman is not eligible for continued Medicaid, there is not an overpayment from the presumptive eligibility period.

If the participant does not follow through with their application for Medicaid, presumptive eligibility ends. It ends the last day of the month, after the month the qualified provider determined presumptive eligibility.

If the participant applies for continued Medicaid, presumptive eligibility continues until the Department approves or denies the application.

Self employed individuals must apply for Medicaid and cannot receive presumptive eligibility (PE).                                              (7-1-04)

 03.01.505. CHIP A.

A child may be eligible for CHIP A coverage if all non-financial and financial criteria are met.  The child must meet all the conditions listed in Subsections 505.01 through 505.08  of these rules.  (7-1-04)T 

01. Child’s Income Eligibility. To participate in the CHIP A coverage group, an individual’s countable income must be within the range specified for their age.  There are no earned or unearned income disregards for CHIP A.  (7-1-04)T 

            a. Child under age six (6).  The child’s countable income must exceed one hundred and thirty-three percent (133%) of the FPG for his budget unit size and must be less than or equal to one hundred fifty percent (150%) of the FPG for his budget unit size.  (7-1-04)

            b. Child Age Six (6) through the Month of His Nineteenth (19th) Birthday.  The child’s countable income must exceed one hundred percent (100%) of the FPG for his budget unit size and must be less than or equal to one hundred fifty (150%) of the FPG for his budget unit size.  (7-1-04)T 

Family Size For CHIP A –

-Ineligible Aliens are counted in the family size and their income is counted.

-Disqualified parents are counted in the family size and their income is counted the same.

-If a parent is applying for themselves as well as their child, they are required to cooperate with Child Support. The parent can choose not to apply for CHIP A. The child’s eligibility is not affected for their parent’s non-cooperation with child support.                                                       (7-1-04)

02. Child’s Resource Eligibility.  The child’s countable resources must not exceed five thousand dollars ($5000).  (7-1-04)T  

03. No Creditable Health Insurance. The child must not have creditable health insurance coverage.  (7-1-04)T 

04. Child Disenrolled to Qualify for CHIP A.  If a child is disenrolled from creditable insurance with the intent to qualify for CHIP A, he is not eligible for CHIP A.  A child who is disenrolled from creditable health coverage through no fault of his own will not be denied CHIP A coverage under this provision.  A child did not disenroll with the intent to qualify if he lost creditable insurance for one of the following reasons:  (7-1-04)T 

            a. The child lost health insurance due to the loss of employment, or  (7-1-04)T 

            b. The employee lost eligibility for his employer sponsored insurance, or  (7-1-04)T 

            c. The employer stopped providing creditable insurance coverage, or  (7-1-04)T 

            d. The child lost access to his health insurance because his parent can no longer legally cover him with employer sponsored insurance.  (7-1-04)T 

Note: It is the intent of the Department to insure eligible children. A sanction is to be imposed only if applicant discloses children were disenrolled with the intent to qualify for CHIP A. The CHIP A sanction applies to the month of application only. (1/31/05)

05. Not Eligible for Other Coverage.  The child must not be eligible for any Title XIX Medicaid coverage.  (7-1-04)T 

06. Choice Agreement Signed.  A child who is eligible to participate in CHIP A and chooses Children’s Access Card coverage must have a Choice Agreement signed and on file.  If a Choice Agreement is not signed and on file, the child will be enrolled in the CHIP A program.  (7-1-04)T 

07. Choice Agreement Change Requested.  CHIP A participants can move from  CHIP A to the Children’s Access Card at any time if they request the change in writing at least 45 days in advance of the change.  A Children’s Access Card participant who is income eligible for CHIP A can move to CHIP A at any time if they make the request in writing at least 45 days in advance of the change.  The 45-day advance notice requirement will be waived if the child is moving from Children’s Access Card to CHIP A for one of the reasons listed in Subsection 505.04.a. through 505.04.d. of this rule.  (7-1-04)T 

08. Other Eligibility Criteria.  All other eligibility requirements in IDAPA 16.03.01 are applicable to the CHIP A coverage group unless the rule excludes this coverage group.  (7-1-04)T

03.01.506. CHIP B.

The CHIP B coverage group provides a limited benefit package as described in IDAPA 16.03.18, “CHIP B and Children’s Access Card Rules,” to children who apply and are found eligible during an open enrollment period. Children applying during closed enrollment periods are denied. A child may be eligible for the CHIP B coverage group if all non-financial and financial criteria are met. The child must also meet all the conditions listed in Subsections 506.01 through 506.12 of this rule. (4-6-05)

01. Child's Income Eligibility. The child's countable income must be less than or equal to one hundred eighty-five percent (185%) of the FPG for his budget unit size. There are no earned or unearned income disregards for CHIP B. (4-11-06)

Application Procedure:  

  • If a child is over resources for Low Income Child or CHIP A but is still under 185% FPG, they can be eligible for CHIP B or Access programs.

  • Participants must still apply first for Low Income Child or CHIP A if income & resource eligible.

  • Forward the applications to the CHIP B unit.

  • See Appendix E for detailed information on application procedure.

Renewal Procedure:

If a child is determined ineligible during a renewal for PW or CHIP A, a new CHIP B or Children’s Access Card application must be obtained before the child can be enrolled in for CHIP B or Children’s Access Card. The new application is required for the following reasons:

  • CHIP B /Access has limited enrollment

  • CHIP B/ Access requires a signed Choice Agreement

  • CHIP B/ Access requires participant cost sharing  (8-1-05)

 

 

Family Size For CHIP B –

  • Ineligible Aliens are counted in the family size and their income is counted.

  • Disqualified parents are counted in the family size and their income is counted the same.

  • If a parent is applying for themselves as well as their child, they are required to cooperate with Child Support. The parent can choose not to apply for CHIP B. The child’s eligibility is not affected for their parent’s non-cooperation with child support. (7-1-04)

02. Child's Resource Eligibility. The child's countable resources must not exceed five thousand dollars ($5000). (4-6-05)

03. No Creditable Health Insurance. The child must not have creditable health insurance coverage. (4-6-05)

CREDITABLE HEALTH INSURANCE
CHIP participants must not have creditable health insurance. (See Creditable Health Insurance in the Adult and Children's Health Insurance Handbook for a definition of creditable health insurance.) The CHIP Consolidated Unit makes this determination. If a family lists the child as insured on the application, contact them to obtain the information needed to complete the "CHIP CREDITABLE INSURANCE INFORMATION REQUEST" form. Complete the form, attach a copy of the front and back of the participant's insurance card and fax it to the CHIP Consolidated Unit at:

FAX: 1-208-528-5980

If you need additional information call:  1-866-326-2485  (7-1-04)

04. Child Disenrolled to Qualify for CHIP B. To be enrolled in CHIP B, a child must not have disenrolled from creditable insurance in the six (6) months prior to his application with the intent to qualify for CHIP B. (4-6-05)

05. Not Eligible for Other Coverage. The child must not be eligible for any Title XIX Medicaid coverage group or the CHIP A coverage group. (4-6-05)

Note:  Children on Chip B or Chip A remain in the coverage group in which they are originally placed until the next renewal unless moving them to PW (Title 19) makes them eligible to receive a broader range of services. 

  • Child on CHIP B becomes pregnant, do not move them to PW (pregnant) – they will not have the full medical coverage that comes with CHIP B

  • Child on CHIP B becomes pregnant but is within the PW child (100%), move them to PW – PW allows full Medicaid services, not the limited services available under CHIP B

  • Child on CHIP A becomes pregnant, do not move them to PW (pregnant) until renewal, PW would limit services to pregnancy only

  • Babies born to a mom on CHIP B are not eligible as a Waived Newborn.  CHIP B moms are not considered a “Medicaid eligible” mother.  The baby can be added to the CHIP B case if it is an open enrollment period.

Note:  Be sure to explore PW or CHIP A eligibility for the newborn child, if they can not be added to the CHIP B case. The CHIP B application cannot be used as an application for PW, MA/MU, or CHIP A. Request a new application (AFA).  Refer to CHIP B rule - 03.01.506.12 

06. Dependents of State Employees Not Eligible. The dependent child of a State employee is not eligible to enroll in CHIP B if the State employee is eligible to participate in state-sponsored health insurance. (4-6-05)

07. Choice Agreement Signed. A child who is eligible to participate in CHIP B and chooses Children's Access Card coverage must have a Choice Agreement signed and on file. If a Choice Agreement is not signed and on file, the child will be enrolled in the CHIP B program. The Choice Agreement will describe the differences between the CHIP B program and the Children’s Access Card. (4-6-05)

08. Choice Agreement Change Requested. A CHIP B participant can move from CHIP B to the Children's Access Card at any time if the request is made in writing at least forty-five (45) days in advance of the change. A Children's Access Card participant who is income eligible for CHIP B can move to CHIP B at any time if the request is made in writing at least forty-five (45) days in advance of the change. The forty-five day (45) advance notice requirement will be waived if the child is moving from Children's Access Card to CHIP B for one (1) of the reasons listed in Subsection 505.07 of this rule. (4-6-05)

 09. CHIP B Participants Have Required Cost-Sharing Responsibilities. The parent of a CHIP B participant must comply with any cost-sharing requirements described in IDAPA 16.03.18, “CHIP B and Children’s Access Card Rules”. Native American and Alaskan Eskimo children are not subject to cost-sharing requirements. (4-6-05)

Cost Sharing Requirements
Participants in the CHIP B program are required to pay a $15 per month, per child premium. Premiums are not collected by the local office, they are collected and processed by the CHIP B consolidated Unit.

            CU Address & Phone Number: 

            Department of Health & Welfare
            CHIP B/Access Consolidated Unit 
            150 Shoup Avenue, Suite #5 
            Idaho Falls, ID  83402-3653 
            1-866-326-2485

Currently, co-payments are not required. Co-payments will be collected when automation can support the collection process. (7-1-04)

When the family becomes sixty (60) days delinquent, the CHIP Consolidated Unit will notify the family. The worker will contact the family to determine if the family’s circumstances have changed and if the family is eligible for a non-cost sharing program.  If the family is not eligible for another program, the child remains eligible through the twelve (12) month continuous eligibility period.

If the child is eligible for Title XIX Medicaid or CHIP A, the child will be moved to the appropriate coverage group.  The change is effective the month after the child becomes eligible for Title XIX Medicaid or CHIP A. 

The following items apply to delinquent premium payments:

  1. Any premium debt assessed but not paid after the child became eligible for Title XIX Medicaid or CHIP A will be forgiven.

  2. A child must not be approved for or renewed for CHIP B if his premium payments are sixty (60) or more days delinquent as of the last working day of his twelve-month continuous eligibility period.

  3. A family can reestablish a child’s eligibility during a new open enrollment period by paying the premium debt in full.

  4. A family who is determined ineligible at renewal due to delinquent premiums is ineligible for the following twelve (12) months.  After the 12-month period, the debt is forgiven. (7-1-04)

 

If the family is delinquent on their premiums at the end of the 12 months of continuous eligibility:

  1. Contact the family to determine if the family’s circumstances have changed and if they are eligible for another program.

  2. If the family is not eligible for another program, send a notice to the family notifying them the case will close if the premiums are not paid.

  3. The CHIP Consolidated Unit will use the CHIP Database to determine which children have delinquent payments.

  4. Close the children who have delinquent payments.

  5. Children who do not have delinquent payments remain open. (7-1-04)  

10. Other Eligibility Criteria. All other eligibility requirements in this chapter are applicable to this coverage group unless the rule specifically excludes the CHIP B coverage group. (4-6-05)

11. Enrollment Cap. The number of individuals who can be enrolled in this program is subject to an enrollment cap specified by the Department. Individuals who meet all eligibility criteria for this program will be denied if there are no enrollment openings. (4-6-05)

The Division of Medicaid will set the enrollment cap for the CHIP B and Children’s Access Card Programs. During an open enrollment period, applicants are enrolled on a ‘first come, first served’ basis. During open enrollment applications must be registered immediately upon receipt.

If the application is received in the local office, the application is date stamped immediately. The stamped date is used to determine the applicant’s ‘place in line.’

If the application is received by mail, the postmark is used to determine the applicant’s ‘place in line.’ (7-1-04)

12. Child Entering the Home. A child entering the home during a closed enrollment period will not be automatically enrolled in the CHIP B program. They may apply during open enrollment. (4-6-05)

When a child enters the home, determine if the family is eligible for a CHIP A or a Title XIX program. (7-1-04) 

If a child on CHIP B notifies you she is pregnant, review the child for Title XIX or CHIP A eligibility. If she is eligible for Title XIX or CHIP A, move her to the appropriate coverage group.

Scenario:  A pregnant child on CHIP B delivers her baby after the open enrollment period closes. 

A pregnant child is on the CHIP B program and open enrollment is from January 1 through January 9. Her child is born on January 11. The eligibility worker will: 

  1. Review the family for a Title XIX or CHIP A program. If eligible, move the family to the appropriate coverage group.  If the family is not eligible, the mother remains eligible for CHIP B until the end of the 12 months continuous eligibility period.

  2. Tell her to apply for CHIP B for her child during the next open enrollment period. If known, tell her when the next open enrollment is. (7-1-04)

03.01.507. CHILDREN’S ACCESS CARD. 

The Children’s Access Card coverage group provides insurance premium assistance to children who apply and are found eligible during an open enrollment period.  A child receiving Children’s Access Card can change to Low Income Child, CHIP A or B with a 45 day written notice, subject to the provisions in Subsections 505.07 and 506.08 of these rules.  (4-11-06)

Children’s Access Card participants may move to PW or CHIP coverage at any time.

If the participant is on the Children’s Access Card program and requests PW or CHIP coverage, compare the participant’s income to the FPG poverty guidelines. Move the participant to the appropriate PW or CHIP (A or B) coverage within 45 days of receiving written notice.

If the child loses insurance through no fault of their own and requests PW or CHIP coverage, the worker will redetermine eligibility for the family. If the family or any child is eligible for another program, the worker will move the family or child to the new coverage group within 10 days.  If a child is not eligible for Title XIX or CHIP A coverage, the worker will ask if they would like to enroll the child in CHIP B for the remainder of their 12-month eligibility period. (4-11-06)

01.  Children’s Access Card Eligibility. A child may be eligible for the Children’s Access Card if all eligibility requirements for Low Income Child, CHIP A, or CHIP B listed in sections 501,  505, and 506 of these rules are met and if the person meets all of the conditions specified in Subsections 507.02 through 507.06 of these rules.  (4-11-06)

Child Entering the Home

A child entering the home may be enrolled in the Children’s Access Card program at any time, even when it is not an open enrollment period or the CAP has been met.     (7-1-04) 

02. Co-pays And Deductibles. The family is responsible for the co-pays and deductibles required by their private insurance.  (7-1-04)T

03. Choice Agreement. The family must have a signed Choice Agreement on file requesting Children’s Access Card.  If the family does not sign a Choice Agreement, they will be enrolled in the Low Income Child or CHIP coverage group they are eligible for. (4-11-06)

04. Enrollment Cap.  The number of individuals who can be enrolled in this program is subject to an enrollment cap specified by the Department.  Individuals who meet all eligibility criteria for this program will be denied if there are no enrollment openings.  (7-1-04)T

03.01.508. -- 03.01.599. (RESERVED).