State Children’s Health Insurance Program

PURPOSE: This rule establishes components of the State Children’s Health Insurance Program which will provide health care coverage to uninsured, low income children. (1) Definitions. (A) Children. Persons up to nineteen (19) years of age. (B) Health insurance. Any hospital and medical expense incurred policy, nonprofit health 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) An uninsured child/children in a family(ies) with gross income of more than one hundred fifty percent (150%) of the federal poverty level shall not have had health insurance prior to application pursuant to section 208.631, RSMo. (3) Parent(s) and guardian(s) of uninsured children with gross income of more than one hundred fifty percent (150%) but less than three hundred percent (300%) of the federal poverty level must certify, as a part of the application process, that the child does not have access to affordable employer-sponsored health care insurance or other affordable health care coverage available to the parent(s) or guardian(s) through their association with an identifiable group (for example, a trade association, union, professional organization) or through the purchase of individual health insurance coverage. Access to affordable employer-sponsored health care insurance or other affordable health care coverage shall result in the applicant not being eligible for the Health Care for Uninsured Children program for the child/children in families with gross income of more than one hundred fifty percent (150%) but less than three hundred percent (300%) of the federal poverty level. (A) For families with gross income of more than two hundred twenty-five percent (225%) but less than three hundred percent (300%) of the federal poverty level affordable employer-sponsored health care insurance or other affordable health care coverage is health insurance requiring a monthly dependent premium of five percent (5%) of two hundred twenty-five percent (225%) of the federal poverty level for a family of three (3). (B) For families with gross income of more than one hundred eighty-five percent (185%) but less than two hundred twentysix percent (226%) of the federal poverty level affordable employer-sponsored health care insurance or other affordable health care coverage is health insurance requiring a monthly dependent premium of four percent (4%) of one hundred eighty-five percent (185%) of the federal poverty level for a family of three (3). (C) For families with gross income of more than one hundred fifty percent (150%) but less than one hundred eighty-six percent (186%) of the federal poverty level affordable employersponsored health care insurance or other affordable health care coverage is health insurance requiring a monthly dependent premium of three percent (3%) of one hundred fifty percent (150%) of the federal poverty level for a family of three (3). (4) An uninsured child/children with gross income of more than two hundred twenty-five percent (225%) but less than three hundred percent (300%) of the federal poverty level shall be eligible for service(s) thirty (30) calendar days after the application is received if the required premium has been received. An uninsured child/children with gross income of more than one hundred fifty percent (150%) but less than two hundred twenty-six percent (226%) of the federal poverty level shall be eligible for services once the required premium has been received. (A) Parent(s) or guardian(s) of uninsured children with gross income of more than one hundred fifty percent (150%) but less than one hundred eighty-six percent (186%) of the federal poverty level are responsible for a monthly premium equal to four percent (4%) of monthly income between one hundred fifty percent (150%) and one hundred eighty-five percent (185%) of the federal poverty level for the family size. (B) Parent(s) or guardian(s) of uninsured children with gross income of more than one hundred eighty-five percent (185%) but less than two hundred twenty-six percent (226%) of the federal poverty level are responsible for a monthly premium equal to four percent (4%) of monthly income between one hundred fifty percent (150%) and one hundred eighty-five percent (185%) of the federal poverty level for the family size plus eight percent (8%) of monthly income between one hundred eighty-five percent (185%) and two hundred twentyfive percent (225%) of the federal poverty level for the family size. (C) Parent(s) or guardian(s) of uninsured children with gross income of more than two hundred twenty-five percent (225%) but less than three hundred percent (300%) of the federal poverty level are responsible for a monthly premium equal to four percent (4%) of monthly income between one hundred fifty percent (150%) and one hundred eighty-five percent (185%) of the federal poverty level for the family size plus eight percent (8%) of monthly income between one hundred eightyfive percent (185%) and two hundred twenty-five percent (225%) of the federal poverty level for the family size plus fourteen percent (14%) of monthly income between two hundred twentyfive percent (225%) and three hundred percent (300%) of the federal poverty level for the family size. (D) The monthly premium shall not exceed five percent (5%) of the family’s gross income. (E) The premium must be paid prior to service delivery. (F) The premium notice shall include information on what to do if there is a change in gross income. (G) No service(s) will be covered prior to the effective date which is thirty (30) calendar days after the date the application is received for uninsured children in families with an income of more than two hundred twenty-five percent (225%) of the federal poverty level. (5) If the parent(s) or guardian(s) who owes a premium fails to meet the premium payment requirements, a past due notice shall be sent requesting remittance within thirty (30) calendar days from the date of the past due letter. (6) Premium adjustments shall be calculated yearly in March with an effective date of July 1 of the same calendar year. Individuals shall be notified of the change in premium amount at least thirty (30) days prior to the effective date. (7) The thirty- (30-) calendar-day delay in service delivery is not applicable to a child/children already participating in the program when the parent’s or guardian’s income changes. If the household incurs a premium as the result of an annual review, regardless of whether it is a new amount or the same amount, coverage shall be extended for sixty (60) calendar days to allow for premium collection and to ensure continuity in coverage. Coverage shall be discontinued for the child/children if the premium payment is not made within the sixty- (60-) day extension period. (8) Any child identified as having “special health care needs,” defined as a condition which left untreated would result in the death or serious physical injury of a child, who does not have access to affordable employer-subsidized health care insurance shall not be subject to the thirty- (30-) day waiting period re quired under section 208.646, RSMo, and once enrolled, shall not be required to be without health care coverage for any period of time in order to be eligible for services under sections 208.631 to 208.657, RSMo, for the parent’s or guardian’s failure to pay a premium, as long as the child meets all other qual ifications for eligibility for the remainder of the twelve- (12-) month continuous eligibility period described in section (11) of this rule. (9) The total aggregate premiums for a family covered by this rule shall not exceed five percent (5%) of the family’s gross income for a twelve- (12-) month period of coverage beginning with the first month of service eligibility. Waiver of premiums shall be made upon notification and documentation from the family that payments for premiums have been made up to five percent (5%) of their yearly gross income. (10) For the purposes of this rule, a child/children whose annual maximum benefits of a particular medical service under their private insurance has been exhausted is not considered insured and does not have access to affordable health insurance. (11) When a household pays its first premium, or pays the first premium due after a completed annual review, coverage for the household’s child(ren) shall extend for a twelve (12) month continuous eligibility period from the month of application or the month of the last completed annual review (whichever is later). (A) If the household does not pay its first premium due after a completed annual review, then the case will be closed. (12) A household with children that is not required to pay a premium shall have continuous coverage for the household’s child(ren) for twelve (12) months from the month of application or the month of the last completed annual review (whichever is later). AUTHORITY: section 208.153, RSMo Supp. 2024, and sections 208.201, 208.991, and 660.017, RSMo 2016.* Original rule filed July 15, 1998, effective Feb. 28, 1999. Emergency amendment filed Aug. 4, 2005, effective Sept. 1, 2005, expired Feb. 27, 2006. Amended: Filed April 29, 2005, effective Nov. 30, 2005. Amended: Filed Nov. 15, 2005, effective May 30, 2006. Emergency amendment filed June 15, 2006, effective July 1, 2006, expired Dec. 28, 2006. Amended: Filed June 15, 2006, effective Dec. 30, 2006. Amended: Filed Sept. 17, 2007, effective March 30, 2008. Amended: Filed Feb. 1, 2008, effective Aug. 30, 2008. Amended: Filed June 2, 2008, effective Nov. 30, 2008. Amended: Filed Sept. 25, 2014, effective March 30, 2015. Amended: Filed Sept. 9, 2024, effective April 30, 2025. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; 208.201, RSMo 1987, amended 2007; 208.991, RSMo 2013; and 660.017, RSMo 1993, amended 1995.