Eligibility for Non-Medicaid Eligible Program

PURPOSE: This rule incorporates changes to the non-Medicaid eligible consumer-directed services program required by Senate Bill 74/49, 93rd General Assembly, First Regular Session (2005), to establish the criteria and procedures for determining eligibility for consumer-directed services through the non-Medicaid eligible program. (1) Subject to legislative appropriations, the Department of Health and Senior Services (DHSS) shall provide financial assistance for consumer-directed services (CDS) through eligible vendors, pursuant to applicable state law and regulation, to each person determined eligible to participate in the nonMedicaid eligible (NME) program. All consumers must meet the CDS requirements found in state law and regulations, except for proof of Medicaid eligibility under Title XIX of the Social Security Act. In addition, consumers must meet the following criteria for eligibility under the NME program: (A) Participation in the NME program through the Department of Elementary and Secondary Education, Division of Vocational Rehabilitation, on June 30, 2005, and make application to DHSS; (B) Demonstrate financial need and eligibility pursuant to the applicable rules and regulations; (C) Provide proof of having been found by the Department of Social Services (DSS) ineligible to participate in the Medicaid state plan; and (D) Does not have access to employer-sponsored or other health care coverage that includes personal care assistance, or the costs of such coverage exceed on a monthly basis one hundred thirty-three percent (133%) of the monthly average premium required in the state’s current Missouri Consolidated Health Care Plan (MCHCP). (2) Financial need and eligibility are based upon the adjusted gross income (AGI) of the applicant and the applicant’s spouse and the assets of the applicant and/or the applicant’s spouse. (A) In order to demonstrate a financial need, an applicant and the applicant’s spouse must have an AGI, less disabilityrelated medical expenses as approved by DHSS, that is equal to or less than three hundred percent (300%) of the federal poverty level. 1. AGI is calculated on an annual basis by calendar year, using the AGI as reported to the Internal Revenue Service, less any disability-related medical expenses paid during the same year. 2. Disability-related medical expenses must be documented and proof of payment is required. (B) Applicant and/or the applicant’s spouse shall not have assets in excess of two hundred fifty thousand dollars ($250,000). 1. Any assets of the applicant and/or the applicant’s spouse transferred within twelve (12) months of the date of application shall be included in the calculation of assets. (3) Consumers shall pay a monthly premium to DHSS. (A) The premium shall be equal to the statewide average premium required for the MCHCP, but shall not exceed five percent (5%) of the consumer’s and the consumer’s spouse’s AGI for the previous calendar year. (B) Nonpayment of the required premium shall result in denial or termination of services, unless the person demonstrates good cause for such nonpayment by providing documentation of income and expenses that substantiates the inability to pay the premium. 1. Any consumer who is denied services for nonpayment of the premium shall not receive services until past due and current premiums are paid. 2. Any consumer who does not make any payments for past due premiums for sixty (60) consecutive days shall have their enrollment in the program terminated. 3. Any consumer who is terminated due to non-payment of premiums shall not be re-enrolled unless all past due and current premiums are paid prior to re-enrollment. 4. Nonpayment shall include payment with a returned, refused, or dishonored instrument. (4) Continued participation in the NME program shall require that eligibility be reevaluated on an annual basis, pursuant to applicable state law and regulation. (A) The amount of financial assistance shall be adjusted or eliminated based on the outcome of the reevaluation and shall be recorded in the consumer’s plan of care. (B) Consumers must respond and provide requested documentation within ten (10) days of DHSS’ notice of reevaluation of eligibility. (C) Failure by the consumer to provide requested documentation within ten (10) days will result in DHSS sending the consumer a notification letter that he or she has ten (10) days to file an appeal or services will be terminated. (5) Applicants or consumers whose services are denied, reduced, or terminated have the right to request a hearing under the applicable rules of DHSS. AUTHORITY: section 208.930, RSMo Supp. 2005.* Emergency rule filed Dec. 15, 2005, effective Dec. 25, 2005, expired June 23, 2006. Original rule filed Dec. 15, 2005, effective July 30, 2006. *Original authority: 209.930, RSMo 2005.