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KidsCare ManualSection 1100: PremiumsTable of Contents1105 Penalty for Non-Payment of the Premium 1107 Premiums During the 12-Month Guarantee 1108 Reapplications With a Past Due Amount
1101 PremiumsA. Policy To be eligible for KidsCare with a premium or AHCCCS Health Insurance for Parents, the PI must indicate on the application that someone is willing to pay the premium for the applicant. To remain eligible for KidsCare or AHCCCS Health Insurance for Parents, someone must pay the monthly premium. If the balance due is more than one month behind, the individual is ineligible (1105). If an individual reapplies and has an outstanding balance, the individual is ineligible for KidsCare or AHCCCS Health Insurance for Parents until the total past due amount is paid (1108). B. Requests for Information If a PI telephones the KidsCare office requesting information about the household's account balance or last payment received, look on the FI637 screen. Do not provide this information to anyone other than the PI or a parent in the household. Refer clients with premium billing and collection questions that require further clarification to DBF at (602) 417-4254 or 1-888-827-4420. 1102 Premium AmountsA. General Children enrolled in KidsCare may be charged a monthly premium based on the Income Group's total income and the number of children enrolled in KidsCare. If parents are enrolled in AHCCCS Health Insurance for Parents, the whole family (children and parents) is assessed a premium. B. Native Americans and Alaska Natives Native Americans and Alaska Natives are not charged a premium regardless of the amount of income. C. Medicaid Eligible Individuals who are eligible for Medicaid will not be charged a premium. ACE will automatically assess a zero premium for all children who are potentially Medicaid eligible. Parents who are potentially Medicaid eligible are not eligible for AHCCCS Health Insurance for Parents coverage (MS 802.A). AHCCCS Health Insurance for Parents coverage will be denied or discontinued and the application referred to DES for a Medicaid decision. D. Premium Amounts for Children Only Listed below are the monthly premium amounts for children.
E. Premium Amounts for Family Listed below are the monthly family premium amounts if a parent is eligible for AHCCCS Health Insurance for Parents.
Note: The FPL levels for family premiums are different from the FPL levels for children. For households with eligible parents exactly at 150% or 175% of the FPL, they will fall into the next higher tier from the children. For example, households with income exactly at 150% FPL with only children eligible fall into the first tier. Households with income exactly at 150% FPL with parents eligible fall into the second tier. ACE was not programmed for this change. It will continue to calculate premiums based on the tiers for children. If a household with eligible parents has income exactly at 150% or 175%, increase the total household income by .01 so the income falls into the correct tier. F. Premiums for Cases With Multiple Income Groups A case may consist of multiple income groups. The monthly premium amount for a child is based on the income group with the highest income level and the number of eligible children in income groups. Example:
Because the highest income level is at the 175 - 200% range and there are 2 or more eligible children in the case at an income level over 150%, the premium is $35.00. 1103 Premium Billing ProcessA. Billing Process DBF is responsible for the billing, collection, and tracking of premium payments. The following is an overview of the billing process.
B. Form of Payment AHCCCS does not accept cash payments. The monthly statement instructs the primary informant to mail a check, cashier's check, or money order directly to the Administration's bank lock-box. The bank picks up and processes the payments daily and sends copies of payments received to DBF. DBF posts the payments to the KidsCare account. C. Payments Received by KidsCare If you receive a premium payment in the KidsCare office, follow the procedures below.
1104 Changes to the PremiumA. General A change in income, number of members in the household, or the number of children who are KidsCare eligible may affect the child(ren)'s premium amount. If a parent is eligible, a change in income or the number of members in the household may affect the family's premium amount. B. Effective Date of Change Changes in premium are effective the month following the month the change is verified. However, if the premium amount increases, you must allow for the 10 days adverse action notice. If a change that results in a lower premium was received in the KidsCare office but not processed timely, reduce the premium for the next prospective eligibility boundary and reduce the premium retroactively, beginning the month following the month the change was verified. C. Processing the Change If the household size or income changes after approval, follow the procedures below to reevaluate eligibility and the premium amount for each child and parent in the Income Group.
1105 Penalty for Non-Payment of the PremiumA. Policy If payments for children in the household fall more than one month behind, ACE automatically discontinues eligibility for the children and parents in the household. If payments for the parent(s) in the household fall more than one month behind, ACE automatically discontinues eligibility for the parent(s). B. ACE Process ACE reads the DBF system on the 18th of the month. If the payments are more than one month past due, ACE automatically discontinues benefits at the end of the month using disposition reason Premium Payment Not Made. C. Discontinuance Notice ACE generates the notice, which includes all usual information on a discontinuance notice, the past due premium amount, and an explanation that if the entire outstanding balance is paid prior to the discontinuance effective date, coverage will continue. File a copy of the notice in the case file. D. Payment Prior to the Discontinuance Effective Date ACE reads the DBF system at the end of each month. If the balance is paid (for children and/or parents) or waived (for children only), ACE reopens and redispositions eligibility. At the end of the month, ACE generates a final report of cases that are discontinued due to non-payment. This report does not include individuals who paid the outstanding balance prior to the discontinuance effective date or children whose premiums were waived due to hardship. E. Payment on or After the Discontinuance Effective Date If the outstanding balance is paid after the discontinuance effective date, the PI must reapply to reestablish KidsCare or AHCCCS Health Insurance for Parents eligibility. 1106 Premium Hardship WaiverA. Policy The PI may request a waiver of a child's premium for the prior or current month due to a hardship in the month. If you waive the premium for the current month, waive the premium for the prior month even if there are no expenses in that month. The PI must have paid or be required to pay the expense during the month you waive the premium. If you waive the premium and the PI does not pay the expense, do not waive the premium again using the same expense. Note: The premium hardship waiver does not apply to family's with active adults. B. Hardship Criteria A hardship exists if a member of the income group died or the income group has one or more of the following expenses which exceed 10% of the countable gross income of the income group:
C. Hardship Waiver Request Process The chart below describes the premium hardship waiver request process.
D. Proof Accept the PI's statement on the written request as proof of income and death of an income group member. The PI must provide proof of the expense(s). Proof of the expense(s) includes a copy of the bill or receipt that shows the type, date, and amount of the expense. An estimate is not proof. Send the appropriate notice to the PI.
1106.1 Reevaluating Ongoing Eligibility for the Premium Hardship Waiver at RenewalA. Policy If the premium is currently waived on an ongoing basis, you must reevaluate eligibility for the hardship waiver while conducting the renewal, even if you are discontinuing benefits. If the children remain eligible for the hardship waiver and appeal the discontinuance, the premium is waived during the appeal process. B. Renewal Procedure The Eligibility Specialist is responsible for determining ongoing eligibility for the premium hardship waiver when processing the renewal. Follow the procedures below to complete the reevaluation for the hardship waiver before dispositioning the renewal.
1107 Premiums During the 12-Month GuaranteeA. Policy A child who is eligible under the 12-month guarantee period is counted in the premium calculation. Parents do not receive a 12-month guarantee. B. Premium Calculation After receiving the guarantee period notification from PMMIS, ACE recalculates the premium amount for the number of children who remain either KidsCare eligible or who are eligible under the guarantee period. One premium amount is calculated for all children in the case. If the child's benefits are discontinued due to excess income, ACE calculates the maximum premium amount. C. Notice The Technical Service Center (TSC) receives a report of children whose KidsCare coverage is ending and qualify for some portion of the 12-month guarantee period. The TSC staff completes ACE processing to extend eligibility and sends manual KidsCare Guarantee Notices, indicating that benefits are continuing under the guarantee period and the revised premium amount. If you encounter any problems with notices, contact the Technical Services Center at extension 74200 immediately. D. Changes Premiums do not change during the guarantee period for cases with no children eligible for KidsCare. Therefore, it is not necessary to process changes in income and household members for these cases unless the change results in eligibility. E. Penalty for Non-Payment
1108 Reapplications With a Past Due PremiumA. Policy An applicant cannot be approved if past due premiums as indicated below exist.
B. ACE Process At the time of registration on the Group window or when you indicate that a parent is applying for benefits, ACE searches the DBF system to determine if there are unpaid past due premiums for the child(ren) and parent(s). A record of unpaid past due premiums may be found under a previous case ID located in KEDS (the former eligibility system prior to ACE). Therefore, it is important to enter a former KEDS case ID on the Group window, when applicable, so ACE and DBF systems can complete a thorough search. If unpaid past due premiums are found, ACE automatically generates a KidsCare Billing and Collection request for payment letter to the primary informant, allowing 20 days to pay the outstanding balance. Central Office staff mail the notice to the PI. Note: ACE blocks you from approving the application until the debt is cleared with DBF. C. Processing the Application Nonpayment of the premium does not affect the application for Medicaid. Continue processing the application.
Note: If the 30th processing day falls on a weekend or holiday, deny the application the next business day. 1109 Enrollment FeesA. Policy Any customer that is initially approved for AHCCCS Health Insurance for Parents must pay a one-time enrollment fee. B. Billing The enrollment fee is billed with the first month's premium statement. DBF will track the enrollment fee separately from the premium. DBF applies any payments received for the children's premiums first, then the enrollment fees for the parents, and then the premiums for the parents. Any amount above the enrollment fee is applied to premiums following the procedures in MS 1103.A. C. Amounts The amount of the enrollment fee is equal to one month's premium. The following chart shows the enrollment fees for AHCCCS Health Insurance for Parents.
D. 24 Month Exception Once a parent has paid the enrollment fee, that parent will not be charged another enrollment fee unless the parent is discontinued and reapplies. When the customer reapplies, if the customer was on AHCCCS Health Insurance for Parents within the past 24 months, then the customer will not be charged an enrollment fee.
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