Premiums

Created on: 
Jan 05 2016

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Children's Health Insurance Program - CHIP (N13/N33)

Do all N13 (MAGI - CHIP Federal) and N33 (MAGI - CHIP State) recipients pay a monthly premium?

For more information on whether all N13/N33 recipients pay a monthly premium, see Apple Health eligibility manual - WAC 182-505-0225 - Premium requirements for premium-based health care coverage under programs included in apple health for kids.

How are N13 (MAGI - CHIP Federal) and N33 (MAGI - CHIP State) premiums calculated?

Premium amounts are based on the household’s net countable income.

  • Tier 1 Premiums - Households with income greater than 200% and up to 250% of the Federal Poverty Level (FPL) are required to pay $20 per child with a maximum of two premiums for households with two or more children.
  • Tier 2 Premiums - Households with income greater that 250% and up to 300% of the FPL are required to pay $30 per child with a maximum of two premiums for households with two or more children.

Premium amounts for non-citizen children who are not lawfully present qualified or nonqualified (NQ) alien children in households with income above the 200% FPL have a higher premium amount which is no greater than the average of the state-share of the per capita cost for state-funded children's health coverage.

The orders in which premiums are determined are as follows:

  • Federally Qualified children with Tier 1 premiums.
  • Federally Qualified children with Tier 2 premiums.
  • Non-Qualified/Non-Federally Qualified children.

For more information, see Apple Health eligibility manual - WAC 182-505-0225 - Premium requirements for premium-based health care coverage under programs included in apple health for kids.

EXAMPLE:
1. If a household has three children, two which are citizens and the other is NQ or non-federally qualified, the household is billed for the two citizen children first. Since the cap is 2 children there is no billing for the NQ child.
2. If a household has two children, one child is a citizen and the other child is NQ or non-federally qualified. The household is billed for the citizen child and for the NQ child.

How do clients pay their N13 (MAGI - CHIP Federal) and N33 (MAGI - CHIP State) premiums?

For more information on how clients pay their premiums, see Apple Health eligibility manual - WAC 182-505-0225 - Premium requirements for premium-based health care coverage under programs included in apple health for kids.

What is a "Locked-In" premium tier?

A "Locked-In" premium tier is the lowest tier level that a child active on N13 (MAGI - CHIP Federal) or N33 (MAGI - CHIP State) is eligible for during the child’s Continuous Eligibility tracking period.

EXAMPLE: A child is living with his mother, active on N13, and "Locked-in" to $20.00 Tier 1 monthly Premium. The child leaves mom's home to go live with dad and his two other children. Dad's income is over 250% Federal Poverty Level so the 2 kids living with him are "locked-in" to Tier 2 premiums of $30.00 each, for a household premium of $60.00. When the Tier 1 child is added to dad's household the household's total premium changes from $60.00 to $50.00, because the system uses the lowest "locked-in" premiums for the two premium cap.

What happens if the Children's Health Insurance (CHIP) premium is not paid?

If the CHIP premium is not paid for three consecutive months an interface from the Office of Financial Recovery (OFR) communicates this information to ACES. ACES terminates the N13 (MAGI - CHIP Federal) and N33 (MAGI - CHIP State) Assistance Unit (AU) for Reason Code 342 - Termination/Denial Due to Non-Payment of Premium.

The client has a "Locked-Out" period of 90 days starting the first of the month following the notice of adverse action. For more information on adverse action, see Adverse Action (10 day notice).

Online Processing

Where does premium tier information display?

Premium tier information displays in aces.online on the Premium Payment Status and Premium Amount - Children's Medical pages.

How do I remove a "Locked-In" premium tier?

To remove a "locked-in" premium tier, enter Reason Code 536 - Fail with no Tier Tracking in the Reasons field on the Assistance Unit Details page of the ongoing month to reset the "locked-in" tier level from 1 to 2.

How can I tell what a family's premium amount is?

The Premium Payment Status and Premium Amount - Children's Medical page is AUTO updated when an optional child, not exempt from premiums, is found eligible for N13 (MAGI - CHIP Federal) or N33 (MAGI - CHIP Premium) medical prior to ACES deadline.

Two days after ACES deadline, during the monthly issuance run, ACES sends an interface to Financial Services Administration (FSA) who begins billing for medical coverage received the following month. The Premium Payment Status and Premium Amount - Children's Medical page displays the household’s premium amount after FSA has successfully interface with ACES.

The amount of the premium is determined by the amount of income in the Net Income field in the Net Income section on the Eligibility Details page.

A household’s premium amount and any delinquent payment information can be viewed on the Premium Payment Status and Premium Amount - Children's Medical page.

The Premium Payment Status and Premium Amount - Children's Medical page is not benefit-month driven. The page displays the latest premium that the Head of Household must pay per month.

What happens if a premium is not paid?

If the N13 (MAGI - CHIP Federal) or N33 (MAGI - CHIP State) premiums are not paid for three consecutive months, the child is disenrolled from the program. The family must then pay all past-due premiums before the child can be re-enrolled.

When notification is received from Financial Services Administration (FSA) that a household has delinquent premiums, the following actions take place:

  • ACES reviews each active N13 (MAGI - CHIP Federal) or N33 (MAGI - CHIP State) Assistance Unit (AU) for Optional Children.
  • Each non-exempt optional child’s Financial Responsibility code on the Assistance Unit Details page is changed to Ineligible Child (IC) with Reason Code 342 - Termination/Denial Due to Non-Payment of Premium.
  • AUs without any mandatory or optional children close with Reason Code 342.
  • In ACES Mainframe a Sanction Reason field entry 200 - Delinquent Payment Amount on the SANC screen is added to each non-exempt optional child. The sanction Eff Start Dt is set to the ongoing benefit month. The sanction End Date on the Sanctions Summary page is set at 90 days.
  • The Premium Amount field on the Premium Amount - Children's Medical page is changed to zero and the Premium Effective Date lists the current date.
  • The Delinquent Amount field on the Premium Amount - Children's Medical page and Notification Date field is updated from the FSA interface.

What happens when a delinquent payment is received late?

When notification is received from the Financial Services Administration (FSA) interface that a delinquent premium amount has been paid in full, the following automated process occurs for all N13 (MAGI - CHIP Federal) and N33 (MAGI - CHIP State) Assistance Units (AUs):

  • The Delinquent Amount field on the Premium Amount - Children's Medical page is updated to zero.
  • The Notification Full Payment Received Date field on the Premium Amount - Children's Medical page is updated with information received from FSA.
  • A Narrative entry is AUTO added to the Head of Household indicating the premium payment has been paid in full with the date payment was received.
  • When the AU is re-opened or reinstated, the Sanctions page data is kept or deleted depending on the receipt timeframe of the delinquent payment.
  • There are two valid reasons to enter a sanction exemption code on the SANC screen in ACES Mainframe: continuous medical eligibility pending a fair hearing or department error.
  • For all active AUs, recalculation of eligibility re-determines the household premium amount for the next premium interface with FSA.

Mainframe Processing

Where does premium tier Information display?

Premium tier information displays in the OP field on the STAT and ELIG screens, and on the CTCN screen in the Prem Tier Level field.

How do I remove a "Locked-In" premium tier?

To remove a "locked-in" premium tier enter, Reason Code 536 - Error Initial Eligibility - Removed Locked-in 'Premium Tier' in the AU Status Reasons field on the STAT screen of the ongoing month to reset the "locked-in" tier level from 1 to 2.

How can I tell what a family’s premium amount is?

The PREM screen is AUTO updated when an optional child, not exempt from premiums, is found eligible for N13 (MAGI - CHIP Federal) or N33 (MAGI - CHIP Premium) medical prior to ACES deadline.

Two days after ACES deadline, during the monthly issuance run, ACES sends an interface to Financial Services Administration (FSA) who begins billing for medical coverage received the following month. After FSA has successfully interfaced with ACES, the PREM screen displays the household’s premium amount.

The amount of the premium is determined by the amount of income in the Net Income field on the MAFI screen.

A household’s premium amount and any delinquent payment information can be viewed on the PREM screen. You can also find the PREM information by selecting <F20> from the MAFI screen.

The PREM screen is not benefit-month driven. The PREM screen displays the latest premium that the Head of Household must pay per month. Historical data can be viewed by using the As Of Date field on the AMEN screen, Option B - AU/Client Inquiry.

What happens if a premium is not paid?

If the N13 (MAGI - CHIP Federal) or N33 (MAGI - CHIP State) premiums are not paid for three consecutive months, the child is disenrolled from the program. The family must then pay all past due premiums before the child can be re-enrolled.

When notification is received from Financial Services Administration (FSA) that a household has delinquent premiums, the following actions take place:

  • ACES reviews each active N13 (MAGI - CHIP Federal) or N33 (MAGI - CHIP State) Assistance Unit (AU) for Optional Children.
  • Each non-exempt optional child’s Finl Resp code on the STAT screen is changed to [IC] - Ineligible Child with Reason Code 342 - Termination/Denial Due to Non-Payment of Premium.
  • AUs without any mandatory or optional children close with Reason Code 342.
  • A Sanction Reason field entry 200 - Delinquent Payment Amount on the SANC screen is added to each non-exempt optional child. The sanction Eff Start Dt is set to the ongoing benefit month. The sanction End Dt is set at 90 days.
  • The Premium Amount field on the PREM screen is changed to zero and the Premium Effective Date lists the current date.
  • The Delinquent Amount field on the PREM screen and Notification Date field is updated from the FSA interface.

What happens when a delinquent payment is received late?

When notification is received from the Financial Services Administration (FSA) interface that a delinquent premium amount has been paid in full, the following automated process occurs for all N13 (MAGI - CHIP Federal) and N33 (MAGI - CHIP State) Assistance Units (AUs):

  • The Delinquent Amount field on the PREM screen is updated to zero.
  • The Full Payment Received Date field on the PREM screen is updated with information received from FSA.
  • A Narrative entry is AUTO added to the Head of Household indicating the premium payment has been paid in full with the date payment was received. The entry appears in “pink” when displayed on the NARR screen.
  • When the AU is re-opened or reinstated, the SANC screen data is kept or deleted depending on the receipt timeframe of the delinquent payment.
  • There are two valid reasons to enter a sanction exemption code on the SANC screen: continuous medical eligibility pending a fair hearing or department error.
  • For all active AUs, recalculation of eligibility re-determines the household premium amount for the next premium interface with FSA.

HEALTHCARE FOR WORKERS WITH DISABILITIES – HWD (S08)

How are S08 (Healthcare for Workers with Disabilities) premiums calculated?

For information on how S08 premiums are calculated, see Apple Health eligibility manual - WAC 182-511-1250 Healthcare for workers with disabilities (HWD) - Premium payments.

How do clients pay their S08 (Healthcare for Workers with Disabilities) premiums?

S08 premiums are paid directly to the Office of Financial Recovery (OFR). For more information, see Apple Health eligibility manual - WAC 182-511-1250 Healthcare for workers with disabilities (HWD) - Premium payments - Worker Responsibilities.

What happens if the S08 (Healthcare for Workers with Disabilities) premium is not paid?

If the premium is not paid for four consecutive months an interface from the Office of Financial Recovery communicates this information to ACES.

ACES generates Alert 235 - PREMIUM PAYMENT 120 DAYS OVERDUE. When this alert is received, the worker closes the S08 Assistance Unit and determines eligibility for other medical programs.

If a client does not pay four consecutive monthly premiums, that person is not eligible for S08 coverage for the next four months, and must pay all premium amounts owed before S08 coverage can be approved again.

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.