PM 06-08-02-a: Nonfinancial Eligibility Requirements

WAG 06-08-02-a

Nonfinancial eligibility factors for All Kids Share and Premium are the same as for Assist, except for the additional requirements listed below.

A person cannot be eligible for Moms & Babies or Assist, including met spenddown.
A person cannot be a patient in an institution for mental disease, even if the person is in a Medicaid-covered setting.
For All Kids Premium Level 2, a child cannot have other health insurance unless the child lost medical benefits under All Kids Assist, Share or Premium Level 1 in the 12 months prior to the month of application for All Kids.
For All Kids Premium Level 2, for a child whose health insurance ended, the coverage must have ended at least 90 days prior to the first date of Premium Level 2 coverage unless they meet one of the following criteria:
- The child is a newborn under age 1 who does not have private or employer-sponsored insurance coverage;
- The child lost medical benefits under All Kids Assist, Share, Premium Level 1, or the Health Insurance Marketplace;
- The premium paid by the family for coverage of the child under the group health plan exceeded 5% of household income;
- The child's parent is determined eligible for advance payment of a premium tax credit for enrollment in a Qualified Health Plan through the Marketplace because the employer sponsored insurance in which the family was enrolled is determined unaffordable;
- The cost of family coverage that includes the child exceeds 9.5% of the household income;
- The child lost coverage because the employer that had sponsored the coverage stopped offering coverage of dependents;
- A change in the parent's employment, including involuntary separation, resulted in the child's loss of employer-sponsored insurance (other than through full payment of the premium by the parent under COBRA);
- The child has special health care needs; or
- The child lost insurance due to the parent's death or because the noncustodial parent canceled the insurance as part of a divorce.

Related Terms and Definitions

Term	Definition
Health Insurance	Coverage that includes both hospital and physician services. Most HMO health insurance policies meet this definition. Disease specific policies (such as cancer insurance), medical service specific policies (such as dental, vision, or hospital only policies) and accident policies (such as school-based insurance for grades K-12) are not considered health insurance for this requirement
Child with Special Health Care Need	The child is pregnant, or has a serious illness or chronic physical, developmental, behavioral or emotional condition. Serious illness is a condition that if not treated may result in death, disability, disfigurement, or dysfunction. Chronic illness is a medical condition that requires frequent and ongoing treatment and that if not properly treated will seriously affect the person's overall health.

Term

Definition

Health Insurance

Coverage that includes both hospital and physician services. Most HMO health insurance policies meet this definition. Disease specific policies (such as cancer insurance), medical service specific policies (such as dental, vision, or hospital only policies) and accident policies (such as school-based insurance for grades K-12) are not considered health insurance for this requirement

Child with Special Health Care Need

The child is pregnant, or has a serious illness or chronic physical, developmental, behavioral or emotional condition.

Serious illness is a condition that if not treated may result in death, disability, disfigurement, or dysfunction.

Chronic illness is a medical condition that requires frequent and ongoing treatment and that if not properly treated will seriously affect the person's overall health.

Note: A person is not eligible for All Kids Share or Premium if the person previously received Rebate and has an outstanding overpayment (see PM 06-08-12).