A family may continue to request prior coverage after a case is approved by contacting the HFS All Kids Unit, and completing and returning the Request for Prior Coverage (Form 243KC).
(All Kids Unit) Sends Form 243KC to the client, authorizes prior coverage (use TA 31/TAR 99 until IES Phase 2 is implemented) and sends the family Request for Prior Coverage, Notice of Decision (Form 243KCA) to inform them of the prior coverage eligibility decision.
NOTE: A medical card is not issued for the prior coverage period.
(All Kids Unit or FCRC) After IES Phase 2 implementation, IES will determine eligibility for prior coverage when a child is certified for All Kids Share or Premium Level 1 and the applicant requested at least one month medical backdate coverage on the application for that child.
Example 1: The Z family applies for the first time on 11/12/16 and did not request medical backdate. Eligibility for All Kids Share is authorized effective 01/17. If the family later requests prior coverage timely, it will be authorized for 10/29/16 through 12/31/16.
Example 2: The Y family received All Kids Premium Level 1. They did not request prior coverage at application or within 6 months of the date their coverage began.
Their case was canceled due to nonpayment of their premiums. They reapply and are again eligible for All Kids Premium Level 1. They cannot receive prior coverage, since they received All Kids Share or Premium before.
Example 3: The T family applied on 02/13/16 for their 2 children, Alice and Andy, and were determined eligible effective 04/16. On 05/20/16, Mrs. T had a baby, Barbara, whom she wants added to the case.
Whether or not the other children previously received prior coverage, they can receive prior coverage for Barbara within 6 months of the time Barbara's coverage began, since Barbara has not received All Kids Share or Premium before.
Example 4: The Z family applies for the first time on 11/12/16 and requests medical backdate. Eligibility for All Kids Share is authorized effective 01/17. Prior coverage will be authorized for 10/29/16 through 12/31/16.
Related IES Screen Change (Phase 2)
Prior coverage can be authorized only at initial application or within 6 months of certification the first time a child receives Share or Premium coverage. For this reason the question: "Has the individual received Share or Premium previously?" is being added to the Individual page in Data Collection for Phase 2. A response to this question will be mandatory for children.
A 'Yes' response to the above question will in turn require a response to the nest question on this page: "Has the individual received CHIP Prior Coverage?" The reason for this question is that if there is a break in All Kids Share or Premium coverage after a family has received prior coverage, and the family is later eligible for All Kids Premium, the family must pay their first month's premium before receiving All Kids Premium coverage again.
- NOTE: Since IES will only pick up inactive cases that have been canceled in the 6 months prior to conversion, the worker must review the MMIS screen (PF8 in IPACS/BlueZone) to answer these questions correctly.
- In MMIS, All Kids Share or Premium benefits are identified by SHR, PR1 or PR2 under the 'MANG P' column. Prior coverage is identified by a MANG P code of 4 or 4B.
Prior Coverage or Spenddown?
Approve spenddown coverage for a child who has medical expenses that would meet spenddown before the prior coverage start date. Until IES is programmed to consider spenddown before prior coverage, send HFS 2958-Request for Correction/Addition to MMIS Eligibility File to the Exception Processing Unit (EPU).
Example 5: On December 14th Mr. Big applies for medical benefits for his 10 year old daughter, Joy, and requests one month backdated coverage. His monthly income is $2,000 and Joy's EDG size is 2. On December 30th she is determined eligible for All Kids Share effective February. IES determines that she qualifies for prior coverage from Nov 30th through Jan 31st.
Since medical expenses were submitted, determine whether spenddown would have been met prior to the prior coverage start date.
|Spenddown Standard for EDG size =2
|Medical Expense incurred 11/20
Since the medical expense would have met spenddown on November 20th, before the prior coverage start date, complete Form 2958 to provide spenddown met coverage from Nov 20th through Nov 30th. Update the prior coverage eligibility period to Dec 1st through Jan 31st.