5340          CHILDREN UNDER AGE 19

5340 A.      GENERAL ELIGIBILITY

A child may fall into one of two groups of children eligible for Denali KidCare depending upon the amount of household income and the presence of health insurance coverage.

An insured child under the age of 19 who meets the Family Medicaid nonfinancial eligibility criteria (except deprivation) is eligible for Denali KidCare if the household’s income does not exceed 150% of the federal poverty level for Alaska.  See Addendum - 1.

An uninsured child under the age of 19 who meets the Family Medicaid non-financial eligibility criteria (except deprivation) is eligible for Denali KidCare if the household’s income is greater than 150%, but does not exceed 175% of the federal poverty level for Alaska and

1. Is not currently covered by health insurance as described in paragraph C below; and

2. Did not have private or employer-sponsored health insurance coverage end less than 12 months before the determination of eligibility, unless the division determines there is good cause for ending coverage; see good cause under Section 5350.

A child who is in the custody of the State may also be determined eligible for Denali KidCare.

5340 B.      FINANCIAL ELIGIBILITY CRITERIA

Denali KidCare does not count resources.

To determine income eligibility, take into consideration the needs and income of the child and members of the child's household who are his or her parents and/or siblings.  If the income of a stepparent or sibling causes the household to exceed the income limit, the needs and income of the sibling and/or stepparent are removed and eligibility is redetermined.   Countable income is determined by following Family Medicaid rules except for income or disregards that may not be included in a Denali KidCare determination (see Section 5020).

Any siblings or stepparents removed from a household to avoid attributing their income to another sibling or stepchild must have their eligibility for Denali KidCare determined separately.

Example:  

The household consists of mom, mom's two children ages 10 and 19, mom's husband, and mom and husband's 6-year old common child.   Household applies for Denali KidCare for the 10 and 6-year-old children.  Mom, dad, and 19-year old all receive income and the initial determination shows their total income exceeds the poverty limit for a household size of five.  The following redeterminations may be made for the 6-year old and 10-year old:

(1) An eligibility determination is made for the 6-year old and 10-year old excluding the needs and income of the 19-year old and using the income of the child's parents.  If mom, husband, 6-year old and 10-year old combined income does not exceed the poverty level standard for a 4person family, the 6-year old and 10-year old is eligible.

(2) If no eligibility exists in example (1), a separate determination is made for the 10-year old excluding the needs and income of the 6-year old and 19-year old and using the income of the 10-year olds parent (see stepparent deeming rules in Section 5104-5).  If mom and 10-year olds combined income does not exceed the poverty level standard for a 2person family, the 10-year old is eligible.

A referral for Under 21 Medicaid should be made to the appropriate district office for an eligibility determination for the 19-year old.

5340 C.      HEALTH INSURANCE COVERAGE

To determine whether a child with household income greater than 150% FPG Federal Poverty Guidelines has health insurance coverage and, therefore, is not eligible for Denali KidCare, the following definitions apply:

1. Health insurance coverage includes:

• A group health plan (including a governmental or church plan);

• A group or individual health insurance;

• Medicare;

• Medicaid;

• A military-sponsored health care program such as TRICARE;

• A state high risk insurance pool;

• The Federal Employees Health Benefit Program;

• Public health plan established or maintained by a state or local government; and

• A health benefit plan provided for Peace Corps members.

A child is considered insured even if the health plan or coverage

requires a co-payment or deductible (regardless of amount) or does not cover a particular illness or procedure the child needs.

2. Health insurance coverage does NOT include:

• Coverage limited to a specific service (e.g. dental care or vision care);

• Tribal/IHS Indian Health Service health services;

• Worker’s Compensation;

• Auto, homeowner, or general liability insurance.

5340 D.      PERIOD OF ELIGIBILITY

Denali KidCare is available to children through the month in which they turn age 19.  The continuous 6-month eligibility period described in Section 5007 applies to all children eligible for Denali KidCare.  Coverage may extend three months before the month of application if eligibility exists during that period (see Section 5080).

EXCEPTION:  

If a child is receiving inpatient services at the end of the month in which the child turns 19, Denali KidCare eligibility continues until the end of the inpatient stay as long the child continues to meet the other eligibility criteria.   To be considered an inpatient, the child must be hospitalized or residing in a long-term care facility approved by the Division of Health Care Services.

5340 E.      EIS Eligibility Information System INFORMATION

Denali KidCare is essentially one eligibility category that encompasses existing Medicaid eligibility categories for children and adds additional children up through the highest income standard at 175% FPG.  However, because of complex federal financial claiming requirements and the unique Denali KidCare insurance limitations for children with income above 150% FPG, it is necessary to use the appropriate subtype for each individual depending upon age, income level, and insurance status.

The following matrix shows the subtypes EIS will assign depending on information that is entered about depending upon the age, income level, and insurance status of the child: