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 is not currently covered by health insurance as described in paragraph C below.

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 excludes all resources.

Countable income is determined by following Family Medicaid rules, except that only a $90 work expense deduction is allowed against the earnings of each employed person.  The monthly earned income deduction of $150 + 33% is not allowed.

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, siblings, or other optional children.  If the income of a stepparent, sibling, or optional child causes the household to exceed the income limit, the needs and income of that individual are removed and eligibility is redetermined.  When this occurs, any removed child must also have his or her eligibility for Denali KidCare determined separately.

An unmarried couple may apply for their own and common children as a household.  Eligibility for each child is determined counting only their own parent(s) as financially responsible.  If, after all budgets are run in this manner, any child is left without medical coverage, then reconsider eligibility for that child, by including all household members.

Example 1:  

The household consists of mom and her husband, mom's two children ages 10 and 19, and mom and husband’s 6 year old common child.  The household applies for Denali KidCare for the 10 and 6 year old children.  Mom, her husband, and the 19 year old all receive income.

Step 1:  Determine eligibility for the 10 year old child counting the mom, only, as financially responsible (HH: 02).  If the income from mom does not exceed the poverty level income standard for a household size of two, the child is eligible. If the child is not eligible, see Step 3.

Step 2:  Determine eligibility for the 6 year old child.  Count the income of both parents and keep the 10 year old in the needs standard (HH: 04).  If the income of mom and her husband does not exceed the poverty level income standard for a household size of four, the child is eligible. If the child is not eligible, see Step 3.

Step 3:  If the 10 year old was not eligible in the 2 person household, reconsider his eligibility in the 4 person household which counts both mom and her husband as financially responsible.  If eligibility fails for both children in this budget, add the 19 year old into the needs standard to make a household of five.

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

Example 2:

The household consists of mom, dad, their two daughters, 19 year old Ashley and 17 year old Donna, and a two year old granddaughter, Kaitlyn (Ashley’s daughter).  Ashley is not eligible for DKC Denali KidCare because of her age.  Eligibility determinations for Donna and Kaitlyn are made as follows:

Step 1:  Determine Donna’s eligibility by including her parents as financially responsible, and Ashley and Kaitlyn as optional members to make a household of five.

Step 2:  Determine Kaitlyn’s eligibility by only including her needs and Ashley’s income as the financially responsible parent.  (Donna is not included in Kaitlyn’s eligibility determination because she cannot be included without including her own parents’ income.)  This eligibility determination will be for a household of two.

Note:  Ashley and her child Kaitlyn may be eligible for Family Medicaid.  The DKC Denali KidCare worker should inform her of this possibility and tell her she may apply for Family Medicaid at a local public assistance office.

Example 3:

The household consists of mom and her child Ben, her boyfriend and his child Tommy, and their common child Vanessa.  Eligibility determinations are made as follows:

Step 1:  Determine Ben’s eligibility by considering only his mom’s income and Ben’s needs (a two person household).

Step 2:  Determine Tommy’s eligibility by considering only his dad’s income and Tommy’s needs (a two person household).

Step 3:  Determine Vanessa’s eligibility by considering both parent’s income and Vanessa’s needs.  Vanessa’s siblings (Ben and Tommy) may have their needs and income included, but only if their inclusion does not prevent eligibility for Vanessa.

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 United States Department of Defense regionally managed health care program for active duty and retired members of the uniformed services, their families, and survivors ;

• 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 12-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 Federal Poverty Guidelines .  However, because of complex federal financial claiming requirements and the unique Denali KidCare insurance limitations for children with income above 150% FPG Federal Poverty Guidelines , 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 Eligibility Information System will assign depending on information that is entered about depending upon the age, income level, and insurance status of the child: