Premium Calculation for Children with Disabilities 510-05-58-30

(Revised 5/1/2023 ML 3725)

Individuals eligible under the Children with Disabilities coverage are required to pay a monthly premium amount equal to 5% of the family’s gross countable income. Premiums are computed on a monthly basis and are rounded to the nearest dollar. Indians who are enrolled members of a Federally-recognized Indian tribe are exempt from this requirement.

Note: When there is more than one child in the Medicaid Unit covered under Children with Disabilities, the total premiums cannot exceed 5% of the family’s gross countable income.

Premiums are computed on a monthly basis and are rounded to the nearest dollar. Indians who are enrolled members of a Federally-recognized Indian tribe are exempt from this requirement.

The Children with Disabilities premium is offset by any premium amount the family pays toward a family health insurance policy in which the disabled child is covered.

Prior to authorizing initial eligibility for any month(s) prior to the future benefit month, the individual is required to pay any premiums due for those benefit months. Premium payments received by the county must be submitted to the department's Fiscal Administration unit using the Medicaid credit form, SFN 828. Premiums for future benefit months are due on the fifteenth day of the future month.

When re-budgeting an eligible month of Children with Disabilities coverage, and the individual remains eligible, a previously established premium is not changed unless it can be changed prospectively with a ten-day advance notice, or if the original premium notice has not been mailed.

Monthly premium notifications will be sent informing eligible individuals of any premium amount(s) due. The notice will include a self-addressed envelope for the individual to send the premium payment directly to the Fiscal Administration unit.

Any excess monies received by the Fiscal Administration unit will not be immediately refunded, but will be held as credit, and will be applied to future premiums due. When an individual becomes ineligible for Children with Disabilities coverage for a period of more than 30 days, Fiscal Administration will return any credit balance to the individual in the form of a refund.

If a premium payment by check is returned due to non-sufficient funds, the premium will be considered unpaid.

Any individual who fails to pay the premium established under this section for three consecutive months shall be disenrolled and may not be re-enrolled thereafter without first reestablishing eligibility under this section and paying all outstanding premiums. Any month in which no premium is due shall not be counted as a month in which the individual failed to pay a premium.

An individual who is under age 19 and is continuously eligible for Medicaid who fails to pay the premium for 3 consecutive months cannot be disenrolled prior to the end of their continuous eligibility period. They may not be reenrolled thereafter without first reestablishing eligibility under this section and paying all outstanding premiums.

Payments received by the Department from an individual claiming eligibility under this section shall be credited to the oldest unpaid premium. The Department shall credit payments on the day received, provided that credit for any payment made by an instrument that is not honored shall be reversed. The Department may require any individual who has attempted payment by a dishonored instrument to make subsequent payments in a specified manner.