210.09 Premium Requirements SR 02-04, 02/02 (AAM-A)

Some MEAD-eligible individuals may be required to pay a premium based on their income.

Payment of Premiums

No premium payment is required for individuals whose net income is less than 150% of the Federal Poverty Level Guidelines (FPL). Individuals whose net income is equal to or greater than 150% and less than or equal to 450% of the Federal Poverty Level Guidelines are required to pay a premium based on a sliding scale. Payment of premiums is processed through New Hampshire Healthy Kids Corporation (NHHKC).

The method of determining the amount of premium payments differs from the net income computation in that SSI payments are counted when determining the premium amount, but are excluded when determining MEAD eligibility.

Participants with net income of at least 150% of the FPL and less than or equal to 450% of the FPL must pay premium that does not exceed 7.5% of the appropriate lower income range of the FPL. Refer to the chart below.

Income Ranges by Percentage of FPL

Exception: For individuals with annual adjusted gross income over $75,000, the premium is equal to 7.5% of the participant’s and their spouse’s net income, including any SSI payments that the individual and spouse receive.

The amount of any health insurance premium payments, including Medicare premiums, paid by a participant for the participant or the participant’s spouse or dependent children, are deducted from the participant’s MEAD premium.

Premium Payment Schedules

Premiums due dates are noted below.

• The first premium payment will be applied to the 2nd calendar month of MEAD coverage and is due on the last day of the month following the month in which eligibility is determined. Premiums for retroactive periods are due at the same time that the first premium payment is due.

EXAMPLE 1 - No Retroactive Coverage Requested

The applicant applies for MEAD in February and is determined eligible in March. There is no premium due for February. The premiums for March and April are due on April 30th.

EXAMPLE 2 - Retroactive Coverage Requested

The applicant applies for MEAD on June 1st and requests retroactive coverage for March, April and May. Eligibility is determined in August. There is no premium due for June. The premium for the 3 retroactive periods and the payment for July, August, and September are due September 30th.

• Subsequent payments are due on the last day of the month and applied to the current month.

• No payment is due for the last partial month of coverage for the 12 month period of unemployment.

Non-Payment of Premiums and Good Cause

• Non-payment of premiums for 2 consecutive months without good cause, as determined by NHHKC, will result in termination of MEAD.

• If good cause does not exist, NHHKC will notify the MEAD liaison at New HEIGHTS that the case should be closed for non-payment of the premium. The MEAD liaison will close the case and notify the Case Technician of the closing action.

• A participant may be reinstated for MEAD following termination for non-payment of premiums during the advance notice period, or as a result of a fair hearing when:

- the participant furnishes proof of payment in full for the past due premiums or proof a payment plan for past due premiums; or

- it has been redetermined by NHHKC staff that there is good cause for non-payment and the participant has exhausted all available resources with which to pay past due premiums.

• Good cause for non-payment of premiums exists when the participant has exhausted all available resources with which to pay their premium or cover their unexpected out-of-pocket medical expenses, and that at least one of the following criteria is met:

- the participant experiences a temporary or unexpected loss of income which prevents payment of the premium; or

- the participant incurs an unexpected out-of-pocket medical expense that prevents payment of the premium.

Requests for Fair Hearings for Termination Due to Nonpayment of Premium

Requests for fair hearings on the basis of closing due to nonpayment of premiums require special procedures.

• Upon receiving such a request, notify NHHKC so that a pre-hearing conference can be arranged between their representative and the client.

• If the issue cannot be resolved, notify NHHKC of the date and time of the hearing.

• NHHKC will represent the agency at the hearing.