516 Insurance Ended

Revised 01/15/2020

Policy

When a person chooses to end a child’s creditable health insurance coverage, the child cannot qualify for KidsCare for three months. The three months begins the day after the creditable coverage ends.

Exceptions:

The three-month period does not apply when:

The creditable coverage was from another insurance affordability program.
The premium to cover the child was more than 5% of the household income.
The child's parent is eligible for advance payment of the premium tax credit to enroll in a QHP because the coverage the family had through an employer is determined unaffordable.
The cost of family coverage that includes the child is more than 9.5% of the household income.
The employer stopped offering coverage of dependents (or any coverage).
The child lost coverage because of a family member’s job change.
The child has special health care needs.
The child lost coverage due to the death or divorce of a parent.

Definitions

Term	Definition
Creditable coverage	Health insurance coverage as defined under the Health Insurance Portability and Accountability Act (HIPAA). NOTE Eligibility for services through Indian Health Service (IHS) or a tribal organization is not considered creditable coverage. Examples of creditable coverage include: Medicare; Group health plans; Health insurance coverage through a hospital or medical service policy, certificate or plan contract; or Armed forces insurance, for example Tricare).
Insurance affordability program	AHCCCS Medical Assistance, Advance Premium Tax Credit (APTC) and Cost-Sharing Reductions (CSR)
Children with special health care needs	Children who have or are at risk for chronic physical, developmental, behavioral or emotional conditions that need health and related services of a type or amount beyond what children generally need.

Proof

When the customer provides a coverage end date, accept the statement as proof unless there is information or proof that contradicts the statement.

When there is a discrepancy, proof of coverage end date includes:

Phone call to the insurance company or agent, or the previous employer; or
Written statement or documents from the insurance company or employer.

Proof that a child meets an exception to the three-month period depends on the type of exception. See below for examples of proof for the different types of exceptions.

Exception type…	Proof includes…
Coverage was from another insurance affordability program, or qualified for APTC because employer-sponsored insurance was unaffordable.	Records from the Federally Facilitated Marketplace showing that the person was receiving APTC or CSR.
The child-only premium was more than 5% of household income, OR The family premium was more than 9.5% of household income.	Check stubs (for income amount as well as the cost of the insurance if deducted from the income) Phone call to the income source to confirm the amount Written statement from the income source confirming an income amount or premium amount Cancelled checks or other payment records that show the premium amount. Phone call to the insurance company, agent or employer to confirm the premium amount.
The employer stopped offering coverage, or the family member no longer works for the employer.	Written statement from the employer. Phone call to the employer confirming that coverage is no longer offered or the person is no longer employed. Unemployment Insurance records showing the person no longer works for the employer.
The child lost coverage due to the death or divorce of a parent.	Vital Statistics death records Other proof indicating a parent’s death (ex. an obituary from a newspaper) Divorce decree or other court document
The child has special health care needs.	Written or verbal statement from the parent, guardian or child.

Legal Authority

This requirement applies to the following program:

Program

Legal Authorities

KidsCare

42 CFR 457.805

ARS 36-2983

AAC R9-31-303(8)