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Model Application Template for the State Children’s Health Insurance Program

Effective Date:

October 1, 2009 18 Approval Date: November 19, 2010 Before being approved for participation in the ALL Kids program, health plan vendors must develop and have in place utilization review policies and procedures, demand management, and disease state management mechanisms. Provider networks approved for the ALL Kids program are accepted based on evidence of the vendors’ provider credentialing policies, provider accessibility, cost-effectiveness, and efficiency.

Each ALL Kids PLUS authorizing state agency has a utilization review mechanism particular to that agency. Services approved for ALL Kids PLUS are those which are developmentally necessary and/or physically necessary. Reviewing the appropriate use of services is part of the case manager’s duties. Section 4. Eligibility Standards and Methodology. (Section 2102(b))

∼ Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 5.

4.1. The following standards may be used to determine eligibility of targeted low-income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102)(b)(1)(A)) (42CFR 457.305(a) and 457.320(a))

4.1.1. X Geographic area served by the Plan: Statewide 4.1.2. X Age: A child is eligible for ALL Kids if the date of birth on the application indicates that the child is less than 19 years of age. 4.1.3. X Income: Income eligibility is defined as above 133% of the Federal Poverty Level (FPL) for children less than six years of age and above 100% of FPL for those aged 6-18. It is the State’s intent to cover as many children as possible up to 300% of the FPL. If during the year State matching funds are not available at sufficient levels for coverage of all children to this income level and funding is depleted before the end of the fiscal year, it is the State’s intent to place eligible children on a waiting list until adequate funding becomes available to resume enrollment. Alabama will provide prior public notice and will notify CMS when placing applicants on a waiting list.

The definition of household size is the same as that for children under the Medicaid poverty level definition which includes the biological or adoptive parent(s) in the home, unborn children, and sibling children under 19. Income will be determined by totaling all earned and unearned income of family members included in the family size received on a monthly basis. Like Alabama Medicaid, certain income disregards will be considered under ALL Kids. Specific amounts will be deducted from gross monthly income when determining ALL Kids financial eligibility. The deductions used will be the standard Alabama Medicaid disregards which are: $90 for each wage earner, up to $50 child support received, up to $200 child care expenses for a child up to 24 months of age and up to $175 for child care expenses for a child 24 months of age and over (or incapacitated