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

Effective Date:

October 1, 2009 21 Approval Date: November 19, 2010 prior to the end of the year’s enrollment will have coverage through the end of the month of birth.

Children must have their eligibility redetermined each year. If more than one insurance vendor is available to an applicant, an individual will be “locked in” to the plan s/he chooses for enrollment (after the first month of enrollment) for a period of one year. Exceptions will be made for those children whose parent(s)/guardians(s) move from one provider region to another or if provider networks change significantly.

If an individual is pregnant at the time of annual renewal, her eligibility extends to 60 days post-partum unless she is or will the renewal process is initiated and eligibility is re-determined.

4.1.9. X Other standards (identify and describe): The only other eligibility disqualification is being the dependent of an employee whose children are eligible for state health benefits coverage under a state health benefits plan on the basis of a family member’s employment with a public agency in the state. This disqualification includes children of state employees, children of K-12 public school employees, children of all community colleges, trade and technical schools, and one four-year college (Jacksonville State).

Social Security number is requested of all individuals listed on the application. Non-applicants are not required to supply social security numbers. Social Security numbers are required for all applicant children. If the parent/guardian refuses or is unable to supply a Social Security number for an applicant child and citizenship can be otherwise established, a pseudo-Social Security number is given to the child. Parents are offered assistance in obtaining Social Security numbers as necessary.

4.2. The state assures that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102)(b)(1)(B)) (42CFR 457.320(b))

4.2.1. X These standards do not discriminate on the basis of diagnosis. 4.2.2. X Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. 4.2.3. X These standards do not deny eligibility based on a child having a pre- existing medical condition.