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

Effective Date:

October 1, 2009 23 Approval Date: November 19, 2010 Shield of Alabama (current and in the past three months.)

Organization and Infrastructure Responsible for Making and Reviewing Eligibility Determinations The CHIP enrollment unit is responsible for making and reviewing eligibility determinations for ALL Kids. See Attachment C for a description of the CHIP enrollment unit. For ALL Kids PLUS, the Department will contract with the state agencies who serve CSHCN/C not only to supply the financial match but also to conduct ALL Kids PLUS enrollment procedures and to annually redetermine authorization for ALL Kids PLUS benefits the child is receiving.

Process for Enrollment The ALL Kids enrollment unit receives ALL Kids applications from numerous sources (families, hospitals, doctors’ offices, etc.). The enrollment unit staff review and input data from the application into an automated system which reviews the data for eligibility and, if appropriate, prompts the staff to enroll the child in the ALL Kids system. If an incomplete application is received, the staff contacts the family (by telephone and/or letter) in an attempt to obtain the necessary information. The enrollment unit sends enrollment notification to the insurance plan which the family/child has chosen. Once the enrollment transaction has been completed, the vendor supplies the family with enrollment materials including an insurance card, explanation of benefits, and information on locating providers. The enrollment unit also sends the family premium payment information as appropriate.

If the child is thought to be ineligible for ALL Kids due to possible eligibility for Medicaid or the Alabama Child Caring Foundation, the enrollment unit staff sends the application and/or automated data to the Alabama Medicaid Agency or Alabama Child Caring Foundation, as appropriate. Medicaid or the Alabama Child Caring Foundation assumes processing of the application following their usual rules and procedures. The CHIP enrollment unit notifies the family of its actions. This process works in the reverse if the application is processed initially

through Medicaid or the Alabama Child Caring Foundation. If the child is found to be ineligible for any other reason, the CHIP enrollment unit notifies the family.

ALL Kids PLUS enrollment procedures are conducted by each participating PLUS agency which serves or potentially serves the child. Enrollment procedures will consist of two elements - financial and health-need-based. When a child is referred to an authorizing agency, that agency determines whether or not funds are available to serve the child’s need. If funds are available and the child’s need(s) can be met by that agency, the child may be enrolled in ALL Kids PLUS through that agency and a case manager is assigned to the child. If the child needs services provided by another authorizing agency, the case manager makes a referral for enrollment with the second agency. The case manager may change depending upon the child’s needs.