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

Effective Date:

October 1, 2009 32 Approval Date: November 19, 2010 6.1.3. ∼ Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) [Only applicable to New York; Florida; Pennsylvania] Please attach a description of the benefits package, administration, date of enactment. If existing comprehensive state-based coverage is modified, please provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of 8/5/97 or one of the benchmark plans. Describe the fiscal year 1996 state expenditures for existing comprehensive state-based coverage.

6.1.4. ∼ Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) 6.1.4.1.  Coverage the same as Medicaid State plan 6.1.4.2.  Comprehensive coverage for children under a Medicaid Section 1115 demonstration project 6.1.4.3.  Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population 6.1.4.4. X Coverage that includes benchmark coverage PLUS additional coverage In the second amendment to the Alabama CHIP State Plan, ALL Kids PLUS was established which provided additional benefits for children with special health care conditions/needs. Attachment D contains a detailed description of the ALL Kids PLUS component of CHIP. 6.1.4.5.  Coverage that is the same as defined by existing comprehensive state-based coverage 6.1.4.6.  Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7.  Other (Describe)

6.2.

The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490) A description of the scope, amount and duration of services covered under ALL Kids and ALL Kids PLUS, as well as any exclusions and limitations can be found in Attachments A and B, respectively. 6.2.1. X Inpatient services (Section 2110(a)(1)) 6.2.2. X Outpatient services (Section 2110(a)(2)) 6.2.3. X Physician services (Section 2110(a)(3))