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

Effective Date:

October 1, 2009 45 Approval Date: November 19, 2010 the family in locating assistance from premium payment. Non-payment of premiums is forgiven if the family provides proof of bankruptcy status during the enrollment period.

X In the instance mentioned above, that the state will facilitate enrolling the child in Medicaid or adjust the child’s cost-sharing category as appropriate. (42CFR 457.570(b)) At the time of renewal, if the family’s income has dropped but is still above the Medicaid eligibility level, if the decision is made to forgive the unpaid premium(s), the child is renewed and placed in the appropriate ALL Kids category. If a family’s income has dropped below the ALL Kids eligibility level, the application is automatically sent to Medicaid.

X The state provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42CFR 457.570(c)) This type of grievance is handled in the same impartial manner in which other grievances are handled as described in Attachment D.

8.8 The state assures that it has made the following findings with respect to the payment aspects of its plan: (Section 2103(e))

8.8.1. X No Federal funds will be used toward state matching requirements. (Section 2105(c)(4)) (42CFR 457.220) 8.8.2. X No cost-sharing (including premiums, deductibles, copays, coinsurance and all other types) will be used toward state matching requirements. (Section 2105(c)(5) (42CFR 457.224) (Previously 8.4.5) 8.8.3. X No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under the this title. (Section 2105(c)(6)(A)) (42CFR 457.626(a)(1)) 8.8.4. X Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)) (42CFR 457.622(b)(5)) 8.8.5. X No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. (Section 2105)(c)(7)(B)) (42CFR 457.475) 8.8.6. X No funds provided under this title will be used to pay for any abortion or to assist in the purchase, in whole or in part, for coverage that includes abortion (except as described above). (Section 2105)(c)(7)(A)) (42CFR 457.475)