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

Effective Date:

October 1, 2009 61 Approval Date: November 19, 2010 *

Section 12. Applicant and enrollee protections (Sections 2101(a))  Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan.

Eligibility and Enrollment Matters

12.1 Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120. Alabama’s appeals process meets the requirements of the Program Specific Review as outlined in CFR.457.1120 – 457.1180. The ALL Kids appeals and grievance process can be found in Attachment D. The individuals involved in the Information review (first level) are not involved in the Administrative Review (second level) thus impartiality in the appeals process is provided. The individuals who conduct the Administrative Review are not involved in the Information Review process not in the original determination process.

Health Services Matters

12.2 Please describe the review process for health services matters that complies with 42 CFR 457.1120. The State assures that the State laws or regulations are consistent with the intent of 42 CFR 457,1130(b). This grievance process for health service matters is provided by the insurance vendor and is in compliance with state laws, the Employee Retirement Income Security Act of 1974 (ERISA), and all other applicable regulations of the Department of Labor Procedures. The Blue Cross Blue Shield of Alabama appeals process can be found in Attachment E.

Premium Assistance Programs

12.3 If providing coverage through a group health plan that does not meet the requirements of 42 CFR 457.1120, please describe how the state will assure that applicants and enrollees have the option to obtain health benefits coverage other than through the group health plan at initial enrollment and at each redetermination of eligibility.

* While the effective date for sections 1-10 of this plan is October 1, 2002, the effective date for this section is August 24, 2001