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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 13

The following is paraphrased from Arkansas Medical Services Policy Manual Policy Directive Number MS 00-8 dated August 4, 2000:

A. If the applicant selects “ARKids A”, “either”, or makes no selection, then eligibility will be pursued for ARKids A (regular Medicaid); if the applicant is not eligible for ARKids A, the applicant’s eligibility will be determined for ARKids B (the 1115 demonstration).

B. If the applicant selects “ARKids A only” and the children are eligible for ARKids A, then the children will be certified as ARKids A.

However if the applicant selects “ARKids A only” and the children are not eligible for ARKids A but they are eligible for ARKids B, the caseworker will take the following steps:

1. Attempt to contact the applicant immediately by phone. Inform the applicant that the children are not eligible for ARKids A but are eligible for ARKids B and ask if he or she would like to receive ARKids B. 2. If the caseworker cannot reach the applicant by phone, a form letter will be mailed giving the applicant 15 days to respond if he/she wants to receive ARKids B for the children. 3. Dispose of the application upon receipt of the information from the applicant or after 15 days from the date the form letter was sent, whichever occurs earlier. 4. If the applicant declines ARKids B coverage or doesn’t respond within the 15 day notice period, the application will be denied.

C. If the applicant selects “ARKids B only,” the worker will determine eligibility for ARKids A and ARKids B. If the children are eligible for ARKids A, which would provide more coverage, the caseworker will take the following steps:

1. Attempt to call the applicant immediately. Inform the applicant that the children are eligible for ARKids A and that it provides more coverage than ARKids B. Ask the applicant to again specify which coverage he or she prefers the children to receive. If the applicant states that he or she does want ARKids A then the application will be certified for ARKids A. If the applicant refuses ARKids A, a notice will be sent stating that the children have been approved for ARKids B but are eligible for ARKids A. The notice will also inform the applicant that if he or she changes his or her mind within 30 days and would prefer to receive ARKids A, to contact the worker who can approve the children in ARKids A without a new application. 2. If the applicant cannot be reached by phone, a form letter will be sent