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

Effective Date:

Approval Date: 7 of state employees and children who meet the eligibility criteria for regular Medicaid, however these children are covered in the ARKids B program. The State will not use Title XXI funding for these children. D. Overview of Unborn Child

The Arkansas Department of Human Services administers the SCHIP unborn child program.

The essential elements of the program are:

• Medical verification of the pregnancy is required.

• Applicant must have no other insurance that covers the pregnancy.

• Net income must be at or below 200% FPL.

• The resource limit is the same as the resource limit for the SOBRA pregnant women category under Medicaid.

• The benefits will be the same as the SOBRA pregnant women category under Medicaid.

1.2

Please provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

The State assures that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS.

1.3

Please provide an assurance that the state complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

The state assures that it complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR