Page 38

AIM, like the Healthy Families purchasing pool, operates in a managed care environment. The utilization controls used in the program are like those discussed in the above section on the purchasing pool. Section 4. Eligibility Standards and Methodology. (Section 2102(b)) Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 5. 4.1. The following standards may be used to determine eligibility of targeted low- income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102)(b)(1)(A)) (42CFR 457.305(a) and 457.320(a)) 4.1.1. Geographic area served by the Plan: The S-CHIP plan is available statewide. The C-CHIP is available in Santa Clara, Alameda, San Francisco and San Mateo counties. 4.1.2. Age: a) From confirmed pregnancy to birth. b) From 0 through age 1 enrolled in the AIM Program if they are born to mothers enrolled in AIM before July 1, 2004 c) From 0 through age 19. 4.1.3. Income: a) For eligibles from confirmed pregnancy through birth, 0- 300% FPL (using an income disregard). b) For eligibles from 0 through age 1 (enrolled in the AIM Program if they are born to mothers disenrolled in AIM before July 1, 2004), 200-300% FPL (using an income

disregard). c) For eligibles from 0 through age 2 (if born to a mother enrolled in the AIM Program on or after July 1, 2004), 200-300% FPL (using an income disregard). d) For eligibles from 0 through age 19, 100-250% FPL (using an income disregard) e) Presumptive eligibility is only available to eligibles from 100-200% FPL who receive health a screen or immunization from a CHDP provider Effective Date: Approval Date: November 1, 2009 HFP Family Contribution Increase November 1, 2009 HFP Co-Payment Increase November 1, 2009 HFP Limited Dental Plan Choice for New Subscribers

38