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State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998 131 Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/05, 8/11/05, 10/1/06, 7/1/09, 7/1/10, 7/1/11, 7/1/12 Appendix A KidCare Medicaid Screening Criteria

Eligibility Levels • Children 0 up to age 1, 200% of the most recent Federal Poverty Level (FPL) • Children 1 up to age 6, 133% FPL • Children 6 up to age 19, 100% FPL Standard Filing Unit Policy • Intact Family a. Defined as a family where both the child's mother and father are living in the home. b.All income counted, including Social Security benefits (see “Income Disregards” for exceptions). c. Family size = mother + father + child(ren). d.Adoption is considered parentage. e. Siblings and their income may be excluded if it makes the child potentially Medicaid eligible. f. First, test all family members together at 100% FPL. g.Exclude mutual children from any deprived child’s filing unit. • Single Parent Households a. Defined as a family where only one parent is in the home. b. All income counted, including Social Security benefits - see Section III for exceptions. c. Family size = one parent + child(ren). d. First, test all family members together at 100% FPL. e. Siblings and their income may be excluded if it makes the child potentially Medicaid eligible.

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Page 132

Official source

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998 131 Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/05, 8/11/05, 10/1/06, 7/1/09, 7/1/10, 7/1/11, 7/1/12 Appendix A KidCare Medicaid Screening Criteria

Eligibility Levels • Children 0 up to age 1, 200% of the most recent Federal Poverty Level (FPL) • Children 1 up to age 6, 133% FPL • Children 6 up to age 19, 100% FPL Standard Filing Unit Policy • Intact Family a. Defined as a family where both the child's mother and father are living in the home. b.All income counted, including Social Security benefits (see “Income Disregards” for exceptions). c. Family size = mother + father + child(ren). d.Adoption is considered parentage. e. Siblings and their income may be excluded if it makes the child potentially Medicaid eligible. f. First, test all family members together at 100% FPL. g.Exclude mutual children from any deprived child’s filing unit. • Single Parent Households a. Defined as a family where only one parent is in the home. b. All income counted, including Social Security benefits - see Section III for exceptions. c. Family size = one parent + child(ren). d. First, test all family members together at 100% FPL. e. Siblings and their income may be excluded if it makes the child potentially Medicaid eligible.