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State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

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, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10, 7/1/11, 7/1/12 52

Self-Declaration Information included on a signed Florida KidCare application or renewal form or received through verbal or written correspondence is considered acceptable self-declaration of information for the following policy requirements.

Self-Declaration by the family is accepted for the following: 1. Residency – the family’s statement is accepted that they reside in Florida. Post Office boxes, rural routes and other non-conventional addresses are accepted, provided the address is in Florida.

2. Household size and composition – the family’s statement is accepted for the household size, composition and relationships.

3. Resident of an institution – the family’s statement is accepted that the child is not incarcerated, an inmate in a public institution or a patient in an institution for mental diseases.

4. Child is uninsured – the family’s statement is accepted that the child is not currently covered by other health insurance.

5. Child has not voluntarily cancelled other health insurance in last 60 days – the family’s statement is accepted that other health insurance was not cancelled within the last 60 days prior to the date of application.

6. If child cancelled other health insurance within the past 60 days - the family’s statement is accepted for claiming to meet one of the following good cause exceptions. Good cause exceptions to the 60 day wait are including, but not limited to, the following situations: a. The cost of participation in an employer-sponsored health benefit plan is greater than 5 percent of the family’s gross income; b. The parent lost a job that provided an employer-sponsored health benefit plan for children; c. The parent who had health benefits coverage for the child is deceased; d. The child has a medical condition that, without medical care, would cause serious disability, loss of function, or death; e. The employer of the parent canceled health benefits coverage for children;