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

Effective Date:

Approval Date: 22

status does not restrict eligibility): 4.1.7.

Access to or coverage under other health coverage: A child who is covered under other health insurance is not eligible for coverage under hawk-i unless the coverage is a single service coverage such as a dental only or vision only policy. Access to coverage is not considered if the child is not actually covered. 4.1.8.

Duration of eligibility: Eligibility for hawk-i is granted in 12-month enrollment periods. At the end of the 12 months, a review is completed to establish eligibility for the next 12-month enrollment period. 4.1.9.

Other standards (identify and describe): Pregnancy. During the 12-month enrollment cycle, if an adolescent enrolled in the hawk-i program becomes pregnant, information about the Medicaid program is provided to the pregnant adolescent or her family. However, the pregnant child is not automatically transferred to the Medicaid program. If the adolescent or her family applies for Medicaid and Medicaid eligibility is approved, hawk-i eligibility ends. If the child or her family do not apply for Medicaid, eligibility will continue under hawk-i until the next annual renewal. If, at the next annual renewal, the adolescent is still pregnant, the renewal is referred to Medicaid for a Medicaid eligibility determination. Inmates of nonmedical public institution. At the time of application or annual review of eligibility, the child shall not be an inmate of a nonmedical public institution as defined at 42 CFR Section 435.1009 as amended November 10, 1994. Inmates of institutions for mental disease. At the time of application or annual review of eligibility, the child shall not be an inmate of an institution for mental as defined at 42 CFR 435 Section 435.1009 as amended November 10, 1994.

4.1.10 __X___ Check if the State is electing the option under section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) to provide coverage to the following otherwise eligible and children as specified below who are lawfully residing in the United States including the following: A child shall be considered lawfully present if he or she is: (1) A qualified alien as defined in section 431 of PRWORA (8 U.S.C. §1641); (2) An alien in nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission;