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

Effective Date:

Approval Date: 29

exceeded 5% of the family‟s gross income. Cost of the health care coverage for the child shall be the difference between the premium for coverage with and without the child. 4. The health care coverage was provided through an individual plan. 5. The child‟s health care coverage was lost due to: a. Domestic violence b. Divorce or death of a parent c. An involuntary loss of the parent‟s employment, including, but not limited to layoff, business closure, reduction in hours, termination, etc. d. A change in the parent‟s employer to one who does not offer dependent coverage or requires a waiting period longer than 30 days before the child can be enrolled. e. The child reached the maximum lifetime coverage benefit. f. Expiration of coverage under COBRA. g. The parent‟s employer discontinuing the availability of dependent coverage. h. A reason beyond the control of the parent such as serious illness of the parent, natural disaster, fire, flood, etc.

4.4.4.4. If the state provides coverage under a premium assistance program, describe: The minimum period without coverage under a group health plan, including any allowable exceptions to the waiting period. The minimum employer contribution. The cost-effectiveness determination.

4.4.5 Child health assistance is provided to targeted low-income children in the state who are American Indian and Alaska Native. (Section 2102)(b)(3)(D)) (42 CFR 457.125(a))

American Indian and Alaska Native Children are eligible for the hawk-i program on the same basis as any other children in the State, regardless of whether or not they may be eligible for or served by Indian Health Services-funded care. No premiums or other cost sharing apply to American Indian or Alaska Native children.