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

Effective Date:

Approval Date: 5 Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101) 1.1 The state will use funds provided under Title XXI primarily for (Check appropriate box) (42 CFR 457.70):

1.1.1

Obtaining coverage that meets the requirements for a separate child health program (Section 2103); OR

1.1.2.

Providing expanded benefits under the State‟s Medicaid plan (Title XIX); OR

1.1.3.

A combination of both of the above.

1.1-DS

The State will provide dental-only coverage. Only States operating a separate SCHIP program are eligible for this option. States choosing this option must also complete sections 1.4-DS, 4.1-DS, 4.2-DS, 4.3.1, 6.2–DS, 8.2-DS, and 9.10.1-DS of this SPA template.

Medicaid Expansion (M-CHIP) Effective July 1, 1998 Children ages 15 through 18 in families with income between 37 percent and 100 percent of Federal Poverty Level (FPL). These are the "Waxman" children that are being phased-in to Medicaid as a mandatory coverage group. Beginning October 1, 2002, all of these children will be covered under Medicaid. Children ages 6 through 18 in families with income that is equal to or less than 133 percent of FPL.

Effective July 1, 2000 Infants, up to one year of age, in families with income between 185 percent and 200 percent of FPL.

Effective July 1, 2009 When determining eligibility for infants, up to one year of age, all income between 185 percent and 300 percent of FPL shall be disregarded.

The State has implemented systems changes that allow for identification of children eligible for Medicaid via CHIP so they can be reported separately from children eligible for Medicaid via the 1902(r)(2) Medicaid State Plan