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

Effective Date:

Approval Date: 50

Date Action Length of Time September 21st Invoice for November is sent

October 5th November premium is due 13 days from when the original invoice is sent. October 6th Reminder notice is sent if November premium is not received by October 5th 14th day from when the original invoice is sent. October 21st Invoice for November and December premiums due is sent This is the second invoice for the November premium, which is 17 days after the premium due date. November 5th Notice of cancellation is sent for November premium and reminder notice sent for December premium if it is not received by November 5th. This notice is sent 30 days after the November premium is due. Coverage for November continues. November 8th Notice of cancellation for November 30th is sent if the November premium was not received. This is 33 days after the November due date. November 30th If the November premium has not been paid on or before November 30th, disenrollment occurs and there is no coverage beginning December 1st. This is 56 days after the November premium due date.

Initial Application: When an approval decision has been made on an initial application, the first premium due is for the third month of the twelve-month enrollment period. Example: A child is approved on October 15th with an effective date of November 1st. The first premium is due on December 5th for the month of January.

Renewal Application: When an approval decision has been made on a renewal application, the first premium due is the first month of the new twelve- month enrollment period. Example: The initial enrollment period ends November 30th. The renewal application is received in September and approved in September for a new enrollment period. The first premium due is October 5th for November (the first month of the enrollment period).

If a family reports a decrease in income and a premium is no longer required, premiums will no longer be charged beginning with the month following the