Page 15

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

Effective Date:

Approval Date: September 19, 2002 15 for the child’s health care makes a written requested to terminate coverage.

4.1.9.

Other standards (identify and describe): At the time of application: a) the child is not a patient in an institution for mental diseases, or b) the child is not an inmate of a public institution. In addition, program eligibility is limited by amounts appropriated for KidCare Share and KidCare Premium. If the plan’s enrollment reaches levels that indicate that fiscal year costs for those currently enrolled are approaching the appropriation, the State will stop taking new applications. The State will again take applications once enrollment levels are reduced or funding becomes available. c) the Social Security number or proof of application for a Social Security number must be provided for applicants who are requesting coverage. Individuals on the application that are not requesting coverage are not required to provide Social Security numbers.

4.2. The state assures that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102)(b)(1)(B)) (42CFR 457.320(b))

4.2.1.

These standards do not discriminate on the basis of diagnosis. 4.2.2.

Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. 4.2.3.

These standards do not deny eligibility based on a child having a pre-existing medical condition.

4.3. Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2)) (42CFR 457.350)

A combined application is used for all KidCare plans as described in Section 2.1. Through a single application, children are reviewed for eligibility under all of the five plans and placed into the appropriate plan. If the review finds a child to be eligible under Title XIX, that child is enrolled in a Title XIX funded plan. Applications are reviewed by both local offices and a central processing unit. Face-to-face interviews are not required under any of the KidCare plans.

To determine eligibility for KidCare Share and KidCare Premium under Title XXI, the total gross income of the family is counted, less allowable deductions and exemptions as defined in the Title XIX State Plan. For