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

Effective Date:

14 Approval Date: employee health insurance plan. There is a 3 month waiting period for children who drop employer based coverage. The child may enroll without having to wait 3 months if:

• The employer plan does not pay at least 50% of the cost of the child’s coverage; • The cost of covering the whole family under the employer’s plan is more than 10% of the family income; • The Department determines that good cause exists for dropping the employer based coverage.

In addition, eligibility records are matched against third party liability records to cross check to see if the third party liability records indicate that other insurance is available. A list of Title XXI funded members identified as having insurance is sent to Bureau of Family Independence eligibility specialists to review.

4.4.4.2. Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable.

4.4.4.3. Coverage provided to children in families above 250% FPL: describe how substitution is monitored and identify specific strategies in place to prevent substitution.

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))