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

Effective Date:

2 Approval Date:

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. MaineCare is the umbrella term in use in the State of Maine to collectively refer to all benefits provided under previously separate program names such as Medicaid, SCHIP, CubCare, etc.. The name change (a Legislative mandate) is administrative in nature and represents no change in benefits or rights of beneficiaries.

MaineCare, with Title XIX funding, provides coverage to children from birth to 12 months of age in families with income through 185% of the federal poverty level (FPL), children ages 1 through 5 in families with income through 133% FPL, and children ages 6 through 18 in families with income through 125% FPL. With Title XXI funding, (under MaineCare expansion), MaineCare provides coverage to children ages 1 through 18 in families with income from 133%/125% through 150% of the FPL; and under a separate child health program (formerly “CubCare”) provides coverage to children from birth to 12 months of age in families with income from 186% through 200% of the FPL, and to children ages 1 through 18 in families with income from 151% through 200% of FPL.

1.2

Please provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

1.3

Please provide an assurance that the state complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR