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

Effective Date:

33 Approval Date:

** Minimum monthly income corresponds to 150% (for 150% - 160%), 160% (for 160% - 170%), 170% (for 170% - 185%) and 185% (for 185% - 200%) of 2004 FPL

***The premiums as a % of minimum income will change (lower) when we adjust for the annual FPL increase.

8.6 Describe the procedures the state will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42CFR 457.535)

As noted in Section 4.4.5, any eligible child who is American Indian or Alaskan Native is enrolled in MaineCare under Title XIX or Title XXI and treated as any other eligible child, with the exception that the child is not required to pay a premium or other cost sharing. On the application form, there is a specific question that asks applicants whether they are American Indian or Alaskan Native and informs them that American Indians and Alaskan Native don’t have to pay premiums. If an applicant checks this box and is enrolled in MaineCare, the Department does not generate premium coupons for the member.

8.7 Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c))

Premiums must be paid at the beginning of each month for coverage for that month. When a premium is not paid at the beginning of a month, DHS shall give notice of nonpayment at that time. At the beginning of the 12th month of the 12 month enrollment period, notification will be given if any premiums for the enrollment period have not been paid when due.

There is a grace period for non-payment of premiums. For the first through 11th month of the 12 month enrollment period, the grace period extends through the last day of the 12 month enrollment period. The grace period for payment of the premium due in the 12th month is the 15th of the next month.

There is a month of ineligibility for each month a premium was due, coverage was received, and a premium was not paid. The maximum period of ineligibility is 3 months. The penalty starts in the first month following the end of the enrollment period in which the premium was due. For example, if no premiums are paid for the 12 month enrollment period of January 2002 – December 2002, the child is not eligible for coverage for the months of January – March 2003.

8.7.1 Please provide an assurance that the following disenrollment