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9. The calculator will yield the appropriate result

10.Apply the results to the CHIP case

11.Make a Note on the Head of Household Page Tab > Communications sub-tab > Notes folder explaining:

a. The CHIP Affordability calculator was used and if the participant has access to affordable insurance

b. Copy the CHIP Affordability calculator and paste into Notes on the Head of Household Page

c. Save results of the CHIP Affordability Calculator to PDF and upload to the ECM - click on Save Results in PDF File to create a PDF file.

i. Upload to the ECM using your local office procedure.

Affordability Calculator for CHIP x

CHIP-

Pleuse Enter DCN for the Participant Select County of Residence for the Participant

Select Individual or Couples ~ Individual © Couples

Select Numberof Children - Select Income Rangc for Houschold

Seem © (CHIP73) 150% — 185% of FPL...affordablity standard = $82

a Tar cme © (CHIP74) 186% - 225% of FPL...affordabilty standard = $134

“czany Tixeror aces eee @ (CHIP75) 226% - 300% of FPL...affordatitty standard = $204

Select Age of the Adult(s) in the Household

40 to 49 years 21 to 29 years

30 to 39 years @ 50 years or greater

county Sele Region Sele : 64109 — KO Metro Children in household : One Child

Age of the adult(s) in the household : 50 years or greater Affordability Standard + $204.00

FFM Gold Standard $3,218.53

Affordable insurance is not available