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

Effective Date:

Approval Date: 14 Section 4. Eligibility Standards and Methodology. (Section 2102(b))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 5.

4.1. The following standards may be used to determine eligibility of targeted low- income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102)(b)(1)(A)) (42CFR 457.305(a) and 457.320(a))

4.1.1.

Geographic area served by the Plan: entire state of North Carolina 4.1.2.

Age: Six to the 19th birthday 4.1.3.

Income • At or below 200% of the federal poverty level (FPL) • Methodologies for determining family income will be the same as for Title XIX • Allow deduction for child care and standard work expense consistent with Title XIX poverty level group. • A family must present pay stubs of all working household members for one month prior to enrollment. A small business owner must present business income proofs acceptable to the Medicaid program • Family size is determined by counting all children in the home in the needs unit of the children applying for SCHIP, including those children receiving Medicaid. 4.1.4. Resources (including any standards relating to spend downs and disposition of resources 4.1.5.

Residency (so long as residency requirement is not based on length of time in state): Resident of North Carolina 4.1.6.

Disability Status (so long as any standard relating to disability status does not restrict eligibility): 4.1.7.

Access to or coverage under other health coverage: Uninsured means the applicant is, and was not covered under, any private or employer-sponsored creditable health insurance plan on the date of enrollment into the program, and is ineligible for Medicaid, Medicare or other federal government sponsored insurance. The child must be in a family that meets the following family income requirements: at or below 200% of the federal poverty level and above current NC Title XIX levels (6-18—100%). This will be