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

Effective Date:

Approval Date: 15 determined by the county Social Services case worker after all other eligibility criteria have been established. Enrollment in the plan will begin on the first day of the month following a verified date for end of coverage. Cases that qualify due to dropping private insurance will be electronically coded so the state may determine if the crowd out rate is impacted.

4.1.8

Duration of eligibility: 12 months 4.1.9.

Other standards (identify and describe):

• Eligible under federal law • Ineligible for coverage under Title XIX • Not an inmate in a public institution • If income over 150% FPL, have paid the enrollment fee (with the exception for members of federally recognized Native American tribes.) • Each recipient child shall provide a social security number. A non-recipient parent is not required to submit his own social security number in order for his children to be considered.

4.2. The state assures that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102)(b)(1)(B)) (42CFR 457.320(b))

4.2.1.

These standards do not discriminate on the basis of diagnosis. 4.2.2.

Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. 4.2.3.

These standards do not deny eligibility based on a child having a pre-existing medical condition.

4.3. Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2)) (42CFR 457.350)

Enrollment process:

Families may apply using mail-in applications that can be found at local health departments, and county DSS offices, and on special displays at a variety of locations including but not limited to grocery stores, pharmacies, and discount stores. Applications can also be found at the human resources (personnel) offices of major employers, through all federally funded programs, targeted outreach to public schools and day