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

Effective Date:

Approval Date: 16 care centers (by calling the toll-free hotline published extensively by Title V and DMA), and in person at specially designated outstations. In addition, families may obtain applications at specified medical providers, including Federally Qualified Health Centers (FQHC), Rural Health Centers (RHC), migrant health centers, and Indian health centers. Certain State agencies with frequent public contact such as drivers license and vehicle tag sites also have mail-in application forms available.

Enrollment form:

A self-completed, simplified mail-in application form is used for families with children for both Title XIX and Title XXI. Forms are available in Spanish. These forms were developed through focus groups and tested for ease of readability. Assistance in filling out the forms is available through county DSS offices and at specially designated outstations (see above). Information and a mail-in application form are available and posted on the NC Health Choice site on the internet (http://www.dhhs.state.nc.us/dma/cpcont.htm).

Enrollment fee:

Before a child can be enrolled, a family enrollment fee of $50 for one child or $100 for two or more children shall be paid to the County DSS for those families whose income falls between 150% and 200% of the federal poverty level. Upon presentation of proof of membership in a federally recognized Native American tribe, this requirement shall be waived. These funds are kept by the county to help offset its administrative costs.

Eligibility Determination:

• NC Health Choice provides 12 months continuous eligibility without regard to changes in income. • County DSS determines eligibility for both Title XIX and Title XXI. • County DSS evaluates whether there is Title XIX eligibility, obtain income verifications, and request any additional information if necessary. If income is within Title XIX limits, the child will be enrolled in Medicaid. If over the Medicaid income limit but within 200% of FPL, the child will be enrolled in Health Choice. • Applications are processed within the standard for Title XIX applications (i.e. 45 days from the date of application.) • Counties will collect an enrollment fee when family income is at or above 150% of the federal poverty level unless the family when