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

Effective Date:

Approval Date: 17 declaring race has presented evidence (such as a Tribal Membership Card) that they are members of a federally recognized Native American tribe. If this has occurred, no enrollment fee is owed. • Because North Carolina State Employee dependents receive no subsidy from government sources and parents must pay full premium costs, children of state employees and teachers have been determined to be eligible for coverage under Title XXI.

Enrollment Method:

• County DSS enters enrollment information into statewide Eligibility Information System (EIS) • The EIS sends eligibility updates nightly to the State Employees Health Plan. • EIS generates a notice of denial or approval for benefits for the applicant. • The State Employees Health Plan sends out health identification cards, benefits booklets (in English and Spanish), and other related program information.

Continuing Enrollment:

• NC Health Choice provides 12 months continuous eligibility without regard to changes in income. • Local agencies receive a "kit" of materials to assist in publicizing ongoing enrollment efforts. • During the eleventh month following enrollment, individuals are sent: (1) a post card asking them to expect a reenrollment form, and (2) a copy of the mail-in application form with a cover letter reminding them that it is time to apply to continue enrollment. • Re-enrollment requirements are the same as initial enrollment. For continued enrollment, the family is sent a form with address information completed on it. Forms may be self-completed/edited, signed and mailed into county DSS. • The local agency has administrative flexibility to use mail-in requests for information, telephone follow-up, and face-to-face interviews.

The experience of the typical enrollee will be as follows: