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

Effective Date:

Approval Date: 18

The family, upon hearing about this opportunity and then receiving written material at their child's day care (or other source), fills out the application form and mails it to the county DSS office. The local DSS worker assesses the form and makes one of three possible determinations:

1. The child is eligible for Title XIX. This information is data entered and the child is enrolled in Medicaid.

2. The child is eligible for Title XXI. This information is data entered and sent to the Division of Medical Assistance, whereupon one of two things happens: (a) the child is enrolled in the Title XXI program upon receipt of an enrollment fee for families above 150% of poverty ($50 enrollment fee for one child and $100 fee for two or more children paid to the county Department of Social Services) and their information is forwarded to the State Employees Health Plan for inclusion in the program, or (b) it is determined that the funds have been depleted and the child is denied and placed on a waiting list.

If the child is found eligible for either Title XIX or XXI and is enrolled, the family will receive by mail a card for the child and written instructions. In the case of Title XXI participants, the cover letter and card will be generated by State Employees Health Plan to welcome them to the program. The letter will inform the parent(s) how to access their children's providers and will include information on copays, out of pocket limits, etc. For children enrolled in the Title XXI program, during the eleventh month of eligibility the family will automatically receive a mail-in application form with a cover letter reminding the family that it is time for plan renewal.

3. The child is ineligible for both Title XIX and Title XXI either due to income and/or insurance coverage. In the event of an enrollment freeze an enrolled child whose family submits a valid application for reenrollment prior to the end of the ten-day grace period will be reenrolled in the program.

4.3.1 Describe the state’s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b))