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

Effective Date:

Approval Date: 22 Computerized edits in the Eligibility Information System will prevent enrollment in Title XXI if income is within Title XIX threshold levels. Because state employees and teachers in North Carolina pay full price for their health insurance with no governmental subsidy of any kind, employees of the State of North Carolina are eligible for the program.

4.4.2. The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX. (Section 2102)(b)(3)(B)) (42CFR 457.350(a)(2))

The State uses the same mechanisms and entities in the eligibility determination process for Title XIX and Title XXI. Eligible children are enrolled in the appropriate program as determined by eligibility criteria. One worker processes an application (same application for both Title XIX and XXI). After other criteria are met, the worker assesses family income and determines if the child is eligible for Title XIX or Title XXI or ineligible for either.

4.4.3. The State is taking steps to assist in the enrollment in SCHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4))

The State uses the same mechanisms and entities in the eligibility determination process for Title XIX and Title XXI. Eligible children are enrolled in the appropriate program as determined by eligibility criteria. One worker processes an application (same application for both Title XIX and XXI). After other criteria are met, the worker assesses family income and determines if the child is eligible for Title XIX, Title XXI or ineligible for either. If a Medicaid eligible family (or children) reports increased income that makes them ineligible for Medicaid, the children are automatically assessed for SCHIP eligibility.

4.4.4 The insurance provided under the state child health plan does not substitute for coverage under group health plans. Check the appropriate box. (Section 2102)(b)(3)(C)) (42CFR 457.805) (42 CFR 457.810(a)-(c))

4.4.4.1. Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution.

The applicant must not be covered under any private