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

Effective Date:

Approval Date: 30 apply to extended coverage.

No State or federal funds are used to cover, subsidize or otherwise offset the cost of this extended coverage.

The Department coordinates efforts with the State Health Plan to assure that children with “special needs” receive the same level of services that are available under Title XIX in North Carolina, including case management services to enhance outcomes and control costs. A special fund, comprised of Title XXI federal funds and state matching funds will be established to reimburse the services that are above and beyond those covered by the State Health Plan. This component will be administered by the State Title V Children’s Special Health Services Program in the Department. “Children with Special Needs” are those who have been diagnosed as having one or more of the following conditions which in the opinion of the diagnosing physician (1) is likely to continue indefinitely, (2) interferes with daily routine, and (3) requires extensive medical intervention and extensive family management:

a. Birth defect, including genetic, congenital or acquired disorders; b. Developmental disabilities; or c. Chronic and complex illness

Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 7.

6.1. The state elects to provide the following forms of coverage to children: (Check all that apply.) (42CFR 457.410(a))

6.1.1.

Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420) 6.1.1.1. FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) 6.1.1.2. State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.1.3. HMO with largest insured commercial enrollment (Section