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

Effective Date:

Approval Date: 48 8.7 Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c))

The family whose income is above 150% and does not present a tribal identity card and is, therefore, subject to an enrollment fee and that does not pay an enrollment fee is not enrolled until the fee is paid. A family required to pay a copayment that does not pay remains enrolled in the program. An individual provider may at his or her discretion refuse service over non-payment of a copayment. Enrollment fees are the property of the county in which the application is filed. Copayments are the property of the provider. A family can reenroll at any time during the first ten days of the month and have it count as a reenrollment. This becomes a significant benefit during a time of an enrollment freeze when reenrollees are allowed to stay in the program if they reenroll on a timely basis.

8.7.1 Please provide an assurance that the following disenrollment protections are being applied:

The State of North Carolina does not disenroll anyone under the current system unless the family actively requests a change of DSS status that makes them Medicaid eligible or if the family notifies the state that they have purchased health insurance. If the State makes changes in the program that would permit disenrollment we would make sure that:

State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a))

The disenrollment process affords the enrollee an opportunity to show that the enrollee’s family income has declined prior to disenrollment for non-payment of cost-sharing charges. (42CFR 457.570(b))

In the instance mentioned above, that the state will facilitate enrolling the child in Medicaid or adjust the child’s cost-sharing category as appropriate. (42CFR 457.570(b))

The state provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42CFR 457.570(c))

8.8 The state assures that it has made the following findings with respect to the payment aspects of its plan: (Section 2103(e))

8.8.1.

No Federal funds will be used toward state matching