Page 55

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

Effective Date:

Approval Date: 55 Section 12. Applicant and Enrollee Protections (Sections 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan.

12.1. Eligibility and Enrollment Matters

Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120.

12.2. Health Services Matters

Please describe the review process for health services matters that comply with 42 CFR 457.1120.

12.3. Premium Assistance Programs

If providing coverage through a group health plan that does not meet the requirements of 42 CFR 457.1120, please describe how the state will assure that applicants and enrollees have the option to obtain health benefits coverage other than through the group health plan at initial enrollment and at each redetermination of eligibility.

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Page 55

Official source

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

Effective Date:

Approval Date: 55 Section 12. Applicant and Enrollee Protections (Sections 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan.

12.1. Eligibility and Enrollment Matters

Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120.

12.2. Health Services Matters

Please describe the review process for health services matters that comply with 42 CFR 457.1120.

12.3. Premium Assistance Programs

If providing coverage through a group health plan that does not meet the requirements of 42 CFR 457.1120, please describe how the state will assure that applicants and enrollees have the option to obtain health benefits coverage other than through the group health plan at initial enrollment and at each redetermination of eligibility.