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

Effective Date:

Approval Date: 4-1 Section 4 Eligibility Standards and Methodology (Section 2102(b))

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 5.

4.1. The following standards may be used to determine eligibility of targeted low- income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102)(b)(1)(A)) (42CFR 457.305(a) and 457.320(a))

4.1.1.

Geographic area served by the Plan:

4.1.2.

Age:

A child is eligible for CHPlus or Medicaid if the child is less than 19 years of age. Documentation of proof of age for CHPlus shall include one of the following: copy of birth certificate; religious documents (baptismal papers); school records; and/or signed affidavit stating witness of birth.

4.1.3.

Income:

Effective September 1, 2008, a child residing in a household having a gross household income at or below 400% of the FPL (as defined and annually revised by the federal Office of Management and Budget) is eligible for CHPlus.

Documentation of income shall include any one of the following: annual Federal and State tax returns, paycheck stubs or other documentation of income; written documentation by employer; or an affidavit of self-income declaration. Gross income for the purposes of this plan means income before deduction of income taxes, employees' social security taxes, insurance premiums, bonds, etc. Gross income includes the following:

1.) Monetary compensation for services, including wages, salary, commissions or fees, (excluding all wages paid by the Census Bureau for temporary employment); 2.) Net income from farm and non-farm employment; 3.) Social Security; 4.) Dividends or interest on savings bonds, income from estates or trusts, or net rental income; 5.) Unemployment compensation; 6.) Government civilian employee or military retirement or pensions or veterans' payments; 7.) Private pensions or annuities; 8.) Alimony or child support payments; 9.) Regular contributions from persons not living in the household; 10.) Net royalties; and 11.) Other cash income.