Page 12

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

Effective Date:

Approval Date: 4-2 4.1.4.

Resources (including any standards relating to spenddowns and disposition of resources): ____________

4.1.5.

Residency (so long as residency requirement is not based on length of time in state):

A child must be a resident of New York State. School records, utility bills, rent receipt or any mail addressed to the child and/or responsible adult which has been postmarked may be used as proof of residency.

4.1.6.

Disability Status (so long as any standard relating to disability status does not restrict eligibility): __________

4.1.7.

Access to or coverage under other health coverage:

In addition to the age, income, residency criteria as described above, a child is eligible for CHPlus if, in accordance with Title XXI, the following conditions do not apply:

1. The child is eligible for Medicaid.

2. A child is an inmate of a public institutions or a patient in an institution for mental diseases; or

3. A child is a member of a family that is eligible for health benefits coverage under a State health benefits plan on the basis of a family member's employment with a public agency in the State.

4.1.8.

Duration of eligibility:

The period of eligibility shall commence on the first day of the month during which a child is eligible, as described below, and end on the last day of the twelfth month. The period of eligibility shall cease if the child no longer resides in New York State; has access to the New York State health insurance program or has obtained other health insurance coverage; has become enrolled in Medicaid; has reached the age of 19; or the applicable premium payment has not been paid. Children whose application is received by the 20th of the month shall be enrolled the first day of the next month if determined eligible. Applications received after the 20th day of the month will be processed for the first day of the second subsequent month. In no case is a child enrolled more than 45 days after submitting the application. Children are recertified annually. Families are required to report to the health plans changes in New York State residency or health care coverage through insurance that may make a child ineligible for subsidy payments. If a family submits revised eligibility information to a plan that affects their eligibility status, the health plan implements this information prospectively. A family may incur a lower or higher family contribution or be referred to Medicaid based on this new information.