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

Effective Date:

Approval Date: 4-3 A two month presumptive period of eligibility is available to applicant children as a means of providing services under CHPlus when a child appears eligible for the program, but, pertinent documentation is missing. The health plan performs a review of the child's age, family's gross income, residency, and health care coverage, and from the completed application determines whether the child appears eligible. If one or more pieces of the documentation to support these variables are not submitted with the application, the family is allowed up to two months to submit the documentation or the child is disenrolled from the program.

Effective September 1, 2007, if the child appears Medicaid eligible at initial application, health plans will no longer enroll them in CHPlus on a temporary basis. Temporary CHPlus coverage continues to be available to any child under the age of 19 whose family’s household income does not exceed 400% of the FPL and appears to be Medicaid eligible at recertification. This eligibility period of temporary enrollment shall continue until the earlier of the date a Medicaid eligibility determination is made or two months after the temporary eligibility period begins. A temporary enrollment period may be extended in the event a Medicaid eligibility determination is not made within the two-month period through no fault of the applicant, as long as all the required documentation has been submitted within the two-month period. Once a child has been determined eligible for Medicaid, the child will be disenrolled from CHPlus at the end of the month the determination was made and the claiming of federal funds for expenditures for such child from the first day of the month in which the child was determined eligible for Medicaid will be transferred from Title XXI to Title XIX. If a child is determined not to be eligible for Medicaid prior to the last day of the two-month temporary eligibility period, such child may continue to be presumed eligible for CHPlus until the earlier of the date a CHPlus eligibility determination is made or the last day of the two-month presumptive eligibility period.

4.1.9.

Other standards (identify and describe):

New York does not require an applicant’s social security number as a condition of enrollment but does request the social security number if available. One exception is temporary enrollment. Children who screen eligible for Medicaid are required to provide a social security number.

4.1.10

Check if the State is electing the option under section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) to provide coverage to the following otherwise eligible individuals lawfully residing in the United States:

(1) “Qualified aliens” otherwise subject to the 5-year waiting period per section 403 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA);

(2) Citizens of a Compact of Free Association State (i.e., Federated States of Micronesia, Republic of the Marshall Islands, and the Republic of Palau) who have been