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

Effective Date:

Approval Date: 4-7 reach 19 years of age. Enrollees are required to notify health plans if their residency or health care insurance coverage changes during the year. These changes can also include an income change which affects their subsidy level or make them appear eligible for Medicaid. The health plan would act accordingly based upon the new information.

The Department audits at least annually each health plan’s eligibility verification and recertification procedures to ensure children are enrolled appropriately. This includes an annual review of a statistically valid sample of cases from each health plan. The audit is conducted through site visits and/or desk audits to determine adherence to enrollment policies and procedures.

For the Medicaid program, the methods of establishing eligibility and continuing enrollment are specified in the Title XIX (Medicaid) State Plan.

4.3.1 Describe the State’s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b))

Check here if this section does not apply to your State.

The State does not have a waiting list as there is no cap on enrollment.

4.4. Describe the procedures that assure that:

4.4.1. Through the screening procedures used at intake and follow-up eligibility determination, including any periodic redetermination, that only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including a state health benefits plan) are furnished child health assistance under the state child health plan. (Section 2102)(b)(3)(A)) (42CFR 457.350(a)(1) and 457.80(c)(3))

The applications used to determine eligibility for CHPlus and Medicaid ask if the prospective enrollee currently has health insurance coverage. If they answer yes to this question, the child is not eligible for CHPlus. If the child does not have health insurance, the health plan determining eligibility for the CHPlus program reviews the application and supporting documentation against the eligibility criteria for the Medicaid and CHPlus programs. The application is first screened for Medicaid eligibility. If the child is not determined eligible for Medicaid, they are reviewed against the eligibility criteria for CHPlus. The screening tool has been determined to be an accurate tool for determining eligibility for both programs. This same process is followed at recertification.

4.4.2. The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX. (Section 2102)(b)(3)(B)) (42CFR 457.350(a)(2))

Health plans and facilitated enrollers are required to screen all CHPlus applicants for