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

Effective Date:

Approval Date: 4-10

(a) Loss of employment due to factors other than voluntary separation; (b) Death of the family member which results in termination of coverage under a group health plan under which the child is covered; (c) Change to a new employer that does not provide an option for comprehensive health benefits coverage; (d) Change of residence so that no employer-based comprehensive health benefits coverage is available; (e) Discontinuation of comprehensive health benefits coverage to all employees of the applicant’s employer; (f) Expiration of the coverage periods established by COBRA or the provisions of subsection (m) of section three thousand two hundred twenty-one, subsection (k) of section four thousand three hundred four and subsection (e) of section four thousand three hundred five of the insurance law; (g) Termination of comprehensive health benefits coverage due to long term disability; (h) The cost of employment based health insurance is more than 5 percent of the family’s income; (i) A child applying for coverage under these provisions is pregnant; or (j) A child applying for coverage under this provision is at or below the age of five.

The Department will monitor the number of children who are subject to the waiting period.

4.4.4.4. If the State provides coverage under a Premium Assistance Program, describe:

The minimum period without coverage under a group health plan, including any allowable exceptions to the waiting period.

The minimum employer contribution.

The cost-effectiveness determination.

4.4.5 Child health assistance is provided to targeted low-income children in the State who are American Indian and Alaska Native. (Section 2102)(b)(3)(D)) (42 CFR 457.125(a))

Through statewide CHPlus and Medicaid coverage, the provision of health insurance to targeted low-income children in the State who are Indians as defined in section 4(c) of the Indian Health Care Improvement Act, 25 U.S.C. 1603(c) is ensured. The Department also maintains an Indian Health Program which deals directly with the Native American populations on or near all reservations in the State. All health care providers who deal with the Native American population encourage enrollment in