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

Effective Date:

Approval Date: 8-3 In cases where the family premium contribution has not been received 15 days prior to the start of the coverage month, the health plan must send a notice to the family explaining that coverage for the enrollee will be terminated for non-payment if the premium contribution is not received by the last day of the month of coverage. This notice also informs the family of the right to challenge the termination for non-payment of the premium.

Health plans must disenroll a child effective the last day of the month of coverage if they do not receive the premium contribution for a child by that day. Enrollees have the opportunity to request a review of their income and to provide proof of a decrease in income that would make the child eligible for Medicaid or for a lower family contribution by the last day of the month of coverage. The health plan would redetermine program eligibility and family contribution based on the revised information. A child remains enrolled in CHPlus if a dispute regarding family contribution arises until such dispute is resolved.

If an enrollee fails to pay the family contribution of the premium and they do not avail themselves of the review process, the child will be disenrolled from the program. There are no other charges associated with the program, and the family has the option of paying more than one month’s family contribution at a time.

8.7.1 Please provide an assurance that the following disenrollment protections are being applied:

State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a))

The disenrollment process affords the enrollee an opportunity to show that the enrollee’s family income has declined prior to disenrollment for non-payment of cost-sharing charges. (42CFR 457.570(b))

In the instance mentioned above, that the state will facilitate enrolling the child in Medicaid or adjust the child’s cost-sharing category as appropriate. (42CFR 457.570(b))

The state provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42CFR 457.570(c))

8.8. The State assures that it has made the following findings with respect to the payment aspects of its plan: (Section 2103(e))

8.8.1.

No Federal funds will be used toward State matching requirements. (Section 2105(c)(4)) (42CFR 457.220)

8.8.2.

No cost-sharing (including premiums, deductibles, copays, coinsurance and all other types) will be used toward state