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

Effective Date:

Approval Date: 18 are not able to obtain health benefits through their group plan immediately, and they meet the eligibility requirements for the Medical Assistance Program or CHIP. Children with income above 200% FPL have the opportunity to enroll in Healthy KidsConnect.

Healthy KidsConnect:

OPHP also administers Healthy KidsConnect; a private insurance option for children in families above 200 % up to and including 300% FPL, who do not have access to employer-sponsored insurance or choose not to enroll in it. Healthy KidsConnect provides direct subsidies to children on a sliding scale based on family income. Children in families with incomes above 200 percent FPL are not eligible for CHIP OHP Plus.  Families with incomes above 200 up to and including 250 percent of FPL will pay a maximum of 10% of the child’s monthly premium; and  Families with incomes above 250 up to and including 300 percent of the FPL will pay a maximum of 15% of the child’s monthly premium.  Out of pocket costs (including premium) will not exceed the Title XXI cost-sharing cap of five percent. Private insurance carriers are selected through a competitive bid process. Approved benefit plans must be comparable to the CHIP OHP Plus benefit package. Carriers are licensed and regulated by the Oregon Insurance Division. They must adhere to rules and regulations specific to commercial insurers. The managed care plans that contract with the State to offer this coverage provide a private sector insurance product with potential variations in the scope of coverage that meet the State's comparability requirements, but are unique to the carrier in terms of their particular coverage and how they manage their benefits (e.g. use of prior authorization or other service limits). Enrollees of HKC will have a choice of Health plans. There is 1 insurer that is offered statewide, as well as 4 regional insurers that will be offered in various regions of the state.

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care