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

Effective Date:

Approval Date: 21 Section 4. Eligibility Standards and Methodology. (Section 2102(b))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 5.

4.1. The following standards may be used to determine eligibility of targeted low- income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102)(b)(1)(A)) (42CFR 457.305(a) and 457.320(a))

4.1.1.

Geographic area served by the Plan:

The entire state of Oregon, except Unborn coverage is restricted

to Benton, Clackamas, Columbia, Crook, Deschutes, Douglas,

Hood River, Jackson, Jefferson, Josephine, Lane, Lincoln,

Morrow, Multnomah, Union and Wasco Counties (Lincoln County

expanded October 1, 2009 through December 31, 2009)

4.1.2.

Age:

Birth to age 19, except for Unborn coverage restricted to Benton,

Clackamas, Columbia, Crook, Deschutes, Douglas, Hood River,

Jackson, Jefferson, Josephine, Lane, Lincoln, Morrow,

Multnomah, Union and Wasco Counties, which is from

conception to birth. (Lincoln County expanded October 1, 2009

through December 31, 2009)

4.1.3.

Income: CHIP OHP Plus direct coverage: Birth to six, family income of 133% FPL up to and including 200% FPL, ages 6 to 19, family income 100% up to and including 200% of FPL. Except for redeterminations, we use income in the month of application for the countable income test. For redeterminations, we use the month the Department initiates the redetermination or the last month of current program eligibility. We use gross income, unless they are self employed. When they are self-employed we use adjusted income (allowing for deductions for business costs, or a 50% exclusion). If not eligible using the initial month of determination, we use the same application and reevaluate countable income using income in any calendar month in the 45 days after the date of application. For purposes of income determination the definition of a child’s family will be the same as the state’s OHP Title XIX family composition