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

Effective Date:

Approval Date: 22 definition, whichever applies. When we evaluate the client for eligibility under CHIP or Medicaid we begin by looking at TANF related medical. All wages paid by the Census Bureau for temporary employment related to Census activities and payments made for cash medical support are disregarded.

Unborn coverage: 0% to 185% of the FPL (and not eligible for Medicaid).

FHIAP ESI coverage: Children birth to age 19 with Income zero up to and including 200% of FPL who meet the Title XXI definition of a targeted low- income child and who choose ESI and enrolled in FHIAP. Children who opt for FHIAP are not subject to title XXI benefit and cost sharing rules, and receive waiver authority for this under the Section 1115 demonstration.

FHIAP Individual health insurance: Children birth to age 19 in families with income zero up to and including 200% FPL who meet the Title XXI definition of a targeted low-income child and who do not have employer-sponsored insurance available. Children who opt for FHIAP are not subject to title XXI benefit and cost sharing rules, and receive waiver authority for this under the Section 1115 demonstration.

Healthy Kids ESI Coverage: Children birth to age 19 with family income from zero up to and including 200% of FPL who meet the Title XXI definition of a targeted low-income child and who apply for coverage through DHS and choose employer-sponsored insurance. Also Children birth to age 19 with family income above 200% up to and including 300% of FPL who meet the Title XXI definition of a targeted low- income child and choose employer-sponsored insurance instead of Healthy KidConnect plan. Children who opt for Healthy Kids are not subject to title XXI benefit and cost sharing rules, and receive waiver authority for this under the Section 1115 demonstration.

Healthy KidsConnect Private insurance option: Birth to age 19 with family income above 200% up to and including 300% of FPL who meet the Title XXI definition of a targeted low-income child and who don’t have ESI available or have it but choose not to accept it and enroll for coverage under the private insurance option. Coverage for Healthy KidsConnect is