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

Effective Date:

Approval Date: 31 not apply the decrease in benefits at that time). At the end of the 12-month period, we would redetermine eligibility, update the income information (which could affect the subsidy level) and establish a new 12-month eligibility period for everyone in the family.

Screen and enroll requirement under Express Lane Eligibility:

The State will continue to use the screen and enroll procedures required under section 2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and 457.80(c). Describe this process.

The State is establishing a screening threshold set as 30 percentage of the Federal poverty level (FPL) that exceeds the highest Medicaid income threshold applicable to a child. The thresholds for all children based on 163% FPL.

The State is temporarily enrolling children in CHIP, based on the income finding from the Express Lane agency, pending the completion of the screen and enroll process.

4.4.2. The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX. (Section 2102)(b)(3)(B)) (42CFR 457.350(a)(2)) See 4.4.1 above.

4.4.3. The State is taking steps to assist in the enrollment in CHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4))

Oregon uses one application for CHIP and Medicaid. This application is obtained by calling the toll free application hotline number that provides application assistance and sends applications to people requesting applications. Applications may also be obtained and submitted on line via the Internet, through outreach locations at FQHCs, Tribal health clinics, DSH hospitals, Healthy Start, local health departments and Certified Application Assistance Organizations, Outreach Grant Organizations and DHS branch offices. Potential clients that submit an application over the internet must affirm that the information supplied is true under penalty or perjury Applicants are informed of the Medicaid and