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

Effective Date:

Approval Date: 33 coverage for group health coverage. The first measure is that persons covered by private health insurance are not eligible for benefits under CHIP. Another measure to prevent substitution is that children are ineligible if they have been covered by a group health plan two months immediately preceding the application for CHIP. There are exceptions to the two-month rule, such as when the child has a life threatening or disabling conditions.

DHS also requires that insurance information on the persons seeking medical assistance coverage be provided on the application for CHIP as a measure to avoid substitution for group health coverage. DHS enrollees’ TPR information is maintained in the MMIS system. In addition to self reported insurance information, the OHP Central Processing Center receives TPR insurance information from providers which is verified by Central Processing staff. Eligibility staff also reviews pay stub information that may also indicate whether dependent health insurance is being deducted from the employee paycheck. The State monitors substitution under its Quality Control and Quality Assurance process to analyze the extent to which an applicant drops other health plan coverage. Records are reviewed to ensure that the two- month period of ineligibility is applied appropriately. Action is taken as needed. Trends are monitored to ensure that the policy is consistently applied throughout the program.

Targeted, low-income children of employees of the State of Oregon, who are eligible for employer sponsored insurance benefits, are not eligible for CHIP coverage since the State provides coverage of dependents.

The OHP Central Processing Center conducts standardized audits on an ongoing basis to review eligibility determinations to ensure that children who are Medicaid eligible, or who have private coverage are not enrolled in CHIP. The Quality Assurance Unit at OHP Central Processing conducts random audits on an ongoing basis of eligibility determinations to monitor the integrity of determinations. All eligibility elements are reviewed during this process, including assessment of the client’s access to TPR and the substitution of coverage.

4.4.4.2. Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable. Same as listed under 4.4.4.1

4.4.4.3. Coverage provided to children in families above 250% FPL: describe how substitution is monitored and identify