Page 40

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

Effective Date:

Approval Date: 40 6.1.4.2. Comprehensive coverage for children under a Medicaid Section 1115 demonstration project

Program rules are available at http://www.dhs.state.or.us/policy/healthplan/gu ides/main.html 6.1.4.3. Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population 6.1.4.4. Coverage that includes benchmark coverage plus additional coverage 6.1.4.5. Coverage that is the same as defined by existing comprehensive state-based coverage 6.1.4.6. Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7. Other (Describe) Healthy KidsConnect: This is a private insurance option available to children under the CHIP state plan. Sliding scale subsidies are available to children who enroll in State-approved benefit packages developed and offered by private health insurers. Private insurers are selected through a competitive bid process. Approved benefit plans are comparable, but not identical to OHP Plus benefit package.

6.2. The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490) As long as the Section 1115 waiver authority is effective, children who opt to take up premium assistance are not subject to title XXI benefit rules. Healthy KidsConnect participants receive benefits that are comparable, but not identical to OHP Plus benefits and are delivered through the private insurance marketplace. The insurer’s contract identifies services not covered as benefit limitations and exclusions rather than by use of the prioritized List, which defines the CHIP OHP Plus benefit package. Both CHIP OHP Plus and HKC contain the benefit elements listed below.

*Applicable for Unborn population only- When any grouping below is