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Model Application Template for the State Children’s Health Insurance Program
Effective Date:
Approval Date: 71 Section 12. Applicant and Enrollee Protections (Sections 2101(a))
Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan.
12.1. Eligibility and Enrollment Matters
Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120. DHS CHIP applicants and members have the same rights as OHP Medicaid members with respect to eligibility and enrollment matters. Clients and applicants have a right to a timely, written, impartial external review through the administrative hearing process that complies with 42 CFR 457.1120.
Under Express Lane Eligibility when a child is found eligible for HKC which require premiums, the Department sends a notice informing the client that the child may be eligible for lower or no premiums using our regular eligibility methods. If a child were found to be ineligible using an ELE finding the Department would do a full eligibility determination. 12.2. Health Services Matters
Please describe the review process for health services matters that comply with 42 CFR 457.1120. DHS CHIP members have the same rights as OHP Medicaid members with respect to denials, reductions and termination of services. Clients have a right to a timely, written, impartial external review through the DMAP administrative hearing process that complies with 42 CFR 457.1120. Additionally Healthy KidsConnect plan are regulated by private insurance rules which also guide how insurance appeals and grievances are handled,.
12.3. Premium Assistance Programs
If providing coverage through a group health plan that does not meet the requirements of 42 CFR 457.1120, please describe how the state will assure that applicants and enrollees have the option to obtain health benefits coverage other than through the group health plan at initial enrollment and at each redetermination of eligibility. Not applicable.