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Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

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8.6 Describe the procedures the state will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42CFR 457.535)

Pennsylvania ensures that American Indian and Alaska Native children will be excluded from cost sharing by collecting information on the application and at the time of redetermination of eligibility regarding a child’s status as an American Indian or Alaska Native. The applicant/enrollee will be asked to indicate their tribal membership by stating this on the application. If they are found to be in the American Indian or Alaska Native category, the family will be notified of the exemption and an identification card will be issued with an appropriate group number that excludes cost sharing. All providers are required to verify eligibility by checking the enrollment card which contains a notation regarding copayments, as is the telephone eligibility verification system used by providers.

8.7 Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c)) Failure to pay the premium for the subsidized program may result in termination. Contractors provide for a 10-day grace period for the receipt of premiums. A notice of proposed termination must be sent to the parent or guardian at least 30 calendar days in advance of the effective date of termination. The notice will include the effective date of termination, the reason for termination (non-payment of premium), what corrective measures may be taken to prevent termination from occurring (appeal the decision to the eligibility review officer or provide proof of a decrease in income since the determination was made), and the contact number for any questions or to resolve the situation.

Upon receipt of the termination notice, the enrollee may provide income information that would lead to a reassessment of their eligibility. During a reassessment, eligibility is redetermined. If income appears to have decreased enough that the enrollee appears they may be eligible for Medicaid, the termination is stayed for 60 days and the application and supporting documentation are forwarded to Medicaid for an eligibility determination. If Medicaid denies for income too high, the enrollee will be evaluated for continued coverage in CHIP. For example, if reassessment found the enrollee possibly eligible for Medicaid, they would most likely qualify for free CHIP and would be re-enrolled in the program with no lapse in coverage. Along the same lines, if reassessment results in an income in a lower premium bracket, the individual will be offered the opportunity to pay the lower premium and be re-enrolled in the program.