Page 15

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

Effective Date: August 24, 2001

Approval Date: 15

Section 4. Eligibility Standards and Methodology. (Section 2102(b))

∼ Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 5.

4.1. The following standards may be used to determine eligibility of targeted low-income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102)(b)(1)(A)) (42CFR 457.305(a) and 457.320(a))

4.1.1. X Geographic area served by the Plan: Statewide. 4.1.2. X Age: Birth to age 19 will be served. 4.1.3. X Income: Children from families with incomes over 140% FPL up to 200% FPL. The plan will use current Medicaid definitions of income, and allows deductions for child support paid and actual child care expenses for employment related daycare up to $500 per month for the family. In addition, the first $50 of current child and spousal support paid to the family unit, and earned income of children under 19 years old who are living with a caretaker, are also deducted. For children from families with incomes under 140% FPL, the additional income disregards are 20% of earned income and actual daycare costs associated with employment. 4.1.4. ∼ Resources (including any standards relating to spend downs and disposition of resources): 4.1.5. X Residency (so long as residency requirement is not based on length of time in state) : Children must be residents of the State of South Dakota and meet the citizenship and immigration status requirements applicable to Medicaid. 4.1.6. ∼ Disability Status (so long as any standard relating to disability status does not restrict eligibility): 4.1.7. X Access to or coverage under other health coverage: Children must not be eligible for Medicaid or covered under any other health insurance or group health plan. Children may not have had insurance coverage under a group health plan in the three months immediately prior to CHIP-NM application unless such coverage was dropped for good cause or access to care not available under the policy. 4.1.8. X Duration of eligibility: Eligibility is based on a month to month basis and is redetermined annually for all children. Eligibility may begin up to the first day of the third month prior to the application. Families are required to report all changes that may effect their eligibility, when the