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

Effective Date: August 24, 2001

Approval Date: 16 change occurs. 4.1.9. X Other standards (identify and describe): Families must cooperate with the Department to determine the actual or potential existence of third party coverage for medical expenses, and to establish initial or ongoing eligibility. The Department requires the social security numbers for individuals who are requesting assistance under the SCHIP Medicaid expansion option.

4.2. The state assures that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102)(b)(1)(B)) (42CFR 457.320(b))

4.2.1. X These standards do not discriminate on the basis of diagnosis. 4.2.2. X Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. 4.2.3. X These standards do not deny eligibility based on a child having a pre- existing medical condition.

4.3. Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2)) (42CFR 457.350)

The SCHIP program follows the same eligibility process that is used by the Medicaid program for low-income children. . The process begins with potentially eligible individuals obtaining and completing an application form obtained from the Department of Social Services, or from any of the many local entities that are participating with outreach for the Medicaid and SCHIP programs. The short application form must be completed and signed by the head of household or parent of the children. The forms may then be mailed or delivered to the client’s local office from among the 41 Department of Social Services offices through out the State. Assistance in completing the forms is available from the Department of Social Services, including assistance for persons with Limited English Proficiency or disabilities.

Families applying for medical assistance, including the SCHIP program are provided with a pamphlet that explains SCHIP eligibility, the scope of covered services, and the limited cost sharing. The pamphlets are written in accurate, easy to understand language to assist families in making a decision to apply for medical assistance.

Information collected on the form includes identifying information of the parents of the children under age 19 requesting medical assistance, the children in the home who are under age 19, health insurance information for the persons requesting medical assistance, income information, child support payment information, and child care expense information. Verifications of income, childcare expenses paid so a person can work, and child support paid (unless paid to the child support enforcement office)