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

Effective Date: August 24, 2001

Approval Date: 19 • Insured children, children age 6 through 18 from families with incomes below 100% of FPL, and children under age 6 from families with incomes below 133% of FPL will receive Medicaid. • Children otherwise eligible for Medicaid under other eligibility categories will receive Medicaid. • Children who are residents of public institutions will not be eligible for any coverage. • Income eligible children who are residents of Institutions for Mental Disease will receive Medicaid.

After making an eligibility decision, the caseworkers will enroll the eligible children in the appropriate program for health coverage. Children who are potentially eligible for Medicaid other than under low-income categories based on the information that has been submitted on the short form will not be approved for SCHIP. Denied applications will receive a notice that includes the reason for the denial, a notification of fair hearing, and a form to submit additional information to pursue Medicaid eligibility on another basis of eligibility.

4.4.2. The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX. (Section 2102)(b)(3)(B)) (42CFR 457.350(a)(2))

Children found eligible for Medicaid are enrolled in the Medicaid program as described in 4.4.1.

4.4.3. The State is taking steps to assist in the enrollment in SCHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4))

Children found ineligible for Medicaid enrollment may be enrolled in M- SCHIP or CHIP-NM as described in 4.4.1. All Medical Assistance Programs are jointly administered by the Department of Social Services. A new application is not required if there is not break from Medicaid to SCHIP enrollment. 4.4.4 The insurance provided under the state child health plan does not substitute for coverage under group health plans. Check the appropriate box. (Section 2102)(b)(3)(C)) (42CFR 457.805) (42 CFR 457.810(a)-(c))

4.4.4.1. X Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution.