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

Effective Date: August 24, 2001

Approval Date: 20 SCHIP has specific measures to prevent the program from substituting for coverage under group health plans. The first measure is simply that persons covered by insurance providing hospital and medical services or HMO’s are not eligible for benefits under SCHIP. Another measure to prevent substitution is that children are ineligible if they have been covered by a group health plan in the 3 months immediately preceding the application for SCHIP. The Department has adopted a definition of group health plan that includes employers, self-employed plans, employee organizations, and self insured plans that provide health care directly or otherwise. There are exceptions to the 3-month rule when the parents providing the insurance die, become disabled, lose their jobs, or start new jobs without coverage. Exceptions will also be made if care is not accessible under the group plan, or group plan coverage costs more than 5% of the SCHIP family’s gross income.

The Department also requires that insurance information on the persons seeking medical assistance coverage be provided on the application for SCHIP as a measure to avoid substitution for group health coverage. The Department also requires that members of the SCHIP unit cooperate with the Department to determine the availability of coverage. Failure to cooperate may result in loss of eligibility for the unit.

The Department also maintains a database on persons with insurance coverage for persons applying for or receiving medical assistance from the Department under Medicaid, M-SCHIP or CHIP- NM. The database includes type of coverage, name and address of carrier, policy numbers, plan sponsor, premium payer, and dates of coverage. Information from this database is available to caseworkers to explore potential group health coverage. Caseworkers also have the opportunity to update the information on this database to keep the information up to date.

Targeted, low-income children belonging to employees of State government in South Dakota will not be eligible for SCHIP coverage since the State provides indirect assistance for the coverage of dependants in excess of the cost to cover the employee alone, regardless of the coverage choices made by the family. Children of employees of other government entities in South Dakota will have the coverage evaluated to ensure that there is no meaningful (exceeding $10.00 per month) employer contribution for group health coverage to dependent children.