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Model Application Template for the State Children's Health Insurance Program
Effective Date: August 24, 2001
Approval Date: 24 (Check all that apply.) (42CFR 457.410(a))
6.1.1. ∼ Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420) 6.1.1.1. ∼ FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) 6.1.1.2. ∼ State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.1.3. ∼ HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.)
6.1.2. ∼ Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430) Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Please attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431. See instructions.
6.1.3. ∼ Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) [Only applicable to New York; Florida; Pennsylvania] Please attach a description of the benefits package, administration, date of enactment. If Αexisting comprehensive state-based coverage≅ is modified, please provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of 8/5/97 or one of the benchmark plans. Describe the fiscal year 1996 state expenditures for Αexisting comprehensive state-based coverage.≅
6.1.4. X Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) 6.1.4.1. X Coverage the same as Medicaid State plan 6.1.4.2. Θ Comprehensive coverage for children under a Medicaid Section 1115 demonstration project
6.1.4.3. Θ Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population 6.1.4.4. Θ Coverage that includes benchmark coverage plus additional coverage 6.1.4.5. Θ Coverage that is the same as defined by Αexisting comprehensive state-based coverage≅