Page 13

number), maintenance of forms, and maintenance of data systems. The TPA will make applications available at local sites (e.g., schools, health departments) and will mail applications to families when requested. Applicants may submit paper applications by mail. Online applications are also expected to be available by mid-2007. Initially, there will be a downloadable application but not an interactive web application as that will have to be developed. The downloadable application will require a signature and be mailed to the TPA.

Eligibility Determination and Enrollment Process: The TPA will receive completed applications at a central location and will follow-up with families by phone or mail to obtain any missing information or documentation. When all necessary information has been received, the TPA will determine eligibility for CoverKids based on criteria established by the state and mail notices of approvals/disapprovals. The TPA will also notify the health insurer of new CoverKids enrollees and the insurer will then issue member enrollment cards. Eligibility for CoverKids will begin on the first day of the month following completion of the eligibility determination. For applications processed within five work days of the beginning of the next month, coverage will begin the first day of the following month.

Presumptive Eligibility: CoverKids will permit qualified entities to conduct presumptive eligibility (PE) determinations for pregnant women and newborns from birth through 3 months of age. Qualified entities may include hospitals, physician groups or similar entities that provide health care services to CoverKids enrollees. Entities that choose to determine presumptive eligibility will be provided with application forms and instructions on how to assist families in completing the forms and will have the following responsibilities: • Receive completed applications and any required verifications. • Determine initial eligibility based on information presented within two days of receipt of the completed application. • Follow-up on incomplete applications by telephone or mail. • Forward completed applications within two days to the CoverKids TPA for final determination of CoverKids eligibility.

CoverKids will provide CoverKids providers who volunteer to be qualified entities, with applications and training to perform presumptive eligibility to assure that these entities understand their responsibilities and are capable of conducting accurate presumptive eligibility determinations.

A pregnant woman may only be presumptively eligible if she has no comprehensive health insurance coverage and has not had group or individual coverage within the last 3 calendar months (exceptions permitted). If the qualified entity determines that the family income of the

13