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

Effective Date:

Approval Date: 19

Exceptions to the waiting period:

A child is not subject to the waiting period if the family lost coverage for the child as a result of:

(A) termination of employment because of a layoff or business closing; (B) termination of continuation coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985 (Pub. L. No. 99-272); (C) change in marital status of a parent of the child; (D) termination of the child's Medicaid eligibility because the family's earnings or resources increased or the child reached an age at which Medicaid coverage is not available; (E) a similar circumstance resulting in the involuntary loss of coverage; (F) the family terminated health benefits plan coverage for the child because the cost to the child's family for the coverage exceeded 10 percent of the family's income; (G) the child has access to group-based health benefits plan coverage and will participate in a federally-approved SCHIP premium assistance program administered by HHSC; or (H) HHSC has determined that other grounds exist for a good cause exception.

Unborn children are exempt from the waiting period.

The enrollment fee amount, if applicable (See Section 8.2.3), must be paid and the health plan selection, if applicable, must be made in advance of the enrollment cutoff date. Two months before the end of the six-month term of coverage, families are sent a renewal notice informing them that they must renew the SCHIP coverage. For the CHIP Perinatal Program, two months before the end of the twelve-month term of coverage, families are sent a renewal notice informing them that they must renew the SCHIP coverage.

Upon implementation of the dental benefit, current enrollees will be placed in one of the following tiers based on the criteria below:

• Tier I: All new enrollees, with the exception of those listed in Tier II; • Tier II: Children exempt from cost sharing (less than 133% FPL, Alaskan Natives and American Indians) and children deemed from Medicaid to SCHIP without a gap in coverage; and • Tier III: No child would be placed in Tier III upon implementation.

As children are enrolled, they will be placed in the appropriate tier as follows: • Tier I: All new enrollees, with the exception of those listed in Tier II; • Tier II: Children exempt from cost sharing (less than 133% FPL, Alaskan Natives and American Indians), and children deemed from Medicaid to SCHIP without a gap in coverage; and