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

Effective Date:

Approval Date: 20 • Tier III: No child would be placed in Tier III at initial enrollment.

Members may move up a tier every other consecutive six-month enrollment coverage unless they are already at Tier III.

If there is more than a six-month gap in coverage, their Tier will be based on the criteria for initial enrollment. For the purpose of this policy, Medicaid coverage is not considered a gap in coverage.

Families currently enrolled in SCHIP will receive a packet from the dental contractor at least 30 days prior to implementation. The enrollment packet will contain a Member ID Card, a Provider Directory, a Member Handbook and a Certificate of Coverage. The Certificate of Coverage describes the covered benefits, the cap on preventive coverage, the cap on therapeutic coverage and the complaint and appeal process. The dental contractor will issue a new Certificate of Coverage any time there is a change to benefits.

The dental contractor will be responsible for providing the enrollment broker with a description of the dental benefit for the broker to use in explaining the benefit to enrollees. For specific questions regarding the benefit, the member will need to contact the dental contractor.

4.3.1 Describe the state’s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b))

Check here if this section does not apply to your state.

4.4. Describe the procedures that assure that:

4.4.1. Through the screening procedures used at intake and follow-up eligibility determination, including any periodic redetermination, that only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including access to a state health benefits plan) are furnished child health assistance under the state child health plan. (Sections 2102(b)(3)(A) and 2110(b)(2)(B)) (42 CFR 457.310(b) (42CFR 457.350(a)(1)) 457.80(c)(3))

The SCHIP application asks whether applicant children are covered through existing health insurance. Children with health coverage are ineligible for SCHIP.

As described in Section 4.1 above, the application for Texas SCHIP and Medicaid screens for Medicaid eligibility. Applications for children eligible for Medicaid are processed by Medicaid workers and eligible children are enrolled in Medicaid. Data matches with Medicaid are also carried out to minimize the chances that children found eligible for Texas SCHIP are not already receiving health insurance.