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STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 4-17

Effective Date: 07/01/05

17 Approval Date: _____________/06 431.636(b)(4))

Applications filed on behalf of children determined to be ineligible for Medicaid by Medicaid eligibility staff co-located at the Central Processing Unit or by Medicaid staff at local departments of social services undergo a FAMIS eligibility determination. A single child health insurance application form and process facilitates this eligibility determination and enrollment of children in the appropriate program, either Medicaid or FAMIS.

4.4.4 The insurance provided under the state child health plan does not substitute for coverage under group health plans. Check the appropriate box. (Section 2102)(b)(3)(C)) (42CFR 457.805) (42 CFR 457.810(a)-(c))

4.4.4.1. ⌧ Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution.

Only uninsured children shall be eligible for FAMIS. The single child health application form requests information on health insurance coverage the child may have or had within the past four months. Each application and redetermination of eligibility documents inquiry about health insurance within the past 4 months. If the child has been covered under a health insurance plan within 4 months of application for or receipt of FAMIS services, the child will be ineligible, unless they are pregnant at the time of application or unless good cause for discontinuing the coverage is demonstrated.

Good Cause: A child shall not be ineligible for FAMIS if health insurance was discontinued within the four month period prior to the month of application if one of the following good cause exceptions is met:

1. The family member who carried insurance changed jobs or stopped employment, and no other family member’s employer contributes to the cost of family health insurance coverage. 2. The employer stopped contributing to the cost of family coverage and no other family member’s employer contributes to the cost of family health insurance coverage. 3. The child’s coverage was discontinued by an insurance company for reasons of uninsurability, e.g., the child has used up lifetime benefits or the child’s coverage