Page 17
11 (unless the coverage has such high deductibles that DHCS views the coverage as being tantamount to being uninsured). As approved in California’s SPA, FFP is claimed for infants through the age of one born to MCAP mothers with household incomes above 208 percent of the FPL up to and including 317 percent FPL. This is consistent with the CS9 in Attachment 1. MCAIP provides health benefits for infants up to age two born to MCAP mothers with incomes above 261 percent of the FPL up to and including 317 percent of the FPL.
California CHIP State Plan Attachments Attachment # Name of Attachment Relevant CHIP State Plan Section Purpose of Attachment 1 CA approved ACA Eligibility Templates Section 4/Eligibility To reflect approved eligibility pages referenced in the table in section 1.4, subsections of 4.0, and 8.7 specifically. 2 State Employee Benchmark Benefit for MCAP and CCHIP Section 6.1.1.2/Benefits To describe benefits for Population 1 (CCHIP) and 3 (MCAP) 3 Medicaid benefits for the Unborn Option and MCAIP Section 6.1.4.1/Benefits To describe Medicaid benefits for Population 2 (Unborn Option) and 4 (MCAIP) 4 Medicaid benefit limitations for the Unborn Option and MCAIP Section 6.1.4.1/Benefits To describe applicable limitations under Medicaid for Populations 2 and 4 5 Summary table of benefits for all pops Section 6.2/Benefits To provide a summary of benefits across all separate CHIP populations 6 & 7 Dental coverage for MCAP and CCHIP Section 6.2.2.2/Benefits This attachment includes CDT codes for Delta Dental (Attachment 6) and Liberty Dental (Attachment 7). Also, there is a general description in Attachment 2 on page 11. 8 Dental coverage for the Unborn Option and MCAIP Section 6.2.1/Benefits Attachment 3, Page 4, Paragraph 10 and Attachment 4, Page 53, Section 10.
1.1-DS
The State will provide dental-only supplemental coverage. Only States operating a separate CHIP program are eligible for this option. States choosing this option must also complete sections 4.1-DS, 4.2-DS, 6.2-DS, 8.2-DS, and 9.10 of this SPA template.