Page 4

(ffi"*" CHIP Eligibility State Transm¡ttal Number: TN - l7 - 0045 ApprovalDale:_ OMB Control Number: 093E- I 148 42 CFR 457 .355 and 435.1102,2107 (eX IXL) and 19204 ofthe SSA The ClllP Agercy covers childrcn whcn dctcrnrincd plesumptively eligible by a qualified entity I Describe the population ofchildren to whom presumptive eligibility applies: Presumptive eligibility app¡¡es to a subset ofchildren described in California's approved C59 template, which specifies the :ligibility levels und€r the conception to birlh option in the state's separate CHIP. Speçifically, presumptive eligibility applies to children from conoept¡on to b¡rth from 0 up to 208 percent ofthe Federal povefy level (FPL). E Descr¡be the duration ofthe presumptive eligibility per¡od and any I¡mitat¡ons Ihe presumptive el¡gibility period begins on the date that a determination is made by the qualified entity, and ends on the day the final CHIP eligibility determination is made for children w¡th famil¡es that have filled out a full applicat¡on with¡n that time peliod; oruntil the end ofthe following month if an application forCHIP is notfiled by the fam¡ly w¡th¡nthat t¡me period. An ndividual is eligible for one presumptive eligibility period within a l2 month period, stading with the effective date of the initial PE period (PE is available only one time during pregnancy). I Describe the application process and eligibility determination factors us€d: When a child comes into a CHDP prov¡der's office, the entity helps the appl¡cant complete a presumpt¡ve eligib¡l¡ty form, referred to as a pre-enrollment application in California. The eligibility determinat¡on factors include: CHIP specific eligibility factors, sùch as the child being under age l9 and not enrolled in other health insurance; household income; state rcsidency, and awfully residing status. All ofth¡s information is collected through self-attestat¡on. A noncitizen pregnant appl¡cant without a lawfully residing status is approved for presumptive eligibility coverage ofthe unborn child under CHIP. The presumpt¡ve 3ligib¡lity ent¡ty will make an eligibility determ¡nation according to the income Iimitof20S percent ofthe FPL. Ifthech¡ld meets all ofthe eligib¡l¡ty cr¡ter¡a, the presumptive eligibility form is submitted into DHCS'Medi-Cal Eligibil¡ty Data Systerr iMEDS), and presumptive eligibility is effective immediately. The family is given a temporary Benefits Card. Coverage ;ontinues for up two months while an eligibil¡ty determination is being made. I The CHIP Agency uses qualified entities, as defined in section 19204, to determine eligibility presurnptively for children. sPA# CA-17-0045 DEC 2 7 2011 Effective Date: JUly 1,2017 Page I of3