Initial Application

Template I4 – Children's Health Insurance Program State Plan - Amendment Submission

Statute:

Regulation: 42 CFR 457.60

INTRODUCTION

Template I4 is used by all States with CHIP programs (separate CHIP and Medicaid Expansion) to indicate the sections of the State Plan it wishes to update or amend.

BACKGROUND

Upon submission of an initial State Plan, all States will be required to complete all the templates in the State Plan applicable to the type of CHIP program (separate CHIP, Medicaid expansion or both) for which the State is seeking plan approval. The applicable templates will automatically display for the State to complete.

Regulation allows States to amend its approved CHIP State plan in whole or in part at any time through the submission of an amendment to CMS.

Additionally, a State must amend its State plan whenever necessary to reflect:

(a) Changes in Federal law, regulations, policy interpretations, or court decisions that affect provisions in the approved State plan;

(b) Changes in State law, organization, policy, or operation of the program that affect the following program elements described in the State plan:

(1) Eligibility standards, enrollment caps, and disenrollment policies as described in 42 CFR 457.305.

(2) Procedures to prevent substitution of private coverage as described in 42 CFR 457.805, and in 42 CFR 457.810 for premium assistance programs.

(3) The type of health benefits coverage offered, consistent with the options described in 42 CFR 457.410.

(4) Addition or deletion of specific categories of benefits covered under the State plan.

(5) Basic delivery system approach as described in 42 CFR 457.490.

(6) Cost-sharing as described in 42 CFR 457.505.

(7) Screen and enroll procedures, and other Medicaid coordination procedures as described in 42 CFR 457.350.

(8) Review procedures as described in 42 CFR 457.1120.

(9) Other comparable required program elements.

(c) Changes in the source of the State share of funding, except for changes in the type of non-health care related revenues used to generate general revenue.

TECHNICAL GUIDANCE

Currently, this template consists of the following sections:

• Administration

• Eligibility

The State would first select the section or sections (from the two options listed above) impacted by the State Plan amendment.

Administration

Select the topic from the list of four options displayed. For each topic selected, the system will display the corresponding screen(s) for the State to update.

Eligibility

There are three sub-sections to Eligibility:

• Covered Groups

• Non-Financial Requirements

• General Eligibility

Each sub-section includes a list of topics from which the State can select. For each topic selected, the system will display the corresponding screen(s) for the State to update.

Note: With few exceptions, listed below, the screen(s) displayed will be the screen corresponding to the topic named in the option that was selected (i.e. if Completion of or change to Targeted Low-Income Children is selected, the system will display the screen for Targeted Low-Income Children).

Exceptions:

For ‘Addition of a covered group’ the Separate CHIP Options screen will be displayed first, followed by the Completion of Covered Groups screen.

For ‘Deletion of a Covered Group’, the Separate CHIP Options screen will display for the State to de-select the covered group it wants to delete.

Note: States with only a Medicaid Expansion Program can only access the options under Administration and CS3 (Medicaid Expansion) and CS14 (Children Ineligible for Medicaid Due to Loss of Income Disregards) under the Eligibility section.