CHIP Administration & Eligibility

Children’s Health Insurance Program (CHIP)

Implementation Guide Introduction - CHIP Eligibility

The following guide provides useful information for completion of the eligibility section of the CHIP state plan in the MACPro system. The guide is intended to be used in conjunction with the state plan screens and provides statutory and regulatory background in addition to guidance as to what information is to be provided by the States and how to enter the requested information in the system.

This guide includes the following sections:

Medicaid Expansion (CS3): For states provide the qualifying ages for children and the income eligibility standards the state uses for determining eligibility under its Medicaid expansion program.

Separate CHIP Covered Groups (CS4): Displays a list of covered groups from which a state can select those which it wants to include in its State Plan

Completion of Covered Groups (CS5): Used as a jumping off point for states to enter eligibility information with respect to the covered groups for the State’s separate child health assistance program.

Income Standards (CS6): Is displayed when needed for entry of age and income standards within the templates for some of the covered groups

Targeted Low-Income Child (CS7): To provide information with regards to eligibility criteria specific to this population group.

Targeted Low-Income Pregnant Women (CS8): To provide information with regards to eligibility criteria, including income standards specific to this population group.

Coverage from Conception to Birth (CS9): To provide information with regards to eligibility criteria, including income standards specific to this population group.

Children Who Have Access to Public Employee Coverage (CS10): To provide information with regards to eligibility criteria, including income standards, specific to this population group.

Pregnant Women Who Have Access to Public Employee Coverage (CS11): To provide information with regards to eligibility criteria, including income standards, specific to this population group.

Dental Only Supplemental Coverage (CS12): To provide information with regards to eligibility criteria, including income standards, specific to this population group.

Deemed Newborns (CS13): Describes the one-year coverage for infants born to targeted low-income pregnant women.

Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards (CS14): To provide assurance that separate CHIP coverage will be provided for children ineligible for Medicaid as a result of the elimination of income disregards.

MAGI-Based Income Methodologies (CS15): To provide information with regards to criteria used in the calculation of income for eligibility determination using MAGI-based income methodologies.

Spenddown (CS16): For states to indicate whether they apply spenddown and if so, to provide information as to their application of spenddown.

Residency (CS17): To provide information with regard to residency requirements.

Citizenship (CS18): To provide information with regard to citizenship and non-citizenship requirements.

Social Security Number (CS19): To provide information with regard to social security number requirements.

Substitution of Coverage (CS20): To provide information about the State’s policies and procedures to prevent the substitution of group health coverage or other commercial health insurance with public funded coverage.

Non-Payment of Premiums (CS21): To provide information about the State’s policies and procedures with respect to non-payment of premiums.

Non-Financial Requirements (CS22): To provide assurances with respect to several non-financial eligibility requirements not covered in the other eligibility sections of the plan.

Other Eligibility Standards (CS23): Provides States with the opportunity to include additional eligibility standards used in their State CHIP program.

General Eligibility-Eligibility Processing (CS24): To provide assurances and information with respect to application and redetermination processing, eligibility screening and enrollment.

General Eligibility-Beginning Date of Eligibility (CS25): To provide information as to the methodology used in determining the effective date of eligibility.

General Eligibility-Ending Dates of Eligibility (CS26): To provide information as to the methodology used in determining the ending date of eligibility.

General Eligibility-Continuous Eligibility (CS27): To elect the option to provide continuous eligibility (CE) coverage and if so, provide information as to the administration of continuous eligibility.

General Eligibility–Presumptive Eligibility for Children (CS28): To elect the option to provide presumptive eligibility (PE) for children and if so, provide information as to the administration of presumptive eligibility.

General Eligibility–Presumptive Eligibility for Pregnant Women (CS29): To elect the option to provide presumptive eligibility (PE) to pregnant women and if so, provide information as to the administration of presumptive eligibility for pregnant women.

General Eligibility-List of Qualified Entities (CS30): For states which elected to provide presumptive eligibility, to identify the types of organizations it uses as qualified entities.

General Eligibility-Express Lane Eligibility (CS32): To elect the option to use Express Lane agencies to determine whether a child meets one or more of the requirements for CHIP eligibility and if yes, provide information as to how Express Lane will be administered.

General Eligibility-Express Lane Agencies (CS33): For states which elected to use Express Lane Eligibility, to designate which agencies will be used by the State as Express Lane Agencies.

General Eligibility - Express Lane Eligibility Components (CS34): For states which elected to use Express Lane Eligibility, to specify the eligibility components used by each Express Lane Agency used by the State.