CHIP Administration & Eligibility

CS4 – Separate Child Health Insurance Program - Covered Groups

Statute: 2102

Regulation: 42 CFR 457

Additional References: SHO # 02-004 dated November 12, 2002, SHO # 09-006, dated May 11, 2009, SHO # 09-009, dated August 31, 2009 and SHO # 09-010, dated September 3, 2009.

INTRODUCTION

To be completed by states with a separate child health assistance program

Template CS4 displays a list of covered groups from which a state can select those which it wants to include in its State Plan.

BACKGROUND

States may choose to provide coverage for targeted low-income children (TLIC); children born to targeted low-income pregnant women during their first year of life (Deemed Newborns); from conception to birth for TLIC; to targeted low-income pregnant women; to targeted low-income children and pregnant women who have access to public employee coverage; and dental-only supplemental coverage to children.

In 2014 and 2015 all states must provide coverage through a separate CHIP to children who were enrolled in Medicaid as of December 31, 2013 and who were determined to be ineligible for Medicaid as a result of the loss of income disregards at their first redetermination using MAGI methodologies.

Uninsured, low-income children in families with income above the Medicaid limits are the original group of individuals for whom CHIP was initially created. The definition of Targeted low-income children can be found at 42 CFR 457.310.

The definition of child was revised in October 2002 to include from conception up to age 19. This revision gave states the option to provide coverage for prenatal care to uninsured low-income pregnant women who are not eligible for Medicaid. This option is still available to States although CHIPRA 2009 added a plan amendment option for states to cover pregnant women.

CHIPRA added section 2112 of the SSA effective April 2009 to allow States to provide pregnancy related assistance to uninsured pregnant women, referred to as targeted low-income pregnant women (TLIPW). Prior to this time, some States provided coverage to uninsured pregnant women either through an 1115 demonstration program or under the CHIP State plan by providing coverage from conception to birth, as described above. CHIPRA also added deemed eligibility for children born to targeted low- income pregnant women receiving pregnancy-related assistance on the date of the child’s birth. This group is referred to as ‘Deemed Newborns.’ Additional information for these options may be found in SHO # 02-004 dated November 12, 2002, SHO # 09-006, dated May 11, 2009, SHO # 09-009, dated August 31, 2009 and SHO # 09-010, dated September 3, 2009.

CHIPRA also added paragraph (b)(5) to section 2110 of the SSA, giving states the option to provide dental-only supplemental coverage to children who have health insurance coverage through an employer but are uninsured or underinsured with respect to dental coverage. Additional information for this optional coverage may be found in SHO #09-012, dated October 7, 2009

The definition of a targeted low-income child was revised again in 2011 by the Affordable Care Act (ACA) amending section 2110(b)(6) of the SSA. This change gives States the option to offer CHIP eligibility to children of State employees who are otherwise eligible, except for having access to public employee coverage, if certain conditions are met. States that offer coverage to targeted low-income pregnant women may also extend coverage to pregnant women under this option. Additional information for these options may be found in SHO # 11-002, dated April 4, 2011.

The definition of targeted low-income child was revised again by the ACA to include children enrolled in Medicaid on December 31, 2013, who lose Medicaid eligibility as a result of the elimination of income disregards. States are required to provide separate CHIP coverage to these children until the date of the child's next CHIP renewal.

TECHNICAL GUIDANCE

This section displays a list of covered groups. States select the group or groups which the State elects to cover by placing a check next to the name of the group. Only the group entitled Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards is pre-selected as all states must provide coverage to this group.

Validation: If the State selects ‘Pregnant Women Who Have Access to Public Employee Coverage’, the system checks for whether or not ‘Targeted Low-Income Pregnant Women’ was also selected by the CHIP Agency.

If the validation fails, that is the State checked ‘Pregnant Women Who Have Access to Public Employee Coverage’ and they have not also checked ‘Targeted Low-Income Pregnant Women,’ the following message will display:

‘This option cannot be selected unless the State also elects the option to provide coverage to pregnant women as provided in Section 2112 of the SSA.’

This template will not be accepted by the system if the validation fails and the State does not correct by either selecting ‘Targeted Low-Income Pregnant Women’ or de-selecting ‘Pregnant Women Who Have Access to Public Employee Coverage’.

Validation: if Targeted Low-Income Pregnant Women is selected, the system checks for whether or not ‘Deemed Newborns’ was also selected.

If the validation fails, that is the State checked Targeted Low-Income Pregnant Women, but not ‘Deemed Newborns’ the following message will display:

‘Newborns of TLIPW are deemed approved for CHIP or Medicaid, as appropriate, and the State must select the 'Deemed Newborns' covered group if also covering TLIPW. If you wish to select TLIPW, you must first select Deemed Newborn.’

This template will not be accepted by the system if the validation fails and the State does not correct by either selecting 'Deemed Newborns' or de-selecting ‘Targeted Low-Income Pregnant Women’.

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