CHIP Administration & Eligibility

Template CS12 – Dental Only Supplemental Coverage

Statute: Section 2110(b)(5) of the SSA

Regulation:

Additional References: Section 501 of CHIPRA 2009 and SHO #09-012 dated October 7, 2009

INTRODUCTION

This template applies only to States with separate child health assistance programs.

Template CS12 displays only for and must be completed by States that elected the option to provide Dental Only Supplemental Coverage.

In this template, states provide information with regards to eligibility criteria, including income standards, specific to the Dental Only Supplemental Coverage covered group.

BACKGROUND

CHIPRA 2009 added section 2103(c)(5) of the Social Security Act requiring coverage of dental services ‘necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions’ for children enrolled in CHIP.

CHIPRA also added section 2110(b)(5), which gives States with separate CHIP programs the option to offer dental-only supplemental coverage to children who have health insurance coverage through an employer but are uninsured or underinsured with respect to dental coverage. The same coverage must be provided under the Dental Only Supplemental Coverage as provided to other children enrolled in CHIP.

Children can enroll in the dental-only supplemental coverage even if their group health plan or other health insurance coverage includes some dental benefits.

Children of State employees would qualify for Dental Only supplemental Coverage if they meet the exception under 42 CFR 457.310(c)(1), i.e. when the State makes no more than a nominal payment for the cost of their State employee coverage ($10 or less per month).

A State may limit coverage under this option to children whose family income does not exceed a level specified by the State, so long as the specified level does not exceed the maximum income level used by the State for other CHIP eligible children.

A State may not offer supplemental dental coverage if it has implemented a waiting list for their CHIP medical or their CHIP dental program or if its highest income eligibility level does not equal the highest income eligibility standard permitted under Title XXI (or a waiver) as of January 1, 2009.

Additional information may be found in SHO #09-012 dated October 7, 2009.

TECHNICAL GUIDANCE

This template is broken down into the following sections:

Eligibility Determination Assurance

Income Standards

Additional Assurances

Eligibility Determination Assurance

Template CS12 begins with the CHIP Agency being asked to provide assurance that it determines eligibility for this group in accordance with the provisions that follow.

The State provides this affirmative assurance by checking the box next to the assurance statement. If the State does not check this box, the system will not accept this template for review and approval.

Income Standards

The State is then asked to provide income standards, beginning with a Y/N question as whether the state uses the same income standards for Dental only supplemental coverage as are used for other targeted low income children.

If the answer is yes, the system will assign the standards to this group that the CHIP Agency entered for TLIC and no additional entries need to be made by the Agency

If the answer is no, the system displays a Y/N question as to whether income standards are applied statewide.

• If the answer is yes, another Y/N question displays asking if there are any exceptions, e.g. populations in a county which may qualify either under a statewide income standard or a county income standard.

• If the answer to this second question is no, that is income standards are statewide with no exceptions, a grid asking for age and income is displayed for the CHIP Agency to complete. See guidance for Template CS6 for instructions on completing the age and income standards grid.

Validation: A cross- check will be done of each FPL range entered against FPL standards for TLIC children of the same age to ensure that the upper end of the income standard does not exceed that of TLIC.

If the validation fails, an error message gets displayed and the Agency is given the opportunity to correct.

• If the answer to this second question is yes, then the State must type in an explanation which includes a description of the overlapping geographic area and the reason for having different income standards. The State must then enter both their statewide income standards (see guidance for CS6) as well as income standards which vary by geography. See instructions below for completion of geographic standards.

Review Criteria

The description should be sufficiently clear, detailed and complete to permit the reviewer to determine that the State’s election meets applicable federal statutory, regulatory and policy requirements.

Validation: A cross- check will be done of each FPL range entered against FPL standards for TLIC children of the same age to ensure that the upper end of the income standard does not exceed that of TLIC.

If the validation fails, an error message gets displayed and the Agency is given the opportunity to correct.

• If the answer to whether income standards are applied statewide is no, the State must then select between two options:

  • Standard varies by county or city, or

  • Standard varies in some other geographic way

Standard varies by county or city

If ‘Standard varies by county or city’ gets checked, a dropdown list of counties is displayed for selection. States should select all the counties having the same standards at one time. Once a State has indicated that it has selected all the counties having the same income standards, a grid asking for age and income information is displayed for the CHIP Agency to complete. See guidance for Template CS6 for instructions on completing the age and income standards grid. After the age and income standards grid is completed, the process of selecting counties and completing the age and income grid standards grid is repeated until all the counties have been selected.

After the county standards have been completed, a Y/N question is displayed, asking if have any cities within your State have their own separate income standards. If the answer is yes, the CHIP Agency must enter in the name of the city. The age and income standards screen is then displayed and must be completed for city entered. If there are multiple cities within the State with separate income standards, the State may reselect the city name field and repeat the process until all the cities have been entered. See guidance for Template CS6 for instructions on completing the age and income standards grid.

Validation: A cross- check will be done of each FPL range entered against FPL standards for TLIC children of the same age to ensure that the upper end of the income standard does not exceed that of TLIC.

If the validation fails, an error message gets displayed and the Agency is given the opportunity to correct.

Standard varies in some other geographic way

If ‘Standard varies in some other geographic way’ gets checked, the State is asked to name and describe the geographic area. States may name multiple geographic areas. The age and income standards screen is then displayed and must be completed for each geographic name entered. If there are multiple geographic areas within the State with separate income standards, the State may reselect the name field and repeat the process until all the geographic areas have been entered. See guidance for Template CS6 for instructions on completing the age and income standards grid.

Validation: A cross-check of each FPL range entered against FPL standards for TLIC children of the same age to ensure that the upper end of the income standard does not exceed that of TLIC.

If the validation fails, an error message gets displayed and the Agency is given the opportunity to correct.

Additional Assurances

The income section is followed by the State being asked to provide two assurances:

• That the State has the highest income eligibility standard permitted under Title XXI (or a waiver) as of January 1, 2009; and

• That the State does not limit the acceptance of applications for children or impose any numerical limitation, waiting list, or similar limitation on the eligibility of children under the State plan.

The State provides these affirmative assurances by checking the box next to each assurance statement. If the State does not check this box, the system will not accept this template for review and approval.

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