CHIP Administration & Eligibility

Template CS22 – Non-Financial Requirements

Statute: Section 2110(b)(2)(B) of the SSA

Regulation: 42 CFR 457.310(c)(1)

INTRODUCTION

To be completed by States with separate child health assistance programs.

In template CS22, States provide assurances with respect to several non-financial eligibility requirements not covered in other sections of the plan.

BACKGROUND

As a condition of eligibility, an individual may not be:

• Found eligible for Medicaid;

• Covered under a group health plan or other health insurance coverage as defined in section 2791 of the Public Health Service Act;

• Excluded from CHIP coverage due to a pre-existing medical condition;

• An inmate of a public institution, as defined in 42 CFR 435.1010;

• A patient in an institution for mental diseases, as defined at 42 CFR 435.1010, at the time of initial application or any redetermination of eligibility; or

• Eligible for public employee health benefits coverage (Note: Under section 2110(b)(2)(B) of the Act, States are permitted to extend CHIP eligibility to children of State employees who are otherwise eligible under the State child health plan to the extent that one of two conditions is met at 2110(b)(6). Please see State Health Office letter #11-002 on this state option).

TECHNICAL GUIDANCE

This template includes three assurances, with respect to requirements which would cause an individual to be ineligible for CHIP, that apply to all States.

The fourth assurance regarding the ineligibility of individuals who are eligible for public employee health benefits coverage is displayed only for States who do not cover children or pregnant women with access to public employee coverage.

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

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