CHIP Administration & Eligibility

Template CS24 – General Eligibility - Eligibility Processing

Statute: Section 2102(b)(3) & 2107(e)(1)(O) of the SSA

Regulation: 42 CFR 457, subpart C; 457.110

INTRODUCTION

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

In template CS24, States provide assurances and information with respect to application and redetermination processing, eligibility screening and enrollment.

BACKGROUND

The ACA requires States to have processes/procedures in place for enrollment simplification and coordination with state health insurance exchanges and Medicaid. Section 2107(e)(1)(O) of the Social Security Act requires the application of these requirements to CHIP to the same extent as they apply to Medicaid under section 1943(b) of the SSA.

These processes/procedures must:

• Include the availability of an Internet website for use by individuals to apply for, be enrolled in and to renew their enrollment in medical assistance (including CHIP), and to consent to enrollment or reenrollment through the use of electronic signature;

• Include facilitation of enrollment of individuals who are identified by an Exchange or Medicaid as being eligible for CHIP;

• Ensure that individuals who apply for but are determined to be ineligible CHIP or Medicaid, are screened for eligibility for enrollment in qualified health plans offered through an Exchange and for premium assistance for the purchase of a qualified health plan, and if eligible, enrolled in a such plan or premium assistance without having to submit an additional or separate application;

• Ensure that the Medicaid State agency, the CHIP State agency and the State’s Exchange utilize a secure electronic interface;

• Include coordination for individuals who are enrolled in the Medicaid State plan or under a waiver of the plan and who are also enrolled in a qualified health plan offered through an Exchange, and for individuals who are enrolled in the State child health plan under title XXI and who are also enrolled in a qualified health plan, the provision of medical assistance or child health assistance to such individuals with the coverage provided under the qualified health plan in which they are enrolled; and

• Include outreach to and enrollment of vulnerable and underserved populations eligible for medical assistance, including children, unaccompanied homeless youth, children and youth with special health care needs, pregnant women, racial and ethnic minorities, rural populations, victims of abuse or trauma, individuals with mental health or substance-related disorders, and individuals with HIV/AIDS.

State CHIP agencies may also enter into an agreement:

• With an Exchange established by the State under which the State CHIP agency may determine whether a State resident is eligible for premium assistance for the purchase of a qualified health plan. The agreement would have to meet conditions and requirements as the Secretary of the Treasury may prescribe to reduce administrative costs and the likelihood of eligibility errors and disruptions in coverage.

• With an Exchange or the State Medicaid Agency to accept CHIP eligibility decisions made by the Exchange or the Medicaid Agency and to furnish CHIP to the same extent and in the same manner as if the applicant had been determined by the CHIP Agency to be eligible for CHIP.

State CHIP agencies are required to:

• Participate in and comply with the requirements for the system established by CMS (under section 1413 of the Patient Protection and Affordable Care Act), relating to streamlined procedures for enrollment through an Exchange, Medicaid, and CHIP;

• Use the single, streamlined application form developed by CMS or a State developed application form approved by CMS;

• Participate in a data matching arrangement for determining individual’s eligibility for participation in the program;

• Screen applications for other insurance affordability programs and, where appropriate, transfer the electronic account (electronic application data) of individuals to other insurance affordability programs, promptly and without undue delay.

States utilizing approved enrollment caps or waiting lists must have procedures in place for the administration of the cap or waiting list, including a process for deciding which children will be given priority for enrollment, how children will be informed of their status on a waiting list and the circumstances under which enrollment will reopen.

Due to the ACA maintenance of effort requirement, as a condition of receiving payments under section 1903(a), States cannot have in effect eligibility standards, methodologies, or procedures under its State CHIP plan that are more restrictive than the eligibility standards, methodologies, or procedures in effect on the date of enactment of the ACA. This requirement applies for the time period of March 23, 2010 through September 30, 2019.

Consequently, during this time period, States which did not have an enrollment cap or waiting list in effect as of March 23, 2010 may not impose an enrollment cap or waiting list to categories of populations covered under their CHIP State Plan as of March 23, 2010.

TECHNICAL GUIDANCE

This template is broken down into the following sections:

Assurance

Application Processing

Screen and Enroll Process

Redetermination Processing

Screening by Other Insurance Affordability Programs

Limitation on Enrollment

Assurance

Template CS24 begins with the CHIP Agency being asked to provide assurance that it meets all of the requirements of 42 CFR 457, subpart C for application processing, eligibility screening and enrollment.

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.

Application Processing

This section begins with the State being asked to indicate which application(s) the agency uses for all insurance affordability programs. The options are:

1. The single, streamlined application developed by the Secretary

2. An alternative single, streamlined application developed by the State and approved by the Secretary

3. An alternative application used to apply for multiple human service programs approved by the Secretary

If the State selects option 2 (an alternative single, streamlined application developed by the State and approved by the Secretary), it must attach a copy of the application via the Upload function.

Validation: The system will not allow the selection of option 3 (an alternative application used to apply for multiple human service programs approved by the Secretary), unless the State selected either option 1 or 2 or both options 1 and 2 first. States selecting option 3 must also attach a copy of this application via the Upload function.

Next, the State is asked to provide assurance that the agency's procedures permit the submittal of an application via the internet website described in CFR 457.340(a), by telephone, via mail, in person and other commonly available electronic means.

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.

The last part of this section asks the agency to indicate by what other electronic means (i.e. other than the internet website) it accepts applications. The Agency would do so by checking the box next to the ‘other electronic means’ option and then entering the name and description of this other means of accepting applications. If the State has more than one other electronic means, it can reselect ‘name of method’ until all other means are entered.

Examples of other electronic means include: by fax or an attachment to an email.

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.

Screen and Enroll Process

This section begins with the State being asked to provide assurance that it has coordinated eligibility and enrollment screening procedures in place that are applied at time of initial application, periodic redeterminations, and follow-up eligibility determinations.

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.

This assurance is followed by a listing of three procedures which are pre-checked as they are required by regulation of all States.

This is followed by a Y/N question asking if the CHIP agency has entered into an arrangement with the Exchange to make eligibility determinations for advanced premium tax credits in accordance with section 1943(b)(2) of the SSA. Regardless of whether the State responds with a yes or no to this question, no additional data entry is required.

Redetermination Processing

This section consists or an assurance that redeterminations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed consistent with 42 CFR 457.343.

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.

Screening by Other Insurance Affordability Programs

This section begins with the State being asked to provide assurance that it has adopted procedures to accept and process electronic accounts of individuals screened as potentially eligible for CHIP by other insurance affordability programs in accordance with the requirements of 42 CFR 457.348(b) and to determine eligibility in accordance with 42 CFR 457.340 in the same manner as if the application had been submitted directly to, and processed by the State.

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.

Immediately following the assurance, the CHIP Agency may indicate, by checking the box next to the option, if it elects the option to accept CHIP eligibility decisions made by another Insurance Affordability Program as provided in 42 CFR 457.348 and to furnish CHIP in accordance with requirements of 42 CFR 457.340 to the same extent and in the same manner as if the applicant had been determined by the State to be eligible for CHIP.

If the CHIP Agency checks this option, the State must then select from the three options displayed as to which insurance affordability programs. One, two or all three of the options may be selected.

If the State selects ‘Other Insurance Affordability Program’, it must enter the name of the insurance affordability program in the text box provided. If there is more than one other insurance affordability program, the State may re-select this option until they have all been entered.

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.

The last part of this section asks the Agency to provide assurance that it has entered into an agreement with other insurance affordability programs to fulfill the requirements of 457.348(a) and will provide this agreement to the Secretary upon request.

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.

Limitation on Enrollment

This section is broken down into the following subsections:

Background Information

Request for Placing Limitations on Enrollment

Background Information

This section begins with a Y/N question asking if the State had an approved plan allowing for enrollment limits and the imposition of an enrollment freeze as of March 23, 2010.

If the answer is yes, the State must attach a copy of State's current approved State Plan and letter from CMS granting approval for the enrollment cap and/or waiting list through the Upload function before responding to the next question. See the next paragraph (If the answer is no) for instructions related to this next question.

If the answer is no, a Y/N question is displayed asking if the State has expanded eligibility after 3/23/10.

If the answer is no, there are no additional questions for the State.

If the answer is yes, another Y/N question is displayed asking if the State wants to request approval for placing enrollment limitations to the expansion population.

If the answer is yes, the State must first describe the expansion population in the text box provided before completing the ‘Request for Placing Limitations on Enrollment’ section.

Note: In the description of the expansion population, States should be sure to only include covered groups which were added to the State Plan after March 23, 2010.

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.

Request for Placing Limitations on Enrollment

This subsection is broken down into:

• Amendment Type

• Enrollment Cap

• Waiting List

Amendment Type

This section begins with the State selecting one of the two following options:

• Specific state plan amendment indicating that a cap will be instituted as of a specific date or enrollment number.

• Amendment seeking general authority to implement a cap when needed without specifying a date or enrollment number.

If the State selects ‘Specific state plan amendment indicating that a cap will be instituted as of a specific date or enrollment number’, the State must then select from the following options as to when enrollment becomes capped:

• Enrollment reaches a certain level

• Expenditures reach a certain level

• Other

If the State selects ‘Enrollment reaches a certain level’, the State must then enter in the enrollment cap number in the box provided.

If the State selects ‘Expenditures reach a certain level’, the State must then enter in the dollar amount in the box provided.

If the State selects ‘Other’, it must enter a description in the text box provided. If there is more than one other criterion, the State may reselect the ‘other ‘ option until they have all been entered .

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.

Regardless of which option is selected, the CHIP Agency is asked to provide assurance that it will provide to CMS, written advance notice of at least 30 days prior to implementing an enrollment freeze.

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.

Enrollment Cap

Following the assurance, the State must describe how it will notify applicants and the public of the cap, in the text box provided. States should be sure to include of modes of communication (e.g. written communication; print media, radio or TV ads or public service announcements) as well as the schedule (e.g. written communication to applicants at time of application, ads in local newspapers once a month for the duration of the enrollment freeze).

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.

Next is a Y/N question asking if the enrollment cap can apply to individuals who do not renew their eligibility at redetermination and who subsequently re-apply?

If the answer is yes, States must indicate how it will notify current enrollees from a list of options provided.

If the State selects ‘other’, it must enter a description in the text box provided. States should be sure to include modes of communication (e.g. written communication; print media, radio or TV ads or public service announcements) as well as the schedule (e.g. written communication to applicants at time of application, ads in local newspapers once a month for the duration of the enrollment freeze).

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.

Waiting List

The next Y/N question asks if the state will implement a waiting list.

If the answer is yes, The State is asked to provide assurance that applications are screened for Medicaid or other insurance affordability programs and referred as appropriate.

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.

The first follow-up question asks how the State will provide public notice of the waiting list. States must select one or both of the options listed.

Note: If the State selects ‘other’, it must enter a description in the text box provided. States should be sure to include of modes of communication (e.g. written communication; print media, radio or TV ads or public service announcements) as well as the schedule (e.g. written communication to applicants at time of application, ads in local newspapers once a month for the duration of the enrollment freeze).

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.

The second follow-up question asks if there will be exceptions to the waiting list. States must select one or all four of the options listed.

Note: If the State selects ‘other’, it must enter a description in the text box provided. Examples of additional exceptions include: children with special health care needs or high risk pregnancies.

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.

The third follow-up question asks how long after notification of removal from the waiting list will a family have to enroll. States must select one of the three options listed.

Note: States selecting ‘other’, should enter a number and the time period to which that number applies, e.g. 100 days, 6 months along with any other relevant information.

Review Criteria

The information 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.

The last follow-up question asks if the State will require updated or additional information from the family after removal from the waiting list and before enrolling children into CHIP.

If the answer is yes, the State is asked to provide a description in the text box provided. The description should include the type of follow-up and the time period applicants will be given to respond. An example of an acceptable response is that the State may ask if there has been a change in family circumstances for applicants who were on the waiting list for longer than 3 months and applicants will be given 15 days to respond.

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.

If the answer to waiting list is no, the State must indicate whether it will implement an open enrollment period.

If the answer is yes, the State is asked to provide an assurance that applications are screened for Medicaid or other insurance affordability programs and referred as appropriate.

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.

The first follow-up question asks How the State will provide public notice of the waiting list. States must select one or both of the options listed.

Note: If the State selects ‘other’, it must enter a description in the text box provided. States should be sure to include modes of communication (e.g. written communication; print media, radio or TV ads or public service announcements) as well as the schedule (e.g. written communication to applicants at time of application, ads in local newspapers once a month for the duration of the enrollment freeze).

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.

The second follow-up question asks if there will be exceptions to the open enrollment period. States must select one or all four of the options listed.

Note: If the State selects ‘other’, it must enter a description in the text box provided. Examples of additional exceptions include: children with special health care needs or high risk pregnancies.

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.

The third follow-up question asks how often will the State implement the open enrollment period. The State must select on one of the options listed.

Note: If the State selects ‘as circumstances warrant’, it must then respond in the text box provided to the following question: ‘On what will the state base this decision?’. Examples include: enrollment will be opened when enrollment reaches a certain level below the enrollment cap and re-frozen when enrollment nears the cap again or that enrollment will opened if expenditures increased at a slower pace than had been projected.

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.

If the State selects ‘other’, it must enter a description in the text box provided. If the State intends to open enrollment based on a schedule, other than once or twice a year, it should note timeframe in the description.

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: The system will check to ensure that the State responded with a yes to at least one of the two questions regarding having a waiting list or open enrollment. If the validation fails, an error message is displayed and the State is given the opportunity to change its answer to one or both of those questions.

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