CHIP Administration & Eligibility

Template CS28 – General Eligibility – Presumptive Eligibility for Children

Statute: Sections 2107(e)(1)(L) and 1920A of the SSA

Regulation: 42 CFR 457.355

INTRODUCTION

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

In template CS28, States indicate if they elect the option to provide presumptive eligibility (PE) for children and if so, provide information as to the administration of presumptive eligibility. This template is used in conjunction with template CS(30) Qualified Entities.

BACKGROUND

States may elect to apply presumptive eligibility for children provided that the requirements of section 1920A of the SSA are satisfied.

Under presumptive eligibility States may pay costs of coverage under CHIP during a period of presumptive eligibility for children applying for CHIP, pending the screening process and a final determination of eligibility, provided that the PE determination was made by a qualified entity. Section 1920A of the SSA defines certain types of entities which may be used as qualified entities for the purpose of making determinations of presumptive eligibility. Agencies must meet at least one of the requirements specified in the Act.

TECHNICAL GUIDANCE

This template is broken down into the following sections:

Selection and Description of Presumptive Eligibility

Selection of Qualified Entities

Selection of Presumptive Eligibility Option

In this section, States respond to a Y/N question as to whether the CHIP Agency covers children when determined presumptively eligible by a qualified entity.

If the answer is no, no additional entries are required by the State on this screen.

If the answer is yes, the State is then asked to:

• Describe the population of children to whom presumptive eligibility applies.

• Describe the duration of the presumptive eligibility period and any limitations.

• Describe the application process and eligibility determination factors used.

The State enters the requested information in the text boxes provided.

Review Criteria

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

Selection of Qualified Entities

This section begins with a pre-checked statement that the CHIP Agency uses qualified entities, as defined in section 1920A, to determine eligibility presumptively for this eligibility group.

Template CS30 is then displayed for the State to indicate which types of organizations are used as qualified entities.

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