CMS-10398 #17 Eligibility - Dental Only Supplemental Coverage

CHIP Eligibility
OMB Control Number: 0938‐1148

Separate Child Health Insurance Program
Eligibility - Dental Only Supplemental Coverage

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Section 501 of CHIPRA 2009 and section 2110(b)(5) of the SSA

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Dental Only Supplemental Coverage - Coverage to targeted low-income children who are otherwise eligible for CHIP but for the
fact that they are enrolled in a group health plan or health insurance offered through an employer.
The CHIP Agency operates this covered group in accordance with the following provisions:
Income Standards
The state uses the same income standards for Dental only supplemental coverage as are used for other targeted low income
children.
The state provides assurance that the state has the highest income eligibility standard permitted under Title XXI (or a waiver) as
of January 1, 2009, in order to be able to provide Dental only supplemental coverage
The state provides assurance 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 such children for child health assistance under the state plan

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #17). The time
required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions,
search existing data resources, gather the data needed, and complete and review the information collection. If you have comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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