CMS-10398 #17 Non-Financial Eligibility - Substitution of Coverage

CHIP Eligibility
OMB Control Number: 0938‐1148

Separate Child Health Insurance Program
Non-Financial Eligibility - Substitution of Coverage

CS20

457.310(b)(2) and (b)(3), 457.320(a)(9) and 2110(b)(1)(C) of the SSA

Substitution of Coverage
The CHIP Agency provides assurance that it has methods and policies in place to prevent the substitution of group health
coverage or other commercial health insurance with public funded coverage. These policies include:
A waiting period during which an individual is ineligible due to having dropped group health coverage.
Other substitution of coverage prevention strategy:
If the state elects to offer dental only supplemental coverage, the following assurances apply:
The other coverage exclusion does not apply to children who are otherwise eligible for dental only supplemental coverage as
provided in section 2110(b)(5) of the SSA.
The waiting period does not apply to children eligible for dental only supplemental coverage.

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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