CMS-10398 #17 General Eligibility - Eligibility Processing

CHIP Eligibility
OMB Control Number: 0938‐1148

Separate Child Health Insurance Program
General Eligibility - Eligibility Processing

CS24

2102(b)(3) & 2107(e)(1)(O) of the SSA and 42 CFR 457, subpart C
The CHIP Agency meets all of the requirements of 42 CFR 457, subpart C for application processing, eligibility screening and
enrollment.
Application Processing
Indicate which application the agency uses for individuals applying for coverage who may be eligible based on the applicable
modified adjusted gross income standard:
The single, streamlined application developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable
Care Act.
An alternative single, streamlined application developed by the state and approved by the Secretary in accordance with
section 1413(b)(1)(B) of the Affordable Care Act.
An attachment is submitted.
The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit 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 agency accepts applications in the following other electronic means.
Other electronic means:
Screen and Enroll Process
The CHIP Agency 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 procedures ensure that only targeted lowincome children are provided CHIP coverage and that enrollment is facilitated for applicants found to be potentially eligible for
other insurance affordability programs.
Procedures include:
■

Screening of application to identify all individuals eligible or potentially eligible for CHIP or other insurance affordability
programs; and

■

Income eligibility test, with calculation of household income consistent with 42 CFR 457.315 for individuals identified as
potentially eligible for Medicaid or other insurance affordability programs based on household income; and

■

Screening process for individuals who may qualify for Medicaid on a basis other than having household income at or below the
applicable MAGI standard, based on information in the single streamlined application.

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.

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CHIP Eligibility
Redetermination Processing
Redeterminations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross
income standard are performed as follows, consistent with 42 CFR 457.343:
■

Once every 12 months.

■

Without requiring information from the individual if able to do so based on reliable information contained in the individual's
account or other more current information available to the agency.

■

If the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional
information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the
information already available.

Screening by Other Insurance Affordability Programs
The CHIP Agency provides 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 CHIP Agency elects the option to accept CHIP eligibility decisions made by the Exchange or other agencies administering
insurance affordability programs 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.
The CHIP Agency has entered into an agreement with agencies administering other insurance affordability programs to fulfill the
requirements of 457.348(b) and will provide this agreement to the Secretary upon request.

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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