GenIC #17 (Revision): CHIP State Plan Eligibility

CS12 – Dental Only Supplemental Coverage

Statute: 2110(b)(5) of the SSA

Formal Guidance: SHOL #09-012 dated October 7, 2009

INTRODUCTION

This state plan page (fillable PDF) applies only to states with separate child health assistance programs.

State plan page CS12 must be completed by states which currently have or elect the option to provide Dental Only Supplemental Coverage. States that do not elect to provide Dental Only Supplemental Coverage need not complete this state plan page.

In this state plan page, states provide information with regard to eligibility criteria, including income standards, specific to the Dental Only Supplemental Coverage covered group.

BACKGROUND

The Children’s Health Insurance Reauthorization Act of 2009 (CHIPRA) added section 2103(c)(5) of the Social Security Act requiring coverage of dental services “necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions” for children enrolled in CHIP.

CHIPRA also added section 2110(b)(5), which gives states with separate CHIP programs the option to offer dental-only supplemental coverage to children who have health insurance coverage through an employer but are uninsured or underinsured with respect to dental coverage. States electing this option must provide the same coverage under the Dental Only Supplemental Coverage as provided to other children enrolled in CHIP.

Children can enroll in the dental-only supplemental coverage even if their group health plan or other health insurance coverage includes some dental benefits.

Children of state employees may qualify for Dental Only Supplemental Coverage if they meet the exception under 42 CFR 457.310(c)(1), i.e. the state makes no more than a nominal payment for the cost of their state employee coverage ($10 or less per month).

A state may limit coverage under this option to children whose family income does not exceed a level specified by the state, so long as the specified level does not exceed the maximum income level used by the state for other targeted low-income children.

In order to offer supplemental dental coverage, a state may not implement a waiting list for its CHIP medical or CHIP dental program, and the CHIP plan must cover children to the highest income eligibility standard permitted under title XXI (or a waiver) as of January 1, 2009 (i.e., if not under a waiver, 200 percent of the FPL or 50 percentage points above the applicable Medicaid income level for the child’s age).

Additional information may be found in SHOL #09-012 dated October 7, 2009.

TECHNICAL GUIDANCE

PREREQUISITES:

State plan page CS7 - Targeted Low-Income Children must also have been submitted prior to or concurrently with state plan page CS12.

State plan page CS15 - MAGI-Based Income Methodologies must also have been submitted prior to or concurrently with state plan page CS12.

Review Criteria

If state plan pages CS7 (targeted low-income children) and CS15 (MAGI-Based Income Methodologies) are not approved, state plan page CS12 cannot be approved.

This state plan page is broken down into the following sections:

• Eligibility Determination Assurance

• Income Standards

• Additional Assurances

Eligibility Determination Assurance

State plan page CS12 begins with the state being asked to provide assurance that it determines eligibility for this group in accordance with the provisions that follow.

The state provides this affirmative assurance by checking the box next to the assurance statement.

Review Criteria

The state must check the assurance box or this state plan page cannot be approved.

Income Standards

The state is then asked to provide income standards, beginning with a Yes/No question as whether the state uses the same income standards for Dental only supplemental coverage as are used for other targeted low income children.

Review Criteria

The state must select either yes or no or this state plan page cannot be approved.

If the answer is yes, then no further entry is required in this section and the state moves on to the last section of this state plan page labeled “Additional Assurances” (see instructions below).

If the answer is no, the state responds to the Yes/No question as to whether income standards are applied statewide.

Review Criteria

The state must select either yes or no or this state plan page cannot be approved.

• If the answer to this second question is yes, the state also responds to the next Yes/No question asking if there are any exceptions, e.g. populations in a county which may qualify either under a statewide income standard or a county income standard.

Review Criteria

The state must select either yes or no or this state plan page cannot be approved.

• If the answer to this third question is no, that is income standards are statewide with no exceptions, the state then enters the ages and income standards for each age range in the grid provided. See below for instructions on completing the age and income standards grid.

Review Criteria

The state must enter their statewide income standards (age and FPL levels) or this state plan page cannot be approved.

• If the answer to this third question is yes, that is there are exceptions to income standards being statewide, the state then enters an explanation which includes a description of the overlapping geographic area and the reason for having different income standards.

Review Criteria

The state must enter a description or this state plan page cannot be approved. 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 state then enters both their statewide income standards as well as income standards which vary by geography (county, city or other geographic way) in the grid provided. See instructions below for completion of the age and income standards grid.

Review Criteria

The state must enter their statewide income standards (age and FPL levels) as well as selecting a geographic option and entering the income standards (age and FPL levels) for that geographic option or this state plan page cannot be approved.

• If the answer to whether income standards are applied statewide is no, the state then selects between the following two options:

• Standard varies by county or city, or

• Standard varies in some other geographic way

Review Criteria

The state must select a geographic option or this state plan page cannot be approved.

Standard varies by county or city

If the state selects “Standard varies by county or city”, it enters all the counties having the same age and income standards at one time and then enters the age and income standards for that set of counties in the grid provided. If there are additional counties with different age and income standards, repeat the process until all the counties with different standards have been entered. See instructions below on completing the income standards information.

Review Criteria

The state must enter the county names and their respective income standards (age and FPL levels) or this state plan page cannot be approved.

After completing the county standards, the state responds to the Y/N question asking if any cities within your state have their own separate income standards. If the answer is yes, the state enters the name of each city having the same age and income standards, and then enters the age and income standards for those cities. If there are additional cities with different age and income standards, repeat the process until all the cities with different standards have been entered. See instructions below on completing the income standards information.

Review Criteria

The state must enter the city names and their respective income standards (age and FPL levels) or this state plan page cannot be approved.

Standard varies in some other geographic way

If the state selects “Standard varies in some other geographic way”, it names and describes the geographic area(s) and then enters the age and income standards for that geographic area in the age and income standards grid. If there are additional geographic areas within the state, with different age and income standards, repeat the process until all the geographic areas with different standards have been entered. See instructions below on completing the age and income standards information.

Review Criteria

The state must enter the names and descriptions of the geographic areas and their respective income standards (age and FPL levels) or this state plan page cannot be approved.

Instructions for Completing the Age and Income Grid

States are asked to first provide the age range to which a qualifying income standard applies and then to enter the household income range that applies to the age range entered.

For “From Age” and “To Age”, states select ages from a drop down list of values from zero through 19.

Note: The “From Age” includes the child’s birthday. The “To Age” should be read as “up to, but not including”. That is, for example, up to age 6 means until the child’s sixth birthday but not including the child’s birthday.

Review Criteria

Unless the state includes an explanation with the reason for having age overlaps, there should not be overlaps from one age range to the next. There should also not be any gaps from one age range to the next. In order to avoid age gaps, the “To Age” of each age range should be the same as the “From Age” of the next age range (e.g., up to (but not including) age 6, and on the next line from age 6 up to…). Although the same number is entered for “To Age” as for “From Age” of the next age range, this does not constitute an overlap. However two age ranges that both include the same ages, such as the first two years of life (From age 0 up to (but not including) age 2 on one line and from age 0 up to (but not including) age 6) on the next line is an overlap and must include a description. The description must include a justification for the age overlap, e.g. a higher income standard is used for targeted populations, such as children with disabilities or children under a specified age born to mothers enrolled in a prenatal program.

Additionally, for each age range the number entered for “To Age” must be greater than the number entered for “From Age”.

There are two fields for household income ranges, labeled “Above” for the lower end of the income standard and “Up to and including” for the upper bound of the income standard. The state enters the Federal Poverty Level (FPL) percentages, applicable to the income standard used for the age range selected.

Note: The “Above” amount does not equal the actual dollar amount represented by the FPL percentage entered, but rather, it is equal to one cent above the dollar amount represented by the FPL percentage entered. However, “Up to and including” is inclusive of the actual dollar amount represented by the FPL percentage entered. Example: for income range of above 185% (dollar value = $1,850) up to and including 250% (dollar value = $2,500), the lower end equals $1,850.01 and the upper end equals $2,500 exactly).

If the state has different income standards for different age groups, the state reselects the button to the left of the age/income grid and repeats the process until all the income standards have been entered.

Review Criteria

Within each income range entered, the number for “Up to and including” must be greater than the number entered for “Above”.

No matter how the state varies the income thresholds for this option, the number entered for the lower end of each income range, which is the “Above” column, must be equal to the qualifying income standard used in CS7 for targeted low-income children of the same age. For example, if the applicable lower income limit (amount entered in “Above”) for targeted low-income children is 133 percent of the FPL, then the number entered for “Above” (i.e. the lower income for dental-only supplemental coverage) would also be 133 percent of the FPL.

Additionally, the number entered for the highest qualifying income limit, which is the “Up to and including” column, must not be greater than the highest income limit entered for targeted low-income children in CS7 for children of the same age.

Additional Assurances

The income section is followed by the state being asked to provide two assurances:

• That the state has the highest income eligibility standard permitted under Title XXI (or a waiver) as of January 1, 2009; and

• 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 children under the state plan.

The state provides these affirmative assurances by checking the box next to each assurance statement.

Review Criteria

The state must check both assurance boxes, or this state plan page cannot be approved.

8