GenIC #17 (Revision): CHIP State Plan Eligibility

CS24 – General Eligibility - Eligibility Processing

Statute: 2102(b)(3) & 2107(e)(1)(O) of the SSA

Regulation: 42 CFR 457, subpart C; 457.110

INTRODUCTION

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

In state plan page CS24, states provide assurances and information with respect to application processing, eligibility screening and enrollment in CHIP and other insurance affordability programs, and redetermination processing for CHIP. This plan page also allows states that wish to use an alternative application for CHIP to request permission to do so.

BACKGROUND

The ACA requires states to have processes/procedures in place for enrollment simplification and coordination with state health insurance exchanges and Medicaid. Section 2107(e)(1)(O) of the Social Security Act requires the application of these requirements to CHIP to the same extent as they apply to Medicaid under section 1943(b) of the SSA.

These processes/procedures must include the use of a single application for all insurance affordability programs and the availability of an internet website for use by individuals to apply for, be enrolled in, and to renew their enrollment in medical assistance (including CHIP); facilitation of enrollment of individuals who are identified by another insurance affordability program; coordination for CHIP-eligible individuals who are also enrolled in other health insurance plans; and outreach to and enrollment of vulnerable and underserved populations eligible for medical assistance.

States must also participate in and comply with the requirements for the system established by CMS (under section 1413 of the ACA), relating to streamlined procedures for enrollment through an Exchange, Medicaid, and CHIP; ensure that individuals who apply for but are determined ineligible for CHIP or Medicaid are screened for eligibility and enrollment in qualified health plans and for premium tax credit/cost-sharing reduction without having to submit an additional or separate application; transfer the electronic application data of individuals to other insurance affordability programs; participate in a data matching arrangement for determining individual’s eligibility for CHIP; and that the state Medicaid agency, the state CHIP agency and the state’s Exchange utilize a secure electronic interface.

State CHIP agencies must enter into an agreement with the Exchange or other agencies administering other insurance affordability programs to fulfill requirements related to application screening, coordination of eligibility, secure transfer of data and other requirements consistent with 42 CFR 457.348(b). State CHIP agencies may also enter into an agreement with the Exchange, under which the state CHIP agency may determine eligibility for premium assistance for the purchase of a qualified health plan; or with the Exchange or Medicaid Agency to accept CHIP eligibility decisions made by the Exchange or the Medicaid Agency.

TECHNICAL GUIDANCE

PREREQUISITES:

None

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

• Assurance

• Application Processing

• Screen and Enroll Process

• Redetermination Processing

• Screening by Other Insurance Affordability Programs

Assurance

State plan page CS24 begins with the CHIP Agency being asked to provide assurance that it meets all of the requirements of 42 CFR 457, subpart C for application processing, eligibility screening and enrollment.

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.

Application Processing

This section begins with the state being asked to indicate which application(s) the agency uses for individuals applying for coverage who may be eligible based on the applicable modified adjusted gross income standard. If a state is requesting approval of an alternative application (either streamlined or for multiple benefits) it must do so in this state plan page by selecting the applicable option. The application form(s) for the selected alternative application(s) must also be attached in order to receive approval from CMS.

The state selects one of the two options displayed.

Review Criteria

The state must select one of the two application options displayed or this state plan page cannot be approved.

• If the state selects “An alternative single, streamlined application developed by the state and approved by the Secretary…” it then attaches a copy of the application for CMS review.

Please note that the button stating “An attachment is submitted” is an inactive button used as a reminder for the state to attach a document to the MMDL. Each state plan amendment submission includes an MMDL screen that provides an upload function for attachments.

Review Criteria

The state must upload the application or this state plan page cannot be approved.

• Once the state has selected at least one of the two options above, a third option “An alternative application used to apply for multiple human service programs approved by the Secretary…” is displayed, which the state may select at its option. If the state selects this option, it must then attach a copy of the alternative application.

Please note that the button stating “An attachment is submitted” is an inactive button used as a reminder for the state to attach a document to the MMDL. Each state plan amendment submission includes an MMDL screen that provides an upload function for attachments.

Review Criteria

The state must upload the application or this state plan page cannot be approved.

Next, the state is asked to provide assurance that the agency’s procedures permit the submittal of 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 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.

If the agency accepts applications by other electronic means (i.e. other than the internet website), the state checks the box next to the “Other electronic means” option and then enters the name(s) and description(s) of these other means of accepting applications. Examples of other electronic means include: by fax or an attachment to an email.

Review Criteria

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.

Screen and Enroll Process

This section begins with the state being asked to provide assurance that it has coordinated eligibility and enrollment screening procedures in place that are applied at the time of initial application, periodic redeterminations, and follow-up eligibility determinations.

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.

This assurance is followed by a listing of three procedures which are pre-checked as they are required of all states.

This is followed by a Yes/No question asking if 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. Regardless of whether the state responds with a yes or no to this question, no additional information is required.

Review Criteria

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

Redetermination Processing

This section consists of an assurance that redeterminations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed consistent with 42 CFR 457.343. The assurance includes three pre-checked requirements related to redetermination processing.

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.

Screening by Other Insurance Affordability Programs

This section begins with the state being asked to provide 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 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.

The following option appears immediately after the assurance: “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.”

If the state checks this option, the state then selects from three options displayed to specify from which agency(ies) it will accept eligibility determinations. One, two or all three of the options may be selected.

Review Criteria

The state must select at least one of the options or this state plan page cannot be approved.

If the state selects “Other agency administering insurance affordability programs”, it then enters the name(s) of the agency or agencies.

Review Criteria

The names of the agencies entered must accurately reflect the names of the agencies, authorized to determine eligibility for insurance affordability programs, with whom the state has entered into an agreement.

The last part of this section asks the Agency to provide assurance that it has entered into an agreement with agencies administering other insurance affordability programs to fulfill the requirements of 457.348(a) and will provide this agreement to the Secretary upon request.

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.

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