Revision 15-4; Effective October 1, 2015

 

 

D—1610 General Policy

Revision 15-4; Effective October 1, 2015

 

CHIP

Individuals enrolled in the Children's Health Insurance Program (CHIP) must complete the administrative renewal process explained in B-122.4, Medical Program Administrative Renewals. 

Depending on the renewal status outcome and client action, final eligibility determinations for CHIP may be made manually by advisors processing renewal documents or automatically by the system.

For individuals required to return a renewal packet, advisors must process the manual renewal as explained in B-122.4.2, Processing a Manual Renewal, while following the timelines explained in D-1630, Timely Redeterminations, and D-1631, Redetermination Processing Time Frames. 

CHIP Perinatal

There is no redetermination of CHIP perinatal coverage. The household is mailed a packet during the ninth month of eligibility, allowing the household to apply for medical coverage for the child.

 

D—1620 Notice of Expiration

Revision 15-4; Effective October 1, 2015

 

CHIP

The system generates and sends renewal correspondence to individuals enrolled in CHIP following the process explained in B-121, Notice of Redetermination/Certification Expiration, for TP 08 and Children's Medicaid (TP 43, TP 44 and TP 48).

CHIP Perinatal

A packet is mailed to the household after cutoff in the ninth month of coverage. This mailing occurs over a five-day period. The household is instructed to complete the application, attach verification and return the application within seven days.

In the 10th month of the perinatal enrollment segment, TIERS determines if the case has both a CHIP and a CHIP perinatal Eligibility Determination Group (EDG). If the CHIP perinatal enrollment segment ends before the end of the CHIP enrollment segment, the perinatal child is added to the CHIP EDG if the child is not eligible for Medicaid.

 

D—1621 Redetermination Reminder Notifications

Revision 15-4; Effective October 1, 2015

 

CHIP

Form H1014-A, Children’s Health Care Benefits – Final Reminder, is mailed to individuals who are required to return a signed renewal form as part of the administrative renewal process, as explained in B-122.4, Medical Program Administrative Renewals, and have not returned the packet. Form H1014-A is sent to individuals who have not responded by the first calendar day of the 11th month of coverage.

The letter reminds households that coverage will end if the completed redetermination form is not received.

 

D—1630 Timely Redeterminations

Revision 15-4; Effective October 1, 2015

 

CHIP

A CHIP redetermination is considered received timely when received by cutoff of the 11th month of the certification period. This allows time for the enrollment process to be completed by the cutoff of the 12th month to avoid the client having a break in coverage.

 

D—1631 Redetermination Processing Time Frames

Revision 15-4; Effective October 1, 2015

 

CHIP

For individuals required to return a renewal form for CHIP, staff must process renewals, received timely or untimely, by the 30th day from the date the renewal form is received or by cutoff of the 11th month of the certification period, whichever is later.

When an acceptable Medical Programs renewal form is not returned, the system automatically makes an eligibility determination through a mass update based on the eligibility outcome from the automated renewal process. This does not require the advisor to run eligibility or dispose the EDG.

If the renewal form is received after the date of denial, advisors follow the policy for TP 08, TP 43, TP 44 and TP 48 explained in B-124, Processing Untimely Redeterminations.

 

D—1632 Changes Reported at Redetermination

Revision 13-4; Effective October 1, 2013

 

 

D—1632.1 New Head of Household

Revision 15-4; Effective October 1, 2015

 

CHIP

Accept a renewal form as valid when it is received reflecting a new head of household who is not someone with existing case authority.

Take the following action:

  • accept the application and link it to the existing case,
  • create a new case number for the household, and
  • certify the new case to begin the month after the old case coverage ends.

 

D—1632.2 Health Insurance

Revision 15-4; Effective October 1, 2015

 

CHIP

When a household reports that it has acquired health insurance, determine if:

  • The monthly premium amount for the child(ren) is less than 5 percent of the household’s net income; or
  • The monthly premium amount for the family’s health insurance that includes the child(ren) is less than 9.5 percent of the household’s net income. 

If the health insurance coverage meets one of the scenarios above, deny the CHIP EDG.

If the health insurance coverage does not meet either of the scenarios above, the child(ren) is(are) still eligible for CHIP, but the household must drop the insurance in order to continue to receive CHIP. Send Form H1020, Request for Information or Action, to the household requesting proof of the insurance end date. If the household does not provide proof, the child(ren) is(are) no longer eligible for CHIP. Deny the CHIP EDG.

Acceptable verification of the private health insurance end date includes:

  • health insurance identification card indicating the end date,
  • letter from the employer indicating the end date, or
  • individual's statement by phone or in writing.

Related Policy
Health Insurance, D-1210
Third Party Resources Changes, D-1437
Exceptions to Continuous Enrollment Period, D-1731

 

D—1633 Missing Information

Revision 15-4; Effective October 1, 2015

 

CHIP

During the automated renewal process, electronic data is used to automatically verify the following required verifications for CHIP:

  • Income and expenses, and
  • Immigration status.

Depending on the outcome of the automated renewal process, the system generates and sends renewal correspondence, including Form H1020, Request for Information or Action, if more information is needed, to individuals enrolled in CHIP following the process explained in B-121, Notice of Redetermination/Certification Expiration, for TP 08 and Children’s Medicaid (TP 43, TP 44 and TP 48).

All missing information must be received before cutoff of the 11th month of the coverage period to receive continuous coverage. If the missing information is received before cutoff of the child's 11th month of coverage, update the EDG with the new information. If the information is received after cutoff of the 11th month of coverage, there may be a break in CHIP coverage.

When a renewal is denied due to failure to provide information or verification, advisors follow the policy for TP 08, TP 43, TP 44 and TP 48 explained in B-122.3.2, Denied for Failure to Provide Information/Verification.

Households that complete the redetermination process (eligibility and enrollment) by cutoff in the 11th month of the eligibility period and remain eligible will be enrolled for a new 12-month period. If the individual fails to pay the enrollment fee by cutoff of the first month of the new 12-month period, the EDG is placed in a Pending Enrollment Fee and/or Plan Selection and/or TPR Delay status for up to three months. If the household pays the enrollment fee within the three months, the EDG is reinstated and the child(ren) receive the remainder of the 12-month enrollment segment beginning with the month of reinstatement.

 

D—1634 Redetermination Application Complete

Revision 13-4; Effective October 1, 2013

 

CHIP

Once the household completes the redetermination and is eligible for CHIP, health care coverage begins the first of the next possible month after the household pays the applicable enrollment fee.

Households that complete the redetermination process receive a Form TF0001, Notice of Case Action, indicating the potential outcome for each child. If an enrollment fee is due, the Enrollment Broker sends the household a payment coupon and return envelope. The enrollment fee due date is set to 10 calendar days.

 

D—1634.1 Missing Enrollment Fee

Revision 15-4; Effective October 1, 2015

 

CHIP

If a household completes the redetermination process, but does not pay the applicable enrollment fee by the cutoff date of the 12th month, the child receives a one-month extension of CHIP coverage. The Enrollment Broker mails the family a letter to inform the family of the one-month extension and the requirement to pay the enrollment fee by cutoff in the first month of the new 12-month period, in order to continue coverage. The extended month of coverage is counted as month one in the new 12-month enrollment segment.

The Enrollment Fee Extension (EFX) letter is mailed the first week of the first month of the new 12-month enrollment segment. The letter advises households that the household must pay the enrollment fee to continue the child(ren)'s coverage.

If the household:

  • pays the enrollment fee by cutoff of the first month of its new 12-month period, then the child remains enrolled for the remainder of the 12-month period.
  • does not pay the enrollment fee by cutoff of the first month of the new 12-month period, then the child is disenrolled. The EDG is placed in Pending Enrollment Fee and/or Plan Selection and/or TPR Delay status starting the second month, for a period of up to three months.

If the household pays the enrollment fee after the:

  • cutoff of the first month in the new 12-month period, but before the cutoff of what would have been the second month, then the child is suspended for one month and reinstated the following month for the remainder of the 12-month enrollment segment.
  • second month's cutoff and before the third month's cutoff, then the child is suspended for two months and reinstated the following month for the remainder of the 12-month enrollment segment.
  • third month's cutoff and before the fourth month's cutoff, then the child is suspended for three months and reinstated the following month for the remainder of the 12-month enrollment segment.
  • cutoff of the fourth month, the application is denied and the household must reapply.

Note: If the payment is returned with non-sufficient funds (NSF), an NSF letter is mailed to the household as if the household had not paid the enrollment fee, and the EDG is placed on Pending Enrollment Fee and/or Plan Selection and/or TPR Delay status the following month.

 

D—1635 Redetermination Applications Eligible for Medicaid

Revision 14-3; Effective July 1, 2014

 

CHIP

When processing a redetermination application, test the application for Medicaid eligibility. If a child in the CHIP household is eligible for Medicaid and the action is processed:

  • before cutoff, CHIP coverage ends the last day of the current month. Medicaid coverage begins the first day of the next month.
  • after cutoff, CHIP coverage ends the last day of the following month. Medicaid coverage begins the first day of the month following the next month.

Any children in the household who are ineligible for Medicaid remain on CHIP through the end of the current CHIP certification period. They are then certified with a new CHIP certification period if they continue to be eligible for CHIP.

A child who is eligible for Medicaid based on income, and who has reported that she is pregnant, is denied at the end of the next possible month and certified for Medicaid. If the pregnancy due date is later than the end date of her CHIP coverage month and she is not eligible for Medicaid, she continues on CHIP through the end of the current certification period. Certify her with a new certification period if she continues to be eligible for CHIP.

If the household no longer qualifies for CHIP, deny the CHIP EDG at the end of the CHIP certification period. Send the household Form TF0001, Notice of Case Action, notifying the household that the child is no longer eligible for CHIP.

Related Policy
Advisor Action for Determining Eligibility for Children, A-126.3