X Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 5.
4.1. The following standards may be used to determine eligibility of targeted low-income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102)(b)(1)(A))
4.1.1. ~ Geographic area served by the Plan:___________________
4.1.2. ~ Age:____________________________________________
4.1.3. ~ Income:_________________________________________
4.1.4. ~ Resources (including any standards relating to spend downs and disposition of resources): _______________________________________________
4.1.5. ~ Residency:_______________________________________
4.1.6. ~ Disability Status (so long as any standard relating to disability status does not restrict eligibility): _______________________________________________
4.1.7. ~ Access to or coverage under other health coverage:_______________________________________
4.1.8. ~ Duration of eligibility ______________________________________________
4.1.9. ~ Other standards (identify and describe): ______________________________________________
4.2. The state assures that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102)(b)(1)(B))
4.2.1. ~ These standards do not discriminate on the basis of diagnosis.
4.2.2. ~ Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income.
4.2.3. ~ These standards do not deny eligibility based on a child having a pre-existing medical condition.
4.3. Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2))
4.4. Describe the procedures that assure:
4.4.1. Through intake and follow up screening, that only targeted low-income children who are ineligible for either Medicaid or other creditable coverage are furnished child health assistance under the state child health plan. (Section 2102)(b)(3)(A))
4.4.2. That children found through the screening to be eligible for medical assistance under the state Medicaid plan under Title XIX are enrolled for such assistance under such plan. (Section 2102)(b)(3)(B))
4.4.3. That the insurance provided under the state child health plan does not substitute for coverage under group health plans. (Section 2102)(b)(3)(C))
4.4.4. The provision of child health assistance to targeted low-income children in the state who are Indians (as defined in section 4© of the Indian Health Care Improvement Act, 25 U.S.C. 1603(c). (Section 2102)(b)(3)(D))
4.4.5. Coordination with other public and private programs providing creditable coverage for low-income children. (Section 2102)(b)(3)(E))
