Telephone Interview Discussion Guide

Fact Sheet ON CHIP PROGRAM IN [STATE NAME]

Program Type:

Medicaid Expansion (M-CHIP)

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Separate CHIP (S-CHIP)

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Combination (M-CHIP and S-CHIP)

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Program Name(s):

Medicaid/M-CHIP:

S-CHIP:

Agency(ies) administering Medicaid and CHIP:

CHIP Program Population Covered

Age

Program Type

Income Range (FPL)

Children

Infants (0-1)

M-CHIP S-CHIP

□ □

1-5

M-CHIP S-CHIP

□ □

6-18

M-CHIP S-CHIP

□ □

Details:

Section 1115 Demonstration Program/Title XXI funds*

Parents and caretaker relatives

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Pregnant Women

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Childless adults

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CHIP State Plan*

Pregnant women

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Unborn children

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Lawfully residing immigrant children

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Lawfully residing immigrant pregnant women

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Children of state employees

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Dental-only supplemental to employer-sponsored insurance (ESI)

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Premium assistance

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Details:

CHIP Eligibility/Enrollment/Renewal

Joint application

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Face-to-face/in-person interview

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Asset test

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Income disregards

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Uninsured waiting period □ Number of months:

Application methods:

Mail-in □

Phone □

Online □

Presumptive eligibility

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Retroactive eligibility

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Express-lane eligibility

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Continuous eligibility □ Number of months:

Premiums required

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Co-pays or co-insurance

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Documentation required:

Income □

Citizenship □

Income status □

Periodicity of renewal:

6 months □

12 months □

Automatic (ex-parte) renewal

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Pre-populated renewal form

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CHIPRA Performance Bonus		FFY 2009	FFY 2010	FFY 2011
Criteria met		□	□	□
Details:
Award amount

Other CHIP Program Details (include as many rows as necessary for each program)
Delivery system:	Fee-for-service □		Managed care □	Primary-care case management (PCCM) □
Benefit package:		Benchmark □	Benchmark-equivalent □		Secretary-approved □
Benefit details:
Cost-sharing:

Coverage Beyond Medicaid and CHIP
CHIP Buy-in Program				□
Income range:
Details:
Immigrant-specific programs using state-only funds				□
Program Name:
Administrator:
Income range:
Details:
Other public health insurance programs covered by State-only funds				□
Program Name:
Income range:
Details:
Utilization of basic health plan (BHP) option				□
Administrator:
Income range:
Details:
Health insurance exchange (HIX) model:		State-only □	Federal-only □		State-Federal □
Details:

* Prior to CHIPRA, States could provide services to pregnant women either through a Section 1115 demonstration program or under the CHIP State plan by covering unborn children. CHIPRA Section III allowed States to continue providing coverage through these two options or through a new option of covering pregnant women under the State plan option under CHIP.