IBM Cúram Social Program Management

8.0.2

Cúram Income Support for Medical

Assistance Children's Health Insurance
Program Guide

IBM
 Note
Before using this information and the product it supports, read the information in “Notices” on page
12

Edition
This edition applies to IBM® Cúram Social Program Management 8.0.0, 8.0.1, and 8.0.2.
Licensed Materials - Property of IBM.
© Copyright International Business Machines Corporation 2012, 2022.
US Government Users Restricted Rights – Use, duplication or disclosure restricted by GSA ADP Schedule Contract with
IBM Corp.
©.
Contents

Chapter 1. Cúram Income Support for Medical Assistance Children's Health

Insurance Program Guide.................................................................................. 1
Introduction................................................................................................................................................. 1
Document Purpose................................................................................................................................. 1
Audience................................................................................................................................................. 1
Available Documentation....................................................................................................................... 1
Children's Health Insurance Program Overview......................................................................................... 1
About Children's Health Insurance Program (CHIP)............................................................................. 1
The Cúram Children's Health Insurance Program................................................................................. 2
Eligibility Determination and Product Delivery Case Creation....................................................................3
Introduction............................................................................................................................................3
Check CHIP Eligibility............................................................................................................................. 3
Rules....................................................................................................................................................... 3
Open Enrollment Rules.......................................................................................................................... 3
Non Financial Requirements.................................................................................................................. 4
Eligibility Requirements......................................................................................................................... 4
Comprehensive Health Insurance......................................................................................................... 4
Good Cause for Loss of Health Insurance reasons................................................................................5
Financial Eligibility Requirements..........................................................................................................5
Financial Unit.......................................................................................................................................... 5
Household Size....................................................................................................................................... 5
Income Rules..........................................................................................................................................6
Household Composition Rules............................................................................................................... 6
Eligibility Result...................................................................................................................................... 7
Create CHIP Product Delivery................................................................................................................ 7
Product Delivery Home Page..................................................................................................................8
Reassessment.............................................................................................................................................. 8
Introduction............................................................................................................................................9
Reassessment.........................................................................................................................................9

Notices................................................................................................................12
Privacy Policy considerations.................................................................................................................... 13
Trademarks................................................................................................................................................ 13

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Chapter 1. Cúram Income Support for Medical
Assistance Children's Health Insurance Program
Guide
The Children's Health Insurance Program is part of Cúram Medical Assistance. It is designed for families
who earn too much money to qualify for medical assistance, but cannot afford to buy private insurance
for their children. Captured evidence is assessed against a set of business rules to determine whether an
individual is eligible for assistance.

Introduction

Document Purpose
The purpose of this document is to provide a business level overview of the Cúram Income Support for
Medical Assistance Children's Health Insurance Program (CHIP) and the implementation of this program
within the Cúram Income Support for Medical Assistance product.
This guide does not describe in detail how to use the application; it does, however, provide some
application specifics where it is deemed helpful to the reader in understanding the CHIP program.

Audience
This document is intended for business users who are interested in understanding the Cúram
implementation of the Children's Health Insurance Program (CHIP). After reading this document, it is
intended that the user would have obtained a business level understanding of the program, the specific
evidence recorded in the system, the process for checking program eligibility, and the creation and
management of the CHIP Product Delivery.

Available Documentation
Supporting documentation relating to Medical Assistance and associated programs, including CHIP can
be found in the Business Analysts guide titled Cúram Income Support for Medical Assistance
Program.
Users may also find the business guides for other Medical Assistance programs useful. For Long Term
Care, see Cúram Income Support for Medical Assistance Long Term Care Guide. For
Spend Down, see Cúram Income Support for Medical Assistance Spend Down Guide.

Children's Health Insurance Program Overview

About Children's Health Insurance Program (CHIP)

In 1997, the balanced budget act established a Children's Health Insurance Program (CHIP) under Title
XXI of the Social Security Act. This program is jointly financed by the federal and state governments and
administered by individual states. Within broad Federal guidelines, each state determines the design
of its program, eligibility groups, benefit packages, payment levels for coverage, and administrative
and operating procedures. Children's Health Insurance Program Reauthorization Act of 2009 later
reauthorized CHIP.
The Children's Health Insurance Program (CHIP) is a national program in the United States designed for
families who earn too much money to qualify for Medical Assistance, yet cannot afford to buy private
insurance for their children. The program was created to address the growing problem of children in the

© Copyright IBM Corp. 2012, 2022 1

 United States without health insurance. CHIP coverage provides eligible children with coverage for a full
range of health services including regular checkups, immunizations, prescription drugs, lab tests, X-rays,
hospital visits, emergency room visits and more.
States are allowed to impose premiums and co-payments for some services and for some groups. To
receive CHIP coverage, families with eligible children, unless exempt, may be required to pay premiums.
The premium payable represents the amount of money required to maintain CHIP coverage. Premiums
are calculated based on the total family income and the number of eligible children being covered under
CHIP. Co-payments may also be imposed for services. A co-payment is a fixed dollar amount paid by
a CHIP enrollee each time certain covered services are received. This amount is paid directly to the
provider.
States can provide care through two different ways, managed care or fee-for-service. Managed care offers
most medical care through one source: a health plan. A health plan is an organization of licensed insurers,
non profit organizations and managed care organizations (MCO's) who are contracted to provide services
to eligible CHIP children. If children are enrolled in a managed care health plan, they go to one person for
their medical care called a Primary Care Provider. A Primary Care Provider is the doctor, nurse practitioner,
or physician assistant who takes care of the children to make sure they get all of the health care they
need. With fee-for-service children do not belong to a health plan. They can go to any doctor, pharmacist,
or other provider who will take the children's medical ID card for payment.

The Cúram Children's Health Insurance Program

The Children's Health Insurance Program (CHIP) provides medical services to eligible children under the
age of 19 who do not have health insurance and do not qualify for Medical Assistance. The Children's
Health Insurance Program (CHIP) is part of Cúram Medical Assistance. Like other Medical Assistance
coverage types, the information required to determine program eligibility is captured as evidence. This
evidence is assessed against a set of business rules to determine whether or not an individual is eligible
for CHIP. Eligibility for CHIP is determined as part of the existing cascading eligibility rules for Medical
Assistance coverage types. The cascading eligibility process determines coverage type eligibility based on
a hierarchy. The hierarchy is used to determine the order in which the coverage type rules are executed.
The eligibility rule set for the coverage type with the highest priority are executed first, followed by the
rules for the coverage type of next highest priority. The rules for the categorically needy coverage types
(including cost sharing coverage types) are executed first followed by the rules for the medically needy
coverage types. CHIP eligibility is only determined if an individual is ineligible for all the categorically
needy/medically needy coverage types. This hierarchy is configurable within the product to meet the
individual requirements of a state.
There are a number of additional features associated with the Children's Health Insurance Program
(CHIP). Because of limitations on funding and available slots in the program, applications for CHIP are
only accepted during open enrollment periods. Open enrollment is the period of time during which eligible
individuals can apply for CHIP. States limit the numbers they enroll according to the funds available for
the program. Once this period has passed, unless exempt, for example a newborn, it is not possible
to apply for this program. A processing entity, Enrollment Details, is used to record time periods when
applications can be accepted by the state.
Unlike Low Income Families with Children (LIFC), individuals eligible for CHIP can choose whether or not
they wish to receive the program. There are no mandatory assistance unit members; therefore, families
can decide what child(ren) in the eligibility result need coverage.
To receive CHIP coverage, families may be required to pay premiums. This depends on whether or not
the state requires premiums for coverage. The application of premiums is controlled by an environment
variable to facilitate customization by individual states.
If premiums are applicable, the billing, collection and allocation of premiums is managed by an external
vendor.

Eligibility Determination and Product Delivery Case Creation

Eligibility is determined for the Children's Health Insurance Program according to a predefined set of
rules. The eligibility determination section describes the CHIP rules executed during the cascading

2 IBM Cúram Social Program Management: Cúram Income Support for Medical Assistance Children's Health
Insurance Program Guide
 eligibility rules, the eligibility decision including the identification of the possible assistance units within
the household.
The product delivery case creation process describes the selection of assistance unit members, viewing
the associated premiums and co-payment limit and creating the CHIP product delivery.

Reassessment
This chapter describes the reassessment process for a CHIP product delivery. Reassessment takes place
as part of ongoing eligibility or as a result of a change of circumstances.

Eligibility Determination and Product Delivery Case Creation

Introduction
This chapter outlines the processes for determining eligibility for the Children's Health Insurance Program
(CHIP) and creating the CHIP product delivery.

Check CHIP Eligibility

The check medical assistance eligibility functionality which determines eligibility for all Medical
Assistance coverage types based on a hierarchy also includes CHIP. When checking Medical Assistance
eligibility on application or on the integrated case home page, the caseworker has the option to check
eligibility for all Medical Assistance coverage types or just CHIP.
If the caseworker has selected 'All Medical Assistance Programs', the Medical Assistance rules check
eligibility for the Categorically Needy and Medically Needy coverage types for all household members.
Eligibility for CHIP will only be carried out if it is determined that a member is not eligible under any
categorically needy or medically needy coverage type. If eligible under Medically Needy with SpendDown
in addition to CHIP, the member must choose which coverage type to receive.
If the caseworker has selected 'Children's Health Insurance Program (CHIP)', the same Medical
Assistance rules are called. The result is filtered to only display children in the household who are eligible
for CHIP. The CHIP only option may be used where a family just want to apply for CHIP for the children. If
none of the children in the household are eligible for CHIP, the caseworker has the option to view the full
eligibility result as determined by the Medical Assistance eligibility rules. It may be that the children are
eligible for other Medical Assistance coverage types that have a higher priority than CHIP in the cascading
hierarchy. For example, a child found eligible for Aged, Blind and Disabled (ABD) during the Medical
Assistance eligibility rules will not have CHIP eligibility determined as the coverage type rules for ABD are
executed before the rules for CHIP.

Rules
This section provides a high level overview of the rules executed for CHIP.
To be eligible for CHIP:
• The child must satisfy the open enrollment rules AND
• The child must satisfy the non financial requirements AND
• The child must satisfy the CHIP specific eligibility requirements AND
• The household must satisfy the financial eligibility rules AND
• The household must satisfy the household composition rules

Open Enrollment Rules

The open enrollment rules determine whether or not an application for CHIP has been received during
an open enrollment period. An open enrollment period is a specific time period set by the organization in

Chapter 1. Cúram Income Support for Medical Assistance Children's Health Insurance Program Guide 3
 which applications for CHIP can be accepted. Once this period has passed, no applications are accepted.
The organization limits the number they enroll according to the funds available for the program.
The following exceptions apply:
• A family, who has a child enrolled in CHIP, may enroll a new child born to or adopted by a household
member without waiting for the next open enrollment period.
• A family, who has a child enrolled in CHIP, may enroll an additional child who loses Medical Assistance
coverage and does not qualify for any other Medical Assistance coverage type without paying a spend
down, without waiting for the next open enrollment period.
• A child who loses Medical Assistance coverage and does not qualify for any other Medical Assistance
coverage type without paying a spend down, may enroll in CHIP without waiting for the next open
enrollment period

Non Financial Requirements

The child must satisfy the standard non financial requirements for Citizenship, SSN and Residency.
See Non Financial Requirements in the Common Rules - Non Financial Requirements chapter.

Eligibility Requirements
There are a number of specific eligibility requirements that must be met in order to receive CHIP:
• The child must be under age 19 or if in receipt of CHIP the child is eligible up to the last day of the
month in which the child's 19th birthday occurs AND
• The child must be ineligible for any categorically needy or medically needy Medical Assistance coverage
type (This is determined as part of cascading eligibility) AND
• The child must not have other comprehensive health insurance coverage AND
• The child must be uninsured for at least 90 days unless they meet one of the Good Cause for Loss of
Health Insurance reasons AND
• The child must not involuntarily reside in a public, non-medical institution AND
• The child must not be in an inpatient psychiatric facility AND
• The child has not been disenrolled from CHIP for failure to pay premiums within the last 3 calendar
months unless the child has been on Medical Assistance in the interim

Comprehensive Health Insurance

Comprehensive coverage is defined by the Health Insurance Portability and Accountability Act (HIPAA) of
1996 as coverage under any of the following:
• Group health insurance plans
• Medicare Part A or Part B
• Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)
• Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)
• Public Health Plan
• Health Care for Peace Corps Volunteers
• Insurance policies (private)
• Employer based plans
• Health insurance coverage on the basis of a family member's active permanent employment by a state,
county, or city government agency
• Entitlement to coverage under employer/group plan

4 IBM Cúram Social Program Management: Cúram Income Support for Medical Assistance Children's Health
Insurance Program Guide
 – When a child is 'entitled' to coverage under an employer based plan or a group health insurance plan
and the cost would be less than 10% of the household's gross income, the child is seen as having
comprehensive medical insurance unless a waiting period applies
– If the child has to wait for a period of time before they can enroll in the employer based plan, they are
eligible for CHIP until they are allowed to enroll in the insurance

Good Cause for Loss of Health Insurance reasons

No waiting period will be imposed if health insurance was discontinued for any of the following reasons:
• Insurance was lost because the individual providing coverage died
• Insurance was lost because the family member who carried insurance changed jobs or stopped
employment due to a layoff, reduction-in-force, or the closure of a business
• The employer stopped contributing to the cost of family coverage
• The child's coverage was discontinued by an insurance company for reasons of uninsurability
• Insurance was discontinued by a family member who was paying the full cost of the insurance premium
under a Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) policy
• Voluntary termination of coverage by a non custodial parent.
• The previous health insurance coverage exceeds 10% of the family's gross monthly income, or exceeds
10% of the family's gross monthly income at the time the insurance was dropped

Financial Eligibility Requirements

To be eligible to enroll in CHIP, the household must pass an income test. CHIP uses the income and
deduction rules that apply to the family coverage types to determine what income is countable/excluded
and what deductions to apply. CHIP has its own rules to determine the financial unit and household size.
The household does not have to pass a resource test to be eligible for CHIP.

Financial Unit
The financial unit is the individuals whose income is counted in determining CHIP eligibility. The following
household members are included in the financial unit:
• The child who meets the CHIP eligibility rules
• The child's siblings, half-siblings, adopted-siblings and step-siblings if they are under age 19
• Parents and step-parents of any child counted in the financial unit.
• Only one non-parent caretaker relative where both of the child's parents are absent from the caretaker
relative's home
• Children of any children counted in the financial unit
• The spouse of any child who is included in the financial unit
• Unborn children of anyone included in the financial unit

Financial Unit Exception

Do not include the following household members in the financial unit:
• SSI recipients

Household Size
The number of individuals counted in the household size determines the income limit used when
comparing against the household's income. The household size is the same as the financial unit.

Chapter 1. Cúram Income Support for Medical Assistance Children's Health Insurance Program Guide 5
Income Rules
Income rules are used to determine the unearned, earned and self employment income that are
countable/non countable for the household. Income is classified as either countable or non-countable.
Only countable income is included in the income eligibility determination.
The household's adjusted gross countable income must be equal to or less than 200% of the federal
poverty level for the household size.
See the Family - Common Income Rules chapter for the steps to calculate the household's total countable
income.

Household Composition Rules

The eligibility determination process for CHIP identifies the possible assistance units which exist in
the current household. Unlike Low Income Families with Children (LIFC), all CHIP eligible household
members are seen as 'optional', as they do not have to receive CHIP coverage if they do not want it.
For example, an applicant (aged 18), the applicant's husband (aged 18), and the applicant's child (aged 1)
are living with the applicant's mother (aged 42) and father (aged 44). The applicant's cousin (aged 16) and
the cousin's son (aged 1) also live in the household. Assuming all the CHIP eligibility criteria is met, there
are a number of different assistance units, based on different combinations, that could apply:
1. Applicant, Applicant's Husband and Applicant's Daughter.
2. Applicant
3. Applicant's Husband
4. Applicant's Daughter
5. Applicant and Applicant's Husband
6. Applicant and Applicant's Daughter
7. Applicant's Husband and Applicant's Daughter
8. Applicant's Cousin and Applicant's Cousin's Son
9. Applicant's Cousin
10. Applicant's Cousin's Son
For CHIP, rather than displaying every possible combination and having validations to ensure a household
member cannot receive CHIP in more than one assistance unit, each different result is displayed with one
assistance unit containing every member who could potentially receive coverage under the same product
delivery. The caseworker chooses which members to proceed with during case creation; these members
then become part of the benefit group. Using the example above, there are 2 results displayed on the
eligibility result page:
1. Applicant, Applicant's Husband and Applicant's Daughter
2. Applicant's Cousin and Applicant's Cousin's Son
If the applicant is the only child who wants coverage, the caseworker selects result 1 from the eligibility
result page, and at a later stage during the process, the caseworker selects the applicant as the one to
proceed with. A product delivery is created for the applicant where she is the only member of the benefit
group.
If the applicant's cousin also wants coverage, both result 1 and 2 are selected, and the caseworker
chooses who to proceed with for both results. Both the applicant and the cousin will have their own
product delivery, as they cannot exist together in the same benefit group based on the household
composition rules.
The household composition rules used to determine what individuals can exist together in an assistance
unit are as follows:
• Child who satisfies the CHIP eligibility rules*
• Child's siblings, half, adopted and step who also satisfy the CHIP eligibility rules

6 IBM Cúram Social Program Management: Cúram Income Support for Medical Assistance Children's Health
Insurance Program Guide
 • Parents and stepparents of any child, if the parents and stepparents satisfy the CHIP eligibility rules
• Children of any child if the children satisfy the CHIP eligibility rules
• The spouse of any child if the spouse satisfies the CHIP eligibility rules
*The CHIP eligibility rules refer to the CHIP Specific Eligibility Requirements and the standard Non-
Financial Requirements rules (Citizenship, SSN and Residency).

Eligibility Result
The output from the eligibility determination process is the eligibility result. It displays a list of Medical
Assistance coverage types including CHIP for which household members are eligible.
It is also possible to view ineligible decisions to see why household members may not be eligible for
certain coverage types.
The household member can select which coverage type to apply for using the results of the eligibility
determination process.

Create CHIP Product Delivery

The standard create product delivery process includes additional processing required to create a CHIP
product delivery.
Selection of assistance unit members is a step specific to the Children's Health Insurance Program
(CHIP). Participation in CHIP is optional for eligible individuals. During the eligibility determination
process eligible household members are grouped into assistance units according to the household
composition rules. Each assistance unit contains one or more eligible household members; however,
an eligible household member only belongs to one assistance unit. The individuals within an assistance
unit represent the household members that can exist together on a CHIP case. The selection process is
required to confirm who is proceeding with CHIP coverage. A CHIP case is created for each assistance
unit.
Once the assistance unit members have been selected, the premium processing rules determine the CHIP
premium payable and the co-payment maximum limit for the assistance unit.
The premium payable is based on the household size, household income (expressed as a percentage of
the federal poverty guideline) and the number of children applying for CHIP. Premium values and the
frequency of premium payment are determined using Rate Tables.
A co-payment is a monetary contribution towards the cost of a service received under CHIP coverage.
Enrollees in CHIP are required to pay co-payments, up to a maximum co-payment limit for a family within
a specified period of time. The maximum co-payment limit for a family is calculated as a percentage of the
family's gross countable income less the total amount payable in CHIP premiums by the family within a
defined period of time. The time period to which the co-payment limit applies is based on the certification
dates of the product delivery. In general, this will be 12 months.
The steps to select assistance unit members and view and accept their premium and co-payment details
are repeated for each CHIP program selected from the Medical Assistance Eligibility Result.
When all CHIP assistance units have been selected and premiums and co-payment limits have been
confirmed, a product delivery is created for each selected program using the standard create product
delivery functionality within the product.

Case Creation
Where premium processing rules determine that premiums are payable for CHIP coverage, the calculated
premium amount and the premium frequency information is stored on the premium entity which is linked
to the CHIP product delivery. A copayment record is also created containing the co-payment limit for the
household and the period of time the co-payment limit covers.
The billing, collection and allocation of premiums is handled by an external vendor.

Chapter 1. Cúram Income Support for Medical Assistance Children's Health Insurance Program Guide 7
 Effective Date Of Coverage
The effective date of coverage for CHIP is the date of application (or date of application minus number of
days Grace Period granted). When an emergency or some other circumstance beyond the control of the
applicant prevents them from filing a CHIP application, a grace period beginning no earlier than a defined
number of days prior to the date an applicant submits a completed and signed application is allowed.
• Date of application (or date of application minus number of days Grace Period granted)
The effective date for coverage is set at case creation. The certification period is also set at case creation
using the effective date plus the CHIP continuous eligibility period.

Product Delivery Home Page

CHIP uses the existing product delivery home page functionality within Cúram. The navigation bar has
some extra links view premium details and record/view co-payments.

Premiums
A premium is defined as the amount of money required for coverage under a specific insurance policy
for a given period of time. The requirement to pay a premium for CHIP is controlled by an environment
variable. If this value is set, families with eligible children (unless exempt) are required to pay a premium
to receive CHIP coverage.
The premium details viewable are the premiums payable for CHIP coverage for household members in
the assistance unit. The billing, collection and allocation of these premiums is handled by an external
vendor.

Co-Payments
In order to track whether the maximum co-payment limit has been reached for a household, co-payment
receipt details must be recorded. The co-payment limit reached indicator is set when the sum of the
values of all receipts received for a case is equal to or greater than the maximum co-payment limit.

Certifications
For CHIP, case certification is controlled by the system and is based on the effective date. The certification
period is set to the effective date plus 12 months and can not be changed by the caseworker manually. A
certifications list page is provided for every case. For CHIP, on the Certifications page, the caseworker can
only view certification details. The functionality relating to adding and modifying certifications has been
removed.

Benefit Group
The benefit group refers to the household members who are eligible for medical assistance under a
specific coverage type. Like other coverage types, the benefit group for CHIP is determined after the
execution of the medical assistance eligibility rules when the CHIP product delivery is created from the
Medical Assistance Eligibility Result. For CHIP, the group members can subsequently be modified by the
caseworker. As a result, there are now two types of Benefit Group pages, one for CHIP and one for all
other coverage types.
The benefit group pages for CHIP allow caseworkers to add and remove household members to and from
a product delivery. The caseworker can only add members who currently exist on the integrated case
and who were determined eligible for CHIP on the most recent decision for the product delivery. This will
be any child who decided not to be covered by CHIP even though eligible originally, any child who was
previously ineligible but who is now eligible as a result of a change in circumstance or a child who is a
recent addition to the household such as a newborn.

Reassessment

8 IBM Cúram Social Program Management: Cúram Income Support for Medical Assistance Children's Health
Insurance Program Guide
Introduction
This chapter describes the reassessment for a CHIP product delivery.

Reassessment
A CHIP case can be reassessed at various stages over a given period of time. Reassessment detects
whether an individual or group of individuals is still eligible for CHIP and whether there is a change in the
premium payable or the co-payment limit. This section details when the reassessment of a case takes
place for the Children's Health Insurance Program. This can take place as part of ongoing eligibility or
when there has been a change of circumstance.

Ongoing Eligibility
The frequency of ongoing eligibility determination can be configured according to an individual state's
requirements. The default value is monthly. As part of ongoing eligibility determination, the child must
meet all the CHIP eligibility rules executed during the Medical Assistance eligibility determination with
the exception of the open enrollment rules. In addition, premiums must be paid on time for coverage
to continue. Premium rules exist to ensure coverage is cancelled when premiums have not been paid
for a specified period. The specified period varies between states. Once coverage has been cancelled,
there is a waiting period before the child can re-enroll in CHIP. Again, this period of time varies between
states, some states do not impose a waiting period at all. If no payments have been made for two
consecutive months, the CHIP case should be closed at the end of the second month. Premium payment
and processing is handled by an external vendor. An eligibility rule exists to check are premiums paid
for the specified period. The external vendor will provide this information to the Cúram Children's Health
Insurance Program.
The caseworker can check eligibility for regular Medical Assistance in case the requirements for another
Medical Assistance coverage type become less restrictive, so even though the child's circumstances are
unchanged, they may become eligible for regular Medical Assistance.

Change of Circumstance
Change of circumstances processing occurs when there has been an evidence change on the integrated
case, when a household member is added or removed from the benefit group, or when a household
member is added or removed from the integrated case. The following section outlines the type of changes
which trigger the change of circumstance processing.

Evidence Changes on Integrated Case

When evidence changes on the integrated case, reassessment is triggered automatically across all
product deliveries and case groups are updated as necessary. This is out of the box functionality. If
one of the product deliveries is a CHIP product delivery, the caseworker is notified to check eligibility
across all Medical Assistance coverage types (in case they are now eligible for a more beneficial coverage
type).
If the child is found ineligible for CHIP, it does not necessarily mean the child will lose coverage. Certain
changes are essentially ignored until eligibility renewal. The types of changes and what happens is
outlined in the sections below.

Changes Causing Ineligibility

If any of the following changes occur, the child loses coverage:
• The child dies.
• The family request that the CHIP coverage be stopped.
• The child no longer meets the age requirements.
• The child no longer meets the residency, citizenship and SSN requirements.
• The child receives other comprehensive medical insurance coverage.

Chapter 1. Cúram Income Support for Medical Assistance Children's Health Insurance Program Guide 9
 • The child becomes eligible for regular medical assistance (the case worker must manually check
eligibility for all other medical assistance coverage types whenever there is a change of circumstance to
determine if the child is now eligible for regular medical assistance).*
• The child takes up residence in a public non medical institution.
• The child takes up residence in a psychiatric facility.
The effective date of disenrollment is the last day of the month the change occurred unless the child has
died, in which case the effective date is the date the child died. The caseworker is notified to take the
appropriate action. If there was only one child on the case or if the change of circumstance affects all
children on the case, the case is closed on the effective date of disenrollment. If only one child is affected
by the change, the case remains open and the affected child is removed from the benefit group on the
effective date of disenrollment.
*If the reason the child is eligible for regular medical assistance is solely because of a decrease in income,
the child does not have to move if he or she does not wish to (until the end of the current eligibility
period). However if the child is eligible for regular medical assistance because of any other change, the
child must be removed from CHIP. This is a manual process which the caseworker must carry out.

Income Changes
When there is a change in income evidence, it must be evaluated to determine if it affects an individual's
eligibility.

Income Increase
A reported income increase (adversely affecting the case or not) is not acted upon until the end of the
current eligibility period when the family is applying for renewal. They remain covered under CHIP with
the same premium amount and co-payment limit until the end of the continuous eligibility period.

Income Decrease
A reported income decrease is not acted upon until the end of the current eligibility period when the
family is applying for renewal. They remain covered under CHIP with the same premium amount and
co-payment limit until the end of the continuous eligibility period (i.e. current certification).

Modification of the Benefit Group in CHIP

When changes are made to the benefit group in the Children's Health Insurance Program (CHIP),
reassessment of CHIP is triggered automatically. The premium and copayment records should be
automatically updated with any new information.
1. Adding a household member to the benefit group
The caseworker can only add household members who currently exist on the integrated case and who
were determined eligible for CHIP on the most recent decision for the product delivery. This will be
any child who decided not to be covered by CHIP even though eligible originally, any child who was
previously ineligible but who is now eligible as a result of a change in circumstance or a child who is a
recent addition to the household such as a newborn.
Once a new member is added to the product delivery, an automatic reassessment of the product
delivery is triggered to ensure this person is still eligible. An additional child can be added to CHIP
only if it is during an open enrollment period unless the child is a newborn or has just lost coverage to
regular medical assistance. This is controlled by the CHIP eligibility rules which have to be run for the
'new' child. If the new child is eligible, the following happens:
• The child is added to the existing benefit group on today's date and is eligible for the remaining
period of certification for the case.
• The premium amount is determined based on the current premium plan level for the household.
While the premium amount may have increased (it costs more for 2 children than for 1 child), the

10 IBM Cúram Social Program Management: Cúram Income Support for Medical Assistance Children's Health
Insurance Program Guide
 premium level (Plan A, B etc.) remains the same. The premium and copayment records should be
updated with any new information
2. Removing a household member from the member group
A child can stop CHIP coverage at any stage if desired. When a household member is removed, the
member will still receive coverage under CHIP up to and including the last day of the month. The
caseworker is notified to take the appropriate action. If there was only one child on the case, the case
is closed after the last day of coverage. If there are other children on the case, the case remains open
and the affected child is removed from the benefit group on the last day of coverage.
A family may reach their co-payment limit by removing a child. It is up to the family, however, to track
their co-payments and notify the department once this happens.

Modification of Household Member Evidence on Integrated Case

1. Adding a member to Integrated Case
When someone is added to the integrated case, the caseworker checks eligibility across all coverage
types. This triggers an automatic assessment across all coverage types. In the case of CHIP, if it is
determined the new household member is part of the financial unit and household size, the member is
automatically added to the financial group and member group of that product delivery.
If the new household member is eligible for CHIP (for example, a newborn), the caseworker must
add the new household member to the CHIP product delivery if the household member wants
CHIP coverage. The new household member is added to the case from today's date, unless a
newborn, in which case, the member is added to the benefit group from his or her date of birth.
The same procedure as discussed in number 1 above (Modification of the Benefit Group in CHIP) will
subsequently take place.
2. Removing a member from Integrated Case
When a household member is removed from the integrated case, the end date is automatically
updated on the case group pages of any active cases on which he or she is a member. Reassessment of
any product deliveries the member was part of is automatically triggered.
If the 'removed' member was part of a CHIP benefit group, he or she remains covered for CHIP up to
and including the last day of the month. The caseworker is notified to take the appropriate action. If
there was only one child on the case, the case is closed after the last day of coverage. If there are other
children on the case, the case remains open and the affected child is removed from the benefit group
on the last day of coverage.

Chapter 1. Cúram Income Support for Medical Assistance Children's Health Insurance Program Guide 11
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12 Notices
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14 IBM Cúram Social Program Management: Cúram Income Support for Medical Assistance Children's Health
Insurance Program Guide
IBM®

Part Number:

(1P) P/N: