THIS DOCUMENT WAS SENT TO GOVERNORS' REPRESENTATIVES, STATE 
MEDICAID DIRECTORS AND OTHER INTERESTED PARTIES ON SEPTEMBER 
15, 1997  
 
 
Attached for your review and comment, as well as assistance, is a draft of the model 
application template, (zipped WP 6.1 format, 35,982 bytes) and instructions, (zipped 
WP 6.1 format, 46,439 bytes) that are being developed to assist states in submitting 
a child health plan under Title XXI of the Social Security Act.  
This draft model application template outlines the types of information that are likely 
to be included in the state child health plan required under Title XXI. It has been 
designed to reflect many of the requirements that will be necessary for state plans 
under Title XXI. It is not intended to be comprehensive or final. We provide it for 
preliminary guidance as well as to solicit additional information from states and other 
interested parties on the appropriate content.  
The Department of Health and Human Services will continue to work collaboratively 
with states and other interested parties to provide specific guidance in key areas like 
benefits definitions, maintenance of effort provisions, collection of baseline data, and 
methods for preventing substitution of new Federal funds for existing state and 
private funds. As such guidance becomes available, the model application template 
will be revised and finalized. We will work to distribute it in a timely fashion to 
provide assistance as states submit their state plans.  
Assistance from the states, advocates and other interested parties, in the form of 
comments and input on the attached documents, is greatly appreciated and all 
suggestions will be taken into consideration.  
Please note that under the law, a state must have an approved state plan for a fiscal 
year in order to receive an allotment that year. In order for the Department to 
determine allotments for FY 98, state plan applications should be submitted as soon 
as possible. The length of time from submission to approval will vary depending upon 
the quality of the plan and the extent to which requirements under the law are met. 
We cannot guarantee that we will be able to approve plans submitted after July 1 
before the close of the fiscal year. Therefore, the sooner a state submits its plan, the 
more quickly Health Care Financing Administration (HCFA) will be able to approve it, 
and the sooner states will have access to their allotments. For States with approved 
plans, the allotment under Title XXI is available for up to three years.  
Comments on the template may be submitted to the HCFA at the following address:  
Center for Medicaid and State Operations  
Health Care Financing Administration  
7500 Security Blvd  
Baltimore, Maryland 21244  
Attn: Family & Children's Health Programs Group  
Mail Stop - C4-14-16    
We hope that you find this information helpful in the development of the State 
Children's Health Insurance Program. If you need further assistance or have 
questions regarding this information, please contact your HCFA regional office or Rick 
Fenton in HCFA's Family and Children's Health Programs Group at 410- 786-5920.  
Note: This page includes links to specialized data and multimedia files. Viewing these files 
requires the use of a third-party plug-in or viewer. For more information or to test whether your 
computer can read these files, visit our File Formats and Plug-Ins page.  
  DRAFT - 9/12/97 
 
 
INSTRUCTIONS FOR COMPLETING 
The Draft Model Application Template for 
State Child Health Plan Under Title XXI of the Social Security Act 
State Children's Health Insurance Program 
 
 
Preamble.  This draft model application template outlines the types of information that are 
likely to be included in the state child health plan required under Title XXI.  It has been designed 
to reflect many of the requirements that will be necessary for state plans under Title XXI.  It is 
not intended to be comprehensive or final.  We provide it for preliminary guidance as well as to 
solicit additional information from states and other interested parties on the appropriate content. 
 
The Department of Health and Human Services will continue to work collaboratively with states 
and other interested parties to provide specific guidance in key areas like benefits definitions, 
maintenance of effort provisions, collection of baseline data, and methods for preventing 
substitution of new Federal funds for existing state and private funds.  As such guidance 
becomes available, the model application template will be revised and finalized.  We will work 
to distribute it in a timely fashion to provide assistance as states submit their state plans. 
 
Disclosure.  According to the Paperwork Reduction Act of 1995, no persons are 
required to respond to a collection of information unless it displays a valid OMB 
control number.  The valid OMB control number for this information collection is 
0938-0707.  The time required to complete this information collection is estimated 
to average 160 hours (or minutes) per response, including the time to review 
instructions, search existing data resources, gather the data needed, and 
complete and review the information collection.  If you have any comments 
concerning the accuracy of the time estimate(s) or suggestions for improving this 
form, please write to: HCFA, P.O. Box 26684, Baltimore, Maryland 21207 and to 
the Office of the Information and Regulatory Affairs, Office of Management and 
Budget, Washington, D.C.  20503. 
 
Introduction.  The purpose of the new State Childrens Health Insurance Program (Title XXI) is 
to provide Federal matching funds to states to enable them to initiate and expand coverage to 
uninsured, low-income children in an effective and efficient manner that is coordinated with 
other sources of health benefits coverage for children.  States are able to use Title XXI funds for: 
(1) obtaining health benefit coverage, (2) expanding Medicaid coverage, or (3) a combination of 
both. 
 
 
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Requirement to Submit a State Plan.  In order to be eligible for payment under this new 
legislation, each state must submit a Title XXI plan for approval by the Secretary that details 
how the state intends to use the funds and fulfill other requirements under the law.  Under the 
law, a state plan is considered approved in 90 days unless the Secretary notifies the state in 
writing that the plan is disapproved or that specified additional information is needed.  If  a state 
wishes to use Medicaid to expand coverage through Title XXI, it must submit a Medicaid plan 
amendment for an eligibility expansion in addition to submitting a state plan for Title XXI.  The 
Title XXI plan should encompass all of the child health assistance being provided using Title 
XXI funding.  The Department will be working with states to facilitate and expedite the 
application and approval process. 
 
Any items that require a description may be addressed in the form of an attachment or in the 
space provided.  It is expected that any attachments will be brief and limited to one page, unless 
more space is needed for an accurate description. 
 
The application template includes the following sections: 
1.  General Description and Purpose of the State Child Health Plans 
2.  General Background and Description of State Approach to Child Health Coverage 
3.  General Contents of State Child Health Plan 
4.  Eligibility Standards and Methodology 
5.  Outreach and Coordination 
6.  Coverage Requirements for Childrens Health Insurance 
7.  Quality and Appropriateness of Care 
8.  Cost Sharing and Payment 
9.  Strategic Objectives and Performance Goals for the Plan Administration 
10. Annual Reports and Evaluations 
11. Glossary 
 
Statement of Purpose.  This model application template and instructions may be employed by 
states for the purpose of submitting a state plan.  The instructions have been designed to 
complement the model application template and to facilitate completion of the template.  States 
should use the instructions in conjunction with the template for guidance regarding what issues 
should be addressed in the narrative sections of the state plan. 
 
With regard to Sections 9 and 10 on performance goals and annual reporting requirements, we 
plan on developing national standards for performance measures, in conjunction with the states, 
advocacy groups, Congress, evaluators, and other interested parties, subsequent to the 
implementation of this legislation.  We believe that, by developing national standards with the 
states, with advocates and with others, we will insure the ability to review and evaluate the 
impact of the program in a way that will be most useful to the public, while limiting the reporting 
burdens on the states, and ensuring accountability and effectiveness of State programs. 
 
 
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Program Options.  As mentioned above, the law allows states to expand coverage for children 
through a separate child health insurance program, through the Medicaid program, or through a 
combination of these programs.  States have the following options under Title XXI: 
 
Option to Expand Medicaid.  States may elect to expand coverage through 
Medicaid.  This option for states would be available for children who do not 
qualify for Medicaid under state rules in effect as of April 15, 1997.  Under this 
option, current Medicaid rules would apply. 
 
Option to Create or Expand a Separate Program.  States electing to use their 
available Title XXI funds to establish or expand a separate child health insurance 
program will be subject to new cost-sharing and benefit rules in the law.  These 
states must establish enrollment systems that are coordinated with Medicaid and 
other sources of health coverage for children and also must screen children during 
the application process to determine if they are eligible for Medicaid and, if they 
are, enroll these children promptly in Medicaid. The law requires that any state 
that lowers its Medicaid eligibility standards for children below the June 1, 1997 
levels be denied access to the new child health funds.  
 
Combination of Options.  The new law allows states to elect to use a 
combination of the Medicaid program and a separate child health insurance 
program to increase health coverage for children.  For example, a state may cover 
children in families with incomes of up to 133% of poverty through Medicaid and 
a targeted group of children above that level through a separate program.  For the 
children the state chooses to cover under Medicaid, the description provided 
under Option to Expand Medicaid would apply.  Similarly, for children the 
state chooses to cover under a separate program, the provisions outlined above in 
Option to Create or Expand a Separate Program would apply. 
 
In order to expedite the application process, states choosing to expand coverage only through an 
expansion of Medicaid eligibility would be required to complete Sections 1 (General 
Description), 2 (General Background), 5 (Outreach and Coordination), 9 (Strategic 
Objectives and Performance Goals for the Plan Administration), and 10 (Annual Reports 
and Evaluations).  States expanding through Medicaid-only will also be required to submit a 
Medicaid State Plan Amendment to modify their Title XIX state plans.  These states may 
complete the first check-off for Sections 3 (General Contents of State Health Plan), 4 (Eligibility 
Standards and Methodology), 6 (Coverage Requirements for Children's Health Insurance), 7 
(Quality and Appropriateness of Care), and 8 (Cost Sharing and Payment) indicating that the 
description of the requirements for these sections are incorporated by reference through their 
state Medicaid plans.  States wishing to use a combination of approaches will be required to 
complete the Title XXI state plan and the necessary state plan amendment under Title XIX. 
Completed state plans for Title XXI should be submitted to the Health Care Financing 
 
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Administration at the following address: 
 
Administrator 
Health Care Financing Administration 
7500 Security Blvd 
Baltimore, Maryland  21244 
 
Attn:  Family & Children's Health Programs Group 
          Center for Medicaid and State Operations 
          Mail Stop - C4-14-16 
 
The state should submit an original package and 10 copies.  In addition, state plan amendments 
for Medicaid expansions should also be sent to this address.  Plans may be submitted on 
computer disk, formatted using WordPerfect 6.1.  An electronic version of the model application 
template can be obtained by contacting HCFA .  The template and instructions are viewable on 
the HCFA website (Http://www.hcfa.gov).  Questions regarding this process may be submitted 
to the Family & Childrens Health Programs Group or the state may contact its servicing Health 
Care Financing Administration regional office.  The contacts and addresses for the regional 
offices are as follows:  
 
HCFA Regional Office Administrators 
Regional Office  Administrator     Address       Phone
 
Atlanta   Rose Crum Johnson    HCFA - Atlanta RO    404/331-2329 
Regional Administrator  101 Marietta Tower Rm. 701 
Atlanta, Georgia 30323 
 
Boston   Sidney Kaplan   HCFA - Boston RO    617/565-1188 
Regional Administrator  JFK Federal Building 
Room 2325 
Boston, MA 02203 
 
Chicago    Dorothy Burke Collins  HCFA - Chicago RO    312/886-6432 
   Regional Administrator  105 W. Adams Street 
15th & 16th Floors 
Chicago, IL 60603 
 
Dallas     Ed Lessard      HCFA - Dallas RO    214/767-6427 
Acting Regional Admin.  1200 Main Street, Ste. 2000 
Dallas, TX 75202-4348 
 
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Denver   Mary Kay Smith    HCFA - Denver RO    303/844-2111 
Regional Administrator  Federal Office Bldg. 
1961 Stout Street, Room 522 
Denver, CO 80294-3538 
 
Kansas City    Joe Tilghman      HCFA - Kansas City RO  816/426-5233 
Regional Administrator  Richard Bolling Federal Bldg. 
601 East 12th Street, Room 235 
Kansas City, MO 64106-2808 
 
New York    Alberta Leone     HCFA - New York RO  212/264-4488 
Acting Regional Admin.  26 Federal Plaza, Room 3811 
New York, NY 10278 
 
Philadelphia    Maurice Hartman    HCFA - Philadelphia RO  215/596-1351 
Regional Admin.    3535 Market Street, Rm. 3100 
Philadelphia, PA 19104 
 
San Francisco   Beth Abbott      HCFA - San Francisco RO  415/744-3507 
Regional Administrator  75 Hawthorne Street, 4th Floor 
San Francisco, CA 94105-3903 
 
Seattle     Nancy Dapper   HCFA - Seattle RO    206/615-2306 
Regional Administrator  2201 Sixth Ave. 
Mail Stop RX 40 
Seattle, WA 98121-2500 
 
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SECTION SPECIFIC INSTRUCTIONS (For attached model application template) 
 
Section 1.  General Description and Purpose of the State Child Health Plans 
 
Introduction
An approved state child health plan is required in order for a state to be eligible for payment 
under Title XXI.   This plan must set forth how the state intends to use the funds provided under 
Title XXI by indicating that child health assistance shall be provided primarily through one of 
the three options listed in Section 2101(a) of the Social Security Act (the Act). 
 
Guidance
Section 1.1.  Check here if child health assistance shall be provided primarily through the 
development of an independent insurance program that meets the requirements of 
Section 2103, which details coverage requirements and the other applicable 
requirements of Title XXI. 
 
Section 1.2.  Check here if child health assistance shall be provided primarily through 
providing expanded eligibility under the states Medicaid program (Title XIX). 
 
Section 1.3.  Check here if child health assistance shall be provided through a combination of 
both 1.1. and 1.2. (Coverage that meets the requirements of Title XXI, in 
conjunction with an expansion in the states Medicaid program). 
 
 
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Section 2.  General Background and Description of State Approach to Child Health 
Coverage 
 
Introduction 
This section is designed to solicit general information related to  the special characteristics of 
each state.  The information being sought concerns the extent and manner to which children in 
the state currently have creditable health coverage, current health state efforts to provide or 
obtain creditable health coverage for uncovered children and how the plan is designed to be 
coordinated with current health insurance or public health efforts.  This information will provide 
a health insurance baseline in terms of the status of the children in a given state and the state 
programs currently in place. 
 
Guidance
Section 2.1.  The demographic information requested in 2.1. in the form of an attachment can 
be used for state planning and will be used strictly for informational purposes.  
THESE NUMBERS WILL NOT BE USED AS A BASIS FOR THE 
ALLOTMENT.  The numbers used to determine the allotment of funds under 
Title XXI will be those provided each year by the U.S. Bureau of the Census. 
 
Factors that the state may consider in the provision of this information are age 
breakouts, income brackets, definitions of insurability, and geographic location, 
as well as race and ethnicity.  To the extent practicable, the state should make a 
distinction between creditable coverage under public health insurance programs 
(e.g., Medicaid and state-only child health insurance) and public-private 
partnerships, and describe its information sources and the assumptions it uses for 
the development of its description.  (A suggested format for describing this 
information can be found in Section 10 of the template). 
 
Section 2.2.  A state child health plan must include an overview of current efforts made by the 
state through child related programs (e.g., Medicaid, the Maternal and Child 
Health Block Grant, Title V, WIC, community and migrant health centers, or 
special state programs for child health care) to provide health care services or 
obtain creditable health coverage for uncovered children by identifying and 
enrolling all uncovered children. 
 
  2.2.1.  Briefly describe the steps being taken by the state to identify and 
enroll all uncovered children who are eligible to participate in 
public health insurance programs (e.g., Medicaid and state-only 
child health insurance).  This information may include a 
description of the state's outreach efforts through Medicaid and 
state-only programs. 
 
 
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  2.2.2.  Briefly describe the steps being taken by the state to identify and 
enroll all uncovered children eligible to participate in health 
insurance programs that involve a public-private partnership.  The 
state may also address the coordination between the public-private 
outreach and the public health programs that is occurring 
statewide. 
 
Section 2.3.  This item requires a brief overview of how new Title XXI efforts -- particularly 
new enrollment outreach efforts -- will be coordinated with and improve upon 
existing state efforts described in Section 2.2.   
 
To help understand the strategy of the state plan to accomplish the intent of Title 
XXI, states need to describe the efforts they are making to coordinate the Title 
XXI plan with the Medicaid program.  Under Title XXI children identified as 
Medicaid-eligible are required to be enrolled in Medicaid.  Therefore, the state 
should describe how its Title XXI program will closely coordinate the enrollment 
with Medicaid. 
 
 
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Section 3.  General Contents of State Child Health Plan 
 
Introduction
The state child health assistance plan must describe the type of child health assistance to be 
provided under the plan (2102(a)(4)).  This section requires a description that must include both 
proposed methods of delivery and proposed utilization control systems.  This section should 
fully describe the delivery system of the Title XXI program including the proposed contracting 
standards, the proposed delivery systems and the plans for enrolling providers.   
 
**Note: States electing to use funds provided under Title XXI only to provide expanded 
eligibility under the states Medicaid plan may check the appropriate box and proceed to 
Section 4. 
 
Guidance  
Section 3.1.  In describing the methods of delivery of the child health assistance using Title 
XXI funds, the state should address the choice of financing the insurance products 
and the methods for assuring delivery of the insurance product(s) to  
  children.  These may include, but are not necessarily limited to:  contracts 
with managed health care plans (including fully and partially capitated plans); 
contracts with indemnity health insurance plans; and other arrangements for 
health care delivery.  The state should describe any variations based upon 
geography, as well as the state methods for establishing and defining the delivery 
systems. 
 
In addition, states may use up to 10 percent of actual or estimated Federal 
expenditures for targeted low-income children to fund other forms of child health 
assistance, including contracts with providers for direct services; other health 
services initiatives to improve childrens health; outreach expenditures; and 
administrative costs (See 2105(a)(2)).  Describe which, if any, of these methods 
will be used.   
 
Examples of the above may include:  direct contracting with school-based health 
services; direct contracting to provide enabling services; contracts with health 
centers receiving funds under section 330 of the Public Health Service Act; 
contracts with hospitals such as those that receive disproportionate share payment 
adjustments under section 1886(d)(5)(F) or 1923 of the Act; contracts with other 
hospitals; and contracts with public health clinics receiving Title V funding.    
 
If applicable, address how the new arrangements under Title XXI will work with 
existing service delivery methods, such as regional networks for chronic illness 
and disability; neonatal care units, or early-intervention programs for at-risk 
infants, in the delivery and utilization of services. 
 
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Section 3.2.  In describing the utilization controls under the child health assistance using Title 
XXI, note that utilization control systems are those administrative mechanisms 
that are designed to ensure that children use only that health care that is 
appropriate, medically necessary, and/or approved by the state or its 
subcontractor. 
 
Examples of utilization control systems include, but may not be limited to, the 
following:  requirements for referrals to specialty care; requirements that 
clinicians use clinical practice guidelines; or demand management systems (e.g., 
use of an 800 number for after-hours and urgent care).  In addition, the state 
should describe its plans for review, coordination, and implementation of 
utilization controls, addressing both procedures and state developed standards for 
review, in order to assure that necessary care is delivered in a cost-effective and 
efficient manner. 
 
 
 
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Section 4.  Eligibility Standards and Methodology 
 
Introduction
The plan must include a description of the standards used to determine the eligibility of 
  targeted low-income children for child health assistance under the plan.  Included on the 
template is a list of potential eligibility standards.  Please check off the standards that will be 
used by the state and provide a short description of how those standards will be applied.  All 
eligibility standards must be consistent with the provisions of Title XXI and may not 
discriminate on the basis of diagnosis.  In addition, if the standards vary within the state, 
describe how they will be applied and under what circumstances they will be applied. 
 
**Note: States electing to use funds provided under Title XXI only to provide expanded 
eligibility under the states Medicaid plan may check the appropriate box and proceed to 
Section 5. 
 
Guidance
Section 4.1.  Check all standards that will apply to the states plan. 
 
  4.1.1.  If eligibility criteria will vary based on geography within the state, check 
and explain. 
  4.1.2.  Identify and explain the states age standards. 
  4.1.3.  Identify the states income standards, including the definition of 
household and family income, deductions, disregards, and methods for 
evaluating family income. 
  4.1.4.  Identify the states resource standards and describe spend down and 
disposition of resources, if applicable. 
  4.1.5.  Identify the states residency requirements. 
  4.1.6.  Identify how disability status affects eligibility. 
  4.1.7.  Identify how access to or coverage under other health coverage affects 
eligibility. 
  4.1.8.  Specify the duration of eligibility. 
  4.1.9.  Identify and describe other standards for or affecting eligibility. 
 
Section 4.2.  Assurances.  The state must assure that its eligibility standards do not 
discriminate on the basis of diagnosis; within a defined group of covered targeted 
low-income children, the standards do not cover children of higher income 
families without covering children with a lower family income; and the standards 
do not deny eligibility based on a child having a pre-existing medical condition.  
Check the appropriate boxes to make the necessary assurances.  The state should 
review its policies and maintain state records necessary to explain how it may 
make these assurances. 
 
 
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Section 4.3.  Methodology.  Describe the methods of establishing and continuing eligibility 
and enrollment.  The description should address the procedures for applying the 
eligibility standards, the organization and infrastructure responsible for making 
and reviewing eligibility determinations, and the process for enrollment of 
individuals receiving covered services, whether the state uses the same 
application form for Medicaid and/or other public benefit programs. 
 
Section 4.4.  This section addresses eligibility screening and coordination with other health 
coverage programs.  States must describe how they will assure: 
 
  4.4.1.  only targeted low-income children are furnished child health assistance 
under the plan; 
  4.4.2.  children found through the screening to be eligible for medical assistance 
under the state Medicaid plan are enrolled for assistance under such plan; 
  4.4.3.  the insurance provided under the state child health plan does not substitute 
for coverage under group health plans; 
  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(c) of the Indian Health 
Care Improvement Act, 25 U.S.C. 1603(c)); and  
  4.4.5.  coordination with other public and private programs providing creditable 
coverage for low-income children. 
 
Describe the states eligibility screening process in a way that addresses the five 
assurances specified above.  The state should consider including in this description 
important definitions, the relationship with affected Federal, state and local agencies, and 
other applicable criteria that will describe the states ability to make assurances. 
 
 
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Section 5.  Outreach and Coordination 
 
Introduction
This section is designed for the state to fully explain its outreach and coordination activities.  
Outreach is defined in law as outreach to families of children likely to be eligible for child health 
assistance under the plan or under other public or private health coverage programs.  The 
purpose is to inform these families of the availability of, and to assist them in enrolling their 
children in such a program. 
 
Guidance
Section 5.1.  Describe how the outreach program will be used to target children in the state 
who would be eligible and enable those children to enroll, utilize and stay in the 
health care system including those served through other child-related programs 
(e.g., MCH Block Grant, WIC, and  community and migrant health centers). 
 
Outreach and enabling services may include, but are not limited to, community 
outreach workers, outstationed eligibility workers, translation and transportation 
services, assistance with enrollment forms, case management and other targeting 
activities to inform families of low-income children of the availability of the 
health insurance program under the plan or other Federal, state or local health 
assistance program. 
 
This section may also include discussions of the following: 
 
  How the outreach program will take advantage of the outreach strategies 
and experience of traditional safety net providers. 
  Coordination of the outreach program with other public and private health 
services, other social services, day care programs, and school-based or 
school-linked services. 
  Special outreach efforts that will target families of migrants, homeless 
children, other children with special health care needs, or those in rural or 
frontier areas. 
  Further outreach efforts the state will require of health plans or providers 
who receive Title XXI funds. 
 
Section 5.2.  Describe how children who are determined to be eligible for Medicaid or another 
state-only childrens health insurance program will be referred to and enrolled 
into that program. 
 
Describe how Medicaid eligibility workers will refer non-Medicaid eligible 
children to the new Childrens Health Insurance Program. 
 
 
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Finally, describe how the outreach efforts described above will be coordinated 
with current outreach efforts for the Medicaid or other state-only childrens health 
insurance program, and how outreach and enrollment efforts for the Childrens 
Health Insurance Program will be coordinated with the states current efforts to 
provide outstationed eligibility services at Federally Qualified Health Centers and 
Disproportionate Share Hospitals (as required by Section 1902(a)(55) of the 
Social Security Act). 
 
 
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Section 6.  Coverage Requirements for Childrens Health Insurance 
 
Introduction
Regarding the required scope of health insurance coverage in a state plan, the child health 
assistance provided must consist of any of the four types of coverage outlined in Section 2103(a) 
(specifically, benchmark coverage; benchmark-equivalent coverage; existing comprehensive 
state-based coverage; and/or Secretary-approved coverage). 
 
Identify the scope of coverage and benefits offered under the plan including the categories under 
which that coverage is offered.  The amount, scope, and duration of each offered service should 
be fully explained, as well as any corresponding limitations or exclusions. 
 
**Note: States electing to use funds provided under Title XXI only to provide expanded 
eligibility under the states Medicaid plan may check the appropriate box and proceed to 
Section 7. 
 
Guidance
Section 6.1.  Check all that apply in terms of the coverage to be offered to eligible children. 
 
  6.1.1.  Benchmark coverage is equivalent to the benefits coverage in a 
benchmark benefit package (FEHBP-equivalent coverage, state employee 
coverage, and/or the HMO coverage plan that has the largest insured 
commercial, non-Medicaid enrollment in the state).  If this box is checked, 
either 6.1.1.1., 6.1.1.2., or 6.1.1.3. must also be checked and an attached 
description provided.  
  6.1.1.1.  Check here if the benchmark benefit package to be offered 
by the state is the standard Blue Cross/Blue Shield 
preferred provider option service benefit plan, as described 
in and offered under Section 8903(1) of Title 5, United 
States Code.  If checked, attach a copy of the plan. 
  6.1.1.2.  Check here if the benchmark benefit package to be offered 
by the state is state employee coverage, meaning a 
coverage plan that is offered and generally available to 
state employees in the state.  Identify the specific state plan 
and attach a copy of the benefits description. 
  6.1.1.3.  Check here if the benchmark benefit package to be offered 
by the state is offered by a health maintenance organization 
(as defined in Section 2791(b)(3) of the Public Health 
Services Act) and has the largest insured commercial, non-
Medicaid enrollment of covered lives of such coverage 
plans offered by an HMO in the state.  Identify the specific 
HMO coverage plan and attach a copy of the benefits 
 
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description. 
 
  6.1.2.  Benchmark-equivalent coverage must meet the following requirements: 
the coverage includes benefits for items and services within each of the 
categories of basic services described in Section 2103(c)(1):  inpatient and 
outpatient hospital services, physicians surgical and medical services, 
laboratory and x-ray services, well-baby and well-child care, including 
age-appropriate immunizations; the coverage has an aggregate actuarial 
value that is at least actuarially equivalent to one of the benchmark benefit 
packages (FEHBP-equivalent coverage, state employee coverage, or 
coverage offered through an HMO coverage plan that has the largest 
insured commercial enrollment in the state); and the coverage has an 
actuarial value that is equal to at least 75 percent of the actuarial value of 
the additional categories in such package, if offered, as described in 
2103(c)(2): coverage of prescription drugs, mental health services, vision 
services and hearing services. 
 
If this box is checked, a signed actuarial memorandum must be attached.  
Sufficient information should be provided so that any actuary could 
review and replicate the results of the states actuary. 
 
The actuarial report must be prepared by an individual who is a member of 
the American Academy of Actuaries. This report must be prepared in 
accordance with the principles and standards of the Actuarial Standards 
Board for such reports.  In preparing the report, the actuary must use 
generally accepted actuarial principles and methodologies, use a 
standardized set of utilization and price factors, use a standardized 
population that is representative of privately insured children of the age of 
children who are expected to be covered under the state child health plan, 
apply the same principles and factors in  comparing the value of different 
coverage (or categories of services), without taking into account any 
differences in coverage based on the method of delivery or means of cost 
control or utilization used, and take into account the ability of a state to 
reduce benefits by taking into account the increase in actuarial value of 
benefits coverage offered under the state child health plan that results 
from the limitations on cost sharing under such coverage. 
 
  6.1.3.  Existing comprehensive state-based coverage is only applicable to New 
York, Florida and Pennsylvania.  If this box is checked, an attached 
description of the benefits package, administration and date of enactment 
must be attached.   
 
 
16  VVeerrssiioonn  99//1122//9977   DRAFT - 9/12/97 
 
A state approved under this provision, may modify its program from time 
to time so long as it continues to provide coverage at least equal to the 
lower of the actuarial value of the coverage under the program as of 
August 5, 1997, or one of the benchmark programs.  If existing 
comprehensive state-based coverage is modified, an actuarial opinion 
documenting that the actuarial value of the modification is greater than the 
value as of August 5, 1997, or one of the benchmark plans must be 
attached. 
 
Also, the fiscal year 1996 state expenditures for existing comprehensive 
state-based coverage must be described in the space provided for all 
states. 
 
  6.1.4.  Secretary-approved coverage refers to any other health benefits 
coverage deemed appropriate and acceptable by the Secretary upon 
application by a state. 
 
Section 6.2.  The term child health assistance means payment for part or all of the cost of 
health benefits coverage for targeted low-income children that includes any of the 
services and products listed in this section of the template (Section 2110(a)).  All 
forms of coverage that the state elects to provide to children in its plan must be 
checked.  The state should also describe the scope, amount and duration of 
services covered under its plan, as well as any exclusions or limitations. 
 
  6.2.1. - 6.2.28.  Check each box the state elects to provide coverage for in its child 
health assistance plan. 
The following are clarifications of certain types of services: 
  6.2.14. Home and community based services may include supportive 
services such as home health nursing services, home health 
aide services, personal care, assistance with activities of 
daily living, chore services, day care services, respite care 
services, training for family members, and minor 
modifications to the home. 
  6.2.15. Nursing services may include nurse practitioner services, nurse 
midwife services, advanced practice nurse services, private 
duty nursing care, pediatric nurse services, and respiratory 
care services in a home, school or other setting. 
  6.2.24. Any other medical, diagnostic, screening, preventive, restorative, 
remedial, therapeutic or rehabilitative service may be 
provided, whether in a facility, home, school, or other 
setting, if recognized by state law and only if the service is: 
 1) prescribed by or furnished by a physician or other 
 
17  VVeerrssiioonn  99//1122//9977   DRAFT - 9/12/97 
 
licensed or registered practitioner within the scope of 
practice as prescribed by state law; 2) performed under the 
general supervision or at the direction of a physician; or 3) 
furnished by a health care facility that is operated by a state 
or local government or is licensed under state law and 
operating within the scope of the license. 
  6.2.27. Enabling services, such as transportation, translation, and outreach 
services, may be offered only if designed to increase the 
accessibility of primary and preventive health care services 
for eligible low-income individuals. 
 
Section 6.3.  There are two types of waivers that states may request that address additional 
purchase options in Title XXI: waivers authorized for cost effective alternatives 
and waivers for the purchase of family coverage.  
 
Review and approval of the waiver application(s) will be separate and distinct 
from the state plan approval process.   
 
  6.3.1.  Check here if the state is requesting a waiver for a cost-effective 
alternative.  Such a waiver allows the state to waive the 10% limitation 
on expenditures not used for Medicaid or health insurance assistance if 
coverage provided to targeted low-income children through such 
expenditures meets the requirements of section 2103; the cost of such 
coverage is not greater, on an average per child basis, than the cost of 
coverage that would otherwise be provided under Section 2103; and such 
coverage is provided through the use of a community-based health 
delivery system, such as through contracts with health centers receiving 
funds under Section 330 of the Public Health Services Act or with 
hospitals such as those that receive disproportionate share payment 
adjustments under Section 1886(d)(5)(F) or 1923.   
 
If the cost-effective alternative waiver is requested, the state must 
demonstrate that payments in excess of the 10% limitation will be used for 
other child health assistance for targeted low-income children; 
expenditures for health services initiatives under the plan for improving 
the health of children (including targeted low-income children and other 
low-income children); expenditures for outreach activities as provided in 
Section 2102(c)(1) under the plan; and other reasonable costs incurred by 
the state to administer the plan.   
 
  6.3.1.1.  If  a waiver for cost-effective alternatives is sought, 
coverage provided to targeted low-income children through 
 
18  VVeerrssiioonn  99//1122//9977   DRAFT - 9/12/97 
 
such expenditures meet the coverage requirements as stated 
above and describe the coverage provided by the 
alternative delivery system in an attachment. 
  6.3.1.2.  If a waiver for cost-effective alternatives is sought, the cost 
of such coverage must not be greater, on an average per 
child basis, than the cost of coverage that would otherwise 
be provided for the coverage described in 6.4.1., and 
describe the cost of such coverage on an average per child 
basis in an attachment. 
  6.3.1.3.  If a waiver for cost-effective alternatives is sought, 
describe the community based delivery system in an 
attachment. 
 
  6.3.2.  Check here if the state is requesting a waiver to purchase family 
coverage under a group health plan.  Any state desiring such a waiver 
will need to attach information that establishes to the Secretarys 
satisfaction that:  1) when compared to the amount of money that would 
have been paid to cover only the children involved with a comparable 
package, the purchase of family coverage is cost effective; and 2) the 
purchase of family coverage is not a substitution for coverage already 
being provided to the child. 
 
  6.3.2.1.  Describe the associated costs for purchasing the family 
coverage relative to the coverage for the low income 
children in an attachment. 
  6.3.2.2.  Describe how the family coverage would not otherwise 
substitute for health insurance that would be provided to 
such children but for the purchase of family coverage. 
 
19  VVeerrssiioonn  99//1122//9977   DRAFT - 9/12/97 
 
Section 7.  Quality and Appropriateness of Care 
 
Introduction
State child health plans must include a description of the methods (including monitoring) to be 
used to assure the quality and appropriateness of care and to assure access to covered services.  
A variety of methods are available for states use in monitoring and evaluating the quality and 
appropriateness of care in its child health assistance program.  Listed below are some of the  
methods which states may consider using.  In addition to methods, there are a variety of tools 
available for state adaptation and use with this program.  A list of some of these tools is provided 
below.  States also have the option to choose who will conduct these activities.  As an alternative 
to using staff of the state agency administering the program, states have the option to contract 
out with other organizations for this quality of care function. 
 
Methods for Evaluating and Monitoring Quality
Methods to assure quality include the application of performance measures, quality standards 
consumer information strategies, and other quality improvement strategies. 
 
Performance measurement strategies could include using measurements for external reporting 
either to the state or to consumers and for internal quality improvement purposes.  They could be 
based on existing measurement sets that have undergone rigorous evaluation for their 
appropriateness (e.g., HEDIS).  They may include the use of standardized member satisfaction 
surveys to assess members experience of care along key dimensions such as access, satisfaction, 
and system performance. 
 
Quality standards are often used to assure the presence of structural and process measures that 
promote quality and could include such approaches as:  the use of external and periodic review 
of health plans by groups such as the National Committee for Quality Assurance; the 
establishment of standards related to consumer protection and quality such as those developed by 
the National Association of Insurance Commissioners; and the formation of an advisory group to 
the state or plan to facilitate consumer and community participation in the plan. 
 
Information strategies could include:  the disclosure of information to beneficiaries about their 
benefits under the plan and their rights and responsibilities; the provision of comparative 
information to consumers on the performance of available health plans and providers; and 
consumer education strategies on how to access and effectively use health insurance coverage to 
maximize quality of care. 
 
Quality improvement strategies could include the establishment of quality improvement goals for 
the plan or the state and provider education.  Other strategies includes specific purchasing 
specifications, ongoing contract monitoring mechanisms, focus groups, etc.  
 
20  VVeerrssiioonn  99//1122//9977   DRAFT - 9/12/97 
 
Tools for Evaluating and Monitoring Quality 
Tools and types of information available include QARI (Medicaids Quality Assurance Review 
Initiative), QISMC (The Quality Improvement System for Managed Care) which is under 
development by HCFA and will replace QARI, HEDIS (Health Employer Data Information Set) 
measures, FACCT (Foundation for Accountability) measures, CAHPS (Consumer Assessments 
of Health Plans Study), vital statistics data, and state health  registries (e.g., immunization 
registries). 
 
Quality monitoring may be done internally by appropriate staff of the state agency administering 
the child health insurance program or may be contracted out to a variety of entities including 
state Health Departments, external quality review organizations, PROs (Professional Review 
Organizations), and others with appropriate skills and expertise.  Establishing grievance 
measures is also an important aspect of monitoring.  
 
States are also expected to comply with any national quality measures developed in the future as 
discussed on page 2.  Any standards that are adopted will be developed in conjunction with the 
states, advocacy groups, and other interested parties. 
 
**Note: States electing to use funds provided under Title XXI only to provide expanded 
eligibility under the states Medicaid plan may check the appropriate box and proceed to 
Section 8. 
 
Guidance
Section 7.1.  Provide a brief description of methods to assure the quality and appropriateness of 
care, particularly with respect to well-baby care, well-child care and 
immunizations provided under the plan.  The state must also specify the 
qualifications of entities that will provide coverage and the conditions of 
participation. 
 
  7.1.1.-7.1.4.  Check each of the tools listed that the state plans to utilize to 
assure quality. 
 
Section 7.2.  Provide a brief description of methods to be used to assure access to covered 
services, including emergency services.  The state should consider whether there 
are sufficient providers of care for the newly enrolled populations and whether 
there is reasonable access to care.  
 
 
 
21  VVeerrssiioonn  99//1122//9977   DRAFT - 9/12/97 
 
Section 8.  Cost-Sharing and Payment 
 
Introduction
This section addresses the requirement of a state child health plan to include a description of its 
proposed cost sharing for enrollees.  Cost-sharing is the amount (if any) of premiums, 
deductibles, coinsurance and other cost-sharing imposed.  The cost-sharing requirements provide 
protection for lower income children in the states cost-sharing plan, ban cost-sharing for 
preventive services, address the limitations on premiums and cost-sharing and address the 
treatment of pre-existing medical conditions. 
 
**Note:  States electing to use funds provided under Title XXI only to provide expanded 
eligibility under the states Medicaid plan may check the appropriate box and proceed to 
Section 9. 
 
Guidance
Section 8.1.  Indicate if the states Title XXI plan will implement any sort of cost-sharing.   
 
  8.1.1.  Check here if the states Title XXI plan will implement any sort of cost-
sharing  in the form of premiums, deductibles, coinsurance or other cost-
sharing. 
  8.1.2.  Check here if the states Title XXI plan will not implement any sort of 
cost-sharing.  If there is no cost-sharing, proceed to question 8.5. 
 
Section 8.2.  This section asks for a description of the cost-sharing under the state plan.  It is 
important to note that, for families below 150% of poverty, the same limitations 
on cost-sharing that are under the Medicaid program apply (These cost-sharing 
limitations have been set forth in Section 1916 of the Social Security Act, as 
implemented by regulations at 42 CFR 447.50-.59).  For families with incomes of 
150% of poverty and above, cost-sharing for all children in the family cannot 
exceed 5% of a familys income per year. 
 
Section 8.3.  Provide a brief description of how beneficiaries and the public will be able to 
obtain information on cost-sharing requirements. 
 
Section 8.4.   To ensure that protection will be provided for lower income children and that 
preventive services will not be subject to cost-sharing, the state must assure that 
the following are descriptive of its plan.  The state should be able to demonstrate 
upon request its rationale and justification regarding these assurances.  This 
section also addresses limitations on payments for certain expenditures and 
requirements for maintenance of effort.   
 
  8.4.1.  Under Title XXI, cost-sharing cannot favor children with higher incomes 
 
22  VVeerrssiioonn  99//1122//9977   DRAFT - 9/12/97 
 
over those with lower incomes.  Please indicate if the states plan follows 
this requirement. 
 
  8.4.2.  Under Title XXI, state plans are not allowed to have cost-sharing on well-
baby and well-child care, including age appropriate immunizations.  
Please indicate if the plan follows this requirement. 
 
8.4.3.  The state must comply with cost-sharing limitations as described in 
1916(b)(1). 
 
  8.4.4.  Funds provided by the Federal government are not eligible for use as the 
state match.  In addition, services assisted by or subsidized to any great 
extent by the Federal Government may not be used for state match either.  
Please confirm that non-Federal funds will only be used for the state 
match. 
 
  8.4.5.  Premiums and cost-sharing from beneficiaries are not eligible for use as 
part of the state match.  Please confirm that no cost-sharing funds will be 
used toward the state match.  Please note that if a state collects cost-
sharing funds, this revenue will be offset by reducing the amount of 
expenditures eligible for state match by the amount of the cost-sharing 
revenue. 
 
  8.4.6.  To prevent duplicative payments, no payment will be made to a state if a 
private insurer  (as defined by the Secretary by regulation and including a 
group health plan -- as defined in Section 607(1) of the Employee 
Retirement Income Security Act of 1974 -- a service benefit plan, and an 
HMO) would have been obligated to provide such assistance but for a 
provision of its insurance contract which has the effect of limiting or 
excluding such obligation because the individual is eligible for or is 
provided health assistance under the plan.  Please confirm that  this 
requirement is incorporated into the state plan.   
 
The following assurance must be made regarding the maintenance of effort requirements: 
  8.4.7.  Under the child health program, a state may not implement income and 
resource standards and methodologies for determining Medicaid eligibility 
that are more restrictive than those in use as of June 1, 1997.  Please 
indicate if the states Medicaid eligibility standards have changed since 
June 1, 1997. 
 
The following assurances must be made regarding limitation of services for abortion under child 
health: 
 
23  VVeerrssiioonn  99//1122//9977   DRAFT - 9/12/97 
 
  8.4.8.  Appropriated funds may not be used to pay for health coverage that 
includes abortion or to assist in the direct purchase of abortion services 
except if necessary to save the life of the mother or if the pregnancy is the 
result of rape or incest.  Please confirm that the states plan follows this 
requirement. 
 
  8.4.9.  Payments shall not be made to a state under this section for any amount 
expended under the state plan to pay for any abortion or to assist in the 
purchase, in whole or in part, of health benefit coverage that includes 
coverage of abortion (except as described in 8.5.5.).  (Note that nothing in 
Title XXI should be construed as affecting the expenditure for any 
abortion or for health benefits coverage that includes coverage of abortion 
by a state, locality, or private person or entity of state, local or private 
funds.)  Please confirm that the states plan follows this requirement. 
 
The state should be able to demonstrate upon request its rationale and supporting 
justification regarding the assurances addressed above. 
 
Section 8.5.  Cost-sharing on children from families with incomes equal to or greater than 
150% of poverty cannot exceed 5% of family income a year.  Please provide a 
description of the methods that will be used to ensure that families in this income 
range will not be charged more than allowed. 
 
Section 8.6.  Under Title XXI, pre-existing condition exclusions are not allowed, with the only 
exception being in relation to another law in existence (HIPAA/ERISA).  Indicate 
that the plan adheres to this requirement by checking the applicable description. 
 
In the event that the state provides benefits through a group health plan or group 
health coverage, or provides family coverage through a group health plan under a 
waiver (see Section 6.3.2. of the template), pre-existing condition limits are 
allowed to the extent permitted by HIPAA/ERISA.  If the state is contracting with 
a group health plan or provides benefits through group health coverage, please 
describe briefly any limitations on pre-existing conditions.  
 
24  VVeerrssiioonn  99//1122//9977   DRAFT - 9/12/97 
 
Section 9.  Strategic Objectives and Performance Goals for the Plan Administration 
 
Introduction
The section addresses the strategic objectives, the performance goals, and the performance 
measures the state has established for providing child health assistance to targeted low-income 
children under the plan for maximizing health benefits coverage for other low-income children 
and children generally in the state.   
 
States are also expected to comply with any national performance measures developed in the 
future as discussed on page 2.  Any standards that are adopted will be developed in conjunction 
with the states, advocacy groups, and other interested parties. 
 
Guidance
Section 9.1.  Identify and list the specific strategic objectives relating to increasing the extent 
of creditable health coverage among targeted low-income children and other 
low-income children.  It is suggested the state identify a minimum of 5, but no 
more than 10 strategic objectives. 
 
Section 9.2.  Specify at least one performance goal and performance measure for each strategic 
objective.  We plan on developing, in conjunction with the states, advocacy 
groups, and other interested parties, national standards for performance measures. 
 We will be working with states to develop the most useful measures.  In the 
interim, we are proposing examples that may be useful for states in designing 
their performance measures.  In the hope of consistent reporting among states, 
and for the aggregation of national results, we suggest that each performance goal 
and performance measure be described as reflected in Section 9.3. 
 
Section 9.3.  Briefly describe how the plans performance will be measured objectively and 
independently.  Check all appropriate measures the state will be utilizing. 
 
It is acceptable for the state to include performance measures for population 
 subgroups chosen by the state for special emphasis, such as racial or ethnic  
minorities, particular high-risk or hard to reach populations, children with 
special needs, etc.   
 
HEDIS (Health Employer Data and Information Set) 3.0 measures directly 
relevant to children and adolescents younger than 19.  In addition, HEDIS 
3.0 contains measures for the general population, for which breakouts by 
childrens age bands (e.g., ages < 1, 1-9, 10-19) are required.  Full definitions, 
explanations of data sources, and other important guidance on the use of 
HEDIS measures can be found in the HEDIS 3.0 manual published by the 
National Committee on Quality Assurance.  So that state HEDIS results are 
 
25  VVeerrssiioonn  99//1122//9977   DRAFT - 9/12/97 
 
consistent and comparable with national and regional data, states should 
check the HEDIS 3.0 manual for detailed definitions of each measure, 
including definitions of the numerator and denominator to be used.  For 
states that do not plan to offer managed care plans, HEDIS measures may 
also be able to be adapted to organizations of care other than managed care.  
HEDIS 3.0 is a set of standardized performance measures designed for 
managed care plans, including plans that enroll Medicaid beneficiaries.  
HEDIS is intended to focus on areas of health important to individual 
consumers and patients, providers, and purchasers, and is being used by 
over 300 managed care plans to report performance experience for the 
reporting year 1996.  Results by plan and summary results (national and 
regional) will be available in early fall 1997.   
 
The following is an example of how the State could provide an objective 
measure. 
 
HEDIS 3.0 Reporting Set Measures Relevant to Children and Adolescents 
 
   
HEDIS Domain /Measure  Rough definition of Measure 
   
Effectiveness of Care   
   
Childhood immunization  % of children in plan who have received appropriate immunizations 
status  by their 2nd birthday 
   
Adolescent immunization  % of 13-year-olds in plan who received all appropriate 
status  immunizations by their 13th birthday 
   
Treating childrens ear  How often a non-preferred antibiotic was given to children with 
infections  uncomplicated acute otitis media 
   
Access/Availability of Care   
   
Childrens access to primary  % of Medicaid enrolled children age 12 months through 24 months 
care providers  and age 25 months through 6 years who had a visit with a health 
plan primary care provider during the reporting year, and the % of 
Medicaid enrolled children age 7 through 11 years who had a visit 
with a health plan primary care provider during the reporting year 
or the year preceding the reporting year. 
   
Satisfaction with the   
Experience of Care 
   
CAHPS -child health module    
   
Use of Services   
   
Well-child visits in the first 15  % of members who turned 15 months old during the reporting year 
months of life  and who received either zero, one, two, three, four, five, or six or more 
well-child visits with a primary care provider during their first 15 
months of life. 
   
Well-child visits in the Third,  % of enrolled members who were 3, 4, 5, or 6 years old during the 
Fourth, Fifth and Sixth Year  reporting year and who received one or more well-child visit(s) with 
 
26  VVeerrssiioonn  99//1122//9977   DRAFT - 9/12/97 
 
of Life  a primary care provider during the reporting year.    
   
Adolescent well-care visits  % of members who were age 12 through 21 years1 during the 
  reporting year who have had at least one comprehensive well-care 
1  visit with a primary care provider during the reporting year. 
  States receiving funds would be required 
to cover, and thus to use, this quality 
 
m easure, only for children less than 19.  
Health Plan Descriptive   
Information 
   
Pediatric physician specialists  % of each that has completed residency training or fellowship 
training in their respective specialties and/or are board certified, 
reported separately for each payer. 
   
Pediatric mental health  A narrative description of the health plans pediatric mental health 
services  provider network, including the number and types of MH providers 
specially trained to treat children and adolescents (including, but not 
limited to, child psychiatrists, child psychologists and social workers, 
counselors, marriage and family therapists and nurses with special 
education and training in child and adolescent mental health).   If the 
plan subcontracts for this service, it is required to describe any 
special requirements included in the subcontracts. 
 
 
 
Section 9.4.  Assure that the state will provide reports to the Secretary as requested.  
 
Section 9.5.  Briefly describe the states plan for annual assessment and evaluation.  
(See section 10 and sections 2108 (a) and (b) of the Act.)   Some questions 
to consider and to assist the state in describing the states plan for annual 
assessment include:  
 
For the annual assessment:  
  How will the state calculate the baseline number of uncovered 
low-income children?    
 
For the evaluation:  
  Who will perform the evaluation? 
  What constitutes "effectiveness"? 
  How will the state measure the "quality of health coverage"?  What 
data elements will the state track?  How will this information be 
collected?  By whom? 
  How are the performance goals and proposed measures the state 
identified in section 9.3 related to the required elements of the 
evaluation?  Are there information systems in place to track these 
performance goals?  Who is responsible for monitoring progress? 
  How will the state identify "changes and trends in the state" affecting 
 
27  VVeerrssiioonn  99//1122//9977   DRAFT - 9/12/97 
 
the provision of health insurance for children? 
 
Section 9.6.  Self-explanatory 
 
Section 9.7.  As stated above, national performance standards will be developed in 
conjunction with states, advocates, and other interested parties.  This 
assurance verifies that the states will participate in the collection and 
evaluation of data when the measures are developed. 
 
Section 9.8.    Assure that the state applies sections of this Act in the same manner as 
they apply under Title XIX as listed in Title XXI, Section 2107(e).  
Check all that apply. 
 
Section 9.9.  Briefly describe the process and document the activity used to involve 
the public, including community-based providers and consumer 
representatives in the design and implementation of the plan and the 
method for ensuring ongoing public involvement.  Issues to address 
include a listing of public meetings or announcements made to the 
public concerning the development of the children's health insurance 
program. 
 
Section 9.10.  Submit the budget for this program including details on the planned 
use of funds and sources of the non-Federal share of plan 
expenditures.  This budget must be updated periodically as necessary. 
 
A form for the budget is being developed, with input from all 
interested parties, to assist in addressing this requirement. 
 
 
 
28  VVeerrssiioonn  99//1122//9977   DRAFT - 9/12/97 
 
Section 10.  Annual Reports and Evaluations 
 
Introduction and Guidance
 
Section 2108(a) requires the state to assess the operation of the State Child Health 
Insurance Program plan and submit to the Secretary an annual report which includes the 
progress made in reducing the number of uncovered low-income children.  The report is 
due by January 1, following the end of the Federal fiscal year.  The report will cover a 
Federal Fiscal Year:  the first report, covering Federal Fiscal Year 1998, is due January 1, 
1999. 
 
By March 31, 2000, each state participating in the program must submit to the Secretary 
an evaluation report addressing the elements set forth in section 2108(b). 
 
States are also expected to comply with any national reporting measures developed in the 
future as discussed on page 2.  Any standards that are adopted will be developed in 
conjunction with the states, advocacy groups, and other interested parties. 
 
In this section, states are asked to assure that they will comply with these requirements, 
indicated by checking the box. 
 
Section 10.1.   These assurances address the annual assessment. 
 
  Chart.  Complete the chart using the performance measures the state have 
developed for analyzing the states Title XXI program.  A chart is included in 
subsection 10.1. listing the types of information that the states annual report 
might include.  Submission of such information will allow comparisons to be 
made between states and on a nationwide basis. 
 
Section 10.2.   State evaluations and assurances.  Complete this section verifying that 
the states annual report will address these areas. 
 
Section 10.3.  Self -explanatory 
 
Section 10.4.   Specify that the state agrees to the assurance that it will comply with 
all Federal laws and regulations, including grant administration and 
reporting rules. 
 
 
 
 
29  VVeerrssiioonn  99//1122//9977   DRAFT - 9/12/97 
 
 GLOSSARY
 
 Adapted directly from SEC. 2110. DEFINITIONS. 
 
CHILD HEALTH ASSISTANCE- For purposes of this title, the term `child health 
assistance' means payment for part or all of the cost of health benefits coverage for 
targeted low-income children that includes any of the following (and includes, in the case 
described in section 2105(a)(2)(A), payment for part or all of the cost of providing any of 
the following),  as specified under the State plan: 
 
(1) Inpatient hospital services. 
(2) Outpatient hospital services. 
  (3) Physician services. 
(4) Surgical services. 
(5) Clinic services (including health center services) and other ambulatory health care 
services. 
(6) Prescription drugs and biologicals and the administration of such drugs and 
biologicals, only if such drugs and biologicals are not furnished for the purpose of 
causing, or assisting in causing, the death, suicide, euthanasia, or mercy killing of a 
person. 
(7) Over-the-counter medications. 
(8) Laboratory and radiological services. 
(9) Prenatal care and prepregnancy family planning services and supplies. 
(10) Inpatient mental health services, other than services described in paragraph (18) 
but including services furnished in a State-operated mental hospital and including 
residential or other 24-hour therapeutically planned structured services. 
(11) Outpatient mental health services, other than services described in paragraph 
(19) but including services furnished in a State-operated mental hospital and 
including community-based services. 
(12) Durable medical equipment and other medically-related or remedial devices 
(such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and 
adaptive devices). 
(13) Disposable medical supplies. 
(14) Home and community-based health care services and related supportive services 
(such as home health nursing services, home health aide services, personal care, 
assistance with activities of daily living, chore services, day care services, respite care 
services, training for family members, and minor modifications to the home). 
(15) Nursing care services (such as nurse practitioner services, nurse midwife 
services, advanced practice nurse services, private duty nursing care, pediatric nurse 
services, and respiratory care services) in a home, school, or other setting. 
(16) Abortion only if necessary to save the life of the mother or if the pregnancy is 
the result of an act of rape or incest. 
 
30  VVeerrssiioonn  99//1122//9977   DRAFT - 9/12/97 
 
(17) Dental services. 
(18) Inpatient substance abuse treatment services and residential substance abuse 
treatment services. 
(19) Outpatient substance abuse treatment services. 
(20) Case management services. 
(21) Care coordination services. 
(22) Physical therapy, occupational therapy, and services for individuals with speech, 
hearing, and language disorders. 
(23) Hospice care. 
(24) Any other medical, diagnostic, screening, preventive, restorative, remedial, 
therapeutic, or rehabilitative services (whether in a facility, home, school, or other 
setting) if recognized by State law and only if the service is-- 
(A) prescribed by or furnished by a physician or other licensed or registered 
practitioner within the scope of practice as defined by State law, 
(B) performed under the general supervision or at the direction of a physician, 
or 
(C) furnished by a health care facility that is operated by a State or local 
government or is licensed under State law and operating within the scope of 
the license. 
(25) Premiums for private health care insurance coverage. 
(26) Medical transportation. 
(27) Enabling services (such as transportation, translation, and outreach services) 
only if designed to increase the accessibility of primary and preventive health care 
services for eligible low-income individuals. 
(28) Any other health care services or items specified by the Secretary and not 
excluded under this section. 
 
TARGETED LOW-INCOME CHILD DEFINED- For purposes of this title-- 
(1) IN GENERAL- Subject to paragraph (2), the term `targeted low-income child' means 
a child-- 
(A) who has been determined eligible by the State for child health assistance under 
the State plan; 
(B)(I) who is a low-income child, or 
(ii) is a child whose family income (as determined under the State child health 
plan) exceeds the Medicaid applicable income level (as defined in paragraph 
(4)), but does not exceed 50 percentage points above the Medicaid applicable 
income level; and 
(C) who is not found to be eligible for medical assistance under title XIX or covered 
under a group health plan or under health insurance coverage (as such terms are 
defined in section 2791 of the Public Health Service Act). 
(2) CHILDREN EXCLUDED- Such term does not include-- 
(A) a child who is a resident of a public institution or a patient in an institution for 
 
31  VVeerrssiioonn  99//1122//9977   DRAFT - 9/12/97 
 
mental diseases; or 
(B) a child who is a member of a family that is eligible for health benefits coverage 
under a State health benefits plan on the basis of a family member's employment with 
a public agency in the State. 
(3) SPECIAL RULE- A child shall not be considered to be described in paragraph (1)(C) 
notwithstanding that the child is covered under a health insurance coverage program that 
has been in operation since before July 1, 1997, and that is offered by a State which 
receives no Federal funds for the program's operation. 
(4) MEDICAID APPLICABLE INCOME LEVEL- The term `medicaid applicable 
income level' means, with respect to a child, the effective income level (expressed as a 
percent of the poverty line) that has been specified under the State plan under title XIX 
(including under a waiver authorized by the Secretary or under section 1902(r)(2)), as of 
June 1, 1997, for the child to be eligible for medical assistance under section 1902(l)(2) 
for the age of such child. 
 
ADDITIONAL DEFINITIONS- For purposes of this title: 
(1)  CHILD- The term `child' means an individual under 19 years of age. 
 
(2) CREDITABLE HEALTH COVERAGE- The term `creditable health coverage' has 
the meaning given the term `creditable coverage' under section 2701(c) of the Public 
Health Service Act (42 U.S.C. 300gg(c)) and includes coverage that meets the 
requirements of section 2103 provided to a targeted low-income child under this title 
or under a waiver approved under section 2105(c)(2)(B) (relating to a direct service 
waiver). 
 
(3)  GROUP HEALTH PLAN; HEALTH INSURANCE COVERAGE; ETC- The terms 
`group health plan', `group health insurance coverage', and `health insurance 
coverage' have the meanings given such terms in section 2191 of the Public 
Health Service Act. 
 
(4) LOW-INCOME CHILD - The term `low-income child' means a child whose family 
income is at or below 200 percent of the poverty line for a family of the size 
involved. 
 
(5) POVERTY LINE DEFINED- The term `poverty line' has the meaning given such 
term in section 673(2) of the Community Services Block Grant Act (42 U.S.C. 
9902(2)), including any revision required by such section. 
 
(6) PREEXISTING CONDITION EXCLUSION- The term `preexisting condition 
exclusion' has the meaning given such term in section 2701(b)(1)(A) of the Public 
Health Service Act (42 U.S.C. 300gg(b)(1)(A)). 
 
 
32  VVeerrssiioonn  99//1122//9977   DRAFT - 9/12/97 
 
(7) STATE CHILD HEALTH PLAN; PLAN- Unless the context otherwise requires, the 
terms `State child health plan' and `plan' mean a State child health plan approved 
under section 2106. 
 
(8) UNCOVERED CHILD- The term `uncovered child' means a child that does not have 
creditable health coverage.'. 
 
33  VVeerrssiioonn  99//1122//9977     DRAFT - 9/12/97 
 
 
DRAFT MODEL APPLICATION TEMPLATE FOR 
STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT 
STATE CHILDRENS HEALTH INSURANCE PROGRAM 
 
 
 
Preamble 
 
This draft model application template outlines the types of information that are likely to be included 
in the state child health plan required under Title XXI.  It has been designed to reflect many of the 
requirements that will be necessary for state plans under Title XXI.  It is not intended to be 
comprehensive or final.  We provide it for preliminary guidance as well as to solicit additional 
information from states and other interested parties on the appropriate content. 
 
The Department of Health and Human Services will continue to work collaboratively with states and 
other interested parties to provide specific guidance in key areas like benefits definitions, 
maintenance of effort provisions, collection of baseline data, and methods for preventing substitution 
of new Federal funds for existing state and private funds.  As such guidance becomes available, the 
model application template will be revised and finalized.  We will work to distribute it in a timely 
fashion to provide assistance as states submit their state plans. 
 
Proposed Effective Date _________    1    Version 9/12/97    DRAFT - 9/12/97 
 
 
MODEL APPLICATION TEMPLATE FOR 
STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT 
STATE CHILDRENS HEALTH INSURANCE PROGRAM 
 
(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b))) 
 
 
 
 
State/Territory:____________________________________________________________ 
(Name of State/Territory) 
 
 
 
As a condition for receipt of Federal funds under Title XXI of the Social Security Act,  
 
________________________________________________________________________ 
(Signature of Governor of State/Territory, Date Signed) 
 
submits the following State Child Health Plan for the State Childrens Health Program and hereby 
agrees to administer the program in accordance with the provisions of the State Child Health Plan, 
the requirements of Title XXI and XIX of the Act and all applicable Federal regulations and other 
official issuances of the Department. 
 
 
 
 
 
 
 
 
 
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of 
information unless it displays a valid OMB control number.  The valid OMB control number for this 
information collection is 0938-0707.  The time required to complete this information collection is estimated 
to average 160 hours (or minutes) per response, including the time to review instructions, search existing 
data resources, gather the data needed, and complete and review the information collection.  If you have any 
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please 
write to: HCFA, P.O. Box 26684, Baltimore, Maryland 21207 and to the Office of the Information and 
Regulatory Affairs, Office of Management and Budget, Washington, D.C.  20503.  
 
Proposed Effective Date _________    2    Version 9/12/97    DRAFT - 9/12/97 
 
 
Section 1.  General Description and Purpose of the State Child Health Plans    (Section 2101) 
 
The state will use funds provided under Title XXI primarily for (Check appropriate box): 
 
  (cid:134)
1.1.   Obtaining coverage that meets the requirements for a State Child Health 
Insurance Plan (Section 2103);   OR  
 
  (cid:134)
1.2.   Providing expanded benefits under the States Medicaid plan (Title XIX);  OR 
 
  (cid:134)
1.3.   A combination of both of the above.  
 
 
Proposed Effective Date _________    3    Version 9/12/97    DRAFT - 9/12/97 
 
 
Section 2.  General Background and Description of State Approach to Child Health Coverage  
            (Section 2102 (a)(1)-(3)) and (Section 2105)(c)(7)(A)-(B))   
 
2.1.    Describe the extent to which, and manner in which, children in the state including 
  targeted low-income children and other classes of children, by income level 
and other relevant factors, such as race and ethnicity and geographic location, 
currently have creditable health coverage (as defined in section 2110(c)(2)).  To the 
extent feasible, make a distinction between creditable coverage under public health 
insurance programs and public-private partnerships (See Section 10 for annual report 
requirements).   
 
2.2.    Describe the current state efforts to provide or obtain creditable health coverage for 
uncovered children by addressing:  (Section 2102)(a)(2) 
 
2.2.1.  The steps the state is currently taking to identify and enroll all uncovered 
children who are eligible to participate in public health insurance programs 
(i.e. Medicaid and state-only child health insurance):  
____________________________________________________________ 
 
2.2.2.  The steps the state is currently taking to identify and enroll all uncovered 
children who are eligible to participate in health insurance programs that 
involve a public-private partnership:  
____________________________________________________________ 
 
 
2.3.    Describe how the new State Title XXI program(s) is(are) designed to be coordinated 
with such efforts to increase the number of children with creditable health coverage so 
that only eligible targeted low-income children are covered:   
(Section 2102)(a)(3)  
___________________________________________________________ 
 
 
  
 
Proposed Effective Date _________    4    Version 9/12/97    DRAFT - 9/12/97 
 
 
Section  3.  General Contents of State Child Health Plan  (Section 2102)(a)(4)) 
(cid:134)
  Check here if the state elects to use funds provided under Title XXI only to provide 
expanded eligibility under the states Medicaid plan, and continue on to Section 4. 
 
3.1.    Describe the methods of delivery of the child health assistance using Title XXI funds 
to targeted low-income children:  (Section 2102)(a)(4) 
_________________________________________________________ 
 
3.2.    Describe the utilization controls under the child health assistance provided under the  
plan for targeted low-income children:  (Section 2102)(a)(4) 
__________________________________________________________ 
 
 
Proposed Effective Date _________    5    Version 9/12/97    DRAFT - 9/12/97 
 
 
Section 4.  Eligibility Standards and Methodology.   (Section 2102(b))  
(cid:134)
  Check here if the state elects to use funds provided under Title XXI only to provide 
expanded eligibility under the states 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)) 
 
(cid:134)
4.1.1.     Geographic area served by the Plan:___________________ 
(cid:134)
4.1.2.     Age:____________________________________________ 
(cid:134)
4.1.3.     Income:_________________________________________ 
(cid:134)
4.1.4.     Resources (including any standards relating to spend downs and 
disposition of resources):___________________________ 
(cid:134)
4.1.5.     Residency:_______________________________________ 
(cid:134)
4.1.6.     Disability Status (so long as any standard relating to disability status 
does not restrict eligibility): _______________________________ 
(cid:134)
4.1.7.     Access to or coverage under other health coverage:_______ 
(cid:134)
4.1.8.     Duration of eligibility _______________________________ 
(cid:134)
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)) 
 
(cid:134)
4.2.1.     These standards do not discriminate on the basis of diagnosis. 
(cid:134)
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. 
(cid:134)
4.2.3.     These standards do not deny eligibility based on a child having a pre-
existing medical condition. 
 
 
Proposed Effective Date _________    6    Version 9/12/97    DRAFT - 9/12/97 
 
 
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 followup 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(c) 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))  
____________________________________________________________ 
  
 
 
Proposed Effective Date _________    7    Version 9/12/97    DRAFT - 9/12/97 
 
 
Section 5.  Outreach and Coordination  (Section 2102(c)) 
 
Describe the procedures used by the state to accomplish: 
 
5.1.    Outreach to families of children likely to be eligible for assistance or under other 
public or private health coverage to inform them of the availability of, and to assist 
them in enrolling their children in such a program:  (Section 2102(c)(1))  
____________________________________________________________ 
 
 
5.2.   Coordination of the administration of this program with other public and private 
health insurance programs:  (Section 2102(c)(2))  
____________________________________________________________ 
 
 
 
Proposed Effective Date _________    8    Version 9/12/97    DRAFT - 9/12/97 
 
 
Section 6.  Coverage Requirements for Childrens Health Insurance  (Section 2103) 
(cid:134)
    Check here if the state elects to use funds provided under Title XXI only to 
provide expanded eligibility under the states Medicaid plan, and continue on to 
Section 7. 
 
 
6.1. The state elects to provide the following forms of coverage to children:  
(Check all that apply.) 
 
(cid:134)
6.1.1.     Benchmark coverage; (Section 2103(a)(1))  
(cid:134)
6.1.1.1.     FEHBP-equivalent coverage;  (Section 2103(b)(1))  
(If checked, attach copy of the plan.)   
(cid:134)
6.1.1.2.     State employee coverage; (Section 2103(b)(2))  (If checked, identify 
the plan and attach a copy of the benefits description.) 
___________________________ 
(cid:134)
6.1.1.3.     HMO with largest insured commercial enrollment (Section 
2103(b)(3))  (If checked, identify the plan and attach a copy of the 
benefits description.)  ___________________________ 
(cid:134)
6.1.2.     Benchmark-equivalent coverage; (Section 2103(a)(2))  Specify the 
coverage, including the amount, scope and duration of each service, as 
well as any exclusions or limitations.  Please attach signed actuarial 
report that meets the requirements specified in Section 2103(c)(4).  See 
instructions. 
(cid:134)
6.1.3.     Existing Comprehensive State-Based Coverage; (Section 2103(a)(3))  [Only 
applicable to New York; Florida; Pennsylvania]  Please attach a 
description of the benefits package, administration, date of enactment.  
If existing comprehensive state-based coverage is modified, please 
provide an actuarial opinion documenting that the actuarial value of the 
modification is greater than the value as of 8/5/97 or one of the 
benchmark plans.  Describe the fiscal year 1996 state expenditures for 
existing comprehensive state-based coverage. 
_______________________________________________________ 
(cid:134)
6.1.4.     Secretary-Approved Coverage. (Section 2103(a)(4))  
 
Proposed Effective Date _________    9    Version 9/12/97    DRAFT - 9/12/97 
 
 
6.2.    The state elects to provide the following forms of coverage to children:  
(Check all that apply.  If an item is checked, describe the coverage with respect to the 
amount, duration and scope of services covered, as well as any exclusions or 
limitations)  (Section 2110(a)) 
 
(cid:134)
6.2.1.     Inpatient services  (Section 2110(a)(1)) 
(cid:134)
6.2.2.     Outpatient services  (Section 2110(a)(2)) 
(cid:134)
6.2.3.     Physician services  (Section 2110(a)(3)) 
(cid:134)
6.2.4.     Surgical services  (Section 2110(a)(4)) 
(cid:134)
6.2.5.     Clinic services (including health center services) and other ambulatory 
health care services.  (Section 2110(a)(5)) 
(cid:134)
6.2.6.     Prescription drugs  (Section 2110(a)(6)) 
(cid:134)
6.2.7.     Over-the-counter medications  (Section 2110(a)(7)) 
(cid:134)
6.2.8.     Laboratory and radiological services  (Section 2110(a)(8)) 
(cid:134)
6.2.9.     Prenatal care and prepregnancy family services and supplies  (Section 
2110(a)(9)) 
(cid:134)
6.2.10.    Inpatient mental health services, other than services described in 
6.2.18., but including services furnished in a state-operated mental 
hospital and including residential or other 24-hour therapeutically 
planned structural services  (Section 2110(a)(10)) 
 (cid:134) 
6.2.11. Outpatient mental health services, other than services described in 
6.2.19, but including services furnished in a state-operated mental 
hospital and including community-based services (Section 2110(a)(11) 
(cid:134)
6.2.12.    Durable medical equipment and other medically-related or remedial 
devices (such as prosthetic devices, implants, eyeglasses, hearing aids, 
dental devices, and adaptive devices)  (Section 2110(a)(12)) 
(cid:134)
6.2.13.    Disposable medical supplies  (Section 2110(a)(13)) 
(cid:134)
6.2.14.    Home and community-based health care services (See instructions) 
(Section 2110(a)(14)) 
(cid:134)
6.2.15.    Nursing care services  (See instructions)  (Section 2110(a)(15)) 
(cid:134)
6.2.16.    Abortion only if necessary to save the life of the mother or if the 
pregnancy is the result of an act of rape or incest (Section 2110(a)(16) 
(cid:134)
6.2.17.    Dental services  (Section 2110(a)(17)) 
(cid:134)
6.2.18.    Inpatient substance abuse treatment services and residential substance 
abuse treatment services  (Section 2110(a)(18))  
(cid:134)
6.2.19.    Outpatient substance abuse treatment services  (Section 2110(a)(19)) 
 
Proposed Effective Date _________    10    Version 9/12/97    DRAFT - 9/12/97 
 
 
(cid:134)
6.2.20.    Case management services  (Section 2110(a)(20)) 
(cid:134)
6.2.21.    Care coordination services  (Section 2110(a)(21)) 
(cid:134)
6.2.22.    Physical therapy, occupational therapy, and services for individuals 
with speech, hearing, and language disorders  (Section 2110(a)(22)) 
(cid:134)
6.2.23.    Hospice care  (Section 2110(a)(23)) 
(cid:134)
6.2.24.    Any other medical, diagnostic, screening, preventive, restorative, 
remedial, therapeutic, or rehabilitative services.  (See instructions) 
(Section 2110(a)(24)) 
(cid:134)
6.2.25.    Premiums for private health care insurance coverage (Section 2110(a)(25)) 
(cid:134)
6.2.26.    Medical transportation  (Section 2110(a)(26))   
(cid:134)
6.2.27.    Enabling services (such as transportation, translation, and outreach 
services  (See instructions)  (Section 2110(a)(27)) 
 (cid:134)
6.2.28.   Any other health care services or items specified by the Secretary and 
not included under this section (Section 2110(a)(28)) 
 
Proposed Effective Date _________    11    Version 9/12/97    DRAFT - 9/12/97 
 
 
 
6.3.    Waivers - Additional Purchase Options.  If the state wishes to provide services 
under the plan through cost effective alternatives or the purchase of family coverage, 
it must request the appropriate waiver.  Review and approval of the waiver 
application(s) will be distinct from the state plan approval process.  To be approved, 
the state must address the following:  (Section 2105(c)(2) and(3))  
 
(cid:134)
6.3.1.    Cost Effective Alternatives.  Payment may be made to a state in 
excess of the 10% limitation on use of funds for payments for:  1) 
other child health assistance for targeted low-income children; 2)  
expenditures for health services initiatives under the plan for 
improving the health of children (including targeted low-income 
children and other low-income children); 3)  expenditures for 
outreach activities as provided in section 2102(c)(1) under the plan; 
and 4)  other reasonable costs incurred by the state to administer 
the plan, if it demonstrates the following: 
 
6.3.1.1.  Coverage provided to targeted low-income children through 
such expenditures must meet the coverage requirements 
above;  Describe the coverage provided by the alternative 
delivery system.  The state may cross reference section 6.2.1 
- 6.2.28.   (Section 2105(c)(2)(B)(i))     
 
6.3.1.2.  The cost of such coverage must not be greater, on an average 
per child basis, than the cost of coverage that would otherwise 
be provided for the coverage described above;  and Describe 
the cost of such coverage on an average per child basis.  
(Section 2105(c)(2)(B)(ii))  
 
6.3.1.3.  The coverage must be provided through the use of a 
community-based health delivery system, such as through 
contracts with health centers receiving funds under section 330 
of the Public Health Service Act or with hospitals such as those 
that receive disproportionate share payment adjustments under 
section 1886(d)(5)(F) or 1923 of the Social Security Act.  
Describe the community based delivery system.  (Section 
2105(c)(2)(B)(iii))     
 
 
Proposed Effective Date _________    12    Version 9/12/97    DRAFT - 9/12/97 
 
 
(cid:134)
6.3.2.     Purchase of Family Coverage.  Describe the plan to provide family 
coverage.  Payment may be made to a state for the purpose of family 
coverage under a group health plan or health insurance coverage that 
includes coverage of targeted low-income children, if it demonstrates 
the following:  (Section 2105(c)(3))   
 
6.3.2.1.    Purchase of family coverage is cost-effective relative to the 
amounts that the state would have paid to obtain comparable 
coverage only of the targeted low-income children involved; 
and  (Describe the associated costs for purchasing the family 
coverage relative to the coverage for the low income 
children.)  (Section 2105(c)(3)(A))   
 
6.3.2.2.   The state assures that the family coverage would not otherwise 
substitute for health insurance coverage that would be provided 
to such children but for the purchase of family coverage.  (Section 
2105(c)(3)(B))   
 
Proposed Effective Date _________    13    Version 9/12/97    DRAFT - 9/12/97 
 
 
Section 7.  Quality and Appropriateness of Care 
(cid:134)
  Check here if the state elects to use funds provided under Title XXI only to provide 
expanded eligibility  under the states Medicaid plan, and continue on to Section 8. 
 
 
7.1.   Describe the methods (including external and internal monitoring) used to assure the 
quality and appropriateness of care, particularly with respect to well-baby care, well-
child care, and immunizations provided under the plan. (2102(a)(7)(A)) 
____________________________________________________________ 
 
Will the state utilize any of the following tools to assure quality?   
(Check all that apply and describe the activities for any categories utilized.) 
(cid:134)
7.1.1.     Quality standards 
(cid:134)
7.1.2.     Performance measurement 
(cid:134)
7.1.3.     Information strategies 
(cid:134)
7.1.4.     Quality improvement strategies 
 
 
7.2.   Describe the methods used, including monitoring, to assure access to covered services, 
including emergency services. (2102(a)(7)(B)) 
____________________________________________________________ 
 
 
Proposed Effective Date _________    14    Version 9/12/97    DRAFT - 9/12/97 
 
 
Section 8.   Cost Sharing and Payment   (Section 2103(e)) 
(cid:134)
  Check here if the state elects to use funds provided under Title XXI only to provide 
expanded eligibility under the states Medicaid plan, and continue on  
to Section 9.   
 
8.1.  Is cost-sharing imposed on any of the children covered under the plan? 
 
(cid:134)
8.1.1.    YES 
(cid:134)
8.1.2.    NO, skip to question 8.5.   
 
 
8.2.   Describe the amount of cost-sharing and any sliding scale based on income: 
(Section 2103(e)(1)(A)) 
 
8.2.1.  Premiums:_______________________________________    
8.2.2.  Deductibles:______________________________________ 
8.2.3.  Coinsurance:______________________________________ 
8.2.4.  Other:___________________________________________ 
 
8.3.    Describe how the public will be notified of this cost-sharing and any differences based 
on income:   _____________________________________________ 
 
 
8.4.   The state assures that it has made the following findings with respect to the cost 
sharing and payment aspects of its plan:  (Section 2103(e))   
 
(cid:134) 
8.4.1.   Cost-sharing does not favor children from higher income families over 
lower income families.  (Section 2103(e)(1)(B)) 
(cid:134)
8.4.2.     No cost-sharing applies to well-baby and well-child care, including 
age-appropriate immunizations.  (Section 2103(e)(2)) 
(cid:134)
8.4.3.     No child in a family with income less than 150% of the Federal Poverty 
Level will incur cost-sharing that is not permitted under 1916(b)(1). 
(cid:134)
8.4.4.     No Federal funds will be used toward state matching requirements.  
(Section 2105(c)(4)) 
(cid:134)
8.4.5.     No premiums or cost-sharing will be used toward state matching 
requirements.  (Section 2105(c)(5) 
(cid:134)
8.4.6.     No funds under this title will be used for coverage if a private insurer 
would have been obligated to provide such assistance except for a 
provision limiting this obligation because the child is eligible under the 
this title.   
(Section 2105(c)(6)(A)) 
 
Proposed Effective Date _________    15    Version 9/12/97    DRAFT - 9/12/97 
 
 
(cid:134)
8.4.7.     Income and resource standards and methodologies for determining 
Medicaid eligibility are not more restrictive than those applied as of 
June 1, 1997.  (Section 2105(d)(1)) 
(cid:134)
8.4.8.     No funds provided under this title or coverage funded by this title will 
include coverage of abortion except if necessary to save the life of the 
mother or if the pregnancy is the result of an act of rape or incest.  
(Section 2105)(c)(7)(B))   
(cid:134)
8.4.9.    No funds provided under this title will be used to pay for any abortion 
or to assist in the purchase, in whole or in part, for coverage that 
includes abortion (except as described above).  (Section 2105)(c)(7)(A)) 
 
 
8.5.   Describe how the state will ensure that the annual aggregate cost-sharing for a family 
does not exceed 5 percent of such familys annual income for the year involved:  
(Section 2103(e)(3)(B)) 
__________________________________________________________ 
 
 
8.6.   The state assures that, with respect to pre-existing medical conditions, one of the 
following two statements applies to its plan: 
 
(cid:134)
8.6.1.     The state shall not permit the imposition of any pre-existing medical 
condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR 
(cid:134)
8.6.2.     The state contracts with a group health plan or group health insurance 
coverage, or contracts with a group health plan to provide family 
coverage under a waiver (see Section 6.3.2. of the template).  Pre-
existing medical conditions are permitted to the extent allowed by 
HIPAA/ERISA   (Section 2109(a)(1),(2)).  Please describe: 
________________________________________________ 
 
 
Proposed Effective Date _________    16    Version 9/12/97    DRAFT - 9/12/97 
 
 
 
Section 9.  Strategic Objectives and Performance Goals for the Plan Administration (Section 2107) 
 
 
9.1.   Describe strategic objectives for increasing the extent of creditable health coverage 
among targeted low-income children and other low-income children:  (Section 2107(a)(2)) 
________________________________________________________ 
 
 
9.2.   Specify one or more performance goals for each strategic objective identified:  (Section 
2107(a)(3)) 
_________________________________________________________ 
 
 
9.3.   Describe how performance under the plan will be measured through  
  objective, independently verifiable means and compared against performance 
goals in order to determine the states performance, taking into account suggested 
performance indicators as specified below or other indicators the state develops:   
(Section 2107(a)(4)(A),(B)) 
_______________________________________________________ 
 
Check the applicable suggested performance measurements listed below that the state 
plans to use:  (Section 2107(a)(4)) 
(cid:134)
9.3.1.     The increase in the percentage of Medicaid-eligible children enrolled in 
Medicaid. 
(cid:134)
9.3.2.     The reduction in the percentage of uninsured children. 
(cid:134)
9.3.3.     The increase in the percentage of children with a usual source of care. 
(cid:134)
9.3.4.     The extent to which outcome measures show progress on one or more 
of the health problems identified by the state. 
(cid:134)
9.3.5.     HEDIS Measurement Set relevant to children and adolescents younger 
than 19. 
(cid:134)
9.3.6.     Other child appropriate measurement set.  List or describe the set used. 
(cid:134)
9.3.7.     If not utilizing the entire HEDIS Measurement Set, specify which 
measures will be collected, such as: 
(cid:134)
9.3.7.1.     Immunizations 
(cid:134)
9.3.7.2.     Well child care 
(cid:134)
9.3.7.3.     Adolescent well visits 
(cid:134)
9.3.7.4.     Satisfaction with care 
(cid:134)
9.3.7.5.     Mental health 
(cid:134)
9.3.7.6.     Dental care 
(cid:134)
9.3.7.7.     Other, please list: __________________ 
 
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(cid:134)
9.3.8.     Performance measures for special targeted populations. 
 
(cid:134)
9.4.     The state assures it will collect all data, maintain records and furnish reports to 
the Secretary at the times and in the standardized format that the Secretary 
requires.  (Section 2107(b)(1)) 
 
(cid:134)
9.5.     The state assures it will comply with the annual assessment and evaluation 
required under Section 10.1. and 10.2.  (See Section 10)  Briefly describe the 
states plan for these annual assessments and reports.  (Section 2107(b)(2)) 
___________________________________________________ 
 
(cid:134)
9.6.     The state assures it will provide the Secretary with access to any records or 
information relating to the plan for purposes of review of audit.  (Section 
2107(b)(3)) 
 
(cid:134)
9.7.     The state assures that, in developing performance measures, it will modify 
those measures to meet national requirements when such requirements are 
developed. 
 
 
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9.8.   The state assures, to the extent they apply, that the following provisions of the Social Security 
Act will apply under Title XXI, to the same extent they apply to a state under Title XIX:  
(Section 2107(e))  
 
(cid:134)
9.8.1.     Section 1902(a)(4)(C) (relating to conflict of interest standards) 
(cid:134)
9.8.2.     Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations 
on payment) 
(cid:134)
9.8.3.     Section 1903(w) (relating to limitations on provider donations and 
taxes) 
(cid:134)
9.8.4.     Section 1115 (relating to waiver authority) 
(cid:134)
9.8.5.     Section 1116 (relating to administrative and judicial review), but only 
insofar as consistent with Title XXI 
(cid:134)
9.8.6.     Section 1124 (relating to disclosure of ownership and related 
information) 
(cid:134)
9.8.7.     Section 1126 (relating to disclosure of information about certain 
convicted individuals) 
(cid:134)
9.8.8.     Section 1128A (relating to civil monetary penalties) 
(cid:134)
9.8.9.     Section 1128B(d) (relating to criminal penalties for certain additional 
charges) 
(cid:134)
9.8.10.   Section 1132 (relating to periods within which claims must be filed) 
 
9.9.  Describe the process used by the state to accomplish involvement of the public in the 
design and implementation of the plan and the method for insuring ongoing public 
involvement.  (Section 2107(c)) 
____________________________________________________________ 
 
  
9.10.  Provide a budget for this program.  Include details on the planned use of funds and 
sources of the non-Federal share of plan expenditures.  (Section 2107(d))  
 
A financial form for the budget is being developed, with input from all interested 
parties, for states to utilize. 
 
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Section 10.  Annual Reports and Evaluations    (Section 2108) 
 
 
10.1.  Annual Reports.  The state assures that it will assess the operation of the state plan 
under this Title in each fiscal year, including:  (Section 2108(a)(1),(2))   
(cid:134)
10.1.1.     The progress made in reducing the number of uncovered low-
income children and report to the Secretary by January 1 
following the end of the fiscal year on the result of the 
assessment, and 
 
(cid:134)
10.1.2.     Report to the Secretary, January 1 following the end of the 
fiscal year, on the result of the assessment. 
 
 
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Below is a chart listing the types of information that the states annual report might include.  
Submission of such information will allow comparisons to be made between states and on a 
nationwide basis. 
 
       
Attributes of Population Number of Children with  Number of Children without  TOTAL 
Creditable Coverage  Creditable Coverage 
XIX     OTHER CHIP
       
Income Level:       
       
< 100%       
       
< 133%       
       
< 185%       
       
< 200%       
       
> 200%       
       
Age      
       
0 - 1       
       
1 - 5       
       
6 - 12       
       
13 - 18       
       
Race and Ethnicity      
       
American Indian or Alaskan       
Native 
       
Asian or Pacific Islander       
       
Black, not of Hispanic origin       
       
Hispanic       
       
White, not of Hispanic origin       
       
Location      
       
MSA       
       
Non-MSA       
 
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(cid:134)
10.2.     State Evaluations.  The state assures that by March 31, 2000 it will submit to 
the Secretary an evaluation of each of the items described and listed below:  
(Section 2108(b)(A)-(H))   
 
(cid:134)
10.2.1.     An assessment of the effectiveness of the state plan in increasing the 
number of children with creditable health coverage. 
 
 
10.2.2.   A description and analysis of the effectiveness of elements of the state 
plan, including: 
(cid:134)
10.2.2.1.     The characteristics of the children and families assisted under 
the state plan including age of the children, family income, and 
the assisted childs access to or coverage by other health 
insurance prior to the state plan and after eligibility for the state 
plan ends; 
(cid:134)
10.2.2.2.     The quality of health coverage provided including the types of 
benefits provided; 
(cid:134)
10.2.2.3.     The amount and level (including payment of part or all of any 
premium) of assistance provided by the state; 
(cid:134)
10.2.2.4.     The service area of the state plan; 
(cid:134)
10.2.2.5.     The time limits for coverage of a child under the state plan; 
(cid:134)
10.2.2.6.     The states choice of health benefits coverage and other 
methods used for providing child health assistance, and 
(cid:134)
10.2.2.7.     The sources of non-Federal funding used in the state plan. 
 
(cid:134)
10.2.3.     An assessment of the effectiveness of other public and private 
programs in the state in increasing the availability of affordable quality 
individual and family health insurance for children. 
 
 
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(cid:134)
10.2.4.     A review and assessment of state activities to coordinate the plan under 
this Title with other public and private programs providing health care 
and health care financing, including Medicaid and maternal and child 
health services. 
 
(cid:134)
10.2.5.     An analysis of changes and trends in the state that affect the provision 
of accessible, affordable, quality health insurance and health care to 
children. 
 
(cid:134)
10.2.6.     A description of any plans the state has for improving the availability 
of health insurance and health care for children. 
 
(cid:134)
10.2.7.     Recommendations for improving the program under this Title. 
 
(cid:134)
10.2.8.     Any other matters the state and the Secretary consider appropriate. 
 
(cid:134)
10.3.    The state assures it will comply with future reporting requirements as they are 
developed. 
 
 (cid:134)
10.4.     The state assures that it will comply with all applicable Federal laws and regulations, 
including but not limited to Federal grant requirements and Federal reporting 
requirements. 
 
 
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