Model Application Template for the State Children’s Health Insurance Program OMB #: 0938-0707 Exp. Date: MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM Preamble Section 4901 of the Balanced Budget Act of 1997 (BBA) amended the Social Security Act (the Act) by adding a new title XXI, the State Children’s Health Insurance Program (SCHIP). Title XXI provides funds to states to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner. To be eligible for funds under this program, states must submit a state plan, which must be approved by the Secretary. A state may choose to amend its approved state plan in whole or in part at any time through the submittal of a plan amendment. This model application template outlines the information that must be included in the state child health plan, and any subsequent amendments. It has been designed to reflect the requirements as they exist in current regulations, found at 42 CFR part 457. These requirements are necessary for state plans and amendments under Title XXI. 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 applicant and enrollee protections, collection of baseline data, and methods for preventing substitution of Federal funds for existing state and private funds. As such guidance becomes available; we will work to distribute it in a timely fashion to provide assistance as states submit their state plans and amendments. Form CMS-R-211 Effective Date: January 1, 2017 Approval Date: November 14, 2016 1 Model Application Template for the State Children’s Health Insurance Program MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN S HEALTH INSURANCE PROGRAM (Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b))) State/Territory:_______Michigan____________________________________________________ (Name of State/Territory) As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b)) ________________________________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed) submits the following State Child Health Plan for the State Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved State Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department. The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name: Logan Dreasky Position/Title: Manager, Eligibility Policy Section Name: Position/Title: Name: Position/Title: 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 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: CMS, N2-14- 26, Baltimore, Maryland 21244. Effective Date: January 1, 2017 Approval Date: November 14, 2016 2 Model Application Template for the State Children’s Health Insurance Program Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101) 1.1 The state will use funds provided under Title XXI primarily for (Check appropriate box) (42 CFR 457.70): 1.1.1 Obtaining coverage that meets the requirements for a separate child health program (Section 2103); OR  1.1.2. Providing expanded benefits under the State’s Medicaid plan (Title XIX); OR X 1.1.3. A combination of both of the above. 1.2 Please provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d)) Michigan received federal approval to implement MIChild effective May 1, 1998. All claimed expenditures were after May 1, 1998. 1.3 Please provide an assurance that the state complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130) Michigan complies with the above by including the following statements on the application: Michigan Department of Health and Human Services (MDHHS) will not discriminate against any individual or group because of race, sex, religion, age, national origins, marital status, disability or political beliefs.” “If you need help with this application, call toll free 1-888/988-6300 Spanish: If you need help with this application, call toll free 1-888/988-6300 Arabic: If you need help with this application call toll free 1-888/988-6300” “If you need help with reading or writing to complete this application, under the Americans with Disabilities Act, you are invited to make your needs known by calling 1-888/988-6300 or your local FIA office.” Effective Date: January 1, 2017 Approval Date: November 14, 2016 3 Model Application Template for the State Children’s Health Insurance Program “You have the right to appeal a decision made by the MDHHS. You will be notified of your rights if your application is denied for any reason.” 1.4 Please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment (42 CFR 457.65): Date of Plan Submitted: December 29, 1997 Date Plan Approved: April 7, 1998 State Plan Effective Date: May 1, 1998 Date Amendment #1 Submitted: April 16, 1998 Date Amendment #1 Effective: May 1, 1998 Date Amendment #2 Submitted: December 21, 1998 Date Amendment #2 Effective: January 1, 1999 Date Amendment #3 Submitted: May 28, 1999 Date Amendment #3 Effective: June 28, 1999 Date Amendment #4 Submitted: May 30, 2000 Date Amendment #4 Effective: July 1, 2000 Date Amendment #5 Submitted: August 13, 2001 Date Amendment #5 Effective: July 1, 2001 Date Amendment #6 Submitted: December 20, 2003 Date Amendment #6 Effective: July 1, 2002 Date Amendment #7 Submitted: January 9, 2003 Date Amendment #7 Effective: December 1, 2002 Date Amendment #8 Submitted: June 1, 2005 Date Amendment #8 Effective: November 1, 2005 Date Amendment #9 Submitted: January 16, 2007 Date Amendment #9 Effective: October 1, 2006 Date Amendment #10 Submitted: March 8, 2007 Date Amendment #10 Effective: April 1, 2007 Effective Date: January 1, 2017 Approval Date: November 14, 2016 4 Model Application Template for the State Children’s Health Insurance Program Date Amendment #11 Submitted: March 30, 2010 Date Amendment #11 Effective January 1, 2010 Date Amendment #12 Submitted: August 28, 2010 Date Amendment #12 Effective: October 1, 2010 Date Amendment #13 Submitted: September 28, 2011 Date Amendment #13 Effective: October 1, 2010 Date Amendment #14 Submitted: February 21, 2013 Date Amendment #14 Effective: April 1, 2013 Date Amendment #15 Submitted: October 4, 2013 Date Amendment #15 Withdrawn: October 14, 2013 Date Amendment #16 Submitted: March 21, 2014 Date Amendment #16 Effective: July 1, 2014 Date Amendment #MI-15-0001-CHIP Submitted: March 31, 2015 Date Amendment #MI-15-0001-CHIP Withdrawn: June 4, 2015 Date Amendment #MI-15-0002-CHIP Submitted: December 17, 2015 Date Amendment #MI-15-0002-CHIP Effective: January 1, 2016 Date Amendment #MI-16-0017-CHIP Submitted: November 3, 2016 Date Amendment #MI-16-0017-CHIP Effective: January 1, 2017 Superseding Eligibility Pages of Modified Adjusted Gross Income (MAGI) CHIP State Plan Material State: Michigan Transmittal SPA Group PDF # Description Superseded Plan Number Section(s) MI-13-0001 MAGI CS7 Eligibility – Supersedes the Eligibility & Targeted Low current sections Date Submitted: Methods Income Children 4.1.1, 4.1.2 and 4.1.3 12/20/13 Approval Date: Eligibility – Supersedes the 10/09/14 CS9 Coverage from current sections Effective/Implemen Conception to Birth 4.1.1, 4.1.2 and 4.1.3 tation Date: January 1, 2014 CS15 MAGI-Based Incorporated within Effective Date: January 1, 2017 Approval Date: November 14, 2016 5 Model Application Template for the State Children’s Health Insurance Program Transmittal SPA Group PDF # Description Superseded Plan Number Section(s) Income a separate subsection Methodologies under section 4.3 MI-13-0002 XXI Medicaid CS3 Eligibility for Supersedes the Expansion Medicaid Expansion current Medicaid Date Submitted: Program expansion section 12/20/13 4.0 Approval Date: 12/22/14 Effective/Implemen tation Date: January 1, 2014 MI-13-0003 Establish CS14 Children Ineligible Incorporated within 2101(f) Group for Medicaid as a a separate subsection Date Submitted: Result of the under section 4.1 12/20/13 Elimination of Approval Date: Income Disregards 03/17/14 Effective/Implemen tation Date: January 1, 2014 MI-13-0004 Eligibility CS24 MAGI-Based Supersedes the Processing Eligibility Process current items in Date Submitted: sections 4.3 and 4.4 12/20/13 related to application Approval Date: processing, 03/11/14 eligibility screening Effective/Implemen and enrollment, and tation Date: renewals October 1, 2013 MI-13-0005 Non-Financial CS17 Non-Financial Supersedes the Eligibility Eligibility – current section 4.1.5 Date Submitted: Residency 12/20/13 Supersedes the Approval Date: CS18 Non-Financial current section 4.1.0 12/17/15 Eligibility – Effective/Implemen Citizenship Effective Date: January 1, 2017 Approval Date: November 14, 2016 6 Model Application Template for the State Children’s Health Insurance Program Transmittal SPA Group PDF # Description Superseded Plan Number Section(s) tation Date: Supersedes the January 1, 2014 CS19 Non-Financial current section 4.1.9 Eligibility – Social Security Number Effective/Implemen tation Date for CS20 Non-Financial Supersedes the CS20 only: Eligibility – current section 4.4.4 January 24, 2014 Substitution of Coverage CS21 Non-Financial Supersedes the Eligibility – current Cost Sharing Non-Payment of and Payment section Premiums 8.7 MI-15-0003 XXI Medicaid CS3 Eligibility for Supersedes the Expansion Medicaid Expansion current Medicaid Date Submitted: Program expansion section 12/17/15 4.0 and MI-13-0002 Approval Date: 03/08/16 Effective/Implemen tation Date: January 1, 2016 MI-15-0004 Non-Financial CS21 Non-Financial Supersedes the Eligibility Eligibility – current Cost Sharing Date Submitted: Non-Payment of and Payment section 12/17/15 Premiums 8.7 Approval Date: 03/08/16 Effective/Implemen tation Date: January 1, 2016 Effective Date: January 1, 2017 Approval Date: November 14, 2016 7 Model Application Template for the State Children’s Health Insurance Program Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (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 42 CFR 457.10). 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). (42 CFR 457.80(a)) State Response: Much attention has been given to the problem of the lack of health insurance coverage for the unborn child in low-income families whose incomes are at or below 195 percent of the Federal Poverty Level and who are uninsured. This is the baseline figure used by Michigan as the target for Medicaid or Maternity Outpatient Medical Services (MOMS) enrollment. 2.2. Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42CFR 457.80(b)) 2.2.1. The steps the state is currently taking to identify and enroll all unborn children who are eligible to participate in public health insurance programs (i.e. Medicaid and state-only child health insurance): State Response: Michigan currently has several programs focused on identifying potentially eligible Medicaid clients and assisting them to complete enrollment forms to become Medicaid recipients. All local health departments in the state have at least two sources of funding specifically for outreach to families and children not currently enrolled in Medicaid and for provision of assistance in applying for Medicaid eligibility. Medicaid provides funding to all forty-two local health departments so they can identify pregnant women whose unborn child is not currently enrolled in Medicaid, assist them in completing enrollment materials, and in selecting and obtaining access to health care providers serving Medicaid eligible pregnant women and the unborn child. The health departments also have a Prenatal Care Enrollment and Coordination Program which provides outreach to facilitate access to prenatal care through the Healthy Kids Program, and assistance in obtaining access to a prenatal care provider. This program also provides families with assistance in completing Medicaid enrollment forms for children, which are then forwarded to Medicaid for determination of eligibility. Services provided through this program include assistance in completion of the, Medicaid application gathering all required verifications, negotiating the Medicaid system, obtaining health care providers, responding to managed care problems/concerns, and obtaining access to other support programs. Effective Date: January 1, 2017 Approval Date: November 14, 2016 8 Model Application Template for the State Children’s Health Insurance Program Several other programs provide outreach for special populations as identified below.  Maternal Support Services (MSS): Pregnant women and teens that are potentially Medicaid-eligible are assisted in obtaining Medicaid enrollment by providers throughout the state. As with the ISS program, both public and private agencies are providers. This program also provides services to non-Medicaid-eligible women and teens with additional state funding made available for this purpose.  Maternal and Infant Health Advocacy Services Program (MIHAS): This program provides outreach to pregnant women who are not currently receiving prenatal care, assists them in dealing with situations which may keep them from remaining in prenatal care, and supports and reinforces the health education messages delivered by health care providers. MIHAS services are delivered by a team of paraprofessional advocates and a supervisor specifically trained to deal with the psychosocial problems of high-risk, low- income pregnant women. Paraprofessional advocates must be indigenous to the community and have been on Medicaid.  Special Supplemental Nutrition Program for Women, Infants and Children (WIC): WIC screens and refers clients to other appropriate health and social services, including Medicaid, food stamps, prenatal care, immunizations, smoking cessation programs, and substance abuse programs. Referral of WIC clients for Medicaid enrollment is a required outreach activity in this program. Nearly half of the infants born in Michigan are served by the WIC Program, making this an important source of outreach for Medicaid enrollment. 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: State Response: Prenatal Care Enrollment and Coordination Program provides outreach to facilitate access to prenatal care and assistance in obtaining access to a prenatal care provider. Michigan is working with Covering Kids, a national public/private partnership, by providing staffing and materials to promote education and outreach at health-related conferences. The Michigan initiative is called Covering Michigan’s Kids. NOTE: In the revised “Template for Child Health Plan under title XXI of the Social Security Act Children’s Health Insurance Program,” section 2.2 is designed specifically for states to request to use the funds available under the 10 percent limit on administrative expenditures to implement a health services initiative. The revised section 2.2 reads as follows: Effective Date: January 1, 2017 Approval Date: November 14, 2016 9 Model Application Template for the State Children’s Health Insurance Program 2.2. Health Services Initiatives - Describe if the State will use the health services initiative option as allowed at 42 CFR 457.10. If so, describe what services or programs the State is proposing to cover with administrative funds, including the cost of each program, and how it is currently funded (if applicable), and also update the budget accordingly. (Section 2105(a)(1)(D)(ii)); (42 CFR 457.10) As permitted under section 2105(a)(1)(D)(ii) of the Social Security Act and federal regulations at 42 CFR 457.10, the State of Michigan is doing a health services initiative that will use CHIP funds, within the federal administrative expenditures cap allowed for states, to support the Michigan Regional Poison Control Center (MRPCC) at Children’s Hospital of Michigan. The MRPCC provides emergency telephone treatment advice, referral assistance, and information to manage exposures to poisonous and hazardous substances. The MRPCC answers poisoning emergency calls from the general public as well as health care providers needing assistance 24 hours a day, 365 days each year at no charge. The MRPCC provides numerous services including:  24-hour emergency and information hotline services  follow-up calls regarding continuing care in poison exposure cases  health and safety professional education  state and national data collection providing epidemiologic public health surveillance  access to emergency information as an integral part of local, state and national emergency preparedness  responses for natural and manmade disasters  acting as a clearinghouse for scarce resources and antidotes  providing guidance in the treatment of hazardous incidents to the public  providing interpretative assistance of forensic data for law enforcement and medical examiners  assisting other federal and state agencies in risk-assessment for potentially toxic exposures Certified Specialists in Poison Information and medical or clinical toxicologists are available 24 hours a day, 365 days a year to manage cases. The service is provided via a toll-free telephone number to every community throughout Michigan, including under-served, low income, and indigent populations. Services are available by use of an interpreter in over 150 languages and via telecommunications devices for the deaf and hearing impaired (TTY). The MRPCC provides public education programs directed towards pediatric accidental poisoning as well as targeted “at-risk” populations. Educational materials and teaching curricula are distributed throughout the state, free of charge. Materials are also available in Spanish and Arabic. The MRPCC participates in a variety of community injury prevention including health fairs. The MRPCC also provides a robust professional educational program designed to train Effective Date: January 1, 2017 Approval Date: November 14, 2016 10