806  Improper CHIP Coverage

Effective Date: August 1, 2011

Previous Policy

Improper CHIP coverage occurs when an enrollee receives CHIP coverage he is not eligible for or when  an enrollee receives coverage under an incorrect CHIP plan.  

1. Upon discovery, an enrollee who is not eligible must be removed from the CHIP case.  

• Ineligible cases that result from a child enrolled in a group health plan or other health insurance because of an untimely report or a Suspected Intentional Program Violation (SIPV) on the part of the enrollee must be referred for an overpayment.   (See Section 806-1)

2. When a household has been approved for the wrong CHIP plan, correct the CHIP plan and do not submit an overpayment.

• Higher Cost CHIP Plan – (i.e. Plan A to B or C; or B to C) - Correct CHIP the following month.

• Lower Cost CHIP Plan – (i.e. Plan C to B or A; or B to A) - Correct the plan for each month in the certification period.  Premium payments must be adjusted as part of the process.

3. Underpayments and overpayments may be discovered during quality reviews that the Department or the eligibility agency conducts. Applicants and enrollees are required to cooperate with the Department and the eligibility agency in quality reviews. See 102-5.