05.11.2024
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Posted by Provider Relations
Fidelis Care would like to inform providers of a federal amendment to the Consolidated Appropriations Act, 2023, that requires states to provide 12-months of continuous eligibility (CE) for children enrolled in Child Health Plus (CHP) plans and under the age of 19.
While New York currently has 12-months of continuous coverage in CHP, it has state specific exceptions which are no longer permitted under federal requirements. A child can only be terminated during the 12-month CE period due to one of the following exceptions:
1. The child reaches the age of 19;
2. The child or parent/guardian requests voluntary disenrollment from the program;
3. The child ceases to be a state resident;
4. The agency determines the eligibility was erroneously granted at the most recent
determination or redetermination of eligibility due to agency error or fraud, abuse or
perjury attributed to the child or the parent/guardian;
5. The child becomes eligible for Medicaid; or
6. The child dies.
In accordance with this guidance, effective January 1, 2024, subsidized enrollees who obtain other third-party health insurance (TPHI), including NYSHIP or public MEC other than Medicaid, gain access to NYSHIP, become incarcerated in a juvenile justice facility, or fail to pay their monthly family premium contribution will maintain their CHP coverage for the remainder of their 12-month CE period. Please note, this directive does not apply to unsubsidized CHP enrollees.
In addition to maintaining CE in accordance with this amendment, health plans will be required to coordinate benefits if the child has other coverage. The TPHI will be captured in the 2750 loops on the 834- enrollment transaction. Please note, for purposes of coordination of benefits, CHP is the payor of last resort.
For additional questions, or if we can be of assistance in any way, please contact your Fidelis Care Provider Engagement Account Manager. To find your designated representative, please visit Contact Your Designated Provider Relations Specialist. Thank you for being a valued Fidelis Care partner in the provision of quality care.