1840.010.00 Eligibility Requirements

1840.010.15.08 Affordability Test

It is required that CHIP cases explore the potential for private affordable health care coverage prior to approval, outlined in 1840.010.15.05 Affordable Insurance Definition.

FSD will determine affordability using the CHIP Affordability Calculator.  The calculator will compare CHIP premium amounts to insurance premium amounts on the FFM to determine affordability based on the size of the household and the region of the state they live in.

The individual can choose to provide an insurance quote if that is their preference but do not request them to provide insurance quotes since FSD can make the affordability determination using the calculator.

NOTE:  Individuals will still be required to provide employer-sponsored insurance quotes when applicable.

Undocumented aliens are not insurable.  Do not ask for private insurance quotes for undocumented aliens.

Individuals may research quotes during closed and open enrollment periods at www.healthcare.gov, but FFM coverage can only be purchased during the annual open enrollment period.  Private insurance is considered available during open, closed, and special enrollment periods.

NOTE:  The open-enrollment dates changes yearly.  See www.CMS.gov to view the current enrollment period.

Closed enrollment period:

  • Apply employer-sponsored insurance affordability test.
  • Apply the CHIP private affordable health care coverage affordability test.
    • Individuals who failed, or would fail, the affordability test during the open enrollment period may qualify during closed enrollment period.

Open enrollment period:

  • Apply the employer-sponsored insurance affordability test.
  • Apply the private affordable health care coverage affordability test.
    • If they are ineligible for CHIP coverage they will be rejected and referred to the FFM.  Exceptions will be made for children with special needs.

Special enrollment period:

  • An individual may qualify for a special open enrollment period with the FFM.  During a special open enrollment individuals may qualify to purchase FFM insurance during the closed enrollment period.
  • FSD does not determine if an individual meets a special enrollment period.

CHIP Affordability Test

  1. CHIP Affordability Test should be applied to CHIP 73, CHIP 74 and CHIP 75 cases.
  2. FSD will complete the CHIP Affordability Calculator for purposes of determining the private affordable health care coverage affordability test.

NOTE: Compare the CHIP Premium to the FFM Highest Gold Premium.  If it is more than the CHIP premium, no affordable insurance is available.

For the Instructions for Affordability Tests Using FFM Premiums, see Appendix F – CHIP Affordability Test Calculator Instructions.