Indiana Administrative Code Title 407 - OFFICE OF THE CHILDREN'S HEALTH INSURANCE PROGRAM
Indiana Administrative Code – Title 407: Office of the Children’s Health Insurance Program
Title 407 establishes the Office of the Children’s Health Insurance Program (CHIP) and its rules for administering health coverage for children in Indiana. It provides the administrative structure, eligibility rules, benefits, enrollment process, and operational standards for the program.
1. Purpose of Title 407
To create and regulate the Children’s Health Insurance Program (CHIP).
To provide affordable health coverage for children in families who do not qualify for Medicaid but cannot afford private insurance.
To set clear rules on eligibility, benefits, premiums, cost-sharing, and program management.
2. Administrative Authority
The program is administered by the Office of the Children’s Health Insurance Program, which is a state agency responsible for:
Implementing CHIP rules.
Contracting with managed care entities, providers, and vendors.
Ensuring compliance with federal standards (but within this Title, the focus is administrative rules).
The office also develops policies, forms, and procedures for enrollment, eligibility determination, and benefits delivery.
3. Eligibility
CHIP defines who can receive coverage:
Age Requirement – Children up to a certain age limit (generally through adolescence).
Residency – Must be a resident of Indiana.
Income Limits – Family income must fall within a defined percentage range of the federal poverty level.
Insurance Status – Child must be uninsured or not eligible for other comprehensive insurance.
Other Conditions – No access to equivalent employer-sponsored or government health coverage.
The rules also cover special cases, such as newborns or children transitioning from other coverage.
4. Enrollment & Application Process
Families must submit an application with income and household information.
The Office reviews and verifies eligibility.
Enrollment Periods: There may be waiting periods, re-enrollment requirements, or continuous eligibility rules.
Applicants receive a written notice of eligibility or denial.
5. Benefits Provided
CHIP under Title 407 covers a comprehensive range of health services for children, such as:
Preventive Care – immunizations, well-child visits, screenings.
Medical Care – doctor visits, hospital services, emergency care.
Dental & Vision – exams, treatments, corrective devices.
Prescription Drugs – medically necessary medications.
Mental Health Services – counseling, therapy, inpatient and outpatient treatment.
6. Premiums & Cost-Sharing
Families may be required to pay low-cost premiums or co-payments based on income.
Title 407 establishes rules on:
How premiums are calculated.
When co-pays apply (for doctor visits, prescriptions, ER use, etc.).
Protections so that cost-sharing does not create a financial barrier to care.
7. Program Operations
CHIP contracts with managed care organizations (MCOs) to deliver services.
Providers must meet network and credentialing requirements.
The Office monitors quality of care and service delivery.
Grievance and appeals procedures exist for families who disagree with decisions on eligibility, coverage, or services.
8. Redetermination & Renewal
Eligibility is reviewed at regular intervals (e.g., annually).
Families must provide updated income and household information.
Failure to renew or submit documents may result in termination of coverage.
9. Termination of Coverage
CHIP coverage can end if:
The child ages out of eligibility.
Family income rises above the limit.
The child obtains other health insurance.
Failure to pay required premiums.
10. Appeals & Fair Hearings
Families have the right to appeal eligibility denials, terminations, or service denials.
Title 407 establishes the procedure for requesting a fair hearing.
Appeals must be filed within a set time frame, and hearings are conducted before an administrative law judge or designated officer.
11. Program Integrity
The Office investigates fraud, waste, or abuse in CHIP.
False information or misuse of benefits can lead to penalties, disqualification, or repayment obligations.
✅ In summary:
Indiana Administrative Code Title 407 – Office of the Children’s Health Insurance Program lays out the full administrative structure for providing affordable health coverage to uninsured children in Indiana. It defines eligibility, enrollment, benefits, cost-sharing, provider participation, oversight, and appeals. Its central purpose is ensuring that children in working families have access to comprehensive healthcare without financial hardship.
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