S-CHIP

What if the Child's Application for S-CHIP is Denied?

The two most common reasons for denial are not meeting eligibility rules and not sending complete information. Not meeting eligibility rules might mean that your family income is higher than the limits your state set for this program. Another reason for denial might be because you did not include requested information or documents in the application.

If your child is denied coverage, review your state program’s written explanation as to why. If this written explanation is not clear, contact your state program to make sure you fully understand the reasons for denial of coverage.

If you don’t agree with the reasons for denial and want to appeal, contact your state program. They will tell you how to appeal. This may include filling out an appeal form.

When you appeal, you will need to provide reasons why you think the decision was wrong. You may be asked for additional information in the appeal process.

Your first appeal will probably be decided by persons in your state’s S-CHIP office. If you are not satisfied with their ruling on your appeal, they can tell you how to make a second appeal, which will probably go to an independent governmental agency. A final appeal may result in a hearing before an administrative law judge who has the authority to make a final ruling.

At some point in the process, you may want or need legal representation. If you cannot afford this, contact the legal aid program in your community to determine if you qualify for assistance. Persons at your state’s S-CHIP program may also be able to direct you to someone in your community who can help you in the appeal process.

There may be other decisions you wish to appeal. For example, if your child loses benefits because of not paying monthly premiums, or when there is a disagreement over the starting date of coverage. The appeal process can be used for these and other grievances.