CHIP Policy

806-1 Causes of Improper CHIP Coverage

Effective Date: July 1, 2011

Previous Policy

1. Agency Error

Agency errors are the result of mistakes made when determining eligibility.  Agency errors include:

• Untimely action on a change the household reported.

• Incorrect decisions about the household’s CHIP assistance eligibility.

• Policy incorrectly applied.

• Information entered incorrectly.

2. Inadvertent Error

Inadvertent errors are unintended mistakes the enrollee or their representative makes when providing information, or a failure to report changes  that affect eligibility.  

3. Suspected Intentional Program Violation (SIPV)

Use this cause when you suspect that the enrollee or their representative committed any of the acts described under “Intentional Program Violation”.  Use the SIPV until the DWS adjudication process proves the action was intentional or the enrollee or their representative acknowledges the IPV in writing.  SIPV includes any of the reason listed in #4 (IPV) below.

4. Intentional Program Violation (IPV)

As determined by the adjudication process, any person who personally or through a representative, commits any of the acts described below to obtain, maintain, increase or prevent the decrease or termination of CHIP assistance benefits is guilty of an Intentional Program Violation (IPV). Acts which constitute an IPV include, but are not limited to:

• Knowingly making false or misleading statements

• Misrepresenting, concealing, or withholding facts

• Violating program regulations on the use, presentation, acquisition, receipt or possession of CHIP assistance or the CHIP card; or

• Not reporting the receipt of a CHIP card or CHIP service that the individual knows the enrollee was not eligible to receive;

• Posing as someone else;

• Not reporting a change within 10 days after the change occurs; and the individual knew the reporting requirements;

• Intentionally submitting a signed application or eligibility review containing false or misleading statements in an attempt to obtain public assistance payments, even if no assistance was received;

• Intentionally receiving CHIP coverage for which the enrollee or representative knows he is not eligible.  

• Intentionally failing to report when a child obtains health insurance coverage.