CHIP Coverage Coordination Disclosure Form

This document is about a draft CHIP Coverage Coordination Disclosure Form developed by the CHIP Working Group for public comment. The form is intended to be sent by a state to a group health plan administrator to determine the availability and cost-effectiveness of coverage for employees' family members eligible for premium assistance under state Medicaid or CHIP plans, and to allow for coordination of coverage between the plans. The document provides detailed instructions on how the plan administrator should complete and return the form.