Form CMS-10232 Attachment 2.2-A

OMB Approval # 0938-xxxx

Revision: ATTACHMENT 2.2‑A

PAGE 23.e

State/Territory: ______________________________

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Citation Groups Covered

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B. Optional Groups Other Than the Medically Needy

(Continued)

1902(a)(10)(A) [ ] 26. Family Opportunity Act –

(ii)(XIX) of the Act Children who have not attained 19 years of age, who would be considered disabled under Section 1614(a)(3)(C) of the Act, and whose family income meets the standard described on Page 12p of Attachment 2.6-A.

____ Beginning with the effective date of its plan amendment, the State covers all children eligible under this group, as described below.

In the case of the second, third, and fourth quarters of fiscal year 2007, the State covers children who were born on or after January 1, 2001, or who were born on or after the following earlier date ______________.

In the case of each quarter of fiscal year 2008, the State covers children who were born on or after October 1, 1995, or who were born on or after the following earlier date ___________.

In the case of each quarter of fiscal year 2009 and each quarter of any fiscal year thereafter, the State covers children who were born after October 1, 1989.

________________________________________________________________

TN No. __________

Supersedes Approval Date__________ Effective Date ____________

TN No. __________

Revision: ATTACHMENT 2.6‑A

Page 12p

State/Territory: _______________________________

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Citation Condition or Requirement

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1902(a)(10)(A) Income Standards

(ii)(XIX) of the Act (cont.)

____ The agency uses the family income standard of 300% of federal poverty level;

____ The agency uses the family income standard of less than 300% of the federal poverty level.

Specify the income standard _______

____ The agency uses a family income standard higher than 300% of the federal poverty level, (no federal financial participation is provided for benefits to families above 300% FPL).

Specify the income standard _______

Resource Standards

Under this provision agencies may not impose resource standards or asset tests in determining eligibility.

____________________________________________________________________

TN No. __________

Supersedes Approval Date__________ Effective Date ____________

TN No. __________

Revision: ATTACHMENT 2.6‑A

Page 12q

State/Territory: _______________________________

_____________________________________________________________________

Citation Condition or Requirement

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1902(a)(10)(A) Income Methodologies

(ii)(XIX) of the Act (cont.)

In determining whether a family meets the income standard described above, the agency uses the following methodologies.

____ The income methodologies of the SSI program.

____ The agency uses methodologies for treatment of income that are more restrictive than the SSI program. These more restrictive methodologies are described in Supplement 4 to Attachment 2.6-A.

____ The agency uses more liberal income methodologies than the SSI program. More liberal income methodologies are described in Supplement 8a to Attachment 2.6-A.

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TN No. __________

Supersedes Approval Date__________ Effective Date ____________

TN No. __________ CMS ID:

Revision: ATTACHMENT 2.6‑A

Page 12r

State/Territory: _______________________________

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Citation Condition or Requirement

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1902(cc) of the Act Interaction with Employer Sponsored Family Coverage

and 1903(a)

For individuals eligible under the FOA eligibility group described in No. 26 on page 23e of Attachment 2.2‑A:

The agency requires parents to enroll in available group health plans through their employers if the plan qualifies under Section 2791(a) of the Public Health Service Act and the employer contributes at least 50 percent of the total cost of annual premiums for such coverage.

If such coverage is obtained, the agency (subject to the payment of premiums described in Attachment 2.6-A, pages 12s and t) reduces any premium imposed by the State by an amount that reasonably reflects the premium contribution made by the parent for private coverage on behalf of a child with a disability; and treats such coverage as a third party liability.

_____The agency provides for payment of all or some portion of the annual premium for the employer-provided private family coverage that the parent is required to pay. Any payments made by the State are considered, for purposes of section 1903(a), to be payments for medical assistance.

The agency pays __________ percent of the premium.

__________________________________________________________________

TN No. __________

Supersedes Approval Date__________ Effective Date ____________

TN No. __________

Revision: ATTACHMENT 2.6‑A

Page 12s

State/Territory: _______________________________

_____________________________________________________________________

Citation Condition or Requirement

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1902(a)(10)(A)(ii)(XIX), 1916(i) Payment of Premiums

and 1902(cc)(2)(A)(ii)(I)

of the Act For individuals eligible under the FOA eligibility group described in No. 26 on page 23e of Attachment 2.2‑A:

____ The agency does not require the payment of premiums for Medicaid coverage.

____ The agency requires payment of premiums on a sliding scale based on income. The premiums, and how they are applied are described below:

NOTE: Amounts paid for premiums for Medicaid, required family coverage, and other cost- sharing may not exceed 5% of a family’s income for families with income up to and including 200% FPL and 7.5% of a family’s income for families above 200% and up to 300% FPL.

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TN No. __________

Supersedes Approval Date__________ Effective Date ____________

TN No. __________

Revision: ATTACHMENT 2.6‑A

Page 12t

State/Territory: _______________________________

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Citation Condition or Requirement

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1902(a)(10)(A)(ii)(XIX), 1916(i) Payment of Premiums

and 1902(cc)(2)(A)(ii)(I) (Continued)

of the Act

NOTE: A State may not require prepayment of premiums and may not terminate eligibility of a child for medical assistance on the basis of failure to pay a premium until the failure to pay continues for at least 60 days from the date on which the premium was past due.

NOTE: The State may waive payment of any such

premium in any case where the State

determines that requiring payment would

create an undue hardship.

___________________________________________________________________

TN No. __________

Supersedes Approval Date__________ Effective Date ____________

TN No. __________

__________________

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CMS-10232