Form CMS-10284 Addendum to State Health Plan Describing Coverage of Pre

Addendum to State Child Health Plan Describing Coverage of Pregnant
Women
Section 1. General Description and Purpose of the State Child Health Plans and State
Child Health Plan Requirements. (Section 2101)
1.1

The State will use funds provided under Title XXI primarily for (Check appropriate box)
(42 CFR 457.70):
1.1.1



1.1.2.



1.1.3.



1.2



1.3



1.4



Obtaining coverage that meets the requirements for a separate child health
program (Section 2103); or
Providing expanded benefits under the State’s Medicaid plan (Title XIX);
or
A combination of both of the above.

Please provide an assurance that expenditures for child health assistance will not
be claimed prior to the time that the State has legislative authority to operate the
State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))
Please provide an assurance that the State complies with all applicable civil rights
requirements, including title VI of the Civil Rights Act of 1964, title II of the
Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of
1973, the Age Discrimination Act of 1975, 45 CFR Part 80, Part 84, and Part 91,
and 28 CFR Part 35. (42 CFR 457.130)
Please provide the effective (date costs begin to be incurred) and implementation
(date services begin to be provided) dates for this plan or plan amendment
(42 CFR 457.65):
Effective date:
Implementation date:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-XXXX. The time required to complete this
information collection is estimated to average 80 hours per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.

Section 2.

2.2.

General Background and Description of State Approach to Child Health
Coverage and Coordination. (Section 2102 (a)(1)-(3) and Section
2105)(c)(7)(A)-(B))
Describe the current State efforts to provide or obtain creditable health coverage
for uncovered children by addressing: (Section 2102(a)(2) and 42 CFR
457.80(b))
2.2.1. The steps the State is currently taking to identify and enroll all uncovered
children who are eligible to participate in public health insurance
programs (i.e., Medicaid and State-only child health insurance):

Section 4.
4.1.

Eligibility Standards and Methodology. (Section 2102(b))
The following standards may be used to determine eligibility of targeted lowincome children for child health assistance under the plan. Please note whether
any of the following standards are used and check all that apply. If applicable,
describe the criteria that will be used to apply the standard.
(Section 2102(b)(1)(A), 42 CFR 457.305(a), and 457.320(a))

4.1.4.






4.1.5.



4.1.6.



4.1.1.
4.1.2.
4.1.3.

4.1.7.
4.1.8.
4.1.9.
4.1-P .







Geographic area served by the Plan:
Age:
Income:
Resources (including any standards relating to spend downs and
disposition of resources):
Residency (as long as residency requirement is not based on length
of time in State) :
Disability Status (so long as any standard relating to disability
status does not restrict eligibility):
Access to or coverage under other health coverage:
Duration of eligibility:
Other standards (identify and describe):

The State includes eligibility for one or more populations of targeted lowincome pregnant women under the plan. Please describe the population
of pregnant women that the State proposes to cover in this section.
Please include any criteria, such as the above categories (e.g., income
and resources) that will be applied to this population. Please use the

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-XXXX. The time required to complete this
information collection is estimated to average 80 hours per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.

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same reference number system for those criteria (for example, 4.1.1-P
for a geographic restriction).
4.2.

4.3.

The State assures that it has made the following findings with respect to the
eligibility standards in its plan: (Section 2102(b)(1)(B) and 42 CFR 457.320(b))
4.2.1.



4.2.2.



4.2.3.



These standards do not discriminate on the basis of diagnosis.
Within a defined group of covered targeted low-income children,
these standards do not cover children of higher income families
without covering children with a lower family income. Please
confirm that this applies to pregnant women as well as targeted
low-income children.
These standards do not deny eligibility based on a child having a
pre-existing medical condition. Please confirm that this applies to
pregnant women as well as targeted low-income children.

Describe the methods of establishing eligibility and continuing enrollment.
(Section 2102(b)(2) and 42 CFR 457.350)
4.3.1

Describe the State’s policies governing enrollment caps and waiting lists
(if any). (Section 2106(b)(7) and 42 CFR 457.305(b))



Check here if this section does not apply to your State.

Please note that this box should be checked as related to children because
States may not have an enrollment cap or waiting list for children and cover
pregnant women.
4.4.

Describe the procedures that assure that:
4.4.1. Through the screening procedures used at intake and follow-up eligibility
determination, including any periodic redetermination, that only targeted
low-income children who are ineligible for Medicaid or not covered under
a group health plan or health insurance coverage (including access to a
State health benefits plan) are furnished child health assistance under the
State child health plan. (Sections 2102(b)(3)(A), 2110(b)(2)(B), 42 CFR
457.310(b), 42 CFR 457.350(a)(1), and 457.80(c)(3))
Please confirm that the State does not apply a waiting period for
pregnant women.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-XXXX. The time required to complete this
information collection is estimated to average 80 hours per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.

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Section 8. Cost Sharing and Payment. (Section 2103(e))
8.1. Is cost-sharing imposed on any of the children covered under the plan? (42 CFR
457.505) Please indicate if this applies for pregnant women also.
8.1.1.
8.1.2.
8.2.




YES
NO, skip to question 8.8.

Describe the amount of cost-sharing, any sliding scale based on income, the group
or groups of enrollees that may be subject to the charge, and the service for which
the charge is imposed or time period for the charge, as appropriate.
(Section 2103(e)(1)(A), 42 CFR 457.505(a), 457.510(b) and (c), and 457.515(a)
and (c))
8.2.1.
8.2.2.
8.2.3.
8.2.4.

Premiums:
Deductibles:
Coinsurance or copayments:
Other:

Please include a statement that no cost sharing will be charged for pregnancyrelated services.
9.9.

Describe the process used by the State to accomplish involvement of the public in
the design and implementation of the plan and the method for ensuring ongoing
public involvement. (Section 2107(c) and 42 CFR 457.120(a) and (b))
9.9.1

Describe the process used by the State to ensure interaction with Indian
Tribes and organizations in the State on the development and
implementation of the procedures required at 42 CFR section 457.125.
(Section 2107(c) and 42 CFR 457.120(c))

States should provide notice and consultation with Tribes on proposed pregnant
women expansions.
9.10.

Provide a 1-year projected budget. (Section 2107(d) and 42 CFR 457.140)
The budget must describe:
Planned use of funds, including:
Projected amount to be spent on health services;
Projected amount to be spent on administrative costs, such as outreach,
child health initiatives, and evaluation; and

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-XXXX. The time required to complete this
information collection is estimated to average 80 hours per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.

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Assumptions on which the budget is based, including cost per child and
expected enrollment.
Projected sources of non-Federal plan expenditures, including any
requirements for cost-sharing by enrollees.
Please include a separate budget line to indicate the cost of providing coverage
to pregnant women.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-XXXX. The time required to complete this
information collection is estimated to average 80 hours per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.

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