State Plan Template to Implement Section 6062 of the DRA (Opportunity for families of Disabled Children to Purchase Medicaid Coverage for Such Children) CMS-10232

OMB Approval # 0938-1045

Revision:

ATTACHMENT 2.2-A
PAGE 23e

State/Territory: ______________________________
_____________________________________________________________________
Citation
Groups Covered
_____________________________________________________________________
B.

Optional Groups Other Than the Medically Needy (Continued)

1902(a)(10)(A)
(ii)(XIX) of the Act

[

]

26.

Family Opportunity 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.
Income Standards
____ 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
TN No. __________
CMS-10232

Approval Date __________

Effective Date ____________

OMB Approval # 0938-1045

Revision:

ATTACHMENT 2.6-A
Page 12p

State/Territory: ______________________________
_____________________________________________________________________
Citation
Condition or Requirement
_____________________________________________________________________
1902(a)(10)(A)(ii)(XIX) of the Act

Income Methodologies
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.

1902(cc) and 1903(a)
of the Act

Interaction with Employer Sponsored Family
Coverage
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.
_____________________________________________________________________
TN No. __________
Approval Date__________ Effective Date ____________
Supersedes
TN No. __________
CMS-10232

OMB Approval # 0938-1045

Revision:

ATTACHMENT 2.6-A
Page 12r

State/Territory: _______________________________
_____________________________________________________________________
Citation
Condition or Requirement
_____________________________________________________________________
1902(cc) and 1903(a)
of the Act

Interaction with Employer Sponsored Family
Coverage (Continued)
If such coverage is obtained, the agency
(subject to the payment of premiums described
in Attachment 2.6-A, pages 12r and s) 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.

1902(a)(10)(A)(ii)(XIX),
1902(cc)(2)(A)(ii)(I) and 1916(i)
of the Act

Payment of Premiums
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:
__________________________________________________________________
TN No. __________
Approval Date__________ Effective Date ____________
Supersedes
TN No. __________
CMS-10232

OMB Approval # 0938-1045

Revision:

ATTACHMENT 2.6-A
Page 12s

State/Territory: _______________________________
_____________________________________________________________________
Citation
Condition or Requirement
_____________________________________________________________________
1902(a)(10)(A)(ii)(XIX),
1902(cc)(2)(A)(ii)(I) and 1916(i)
of the Act

Payment of Premiums (Continued)
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.
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. __________
Approval Date__________ Effective Date ____________
Supersedes
TN No. __________
__________________
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 0938-1045. The time required to complete this information collection is estimated to average 6 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.
CMS-10232