Form CMS-R-211 Template for Child Health Plan Under Title XXI of the SS

TEMPLATE FOR CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY
ACT CHILDREN’S HEALTH INSURANCE PROGRAM
(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory:___________________________________________________________
(Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR,
457.40(b))
________________________________________________________________________
(Signature of Governor, or designee, of State/Territory, Date Signed)
submits the following Child Health Plan for the Children‘s Health Insurance Program and hereby agrees
to administer the program in accordance with the provisions of the approved Child Health Plan, the
requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and
other official issuances of the Department.
The following State officials are responsible for program administration and financial oversight (42
CFR 457.40(c)):
Name:
Name:
Name:

Position/Title:
Position/Title:
Position/Title:

*Disclosure. 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 0938-0707. 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 any comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 1005-33. amended
the Social Security Act (the Act) by adding a new title XXI, the Children‘s Health Insurance Program
(CHIP). In February 2009, the Children‘s Health Insurance Program Reauthorization Act (CHIPRA)
renewed the program. The Patient Protection and Affordable Care Act of 2010 further modified the
program.
This template outlines the information that must be included in the state plans and the state plan
amendments (SPAs). It reflects the regulatory requirements at 42 CFR Part 457 as well as the previously
approved SPA templates that accompanied guidance issued to States through State Health Official
(SHO) letters. Where applicable, we indicate the SHO number and the date it was issued for your
reference. The CHIP SPA template includes the following changes:
o Combined the instruction document with the CHIP SPA template to have a single document. Any
modifications to previous instructions are for clarification only and do not reflect new policy
guidance.
o Incorporated the previously issued guidance and templates (see the Key following the template for
information on the newly added templates), including:
Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002)
Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009)
Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009)
Dental and supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009)
Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010)
Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010)
Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010)
o Moved sections 2.2 and 2.3 into section 5 to eliminate redundancies between sections 2 and 5.
o Removed crowd-out language that had been added by the August 17 letter that later was repealed.
The Centers for Medicare & Medicaid Services (CMS) is developing regulations to implement the
CHIPRA requirements. When final regulations are published in the Federal Register, this template will
be modified to reflect those rules and States will be required to submit SPAs illustrating compliance
with the new regulations. States are not required to resubmit their State plans based on the updated
template. However, States must use the updated template when submitting a State Plan Amendment.
Federal Requirements for Submission and Review of a Proposed SPA. (42 CFR Part 457 Subpart
A) In order to be eligible for payment under this statute, each State must submit a Title XXI plan for
approval by the Secretary that details how the State intends to use the funds and fulfill other
requirements under the law and regulations at 42 CFR Part 457. A SPA is approved in 90 days unless
the Secretary notifies the State in writing that the plan is disapproved or that specified additional
information is needed. Unlike Medicaid SPAs, there is only one 90 day review period, or clock for CHIP
SPAs, that may be stopped by a request for additional information and restarted after a complete
response is received. More information on the SPA review process is found at 42 CFR 457 Subpart A.
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When submitting a State plan amendment, states should redline the changes that are being made to the
existing State plan and provide a ―clean‖ copy including changes that are being made to the existing
state plan.
The template includes the following sections:
1. General Description and Purpose of the Children’s Health Insurance Plans and the
Requirements- This section should describe how the State has designed their program. It also is
the place in the template that a State updates to insert a short description and the proposed
effective date of the SPA, and the proposed implementation date(s) if different from the effective
date. (Section 2101); (42 CFR, 457.70)).
2. General Background and Description of State Approach to Child Health Coverage and
Coordination- This section should provide general information related to the special
characteristics of each state‘s program. The information should include the extent and manner to
which children in the State currently have creditable health coverage, current State efforts to
provide or obtain creditable health coverage for uninsured children and how the plan is designed
to be coordinated with current health insurance, public health efforts, or other enrollment
initiatives. This information provides a health insurance baseline in terms of the status of the
children in a given State and the State programs currently in place. (Section 2103); (42 CFR
457.410(A))

3. Methods of Delivery and Utilization Controls- This section requires a description that must
include both proposed methods of delivery and proposed utilization control systems. This section
should fully describe the delivery system of the Title XXI program including the proposed
contracting standards, the proposed delivery systems and the plans for enrolling providers.
(Section 2103); (42 CFR 457.410(A))

4. Eligibility Standards and Methodology- The plan must include a description of the standards
used to determine the eligibility of targeted low-income children for child health assistance under
the plan. This section includes a list of potential eligibility standards the State can check off and
provide a short description of how those standards will be applied. All eligibility standards must
be consistent with the provisions of Title XXI and may not discriminate on the basis of
diagnosis. In addition, if the standards vary within the state, the State should describe how they
will be applied and under what circumstances they will be applied. In addition, this section
provides information on income eligibility for Medicaid expansion programs (which are exempt
from Section 4 of the State plan template) if applicable. (Section 2102(b)); (42 CFR 457.305 and
457.320)

Outreach- This section is designed for the State to fully explain its outreach activities. Outreach
is defined in law as outreach to families of children likely to be eligible for child health
assistance under the plan or under other public or private health coverage programs. The purpose
is to inform these families of the availability of, and to assist them in enrolling their children in,
such a program. (Section 2102(c)(1)); (42CFR, 457.90)
6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of
health insurance coverage in a State plan, the child health assistance provided must consist of
any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage;
benchmark-equivalent coverage; existing comprehensive state-based coverage; and/or Secretaryapproved coverage). In this section States identify the scope of coverage and benefits offered

5.

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under the plan including the categories under which that coverage is offered. The amount, scope,
and duration of each offered service should be fully explained, as well as any corresponding
limitations or exclusions. (Section 2103); (42 CFR 457.410(A))
7. Quality and Appropriateness of Care- This section includes a description of the methods
(including monitoring) to be used to assure the quality and appropriateness of care and to assure
access to covered services. A variety of methods are available for State‘s use in monitoring and
evaluating the quality and appropriateness of care in its child health assistance program. The
section lists some of the methods which states may consider using. In addition to methods, there
are a variety of tools available for State adaptation and use with this program. The section lists
some of these tools. States also have the option to choose who will conduct these activities. As
an alternative to using staff of the State agency administering the program, states have the option
to contract out with other organizations for this quality of care function. (Section 2107); (42 CFR
457.495)

8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan
to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if
any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost-sharing
requirements provide protection for lower income children, ban cost sharing for preventive
services, address the limitations on premiums and cost-sharing and address the treatment of preexisting medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E)
9. Strategic Objectives and Performance Goals and Plan Administration- The section
addresses the strategic objectives, the performance goals, and the performance measures the
State has established for providing child health assistance to targeted low income children under
the plan for maximizing health benefits coverage for other low income children and children
generally in the state. (Section 2107); (42 CFR 457.710)
10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess the operation of
the Children‘s Health Insurance Program plan and submit to the Secretary an annual report
which includes the progress made in reducing the number of uninsured low income children. The
report is due by January 1, following the end of the Federal fiscal year and should cover that
Federal Fiscal Year. In this section, states are asked to assure that they will comply with these
requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750)
11. Program Integrity- In this section, the State assures that services are provided in an effective
and efficient manner through free and open competition or through basing rates on other public
and private rates that are actuarially sound. (Sections 2101(a) and 2107(e); (42 CFR 457, subpart I)
12. Applicant and Enrollee Protections- This section addresses the review process for eligibility
and enrollment matters, health services matters (i.e., grievances), and for states that use premium
assistance a description of how it will assure that applicants and enrollees are given the
opportunity at initial enrollment and at each redetermination of eligibility to obtain health
benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)
Program Options. As mentioned above, the law allows States to expand coverage for children through
a separate child health insurance program, through a Medicaid expansion program, or through a
combination of these programs. These options are described further below:
o Option to Create a Separate Program- States may elect to establish a separate child health
program that are in compliance with title XXI and applicable rules. These states must
4

establish enrollment systems that are coordinated with Medicaid and other sources of health
coverage for children and also must screen children during the application process to
determine if they are eligible for Medicaid and, if they are, enroll these children promptly in
Medicaid.
o Option to Expand Medicaid- States may elect to expand coverage through Medicaid. This
option for states would be available for children who do not qualify for Medicaid under State
rules in effect as of March 31, 1997. Under this option, current Medicaid rules would apply.
Medicaid Expansion- CHIP SPA Requirements
In order to expedite the SPA process, states choosing to expand coverage only through an expansion
of Medicaid eligibility would be required to complete sections:
1 (General Description)
2 (General Background)
They will also be required to complete the appropriate program sections, including:
4 (Eligibility Standards and Methodology)
5 (Outreach)
9 (Strategic Objectives and Performance Goals and Plan Administration including the
budget)
10 (Annual Reports and Evaluations).
Medicaid Expansion- Medicaid SPA Requirements
States expanding through Medicaid-only will also be required to submit a Medicaid State Plan
Amendment to modify their Title XIX State plans. These states may complete the first check-off and
indicate that the description of the requirements for these sections are incorporated by reference
through their State Medicaid plans for sections:
3 (Methods of Delivery and Utilization Controls)
4 (Eligibility Standards and Methodology)
6 (Coverage Requirements for Children's Health Insurance)
7 (Quality and Appropriateness of Care)
8 (Cost Sharing and Payment)
11 (Program Integrity)
12 (Applicant and Enrollee Protections) indicating State
Combination of Options- CHIP allows states to elect to use a combination of the Medicaid program
and a separate child health program to increase health coverage for children. For example, a State
may cover optional targeted-low income children in families with incomes of up to 133 percent of
poverty through Medicaid and a targeted group of children above that level through a separate child
health program. For the children the State chooses to cover under an expansion of Medicaid, the
description provided under ―Option to Expand Medicaid‖ would apply. Similarly, for children the
State chooses to cover under a separate program, the provisions outlined above in ―Option to Create
a Separate Program‖ would apply. States wishing to use a combination of approaches will be
required to complete the Title XXI State plan and the necessary State plan amendment under Title
XIX.
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Proposed State plan amendments should be submitted electronically and one signed hard copy to the
Centers for Medicare & Medicaid Services at the following address:
Name of Project Officer
Centers for Medicare & Medicaid Services
7500 Security Blvd
Baltimore, Maryland 21244
Attn: Children and Adults Health Programs Group
Center for Medicaid, CHIP and Survey & Certification
Mail Stop - S2-01-16

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Section 1.

General Description and Purpose of the Children’s Health Insurance Plans and the
Requirements
1.1. The state will use funds provided under Title XXI primarily for (Check appropriate box) (section
2101)(a)( 1)); (42 CFR 457.70):

Guidance:

1.1.1

Check below if child health assistance shall be provided primarily through the
development of a separate program that meets the requirements of Section 2101,
which details coverage requirements and the other applicable requirements of Title
XXI.
Obtaining coverage that meets the requirements for a separate child health program
OR

(Sections 2101(a)(1) and 2103);

Guidance:

1.1.2.
OR

Check below if child health assistance shall be provided primarily through
providing expanded eligibility under the State’s Medicaid program (Title XIX).
Note that if this is selected the State must also submit a corresponding Medicaid
SPA to CMS for review and approval.

Providing expanded benefits under the State‘s Medicaid plan (Title XIX) (Section 2101(a)(2));

Guidance:

Check below if child health assistance shall be provided through a combination of
both 1.1. and 1.2. (Coverage that meets the requirements of Title XXI, in
conjunction with an expansion in the State’s Medicaid program). Note that if this
is selected the state must also submit a corresponding Medicaid state plan
amendment to CMS for review and approval.

1.1.3.

A combination of both of the above. (Section 2102(a)(2))

1.1-DS

1.2
1.3

The State will provide dental-only supplemental coverage. Only States operating a
separate CHIP program are eligible for this option. States choosing this option must also
complete sections 1.5, 4.2, 4.4, 6.3, 6.4, 8.3, and 9.10 of this SPA template. (Section
2110(b)(5))

Check to 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))
Check to 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.
(42CFR 457.130)

Guidance:

The effective date as specified below is defined as the date on which the State begins to
incur costs to implement its State plan or amendment. (42 CFR, 457.65) The
7

implementation date is defined as the date the State begins to provide services; or, the
date on which the State puts into practice the new policy described in the State plan or
amendment. For example, in a State that has increased eligibility, this is the date on
which the State begins to provide coverage to enrollees (and not the date the State begins
outreach or accepting applications).
1.4

Provide the effective (date costs begin to be incurred) and implementation (date services
begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one
effective date, but provisions within the SPA may have different implementation dates
that must be after the effective date.
Original Plan
Effective Date:
Implementation Date:
SPA #___, Purpose of SPA_______________
Proposed effective date:
Proposed implementation date:

1.4- TC

Tribal Consultation (section 2107(e)(1)) Describe the consultation process that
occurred specifically for the development and submission of this State Plan Amendment,
when it occurred and who was involved.
TN No: Approval Date Effective Date _____

Section 2.

General Background and Description of Approach to Children’s Health Insurance
Coverage and Coordination

Guidance:

The demographic information requested in 2.1. can be used for State planning and will
be used strictly for informational purposes. THESE NUMBERS WILL NOT BE USED AS
A BASIS FOR THE ALLOTMENT.
Factors that the State may consider in the provision of this information are age
breakouts, income brackets, definitions of insurability, and geographic location, as well
as race and ethnicity. The State should describe its information sources and the
assumptions it uses for the development of its description.
Population
Number of uninsured
Race demographics
Age Demographics
Info per region/Geographic information
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2.1.

Describe the extent to which, and manner in which, children in the State (including targeted lowincome children and other groups of children specified) identified , by income level and other
relevant factors, such as race, ethnicity and geographic location, currently have creditable health
coverage (as defined in 42 CFR 457.10). To the extent feasible, distinguish between creditable
coverage under public health insurance programs and public-private partnerships (See Section 10
for annual report requirements). (section 2102(a)(1)); (42 CFR 457.80(a))

Guidance:

2.2.

Section 2.2 allows states to request to use the funds available under the 10 percent limit
on administrative expenditures in order to fund services not otherwise allowable. The
health services initiatives must meet the requirements of 42 CFR 457.1005.

Health Services Initiatives- (formerly 2.4) Describe if the State will use the health services
initiative option as allowed at 42 CFR 457.1005. If so, describe what services or programs
the State is proposing to cover with administrative funds, including the cost of each program,
and how it is currently funded (if applicable, also update the budget accordingly. (Section
2105(c)(2)(B)); (42 CFR 457.1005)

2.3-TC Tribal Consultation Requirements- (sections 1902(a)(73) and 2107(e)(1)) ; (ARRA #2, CHIPRA #3,
issued May 28, 2009) Section 1902(a)(73) of the Social Security Act (the Act) requires a State in which
one or more Indian Health Programs or Urban Indian Organizations furnish health care services
to establish a process for the State Medicaid agency to seek advice on a regular, ongoing basis
from designees of Indian health programs, whether operated by the Indian Health Service (IHS),
Tribes or Tribal organizations under the Indian Self-Determination and Education Assistance Act
(ISDEAA), or Urban Indian Organizations under the Indian Health Care Improvement Act
(IHCIA). Section 2107(e)(1)(C) of the Act was also amended to apply these requirements to the
Children‘s Health Insurance Program (CHIP). Consultation is required concerning Medicaid and
CHIP matters having a direct impact on Indian health programs and Urban Indian organizations.
Describe the process the State uses to seek advice on a regular, ongoing basis from federallyrecognized tribes, Indian Health Programs and Urban Indian Organizations on matters related to
Medicaid and CHIP programs and for consultation on State Plan Amendments, waiver proposals,
waiver extensions, waiver amendments, waiver renewals and proposals for demonstration
projects prior to submission to CMS. Include information about the frequency, inclusiveness and
process for seeking such advice.
Section 3. Methods of Delivery and Utilization Controls
Check here if the State elects to use funds provided under Title XXI only to provide expanded
eligibility under the State‘s Medicaid plan, and continue on to Section 4.
Guidance:

In Section 3.1., discussion may include, but is not limited to: contracts with managed
health care plans (including fully and partially capitated plans); contracts with indemnity
health insurance plans; and other arrangements for health care delivery. The State
should describe any variations based upon geography, as well as the State methods for
establishing and defining the delivery systems.
9

Should the State choose to cover unborn children under the Title XXI State plan, the State
must describe how services are paid. For example, some states make a global payment
for all unborn children while other states pay for services on fee-for-services basis. The
State’s payment mechanism and delivery mechanism should be briefly described here.
Section 2103(f)(3) of the Act, as amended by section 403 of CHIPRA, requires separate
or combination CHIP programs that operate a managed care delivery system to apply
several provisions of section 1932 of the Act in the same manner as these provisions
apply under title XIX of the Act. Specific provisions include: section 1932(a)(4), Process
for Enrollment and Termination and Change of Enrollment; section 1932(a)(5),
Provision of Information; section 1932(b), Beneficiary Protections; section 1932(c),
Quality Assurance Standards; section 1932(d), Protections Against Fraud and Abuse;
and section 1932(e), Sanctions for Noncompliance. If the State CHIP program operates
a managed care delivery system, provide an assurance that the State CHIP managed care
contract(s) complies with the relevant sections of section 1932 of the Act. States must
submit the managed care contract(s) to CMS’ Regional Office servicing them for review
and approval.
In addition, states may use up to 10 percent of actual or estimated Federal expenditures
for targeted low-income children to fund other forms of child health assistance, including
contracts with providers for a limited range of direct services; other health services
initiatives to improve children’s health; outreach expenditures; and administrative costs
(See 2105(a)(2)). Describe which, if any, of these methods will be used.
Examples of the above may include, but are not limited to: direct contracting with
school-based health services; direct contracting to provide enabling services; contracts
with health centers receiving funds under section 330 of the Public Health Service Act;
contracts with hospitals such as those that receive disproportionate share payment
adjustments under section 1886(d)(5)(F) or 1923 of the Act; contracts with other
hospitals; and contracts with public health clinics receiving Title V funding.
If applicable, address how the new arrangements under Title XXI will work with existing
service delivery methods, such as regional networks for chronic illness and disability;
neonatal care units, or early-intervention programs for at-risk infants, in the delivery and
utilization of services. (42CFR, 457.490(a))
3.1.

Delivery Standards Describe the methods of delivery of the child health assistance using Title
XXI funds to targeted low-income children. Include a description of the choice of financing and
the methods for assuring delivery of the insurance products and delivery of health care services
covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42CFR
457.490(a))

Check here if the State child health program delivers services using a managed care
delivery model. The State provides an assurance that its managed care contract(s)
complies with the relevant provisions of section 1932 of the Act, including section
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1932(a)(4), Process for Enrollment and Termination and Change of Enrollment; section
1932(a)(5), Provision of Information; section 1932(b), Beneficiary Protections; section
1932(c), Quality Assurance Standards; section 1932(d), Protections Against Fraud and
Abuse; and section 1932(e), Sanctions for Noncompliance. The State also assures that it
will submit the contract(s) to the CMS‘ Regional Office for review and approval. (section
2103(f)(3))

Guidance:

In Section 3.2., note that utilization control systems are those administrative mechanisms
that are designed to ensure that enrollees receiving health care services under the State
plan receive only appropriate and medically necessary health care consistent with the
benefit package.
Examples of utilization control systems include, but are not limited to: requirements for
referrals to specialty care; requirements that clinicians use clinical practice guidelines;
or demand management systems (e.g., use of an 800 number for after-hours and urgent
care). In addition, the State should describe its plans for review, coordination, and
implementation of utilization controls, addressing both procedures and State developed
standards for review, in order to assure that necessary care is delivered in a costeffective and efficient manner. (42CFR, 457.490(b))

3.2.

Describe the utilization controls under the child health assistance provided under the plan for
targeted low-income children. Describe the systems designed to ensure that enrollees receiving
health care services under the State plan receive only appropriate and medically necessary health
care consistent with the benefit package described in the approved State plan. (Section 2102)(a)(4)
(42CFR 457.490(b))

Section 4. Eligibility Standards and Methodology
Guidance:
States electing to use funds provided under Title XXI only to provide expanded
eligibility under the State’s Medicaid plan or combination plan should check the
appropriate box and provide the ages and income level for each eligibility group.
If the State is electing to take up the option to expand Medicaid eligibility as allowed
under section 214 of CHIPRA regarding lawfully residing, complete section 4.1.12 as
well as update the budget to reflect the additional costs if the state will claim title XXI
match for these children until and if the time comes that the children are eligible for
Medicaid.
4.0.
4.1.

Medicaid Expansion
4.0.1. Ages of each eligibility group and the income standard for that group :
Separate Program Check all standards that will apply to the State plan. (42CFR 457.305(a)
and 457.320(a))

4.1.0
Describe how the State meets the citizenship verification requirements.
Include whether or not State has opted to use SSA verification option.
4.1.1
Geographic area served by the Plan if less than Statewide:
4.1.2
Ages of each eligibility group, including unborn children and pregnant
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women (if applicable) and the income standard for that group:
4.1.2.1-PC
Age: _______________ through birth (SHO #02-004, issued
4.1.3

November 12, 2002)

Income of each separate eligibility group (if applicable):
4.1.3.1-PC
0% of the FPL (and not eligible for Medicaid) through
________% of the FPL (SHO #02-004, issued November 12, 2002)
4.1.4
Resources of each separate eligibility group (including any standards
relating to spend downs and disposition of resources):
4.1.5
Residency (so long as residency requirement is not based on length of
time in state) :
4.1.6
Disability Status (so long as any standard relating to disability status
does not restrict eligibility):
4.1.7
Access to or coverage under other health coverage:
4.1.8
Duration of eligibility, not to exceed 12 months:
4.1.9
Other Standards- Identify and describe other standards for or affecting
eligibility, including those standards in 457.310 and 457.320 that are not
addressed above. For instance:
Guidance:

States may only require the SSN of the child who is applying for coverage.
If SSNs are required and the State covers unborn children, indicate that
the unborn children are exempt from providing a SSN. Other standards
include, but are not limited to presumptive eligibility and deemed
newborns.
4.1.9.1
required.

Guidance:

States should describe their continuous eligibility process and populations
that can be continuously eligible.
4.1.9.2

4.9-PW

Guidance:

States should specify whether Social Security Numbers (SSN) are

Continuous eligibility

Pregnant Women Option (section 2112)- The State includes eligibility for one or
more populations of targeted low-income pregnant women under the plan.
Describe the population of pregnant women that the State proposes to cover in
this section. Include all eligibility criteria, such as those described in the above
categories (for instance, income and resources) that will be applied to this
population. Use the same reference number system for those criteria (for example,
4.1.1-P for a geographic restriction). Please remember to update section 9.10
when electing this option.

States have the option to cover groups of “lawfully residing” children and/or pregnant
women. States may elect to cover (1)“lawfully residing” children described at section
2107(e)(1)(D) of the Act; (2) “lawfully residing” pregnant women described at section
12

2107(e)(1)(D) of the Act; or (3) both. A state electing to cover children and/or pregnant
women who are considered lawfully residing in the U.S. must offer coverage to all such
individuals who meet the definition of lawfully residing, and may not cover a subgroup or
only certain groups. In other words, a State that chooses to cover pregnant women under
this option must otherwise cover pregnant women under their State plan as described in
4.1.11. In addition, states may not cover these new groups only in CHIP, but must also
extend the coverage option to Medicaid. States will need to update their budget to reflect
the additional costs for coverage of these children. If a State has been covering these
children with State only funds, it is helpful to indicate that so CMS understands the basis
for the enrollment estimates and the projected cost of providing coverage. Please
remember to update section 9.10 when electing this option.
4.9- LR

Lawfully Residing Option (Sections 2107(e)(1)(E) and 1993(v)(4)(A); (CHIPRA # 17,

SHO #

Check if the State is electing the option under section
214 of the Children‘s Health Insurance Program Reauthorization Act of 2009
(CHIPRA) regarding lawfully residing to provide coverage to the following
otherwise eligible pregnant women and children as specified below who are
lawfully residing in the United States including the following:
A child or pregnant woman shall be considered lawfully present if he or
she is:
(1) A qualified alien as defined in section 431 of PRWORA (8 U.S.C.
§1641);
(2) An alien in nonimmigrant status who has not violated the terms of the
status under which he or she was admitted or to which he or she has
changed after admission;
(3) An alien who has been paroled into the United States pursuant to
section 212(d)(5) of the Immigration and Nationality Act (INA) (8
U.S.C. §1182(d)(5)) for less than 1 year, except for an alien paroled
for prosecution, for deferred inspection or pending removal
proceedings;
(4) An alien who belongs to one of the following
classes:
(i) Aliens currently in temporary resident status pursuant to section
210 or 245A of the INA (8 U.S.C. §§1160 or 1255a, respectively);
(ii) Aliens currently under Temporary Protected Status (TPS)
pursuant to section 244 of the INA (8 U.S.C. §1254a), and pending
applicants for TPS who have been granted employment
authorization;
(iii) Aliens who have been granted employment authorization
under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24);
(iv) Family Unity beneficiaries pursuant to section 301 of Pub. L.
101-649, as amended;
10-006 issued July 1, 2010)

13

(v) Aliens currently under Deferred Enforced Departure (DED)
pursuant to a decision made by the President;
(vi) Aliens currently in deferred action status; or
(vii) Aliens whose visa petition has been approved and who have a
pending application for adjustment of status;
(5) A pending applicant for asylum under section 208(a) of the
INA (8 U.S.C. § 1158) or for withholding of removal under
section 241(b)(3) of the INA (8 U.S.C. § 1231) or under the
Convention Against Torture who has been granted employment
authorization, and such an applicant under the age of 14 who
has had an application pending for at least180 days;
(6) An alien who has been granted withholding of removal under the
Convention Against Torture;
(7) A child who has a pending application for Special Immigrant Juvenile
status as described in section 101(a)(27)(J) of the INA (8 U.S.C. §
1101(a)(27)(J));
(8) An alien who is lawfully present in the Commonwealth of the Northern
Mariana Islands under 48 U.S.C. § 1806(e); or
(9) An alien who is lawfully present in American Samoa under the
immigration laws of American Samoa.
Elected for pregnant women.
Elected for children under age _____.
4.9.1-LR

4.9-DS

The State provides assurance that for an individual whom it enrolls in
Medicaid under the CHIPRA Lawfully Residing option, it has verified, at
the time of the individual‘s initial eligibility determination and at the time
of the eligibility redetermination, that the individual continues to be
lawfully residing in the United States. The State must first attempt to
verify this status using information provided at the time of initial
application. If the State cannot do so from the information readily
available, it must require the individual to provide documentation or
further evidence to verify satisfactory immigration status in the same
manner as it would for anyone else claiming satisfactory immigration
status under section 1137(d) of the Act.

Supplemental Dental (Section 2103(a)(5)- A child who is eligible to enroll in dental-only
supplemental coverage, effective January 1, 2009. Eligibility is limited to only targeted lowincome children who are otherwise eligible for CHIP but for the fact that they are enrolled in a
group health plan or health insurance offered through an employer. The State‘s CHIP plan
income eligibility level is at least the highest income eligibility standard under its approved State
child health plan (or under a waiver) as of January 1, 2009. All who meet the eligibility
standards and apply for dental-only supplemental coverage shall be provided benefits. States
choosing this option must report these children separately in SEDS. Please update section 9.10
14

when electing this option.
4.2.

Assurances The State assures by checking the box below 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.
These standards do not discriminate on the basis of diagnosis.
4.2.2.
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. This applies to pregnant women included in the State plan as well
as targeted low-income children.
4.2.3.
These standards do not deny eligibility based on a child having a pre-existing
medical condition. This applies to pregnant women as well as targeted low-income
children.

4.2-DS Supplemental Dental Please update section 9.10 when electing this option. For dental-only
supplemental coverage, the State assures that it has made the following findings with standards
in its plan: (Section 2102(b)(1)(B) and 42 CFR 457.320(b))
4.2.1-DS
These standards do not discriminate on the basis of diagnosis.
4.2.2-DS
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.
4.2.3-DS
These standards do not deny eligibility based on a child having a preexisting medical condition.
4.3

Methodology. Describe the methods of establishing and continuing eligibility and enrollment.
The description should address the procedures for applying the eligibility standards, the
organization and infrastructure responsible for making and reviewing eligibility determinations,
and the process for enrollment of individuals receiving covered services, and whether the State
uses the same application form for Medicaid and/or other public benefit programs. (Section
2102)(b)(2)) (42CFR, 457.350)

Guidance:

The box below should be checked as related to children because States may not
have an enrollment cap or waiting list for children and pregnant women. A State
providing dental-only supplemental coverage may not have a waiting list or limit
eligibility in any way.

4.3.1 Limitation on Enrollment (formerly 4.3.1) Describe the processes, if any, that a State will
use for instituting enrollment caps, establishing waiting lists, and deciding which children will be
given priority for enrollment. If this section does not apply to your state, check the box below.
(Section 2106(b)(7)) (42CFR, 457.305(b))

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

Note that for purposes of presumptive eligibility, States do not need to verify the
citizenship status of the child. States electing this option should indicate so in the
15

State plan.(42 CFR 457.355)
4.3.2.
Check if the State elects to provide presumptive eligibility for children that meets the
requirements of section 1920A of the Act. (Section 2107(e)(1)(D)); (42 CFR 457.355).
Guidance:

Describe how the State intends to implement the Express Lane option. Include
information on the identified Express Lane agency or agencies, and whether the
State will be using the Express Lane eligibility option for the initial eligibility
determinations, redeterminations, or both.

4.3.3-EL Express Lane Eligibility Check here if the state elects the option to rely on a
finding from an Express Lane agency when determining whether a child satisfies one or
more components of CHIP eligibility. The state agrees to comply with the requirements
of sections 2107(e)(1)(B) and 1902(e)(13) of the Act for this option. Please update
section 9.10 when electing this option. This authority may not apply to eligibility
determinations made before February 4, 2009, or after September 30, 2013. (section
2107(e)(1)(B))

4.3.3.1-EL Also indicate whether the Express Lane option is
applied to (1) initial eligibility determination, (2) redetermination,
or (3) both.
4.3.3.2-EL List the public agencies approved by the State as
Express Lane agencies.
4.3.3.3-EL List the components/components of CHIP eligibility
that are determined under the Express Lane. In this section, specify
any differences in budget unit, deeming, income exclusions,
income disregards, or other methodology between CHIP eligibility
determinations for such children and the determination under the
Express Lane option.
4.3.3.3-EL List the component/components of CHIP eligibility that
are determined under the Express Lane.
4.3.3.4-EL Describe the option used to satisfy the screen and
enrollment requirements before a child may be enrolled under
title XXI.

Guidance:

States should describe the process they use to screen and enroll children required under
section 2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and
457.80(c). Describe the screening threshold set as a percentage of the Federal poverty
level (FPL) that exceeds the highest Medicaid income threshold applicable to a child by a
minimum of 30 percentage points. (NOTE: The State may set this threshold higher than
30 percentage points to account for any differences between the income calculation
16

methodologies used by an Express Lane agency and those used by the State for its
Medicaid program. The State may set one screening threshold for all children, based on
the highest Medicaid income threshold, or it may set more than one screening threshold,
based on its existing, age-related Medicaid eligibility thresholds.) Include the screening
threshold(s) expressed as a percentage of the FPL, and provide an explanation of how
this was calculated. Describe whether the State is temporarily enrolling children in
CHIP, based on the income finding from an Express Lane agency, pending the
completion of the screen and enroll process.
In this section, states should describe their eligibility screening process in a way that
addresses the five assurances specified below. The State should consider including
important definitions, the relationship with affected Federal, State and local agencies,
and other applicable criteria that will describe the State’s ability to make assurances.
(Sections 2102)(b)(3)(A) and 2110(b)(2)(B)), (42 CFR 457.310(b)(2), 42CFR
457.350(a)(1) and 457.80(c)(3))
4.4

Eligibility screening and coordination with other health coverage programs
States must describe how they will assure that:
4.4.1.
only targeted low-income children who are ineligible for Medicaid or not
covered under a group health plan or health insurance (including access to a State health
benefits plan) are furnished child health assistance under the plan. (Sections 2102)(b)(3)(A),
2110(b)(2)(B)) (42 CFR, 457.310(b), 42CFR 457.350(a)(1) and 457.80(c)(3)) Confirm that the State
does not apply a waiting period for pregnant women.
4.4.2.
children found through the screening process to be potentially eligible for
medical assistance under the State Medicaid plan are enrolled for assistance under such
plan; (Section 2102)(b)(3)(B)) (42CFR, 457.350(a)(2))
4.4.3.
children found through the screening process to be ineligible for Medicaid are
enrolled in CHIP; (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR, 431.636(b)(4))
4.4.4.
the insurance provided under the State child health plan does not substitute for
coverage under group health plans; states should check the appropriate box. (Section
2102)(b)(3)(C)) (42CFR, 457.805) (42CFR, 457.810(a)-(c))

4.4.4.1.
(formerly 4.4.4.4) If the State provides coverage under a premium
assistance program, describe: 1) the minimum period without coverage under a group
health plan. This should include any allowable exceptions to the waiting period; 2)
the expected minimum level of contribution employers will make; and 3) how costeffectiveness is determined.
4.4.5
Child health assistance is provided to targeted low-income children in the State
who are American Indian and Alaska Native. (Section 2102)(b)(3)(D)) (42 CFR 457.125(a))

Guidance:

When the State is using an income finding from an Express Lane agency, the State must
still comply with screen and enroll requirements before enrolling children in CHIP. The
State may either continue its current screen and enroll process, or elect one of two new
options to fulfill these requirements.
17

4.3-EL

The State should designate the option it will be using to carry out screen and enroll
requirements:
The State will continue to use the screen and enroll procedures required under section
2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and 457.80(c).
Describe this process.
The State is establishing a screening threshold set as a percentage of the Federal
poverty level (FPL) that exceeds the highest Medicaid income threshold applicable to a
child by a minimum of 30 percentage points. (NOTE: The State may set this threshold
higher than 30 percentage points to account for any differences between the income
calculation methodologies used by the Express Lane agency and those used by the State
for its Medicaid program. The State may set one screening threshold for all children,
based on the highest Medicaid income threshold, or it may set more than one screening
threshold, based on its existing, age-related Medicaid eligibility thresholds.) Include the
screening threshold(s) expressed as a percentage of the FPL, and provide an explanation
of how this was calculated.
The State is temporarily enrolling children in CHIP, based on the income finding from
the Express Lane agency, pending the completion of the screen and enroll process.

Section 5.
5.1.

Outreach and Coordination
(formerly 2.2) Describe the current State efforts to provide or obtain creditable health
coverage for uninsured children by addressing sections 5.1.1 and 5.1.2. (Section 2102)(a)(2)
(42CFR 457.80(b))

Guidance:

The information below may include whether the state elects express lane
eligibility a description of the State’s outreach efforts through Medicaid and
state-only programs.

5.1.1. (formerly 2.2.1.) The steps the State is currently taking to identify and enroll all
uninsured children who are eligible to participate in public health insurance programs
(i.e., Medicaid and state-only child health insurance):
Guidance:

The State may address the coordination between the public-private outreach and
the public health programs that is occurring statewide. This section will provide a
historic record of the steps the State is taking to identify and enroll all uninsured
children from the time the State’s plan was initially approved. States do not have
to rewrite his section but may instead update this section as appropriate.

5.1.2. (formerly 2.2.2.) The steps the State is currently taking to identify and enroll all
uninsured children who are eligible to participate in health insurance programs that
involve a public-private partnership:
Guidance:

The State should describe below how it’s Title XXI program will closely coordinate the
enrollment with Medicaid because under Title XXI, children identified as Medicaid18

eligible are required to be enrolled in Medicaid. Specific information related to
Medicaid screen and enroll procedures is requested in Section 4.4. (42CFR, 457.80(c))
5.2.

(formerly 2.3) Describe how CHIP coordinates with other public and private health insurance
programs, other sources of health benefits coverage for children, other relevant child health
programs, (such as title V), that provide health care services for low-income children to increase
the number of children with creditable health coverage. Section 2102)(a)(3) and 2102(c)(2) and
2102(b)(3)(E))(42CFR 457.80(c)). This item requires a brief overview of how Title XXI efforts -particularly new enrollment outreach efforts will be coordinated with and improve upon existing
State efforts described in Section 5.2.

5.2-EL The State should include a description of its election of the Express Lane eligibility option to
provide a simplified eligibility determination process and expedited enrollment of eligible
children into Medicaid or CHIP.
5.3 Strategies
Guidance:
Describe the procedures used by the State to accomplish outreach to families of children
likely to be eligible for child health assistance or other public or private health coverage
to inform them of the availability of the programs, and to assist them in enrolling their
children in such a program: (Section 2102(c)(1)) (42CFR 457.90) The description
should include information on how the State will inform the target of the availability of
the programs, including American Indians and Alaska Natives, and assist them in
enrolling in the appropriate program.
Outreach strategies may include, but are not limited to, community outreach workers,
outstationed eligibility workers, translation and transportation services, assistance with
enrollment forms, case management and other targeting activities to inform families of
low-income children of the availability of the health insurance program under the plan or
other private or public health coverage.
Section 6.

6.1.

Coverage Requirements for Children’s Health Insurance
Check here if the State elects to use funds provided under Title XXI only to provide
expanded eligibility under the State‘s Medicaid plan and proceed to Section 7 since
children covered under a Medicaid expansion program will receive all Medicaid covered
services including EPSDT.

The State elects to provide the following forms of coverage to children: (Check all that apply.)
(section 2103(c)); (42CFR 457.410(a))

Guidance:

Benchmark coverage is substantially equal to the benefits coverage in a
benchmark benefit package (FEHBP-equivalent coverage, State employee
coverage, and/or the HMO coverage plan that has the largest insured
commercial, non-Medicaid enrollment in the state). If box below is checked,
either 6.1.1.1., 6.1.1.2., or 6.1.1.3. must also be checked. (Section 2103(a)(1))
19

6.1.1.

Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420)
Guidance:

Check box below if the benchmark benefit package to be offered by the
State is the standard Blue Cross/Blue Shield preferred provider option
service benefit plan, as described in and offered under Section 8903(1) of
Title 5, United States Code. (Section 2103(b)(1) (42 CFR 457.420(b) )

6.1.1.1.

FEHBP-equivalent coverage; (Section 2103(b)(1) (42 CFR 457.420(a)) (If
checked, attach copy of the plan.)

Guidance:

Check box below if the benchmark benefit package to be offered by the
State is State employee coverage, meaning a coverage plan that is offered
and generally available to State employees in the state. (Section 2103(b)(2))

6.1.1.2.

State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan
and attach a copy of the benefits description.)

Guidance:

Check box below if the benchmark benefit package to be offered by the
State is offered by a health maintenance organization (as defined in
Section 2791(b)(3) of the Public Health Services Act) and has the largest
insured commercial, non-Medicaid enrollment of covered lives of such
coverage plans offered by an HMO in the state. (Section 2103(b)(3) (42 CFR
457.420(c)) )

6.1.1.3.
Guidance:




HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If
checked, identify the plan and attach a copy of the benefits description.)

States choosing Benchmark-equivalent coverage must check the box below and
ensure that the coverage meets the following requirements:
the coverage includes benefits for items and services within each of the categories
of basic services described in 42 CFR 457.430:
dental services
inpatient and outpatient hospital services,
physicians’ services,
surgical and medical services,
laboratory and x-ray services,
well-baby and well-child care, including age-appropriate immunizations,
and
emergency services;
the coverage has an aggregate actuarial value that is at least actuarially
equivalent to one of the benchmark benefit packages (FEHBP-equivalent
coverage, State employee coverage, or coverage offered through an HMO
coverage plan that has the largest insured commercial enrollment in the state);
20



and
the coverage has an actuarial value that is equal to at least 75 percent of the
actuarial value of the additional categories in such package, if offered, as
described in 42 CFR 457.430:
coverage of prescription drugs,
mental health services,
vision services and
hearing services.
If 6.1.2. is checked, a signed actuarial memorandum must be attached. The
actuary who prepares the opinion must select and specify the standardized set and
population to be used under paragraphs (b)(3) and (b)(4) of 42 CFR 457.431. The
State must provide sufficient detail to explain the basis of the methodologies used
to estimate the actuarial value or, if requested by CMS, to replicate the State
results.
The actuarial report must be prepared by an individual who is a member of the
American Academy of Actuaries. This report must be prepared in accordance
with the principles and standards of the American Academy of Actuaries. In
preparing the report, the actuary must use generally accepted actuarial principles
and methodologies, use a standardized set of utilization and price factors, use a
standardized population that is representative of privately insured children of the
age of children who are expected to be covered under the State child health plan,
apply the same principles and factors in comparing the value of different
coverage (or categories of services), without taking into account any differences
in coverage based on the method of delivery or means of cost control or
utilization used, and take into account the ability of a State to reduce benefits by
taking into account the increase in actuarial value of benefits coverage offered
under the State child health plan that results from the limitations on cost sharing
under such coverage. (Section 2103(a)(2))

6.1.2.

Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430) Specify the
coverage, including the amount, scope and duration of each service, as well as any
exclusions or limitations. Attach a signed actuarial report that meets the
requirements specified in 42 CFR 457.431.

Guidance:

A State approved under the provision below, may modify its program from time to
time so long as it continues to provide coverage at least equal to the lower of the
actuarial value of the coverage under the program as of August 5, 1997, or one of
the benchmark programs. If ”existing comprehensive state-based coverage” is
modified, an actuarial opinion documenting that the actuarial value of the
modification is greater than the value as of August 5, 1997, or one of the
benchmark plans must be attached. Also, the fiscal year 1996 State expenditures
for ”existing comprehensive state-based coverage” must be described in the
space provided for all states. (Section 2103(a)(3))
21

6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR
457.440) This option is only applicable to New York, Florida, and Pennsylvania.
Attach a description of the benefits package, administration, and date of
enactment. If existing comprehensive state-based coverage is modified, provide
an actuarial opinion documenting that the actuarial value of the modification is
greater than the value as of 8/5/97 or one of the benchmark plans. Describe the
fiscal year 1996 State expenditures for existing comprehensive state-based
coverage.

Guidance:

Secretary-approved coverage refers to any other health benefits coverage deemed
appropriate and acceptable by the Secretary upon application by a state. (Section
2103(a)(4)) (42 CFR 457.250)

6.1.4.

Secretary-approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450)
6.1.4.1.
6.1.4.2.
6.1.4.3.

Coverage the same as Medicaid State plan
Comprehensive coverage for children under a Medicaid Section
1115 demonstration waiver
Coverage that either includes the full EPSDT benefit or that the
State has extended to the entire Medicaid population

Guidance:

Check below if the coverage offered includes benchmark coverage,
. Under this
option, the State must clearly demonstrate that the coverage it
provides includes the same coverage as the benchmark package,
and also describes the services that are being added to the
benchmark package.

6.1.4.4.

Coverage that includes benchmark coverage plus additional
coverage
Coverage that is the same as defined by existing comprehensive
state-based coverage applicable only New York, Pennsylvania, or
Florida(
)

6.1.4.5.

Guidance:

Check below if the State is purchasing coverage through a group
health plan, and intends to demonstrate that the group health plan
is substantially equivalent to or greater than to coverage under
benefit-by-benefit comparison of the coverage. Provide a sample of
the comparison format that will be used. Under this option, if
coverage for any benefit does not meet or exceed the coverage for
that benefit under the benchmark, the State must provide an
actuarial analysis as descr
457.431 to determine actuarial
22

equivalence.

Guidance:

6.1.4.6.

Coverage under a group health plan that is substantially equivalent
to or greater than benchmark coverage through a benefit by benefit
comparison (Provide a sample of how the comparison will be
done)

Guidance:

Check below if the State elects to provide a source of coverage that
is not described above. Describe the coverage that will be offered,
including any benefit limitations or exclusions.

6.1.4.7.

Other (Describe)

All forms of coverage that the State elects to provide to children in its plan must be
checked. The State should also describe the scope, amount and duration of services
covered under its plan, as well as any exclusions or limitations. States that choose to
cover unborn children under the State plan should include a separate section 6.2 that
specifies benefits for the unborn child population. (Section 2110(a)) (42CFR, 457.490)
If the state elects to cover the new option of targeted low income pregnant women, but
chooses to provide a different benefit package for these pregnant women under the CHIP
plan, the state must include a separate section 6.2 describing the benefit package for
pregnant women (Section 2112)

6.2.

The State elects to provide the following forms of coverage to children: (Check all that apply. If
an item is checked, describe the coverage with respect to the amount, duration and scope of
services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490)
6.2.1.
6.2.2.
6.2.3.
6.2.4.
6.2.5.
6.2.6.
6.2.7.
6.2.8.
6.2.9.
6.2.10.

6.2.11.

Inpatient services (Section 2110(a)(1))
Outpatient services (Section 2110(a)(2))
Physician services (Section 2110(a)(3))
Surgical services (Section 2110(a)(4))
Clinic services (including health center services) and other ambulatory health care
services. (Section 2110(a)(5))
Prescription drugs (Section 2110(a)(6))
Over-the-counter medications (Section 2110(a)(7))
Laboratory and radiological services (Section 2110(a)(8))
Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9))
Inpatient mental health services, other than services described in 6.2.18., but
including services furnished in a state-operated mental hospital and including
residential or other 24-hour therapeutically planned structural services (Section
2110(a)(10))

Outpatient mental health services, other than services described in 6.2.19, but
including services furnished in a state-operated mental hospital and including
23

6.2.12.
6.2.13.
Guidance:

6.2.14.

community-based services (Section 2110(a)(11)
Durable medical equipment and other medically-related or remedial devices (such
as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and
adaptive devices) (Section 2110(a)(12))
Disposable medical supplies (Section 2110(a)(13))
Home and community based services may include supportive services such as
home health nursing services, home health aide services, personal care,
assistance with activities of daily living, chore services, day care services, respite
care services, training for family members, and minor modifications to the home.
Home and community-based health care services (See instructions) (Section
2110(a)(14))

Guidance:

Nursing services may include nurse practitioner services, nurse midwife services,
advanced practice nurse services, private duty nursing care, pediatric nurse
services, and respiratory care services in a home, school or other setting.

6.2.15.
6.2.16.

Nursing care services (Section 2110(a)(15))
Abortion only if necessary to save the life of the mother or if the pregnancy is the
result of an act of rape or incest (Section 2110(a)(16)
Dental services (Section 2110(a)(17)) States updating their dental benefits must
complete 6.2-DC (CHIPRA # 7, SHO # #09-012 issued October 7, 2009)
Inpatient substance abuse treatment services and residential substance abuse
treatment services (Section 2110(a)(18))
Outpatient substance abuse treatment services (Section 2110(a)(19))
Case management services (Section 2110(a)(20))
Care coordination services (Section 2110(a)(21))
Physical therapy, occupational therapy, and services for individuals with speech,
hearing, and language disorders (Section 2110(a)(22))
Hospice care (Section 2110(a)(23))

6.2.17.
6.2.18.
6.2.19.
6.2.20.
6.2.21.
6.2.22.
6.2.23.
Guidance:

Any other medical, diagnostic, screening, preventive, restorative, remedial,
therapeutic or rehabilitative service may be provided, whether in a facility, home,
school, or other setting, if recognized by State law and only if the service is: 1)
prescribed by or furnished by a physician or other licensed or registered
practitioner within the scope of practice as prescribed by State law; 2) performed
under the general supervision or at the direction of a physician; or 3) furnished
by a health care facility that is operated by a State or local government or is
licensed under State law and operating within the scope of the license.

6.2.24.

Any other medical, diagnostic, screening, preventive, restorative, remedial,
therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24))
Premiums for private health care insurance coverage (Section 2110(a)(25))

6.2.25.

24

6.2.26.

Medical transportation (Section 2110(a)(26))

Guidance:

Enabling services, such as transportation, translation, and outreach services, may
be offered only if designed to increase the accessibility of primary and preventive
health care services for eligible low-income individuals.

6.2.27.

Enabling services (such as transportation, translation, and outreach services (See
instructions) (Section 2110(a)(27))
Any other health care services or items specified by the Secretary and not
included under this section (Section 2110(a)(28))

6.2.28.

6.2-DC Dental Coverage (CHIPRA # 7, SHO # #09-012 issued October 7, 2009) The State will provide dental
coverage to children through one of the following. Please update section 9.10 when electing this
option. Dental services provided to children eligible for dental-only supplemental services must
receive the same dental services as provided to otherwise eligible CHIP children (Section
2103(a)(5)):

6.2.1-DC State Specific Dental Benefit Package. The State assures dental services represented
by the following categories of common dental terminology (CDT1) codes are included in the
dental benefits:
1. Diagnostic (i.e., clinical exams, x-rays) (CDT codes: D0100-D0999) (must follow periodicity
schedule)
2. Preventive (i.e., dental prophylaxis, topical fluoride treatments, sealants) (CDT codes:
D1000-D1999) (must follow periodicity schedule)
3. Restorative (i.e., fillings, crowns) (CDT codes: D2000-D2999)
4. Endodontic (i.e., root canals) (CDT codes: D3000-D3999)
5. Periodontic (treatment of gum disease) (CDT codes: D4000-D4999)
6. Prosthodontic (dentures) (CDT codes: D5000-D5899, D5900-D5999, and D6200-D6999)
7. Oral and Maxillofacial Surgery (i.e., extractions of teeth and other oral surgical procedures)
(CDT codes: D7000-D7999)
8. Orthodontics (i.e., braces) (CDT codes: D8000-D8999)
9. Emergency Dental Services
6.2.1.1-DC Periodicity Schedule. The State has adopted the following periodicity schedule:
State-developed Medicaid-specific
American Academy of Pediatric Dentistry
Other Nationally recognized periodicity schedule
Other (description attached)
6.2.2-DC

Benchmark coverage; (Section 2103(c)(5), 42 CFR 457.410, and 42 CFR 457.420)

Current Dental Terminology, © 2010 American Dental Association. All rights reserved.

25

6.2.2.1-DC
FEHBP-equivalent coverage; (Section 2103(c)(5)(C)(i)) (If checked, attach copy
of the dental supplemental plan benefits description and the applicable CDT2 codes. If the
State chooses to provide supplemental services, also attach a description of the services and
applicable CDT codes)
6.2.2.2-DC
State employee coverage; (Section 2103(c)(5)(C)(ii)) (If checked, identify the
plan and attach a copy of the benefits description and the applicable CDT codes. If the
State chooses to provide supplemental services, also attach a description of the services and
applicable CDT codes)Page - 11 – State Health Official
6.2.2.3-DC
HMO with largest insured commercial enrollment (Section 2103(c)(5)(C)(iii))
(If checked, identify the plan and attach a copy of the benefits description and the
applicable CDT codes. If the State chooses to provide supplemental services, also attach a
description of the services and applicable CDT codes)
6.2-DS

Supplemental Dental Coverage- The State will provide dental coverage to
children eligible for dental-only supplemental services. Children eligible for
this option must receive the same dental services as provided to otherwise
eligible CHIP children (Section 2103(a)(5). Please update section 9.10 when
electing this option.

Guidance:

Under Title XXI, pre-existing condition exclusions are not allowed, with the only
exception being in relation to another law in existence (HIPAA/ERISA). Indicate that the
plan adheres to this requirement by checking the applicable description

.
In the event that the State provides benefits through a group health plan or group health
coverage, or provides family coverage through a group health plan under a waiver (see
Section 6.4.2.), pre-existing condition limits are allowed to the extent permitted by
HIPAA/ERISA. If the State is contracting with a group health plan or provides benefits
through group health coverage, describe briefly any limitations on pre-existing
conditions. Previously 8.6
6.3

The State assures that, with respect to pre-existing medical conditions, one of the following two
statements applies to its plan: (42CFR 457.480)
6.3.1.
6.3.2.

The State shall not permit the imposition of any pre-existing medical condition
exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR
The State contracts with a group health plan or group health insurance coverage,
or contracts with a group health plan to provide family coverage under a waiver
(see Section 6.6.2. (formerly 6.4.2) of the template). Pre-existing medical
conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)).
Describe: Previously 8.6

Current Dental Terminology, © 2010 American Dental Association. All rights reserved.

26

Guidance:

6.4

States may request two additional purchase options in Title XXI: cost effective coverage
through a community-based health delivery system and for the purchase of family
coverage. (Section 2105(c)(2) and (3)) (457.1005 and 457.1010)

Additional Purchase Options- If the State wishes to provide services under the plan through
cost effective alternatives or the purchase of family coverage, it must request the appropriate
option. To be approved, the State must address the following: (Section 2105(c)(2) and (3)) (42 CFR
457.1005 and 457.1010)

6.4.1.

Cost Effective Coverage- Payment may be made to a State in excess of the
10% limitation on use of funds for payments for: 1) other child health assistance
for targeted low-income children; 2) expenditures for health services initiatives
under the plan for improving the health of children (including targeted lowincome children and other low-income children); 3) expenditures for outreach
activities as provided in section 2102(c)(1) under the plan; and 4) other reasonable
costs incurred by the State to administer the plan, if it demonstrates the following
(42CFR 457.1005(a)):

6.4.1.1.

Coverage provided to targeted low-income children through such
expenditures must meet the coverage requirements above; Describe the
coverage provided by the alternative delivery system. The State may cross
reference section 6.2.1 - 6.2.28. (Section 2105(c)(2)(B)(i)) (42CFR 457.1005(b))

6.4.1.2.

The cost of such coverage must not be greater, on an average per child
basis, than the cost of coverage that would otherwise be provided for the
coverage described above; Describe the cost of such coverage on an
average per child basis. (Section 2105(c)(2)(B)(ii)) (42CFR 457.1005(b))

Guidance:

Check below if the State is requesting to provide cost-effective coverage
through a community-based health delivery system. This allows the State
to waive the 10% limitation on expenditures not used for Medicaid or
health insurance assistance if coverage provided to targeted low-income
children through such expenditures meets the requirements of section
2103; the cost of such coverage is not greater, on an average per child
basis, than the cost of coverage that would otherwise be provided under
Section 2103; and such coverage is provided through the use of a
community-based health delivery system, such as through contracts with
health centers receiving funds under Section 330 of the Public Health
Services Act or with hospitals such as those that receive disproportionate
share payment adjustments under Section 1886(dc)(5)(F) or 1923.
If the cost-effective alternative waiver is requested, the State must
demonstrate that payments in excess of the 10% limitation will be used for
27

other child health assistance for targeted low-income children;
expenditures for health services initiatives under the plan for improving
the health of children (including targeted low-income children and other
low-income children); expenditures for outreach activities as provided in
Section 2102(c)(1) under the plan; and other reasonable costs incurred by
the State to administer the plan. (42CFR, 457.1005(a))
6.4.1.3.

The coverage must be provided through the use of a community based
health delivery system, such as through contracts with health centers
receiving funds under section 330 of the Public Health Service Act or with
hospitals such as those that receive disproportionate share payment
adjustments under section 1886(c)(5)(F) or 1923 of the Social Security
Act. Describe the community-based delivery system. (Section
2105(c)(2)(B)(iii)) (42CFR 457.1005(a))

Guidance:

Check 6.6.2.if the State is requesting to purchase family coverage. Any State
requesting to purchase such coverage will need to include information that
establishes to the Secretary's satisfaction that: 1) when compared to the amount
of money that would have been paid to cover only the children involved with a
comparable package, the purchase of family coverage is cost effective; and 2) the
purchase of family coverage is not a substitution for coverage already being
provided to the child. (Section 2105(c)(3)) (42CFR, 457.1010)

6.4.2.

Purchase of Family Coverage- Describe the plan to purchase family coverage.
Payment may be made to a State for the purpose of family coverage under a group
health plan or health insurance coverage that includes coverage of targeted lowincome children, if it demonstrates the following: (Section 2105(c)(3)) (42CFR
457.1010)

6.4.2.1.

Purchase of family coverage is cost-effective. The State's cost of
purchasing family coverage, including administrative expenditures, that
includes coverage for the targeted low-income children involved or the
family involved (as applicable) under premium assistance programs must
not be greater than the cost of obtaining coverage under the State plan for
all eligible targeted low-income children or families involved; and (2)
The State may base its demonstration of cost effectiveness on an
assessment of the cost of coverage, including administrative costs, for
children or families under premium assistance programs to the cost of
other CHIP coverage for these children or families, done on a case-by-case
basis, or on the cost of premium assisted coverage in the aggregate.

6.4.2.2.

The State assures that the family coverage would not otherwise substitute
for health insurance coverage that would be provided to such children but
for the purchase of family coverage. (Section 2105(c)(3)(B)) (42CFR
28

457.1010(b))

6.4.2.3.

The State assures that the coverage for the family otherwise meets title
XXI requirements. (42CFR 457.1010(c))

6.4.3-PA: Additional State Options for Providing Premium Assistance (CHIPRA # 13, SHO #
10-002 issued February, 2, 2010)A State may elect to offer a premium assistance subsidy for qualified
employer-sponsored coverage, as defined in section 2105(c)(10)(B), to all targeted low-income
children who are eligible for child health assistance under the plan and have access to such
coverage. No subsidy shall be provided to a targeted low-income child (or the child‘s parent)
unless the child voluntarily elects to receive such a subsidy. (section 2105(c)(10)(A)). Please
remember to update section 9.10 when electing this option. Does the State provide this option to
targeted low-income children?
Yes
No
6.4.3.1-PA Qualified Employer-Sponsored Coverage and Premium Assistance
Subsidy
6.4.3.1.1-PA Provide an assurance that the qualified employer-sponsored
insurance meets the definition of qualified employer-sponsored coverage as
defined in section 2105(c)(10)(B), and that the premium assistance subsidy meets
the definition of premium assistance subsidy as defined in 2105(c)(10)(C).
6.4.3.1.2-PA Describe whether the State is providing the premium assistance
subsidy as reimbursement to an employee or for out-of-pocket expenditures or
directly to the employee‘s employer.
6.4.3.2-PA: Supplemental Coverage for Benefits and Cost Sharing Protections Provided
under the Child Health Plan.
6.4.3.2.1-PA If the State is providing premium assistance for qualified employersponsored coverage, as defined in section 2105(c)(10)(E)(i), provide an assurance
that the State is providing for each targeted low-income child enrolled in such
coverage, supplemental coverage consisting of all items or
services that are not covered or are only partially covered, under the qualified
employer-sponsored coverage consistent with 2103(a) and cost sharing
protections consistent with section 2103(e).
6.4.2.2.2-PA Describe whether these benefits are being provided through the
employer or by the State providing wraparound benefits.
6.4.3.2.3-PA If the State is providing premium assistance for benchmark or
benchmark-equivalent coverage, the State ensures that such group health plans or
health insurance coverage offered through an employer will be certified by an
actuary as coverage that is equivalent to a benchmark benefit package described
in section 2103(b) or benchmark equivalent coverage that meets the requirements
of section 2103(a)(2).

29

6.4.3.3-PA: Application of Waiting Period Imposed Under State Plan: States are required
to apply the same waiting period to premium assistance as is applied to direct coverage
for children under their CHIP State plan, as specified in section 2105(c)(10)(F).
6.4.3.3.1-PA Provide an assurance that the waiting period for children in premium
assistance is the same as for those children in direct coverage (if State has a waiting
period in place for children in direct CHIP coverage).
6.4.3.4-PA: Opt-Out and Outreach, Education, and Enrollment Assistance
6.4.3.4.1-PA Describe the State‘s process for ensuring parents are permitted to disenroll
their child from qualified employer-sponsored coverage and to enroll in CHIP effective
on the first day of any month for which the child is eligible for such assistance and in a
manner that ensures continuity of coverage for the child (section 2105(c)(10)(G)).
6.4.3.4.2-PA Describe the State‘s outreach, education, and enrollment efforts related to
premium assistance programs, as required under section 2102(c)(3). How does the State
inform families of the availability of premium assistance, and assist them in obtaining
such subsidies? What are the specific significant resources the State intends to apply to
educate employers about the availability of premium assistance subsidies under the State
child health plan? (section 2102(c))
6.4.3.5-PA: Purchasing Pool- A State may establish an employer-family premium assistance
purchasing pool and may provide a premium assistance subsidy for enrollment in coverage made
available through this pool (section 2105(c)(10)(I)). Does the State provide this option?
Yes
No
6.6.3.5.1-PA Describe the plan to establish an employer-family premium assistance
purchasing pool.
6.6.3.5.2-PA Provide an assurance that employers who are eligible to participate: 1) have
less than 250 employees; 2) have at least one employee who is a pregnant woman eligible
for CHIP or a member of a family that has at least one child eligible under the State‘s
CHIP plan.
6.6.3.5.3-PA Provide an assurance that the State will not claim for any administrative
expenditures attributable to the establishment or operation of such a pool except to the
extent such payment would otherwise be permitted under this title.
6.4.3.6-PA Notice of Availability of Premium Assistance- Describe the procedures that assure
that if a State provides premium assistance subsidies under this section, it must: 1) provide as
part of the application and enrollment process, information describing the availability of
premium assistance and how to elect to obtain a subsidy; and 2) establish other procedures to
ensure that parents are fully informed of the choices for child health assistance or through the
receipt of premium assistance subsidies (section 2105(c)(10)(K)).
6.4.3.6.1-PA Provide an assurance that the State includes information about premium
assistance on the CHIP application or enrollment form.

30

Section 7. Quality and Appropriateness of Care
Guidance:
Methods for Evaluating and Monitoring Quality- Methods to assure quality include
the application of performance measures, quality standards consumer information
strategies, and other quality improvement strategies.
Performance measurement strategies could include using measurements for external
reporting either to the State or to consumers and for internal quality improvement
purposes. They could be based on existing measurement sets that have undergone
rigorous evaluation for their appropriateness (e.g., HEDIS). They may include the
use of standardized member satisfaction surveys (e.g., CAHPS) to assess members’
experience of care along key dimensions such as access, satisfaction, and system
performance.
Quality standards are often used to assure the presence of structural and process
measures that promote quality and could include such approaches as: the use of
external and periodic review of health plans by groups such as the National
Committee for Quality Assurance; the establishment of standards related to consumer
protection and quality such as those developed by the National Association of
Insurance Commissioners; and the formation of an advisory group to the State or plan
to facilitate consumer and community participation in the plan.
Information strategies could include: the disclosure of information to beneficiaries
about their benefits under the plan and their rights and responsibilities; the provision
of comparative information to consumers on the performance of available health
plans and providers; and consumer education strategies on how to access and
effectively use health insurance coverage to maximize quality of care.
Quality improvement strategies should include the establishment of quantified quality
improvement goals for the plan or the State and provider education. Other strategies
include specific purchasing specifications, ongoing contract monitoring mechanisms,
focus groups, etc.
Where States use managed care organizations to deliver CHIP care, recent legal
changes require the State to use managed care quality standards and quality
strategies similar to those used in Medicaid managed care.
Tools for Evaluating and Monitoring Quality- Tools and types of information
available include, HEDIS (Health Employer Data Information Set) measures, CAHPS
(Consumer Assessments of Health Plans Study) measures, vital statistics data, and
State health registries (e.g., immunization registries).
Quality monitoring may be done by external quality review organizations, or, if the
State wishes, internally by a State board or agency independent of the State CHIP
Agency. Establishing grievance measures is also an important aspect of monitoring.
31

Check here if the State elects to use funds provided under Title XXI only to provide expanded
eligibility under the State‘s Medicaid plan, and continue on to Section 8.
Guidance:

The State must specify the qualifications of entities that will provide coverage and the
conditions of participation. States should also define the quality standard they are using,
for example, NCQA Standards or other professional standards. Any description of the
information strategies used should be linked to section 9. (2102(a)(7)(A)) (42CFR, 457.495)

7.1.
Describe the methods (including external and internal monitoring) used to assure the quality and
appropriateness of care, particularly with respect to well-baby care, well-child care, and immunizations
provided under the plan. (2102(a)(7)(A)) (42CFR 457.495(a)) Will the State utilize any of the following tools
to assure quality? (Check all that apply and describe the activities for any categories utilized.)
7.1.1.
7.1.2.

Quality standards
Performance measurement
7.1.2 (a)
7.1.2 (b)

7.1.3.
7.1.4.
Guidance:

CHIPRA Quality Core Set
Other

Information strategies
Quality improvement strategies

Provide a brief description of methods to be used to assure access to covered services,
including a description of how the State will assure the quality and appropriateness of
the care provided. The State should consider whether there are sufficient providers of
care for the newly enrolled populations and whether there is reasonable access to care.
(2102(a)(7)(B))

7.2.

Describe the methods used, including monitoring, to assure: (2102(a)(7)(B)) (42CFR 457.495)
7.2.1
7.2.2

Access to well-baby care, well-child care, well-adolescent care and childhood and
adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a))
Access to covered services, including emergency services as defined in 42 CFR 457.10.
(Section 2102(a)(7)) 42CFR 457.495(b))

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex,
or serious medical conditions, including access to an adequate number of visits to
specialists experienced in treating the specific medical condition and access to out-ofnetwork providers when the network is not adequate for the enrollee‘s medical condition.
(Section 2102(a)(7)) (42CFR 457.495(c))

32

7.2.4

Decisions related to the prior authorization of health services are completed in
accordance with State law or, in accordance with the medical needs of the patient, within
14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR 457.495(d))
Exigent medical circumstances may require more rapid response according to the medical
needs of the patient.

Section 8. Cost-Sharing and Payment
Check here if the State elects to use funds provided under Title XXI only to provide expanded
eligibility under the State‘s Medicaid plan, and continue on to Section 9.
8.1.

Is cost-sharing imposed on any of the children covered under the plan? (42CFR 457.505)
Indicate if this also applies for pregnant women. (CHIPRA #2, SHO # 09-006, issued May 11, 2009)
8.1.1.
8.1.2.

Yes
No, skip to question 8.8.

8.1.1-PW
8.1.2-PW

Yes
No, skip to question 8.8.

Guidance:

It is important to note that for families below 150% of poverty, the same limitations on
cost sharing that are under the Medicaid program apply. (These cost-sharing limitations
have been set forth in Section 1916 of the Social Security Act, as implemented by
regulations at 42 CFR 447.50-.59). For families with incomes of 150% of poverty and
above, cost sharing for all children in the family cannot exceed 5% of a family's income
per year. Include a statement that no cost sharing will be charged for pregnancy-related
services. (CHIPRA #2, SHO # 09-006, issued May 11, 2009) (Section 2103(e)(1)(A)) (42CFR
457.505(a), 457.510(b) &(c), 457.515(a)&(c))

8.2.

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 by age and income (if applicable) and the service for
which the charge is imposed or time period for the charge, as appropriate. (Section 2103(e)(1)(A))
(42CFR 457.505(a), 457.510(b) &(c), 457.515(a)&(c))

8.2.1. Premiums:
8.2.2. Deductibles:
8.2.3. Coinsurance or copayments:
8.2.4. Other:
8.2-DS

Supplemental Dental (CHIPRA # 7, SHO # #09-012 issued October 7, 2009)For children
enrolled in the dental-only supplemental coverage, describe the amount of cost-sharing,
specifying any sliding scale based on income. Also describe how the State will track that
33

the cost sharing does not exceed 5 percent of gross family income. The 5 percent of
income calculation shall include all cost-sharing for health insurance and dental insurance
(Section 2103(e)(1)(A)) (42 CFR 457.505(a), 457.510(b), and (c), 457.515(a) and (c), and
457.560(a)) Please update section 9.10 when electing this option.
8.2.1-DS Premiums:
8.2.2-DS Deductibles:
8.2.3-DS Coinsurance or copayments:
8.2.4-DS Other:
8.3

Describe how the public will be notified, including the public schedule, of this cost sharing
(including the cumulative maximum) and changes to these amounts and any differences based on
income. (Section 2103(e)((1)(B)) (42CFR 457.505(b))

Guidance:

8.4

The State should be able to demonstrate upon request its rationale and justification
regarding these assurances. This section also addresses limitations on payments for
certain expenditures and requirements for maintenance of effort.

The State assures that it has made the following findings with respect to the cost sharing in its
plan: (Section 2103(e))
8.4.1.
8.4.2.
8.4.3

Cost-sharing does not favor children from higher income families over lower
income families. (Section 2103(e)(1)(B)) (42CFR 457.530)
No cost-sharing applies to well-baby and well-child care, including ageappropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520)
No additional cost-sharing applies to the costs of emergency medical services
delivered outside the network. (Section 2103(e)(1)(A)) (42CFR 457.515(f))

8.5

Describe how the State will ensure that the annual aggregate cost-sharing for a family does not
exceed 5 percent of such family‘s income for the length of the child‘s eligibility period in the
State. Include a description of the procedures that do not primarily rely on a refund given by the
State for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e))

8.6

Describe the procedures the State will use to ensure American Indian (as defined by the Indian
Health Care Improvement Act of 1976) and Alaska Native children will be excluded from costsharing. (Section 2103(b)(3)(D)) (42CFR 457.535)

8.7

Provide a description of the consequences for an enrollee or applicant who does not pay a
charge. (42CFR 457.570 and 457.505(c))

Guidance:

Section 8.8.1is based on Section 2101(a) of the Act provides that the purpose of title XXI
is to provide funds to States to enable them to initiate and expand the provision of child
health assistance to uninsured, low-income children in an effective and efficient manner
that is coordinated with other sources of health benefits coverage for children.

34

8.7.1 Provide an assurance that the following disenrollment protections are being applied:
Guidance:

Provide a description below of the State’s premium grace period process and how
the State notifies families of their rights and responsibilities with respect to
payment of premiums. (42CFR 457.570(a))
State has established a process that gives enrollees reasonable notice of and an
opportunity to pay past due premiums, copayments, coinsurance, deductibles or
similar fees prior to disenrollment.
The disenrollment process affords the enrollee an opportunity to show that the
enrollee‘s family income has declined prior to disenrollment for non-payment of
cost-sharing charges. (42CFR 457.570(b))
In the instance mentioned above, that the State will facilitate enrolling the child in
Medicaid or adjust the child‘s cost-sharing category as appropriate. (42CFR
457.570(b))

The State provides the enrollee with an opportunity for an impartial review to
address disenrollment from the program. (42CFR 457.570(c))
8.8.

The State assures that it has made the following findings with respect to the payment aspects of
its plan: (Section 2103(e))
8.8.1.
8.8.2.
8.8.3.

8.8.4.
8.8.5.

8.8.5.

No Federal funds will be used toward State matching requirements. (Section
2105(c)(4)) (42CFR 457.220)

No cost-sharing (including premiums, deductibles, copayments, coinsurance and
all other types) will be used toward State matching requirements. (Section 2105(c)(5)
(42CFR 457.224) (Previously 8.4.5)
No funds under this title will be used for coverage if a private insurer would have
been obligated to provide such assistance except for a provision limiting this
obligation because the child is eligible under the this title. (Section 2105(c)(6)(A))
(42CFR 457.626(a)(1))

Income and resource standards and methodologies for determining Medicaid
eligibility are not more restrictive than those applied as of June 1, 1997. (Section
2105(d)(1)) (42CFR 457.622(b)(5))

No funds provided under this title or coverage funded by this title will include
coverage of abortion except if necessary to save the life of the mother or if the
pregnancy is the result of an act of rape or incest. (Section 2105)(c)(7)(B)) (42CFR
457.475)

No funds provided under this title will be used to pay for any abortion or to assist
in the purchase, in whole or in part, for coverage that includes abortion (except as
described above). (Section 2105)(c)(7)(A)) (42CFR 457.475)

35

Section 9. Strategic Objectives and Performance Goals and Plan Administration
Guidance:
States should consider aligning its strategic objectives with those discussed in Section II
of the CHIP Annual Report.
9.1.

Describe strategic objectives for increasing the extent of creditable health coverage among
targeted low-income children and other low-income children: (Section 2107(a)(2)) (42CFR 457.710(b))

Guidance:
9.2.

Goals should be measurable, quantifiable and convey a target the State is working
towards.

Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3))
(42CFR 457.710(c))

Guidance:

The State should include data sources to be used to assess each performance goal. In
addition, check all appropriate measures from 9.3.1 to 9.3.8 that the State will be
utilizing to measure performance, even if doing so duplicates what the State has already
discussed in Section 9.
It is acceptable for the State to include performance measures for population subgroups
chosen by the State for special emphasis, such as racial or ethnic minorities, particular
high-risk or hard to reach populations, children with special needs, etc.
HEDIS (Health Employer Data and Information Set) 2008 contains performance
measures relevant to children and adolescents younger than 19. In addition, HEDIS 3.0
contains measures for the general population, for which breakouts by children’s age
bands (e.g., ages < 1, 1-9, 10-19) are required. Full definitions, explanations of data
sources, and other important guidance on the use of HEDIS measures can be found in the
HEDIS 2008 manual published by the National Committee on Quality Assurance. So that
State HEDIS results are consistent and comparable with national and regional data,
states should check the HEDIS 2008 manual for detailed definitions of each measure,
including definitions of the numerator and denominator to be used. For states that do not
plan to offer managed care plans, HEDIS measures may also be able to be adapted to
organizations of care other than managed care.

9.3.

Describe how performance under the plan will be measured through objective, independently
verifiable means and compared against performance goals in order to determine the State‘s
performance, taking into account suggested performance indicators as specified below or other
indicators the State develops: (Section 2107(a)(4)(A),(B)) (42CFR 457.710(d))
Check the applicable suggested performance measurements listed below that the State plans to
use: (Section 2107(a)(4))
9.3.1.
The increase in the percentage of Medicaid-eligible children enrolled in Medicaid.
9.3.2.
The reduction in the percentage of uninsured children.
9.3.3.
The increase in the percentage of children with a usual source of care.
36

9.3.4.
9.3.5.
9.3.6.
9.3.7.

9.3.8.
9.4.

The extent to which outcome measures show progress on one or more of the
health problems identified by the state.
HEDIS Measurement Set relevant to children and adolescents younger than 19.
Other child appropriate measurement set. List or describe the set used.
If not utilizing the entire HEDIS Measurement Set, specify which measures will
be collected, such as:
9.3.7.1.
Immunizations
9.3.7.2.
Well childcare
9.3.7.3.
Adolescent well visits
9.3.7.4.
Satisfaction with care
9.3.7.5.
Mental health
9.3.7.6.
Dental care
9.3.7.7.
Other, list:
Performance measures for special targeted populations.
The State assures it will collect all data, maintain records and furnish reports to the
Secretary at the times and in the standardized format that the Secretary requires. (Section
2107(b)(1)) (42CFR 457.720)

Guidance:

The State should include an assurance of compliance with the annual reporting
requirements, including an assessment of reducing the number of low-income uninsured
children. The State should also discuss any annual activities to be undertaken that relate
to assessment and evaluation of the program.

9.5.

The State assures it will comply with the annual assessment and evaluation required
under Section 10. Briefly describe the State‘s plan for these annual assessments and
reports. (Section 2107(b)(2)) (42CFR 457.750)

9.6.

The State assures it will provide the Secretary with access to any records or information
relating to the plan for purposes of review of audit. (Section 2107(b)(3)) (42CFR 457.720)

Guidance:

The State should verify that they will participate in the collection and evaluation of data
as new measures are developed or existing measures are revised as deemed necessary by
CMS, the states, advocates, and other interested parties.

9.7.

The State assures that, in developing performance measures, it will modify those
measures to meet national requirements when such requirements are developed. (42CFR
457.710(e))

9.8.

The State assures, to the extent they apply, that the following provisions of the Social Security
Act will apply under Title XXI, to the same extent they apply to a State under Title XIX: (Section
2107(e)) (42CFR 457.135)

9.8.1.

Section 1902(a)(4)(C) (relating to conflict of interest standards)
37

9.8.2.
9.8.3.
9.8.4.
Guidance:

9.9.

Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on
payment)
Section 1903(w) (relating to limitations on provider donations and taxes)
Section 1132 (relating to periods within which claims must be filed)
Section 9.9 can include discussion of community-based providers and consumer
representatives in the design and implementation of the plan and the method for ensuring
ongoing public involvement. Issues to address include a listing of public meetings or
announcements made to the public concerning the development of the children's health
insurance program or public forums used to discuss changes to the State plan.

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 insuring ongoing public involvement. (Section
2107(c)) (42CFR 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 in 42 CFR 457.125. States should provide notice and consultation with Tribes on
proposed pregnant women expansions. (Section 2107(c)) (42CFR 457.120(c))

9.9.2

For an amendment relating to eligibility or benefits (including cost sharing and
enrollment procedures), describe how and when prior public notice was provided as
required in 42 CFR457.65(b) through (d).

9.9.2 Describe the State‘s interaction, consultation, and coordination with any Indian tribes and
organizations in the State regarding implementation of the Express Lane eligibility
option.
9.10

Provide a 1-year projected budget. A suggested financial form for the budget is below. The
budget must describe: (Section 2107(d)) (42CFR 457.140)
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
Assumptions on which the budget is based, including cost per child and
expected enrollment.
projected expenditures for the separate child health plan, including but not
limited to expenditures for targeted low income children, the optional
coverage of the unborn, lawfully residing eligibles, dental services, etc.
All cost sharing, benefit, payment, eligibility need to be reflected in the
budget.

38

Projected sources of non-Federal plan expenditures, including any requirements
for cost-sharing by enrollees.
Include a separate budget line to indicate the cost of providing coverage to
pregnant women.
States must include a separate budget line item to indicate the cost of providing
coverage to premium assistance children.
Include a separate budget line to indicate the cost of providing dental-only
supplemental coverage.
Include a separate budget line to indicate the cost of implementing Express Lane
Eligibility.
Provide a 1-year projected budget for all targeted low-income children covered
under the state plan using the attached form. Additionally, provide the following:
- Total 1-year cost of adding prenatal coverage
- Estimate of unborn children covered in year 1
STATE:

CHIP Budget

Federal Fiscal Year
State's enhanced FMAP rate
Benefit Costs
Insurance payments
Managed care
per member/per month rate
Fee for Service
Health Services Initiatives
Cost of Proposed SPA changes
Total Benefit Costs
(Offsetting beneficiary cost sharing
payments)
Net Benefit Costs
Administration Costs
Personnel
General administration
Contractors/Brokers
Claims Processing
Outreach/marketing costs
Other
Total Administration Costs
10% Administrative Cap

39

FFY Budget

Federal Share
State Share
Total Costs of Approved CHIP Plan
NOTE: Include the costs associated with the current SPA.
The Source of State Share Funds:
Section 10. Annual Reports and Evaluations
Guidance:
The National Academy for State Health Policy (NASHP), CMS and the states
developed framework for the annual report that states have the option to use to
complete the required evaluation report. The framework recognizes the diversity in
State approaches to implementing CHIP and provides consistency across states in the
structure, content, and format of the evaluation report. Use of the framework and
submission of this information will allow comparisons to be made between states and
on a nationwide basis. The framework for the annual report can be obtained from
NASHP’s website at http://www.nashp.org. Per the title XXI statute at Section
2108(a), states must submit reports by January 1st to be compliant with requirements.
10.1. Annual Reports. The State assures that it will assess the operation of the State plan under this
Title in each fiscal year, including: (Section 2108(a)(1),(2)) (42CFR 457.750)
10.1.1.

10.2.
10.3.

The progress made in reducing the number of uninsured low-income children and
report to the Secretary by January 1 following the end of the fiscal year on the
result of the assessment, and
The State assures it will comply with future reporting requirements as
they are developed. (42CFR 457.710(e))

The State assures that it will comply with all applicable Federal laws and regulations,
including but not limited to Federal grant requirements and Federal reporting requirements.

10.3-DC

Specify that the State agrees to submit yearly the approved dental benefit package and to
submit quarterly current and accurate information on enrolled dental providers in the
State to the Health Resources and Services Administration for posting on the Insure Kids
Now! Website.

Section 11. Program Integrity (Section 2101(a))
Check here if the State elects to use funds provided under Title XXI only to provide expanded
eligibility under the State‘s Medicaid plan, and continue to Section 12.
11.1.

The State assures that services are provided in an effective and efficient manner through
free and open competition or through basing rates on other public and private rates that
40

are actuarially sound. (Section 2101(a)) (42CFR 457.940(b))
11.2.

The State assures, to the extent they apply, that the following provisions of the Social Security
Act will apply under Title XXI, to the same extent they apply to a State under Title XIX: (Section
2107(e)) (42CFR 457.935(b)) The items below were moved from section 9.8. (Previously items
9.8.6. - 9.8.9)
11.2.1.
11.2.2.
11.2.3.
11.2.4.
11.2.5.
11.2.6.

42 CFR Part 455 Subpart B (relating to disclosure of information by providers
and fiscal agents)
Section 1124 (relating to disclosure of ownership and related information)
Section 1126 (relating to disclosure of information about certain convicted
individuals)
Section 1128A (relating to civil monetary penalties)
Section 1128B (relating to criminal penalties for certain additional charges)
Section 1128E (relating to the National health care fraud and abuse data collection
program)

Section 12. Applicant and Enrollee Protections (Sections 2101(a))
Check here if the State elects to use funds provided under Title XXI only to provide expanded
eligibility under the State‘s Medicaid plan.
12.1.

Eligibility and Enrollment Matters- Describe the review process for eligibility and
enrollment matters that complies with 42 CFR 457.1120. Describe any special processes and
procedures that are unique to the applicant‘s rights when the State is using the Express Lane
option when determining eligibility.

Guidance:

“Health services matters” refers to grievances relating to the provision of health care.

12.2.

Health Services Matters- Describe the review process for health services matters
that comply with 42 CFR 457.1120.
12.3. Premium Assistance Programs- If providing coverage through a group health plan that does
not meet the requirements of 42 CFR 457.1120, describe how the State will assure that applicants and
enrollees have the option to obtain health benefits coverage other than through the group health plan at
initial enrollment and at each redetermination of eligibility.

41

Key for Newly Incorporated Templates
The newly incorporated templates are indicated with the following letters after the numerical section
throughout the template.
PC- Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002)
PW- Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009)
TC- Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009)
DC- Dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009)
DS- Supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009)
PA- Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010)
EL- Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010)
LR- Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010)

42

CMS Regional Offices
CMS
Regional
Offices
Region 1Boston

Associate Regional
Administrator

States
Connecticut
Massachusetts
Maine
New York
Virgin Islands

New Hampshire
Rhode Island
Vermont
New Jersey
Puerto Rico

Region 3Philadelphia

Delaware
District of
Columbia
Maryland

Pennsylvania
Virginia
West Virginia

Ted Gallagher
[email protected]

The Public Ledger Building
150 South Independence Mall
West
Suite 216
Philadelphia, PA 19106

Region 4Atlanta

Alabama
Florida
Georgia
Kentucky

Mississippi
North Carolina
South Carolina
Tennessee

Jackie Glaze
[email protected]

Region 5Chicago

Illinois
Indiana
Michigan
Arkansas
Louisiana
New Mexico
Iowa
Kansas

Minnesota
Ohio
Wisconsin
Oklahoma
Texas

Verlon Johnson
[email protected]

Atlanta Federal Center
4th Floor
61 Forsyth Street, S.W.
Suite 4T20
Atlanta, GA 30303-8909
233 North Michigan Avenue,
Suite 600
Chicago, IL 60601
1301 Young Street, 8th Floor
Dallas, TX 75202

Missouri
Nebraska

James G. Scott
[email protected]

Colorado
Montana
North Dakota
Arizona
California
Hawaii
Nevada

South Dakota
Utah
Wyoming
American
Samoa
Guam
Northern
Mariana Islands
Alaska
Oregon

Richard Allen
[email protected]

Region 2New York

Region 6Dallas
Region 7Kansas City
Region 8Denver
Region 9- San
Francisco

Region 10Seattle

Idaho
Washington

Richard R. McGreal
[email protected]

Regional Office Address

Sue Kelly
[email protected]

Bill Brooks
[email protected]

Gloria Nagle
[email protected]

Barbara Richards
[email protected]

43

John F. Kennedy Federal Bldg.
Room 2275
Boston, MA 02203-0003
26 Federal Plaza
Room 3811
New York, NY 10278-0063

Richard Bulling Federal Bldg.
601 East 12 Street, Room 235
Kansas City, MO 64106-2808
Federal Office Building, Room
522 1961 Stout Street
Denver, CO 80294-3538
90 Seventh Street Suite 5-300
San Francisco Federal Building
San Francisco, CA 94103

2001 Sixth Avenue
MS RX-43
Seattle, WA 98121

GLOSSARY
Adapted directly from SEC. 2110. DEFINITIONS.
CHILD HEALTH ASSISTANCE- For purposes of this title, the term `child health assistance' means
payment for part or all of the cost of health benefits coverage for targeted low-income
children that includes any of the following (and includes, in the case described in section
2105(a)(2)(A), payment for part or all of the cost of providing any of the following), as
specified under the State plan:
1. Inpatient hospital services.
2. Outpatient hospital services.
3. Physician services.
4. Surgical services.
5. Clinic services (including health center services) and other ambulatory health care services.
6. Prescription drugs and biologicals and the administration of such drugs and biologicals, only if
such drugs and biologicals are not furnished for the purpose of causing, or assisting in causing,
the death, suicide, euthanasia, or mercy killing of a person.
7. Over-the-counter medications.
8. Laboratory and radiological services.
9. Prenatal care and prepregnancy family planning services and supplies.
10. Inpatient mental health services, other than services described in paragraph (18) but including
services furnished in a State-operated mental hospital and including residential or other 24-hour
therapeutically planned structured services.
11. Outpatient mental health services, other than services described in paragraph (19) but including
services furnished in a State-operated mental hospital and including community-based services.
12. Durable medical equipment and other medically-related or remedial devices (such as prosthetic
devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices).
13. Disposable medical supplies.
14. Home and community-based health care services and related supportive services (such as home
health nursing services, home health aide services, personal care, assistance with activities of
daily living, chore services, day care services, respite care services, training for family members,
and minor modifications to the home).
15. Nursing care services (such as nurse practitioner services, nurse midwife services, advanced
practice nurse services, private duty nursing care, pediatric nurse services, and respiratory care
services) in a home, school, or other setting.
16. Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act
of rape or incest.
17. Dental services.
18. Inpatient substance abuse treatment services and residential substance abuse treatment services.
19. Outpatient substance abuse treatment services.
20. Case management services.
21. Care coordination services.
22. Physical therapy, occupational therapy, and services for individuals with speech, hearing, and
language disorders.
23. Hospice care.
44

24. Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or
rehabilitative services (whether in a facility, home, school, or other setting) if recognized by
State law and only if the service is-a. prescribed by or furnished by a physician or other licensed or registered practitioner
within the scope of practice as defined by State law,
b. performed under the general supervision or at the direction of a physician, or
c. furnished by a health care facility that is operated by a State or local government or is
licensed under State law and operating within the scope of the license.
25. Premiums for private health care insurance coverage.
26. Medical transportation.
27. Enabling services (such as transportation, translation, and outreach services) only if designed to
increase the accessibility of primary and preventive health care services for eligible low-income
individuals.
28. Any other health care services or items specified by the Secretary and not excluded under this
section.
TARGETED LOW-INCOME CHILD DEFINED- For purposes of this title-1. IN GENERAL- Subject to paragraph (2), the term `targeted low-income child' means a child-a. who has been determined eligible by the State for child health assistance under the State
plan;
b. (i) who is a low-income child, or
(ii) is a child whose family income (as determined under the State child health plan) exceeds
the Medicaid applicable income level (as defined in paragraph (4)), but does not exceed 50
percentage points above the Medicaid applicable income level; and
c. who is not found to be eligible for medical assistance under title XIX or covered under a
group health plan or under health insurance coverage (as such terms are defined in section
2791 of the Public Health Service Act).
2. CHILDREN EXCLUDED- Such term does not include-a. a child who is a resident of a public institution or a patient in an institution for mental
diseases; or
b. a child who is a member of a family that is eligible for health benefits coverage under a State
health benefits plan on the basis of a family member's employment with a public agency in
the State.
3. SPECIAL RULE- A child shall not be considered to be described in paragraph (1)(C)
notwithstanding that the child is covered under a health insurance coverage program that has been in
operation since before July 1, 1997, and that is offered by a State which receives no Federal funds
for the program's operation.
4. MEDICAID APPLICABLE INCOME LEVEL- The term `Medicaid applicable income level' means,
with respect to a child, the effective income level (expressed as a percent of the poverty line) that has
been specified under the State plan under title XIX (including under a waiver authorized by the
Secretary or under section 1902(r)(2)), as of June 1, 1997, for the child to be eligible for medical
assistance under section 1902(l)(2) for the age of such child.
5. TARGETED LOW-INCOME PREGNANT WOMAN.—The term ‗targeted low-income pregnant
45

woman‘ means an individual—‗‗(A) during pregnancy and through the end of the month in which
the 60-day period (beginning on the last day of her pregnancy) ends; ‗‗(B) whose family income
exceeds 185 percent (or, if higher, the percent applied under subsection (b)(1)(A)) of the poverty line
applicable to a family of the size involved, but does not exceed the income eligibility level
established under the State child health plan under this title for a targeted low-income child; and
‗‗(C) who satisfies the requirements of paragraphs (1)(A), (1)(C), (2), and (3) of section 2110(b) in
the same manner as a child applying for child health assistance would have to satisfy such
requirements.
ADDITIONAL DEFINITIONS- For purposes of this title:
1. CHILD- The term `child' means an individual under 19 years of age.
2. CREDITABLE HEALTH COVERAGE- The term `creditable health coverage' has the meaning
given the term `creditable coverage' under section 2701(c) of the Public Health Service Act (42
U.S.C. 300gg(c)) and includes coverage that meets the requirements of section 2103 provided to
a targeted low-income child under this title or under a waiver approved under section
2105(c)(2)(B) (relating to a direct service waiver).
3. GROUP HEALTH PLAN; HEALTH INSURANCE COVERAGE; ETC- The terms `group
health plan', `group health insurance coverage', and `health insurance coverage' have the
meanings given such terms in section 2191 of the Public Health Service Act.
4. LOW-INCOME CHILD - The term `low-income child' means a child whose family income is at
or below 200 percent of the poverty line for a family of the size involved.
5. POVERTY LINE DEFINED- The term `poverty line' has the meaning given such term in section
673(2) of the Community Services Block Grant Act (42 U.S.C. 9902(2)), including any revision
required by such section.
6. PREEXISTING CONDITION EXCLUSION- The term `preexisting condition exclusion' has the
meaning given such term in section 2701(b)(1)(A) of the Public Health Service Act (42 U.S.C.
300gg(b)(1)(A)).
7. STATE CHILD HEALTH PLAN; PLAN- Unless the context otherwise requires, the terms
`State child health plan' and `plan' mean a State child health plan approved under section 2106.
8. UNINSURED CHILD- The term `uninsured child' means a child that does not have creditable
health coverage.

46