GenIC #2 - CHIP State Plan Eligibility

Template CS9 – Coverage from Conception to Birth

Statute: 2102(b) of the SSA

Regulation: 42 CFR 457.10

Additional Reference: SHO #02-004, dated November 12, 2002

INTRODUCTION

This template applies only to States with separate child health assistance programs.

Template CS9 displays only for and must be completed by States that elected the option to provide coverage under the Coverage from Conception to Birth in the Separate CHIP Options template CS4.

In this template, states provide information with regards to eligibility criteria, including income standards specific to the ‘Coverage from Conception to Birth’ option.

BACKGROUND

In the interest of providing necessary prenatal care and other health services to children, CMS promulgated a final rule on October 2, 2002 that revised the definition of “child” at 42 CFR 457.10 to clarify that “child” means an individual from conception up to age 19. This definitional change provided States with the option to make children eligible for coverage from conception to birth if other applicable state eligibility requirements are met, regardless of the mother’s eligibility status. As part of the definition of targeted low-income child, the conception to birth option is available in a separate CHIP under the state plan.

This covered group is distinct from the option added by section 111 of CHIPRA, giving States the option to provide coverage to uninsured, low-income pregnant women under the CHIP plan (targeted low-income pregnant women). Under this option, the pregnant woman is eligible for coverage, rather than her child. Therefore, states may elect both options, at their discretion.

TECHNICAL GUIDANCE

This template is broken down into the following sections:

Eligibility Determination Assurance

Age Standard

Income Standards

Additional Assurances

Eligibility Determination Assurance

Template CS9 begins with the State being asked to provide an assurance that it operates this eligibility group in accordance with the provisions that follow.

The State provides this affirmative assurance by checking the box next to the assurance statement. If the State does not check this box, the system will not accept this template for review and approval.

Age Standard

The age standard section begins with a statement of the age standard being from conception through birth. This is followed by a Y/N question asking if the State has additional age definition or other age-related conditions.

• If the response if yes, the State is asked to provide a description of the additional definition or age-related conditions. States have flexibility in establishing eligibility guidelines, such as when coverage begins.

Review Criteria

The description should be sufficiently clear, detailed and complete to permit the reviewer to determine that the State’s election meets applicable federal statutory, regulatory and policy requirements.

Income Standards

The income standard section begins with a Y/N question as to whether income standards are applied statewide.

• If the answer is yes, another Y/N question displays asking if there are any exceptions, e.g. populations in a county which may qualify either under a statewide income standard or a county income standard.

• If the answer to this second question is no, that is income standards are statewide with no exceptions, a field is displayed for the CHIP Agency to enter the statewide income standard.

Income Standard

Since Medicaid does not provide coverage for this group, the lowest income amount is zero. The CHIP Agency enters the upper income bound. This amount is inclusive of the actual dollar amount represented by the FPL percentage entered.

• If the answer to this second question is yes, that is there are exceptions to income standards being statewide, the State must then enter an explanation which includes a description of the overlapping geographic area and the reason for having different income standards. The State must then enter both their statewide income standard (see instructions above) as well as income standards which vary by geography. See instructions below for completion of geographic standards.

Review Criteria

The description should be sufficiently clear, detailed and complete to permit the reviewer to determine that the State’s election meets applicable federal statutory, regulatory and policy requirements.

• If the answer to whether income standards are applied statewide is no, the State must then select between two options:

• Standard varies by county or city, or

• Standard varies in some other geographic way

Standard varies by county or city

If ‘Standard varies by county or city’ gets checked, a dropdown list of counties is displayed for selection. States should select all the counties having the same standard at one time and then enter the income standard. See above for instructions on completing the income standards. The process of selecting counties and entering the income standards is repeated until all the counties have been selected.

Validation: ‘above’ value cannot be greater than 300. If the validation fails, a message saying that the upper limit cannot exceed 300% FPL gets displayed and the State is given the opportunity to correct.

After the county standards have been completed, a Y/N question is displayed, asking if have any cities within your State have their own separate income standards. If the answer is yes, the CHIP Agency must enter the name of the city and its income standard. If there are multiple cities within the State with separate income standards, the State may add more fields and repeat the process until all the cities have been entered. See above for instructions on completing the income standards.

Validation: ‘above’ value cannot be greater than 300. If the validation fails, a message saying that the upper limit cannot exceed 300% FPL gets displayed and the State is given the opportunity to correct.

Standard varies in some other geographic way

If ‘Standard varies in some other geographic way’ gets checked, a geographic area grid is displayed. The State is asked to name and describe the geographic area and enter the income standard for the area. If there are multiple geographic areas within the State with separate income standards, the State may reselect the name field and repeat the process until all the geographic areas have been entered. See above for instructions on completing the income standards.

Validation: ‘above’ value cannot be greater than 300. If the validation fails, a message saying that the upper limit cannot exceed 300% FPL gets displayed and the State is given the opportunity to correct.

Additional Assurances

The bottom of the template contains two assurances from the State. The State provides these affirmative assurances by checking the boxes next to assurance statement. If the State does not check this box, the system will not accept this template for review and approval.

4