GenIC #2 - CHIP State Plan Eligibility

Template CS8 – Targeted Low-Income Pregnant Women

Statute: Section 2112 of the SSA

Regulation:

Additional References: SHO # 09-006, dated May 11, 2009

INTRODUCTION

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

This template displays only for and must be completed by States which checked that they elected the option to provide coverage to Targeted Low-Income Pregnant Women in the Separate CHIP Options template CS4.

In this template, states provide information with regards to eligibility criteria, including income standards specific to the targeted low-income pregnant women (TLIPW) covered group.

BACKGROUND

Section 2112 of the Social Security Act was added by section 111 of CHIPRA to give States the option to provide healthcare coverage for necessary prenatal, delivery, and postpartum care to low-income uninsured pregnant women through an amendment to its State CHIP plan. Unlike prenatal coverage provided under the ‘coverage from conception to birth’ covered group, under this option, the pregnant woman is eligible for coverage, rather than the unborn child.

In order to cover pregnant women through the CHIP State plan option, States must meet certain criteria:

• Pregnant women must be covered under Medicaid up to the minimum income level of 185% of the FPL.

• The income level for targeted low-income pregnant women may not be higher than for targeted low-income children.

• States must cover children, under Medicaid, up to age 19 at an income level no lower than 200% of the FPL.

• The income level for pregnant women under CHIP cannot be lower than it is under the State’s Medicaid program.

• Higher income pregnant women cannot be covered without covering lower income pregnant women.

Additional information may be found in SHO # 09-006, dated May 11, 2009

TECHNICAL GUIDANCE

This template is broken down into the following sections:

Eligibility Determination Assurance

Age Standard

Pregnancy Status

Income Standards

Eligibility Determination Assurance

Template CS8 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

In this section States are asked to provide information about the age standard they apply to this group. The State may check either that it has no age restriction or if there are restrictions, to provide the lower (from age) and upper end (up to) of that age range. An explanation defining ‘from’ and ‘up to’ can be found in the income standards screen CS6.

Validation: Compares the 'from age' entered with the highest age entered for children. If the 'from age' entered for TLIPW is less than the highest age entered for children, the following message is displayed: ‘The 'from age' entered overlaps with the qualifying ages for children’ and the State is asked to select one of the following options:

• This was done in error

• This is the correct age used by the State for targeted low-income women

If ‘this was done in error is selected, the State is given the opportunity to correct.

If the State selects that it is correct, the State is asked to describe how the determination is made as to whether the applicant will be provided coverage as a child or as a pregnant woman.

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.

Pregnancy Status

A statement is displayed saying that a woman must be pregnant or post-partum. Since this criterion is required of all States, it is pre-checked and does not require any action by the CHIP Agency.

Income Standards

In this section, States are asked to provide the income standards used by the State to determine eligibility for targeted low-income women.

Validation: A check is done to ensure that income standards for children’s covered groups are greater than or equal to 200%.

If the validation fails, a message is displayed saying that ‘Pregnant women coverage may only be provided if children's qualifying income standards under the plan is at least up to 200% of FPL for all age ranges’. States must then select between two options:

• Go back to targeted low income children screens for correction, or

• De-select pregnant women coverage option

If ‘Go back to targeted low income children screens for correction’ is selected, the system will display the income section for the children’s covered group(s) having income standards lower than 200% of the FPL for the State to make the correction.

If ‘De-select pregnant women coverage option’ is selected, the system will display the separate CHIP options template CS4 for the State to uncheck the targeted low-income pregnant women option.

If the validation passes, a Y/N question displays asking 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, the CHIP Agency enters the statewide income standards.

Income Standards

Two fields are displayed for percentage of Federal poverty level (FPL) labeled ‘Above’ for the lower end of the income standard and ‘Up to and including’ for the upper bound of the income standard. The State enters the FPL amounts in both fields.

Note: The ‘above’ amount does not equal the actual dollar amount represented by the FPL percentage entered, but rather is equal to the dollar amount plus one cent of the FPL percentage entered. However, ‘up to and including’ is inclusive of the actual dollar amount represented by the FPL percentage entered. Example: for income range of above 185% (dollar value = $1,850) up to and including 250% (dollar value = $2,500), the lower end equals $1,850.01 and the upper end equals $2,500 exactly).

Note: Each time that an income standard is entered, regardless of whether it’s statewide or varies by county, city or other geographic area, series of validations are conducted.

Validation 1: Checks if the 'above' value (lower end of the income standard) is equal to or greater than 185% of the FPL.

If the validation fails, a message is displayed saying that ‘CHIP coverage for pregnant women may only be provided if the qualifying income standard under Medicaid for pregnant women is at least up to 185%’. And the Agency is given the opportunity to correct. If the amount is not corrected, pregnant women coverage will be deselected’. The CHIP Agency must correct the amount in order to continue.

Validation 2: Checks to make sure that the value for 'up to' is greater than the value for ‘above’.

If the validation fails, an error message is displayed and the CHIP Agency is given the opportunity to correct.

Validation 3: Checks to make sure that value for 'up to' is greater than the highest income level for children.

If the validation fails, a message is displayed and the CHIP Agency is given the opportunity to correct.

• If the answer to this second question is yes, that is there are exceptions to income standards being statewide, the State must then type in 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. Once a State has indicated that it has selected all the counties having the same income standard, a grid asking for income information is displayed for the CHIP Agency to complete. See above for instructions on completing the income standards grid. After the income standards grid is completed, the process of selecting counties and completing the income standards grid is repeated until all the counties have been selected.

After the county standards have been completed, a Y/N question is displayed, asking if any cities within your State have their own separate income standards. If the answer is yes, the CHIP Agency must enter in the name of the city. The income standards screen is then displayed and must be completed. If there are multiple cities within the State with separate income standards, the State may reselect the city name field and repeat the process until all the cities have been entered.

Standard varies in some other geographic way

If ‘Standard varies in some other geographic way’ gets checked, the State is asked to name and describe the geographic area. States may name multiple geographic areas. The income standards screen is then displayed and must be completed for each geographic name entered. 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 grid.

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