GenIC #2 - CHIP State Plan Eligibility

Template CS11 – Pregnant Women Who Have Access to Public Employee Coverage

Statute: Sec. 2110(b)(2)(B) and (b)(6) of the SSA

Regulation:

Additional References: SHO # 11-002, dated April4, 2011

INTRODUCTION

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

Template CS11 displays only for and must be completed by States that elected the option to provide coverage to Pregnant Women Who Have Access to Public Employee Coverage (PWAPEC) in the Separate CHIP Options template CS4.

In this template, states provide information with regards to eligibility criteria, including income standards, specific to this population group.

BACKGROUND

Prior to passage of the Affordable Care Act, section 2110(b) of the Social Security Act excluded from eligibility CHIP children who were eligible for State employee health benefits plan. This exclusion also applied to pregnant women.

An individual is considered eligible for health benefits coverage under a State health benefits plan if a more than nominal contribution to the cost of health benefits coverage under a State health benefits plan is available from the State or public agency. A contribution is considered more than nominal if the State or public agency makes a contribution toward the cost of an employee's dependent(s) that is $10 per family, per month, more than the State or public agency's contribution toward the cost of covering the employee only.

In response to concerns raised that some children of State employees did not have access to comprehensive, affordable coverage, the definition of a targeted low-income child in section 2110(b)(2)(B) of the Act was amended by the ACA by permitting States to extend CHIP eligibility to children of State employees. This option was also extended to pregnant women.

The conditions which must be met for pregnant women to qualify for this option are the same as those for children. One of the following conditions must be met.

Maintenance of Agency Contribution Condition

For this condition to be met, States must demonstrate that they have been consistently contributing to the cost of employee coverage, with increases for inflation, since 1997.

This condition is met when the public agency expenditures for health coverage for employees that have dependent coverage is not less than the amount of such expenditures in the 1997 State fiscal year, increased by the percentage increase of the medical care expenditure category of the Consumer Price Index.

This does not require a case-by-case determination but can be calculated on an average basis for each public agency or it can be done in the aggregate for all multiple agencies having the same contribution rate structures.

Hardship Condition

For this condition to be met, States must demonstrate that the coverage currently available through the public employee system poses a financial hardship for families. In making a hardship determination, States would assess whether the annual aggregate premiums and cost-sharing imposed by the State health benefits plan would exceed 5 percent of a family’s income during the time period the pregnant woman would be enrolled in CHIP.

State Plan Option

States may offer this option to a subset of their CHIP eligible population. For example, States may limit coverage under this option to pregnant women in families with family income under 250% of the FPL although coverage for targeted low-income pregnant women is offered up to 300% of the FPL. States also have the option of limiting coverage under this option to certain public agencies.

The State may also choose to apply one of the conditions to a subset of their CHIP eligible population and the other to a different subset.

Additional information may be found in SHO # 11-002, dated April 4, 2011.

Note: If States have questions or need technical assistance regarding the methodology for expanding CHIP to children who have access to public employee coverage, the CMS project officer may provide guidance.

TECHNICAL GUIDANCE

This template is broken down into the following sections:

Eligibility Determination Assurance

Selection of Condition/Criteria

Age Standards

Pregnancy Status

Additional Assurances

Eligibility Determination Assurance

Template CS11 begins with the CHIP Agency being asked to provide assurance that it determines eligibility for this 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.

Selection of Condition/Criteria

The State is then asked to select one of the following two options:

• Maintenance of agency contribution as provided in 2110(b)(6)(B) of the SSA

• Hardship criteria as provided in section 2110(b)(6)(C) of the Social Security Act

For each option selected, States are asked to provide household income standards and to identify the population(s) to whom that option is offered.

Household Income

States are asked to choose between one of two options:

• The same as the standards for Targeted Low Income Pregnant Women

• Lower than the income standards for Targeted Low Income Pregnant Women

If the State selects ‘The same as the standards for Targeted Low Income Pregnant Women’, the system will assign the standards to this group that the CHIP Agency entered for TLIPW and no additional entries need to be made by the State.

If the State selects ‘Lower than the income standards for Targeted Low Income Pregnant Women’, the system displays 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 grid is displayed for the CHIP Agency to enter the statewide income standards.

Income Standards Grid

The grid contains two fields 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).

• 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.

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.

• 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.

Validation: the system will cross check the FPL range entered against FPL standards for TLIPW to ensure that the upper end of the income standard does not exceed that of TLIPW.

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

• 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.

Validation: the system will cross check each FPL range entered against FPL standards for TLIPW to ensure that the upper end of the income standard does not exceed that of TLIPW.

If the validation fails, an error message gets displayed and the Agency 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 in the name of the city. The State must then enter their statewide income standard (see instructions above) for the city entered. 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.

Validation: the system will cross check each FPL range entered against FPL standards for TLIPW to ensure that the upper end of the income standard does not exceed that of TLIPW.

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

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 State must then enter their statewide income standard (see instructions above) for the geographic area(s) 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.

Validation: the system will cross check each FPL range entered against FPL standards for TLIPW to ensure that the upper end of the income standard does not exceed that of TLIPW.

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

Population(s) to Whom this Option is Offered

States are asked to indicate the population(s) offered this option by checking one of the following options:

• All pregnant women who have access to public employee coverage.

• Pregnant women who are employees or dependents of employees, limited to certain public agencies.

• Pregnant women who are employees or dependents of employees, limited to certain types of public employees or are dependents of certain types of public employees.

If the State selects ‘Pregnant women who are employees or dependents of employees, limited to certain public agencies’, the State then enters the type of agency. If more than one agency, the State can re-select the ‘type of agency’ field until all the State agencies have been entered.

• If the State selects ‘Pregnant women who are employees or dependents of employees, limited to certain types of public employees or are dependents of certain types of public employees’, the State is asked to describe the type of public employees. If more than one type of public employees, the State can re-select the ‘describe type of public employee’ field until all the types of public employees have been entered.

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.

After the State has completed the income and population sections it must attach a copy of the documentation demonstrating that the State meets the conditions specific to that option.

Review Criteria

For maintenance of effort, the documentation should include the methodology the State used to calculate the maintenance of agency contribution. The documentation 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.

For technical assistance in developing the methodology, please contact CMS.

The State is then asked to provide assurance that it will, on an annual basis, recalculate expenditures for each participating public agency to determine if the maintenance of effort condition continues to be met.

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.

Review Criteria

For hardship, the documentation should include the methodology the State used to calculate the financial hardship. The documentation 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.

For technical assistance in developing the methodology, please contact CMS.

The State is then asked to provide assurance that it will, on an annual basis, recalculate the financial status to determine if the hardship condition continues to be met.

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, the State is asked to select one of the following options as to the age standard used:

• Same as the age criteria used for Targeted Low-Income Pregnant Women

• Different than the age criteria used for Targeted Low-Income Pregnant Women

If the State selects ‘Same as the age criteria used for Targeted Low-Income Pregnant Women’, the system will copy that information over to this group.

If the State selects ‘Different than the age criteria used for Targeted Low-Income Pregnant Women’ the State is asked 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: a comparison is done of the 'from age' entered for PWAPEC with the highest age entered for children. If the 'from age' entered for PWAPEC 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

This is followed by a statement 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.

Additional Assurances

The State is asked to provide another more general assurance that pregnant women considered to have access to public employee coverage, and therefore not excluded from CHIP through this option, meet the definition provided at 457.310(c)(1).

If the State does not cover all pregnant women, i.e. the State selected either pregnant women who are employees of or dependents of employees of certain public agencies or pregnant women who are employees of or dependents of certain types of public employees, an additional assurance will display. Here, the Agency assures that pregnant women who are eligible for public employee health benefits coverage who are not described above are excluded from eligibility under the plan.

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

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