GenIC #2 - CHIP State Plan Eligibility

Template CS29 – General Eligibility – Presumptive Eligibility for Pregnant Women

Statute: Sections 2112(c) of the SSA

Regulation:

INTRODUCTION

To be completed by States with separate child health assistance programs which also provide coverage to pregnant women.

In template CS29, States indicate if they elect the option to provide presumptive eligibility (PE) to pregnant women and if so, provide information as to the administration of presumptive eligibility for pregnant women. This template is used in conjunction with template CS(30) Qualified Entities.

BACKGROUND

States may elect to apply presumptive eligibility for pregnant women coverage under CHIP, provided that the requirements of section 1920 of the SSA are satisfied. Section 1920 of the SSA defines certain types of providers which may be used as qualified providers for the purpose of making determinations of presumptive eligibility for pregnant women. Since qualified entities are included in the definition of qualified providers, States may also elect to use qualified entities to determine presumptive eligibility for pregnant women.

Under presumptive eligibility, States may pay costs of coverage under CHIP during a period of presumptive eligibility for pregnant women applying for CHIP, pending the screening process and a final determination of eligibility, provided that the PE determination was made by a qualified provider.

TECHNICAL GUIDANCE

This template is broken down into the following sections:

Selection and Description of Presumptive Eligibility

Selection of Qualified Entities

Selection and Description of Presumptive Eligibility

In this section, States respond to a Y/N question as to whether the CHIP Agency covers pregnant women when determined presumptively eligible by a qualified entity.

If the answer is no, no additional entries are required by the State on this screen.

If the answer is yes, the State is then asked to:

• Describe the population of pregnant women to whom presumptive eligibility applies.

• Describe the duration of the presumptive eligibility period and any limitations.

• Describe the application process and eligibility determination factors used.

The State enters the requested information in the text boxes provided.

Review Criteria

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

Selection of Qualified Entities

This section begins with a pre-checked statement that the CHIP Agency uses the following entities to determine presumptive eligibility for pregnant women.

The State must then respond to a Y/N question as to whether the same qualified entities are used to determine presumptive eligibility for pregnant women as used for children.

If the answer is no, template CS30 is displayed for the State to indicate which types of organizations are used as qualified entities to determine presumptive eligibility for pregnant women.

If the answer is yes, the State may view the list of qualified entities selected by the State to determine presumptive eligibility for children.

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