1 Infants and Children under Age 19

Centers for Medicare & Medicaid
Services
CMS eXpedited Life Cycle (XLC)

Medicaid and CHIP Program (MACPro)
S30 – Infants and Children under Age 19 RU PRA
Document
Version 1.0
08/18/2017

Document Number: 209-QSSI-MACPro-R5.1-S30-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S30 - Infants and Children under Age 19 Screenshots ....................................................... 1
1.1
1.2
1.3
1.4
1.5
1.6
1.7

Package Header ............................................................................................. 1
A. Characteristics and B. Financial Methodologies and C. Income Standards
Used ................................................................................................................ 1
D. Basis for the Income Standard for Infants under Age 1 – Path 1 ................ 2
D. Basis for the Income Standard for Infants under Age 1 – Path 2 ................ 2
E. Basis for the Income Standard for Children Age One through Age Five ..... 3
F. Basis for the Income Standard for Children Age Six through Age Eighteen 3
G. Additional Information (optional) ................................................................. 4

List of Figures
Figure 1: Package Header .............................................................................................. 1
Figure 2: Section A, Section B and Section C ................................................................. 1
Figure 3: Section D-Path1 ............................................................................................... 2
Figure 4: Section D-Path2 ............................................................................................... 2
Figure 5 : Section E ......................................................................................................... 3
Figure 6 : Section F ......................................................................................................... 3
Figure 7 : Section G ........................................................................................................ 4

List of Tables
No table of figures entries found.

S30 – Infants and Children under Age 19 RU PRA Document
Version 1.0

i

08/18/2017

CMS XLC

Package Header

1. S30 - Infants and Children under Age 19 Screenshots
1.1

Package Header

Figure 1: Package Header

1.2

A. Characteristics and B. Financial Methodologies and C. Income
Standards Used

Figure 2: Section A, Section B and Section C

S30 – Infants and Children under Age 19 RU PRA Document
Version 1.0

1

08/18/2017

CMS XLC

1.3

D. Basis for the Income Standard for Infants under Age 1 – Path 1

D. Basis for the Income Standard for Infants under Age 1 – Path 1

Figure 3: Section D-Path1

1.4

D. Basis for the Income Standard for Infants under Age 1 – Path 2

Figure 4: Section D-Path2

S30 – Infants and Children under Age 19 RU PRA Document
Version 1.0

2

08/18/2017

CMS XLC

1.5

E. Basis for the Income Standard for Children Age One through Age Five

E. Basis for the Income Standard for Children Age One through Age
Five

Figure 5 : Section E

1.6

F. Basis for the Income Standard for Children Age Six through Age
Eighteen

Figure 6 : Section F

S30 – Infants and Children under Age 19 RU PRA Document
Version 1.0

3

08/18/2017

CMS XLC

1.7

G. Additional Information (optional)

G. Additional Information (optional)

Figure 7 : Section G

S30 – Infants and Children under Age 19 RU PRA Document
Version 1.0

4

08/18/2017