1 Infants and Children under Age 19 – Territories

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

Medicaid and CHIP Program (MACPro)
S30T - Infants and Children under Age 19 Territories RU PRA Document
Version 1.0
08/16/2017

Document Number: 191-QSSI-MACPro-R5.1-S30T-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S30T- Infants and Children under Age 19 - Territories Screenshots ..................................... 1
1.1
1.2
1.3
1.4
1.5

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

List of Figures
Figure 1: Package Header .............................................................................................. 1
Figure 2: Section A and Section B .................................................................................. 1
Figure 3: Section C and Section D .................................................................................. 2
Figure 4: Section E and Section F ................................................................................... 2
Figure 5: Section G ......................................................................................................... 3

List of Tables
No table of figures entries found.

S30T - Infants and Children under Age 19 - Territories RU PRA Document Version
1.0
i

08/16/2017

CMS XLC

Package Header

1. S30T- Infants and Children under Age 19 - Territories
Screenshots
1.1

Package Header

Figure 1: Package Header

1.2

A. Characteristics and B. Financial Methodologies

Figure 2: Section A and Section B

S30T - Infants and Children under Age 19 - Territories RU PRA Document Version
1.0
1

08/16/2017

CMS XLC

1.3

C. Income Standards Used and D. Basis for the Income Standard for Infants under Age 1

C. Income Standards Used and D. Basis for the Income Standard
for Infants under Age 1

Figure 3: Section C and Section D

1.4

E. Basis for the Income Standard for Children Age One through Age
Five and F. Basis for the Income Standard for Children Age Six
through Age Eighteen

Figure 4: Section E and Section F

S30T - Infants and Children under Age 19 - Territories RU PRA Document Version
1.0
2

08/16/2017

CMS XLC

1.5

G. Additional Information (optional)

G. Additional Information (optional)

Figure 5: Section G

S30T - Infants and Children under Age 19 - Territories RU PRA Document Version
1.0
3

08/16/2017