1 Individuals above 133% FPL under Age 65

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

Medicaid and CHIP Program (MACPro)
S50 – Individuals above 133% FPL under Age 65
RU PRA Document
Version 1.0
08/18/2017

Document Number: 220-QSSI-MACPro-R5.1-S50-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S50 - Individuals above 133% FPL under Age 65 Screenshots ........................... 1
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
1.11
1.12
1.13
1.14
1.15
1.16
1.17

Package Header ............................................................................................. 1
A. Characteristics, B. Financial Methodologies, .............................................. 1
C. Individuals Covered .................................................................................... 2
D. Income Standard Used – Path 1................................................................. 2
D. Income Standard Used – Path 2................................................................. 2
D. Income Standard Used – Path 3 – Screenshot 1........................................ 3
D. Income Standard Used – Path 3 – Screenshot 2........................................ 3
E. Coverage of Dependent Children ............................................................... 4
F. Phase-In...................................................................................................... 4
F. Phase-In – Add or Edit Phase – Path 1 – Screenshot 1 ............................. 5
F. Phase-In – Add or Edit Phase – Path 1 – Screenshot 2 ............................. 5
F. Phase-In – Add or Edit Phase – Path 2....................................................... 6
F. Phase-In – Add or Edit Phase – Path 3....................................................... 6
F. Phase-In – Add or Edit Phase – Path 4....................................................... 7
F. Phase-In – Add or Edit Phase – Path 5....................................................... 7
F. Phase-In – Add or Edit Phase – Path 6....................................................... 8
G. Additional Information (optional) ................................................................. 8

List of Figures
Figure 1: Package Header .............................................................................................. 1
Figure 2: Section A and Section B .................................................................................. 1
Figure 3: Section C.......................................................................................................... 2
Figure 4: Section D – Path 1 ........................................................................................... 2
Figure 5: Section D – Path 2 ........................................................................................... 2
Figure 6: Section D – Path 3 – Screenshot 1 .................................................................. 3
Figure 7: Section D – Path 3 – Screenshot 2 .................................................................. 3
Figure 8: Section E .......................................................................................................... 4
Figure 9: Section F – Phase-In........................................................................................ 4
Figure 10 : Section F - Add or Edit Phase – Path 1 – Screenshot 1 ................................ 5
Figure 11 : Section F - Add or Edit Phase – Path 1 – Screenshot 2 ................................ 5
Figure 12: Section F - Add or Edit Phase – Path 2 .......................................................... 6

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List of Tables

Figure 13: Section F - Add or Edit Phase – Path 3 .......................................................... 6
Figure 14: Section F - Add or Edit Phase – Path 4 .......................................................... 7
Figure 15: Section F - Add or Edit Phase – Path 5 .......................................................... 7
Figure 16: Section F - Add or Edit Phase – Path 6 .......................................................... 8
Figure 17: Section G ....................................................................................................... 8

List of Tables
No table of figures entries found.

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Package Header

1. S50 - Individuals above 133% FPL under Age 65
Screenshots
1.1

Package Header

Figure 1: Package Header

1.2

A. Characteristics, B. Financial Methodologies,

Figure 2: Section A and Section B

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1.3

C. Individuals Covered

C. Individuals Covered

Figure 3: Section C

1.4

D. Income Standard Used – Path 1

Figure 4: Section D – Path 1

1.5

D. Income Standard Used – Path 2

Figure 5: Section D – Path 2
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1.6

D. Income Standard Used – Path 3 – Screenshot 1

D. Income Standard Used – Path 3 – Screenshot 1

Figure 6: Section D – Path 3 – Screenshot 1

1.7

D. Income Standard Used – Path 3 – Screenshot 2

Figure 7: Section D – Path 3 – Screenshot 2

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1.8

E. Coverage of Dependent Children

E. Coverage of Dependent Children

Figure 8: Section E

1.9

F. Phase-In

Figure 9: Section F – Phase-In

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F. Phase-In – Add or Edit Phase – Path 1 – Screenshot 1

1.10 F. Phase-In – Add or Edit Phase – Path 1 – Screenshot 1

Figure 10 : Section F - Add or Edit Phase – Path 1 – Screenshot 1

1.11 F. Phase-In – Add or Edit Phase – Path 1 – Screenshot 2

Figure 11 : Section F - Add or Edit Phase – Path 1 – Screenshot 2

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F. Phase-In – Add or Edit Phase – Path 2

1.12 F. Phase-In – Add or Edit Phase – Path 2

Figure 12: Section F - Add or Edit Phase – Path 2

1.13 F. Phase-In – Add or Edit Phase – Path 3

Figure 13: Section F - Add or Edit Phase – Path 3

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F. Phase-In – Add or Edit Phase – Path 4

1.14 F. Phase-In – Add or Edit Phase – Path 4

Figure 14: Section F - Add or Edit Phase – Path 4

1.15 F. Phase-In – Add or Edit Phase – Path 5

Figure 15: Section F - Add or Edit Phase – Path 5

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F. Phase-In – Add or Edit Phase – Path 6

1.16 F. Phase-In – Add or Edit Phase – Path 6

Figure 16: Section F - Add or Edit Phase – Path 6

1.17 G. Additional Information (optional)

Figure 17: Section G

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