1 Children with Non IV-E Adoption Assistance

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

Medicaid and CHIP Program (MACPro)
S53 – Children with Non IV-E Adoption
Assistance RU PRA Document
Version 1.0
08/20/2017

Document Number: 236-QSSI-MACPro-R5.1-S53-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S53 - Children with Non IV-E Adoption Assistance 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

Package Header ............................................................................................. 1
A. Characteristics, B. Financial Methodologies, .............................................. 1
C. Individuals Covered – Path 1 ...................................................................... 2
C. Individuals Covered – Path 2 – Screenshot 1 ............................................. 2
C. Individuals Covered – Path 2 – Screenshot 2 ............................................. 3
D. Income Standard Used – Path 1 – Screenshot 1........................................ 3
D. Income Standard Used – Path 1 – Screenshot 2 – Path 1 ......................... 4
D. Income Standard Used – Path 1 – Screenshot 2 – Path 2 ......................... 4
D. Income Standard Used – Path 2................................................................. 5
Income Standard Used – Path 3 ..................................................................... 5
E. Basis for Income Standard - Maximum Income Standard ........................... 5
F. Additional Information (optional) ................................................................. 6

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

List of Tables
No table of figures entries found.

S53 – Children with Non IV-E Adoption Assistance RU PRA Document
Version 1.0
i

08/20/2017

CMS XLC

Package Header

1. S53 - Children with Non IV-E Adoption Assistance
Screenshots
1.1

Package Header

Figure 1: Package Header

1.2

A. Characteristics, B. Financial Methodologies,

Figure 2: Section A and Section B

S53 – Children with Non IV-E Adoption Assistance RU PRA Document
Version 1.0
1

08/20/2017

CMS XLC

1.3

C. Individuals Covered – Path 1

C. Individuals Covered – Path 1

Figure 3: Section C- Path 1

1.4

C. Individuals Covered – Path 2 – Screenshot 1

Figure 4 : Section C – Path 2 – Screenshot 1

S53 – Children with Non IV-E Adoption Assistance RU PRA Document
Version 1.0
2

08/20/2017

CMS XLC

1.5

C. Individuals Covered – Path 2 – Screenshot 2

C. Individuals Covered – Path 2 – Screenshot 2

Figure 5: Section C – Path 2 – Screenshot 2

1.6

D. Income Standard Used – Path 1 – Screenshot 1

Figure 6: Section D – Path 1 – Screenshot 1

S53 – Children with Non IV-E Adoption Assistance RU PRA Document
Version 1.0
3

08/20/2017

CMS XLC

1.7

D. Income Standard Used – Path 1 – Screenshot 2 – Path 1

D. Income Standard Used – Path 1 – Screenshot 2 – Path 1

Figure 7: Section D – Path 1 – Screenshot 2 – Path 1

1.8

D. Income Standard Used – Path 1 – Screenshot 2 – Path 2

Figure 8 : Section D – Path 1 – Screenshot 2 – Path 2

S53 – Children with Non IV-E Adoption Assistance RU PRA Document
Version 1.0
4

08/20/2017

CMS XLC

1.9

D. Income Standard Used – Path 2

D. Income Standard Used – Path 2

Figure 9: Section D – Path 2

1.10 Income Standard Used – Path 3

Figure 10: Section D – Path 3

1.11

E. Basis for Income Standard - Maximum Income Standard

Figure 11: Section E

S53 – Children with Non IV-E Adoption Assistance RU PRA Document
Version 1.0
5

08/20/2017

CMS XLC

F. Additional Information (optional)

1.12 F. Additional Information (optional)

Figure 12: Section F

S53 – Children with Non IV-E Adoption Assistance RU PRA Document
Version 1.0
6

08/20/2017