1 Independent Foster Care Adolescents

Medicaid and CHIP Program (MACPro) (CMS-10434)

QSSI-MACPro-PRA-S57

GenIC #15 (Transition from 0938-1148) - Medicaid State Plan Eligibility

OMB: 0938-1188

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1188 can be found here:
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Centers for Medicare & Medicaid
Services
CMS eXpedited Life Cycle (XLC)

Medicaid and CHIP Program (MACPro)
S57 – Independent Foster Care Adolescents RU
PRA Document
Version 1.0
08/18/2017

Document Number: 218-QSSI-MACPro-R5.1-S57-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S57 - Independent Foster Care Adolescents 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
1.18
1.19
1.20
1.21
1.22
1.23
1.24
1.25

Package Header ............................................................................................. 1
A. Characteristics, B. Financial Methodologies, .............................................. 1
C. Individuals Covered – Path 1 – Screenshot 1 ............................................. 2
D. Income Standard Used and E. Basis for Income Standard – Path 1 –
Screenshot 2 – Path 1 ..................................................................................... 2
D. Income Standard Used and E. Basis for Income Standard – Path 1 –
Screenshot 3 ................................................................................................... 3
D. Income Standard Used and E. Basis for Income Standard – Path 1 –
Screenshot 2 – Path 2 – Screenshot 1 ............................................................ 4
D. Income Standard Used and E. Basis for Income Standard – Path 1 –
Screenshot 2 – Path 2- Screenshot 2 ............................................................. 4
C. Individuals Covered – Path 2 – Screenshot 1 ............................................. 5
D. Income Standard Used and E. Basis for Income Standard – Path 2 –
Screenshot 2 – Path 1 ..................................................................................... 6
D. Income Standard Used and E. Basis for Income Standard – Path 2 –
Screenshot 3 ................................................................................................... 7
D. Income Standard Used and E. Basis for Income Standard – Path 2 –
Screenshot 2 – Path 2 – Screenshot 1 ............................................................ 8
D. Income Standard Used and E. Basis for Income Standard – Path 2 –
Screenshot 2 – Path 2 – Screenshot 2 ............................................................ 8
C. Individuals Covered– Path 3 – Screenshot 1 .............................................. 9
D. Income Standard Used and E. Basis for Income Standard – Path 3 –
Screenshot 2 – Path 1 ................................................................................... 10
D. Income Standard Used and E. Basis for Income Standard – Path 3 –
Screenshot 3 ................................................................................................. 11
D. Income Standard Used and E. Basis for Income Standard – Path 3 –
Screenshot 2 – Path 2 – Screenshot 1 .......................................................... 12
D. Income Standard Used and E. Basis for Income Standard – Path 3 –
Screenshot 2 – Path 2 – Screenshot 2 .......................................................... 13
D. Income Standard Used and E. Basis for Income Standard – Path 3 –
Screenshot 2 – Path 2 – Screenshot 3 .......................................................... 13
C. Individuals Covered– Path 4 – Screenshot 1 ............................................ 14
D. Income Standard Used and E. Basis for Income Standard – Path 4 –
Screenshot 2 – Path 1 ................................................................................... 14
D. Income Standard Used and E. Basis for Income Standard – Path 4 –
Screenshot 2 – Path 2 ................................................................................... 15
C. Individuals Covered– Path 5 – Screenshot 1 ............................................ 15
D. Income Standard Used and E. Basis for Income Standard – Path 5 –
Screenshot 2 – Path 1 ................................................................................... 16
1.21 D. Income Standard Used and E. Basis for Income Standard – Path 5 –
Screenshot 2 – Path 2 ................................................................................... 16
C. Individuals Covered– Path 6 – Screenshot 1 ............................................ 17

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1.26
1.27
1.28
1.29
1.30
1.31
1.32

List of Figures

D. Income Standard Used and E. Basis for Income Standard – Path 6 –
Screenshot 2 – Path 1 ................................................................................... 17
1.21 D. Income Standard Used and E. Basis for Income Standard – Path 6 –
Screenshot 2 – Path 2 ................................................................................... 18
C. Individuals Covered– Path 7 – Screenshot 1 ............................................ 18
D. Income Standard Used– Path 7 – Screenshot 2 – Path 1 ........................ 19
D. Income Standard Used – Path 7 – Screenshot 2 – Path 2 ....................... 19
E. Basis for Income Standard – Path 7 – Screenshot 3 ................................ 20
F. Additional Information (optional) ............................................................... 20

List of Figures
Figure 1: Package Header .............................................................................................. 1
Figure 2: Section A and Section B .................................................................................. 1
Figure 3: Section C – Path 1 – Screenshot 1 .................................................................. 2
Figure 4: Section D, Section E – Path 1 – Screenshot 2 – Path 1................................... 2
Figure 5: Section D, Section E – Path 1 – Screenshot 3 ................................................. 3
Figure 6: Section D, Section E – Path 1 – Screenshot 2 – Path 2 – Screenshot 1.......... 4
Figure 7: Section D, Section E – Path 1 – Screenshot 2 – Path 2- Screenshot 2 ........... 4
Figure 8: Section C– Path 2 – Screenshot 1 ................................................................... 5
Figure 9: Section D, Section E – Path 2 – Screenshot 2 – Path 1................................... 6
Figure 10: Section D, Section E – Path 2 – Screenshot 3 ............................................... 7
Figure 11: Section D, Section E – Path 2 – Screenshot 2 – Path 2 – Screenshot 1 ........ 8
Figure 12: Section D, Section E – Path 2 – Screenshot 2 – Path 2 – Screenshot 2 ........ 8
Figure 13: 1.13

Section C – Path 3 – Screenshot 1 .................................................... 9

Figure 14: Section D, Section E – Path 3 – Screenshot 2 – Path 1 ............................... 10
Figure 15: 1.15

Section D, Section E – Path 3 – Screenshot 3................................. 11

Figure 16: Section D, Section E – Path 3 – Screenshot 2 – Path 2 – Screenshot 1 ...... 12
Figure 17: Section D, Section E – Path 3 – Screenshot 2 – Path 2 – Screenshot 2 ...... 13
Figure 18: Section D, Section E – Path 3 – Screenshot 2 – Path 2 – Screenshot 3 ...... 13
Figure 19 : Section C– Path 4 – Screenshot 1 .............................................................. 14

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List of Tables

Figure 20 : Section D, Section E – Path 4 – Screenshot 2 – Path 1 .............................. 14
Figure 21: Section D, Section E – Path 4 – Screenshot 2 – Path 2 ............................... 15
Figure 22: Section C – Path 5 – Screenshot 1 .............................................................. 15
Figure 23 ....................................................................................................................... 16
Figure 24 : Section D, Section E – Path 5 – Screenshot 2 - Path 2 .............................. 16
Figure 25 : Section C– Path 6 – Screenshot 1 .............................................................. 17
Figure 26: Section D, Section E – Path 6 – Screenshot 2 - Path 1 ............................... 17
Figure 27: Section D, Section E – Path 6 – Screenshot 2 - Path 2 ............................... 18
Figure 28: Section C– Path 7 – Screenshot 1 ............................................................... 18
Figure 29: Section D, Section E – Path 7 – Screenshot 2 - Path 1 ............................... 19
Figure 30: Section D, Section E – Path 7 – Screenshot 2 - Path 2 ............................... 19
Figure 31: Section E ...................................................................................................... 20
Figure 32: Section F ...................................................................................................... 20

List of Tables
No table of figures entries found.

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Package Header

1. S57 - Independent Foster Care Adolescents
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 – Path 1 – Screenshot 1

C. Individuals Covered – Path 1 – Screenshot 1

Figure 3: Section C – Path 1 – Screenshot 1

1.4

D. Income Standard Used and E. Basis for Income Standard – Path
1 – Screenshot 2 – Path 1

Figure 4: Section D, Section E – Path 1 – Screenshot 2 – Path 1

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D. Income Standard Used and E. Basis for Income Standard – Path 1 – Screenshot 3

D. Income Standard Used and E. Basis for Income Standard – Path
1 – Screenshot 3

Figure 5: Section D, Section E – Path 1 – Screenshot 3

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1.6

D. Income Standard Used and E. Basis for Income Standard – Path 1 – Screenshot 2 – Path 2 – Screenshot 1

D. Income Standard Used and E. Basis for Income Standard – Path
1 – Screenshot 2 – Path 2 – Screenshot 1

Figure 6: Section D, Section E – Path 1 – Screenshot 2 – Path 2 – Screenshot 1

1.7

D. Income Standard Used and E. Basis for Income Standard – Path
1 – Screenshot 2 – Path 2- Screenshot 2

Figure 7: Section D, Section E – Path 1 – Screenshot 2 – Path 2- Screenshot 2

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1.8

C. Individuals Covered – Path 2 – Screenshot 1

C. Individuals Covered – Path 2 – Screenshot 1

Figure 8: Section C– Path 2 – Screenshot 1

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1.9

D. Income Standard Used and E. Basis for Income Standard – Path 2 – Screenshot 2 – Path 1

D. Income Standard Used and E. Basis for Income Standard – Path
2 – Screenshot 2 – Path 1

Figure 9: Section D, Section E – Path 2 – Screenshot 2 – Path 1

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D. Income Standard Used and E. Basis for Income Standard – Path 2 – Screenshot 3

1.10 D. Income Standard Used and E. Basis for Income Standard – Path
2 – Screenshot 3

Figure 10: Section D, Section E – Path 2 – Screenshot 3

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D. Income Standard Used and E. Basis for Income Standard – Path 2 – Screenshot 2 – Path 2 – Screenshot 1

1.11 D. Income Standard Used and E. Basis for Income Standard – Path
2 – Screenshot 2 – Path 2 – Screenshot 1

Figure 11: Section D, Section E – Path 2 – Screenshot 2 – Path 2 – Screenshot 1

1.12 D. Income Standard Used and E. Basis for Income Standard – Path
2 – Screenshot 2 – Path 2 – Screenshot 2

Figure 12: Section D, Section E – Path 2 – Screenshot 2 – Path 2 – Screenshot 2

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C. Individuals Covered– Path 3 – Screenshot 1

1.13 C. Individuals Covered– Path 3 – Screenshot 1

Figure 13: 1.13 Section C – Path 3 – Screenshot 1

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D. Income Standard Used and E. Basis for Income Standard – Path 3 – Screenshot 2 – Path 1

1.14 D. Income Standard Used and E. Basis for Income Standard – Path
3 – Screenshot 2 – Path 1

Figure 14: Section D, Section E – Path 3 – Screenshot 2 – Path 1

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D. Income Standard Used and E. Basis for Income Standard – Path 3 – Screenshot 3

1.15 D. Income Standard Used and E. Basis for Income Standard – Path
3 – Screenshot 3

Figure 15: 1.15 Section D, Section E – Path 3 – Screenshot 3

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D. Income Standard Used and E. Basis for Income Standard – Path 3 – Screenshot 2 – Path 2 – Screenshot 1

1.16 D. Income Standard Used and E. Basis for Income Standard – Path
3 – Screenshot 2 – Path 2 – Screenshot 1

Figure 16: Section D, Section E – Path 3 – Screenshot 2 – Path 2 – Screenshot 1

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D. Income Standard Used and E. Basis for Income Standard – Path 3 – Screenshot 2 – Path 2 – Screenshot 2

1.17 D. Income Standard Used and E. Basis for Income Standard – Path
3 – Screenshot 2 – Path 2 – Screenshot 2

Figure 17: Section D, Section E – Path 3 – Screenshot 2 – Path 2 – Screenshot 2

1.18 D. Income Standard Used and E. Basis for Income Standard – Path
3 – Screenshot 2 – Path 2 – Screenshot 3

Figure 18: Section D, Section E – Path 3 – Screenshot 2 – Path 2 – Screenshot 3

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C. Individuals Covered– Path 4 – Screenshot 1

1.19 C. Individuals Covered– Path 4 – Screenshot 1

Figure 19 : Section C– Path 4 – Screenshot 1

1.20 D. Income Standard Used and E. Basis for Income Standard – Path
4 – Screenshot 2 – Path 1

Figure 20 : Section D, Section E – Path 4 – Screenshot 2 – Path 1

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D. Income Standard Used and E. Basis for Income Standard – Path 4 – Screenshot 2 – Path 2

1.21 D. Income Standard Used and E. Basis for Income Standard – Path
4 – Screenshot 2 – Path 2

Figure 21: Section D, Section E – Path 4 – Screenshot 2 – Path 2

1.22 C. Individuals Covered– Path 5 – Screenshot 1

Figure 22: Section C – Path 5 – Screenshot 1

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D. Income Standard Used and E. Basis for Income Standard – Path 5 – Screenshot 2 – Path 1

1.23 D. Income Standard Used and E. Basis for Income Standard – Path
5 – Screenshot 2 – Path 1

Figure 23

1.24 1.21
D. Income Standard Used and E. Basis for Income
Standard – Path 5 – Screenshot 2 – Path 2

Figure 24 : Section D, Section E – Path 5 – Screenshot 2 - Path 2

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C. Individuals Covered– Path 6 – Screenshot 1

1.25 C. Individuals Covered– Path 6 – Screenshot 1

Figure 25 : Section C– Path 6 – Screenshot 1

1.26 D. Income Standard Used and E. Basis for Income Standard – Path
6 – Screenshot 2 – Path 1

Figure 26: Section D, Section E – Path 6 – Screenshot 2 - Path 1

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XLC

1.21
D. Income Standard Used and E. Basis for Income Standard – Path 6 – Screenshot 2 – Path 2

1.27 1.21
D. Income Standard Used and E. Basis for Income
Standard – Path 6 – Screenshot 2 – Path 2

Figure 27: Section D, Section E – Path 6 – Screenshot 2 - Path 2

1.28 C. Individuals Covered– Path 7 – Screenshot 1

Figure 28: Section C– Path 7 – Screenshot 1

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D. Income Standard Used– Path 7 – Screenshot 2 – Path 1

1.29 D. Income Standard Used– Path 7 – Screenshot 2 – Path 1

Figure 29: Section D, Section E – Path 7 – Screenshot 2 - Path 1

1.30 D. Income Standard Used – Path 7 – Screenshot 2 – Path 2

Figure 30: Section D, Section E – Path 7 – Screenshot 2 - Path 2

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E. Basis for Income Standard – Path 7 – Screenshot 3

1.31 E. Basis for Income Standard – Path 7 – Screenshot 3

Figure 31: Section E

1.32 F. Additional Information (optional)

Figure 32: Section F

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