Form CMS-10434 #2 CMS-10434 #2 CHIP State Plan Eligibility

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

#2 CHIP State Plan Eligibility Combined

GenIC #2 (Extension) - CHIP 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⚠️ Notice: This form may be outdated.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:

Document [pdf]

Download: pdf | pdf

Template CA1 – Program Type Designation
Statute: Sections 2101(a)(1); (a)(2) and (a)(3) of the SSA
Regulation: 42 CFR 457.70
INTRODUCTION
Template CA1 must be completed by all States with a CHIP program.
In this template, States provide information about the structure of their program.
BACKGROUND

Title XXI of the Social Security Act authorizes Federal grants to States for provision of
child health assistance to uninsured, low-income children. The program is jointly
financed by the Federal and State governments and administered by the States. States are
given three options for expanding coverage for children:
1. A separate child health insurance program;
2. A Medicaid expansion program; or
3. A combination of these programs.

Separate child health program means a program under which a State receives Federal
funding from its title XXI allotment to provide child health assistance through obtaining
coverage that meets the requirements of section 2103 of the Act and 42 CFR 457.402.
Medicaid expansion program means a program under which a state receives Federal
funding to expand Medicaid eligibility to optional targeted low-income children under
title XIX pursuant to 42 CFR 457.70(c).
TECHNICAL GUIDANCE
The State must select from one of the three options provided.
First Option
If the State selects ‘Coverage that meets the requirements for a separate child health
program as provided in section 2101(a)(1) of the SSA’, it must then select one of the
following options:
•

There is one program name for the State's separate child health program

•

There is one overarching program name, with individual names for groups or
components within the program

If the State selects ‘There is one program name for the State's separate child health
program’, it must then enter the program name in the text box provided.
If the State selects ‘There is one overarching program name, with individual names
for groups or components within the program’, it must first enter the name of the
program (i.e. overarching name), then enter the sub-group/component program name
and a description in the text boxes provided. For multiple entries, reselect ‘subgroup/component program name’ until all entries have been made.
Second Option
If the State selects ‘Expanded coverage under the State’s Medicaid plan utilizing Title
XXI funds as provided in section 2101(a)(2) of the SSA’, it must then select one of the
following options:
•

There is one program name for the State's Medicaid Expansion coverage

•

There is one overarching program name, with individual names for groups or
components within the program
If the State selects ‘There is one program name for the State's Medicaid
Expansion coverage’, it must first enter the program name in the text box
provided, then select one of the three options listed in the template.
o The program name applies to the all Medicaid children, including the
expansion group;
o The program name applies only to the CHIP Medicaid expansion program;
or
o Other Description. If selected, a description must be entered.
If the State selects ‘There is one overarching program name, with individual
names for groups or components within the program’, it must first enter the name
of the program (i.e. overarching name), then enter the sub-group/component
program name and a description in the text boxes provided. For multiple entries,
reselect ’sub-group/component program name’ until all entries have been made.

Third Option
If the State selects ‘Combination of both of the above as provided in section 2101(a)(3)
of the SSA’, it must then select one of the following options:
•

There is one overarching program name for both the separate child health
program and Medicaid expansion

•

There is one overarching program name for both the separate child health
program and Medicaid expansion, with individual names for groups or
components within the program

•

The separate child health program and Medicaid expansion each have a different
program name. There are no additional names for subgroups
If the State selects ‘There is one overarching program name for both the separate
child health program and Medicaid expansion’, it must then enter the name in the
text box provided.
If the State selects ‘There is one overarching program name for both the separate
child health program and Medicaid expansion, with individual names for groups
or components within the program’, it must first enter the name of the program
(i.e. overarching name) and then the individual program name and description in
the text boxes provided. For multiple entries, reselect ‘Individual program name’
until all entries have been made.
If the State selects ‘The separate child health program and Medicaid expansion
each have a different program name. There are no additional names for
subgroups’, it must then enter the name of the separate CHIP and the name of the
Medicaid expansion program in the text boxes provided.

Template CA2 – Designation and Authority
Statute:
Regulation: 42 CFR 457.40
INTRODUCTION
Template CA2 must be completed by all States with a CHIP program.
In this template, the State names the State agency authorized to administer and submit the
State Plan for the child health assistance program, and agrees to administer the program
in accordance with the provisions of the State Plan, the requirements of title XXI and
XIX (as appropriate) of the Act, and all applicable Federal regulations and other official
issuances.
BACKGROUND
A State must implement its program in accordance with the approved State plan, any
approved State plan amendments, the requirements of title XXI and title XIX (as
appropriate), and all applicable Federal regulations. CMS monitors the operation of the
approved State plan and plan amendments to ensure compliance.
The responsibility for the administration of child health assistance through an expansion
of Medicaid falls to the State agency having responsibility for the administration of the
Medicaid program. For the separate CHIP program, administrative responsibility may
also rest with the State’s Medicaid agency or with a different State agency.
TECHNICAL GUIDANCE
Following the introductory statement, this template contains the following sections:
Agency Type
Administrative Responsibility
Responsibility for Eligibility Determinations
Agency Type
PREREQUISITE: Template CA1 (Program Type Designation) must have been
completed before completing this section.
What gets displayed in this section of the template varies depending on the type of
program offered by the State (i.e. program type selected in CA1).
States with only a separate child health program
The name of the CHIP Agency is displayed at the top of this section and the State
must then select the agency type that corresponds to the Agency named above.
Only one option may be selected from the list provided.
1

If ‘Other’ is selected, the State must then enter the agency type in the text box
provided.
This is followed by a statement that the named agency (the CHIP agency name
will be prefilled here) is the State agency designated to administer or supervise
the administration of the Separate Children's Health Insurance Program (CHIP)
under title XXI of the Social Security Act. (All references in this plan to 'the
CHIP agency' mean the agency named as the State Agency administering CHIP.)
States with only a Medicaid expansion program
The name of the Medicaid Agency is displayed at the top of this section and the
State must then select the agency type that corresponds to the Agency named
above. Only one option may be selected from the list provided.
If ‘Other’ is selected, the State must then enter the agency type in the text box
provided.
This is followed by a statement that the named agency (the Medicaid agency
name will be prefilled here) is the State agency designated to administer or
supervise the administration of Expanded coverage under the State’s Medicaid
plan under Titles XIX and XXI of the Social Security Act. (All references in this
plan to 'the Medicaid agency' mean the agency named as the State Agency
administering Medicaid Expansion utilizing Title XXI funds.)
States with both a separate child health program and a Medicaid expansion
program
The State is asked to select one of the following options:
•

The Medicaid Agency for both the Medicaid Expansion and Separate
CHIP

•

The CHIP Agency for the Separate CHIP and the Medicaid Agency for the
Medicaid Expansion

If the State selects ‘The Medicaid Agency for both the Medicaid Expansion and
Separate CHIP’, the name of the Medicaid Agency is displayed and the State must
then select the agency type that corresponds to the agency named. Only one
option may be selected from the list provided.
If ‘Other’ is selected, the State must then enter the agency type in the text box
provided.

This is followed by a statement that the named agency (Medicaid agency name
will be prefilled here) is the State agency designated to administer or supervise
the administration of both the Expanded coverage under the State’s Medicaid plan
and the Separate CHIP program under Titles XIX and XXI of the Social Security
Act. (All references in this plan to 'the Medicaid Agency' mean the agency named
as the State Agency administering CHIP.)
If the State selects ‘The CHIP Agency for the Separate CHIP and the Medicaid
Agency for the Medicaid Expansion’, the name of the CHIP Agency is displayed
and the State must then select the agency type that corresponds to the agency
named. Only one option may be selected from the list provided.
If ‘Other’ is selected, the State must then enter the agency type in the text box
provided.
This is followed by a statement that the named agency (the CHIP Agency name
will be prefilled here) is the State agency designated to administer or supervise
the administration of the Separate Children's Health Insurance Program (CHIP)
under title XXI of the Social Security Act. (All references in this plan to 'the
CHIP agency' mean the agency named as the State Agency administering CHIP.)
Note: In this circumstance, it is not necessary to name the type of agency
responsible for the administration of the Medicaid Expansion program because
the State Plan submitted by the CHIP agency must also include completion of the
plan sections required of Medicaid expansion programs.
Administrative Responsibility
The state must select one of the two following options:
•

Administering the plan

•

Supervising the administration of the plan by local political subdivisions

If ‘Administering the plan’ is selected, the State must then enter the statutory citation for
the legal authority under which the agency administers the plan on a statewide basis, in
the text box provided.
If ‘Supervising the administration of the plan by local political subdivisions’ is selected,
the State must then enter the statutory citations for both the legal authority under which
the agency administers the plan on a statewide basis and under which the CHIP agency
has legal authority to make rules and regulations that are binding on the political
subdivisions administrating the plan in the text boxes provided.
PREREQUISITE: Template CA1 (Program Type Designation) and the Agency Type
section (above) must have been completed before completing the remainder of this
section.
3

The following question is displayed only for Separate CHIP or Combination States and
pertains to the separate CHIP program only:
A Y/N question is displayed for the State to indicate if the CHIP agency administers the
entire Separate CHIP program under title XXI. The name of the CHIP agency is prefilled
with the name of the agency entered in the Agency Type section above.
If the response is no, the State must name the agency which has responsibility for
administering a portion of the separate CHIP program and which will be submitting a
separate CHIP plan for that portion of the program. After entering the name of the
agency in the text box provided, the State must also indicate the type of agency by
selecting one of the options from the list provided.
The following subsection is displayed only for Medicaid Expansion and Combination
States and pertains only to Medicaid Expansion:
A Y/N question is displayed for the State to indicate if the Medicaid agency administers
the entire Medicaid Expansion program under title XXI. The name of the Medicaid
agency is prefilled with the name of the agency entered in the Agency Type section
above.
If the response is no, the State must name the agency which has responsibility for
administering a portion of the Medicaid Expansion program and which will be
submitting a separate CHIP plan for that portion of the program. After entering the name
of the agency in the text box provided, the State must also indicate the type of agency by
selecting one of the options from the list provided.
Responsibility for Eligibility Determinations
PREREQUISITE: Template CA1 (Program Type Designation) must have been
completed before completing this section. This section displays only for Separate CHIP
and Combination States and pertains to the separate CHIP program.
The state is asked to select the entity or entities that make determinations of eligibility for
the Separate CHIP program from the list of options provided.
If ‘A non-governmental organization’ is selected, the State must then enter the type of
organization and the name and address or the organization in the text boxes provided.

Template CA3 – Organization and Administration
Statute:
Regulation:
INTRODUCTION
Template CA3 must be completed by all States with a CHIP program.
In this template, the State provides a description of the organization and functions of the
CHIP agency and the staff making eligibility decisions for the separate CHIP program.
BACKGROUND

TECHNICAL GUIDANCE
There are two parts to template CA3.
In the first part, States must provide a description of the organization and functions of the
CHIP agency in the text box provided.
Review Criteria
The description should be sufficiently clear, detailed and complete to permit the
reviewer to determine that the State’s organizational structure provides adequate
support for the administration and operation of the State’s child health assistance
program.
Then the State must attach an organizational chart of the CHIP agency via the upload
function.
PREREQUISITE: Template CA2 (Designation and Authority) must have been completed
before completing the second part of the template. This part displays only for States
which indicated in CA2 (Designation and Authority) that eligibility decisions are made
by other than the CHIP agency or the CHIP agency plus other agencies.
States utilizing other entities to make CHIP eligibility decisions must provide a
description of the staff designated by those other agencies and the functions they perform
in carrying out their responsibility.
Review Criteria
The description should be sufficiently clear, detailed and complete to permit the
reviewer to determine that the staffing and the functions they provide adequately
support the determination of eligibility and related functions.

Template CA4 – CHIP State Plan Administration - Assurances
Statute: Title XXI of the Social Security Act
Regulation: 42 CFR 457
INTRODUCTION
Template CA4 must be completed by all States with a CHIP program.
In this template, the State provides assurances as to various administrative functions and
compliance with certain regulatory requirements.
BACKGROUND
States must indicate that they comply with certain statutory or regulatory provisions by
providing assurances to that effect in their State plans. Assurances required in this section
include:
•

That expenditures for child health assistance will not be claimed prior to the time
that the State has legislative authority to operate the State plan or plan amendment
as approved by CMS consistent with the requirements in 42 CFR 457.40(d).

•

That the State collects data, maintains records, and will furnish reports to the
Secretary, at the times and in the standardized format the Secretary may require to
enable the Secretary to monitor State program administration and compliance and
to evaluate and compare the effectiveness of State plans under Title XXI of the
Act consistent with the requirements in 42 CFR 457.720.

•

That eligibility standards, in the State’s plan do not discriminate on the basis of
diagnosis; that within a defined covered group, do not cover individuals of higher
income families without covering individuals with a lower family income and do
not deny eligibility based on an individual having a pre-existing medical
condition consistent with the requirements in 42 CFR 320(b)(1), (2) and (3).

•

That the State will comply with all applicable Federal laws and regulations,
including but not limited to Federal grant requirements and Federal reporting
requirements consistent with the requirements in 42 CFR 457.204.

•

That the State provides child health assistance to targeted low-income children in
the State who are Indians consistent with the requirements in 42 CFR 457.125(a)
(Section 2102(b)(3)(D)).

TECHNICAL GUIDANCE
In template CA4 the State is being asked to provide the assurances listed above.

The State provides these affirmative assurances by checking the boxes next to the
assurance statements. If the State does not check this box, the system will not accept this
template for review and approval.

Children’s Health Insurance Program (CHIP)
Implementation Guide for Release One: Administration
The following guide provides useful information for completion of the Administrative section in
release one of the CHIP state plan. The guide is intended to be used in conjunction with the state
plan screens and provides statutory and regulatory background in addition to guidance as to what
information is to be provided by the States and how to enter the requested information in the
system.
The guide includes the following sections:
Program Type Designation (CA1): For states to provide information about the structure of
their program.
Designation and Authority (CA2): For states to name the state agency authorized to administer
and submit the State Plan for the child health assistance program, and agreement to administer
the program in accordance with the provisions of the State Plan and statutory and regulatory
requirements.
Organization and Administration (CA3): To provide a description of the organization and
functions of the CHIP agency and the staff making eligibility decisions for the separate CHIP
program.
Assurances (CA4): To provide assurances as to various administrative functions and
compliance with certain regulatory requirements.

Children’s Health Insurance Program (CHIP)
Implementation Guide Introduction - CHIP Eligibility
The following guide provides useful information for completion of the eligibility section of the
CHIP state plan in the MACPro system. The guide is intended to be used in conjunction with the
state plan screens and provides statutory and regulatory background in addition to guidance as to
what information is to be provided by the States and how to enter the requested information in
the system.
This guide includes the following sections:
Medicaid Expansion (CS3): For states provide the qualifying ages for children and the income
eligibility standards the state uses for determining eligibility under its Medicaid expansion
program.
Separate CHIP Covered Groups (CS4): Displays a list of covered groups from which a state
can select those which it wants to include in its State Plan
Completion of Covered Groups (CS5): Used as a jumping off point for states to enter
eligibility information with respect to the covered groups for the State’s separate child health
assistance program.
Income Standards (CS6): Is displayed when needed for entry of age and income standards
within the templates for some of the covered groups
Targeted Low-Income Child (CS7): To provide information with regards to eligibility criteria
specific to this population group.
Targeted Low-Income Pregnant Women (CS8): To provide information with regards to
eligibility criteria, including income standards specific to this population group.
Coverage from Conception to Birth (CS9): To provide information with regards to eligibility
criteria, including income standards specific to this population group.
Children Who Have Access to Public Employee Coverage (CS10): To provide information
with regards to eligibility criteria, including income standards, specific to this population group.
Pregnant Women Who Have Access to Public Employee Coverage (CS11): To provide
information with regards to eligibility criteria, including income standards, specific to this
population group.
Dental Only Supplemental Coverage (CS12): To provide information with regards to
eligibility criteria, including income standards, specific to this population group.
Deemed Newborns (CS13): Describes the one-year coverage for infants born to targeted lowincome pregnant women.

Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards
(CS14): To provide assurance that separate CHIP coverage will be provided for children
ineligible for Medicaid as a result of the elimination of income disregards.
MAGI-Based Income Methodologies (CS15): To provide information with regards to criteria
used in the calculation of income for eligibility determination using MAGI-based income
methodologies.
Spenddown (CS16): For states to indicate whether they apply spenddown and if so, to provide
information as to their application of spenddown.
Residency (CS17): To provide information with regard to residency requirements.
Citizenship (CS18): To provide information with regard to citizenship and non-citizenship
requirements.
Social Security Number (CS19): To provide information with regard to social security number
requirements.
Substitution of Coverage (CS20): To provide information about the State’s policies and
procedures to prevent the substitution of group health coverage or other commercial health
insurance with public funded coverage.
Non-Payment of Premiums (CS21): To provide information about the State’s policies and
procedures with respect to non-payment of premiums.
Non-Financial Requirements (CS22): To provide assurances with respect to several nonfinancial eligibility requirements not covered in the other eligibility sections of the plan.
Other Eligibility Standards (CS23): Provides States with the opportunity to include additional
eligibility standards used in their State CHIP program.
General Eligibility-Eligibility Processing (CS24): To provide assurances and information with
respect to application and redetermination processing, eligibility screening and enrollment.
General Eligibility-Beginning Date of Eligibility (CS25): To provide information as to the
methodology used in determining the effective date of eligibility.
General Eligibility-Ending Dates of Eligibility (CS26): To provide information as to the
methodology used in determining the ending date of eligibility.
General Eligibility-Continuous Eligibility (CS27): To elect the option to provide continuous
eligibility (CE) coverage and if so, provide information as to the administration of continuous
eligibility.
General Eligibility–Presumptive Eligibility for Children (CS28): To elect the option to
provide presumptive eligibility (PE) for children and if so, provide information as to the
administration of presumptive eligibility.

General Eligibility–Presumptive Eligibility for Pregnant Women (CS29): To elect the option
to provide presumptive eligibility (PE) to pregnant women and if so, provide information as to
the administration of presumptive eligibility for pregnant women.
General Eligibility-List of Qualified Entities (CS30): For states which elected to provide
presumptive eligibility, to identify the types of organizations it uses as qualified entities.
General Eligibility-Express Lane Eligibility (CS32): To elect the option to use Express Lane
agencies to determine whether a child meets one or more of the requirements for CHIP eligibility
and if yes, provide information as to how Express Lane will be administered.
General Eligibility-Express Lane Agencies (CS33): For states which elected to use Express
Lane Eligibility, to designate which agencies will be used by the State as Express Lane
Agencies.
General Eligibility - Express Lane Eligibility Components (CS34): For states which elected
to use Express Lane Eligibility, to specify the eligibility components used by each Express Lane
Agency used by the State.

Template CS3 – Medicaid Expansion
Statute:
Section 2101(a)(2)
Regulation: 42 CFR 457.320(a)(2) and (3)
INTRODUCTION
To be completed only by States which have a Medicaid Expansion program.
In this template states provide the qualifying ages for children and the income eligibility
standards the state uses for determining eligibility under its Medicaid expansion program.
BACKGROUND
One of the options states have to provide child health assistance to uninsured, lowincome children using CHIP funding, is via an expansion of their Medicaid program.
States may choose to offer child health assistance solely under a Medicaid expansion
or in combination with coverage offered under a separate program.

Under this option states can expand coverage to children who do not qualify for
Medicaid under the State’s income rules in effect as of March 31, 1997. States
establish the qualifying income limits to be used under this option. All other
Medicaid rules under the State’s Medicaid plan apply.

The same financial requirements (income restrictions) applicable to a separate child
health program also apply to a Medicaid expansion.
This option applies only to targeted low-income children and cannot be used for coverage
of pregnant women.
TECHNICAL GUIDANCE
Template CS3 must be completed by states offering coverage to targeted low-income
children through an expansion of Medicaid or a combination of a Medicaid expansion
and separate CHIP. This template displays only for states with a Medicaid expansion
program.
States are asked to first provide the age range to which a qualifying income standard
applies and then to enter the income range that applies to that age range.
For age, the screen displays ‘From Age’ and ‘Up to Age’ fields with dropdown boxes of
a list of ages, zero through 19, from which the state can select.
Note to CMS: I need to confirm with Northrup Grumman as to whether they used zero or
birth and will revise accordingly.
Where income standards are requested, a grid is displayed with the following fields:

Two fields for age, labeled ‘From Age’ for the lower end of the age range and
‘Up to Age’ for the upper bound of the age range. States select the ages from a
dropdown list with values from 0 to 19.
Note: The ‘From Age’ includes the child’s birthday. The Up to Age
should be read as ‘up to be but not including’. That is, for example, up to
age 6 means until the child’s sixth birthday but not including the child’s
birthday.
Two fields for percentage of Federal poverty level (FPL) labeled ‘Above’ for the
lower end of the income standard and ‘Up to and including’ for the upper bound
of the income standard. The State enters in the FPL amounts in both fields.
Note: The ‘above’ amount does not equal the actual dollar amount
represented by the FPL percentage entered, but rather is equal to the dollar
amount plus one cent of the FPL percentage entered. However, ‘up to and
including’ is inclusive of the actual dollar amount represented by the FPL
percentage entered. Example: for income range of above 185% (dollar
value = $1,850) up to and including 250% (dollar value = $2,500), the
lower end equals $1,850.01 and the upper end equals $2,500 exactly). To
avoid gaps, after the State has entered in the first income standard, the
amount entered for the ‘above’ value for the subsequent income standard
should equal the previous ‘up to and including’.
The age and income grid may be completed in two ways:
1. By first entering in an age range and then the income range that applies to that age
range. This process would get repeated until all the age and income ranges are
entered, or
2.

Entering all the individual age ranges first. By doing this, a list of the ages gets
created on the left hand side of the grid. The income ranges would then be entered
in the columns next to each individual age range.

Age Validation 1: checks the first entry for ‘up to’ age to ensure that it does not equal
zero. If the validation fails, an error message is displayed and the state is given the
opportunity to correct.
Age validation 2: checks to make sure that the 'Up to' value is greater than the 'From'
value. If the validation fails, an error message is displayed and the state is given the
opportunity to correct.
Note: when selecting multiple age ranges, the second and subsequent ‘From Age’
field is auto-populated with the previous ‘Up to Age’ value. This eliminates gaps in
coverage by age group.
2

Once the State has entered the age range, the system will display income range fields. For
income ranges, the State must enter both the lower (above) and upper bounds (up to and
including) of the Federal Poverty Level percentages used for the qualifying income limit
for the age range entered.
Income validation 1: checks to make sure that the number entered for 'up to and
including ' is greater than that entered for 'above'. If the validation fails, entries must be
corrected.
Income validation 2: checks to make sure that the number entered for 'up to' is not
greater than 300. If a value of greater than 300% is entered, a message will display
stating ‘Upper limit cannot exceed 300% FPL’. If the error message displays, the State
must correct, the number entered in the ‘'up to and including ' field, before they can
proceed.
If the State uses different income standards for different ages, the State can select the
fields for the age ranges multiple times until all the age and income ranges used by the
State have been entered.

CS4 – Separate Child Health Insurance Program - Covered Groups
Statute:
2102
Regulation: 42 CFR 457
Additional References: SHO # 02-004 dated November 12, 2002, SHO # 09-006, dated
May 11, 2009, SHO # 09-009, dated August 31, 2009 and SHO # 09-010, dated
September 3, 2009.
INTRODUCTION
To be completed by states with a separate child health assistance program
Template CS4 displays a list of covered groups from which a state can select those which
it wants to include in its State Plan.
BACKGROUND
States may choose to provide coverage for targeted low-income children (TLIC); children
born to targeted low-income pregnant women during their first year of life (Deemed
Newborns); from conception to birth for TLIC; to targeted low-income pregnant women;
to targeted low-income children and pregnant women who have access to public
employee coverage; and dental-only supplemental coverage to children.
In 2014 and 2015 all states must provide coverage through a separate CHIP to children
who were enrolled in Medicaid as of December 31, 2013 and who were determined to be
ineligible for Medicaid as a result of the loss of income disregards at their first
redetermination using MAGI methodologies.
Uninsured, low-income children in families with income above the Medicaid limits are
the original group of individuals for whom CHIP was initially created. The definition of
Targeted low-income children can be found at 42 CFR 457.310.
The definition of child was revised in October 2002 to include from conception up to age
19. This revision gave states the option to provide coverage for prenatal care to uninsured
low-income pregnant women who are not eligible for Medicaid. This option is still
available to States although CHIPRA 2009 added a plan amendment option for states to
cover pregnant women.
CHIPRA added section 2112 of the SSA effective April 2009 to allow States to provide
pregnancy related assistance to uninsured pregnant women, referred to as targeted lowincome pregnant women (TLIPW). Prior to this time, some States provided coverage to
uninsured pregnant women either through an 1115 demonstration program or under the
CHIP State plan by providing coverage from conception to birth, as described above.
CHIPRA also added deemed eligibility for children born to targeted low- income
pregnant women receiving pregnancy-related assistance on the date of the child’s birth.
This group is referred to as ‘Deemed Newborns.’ Additional information for these
options may be found in SHO # 02-004 dated November 12, 2002, SHO # 09-006, dated
1

May 11, 2009, SHO # 09-009, dated August 31, 2009 and SHO # 09-010, dated
September 3, 2009.
CHIPRA also added paragraph (b)(5) to section 2110 of the SSA, giving states the option
to provide dental-only supplemental coverage to children who have health insurance
coverage through an employer but are uninsured or underinsured with respect to dental
coverage. Additional information for this optional coverage may be found in SHO #09012, dated October 7, 2009
The definition of a targeted low-income child was revised again in 2011 by the
Affordable Care Act (ACA) amending section 2110(b)(6) of the SSA. This change gives
States the option to offer CHIP eligibility to children of State employees who are
otherwise eligible, except for having access to public employee coverage, if certain
conditions are met. States that offer coverage to targeted low-income pregnant women
may also extend coverage to pregnant women under this option. Additional information
for these options may be found in SHO # 11-002, dated April 4, 2011.
The definition of targeted low-income child was revised again by the ACA to include
children enrolled in Medicaid on December 31, 2013, who lose Medicaid eligibility as a
result of the elimination of income disregards. States are required to provide separate
CHIP coverage to these children until the date of the child's next CHIP renewal.
TECHNICAL GUIDANCE
This section displays a list of covered groups. States select the group or groups which the
State elects to cover by placing a check next to the name of the group. Only the group
entitled Children Ineligible for Medicaid as a Result of the Elimination of Income
Disregards is pre-selected as all states must provide coverage to this group.
Validation: If the State selects ‘Pregnant Women Who Have Access to Public Employee
Coverage’, the system checks for whether or not ‘Targeted Low-Income Pregnant
Women’ was also selected by the CHIP Agency.
If the validation fails, that is the State checked ‘Pregnant Women Who Have Access to
Public Employee Coverage’ and they have not also checked ‘Targeted Low-Income
Pregnant Women,’ the following message will display:
‘This option cannot be selected unless the State also elects the option to
provide coverage to pregnant women as provided in Section 2112 of
the SSA.’
This template will not be accepted by the system if the validation fails and the State does
not correct by either selecting ‘Targeted Low-Income Pregnant Women’ or de-selecting
‘Pregnant Women Who Have Access to Public Employee Coverage’.

Validation: if Targeted Low-Income Pregnant Women is selected, the system checks for
whether or not ‘Deemed Newborns’ was also selected.
If the validation fails, that is the State checked Targeted Low-Income Pregnant Women,
but not ‘Deemed Newborns’ the following message will display:
‘Newborns of TLIPW are deemed approved for CHIP or Medicaid, as appropriate, and
the State must select the 'Deemed Newborns' covered group if also covering TLIPW. If
you wish to select TLIPW, you must first select Deemed Newborn.’
This template will not be accepted by the system if the validation fails and the State does
not correct by either selecting 'Deemed Newborns' or de-selecting ‘Targeted Low-Income
Pregnant Women’.

Template CS5 – Completion of Covered Groups
Statute: N. A.
Regulation: N. A.
INTRODUCTION
To be completed by States with Separate CHIP programs.
PREREQUISITE: States must complete the Separate CHIP Options template CS4 prior
to completing this template.
Template CS5 is used as a jumping off point for states to enter eligibility information
with respect to the covered groups for the State’s separate child health assistance
program. This is done for the initial submission of the plan and whenever a covered
group is added by the state. Based on the selections made in template CS5, states will
also need to complete the corresponding covered group templates (CS7 – CS14).
BACKGROUND
Section 2102(a)(5) of the SSA and 42 CFR 457.305(a) require the inclusion of eligibility
standards in the CHIP State Plan. This template allows access to the covered groups
templates for states to enter their state’s eligibility standards, with the exception of some
non-financial standards covered in other templates, for the groups covered by the State.
TECHNICAL GUIDANCE
This template displays a list of the covered groups selected by the CHIP Agency in
template CS4. The CHIP agency is asked to select one or more from this list which
require completion for the first time. The covered group templates corresponding to the
selection(s) made will display for completion.

Template CS6 – Income Standards
Statute: 2102(b)
Regulation: 42 CFR 457.320(a)(2) and (3)
Additional References: SHO # 10-005, dated March 2, 2010
INTRODUCTION
This template applies only to States with separate child health assistance programs.
This template is not accessed directly. It is displayed when needed for entry of age and
income standards within the templates for the following covered groups:
CS7 – Targeted Low-Income Child
CS10 - Children Who Have Access to Public Employee Coverage
CS12- Dental Only Supplemental Coverage
BACKGROUND
The State must specify eligibility standards used for its separate child health assistance
program, including age and income standards.
Please note: CHIPRA section 114 changed the applicable federal matching rate for
expenditures for child health assistance or health benefits coverage for a targeted low-income
child whose effective family income would exceed 300 percent of the FPL if not for the
application of a general exclusion of a block of income that is not determined by type of
expense or type of income. Instead of using the enhanced FMAP rate that would otherwise
apply for CHIP expenditures, the regular Medicaid FMAP rate as determined under section
1905(b) of the Act would apply. An exception was made for States that had existing authority
to cover children above 300 percent of the FPL as of the date of enactment of CHIPRA
(February 4, 2009). States qualifying for an exception may receive the enhanced FMAP rate
to provide coverage to children with family incomes above 300 percent of the FPL.

TECHNICAL GUIDANCE
Where income standards are requested, a grid is displayed with the following fields:
Two fields for age, labeled ‘From Age’ for the lower end of the age range and
‘Up to Age’ for the upper bound of the age range. States select the ages from a
dropdown list with values from 0 to 19.
Note: The ‘From Age’ includes the child’s birthday. The Up to Age
should be read as ‘up to be but not including’. That is, for example, up to
age 6 means until the child’s sixth birthday but not including the child’s
birthday.

Two fields for percentage of Federal poverty level (FPL) labeled ‘Above’ for the
lower end of the income standard and ‘Up to and including’ for the upper bound
of the income standard. The State enters in the FPL amounts in both fields.
Note: The ‘above’ amount does not equal the actual dollar amount
represented by the FPL percentage entered, but rather is equal to the dollar
amount plus one cent of the FPL percentage entered. However, ‘up to and
including’ is inclusive of the actual dollar amount represented by the FPL
percentage entered. Example: for income range of above 185% (dollar
value = $1,850) up to and including 250% (dollar value = $2,500), the
lower end equals $1,850.01 and the upper end equals $2,500 exactly). To
avoid gaps, after the State has entered in the first income standard, the
amount entered for the ‘above’ value for the subsequent income standard
should equal the previous ‘up to and including’.
The age and income grid may be completed in two ways:
•

By first entering in an age range and then the income range that applies to that age
range. This process would get repeated until all the age and income ranges are
entered, or

•

Note: After the first age range is entered, to enter more age ranges, click on the plus sign
in the left hand column of the grid.
Validation 1 for ages: first entry of 'up to age' cannot equal '0'. If the validation fails, i.e.
zero was entered as a value, an error message gets displayed and the State is given the
opportunity to correct.
Validation 2 for ages: 'up to' value to be greater than 'from' value. If the validation fails,
that is a lower number was entered for the upper bound than for the lower end of the age
range, an error message gets displayed and the State is given the opportunity to correct.
Validation 3 for ages: each time that an age range is entered, it is cross-checked to
previously entered age ranges to check for any overlap. If the cross-check finds that there
is an overlap, an error message is displayed and the State is asked to check one of two
options:
1. This was done in error. If the State checks this option, the State is given the
opportunity to correct.
2. This age group has more than one income standard. If the State checks this option,
the State must then enter an explanation. The explanation must include the reason
2

for having different income standards for children within the same age, the
individual ages that overlap and the income standards for the overlap ages.
With each entry of income levels, the State must answer the question ‘Does this equal the
highest income standard used for this age group in Medicaid?’ by selecting Y or N.
•

If the response is yes, an error message is displayed saying ‘Please note that the
lower bound for CHIP eligibility is the highest standard for Medicaid povertylevel children for this age group. Cannot proceed unless correction is made.’ and
the State is given the opportunity to correct.

Validation 1 for income standards: 'up to' value must be greater than 'above' value. If the
validation fails, that is a lower number was entered for the upper bound than for the lower
end of the income standard, an error message gets displayed and the State is given the
opportunity to correct.
Validation 2 for income standards: ‘above’ value cannot be greater than 300. If the
validation fails, a message saying that the upper limit cannot exceed 300% FPL gets
displayed and the State is given the opportunity to correct.

Template CS7 – Targeted Low-Income Child
Statute: 2102(b) of the SSA
Regulation: 42 CFR 457.310, 315 and 320
INTRODUCTION
This template applies only to States with separate child health assistance programs.
This template displays only for and must be completed by States which checked that they
elected the option to provide coverage to Targeted Low-Income Children in the Separate
CHIP Options template CS4.
In this template, States provide information with regards to eligibility criteria specific to
the targeted low-income child (TLIC) covered group. States are asked to provide income
standards used for this covered group and information regarding their program for
children with disabilities, if they have one.
BACKGROUND
Uninsured, low-income children in families with incomes too high to qualify for
Medicaid, but too low to be able to afford private coverage are the original group of
individuals for whom CHIP was initially created.
Section 2110(b) of the SSA and 42 CFR 457.310 provide the definition of TLIC,
including income standards, age, health insurance status and other non-financial
standards. Although this definition has been modified and expanded over the years, the
core group of eligibles continues to be the original group of uninsured low-income
children.
Many States adjust the qualifying income levels based on the age of the child, family
income and/or geographic area, such as counties.
TECHNICAL GUIDANCE
This template is broken down into the following sections:
Eligibility Determination Assurance
Age Standard
Income Standards
Special Program for Children with Disabilities
Eligibility Determination Assurance
Template CS7 begins with the CHIP Agency being asked to provide assurance that it
operates this eligibility group in accordance with the provisions that follow.

The State provides this affirmative assurance by checking the box next to the assurance
statement. If the State does not check this box, the system will not accept this template
for review and approval.
Age Standard
This section consists of a statement that the child’s age must be under 19. Since this age
standard is required of all States, it is pre-checked and does not require any action by the
CHIP Agency.
Income Standards
States are asked to provide the income standards used by the State to determine eligibility
for targeted low-income children, beginning with a Y/N question as to whether income
standards are applied statewide.
•

If the answer is yes, another Y/N question displays asking if there are any
exceptions, e.g. populations in a county which may qualify either under a
statewide income standard or a county income standard.
o If the answer to this second question is no, that is income standards are
statewide with no exceptions, a grid asking for age and income is
displayed for the CHIP Agency to complete. See guidance for Template
CS6 for instructions on completing the age and income standards grid.
o If the answer to this second question is yes, then the State must enter an
explanation which includes a description of the overlapping geographic
area and the reason for having different income standards. The State must
then enter both their statewide income standards (see guidance for CS6) as
well as income standards which vary by geography. See instructions
below for completion of geographic standards.
Review Criteria
The description should be sufficiently clear, detailed and complete to permit
the reviewer to determine that the State’s election meets applicable federal
statutory, regulatory and policy requirements.

•

Template CS6 for instructions on completing the age and income standards grid.
After the age and income standards grid is completed, the process of selecting
counties and completing the age and income grid standards grid is repeated until
all the counties have been selected.
After the county standards have been completed, a Y/N question is displayed,
asking if any cities within your State have their own separate income standards. If
the answer is yes, the CHIP Agency must enter in the name of the city. The age
and income standards screen is then displayed and must be completed for the city
entered. If there are multiple cities within the State with separate income
standards, the State may reselect the city name field and repeat the process until
all the cities have been entered. See guidance for Template CS6 for instructions
on completing the age and income standards grid.
Standard varies in some other geographic way
If ‘Standard varies in some other geographic way’ gets checked, the State is asked
to name and describe the geographic area. States may name multiple geographic
areas. The age and income standards screen is then displayed and must be
completed for each geographic name entered. If there are multiple geographic
areas within the State with separate income standards, the State may reselect the
name field and repeat the process until all the geographic areas have been entered.
See guidance for Template CS6 for instructions on completing the age and
income standards grid.
Special Program for Children with Disabilities
This section begins with a Y/N question as to whether the State has a special program for
children with disabilities.
•

If the answer is yes, another question gets displayed asking if the program is
available to all eligible targeted low-income children.
o If the answer is yes, the State is asked to provide a program description
consisting of two parts: disability criteria used and a description of the
program, including additional benefits offered.
Review Criteria
The description should be sufficiently clear, detailed and complete to permit
the reviewer to determine that the State’s election meets applicable federal
statutory, regulatory and policy requirements.
o It the answer is no, the State is asked to select none, one or both from the
following options:


The program is limited to certain age groups



The program is limited to TLIC under a certain income level
3

If the State selects that the program is limited to certain age groups is
selected, the State is then asked to provide the ages. Two fields are
displayed for age, labeled ‘From’ for the lower end of the age range
and ‘Up to’ for the upper bound of the age range. States select the ages
from a dropdown list with values the State entered above for ages for
TLIC.
Validation: Entries for ‘from’ age greater than or equal to’ Up to age’
will not be permitted. If this occurs, an error message is displayed and
the State is given the opportunity to correct.
If the State selects that the program is limited to TLIC under a certain
income level, the State is then asked to provide the income level. Two
fields for percentage of Federal poverty level (FPL) labeled ‘Above’
for the lower end of the income standard and ‘Up to and including’ for
the upper bound of the income standard. The State enters in the FPL
amounts in both fields.
This is followed by the State being asked to provide a program
description consisting of two parts: disability criteria used and a
description of the program, including additional benefits offered.
Review Criteria
The description should be sufficiently clear, detailed and complete to
permit the reviewer to determine that the State’s election meets
applicable federal statutory, regulatory and policy requirements.

Template CS8 – Targeted Low-Income Pregnant Women
Statute: Section 2112 of the SSA
Regulation:
Additional References: SHO # 09-006, dated May 11, 2009
INTRODUCTION
This template applies only to States with separate child health assistance programs.
This template displays only for and must be completed by States which checked that they
elected the option to provide coverage to Targeted Low-Income Pregnant Women in the
Separate CHIP Options template CS4.
In this template, states provide information with regards to eligibility criteria, including
income standards specific to the targeted low-income pregnant women (TLIPW) covered
group.
BACKGROUND
Section 2112 of the Social Security Act was added by section 111 of CHIPRA to give
States the option to provide healthcare coverage for necessary prenatal, delivery, and
postpartum care to low-income uninsured pregnant women through an amendment to
its State CHIP plan. Unlike prenatal coverage provided under the ‘coverage from
conception to birth’ covered group, under this option, the pregnant woman is eligible
for coverage, rather than the unborn child.

In order to cover pregnant women through the CHIP State plan option, States must meet
certain criteria:
•

Pregnant women must be covered under Medicaid up to the minimum income level
of 185% of the FPL.

•

The income level for targeted low-income pregnant women may not be higher than
for targeted low-income children.

•

States must cover children, under Medicaid, up to age 19 at an income level no
lower than 200% of the FPL.

•

The income level for pregnant women under CHIP cannot be lower than it is under
the State’s Medicaid program.

•

Higher income pregnant women cannot be covered without covering lower income
pregnant women.

Additional information may be found in SHO # 09-006, dated May 11, 2009
1

TECHNICAL GUIDANCE
This template is broken down into the following sections:
Eligibility Determination Assurance
Age Standard
Pregnancy Status
Income Standards
Eligibility Determination Assurance
Template CS8 begins with the State being asked to provide an assurance that it operates
this eligibility group in accordance with the provisions that follow.
The State provides this affirmative assurance by checking the box next to the assurance
statement. If the State does not check this box, the system will not accept this template
for review and approval.
Age Standard
In this section States are asked to provide information about the age standard they apply
to this group. The State may check either that it has no age restriction or if there are
restrictions, to provide the lower (from age) and upper end (up to) of that age range. An
explanation defining ‘from’ and ‘up to’ can be found in the income standards screen CS6.
Validation: Compares the 'from age' entered with the highest age entered for children. If
the 'from age' entered for TLIPW is less than the highest age entered for children, the
following message is displayed: ‘The 'from age' entered overlaps with the qualifying ages
for children’ and the State is asked to select one of the following options:
• This was done in error
• This is the correct age used by the State for targeted low-income women
If ‘this was done in error is selected, the State is given the opportunity to correct.
If the State selects that it is correct, the State is asked to describe how the determination is
made as to whether the applicant will be provided coverage as a child or as a pregnant
woman.
Review Criteria
The description should be sufficiently clear, detailed and complete to permit the
reviewer to determine that the State’s election meets applicable federal statutory,
regulatory and policy requirements.
Pregnancy Status
A statement is displayed saying that a woman must be pregnant or post-partum. Since
this criterion is required of all States, it is pre-checked and does not require any action by
the CHIP Agency.
Income Standards
2

In this section, States are asked to provide the income standards used by the State to
determine eligibility for targeted low-income women.
Validation: A check is done to ensure that income standards for children’s covered
groups are greater than or equal to 200%.
If the validation fails, a message is displayed saying that ‘Pregnant women coverage may
only be provided if children's qualifying income standards under the plan is at least up to
200% of FPL for all age ranges’. States must then select between two options:
•
•

Go back to targeted low income children screens for correction, or
De-select pregnant women coverage option

If ‘Go back to targeted low income children screens for correction’ is selected, the
system will display the income section for the children’s covered group(s) having
income standards lower than 200% of the FPL for the State to make the correction.
If ‘De-select pregnant women coverage option’ is selected, the system will display
the separate CHIP options template CS4 for the State to uncheck the targeted lowincome pregnant women option.
If the validation passes, a Y/N question displays asking whether income standards are
applied statewide.
•

If the answer is yes, another Y/N question displays asking if there are any
exceptions, e.g. populations in a county which may qualify either under a
statewide income standard or a county income standard.
o If the answer to this second question is no, that is, income standards are
statewide with no exceptions, the CHIP Agency enters the statewide
income standards.
Income Standards
Two fields are displayed for percentage of Federal poverty level (FPL)
labeled ‘Above’ for the lower end of the income standard and ‘Up to and
including’ for the upper bound of the income standard. The State enters
the FPL amounts in both fields.
Note: The ‘above’ amount does not equal the actual dollar amount
represented by the FPL percentage entered, but rather is equal to the dollar
amount plus one cent of the FPL percentage entered. However, ‘up to and
including’ is inclusive of the actual dollar amount represented by the FPL
percentage entered. Example: for income range of above 185% (dollar
value = $1,850) up to and including 250% (dollar value = $2,500), the
lower end equals $1,850.01 and the upper end equals $2,500 exactly).

Note: Each time that an income standard is entered, regardless of whether
it’s statewide or varies by county, city or other geographic area, series of
validations are conducted.
Validation 1: Checks if the 'above' value (lower end of the income
standard) is equal to or greater than 185% of the FPL.
If the validation fails, a message is displayed saying that ‘CHIP coverage
for pregnant women may only be provided if the qualifying income
standard under Medicaid for pregnant women is at least up to 185%’. And
the Agency is given the opportunity to correct. If the amount is not
corrected, pregnant women coverage will be deselected’. The CHIP
Agency must correct the amount in order to continue.
Validation 2: Checks to make sure that the value for 'up to' is greater than
the value for ‘above’.
If the validation fails, an error message is displayed and the CHIP Agency
is given the opportunity to correct.
Validation 3: Checks to make sure that value for 'up to' is greater than the
highest income level for children.
If the validation fails, a message is displayed and the CHIP Agency is
given the opportunity to correct.
o If the answer to this second question is yes, that is there are exceptions to
income standards being statewide, the State must then type in an
explanation which includes a description of the overlapping geographic
area and the reason for having different income standards. The State must
then enter both their statewide income standard (see instructions above) as
well as income standards which vary by geography. See instructions
below for completion of geographic standards.
Review Criteria
The description should be sufficiently clear, detailed and complete to permit
the reviewer to determine that the State’s election meets applicable federal
statutory, regulatory and policy requirements.
•

If ‘Standard varies by county or city’ gets checked, a dropdown list of counties is
displayed for selection. States should select all the counties having the same
standard at one time. Once a State has indicated that it has selected all the
counties having the same income standard, a grid asking for income information
is displayed for the CHIP Agency to complete. See above for instructions on
completing the income standards grid. After the income standards grid is
completed, the process of selecting counties and completing the income standards
grid is repeated until all the counties have been selected.
After the county standards have been completed, a Y/N question is displayed,
asking if any cities within your State have their own separate income standards. If
the answer is yes, the CHIP Agency must enter in the name of the city. The
income standards screen is then displayed and must be completed. If there are
multiple cities within the State with separate income standards, the State may
reselect the city name field and repeat the process until all the cities have been
entered.
Standard varies in some other geographic way
If ‘Standard varies in some other geographic way’ gets checked, the State is asked
to name and describe the geographic area. States may name multiple geographic
areas. The income standards screen is then displayed and must be completed for
each geographic name entered. If there are multiple geographic areas within the
State with separate income standards, the State may reselect the name field and
repeat the process until all the geographic areas have been entered. See above for
instructions on completing the income standards grid.

Template CS9 – Coverage from Conception to Birth
Statute: 2102(b) of the SSA
Regulation: 42 CFR 457.10
Additional Reference: SHO #02-004, dated November 12, 2002
INTRODUCTION
This template applies only to States with separate child health assistance programs.
Template CS9 displays only for and must be completed by States that elected the option
to provide coverage under the Coverage from Conception to Birth in the Separate CHIP
Options template CS4.
In this template, states provide information with regards to eligibility criteria, including
income standards specific to the ‘Coverage from Conception to Birth’ option.
BACKGROUND
In the interest of providing necessary prenatal care and other health services to children,
CMS promulgated a final rule on October 2, 2002 that revised the definition of “child” at
42 CFR 457.10 to clarify that “child” means an individual from conception up to age 19.
This definitional change provided States with the option to make children eligible for
coverage from conception to birth if other applicable state eligibility requirements are
met, regardless of the mother’s eligibility status. As part of the definition of targeted lowincome child, the conception to birth option is available in a separate CHIP under the
state plan.
This covered group is distinct from the option added by section 111 of CHIPRA, giving
States the option to provide coverage to uninsured, low-income pregnant women under
the CHIP plan (targeted low-income pregnant women). Under this option, the pregnant
woman is eligible for coverage, rather than her child. Therefore, states may elect both
options, at their discretion.
TECHNICAL GUIDANCE
This template is broken down into the following sections:
Eligibility Determination Assurance
Age Standard
Income Standards
Additional Assurances
Eligibility Determination Assurance
Template CS9 begins with the State being asked to provide an assurance that it operates
this eligibility group in accordance with the provisions that follow.
1

The State provides this affirmative assurance by checking the box next to the assurance
statement. If the State does not check this box, the system will not accept this template
for review and approval.
Age Standard
The age standard section begins with a statement of the age standard being from
conception through birth. This is followed by a Y/N question asking if the State has
additional age definition or other age-related conditions.
•

If the response if yes, the State is asked to provide a description of the additional
definition or age-related conditions. States have flexibility in establishing
eligibility guidelines, such as when coverage begins.
Review Criteria
The description should be sufficiently clear, detailed and complete to permit the
reviewer to determine that the State’s election meets applicable federal
statutory, regulatory and policy requirements.

Income Standards
The income standard section begins with a Y/N question as to whether income standards
are applied statewide.
•

If the answer is yes, another Y/N question displays asking if there are any
exceptions, e.g. populations in a county which may qualify either under a
statewide income standard or a county income standard.
o If the answer to this second question is no, that is income standards are
statewide with no exceptions, a field is displayed for the CHIP Agency to
enter the statewide income standard.
Income Standard
Since Medicaid does not provide coverage for this group, the lowest
income amount is zero. The CHIP Agency enters the upper income bound.
This amount is inclusive of the actual dollar amount represented by the
FPL percentage entered.
o If the answer to this second question is yes, that is there are exceptions to
income standards being statewide, the State must then enter an explanation
which includes a description of the overlapping geographic area and the
reason for having different income standards. The State must then enter
both their statewide income standard (see instructions above) as well as
income standards which vary by geography. See instructions below for
completion of geographic standards.
Review Criteria
2

If the answer to whether income standards are applied statewide is no, the State
must then select between two options:
o Standard varies by county or city, or
o Standard varies in some other geographic way
Standard varies by county or city
If ‘Standard varies by county or city’ gets checked, a dropdown list of counties is
displayed for selection. States should select all the counties having the same
standard at one time and then enter the income standard. See above for
instructions on completing the income standards. The process of selecting
counties and entering the income standards is repeated until all the counties have
been selected.
Validation: ‘above’ value cannot be greater than 300. If the validation fails, a
message saying that the upper limit cannot exceed 300% FPL gets displayed and
the State is given the opportunity to correct.
After the county standards have been completed, a Y/N question is displayed,
asking if have any cities within your State have their own separate income
standards. If the answer is yes, the CHIP Agency must enter the name of the city
and its income standard. If there are multiple cities within the State with separate
income standards, the State may add more fields and repeat the process until all
the cities have been entered. See above for instructions on completing the income
standards.
Validation: ‘above’ value cannot be greater than 300. If the validation fails, a
message saying that the upper limit cannot exceed 300% FPL gets displayed and
the State is given the opportunity to correct.
Standard varies in some other geographic way
If ‘Standard varies in some other geographic way’ gets checked, a geographic
area grid is displayed. The State is asked to name and describe the geographic
area and enter the income standard for the area. If there are multiple geographic
areas within the State with separate income standards, the State may reselect the
name field and repeat the process until all the geographic areas have been entered.
See above for instructions on completing the income standards.
Validation: ‘above’ value cannot be greater than 300. If the validation fails, a
message saying that the upper limit cannot exceed 300% FPL gets displayed and
the State is given the opportunity to correct.

Additional Assurances
The bottom of the template contains two assurances from the State. The State provides
these affirmative assurances by checking the boxes next to assurance statement. If the
State does not check this box, the system will not accept this template for review and
approval.

Template CS10 – Children Who Have Access to Public Employee Coverage
Statute: Sec. 2110(b)(2)(B) and (b)(6) of the SSA
Regulation:
Additional References: SHO # 11-002, dated April 4, 2011
INTRODUCTION
This template applies only to States with separate child health assistance programs.
Template CS10 displays only for and must be completed by States that elected the option
to provide coverage to Children Who Have Access to Public Employee Coverage in the
Separate CHIP Options template CS4.
In this template, states provide information with regards to eligibility criteria, including
income standards, specific to this population group.
BACKGROUND
Prior to passage of the Affordable Care Act, section 2110(b) of the Social Security Act
excluded from eligibility CHIP children who are eligible for State employee health
benefits plan.
An individual is considered eligible for health benefits coverage under a State health
benefits plan if a more than nominal contribution to the cost of health benefits coverage
under a State health benefits plan is available from the State or public agency. A
contribution is considered more than nominal if the State or public agency makes a
contribution toward the cost of an employee's dependent(s) that is $10 per family, per
month, more than the State or public agency's contribution toward the cost of covering
the employee only.
In response to concerns raised that some children of State employees did not have access
to comprehensive, affordable coverage, the definition of a targeted low-income child in
section 2110(b)(2)(B) of the Act was amended by the ACA by permitting States to extend
CHIP eligibility to children of State employees if one of two conditions is met:
Maintenance of Agency Contribution Condition
For this condition to be met, States must demonstrate that they have been consistently
contributing to the cost of employee coverage, with increases for inflation, since 1997.
This condition is met when the public agency expenditures for health coverage for
employees that have dependent coverage is not less than the amount of such expenditures
in the 1997 State fiscal year, increased by the percentage increase of the medical care
expenditure category of the Consumer Price Index.

This does not require a case-by-case determination but can be calculated on an average basis
for each public agency or it can be done in the aggregate for all multiple agencies having the
same contribution rate structures.
Hardship Condition

For this condition to be met, States must demonstrate that the coverage currently
available through the public employee system poses a financial hardship for families. In
making a hardship determination, States would assess whether the annual aggregate
premiums and cost-sharing imposed by the State health benefits plan would exceed 5
percent of a family’s income during the year the child would be enrolled in CHIP.
State Plan Option
States may offer this option to a subset of their CHIP eligible population. For example,
States may limit coverage under this option to children in families with family income
under 250% of the FPL although coverage for targeted low-income children is offered up
to 300% of the FPL. States also have the option of limiting coverage under this option to
certain public agencies.
The State may also choose to apply one of the conditions to a subset of their CHIP
eligible population and the other to a different subset.
Additional information may be found in SHO # 11-002, dated April4, 2011.
Note: If States have questions or need technical assistance regarding the methodology
for expanding CHIP to children who have access to public employee coverage, the CMS
project officer may provide guidance.
TECHNICAL GUIDANCE
This template is broken down into the following sections:
Eligibility Determination Assurance
Selection of Condition/Criteria
Exclusion Assurance
Eligibility Determination Assurance
Template CS10 begins with the CHIP Agency being asked to provide assurance that it
determines eligibility for this group in accordance with the provisions that follow.
The State provides this affirmative assurance by checking the box next to the assurance
statement. If the State does not check this box, the system will not accept this template
for review and approval.
Selection of Condition/Criteria
The State is then asked to select one of the following two options:
2

•

Maintenance of agency contribution as provided in 2110(b)(6)(B) of the SSA

•

Hardship criteria as provided in section 2110(b)(6)(C) of the Social Security Act

For each option selected, States are asked to provide household income standards and to
identify the population(s) to whom that option is offered.
Household Income
States are asked to choose between one of two options:
•

The same as the standards for Targeted Low Income Children

•

Lower than the income standards for Targeted Low Income Children

If the State selects ‘The same as the standards for Targeted Low Income
Children’, the system will assign the standards to this group that the CHIP
Agency entered for TLIC and no additional entries need to be made by the
Agency
If the State selects ‘Lower than the income standards for Targeted Low Income
Children’, the system displays a Y/N question as to whether income standards are
applied statewide.
•

If the answer is yes, another Y/N question displays asking if there are any
exceptions, e.g. populations in a county which may qualify either under a
statewide income standard or a county income standard.
o If the answer to this second question is no, that is income standards are
statewide with no exceptions, a grid asking for age and income is
displayed for the CHIP Agency to complete. See guidance for Template
CS6 for instructions on completing the age and income standards grid.
Validation: the system will cross check each FPL range entered against FPL
standards for TLIC children of the same age to ensure that the upper end of
the income standard does not exceed that of TLIC of the same age.
If the validation fails, an error message gets displayed and the Agency is given
the opportunity to correct.
o If the answer to this second question is yes, then the State must type in an
explanation which includes a description of the overlapping geographic
area and the reason for having different income standards.
Review Criteria

The description should be sufficiently clear, detailed and complete to
permit the reviewer to determine that the State’s election meets
applicable federal statutory, regulatory and policy requirements.
o The State must then enter both their statewide income standards (see
guidance for CS6) as well as income standards which vary by geography.
See instructions below for completion of geographic standards.
Validation: the system will cross check each FPL range entered against FPL
standards for TLIC children of the same age to ensure that the upper end of
the income standard does not exceed that of TLIC of the same age.
If the validation fails, an error message gets displayed and the Agency is given
the opportunity to correct.
•

If the answer to whether income standards are applied statewide is no, the State
must then select between two options:
o Standard varies by county or city, or
o Standard varies in some other geographic way
Standard varies by county or city
If ‘Standard varies by county or city’ gets checked, a dropdown list of counties is
displayed for selection. States should select all the counties having the same
standards at one time. Once a State has indicated that it has selected all the
counties having the same income standards, a grid asking for age and income
information is displayed for the CHIP Agency to complete. See guidance for
Template CS6 for instructions on completing the age and income standards grid.
After the age and income standards grid is completed, the process of selecting
counties and completing the age and income grid standards grid is repeated until
all the counties have been selected.
Validation: the system will cross check each FPL range entered against FPL
standards for TLIC children of the same age to ensure that the upper end of the
income standard does not exceed that of TLIC of the same age.
If the validation fails, an error message gets displayed and the Agency is given the
opportunity to correct.
After the county standards have been completed, a Y/N question is displayed,
asking if have any cities within your State have their own separate income
standards. If the answer is yes, the CHIP Agency must enter in the name of the
city. The age and income standards screen is then displayed and must be
completed for each city named. If there are multiple cities within the State with
separate income standards, the State may reselect the city name field and repeat

the process until all the cities have been entered. See guidance for Template CS6
for instructions on completing the age and income standards grid.
Validation: the system will cross check each FPL range entered against FPL
standards for TLIC children of the same age to ensure that the upper end of the
income standard does not exceed that of TLIC of the same age.
If the validation fails, an error message gets displayed and the Agency is given the
opportunity to correct.
Standard varies in some other geographic way
If ‘Standard varies in some other geographic way’ gets checked, the State is asked
to name and describe the geographic area. States may name multiple geographic
areas. The age and income standards screen is then displayed and must be
completed for each geographic name entered. If there are multiple geographic
areas within the State with separate income standards, the State may reselect the
name field and repeat the process until all the geographic areas have been entered.
See guidance for Template CS6 for instructions on completing the age and
income standards grid.
Validation: the system will cross check each FPL range entered against FPL
standards for TLIC children of the same age to ensure that the upper end of the
income standard does not exceed that of TLIC of the same age.
If the validation fails, an error message gets displayed and the Agency is given the
opportunity to correct.
Population(s) to Whom this Option is Offered
States are asked to indicate the population(s) offered this option by checking one
of the following options:
•

All children who have access to public employee coverage

•

Children of employees of certain public agencies

•

Children of certain types of public employees

If the State selects ‘Children of employees of certain public agencies’, the State
then enters the type of agency. If more than one agency, the State can re-select the
‘type of agency’ field until all the State agencies have been entered.
If the State selects Children of certain types of public employees, the State is
asked to describe the type of public employees. If more than one type of public
employees, the State can re-select the ‘describe type of public employee’ field
until all the types of public employees have been entered.

Review Criteria
The description should be sufficiently clear, detailed and complete to permit the
reviewer to determine that the State’s election meets applicable federal
statutory, regulatory and policy requirements.
After the State has completed the income and population sections it must attach a
copy of the documentation demonstrating that the State meets the conditions
specific to that option:
Review Criteria
For maintenance of effort, the documentation should include the methodology
the State used to calculate the maintenance of agency contribution. The
documentation should be sufficiently clear, detailed and complete to permit the
reviewer to determine that the State’s election meets applicable federal
statutory, regulatory and policy requirements.
For technical assistance in developing the methodology, please contact CMS.
The State is then asked to provide assurance that it will, on an annual basis,
recalculate expenditures for each participating public agency to determine if the
maintenance of effort condition continues to be met.

Review Criteria
For hardship, the documentation should include the methodology the State
used to calculate the financial hardship. The documentation should be
sufficiently clear, detailed and complete to permit the reviewer to determine that
the State’s election meets applicable federal statutory, regulatory and policy
requirements.
For technical assistance in developing the methodology, please contact CMS.

The State is then asked to provide assurance that it will, on an annual basis,
recalculate the financial status to determine if the hardship condition continues to
be met.
Under each option, the State is also asked to provide another more general
assurance that children considered to have access to public employee coverage,
and therefore not excluded from CHIP through this option, meet the definition
provided at 457.310(c )(1).
The State provides these affirmative assurances by checking the box next to each
assurance statement. If the State does not check this box, the system will not
accept this template for review and approval.
Exclusion Assurance

If the State does not cover all children of public employees, i.e. the State selected either
children of employees of certain public agencies or children of certain types of public
employees, an additional assurance will display. Here, the Agency assures that ‘Children
who are eligible for public employee health benefits coverage who are not described
above are excluded from eligibility under the plan’.

Template CS11 – Pregnant Women Who Have Access to Public Employee Coverage
Statute: Sec. 2110(b)(2)(B) and (b)(6) of the SSA
Regulation:
Additional References: SHO # 11-002, dated April4, 2011
INTRODUCTION
This template applies only to States with separate child health assistance programs.
Template CS11 displays only for and must be completed by States that elected the option
to provide coverage to Pregnant Women Who Have Access to Public Employee
Coverage (PWAPEC) in the Separate CHIP Options template CS4.
In this template, states provide information with regards to eligibility criteria, including
income standards, specific to this population group.
BACKGROUND
Prior to passage of the Affordable Care Act, section 2110(b) of the Social Security Act
excluded from eligibility CHIP children who were eligible for State employee health
benefits plan. This exclusion also applied to pregnant women.
An individual is considered eligible for health benefits coverage under a State health
benefits plan if a more than nominal contribution to the cost of health benefits coverage
under a State health benefits plan is available from the State or public agency. A
contribution is considered more than nominal if the State or public agency makes a
contribution toward the cost of an employee's dependent(s) that is $10 per family, per
month, more than the State or public agency's contribution toward the cost of covering
the employee only.
In response to concerns raised that some children of State employees did not have access
to comprehensive, affordable coverage, the definition of a targeted low-income child in
section 2110(b)(2)(B) of the Act was amended by the ACA by permitting States to extend
CHIP eligibility to children of State employees. This option was also extended to
pregnant women.
The conditions which must be met for pregnant women to qualify for this option are the
same as those for children. One of the following conditions must be met.
Maintenance of Agency Contribution Condition
For this condition to be met, States must demonstrate that they have been consistently
contributing to the cost of employee coverage, with increases for inflation, since 1997.
This condition is met when the public agency expenditures for health coverage for
employees that have dependent coverage is not less than the amount of such expenditures
1

in the 1997 State fiscal year, increased by the percentage increase of the medical care
expenditure category of the Consumer Price Index.
This does not require a case-by-case determination but can be calculated on an average basis
for each public agency or it can be done in the aggregate for all multiple agencies having the
same contribution rate structures.
Hardship Condition

For this condition to be met, States must demonstrate that the coverage currently
available through the public employee system poses a financial hardship for families. In
making a hardship determination, States would assess whether the annual aggregate
premiums and cost-sharing imposed by the State health benefits plan would exceed 5
percent of a family’s income during the time period the pregnant woman would be
enrolled in CHIP.
State Plan Option
States may offer this option to a subset of their CHIP eligible population. For example,
States may limit coverage under this option to pregnant women in families with family
income under 250% of the FPL although coverage for targeted low-income pregnant
women is offered up to 300% of the FPL. States also have the option of limiting coverage
under this option to certain public agencies.
The State may also choose to apply one of the conditions to a subset of their CHIP
eligible population and the other to a different subset.
Additional information may be found in SHO # 11-002, dated April 4, 2011.
Note: If States have questions or need technical assistance regarding the methodology
for expanding CHIP to children who have access to public employee coverage, the CMS
project officer may provide guidance.
TECHNICAL GUIDANCE
This template is broken down into the following sections:
Eligibility Determination Assurance
Selection of Condition/Criteria
Age Standards
Pregnancy Status
Additional Assurances
Eligibility Determination Assurance
Template CS11 begins with the CHIP Agency being asked to provide assurance that it
determines eligibility for this group in accordance with the provisions that follow.

Maintenance of agency contribution as provided in 2110(b)(6)(B) of the SSA

• Hardship criteria as provided in section 2110(b)(6)(C) of the Social Security Act
For each option selected, States are asked to provide household income standards and
to identify the population(s) to whom that option is offered.
Household Income
States are asked to choose between one of two options:
•

The same as the standards for Targeted Low Income Pregnant Women

•

Lower than the income standards for Targeted Low Income Pregnant Women

If the State selects ‘The same as the standards for Targeted Low Income Pregnant
Women’, the system will assign the standards to this group that the CHIP Agency
entered for TLIPW and no additional entries need to be made by the State.
If the State selects ‘Lower than the income standards for Targeted Low Income
Pregnant Women’, the system displays a Y/N question as to whether income
standards are applied statewide.
•

If the answer is yes, another Y/N question displays asking if there are any
exceptions, e.g. populations in a county which may qualify either under a
statewide income standard or a county income standard.
o If the answer to this second question is no, that is income standards are
statewide with no exceptions, a grid is displayed for the CHIP Agency
to enter the statewide income standards.
Income Standards Grid
The grid contains two fields for percentage of Federal poverty level (FPL)
labeled ‘Above’ for the lower end of the income standard and ‘Up to and
including’ for the upper bound of the income standard. The State enters
the FPL amounts in both fields.
Note: The ‘above’ amount does not equal the actual dollar amount
represented by the FPL percentage entered, but rather is equal to the dollar
amount plus one cent of the FPL percentage entered. However, ‘up to and
3

including’ is inclusive of the actual dollar amount represented by the FPL
percentage entered. Example: for income range of above 185% (dollar
value = $1,850) up to and including 250% (dollar value = $2,500), the
lower end equals $1,850.01 and the upper end equals $2,500 exactly).
o If the answer to this second question is yes, that is there are exceptions
to income standards being statewide, the State must then type in an
explanation which includes a description of the overlapping
geographic area and the reason for having different income standards.
Review Criteria
The description should be sufficiently clear, detailed and complete to
permit the reviewer to determine that the State’s election meets
applicable federal statutory, regulatory and policy requirements.
o The State must then enter both their statewide income standard (see
instructions above) as well as income standards which vary by
geography. See instructions below for completion of geographic
standards.
Validation: the system will cross check the FPL range entered against FPL
standards for TLIPW to ensure that the upper end of the income standard does
not exceed that of TLIPW.
If the validation fails, an error message gets displayed and the Agency is given the
opportunity to correct.
•

Standard varies by county or city
If ‘Standard varies by county or city’ gets checked, a dropdown list of counties is
displayed for selection. States should select all the counties having the same
standard at one time. Once a State has indicated that it has selected all the
counties having the same income standard, a grid asking for income information
is displayed for the CHIP Agency to complete. See above for instructions on
completing the income standards grid. After the income standards grid is
completed, the process of selecting counties and completing the income standards
grid is repeated until all the counties have been selected.
Validation: the system will cross check each FPL range entered against FPL
standards for TLIPW to ensure that the upper end of the income standard does
not exceed that of TLIPW.
4

If the validation fails, an error message gets displayed and the Agency is given the
opportunity to correct.
After the county standards have been completed, a Y/N question is displayed,
asking if have any cities within your State have their own separate income
standards. If the answer is yes, the CHIP Agency must enter in the name of the
city. The State must then enter their statewide income standard (see instructions
above) for the city entered. If there are multiple cities within the State with
separate income standards, the State may reselect the city name field and repeat
the process until all the cities have been entered.
Validation: the system will cross check each FPL range entered against FPL
standards for TLIPW to ensure that the upper end of the income standard does
not exceed that of TLIPW.
If the validation fails, an error message gets displayed and the Agency is given the
opportunity to correct.
Standard varies in some other geographic way
If ‘Standard varies in some other geographic way’ gets checked, the State is asked
to name and describe the geographic area. States may name multiple geographic
areas. The State must then enter their statewide income standard (see instructions
above) for the geographic area(s) entered. If there are multiple geographic areas
within the State with separate income standards, the State may reselect the name
field and repeat the process until all the geographic areas have been entered.
Validation: the system will cross check each FPL range entered against FPL
standards for TLIPW to ensure that the upper end of the income standard does
not exceed that of TLIPW.
If the validation fails, an error message gets displayed and the State is given the
opportunity to correct.
Population(s) to Whom this Option is Offered
States are asked to indicate the population(s) offered this option by checking one
of the following options:
•

All pregnant women who have access to public employee coverage.

•

Pregnant women who are employees or dependents of employees, limited
to certain public agencies.

•

Pregnant women who are employees or dependents of employees, limited
to certain types of public employees or are dependents of certain types of
public employees.
5

If the State selects ‘Pregnant women who are employees or dependents of
employees, limited to certain public agencies’, the State then enters the type of
agency. If more than one agency, the State can re-select the ‘type of agency’ field
until all the State agencies have been entered.
•

If the State selects ‘Pregnant women who are employees or dependents of
employees, limited to certain types of public employees or are dependents of
certain types of public employees’, the State is asked to describe the type of
public employees. If more than one type of public employees, the State can reselect the ‘describe type of public employee’ field until all the types of public
employees have been entered.

Review Criteria
The description should be sufficiently clear, detailed and complete to permit the
reviewer to determine that the State’s election meets applicable federal
statutory, regulatory and policy requirements.
After the State has completed the income and population sections it must attach a copy of
the documentation demonstrating that the State meets the conditions specific to that
option.
Review Criteria
For maintenance of effort, the documentation should include the methodology the
State used to calculate the maintenance of agency contribution. The documentation
should be sufficiently clear, detailed and complete to permit the reviewer to determine
that the State’s election meets applicable federal statutory, regulatory and policy
requirements.
For technical assistance in developing the methodology, please contact CMS.

The State is then asked to provide assurance that it will, on an annual basis, recalculate
expenditures for each participating public agency to determine if the maintenance of
effort condition continues to be met.
The State provides this affirmative assurance by checking the box next to the assurance
statement. If the State does not check this box, the system will not accept this template
for review and approval.
Review Criteria
For hardship, the documentation should include the methodology the State used to
calculate the financial hardship. The documentation should be sufficiently clear,
detailed and complete to permit the reviewer to determine that the State’s election
meets applicable federal statutory, regulatory and policy requirements.
For technical assistance in developing the methodology, please contact CMS.
6

The State is then asked to provide assurance that it will, on an annual basis, recalculate
the financial status to determine if the hardship condition continues to be met.
The State provides this affirmative assurance by checking the box next to the assurance
statement. If the State does not check this box, the system will not accept this template
for review and approval.
Age Standard
In this section, the State is asked to select one of the following options as to the age
standard used:
•

Same as the age criteria used for Targeted Low-Income Pregnant Women

•

Different than the age criteria used for Targeted Low-Income Pregnant Women

If the State selects ‘Same as the age criteria used for Targeted Low-Income Pregnant
Women’, the system will copy that information over to this group.
If the State selects ‘Different than the age criteria used for Targeted Low-Income
Pregnant Women’ the State is asked to provide the lower (from age) and upper end (up
to) of that age range. An explanation defining ‘from’ and ‘up to’ can be found in the
income standards screen CS6.
Validation: a comparison is done of the 'from age' entered for PWAPEC with the highest
age entered for children. If the 'from age' entered for PWAPEC is less than the highest
age entered for children, the following message is displayed: ‘The 'from age' entered
overlaps with the qualifying ages for children’ and the State is asked to select one of the
following options:
•
•

This was done in error
This is the correct age used by the State for targeted low-income women

If ‘this was done in error is selected, the State is given the opportunity to correct.
If the State selects that it is correct, the State is asked to describe how the determination is
made as to whether the applicant will be provided coverage as a child or as a pregnant
woman.
Review Criteria
The description should be sufficiently clear, detailed and complete to permit the
reviewer to determine that the State’s election meets applicable federal statutory,
regulatory and policy requirements.
Pregnancy Status
7

This is followed by a statement that a woman must be pregnant or post-partum. Since this
criterion is required of all States, it is pre-checked and does not require any action by the
CHIP Agency.
Additional Assurances
The State is asked to provide another more general assurance that pregnant women
considered to have access to public employee coverage, and therefore not excluded from
CHIP through this option, meet the definition provided at 457.310(c)(1).
If the State does not cover all pregnant women, i.e. the State selected either pregnant
women who are employees of or dependents of employees of certain public agencies or
pregnant women who are employees of or dependents of certain types of public
employees, an additional assurance will display. Here, the Agency assures that pregnant
women who are eligible for public employee health benefits coverage who are not
described above are excluded from eligibility under the plan.
The State provides these affirmative assurances by checking the boxes next to each
assurance statement. If the State does not check this box, the system will not accept this
template for review and approval.

Template CS12 – Dental Only Supplemental Coverage
Statute: Section 2110(b)(5) of the SSA
Regulation:
Additional References: Section 501 of CHIPRA 2009 and SHO #09-012 dated October
7, 2009
INTRODUCTION
This template applies only to States with separate child health assistance programs.
Template CS12 displays only for and must be completed by States that elected the option
to provide Dental Only Supplemental Coverage.
In this template, states provide information with regards to eligibility criteria, including
income standards, specific to the Dental Only Supplemental Coverage covered group.
BACKGROUND
CHIPRA 2009 added section 2103(c)(5) of the Social Security Act requiring coverage of
dental services ‘necessary to prevent disease and promote oral health, restore oral
structures to health and function, and treat emergency conditions’ for children enrolled in
CHIP.
CHIPRA also added section 2110(b)(5), which gives States with separate CHIP programs
the option to offer dental-only supplemental coverage to children who have health
insurance coverage through an employer but are uninsured or underinsured with respect
to dental coverage. The same coverage must be provided under the Dental Only
Supplemental Coverage as provided to other children enrolled in CHIP.
Children can enroll in the dental-only supplemental coverage even if their group health
plan or other health insurance coverage includes some dental benefits.
Children of State employees would qualify for Dental Only supplemental Coverage if
they meet the exception under 42 CFR 457.310(c)(1), i.e. when the State makes no more
than a nominal payment for the cost of their State employee coverage ($10 or less per
month).
A State may limit coverage under this option to children whose family income does not
exceed a level specified by the State, so long as the specified level does not exceed the
maximum income level used by the State for other CHIP eligible children.
A State may not offer supplemental dental coverage if it has implemented a waiting list
for their CHIP medical or their CHIP dental program or if its highest income eligibility
level does not equal the highest income eligibility standard permitted under Title XXI (or
a waiver) as of January 1, 2009.
1

Additional information may be found in SHO #09-012 dated October 7, 2009.
TECHNICAL GUIDANCE
This template is broken down into the following sections:
Eligibility Determination Assurance
Income Standards
Additional Assurances
Eligibility Determination Assurance
Template CS12 begins with the CHIP Agency being asked to provide assurance that it
determines eligibility for this group in accordance with the provisions that follow.
The State provides this affirmative assurance by checking the box next to the assurance
statement. If the State does not check this box, the system will not accept this template
for review and approval.
Income Standards
The State is then asked to provide income standards, beginning with a Y/N question as
whether the state uses the same income standards for Dental only supplemental coverage
as are used for other targeted low income children.
If the answer is yes, the system will assign the standards to this group that the CHIP
Agency entered for TLIC and no additional entries need to be made by the Agency
If the answer is no, the system displays a Y/N question as to whether income standards
are applied statewide.
•

If the answer is yes, another Y/N question displays asking if there are any
exceptions, e.g. populations in a county which may qualify either under a
statewide income standard or a county income standard.
o If the answer to this second question is no, that is income standards are
statewide with no exceptions, a grid asking for age and income is
displayed for the CHIP Agency to complete. See guidance for Template
CS6 for instructions on completing the age and income standards grid.
Validation: A cross- check will be done of each FPL range entered against
FPL standards for TLIC children of the same age to ensure that the upper end
of the income standard does not exceed that of TLIC.
If the validation fails, an error message gets displayed and the Agency is given
the opportunity to correct.
2

o If the answer to this second question is yes, then the State must type in an
explanation which includes a description of the overlapping geographic
area and the reason for having different income standards. The State must
then enter both their statewide income standards (see guidance for CS6) as
well as income standards which vary by geography. See instructions
below for completion of geographic standards.
Review Criteria
The description should be sufficiently clear, detailed and complete to permit
the reviewer to determine that the State’s election meets applicable federal
statutory, regulatory and policy requirements.
Validation: A cross- check will be done of each FPL range entered against
FPL standards for TLIC children of the same age to ensure that the upper end
of the income standard does not exceed that of TLIC.
If the validation fails, an error message gets displayed and the Agency is given
the opportunity to correct.
•

Validation: A cross- check will be done of each FPL range entered against FPL
standards for TLIC children of the same age to ensure that the upper end of the
income standard does not exceed that of TLIC.
If the validation fails, an error message gets displayed and the Agency is given the
opportunity to correct.
Standard varies in some other geographic way
If ‘Standard varies in some other geographic way’ gets checked, the State is asked
to name and describe the geographic area. States may name multiple geographic
areas. The age and income standards screen is then displayed and must be
completed for each geographic name entered. If there are multiple geographic
areas within the State with separate income standards, the State may reselect the
name field and repeat the process until all the geographic areas have been entered.
See guidance for Template CS6 for instructions on completing the age and
income standards grid.
Validation: A cross-check of each FPL range entered against FPL standards for
TLIC children of the same age to ensure that the upper end of the income
standard does not exceed that of TLIC.
If the validation fails, an error message gets displayed and the Agency is given the
opportunity to correct.
Additional Assurances
The income section is followed by the State being asked to provide two assurances:
•

That the State has the highest income eligibility standard permitted under Title
XXI (or a waiver) as of January 1, 2009; and

•

That the State does not limit the acceptance of applications for children or impose
any numerical limitation, waiting list, or similar limitation on the eligibility of
children under the State plan.

The State provides these affirmative assurances by checking the box next to each
assurance statement. If the State does not check this box, the system will not accept this
template for review and approval.

Template CS13 - Deemed Newborns
Statute: Section 2112(e) of the SSA
Regulation:
Additional References: SHO # 09-009, dated August 31, 2009
INTRODUCTION
To be completed by States with separate child health assistance programs.
This template describes the one-year coverage for infants born to targeted low-income
pregnant women.
BACKGROUND
This coverage is provided to newborns if their mother was covered as a targeted lowincome pregnant woman under the CHIP state plan on the date of the child’s birth. The
newborn is deemed eligible for CHIP or Medicaid without an application or further
determination of eligibility and the coverage lasts until the child turns one year of age.
Under the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA),
states were given the option to provide pregnant women coverage through an amendment
to a state’s CHIP plan (Section 2112 of the Social Security Act). CHIPRA also requires
that children born to women receiving pregnancy-related assistance shall be deemed on
the date of the child’s birth to have applied for coverage under CHIP or Medicaid, and
shall be found eligible for the appropriate program until the child reaches age one
(Section 2112(e) of the Act).
Guidance provided in the SHO # 09-009, dated August 31, 2009 notes that states should
use available information to first screen for Medicaid eligibility and then automatically
enroll the newborn in either Medicaid or CHIP as appropriate. In addition, states that
cover pregnant women through a CHIP 1115 demonstration may be required, depending
on the terms of their demonstration, to also deem newborns as eligible for Medicaid or
CHIP. Finally, a newborn born to a woman covered for labor and delivery through
emergency Medicaid (as sometimes happens in the CHIP option of coverage from
conception to birth) is deemed eligible for Medicaid.
TECHNICAL GUIDANCE
This template is broken down into the following sections:
Eligibility Assurance
Mandatory Provision
Optional Provisions
Eligibility Assurance
1

Template CS13 begins with the State assuring that it operates this eligibility group
consistent with the criteria and provisions selected in the template. The State provides
this affirmative assurance by checking the box immediately below the description of the
group at the top of the template. If the State does not check this box, the system will not
accept this template for review and approval.
Mandatory Provision
The first provision is pre-selected as it is required of all States.
Optional Provisions
There are three options from which the State may select either one or more:
•

The child is deemed to have applied for and been found eligible for CHIP or
Medicaid, as appropriate, under the State Plan as of the date of the child's birth,
and remains eligible for CHIP without regard to changes in circumstances until
the child's first birthday.

•

The State elects to cover as a deemed newborn a child born to a mother who was
covered as a child for the date of the newborn's birth under the State's separate
CHIP.

•

The State elects to recognize a child’s deemed newborn status determined by
another state, and provide benefits under this eligibility to that child until the
child’s first birthday.

Template CS14 – Children Ineligible for Medicaid as a Result of the Elimination of
Income Disregards
Statute: Section 2110(b) of the SSA
Regulation: 42 CFR 457.310(d)
Additional references: Section 2101(f) of the ACA

INTRODUCTION
This template applies to all states with CHIP programs, whether they offer a separate
child health assistance program, Medicaid Expansion only or a combination of both.
In this template the CHIP Agency provides an assurance that separate CHIP coverage
will be provided for children ineligible for Medicaid as a result of the elimination of
income disregards.
BACKGROUND
The ACA requires states to treat any child, who is determined to be ineligible under the
State’s Medicaid plan or under a Medicaid waiver as a result of the elimination of the
application of income disregards, under section 1902(e)(14) of the Social Security Act
(income determination using modified adjusted gross income), as a targeted low-income
child. States are required to provide child health assistance to the child under a separate
CHIP plan regardless of whether their child health assistance plan was implemented as a
separate program, a Medicaid expansion or both. This requirement does not apply to a
child who is an inmate of a public institution, a patient in an institution for mental
diseases; or is eligible for coverage under a State health benefits plan on the basis of a
family member’s employment with a public agency in the State (unless the state has
elected the option to provide CHIP coverage to such children). States with Medicaid
Expansion CHIPs may choose to develop a separate CHIP for this population only that is
a mirror of their Medicaid program.
42 CFR 457.310 was amended, with the addition of paragraph d, to include these children
in the definition of targeted low-income children and clarifies that eligibility under this
requirement continues until the date of the child’s next renewal of eligibility under the
separate CHIP plan. At the time of their CHIP renewal, such children must meet all CHIP
eligibility criteria in order to stay enrolled.
TECHNICAL GUIDANCE
In this template, States must provide assurance that separate CHIP coverage will be
provided for children ineligible for Medicaid due to the elimination of income disregards
in accordance with 42 CFR 457.310(d).

The CHIP Agency provides this affirmative assurance by checking the box next to the
assurance statement. If the State does not check this box, the system will not accept this
template for review and approval.

Template CS15 – MAGI-Based Income Methodologies
Statute: 2102(b)(1)(B)(v) of the SSA
Regulation: 42 CFR 457.315
INTRODUCTION
To be completed by States with separate child health assistance programs.
In this template, states provide information with regards to criteria used in the calculation
of income for eligibility determination using MAGI-based income methodologies.
BACKGROUND
The ACA added section 2102(b)(1)(B)(v) of the Social Security Act requiring States,
beginning January 1, 2014, to use a methodology based on modified adjusted gross
income (MAGI) and household income, as defined in section 36B(d)(2) of the Internal
Revenue Code of 1986, to determine eligibility for CHIP or for any other purpose
applicable under the plan or a waiver for which a determination of income is required,
consistent with section 1902(e)(14).
The only exception to this requirement if for individuals for whom the State relies on a
finding of income made by an Express Lane agency.
Aside from a 5 percent FPL across-the-board income disregard for all MAGI populations,
the ACA also eliminated the use of any type of expense, block, or other income disregard
to determine income eligibility or for any other purpose applicable under the plan or
waiver for which a determination of income is required.
Prior to January 1, 2014, States are required, using the new income determination rules,
to establish income eligibility thresholds using MAGI and household income that are not
less than the effective income eligibility levels that applied under the State’s plan or
waiver on the date of enactment of the ACA (3/23/2010). Also prior to the January 2014
effective date, States will have had to submit and receive approval from CMS for the
conversion for all separate CHIP covered group income standards to MAGI-equivalent
standards.
Definitions and rules related to the application of MAGI may be found in 42 CFR
435.603(b)-(h).
TECHNICAL GUIDANCE
This template is broken down into the following sections:
Use of MAGI Assurance
Effective Date of MAGI
1

Determining Family Size in Households with a Pregnant Woman
Financial Eligibility
Household Income Definition
MAGI Conversion Assurance
Template CS15 begins with the CHIP Agency being asked to provide assurance
that it will apply Modified Adjusted Gross Income methodologies for all separate
CHIP covered groups, as described below, and consistent with 42 CFR 457.315
and 435.603(b) through (i).
The CHIP Agency provides this affirmative assurance by checking the box next to the
assurance statement. If the CHIP Agency does not check this box, the system will not
accept this template for review and approval.
Effective Date of MAGI
This section is a statement of the effective date for use of MAGI-based methodology for
individuals eligible for CHIP at the time of conversion to MAGI.
Determining Family Size in Households with a Pregnant Woman
For States which cover pregnant women, this section begins with a statement that ‘in
determining family size for the eligibility determination of a pregnant woman, she is
counted as herself plus each of the children she is expected to deliver’.
All States are asked to select from three options with respect to how the pregnant woman
is counted in determining family size for the eligibility determination of other individuals
in a household that includes a pregnant woman. The State does this by checking the box
next to the applicable option.
Financial Eligibility
In this section, States are asked to provide information with respect to current monthly
income and family size criteria on which financial eligibility is based.
First, the State must select one of the two options listed with regards to determining
eligibility for current beneficiaries:
Then the State must select one or both options listed as to determining current monthly or
projected annual household income.
The State makes their selections by checking the box next to the applicable options.
Household Income Definition
This section provides a definition for household income.
MAGI Conversion Assurance

In this section, the CHIP Agency provides assurance that it has submitted and received
approval for the conversion for all separate CHIP covered group income standards to
MAGI-equivalent standards.
The CHIP Agency provides this affirmative assurance by checking the box next to the
assurance statement. If the CHIP Agency does not check this box, the system will not
accept this template for review and approval.
The State also submits their approval documentation via the Upload feature.

Template CS16 – Spenddown(s)
Statute: Section 2102(b) of the SSA
Regulation: 42 CFR 457.320(a)(5)
INTRODUCTION
In this template States indicate whether they apply spenddown and if so, provide
information as to their application of spenddown.
BACKGROUND
States have the option of applying spenddowns with respect to determining financial
eligibility for CHIP.
TECHNICAL GUIDANCE
This template includes a Y/N question for State to indicate if the State applies a
Spenddown process for any of the covered population groups whose household income
exceeds the CHIP qualifying income limit.
If the answer is yes, a text box displays for the State to provide a description of the types
of spenddowns used in CHIP and how they are applied.
Review Criteria
The description should be sufficiently clear, detailed and complete to permit the
reviewer to understand what expenses are allowed as spenddowns and how the state
treats them in the income calculation for determining eligibility.

Template CS17 - Non-Financial – Residency
Statute:
Regulations: 42 CFR 457.320(d)
INTRODUCTION:
To be completed by States with separate child health assistance programs.
Template CS17 highlights specific requirements as to what constitutes residency, along with
soliciting information from States regarding their policies for individuals who are temporarily
out of the State or temporarily living in the State.
BACKGROUND:
The definition of who is considered a resident of the State takes into consideration certain
conditions that must be met and criteria to be used to determine the residency of individuals who
are not able of indicating intent; are institutionalized or may be absent from the State.
Regulatory changes in final rule 77 FR 17206 published on March 23, 2012, implementing
several provisions of the Patient Protection and Affordable Care Act of 2010, sought to simplify
and clarify residency rules and to align those rules with those that will apply under other
insurance affordability programs.
CHIP residency regulations were revised to align with the Medicaid residency rules, including:
42 CFR 435.403(i) - Residency for a non-institutionalized child who is not a ward of the State;
42 CFR 435.403(h) - Residency for targeted low-income pregnant woman
42 CFR 435.403(m) – Handling of cases of disputed residency.
For non-institutionalized adults, simplification and clarification included removal of the term
‘permanently or for an indefinite period’ from the residency definition; replacement of the term
‘intention to remain’ with ‘intends to reside, including without a fixed address’ and the addition
of ‘inclusion of individuals who have entered the State with a job commitment or are seeking
employment (whether or not currently employed)’ in re-designated § 435.403(h).
For children, simplification and clarification included consolidation of two previously existing
definitions of residency (disabled children with nondisabled, non-institutionalized, non-IV–E
foster care/adoption assistance children) in re-designated § 435.403(i)(2) and the application of
the adult residency rules to children, capable if indicating intent, who are emancipated or,
married.
To address concerns of retention and gaps in coverage of children who, because of migration of
families, emergency evacuations, natural or other disasters, public health emergencies,
educational needs, or otherwise, frequently change their State of residency or otherwise are
1

temporarily located outside of their State of residency, CMS has proposed a model process for
interstate coordination in accordance with section 213 of the Children’s Health Insurance
Program Reauthorization Act (CHIPRA). The model process may be found at
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Childrens-HealthInsurance-Program-CHIP/Downloads/CHIPRA_InterstateCoordination.pdf.
TECHNICAL GUIDANCE:
This template is broken down into the following sections:
Assurance
Residency for Children
Residency for Pregnant Women, if applicable
Interstate Agreement
Assurance
Template CS17 begins with the State providing assurance that it meets the requirement of
providing CHIP to otherwise eligible residents of the State.
The State provides this affirmative assurance by checking the box next to the assurance
statement. If the State does not check this box, the system will not accept this template for
review and approval.
Residency for Children
This section includes a list of conditions under which children are considered to be residents of
the State. Since these are required of all States with separate CHIP programs, they are prechecked and do not require any entry by the State.
Residency for Pregnant Women
This displays only for States which also cover targeted low-income pregnant women.
This section includes a list of conditions under which pregnant women are considered to be
residents of the State. Since these are required of all States with separate CHIP programs, they
are pre-checked and do not require any entry by the State.
Interstate Agreement
This section applies to both children and pregnant women, if the State covers pregnant women.
This section begins with a Y/N question for the State to indicate whether requirements also
include criteria specified in an interstate agreement.
If the response is yes, the State must:
•
•

Select the States with which it has interstate agreements from a drop down list; and
Check the categories of individuals which are included in the interstate agreements from
the provided list. If a category of individuals included in the interstate agreement is not
2

on the list, the State should check the box for ‘other type of individual’ and enter a name
and description for the other type of individual.
This is followed by another Y/N question asking if the State has a policy related to individuals
who are in the State only for educational purposes.
If the response is yes, the State must provide a description of the policy. Examples of what may
be included in the policy include:
•
•

That these individuals are considered as being in the State temporarily and therefore are
not considered to be residents of the State; or
That they are considered to be residents if they are in the State for a specified length of
time (e.g. not less than 90 days).

If the policy varies depending on the State with which there is an interstate agreement, the State
should note the difference here.
Review Criteria
The description should be sufficiently clear, detailed and complete to permit the reviewer to
determine that the State’s election meets applicable federal statutory, regulatory and policy
requirements.

Template CS18 - Non-Financial - Citizenship
Statute: Section 2105(c)(9) of the SSA 2107(e)(1)(J)
Regulations: 42 CFR 457.320(b)(6)
Additional references: Section 211 and 214 of CHIPRA 2009; 8 U.S.C. sections 1612, 1613
and 1641; SHO # 10-006 (Medicaid and CHIP Coverage of “Lawfully Residing” Children and
Pregnant Women) dated July 1, 2010 and SHO # 09-016 (Citizenship Documentation
Requirement) dated December 28, 2009.
INTRODUCTION:
To be completed by States with separate child health assistance programs.
In template CS18, the State provides information regarding its citizenship rules and provision of
Medicaid to citizens and nationals of the United States and to certain non-citizens.
BACKGROUND:
State CHIP programs are required to provide CHIP coverage to otherwise eligible residents of
the United States who are citizens or nationals of the United States or qualified non-citizens
(aliens) as described in section 431 of the Personal Responsibility and Work Opportunity
Reconciliation Act of 1996 (8 U. S. C. section 1641).
Effective January 1, 2010, section 2105(c) of the Act was amended to apply to separate CHIP
programs the same requirements as in Medicaid with respect to required verification of
citizenship or nationality, for individuals who have declared themselves to be U. S. citizens. This
change also applies to citizenship verification (for individuals who are required to verify their
citizenship status), the same requirement of providing coverage during a reasonable opportunity
period pending verification of satisfactory immigration status, as required in sections 1137(d)(4)
and 1903(x) of the SSA to individuals who have not declares themselves as citizens or nationals
of the U.S. Additional information regarding the provision of CHIP during a reasonable
opportunity period can be found in SHO # 09-016, dated December 28, 2009.
States also have the option to cover non-citizen pregnant women and children during the 5 year
waiting period, who are lawfully residing in the United States. This option was added by section
214 of CHIPRA 2009 (P.L. 111-3) and section 2107(e)(1)(J) of the SSA and gives states the
option to provide CHIP to pregnant women (including the 60-day postpartum period) and/or
children up to age 19. To meet the criteria of lawfully residing and to qualify under this option,
an individual must be both lawfully present in the U. S. and a resident of the State. A listing of
individuals who may be considered lawfully present and additional information may be found in
SHO # 10-006 dated July 1, 2010.
States may not select the option to cover lawfully residing non-citizen pregnant women and
children under CHIP if they do not also cover them under their State’s Medicaid program.

Additionally states not elect to cover pregnant women under this option without also covering
children.
TECHNICAL GUIDANCE:
Template C18 begins with the State providing assurance that it provides CHIP to citizens and
nationals of the United States and certain non-citizens, including the time period during which
they are provided with reasonable opportunity to submit verification of their citizenship, national
or immigration status.
The State provides this affirmative assurance by checking the box at the top of Template CS18.
If the State does not check this box, the system will not accept this template for review and
approval.
The first section begins with a statement that supports this assurance, followed by a listing of the
three citizen/non-citizen categories which must be provided CHIP coverage. States must also
enter the length of the reasonable opportunity period, during which CHIP coverage is provided
pending verification of citizenship, national status or immigration status, in the text box
provided.
Review Criteria
For the number entered for the length of the reasonable opportunity period, the state should
also note the specific time period, for example 60 days, 2 months, etc.
This is followed by a statement of the requirement that the State provides extensions to the
reasonable opportunity period for good cause. This statement is pre-checked and the State must
describe good cause reasons used by the State in the text box provided.
Review Criteria
The description should be sufficiently clear, detailed and complete to permit the reviewer to
determine that the State’s election meets applicable federal statutory, regulatory and policy
requirements.
In the second section, the State is asked two questions:
•

The first question asks if the state elects the option to provide CHIP coverage to
otherwise eligible children, lawfully residing in the United States.
If the response is yes, the system displays the definition for ‘otherwise eligible children’,
followed by an assurance by the State that lawfully residing children are also covered
under the State's Medicaid program. The CHIP Agency provides this affirmative
assurance by checking the box next to the assurance statement. If the CHIP Agency does
not check this box, the system will not accept this template for review and approval.
2

•

The second question asks if the state elects the option to provide CHIP coverage to
otherwise eligible pregnant women, lawfully residing in the United States.
If the response is yes, the system displays the definition for ‘otherwise eligible pregnant
women’.
Validation: a check is done to ensure that pregnant women covered under section 111
CHIPRA (targeted low-income pregnant women) are covered under the plan, that is the
State must have checked the ‘targeted low-income pregnant women’ option under the
separate CHIP options (tab CS4)).
If the validation fails, that is the CHIP Agency did not check that it covers targeted lowincome pregnant women, the CHIP Agency must either return to the separate CHIP
options screen to select the option of covering ‘targeted low-income pregnant women’ or
de-select the option of covering lawfully residing pregnant women from this screen.
If the validation passes, an assurance is displayed stating that lawfully residing pregnant
women are also covered under the State's Medicaid program. The CHIP Agency provides
this affirmative assurance by checking the box next to the assurance statement. If the
State does not check this box, the system will not accept this template for review and
approval.
This is followed by an assurance that lawfully residing pregnant women are also covered
under the State's Medicaid program. The CHIP Agency provides this affirmative
assurance by checking the box next to the assurance statement. If the CHIP Agency does
not check this box, the system will not accept this template for review and approval.
Validation: a check is done to ensure that lawfully residing children are covered under
the plan.
If the validation fails, that is lawfully residing children was not checked as an option
under the separate CHIP options (tab CS4)), a message is displayed, stating that this
option cannot be selected unless the State also elects to cover lawfully residing children.
The CHIP Agency must either return to the separate CHIP options screen to select the
option of covering lawfully residing children or de-select the option of covering lawfully
residing pregnant women from this screen.

This section ends with statements providing the definition as to which individuals are
considered to be lawfully residing.

CS19 - Non-Financial – Social Security Number
Statute:
Regulations: 42 CFR 457.340(b)
Additional References: Sec. 211 of CHIPRA 2009; Sec. 1414(a)(2) of the ACA
INTRODUCTION:
Template CS19 includes requirements related to individuals who are required to furnish or who
voluntarily provide their social security number(s) and requirements regarding the State’s
responsibilities related these individuals.
BACKGROUND:
42 CFR 457.340(b), applies to CHIP, the same requirements that apply to Medicaid (42 CFR
435.910 and 435.907(e)) with respect to the provision and use of social security numbers and
non-applicant information .
42 CFR 435.910 places a requirement on States to require, as a condition of eligibility, that each
individual (including children) requesting Medicaid services furnish each of his or her social
security numbers (SSNs). States are also required to inform individuals regarding the use of
SSNs and to assist individuals to apply for an SSN if they do not have one. Additionally, states
must verify each SSN of each applicant and beneficiary with the Social Security Administration
to insure that each SSN furnished was issued to that individual, and to determine whether any
others were issued.
With regulatory changes in final rule 77 FR 17206 published on March 23, 2012, implementing
several provisions of the Patient Protection and Affordable Care Act of 2010, CMS sought to
clarify and modify certain requirements related to social security numbers. Some of these
changes include:
•

•

Revised section 42 CFR 435.910(a) and (h) clarifies the SSN requirement for individuals
who are not eligible for an SSN or do not have one and are only able to be issued an SSN
for a non-work purpose. These individuals do not need to provide an SSN.
Paragraph (e)(3) was added to 42 CFR 435.907 to codify the long standing policy from
previous guidance (Tri-Agency Guidance for Medicaid and CHIP, which is available at
http://www.hhs.gov/ocr/civilrights/resources/specialtopics/tanf/triagencyletter.html,
prohibiting States from requiring a non-applicant from providing a Social Security
Number (SSN). Provision of an SSN may occur on a voluntary basis.

TECHNICAL GUIDANCE:
Template CS19 begins with an introductory statement that the State must require that
individuals, as a condition of eligibility, furnish their social security number or numbers, if they
have more than one number.
1

The first section begins with the State assuring that it requires individuals, as a condition of
eligibility, to furnish their social security number(s), followed by the allowable exceptions.
The State provides this affirmative assurance by checking the box next to the assurance
statement. If the State does not check this box, the system will not accept this template for
review and approval.
The second and third sections are statements of requirements for the State to:
• Provide assistance to individuals, who are required to provide their social security
number, to apply/or obtain a social security number from the Social Security
Administration if the individual does not have or forgot their social security number
•

To inform individuals required to provide their social security number, by what statutory
authority the number is solicited and how the State will use the social security number.

These statements are followed by an assurance from the State that it will verify each social
security number of each applicant and recipient; that it will not deny or delay services to an
otherwise eligible applicant pending issuance or verification of the individual's social security
number and that the State's utilization of the social security numbers is consistent with sections
205 and 1137 of the SSA and the Privacy Act of 1974.

The State provides this affirmative assurance by checking the box next to the assurance
statement. If the State does not check this box, the system will not accept this template for
review and approval.
The last section begins with a statement that the State may request non-applicant household
members to voluntarily provide their social security number. This statement is followed by a
Y/N question which allows the State to indicate whether it request non-applicant household
members to voluntarily provide their social security number.
•

If the response is yes, the CHIP Agency must provide assurance that:
o At the time that the social security number is requested, the State informs the nonapplicant that this information is voluntary and provides information regarding
how the social security number will be used; and
o The State only uses the social security numbers for determination of eligibility for
Medicaid or other insurance affordability programs, or for a purpose directly
connected with the administration of the State plan.

The CHIP Agency provides this affirmative assurance by checking the box next to the
assurance statement. If the CHIP Agency does not check this box, the system will not accept
this template for review and approval.

Template CS20 –Non-Financial Requirements – Substitution of Coverage
Statute: Sections 2102(b)(3)(C) and 2110(b)(1)(C) of the SSA
Regulation: 42 CFR 457.310(b)(2) and (b)(3), 457.320(a)(9) and 457.805
Additional References: SHO dated February 13, 1998
INTRODUCTION
To be completed by States with separate child health assistance programs.
In this template, States provide information about their policies and procedures to prevent
the substitution of group health coverage or other commercial health insurance with
public funded coverage.
BACKGROUND
Children who are eligible or potentially eligible for Medicaid or covered under a
group health plan or under health insurance coverage, as defined in section 2791 of
the Public Health Service Act, are not included in the definition of targeted lowincome children and therefore are not eligible for CHIP.

Section 2102(b)(3)(C) of the Social Security Act requires States to include, in their State
plan, a description of procedures the State uses to ensure that CHIP coverage does not
substitute for coverage under group health plans.
Regulations address two scenarios with respect to the potential for substitution:
individuals dropping private coverage to enroll in coverage provided directly through
CHIP or for States with premium assistance programs, the potential of CHIP funds
substituting for employer contributions towards employer-sponsored insurance (ESI).

Due to its implications with respect to eligibility, this section addresses only substitution
related to enrollment in coverage provided directly through CHIP. Substitution of
coverage for States offering premium assistance or family coverage is addressed in those
respective sections.
The primary mechanism States use to discourage substitution is the imposition of a
minimum period of uninsurance (waiting period) for individuals who drop private
coverage. Some States have also implemented mechanisms to encourage affordable
employer-sponsored health insurance as a way of discouraging substitution.

For States with waiting periods, it is generally understood that there are legitimate
reasons for individuals dropping employer-sponsored insurance for which exceptions
may be made to the waiting period, including, but not limited to: a parent’s involuntary
loss of access to ESI, a job change to an employer not offering dependent coverage, or
lack of access to affordable employer-sponsored insurance.

Note: waiting period does not apply to children losing Medicaid eligibility.
TECHNICAL GUIDANCE
This template is broken down into the following sections:
Substitution of Coverage Assurance
Waiting Period
Other Substitution of Coverage Prevention Strategy
Substitution of Coverage Assurance
Template CS20 begins with the CHIP Agency being asked to provide assurance that it
has methods and policies in place to prevent the substitution of coverage
The State provides this affirmative assurance by checking the box next to the assurance
statement. If the State does not check this box, the system will not accept this template
for review and approval.
Waiting Period
This section begins with a Y/N question as to whether the State has a waiting period
during which an individual is ineligible due to having dropped group health coverage.
If the answer is yes, States are asked for the length of the waiting period, which
they select from the displayed list. If the length of the waiting period is not listed,
the State selects other and enters the time period in the box provided.
Note: States selecting ‘other’, should enter a number and the time period to which
that number applies, e.g. 100 days, 6 months.
In the next Y/N question, States are asked if there are exceptions to the waiting
period.
If the answer is yes, States are asked to select all that apply from a list of
exceptions
If the State selects financial hardship, the State must also enter a description in the
text box provided. States should include the methodology used to determine
financial hardship,( i.e. percentage of family income spent on medical costs,
including premiums and other cost-sharing and unexpected necessary
expenditures or other considerations.
Review Criteria
The description should be sufficiently clear, detailed and complete to permit the
reviewer to determine that the State’s election meets applicable federal
statutory, regulatory and policy requirements.
2

If the State selects other, the State must provide a description in the text box
provided. If the State has more than one other exception, it may reselect other
until all exceptions have been entered.
Review Criteria
The description should be sufficiently clear, detailed and complete to permit the
reviewer to determine that the State’s election meets applicable federal
statutory, regulatory and policy requirements.
Other Substitution of Coverage Prevention Strategy
The State selects this option if the State has a substitution of coverage prevention strategy
or policy other than or in addition to a waiting period.
States selecting this option must enter a name and description of the strategy/policy in the
text boxes provided. If there is more than one other substitution policy, the State may
reselect this other option until all the policies have been entered.
Review Criteria
The description should be sufficiently clear, detailed and complete to permit the
reviewer to determine that the State’s election meets applicable federal statutory,
regulatory and policy requirements.
Pregnant Women Assurance
If the State responded yes above to having a waiting period and provides coverage to
targeted low-income pregnant women, the State must provide assurance that the waiting
period does not apply to pregnant women.
The State provides this affirmative assurance by checking the box next to the assurance
statement. If the State does not check this box, the system will not accept this template
for review and approval.
Dental Only Supplemental Coverage
States that provide Dental only supplemental coverage must provide two assurances:
•

That the other coverage exclusion (i.e. substitution of coverage) does not apply to
children who are otherwise eligible for Dental only supplemental coverage as
provided in section 2110(b)(5) of the SSA, and

•

That the waiting period does not apply to children eligible for dental only
supplemental coverage.

Template CS21 Non-Financial – Non-Payment of Premiums
Statute: 2103(e)(3)(C)
Regulation: 42 CFR 457.510 and 570
Additional references: SHO # 10-001, dated January 22, 2010
INTRODUCTION
To be completed by States with separate child health assistance programs.
In this template, States provide information about their policies and procedures with
respect to non-payment of premiums.
BACKGROUND
When a State imposes premiums or other cost-sharing, the State plan must describe the
consequences of non-payment of those charges in their State plan.
Section 504 of CHIPRA amends the cost-sharing provisions at section 2103(e)(3) of the
Social Security Act (the Act) by adding a requirement that States grant individuals enrolled in
separate child health programs, a 30-day grace period, from the beginning of a new coverage
period, to pay any required premium before enrollment may be terminated. The new
coverage period begins with the month following the last period for which a premium was
paid. Additional information may be found in SHO # 10-001, dated January 22, 2010.

TECHNICAL GUIDANCE
This template begins with a Y/N question as to whether the State imposes premiums.
If the answer is no, the State is not asked any additional questions on this topic.
•

If the answer is yes, States are asked another Y/N question ‘Does the State have a
premium lock out period?’
If the answer is yes, the State must provide a description in the text box provided.
The description should include:
o Whether payment is required for all past-due months or if any portion of the
past-due payment may be forgiven,
o A description of the overdue payment notification process along with the
number of months which could potentially be overdue before eligibility is
terminated,
o Whether it applies until the child’s premium is paid or whether it continues
after the premium has been paid.
Review Criteria
1

The description should be sufficiently clear, detailed and complete to permit the
reviewer to determine that the State’s election meets applicable federal
statutory, regulatory and policy requirements.
The State is then asked ‘What is the length of the time premium lock-out period?’
The State selects the applicable time period from the displayed list. If the
applicable time period is not on the list, the State selects other and enters the time
period in the description box provided.
Note: States selecting ‘Other’ should enter a number and the time period to which
that number applies, e.g. 100 days, 6 months along with any other relevant
information.

Template CS22 – Non-Financial Requirements
Statute: Section 2110(b)(2)(B) of the SSA
Regulation: 42 CFR 457.310(c)(1)
INTRODUCTION
To be completed by States with separate child health assistance programs.
In template CS22, States provide assurances with respect to several non-financial
eligibility requirements not covered in other sections of the plan.
BACKGROUND
As a condition of eligibility, an individual may not be:
•

Found eligible for Medicaid;

•

Covered under a group health plan or other health insurance coverage as defined
in section 2791 of the Public Health Service Act;

•

Excluded from CHIP coverage due to a pre-existing medical condition;

•

An inmate of a public institution, as defined in 42 CFR 435.1010;

•

A patient in an institution for mental diseases, as defined at 42 CFR 435.1010, at
the time of initial application or any redetermination of eligibility; or

•

Eligible for public employee health benefits coverage (Note: Under section
2110(b)(2)(B) of the Act, States are permitted to extend CHIP eligibility to
children of State employees who are otherwise eligible under the State child
health plan to the extent that one of two conditions is met at 2110(b)(6). Please
see State Health Office letter #11-002 on this state option).

TECHNICAL GUIDANCE
This template includes three assurances, with respect to requirements which would cause
an individual to be ineligible for CHIP, that apply to all States.
The fourth assurance regarding the ineligibility of individuals who are eligible for public
employee health benefits coverage is displayed only for States who do not cover children
or pregnant women with access to public employee coverage.
The State provides these affirmative assurances by checking the boxes next to each
assurance statement. If the State does not check these boxes, the system will not accept
this template for review and approval.
1

Template CS23 – Non-Financial Requirements - Other Eligibility Standards
Statute: Sections 2102(b) and 2110(b)
Regulation: 457.320(a)
INTRODUCTION
To be completed by States with separate child health assistance programs.
In template CS23 States specify and provide information about other eligibility standards
used in the determination of eligibility for CHIP.
BACKGROUND
This template provides States with the opportunity to include additional eligibility
standards in their plan, provided that the standards are approved by CMS and not
otherwise prohibited under regulations. To the extent consistent with title XXI of the Act
and except as provided at 457.320(b) of this section, the State plan may adopt eligibility
standards for one or more groups of children related to:
(1) Geographic area(s) served by the plan;
(2) Age (up to, but not including, age 19);
(3) Income;
(4) Resources;
(5) Spenddowns;
(6) Disposition of resources;
(7) Residency, in accordance with paragraph (d) of this section;
(8) Disability status, provided that such standards do not restrict eligibility;
(9) Access to, or coverage under, other health coverage; and
(10) Duration of eligibility, in accordance with paragraph (e) of this section.
See 42 CFR 457.320 (b) for a listing of prohibited eligibility standards.
TECHNICAL GUIDANCE
The option of ‘other eligibility standards’ is displayed.
If the State has other eligibility standards, it must check the box next to this option.
If the State selects this option, it must then provide a name for the standard in the text box
displayed for this purpose.
After the State has entered the name of the standard, the State must select the covered
groups to which this standard applies from a dropdown list of covered groups under the
State’s plan.

After the covered groups have been selected, the State must describe how this standard
affects eligibility in the text box displayed for this purpose.
If the State has more than one additional eligibility standard, it can repeat this process by
re-selecting the box next to the ‘other eligibility standards’ option.
Review Criteria
The description should be sufficiently clear, detailed and complete to permit the
reviewer to determine that the State’s election meets applicable federal statutory,
regulatory and policy requirements.

Template CS24 – General Eligibility - Eligibility Processing
Statute: Section 2102(b)(3) & 2107(e)(1)(O) of the SSA
Regulation: 42 CFR 457, subpart C; 457.110

INTRODUCTION
To be completed by States with separate child health assistance programs.
In template CS24, States provide assurances and information with respect to application
and redetermination processing, eligibility screening and enrollment.
BACKGROUND
The ACA requires States to have processes/procedures in place for enrollment
simplification and coordination with state health insurance exchanges and Medicaid.
Section 2107(e)(1)(O) of the Social Security Act requires the application of these
requirements to CHIP to the same extent as they apply to Medicaid under section 1943(b)
of the SSA.
These processes/procedures must:
•

•

Include the availability of an Internet website for use by individuals to apply
for, be enrolled in and to renew their enrollment in medical assistance
(including CHIP), and to consent to enrollment or reenrollment through the
use of electronic signature;
Include facilitation of enrollment of individuals who are identified by an
Exchange or Medicaid as being eligible for CHIP;

•

Ensure that individuals who apply for but are determined to be ineligible CHIP or
Medicaid, are screened for eligibility for enrollment in qualified health plans
offered through an Exchange and for premium assistance for the purchase of a
qualified health plan, and if eligible, enrolled in a such plan or premium
assistance without having to submit an additional or separate application;

•

Ensure that the Medicaid State agency, the CHIP State agency and the State’s
Exchange utilize a secure electronic interface;

•

Include coordination for individuals who are enrolled in the Medicaid State
plan or under a waiver of the plan and who are also enrolled in a qualified
health plan offered through an Exchange, and for individuals who are
enrolled in the State child health plan under title XXI and who are also
enrolled in a qualified health plan, the provision of medical assistance or
1

•

child health assistance to such individuals with the coverage provided under
the qualified health plan in which they are enrolled; and

Include outreach to and enrollment of vulnerable and underserved
populations eligible for medical assistance, including children,
unaccompanied homeless youth, children and youth with special health care
needs, pregnant women, racial and ethnic minorities, rural populations,
victims of abuse or trauma, individuals with mental health or substancerelated disorders, and individuals with HIV/AIDS.

State CHIP agencies may also enter into an agreement:
•

•

With an Exchange established by the State under which the State CHIP
agency may determine whether a State resident is eligible for premium
assistance for the purchase of a qualified health plan. The agreement would
have to meet conditions and requirements as the Secretary of the Treasury
may prescribe to reduce administrative costs and the likelihood of eligibility
errors and disruptions in coverage.

With an Exchange or the State Medicaid Agency to accept CHIP eligibility
decisions made by the Exchange or the Medicaid Agency and to furnish CHIP to
the same extent and in the same manner as if the applicant had been determined
by the CHIP Agency to be eligible for CHIP.

State CHIP agencies are required to:
•

•

Participate in and comply with the requirements for the system established
by CMS (under section 1413 of the Patient Protection and Affordable Care
Act), relating to streamlined procedures for enrollment through an Exchange,
Medicaid, and CHIP;
Use the single, streamlined application form developed by CMS or a State
developed application form approved by CMS;

•

Participate in a data matching arrangement for determining individual’s eligibility
for participation in the program;

•

Screen applications for other insurance affordability programs and, where
appropriate, transfer the electronic account (electronic application data) of
individuals to other insurance affordability programs, promptly and without undue
delay.

States utilizing approved enrollment caps or waiting lists must have procedures in place
for the administration of the cap or waiting list, including a process for deciding which
children will be given priority for enrollment, how children will be informed of their
status on a waiting list and the circumstances under which enrollment will reopen.
2

Due to the ACA maintenance of effort requirement, as a condition of receiving payments
under section 1903(a), States cannot have in effect eligibility standards, methodologies,
or procedures under its State CHIP plan that are more restrictive than the eligibility
standards, methodologies, or procedures in effect on the date of enactment of the ACA.
This requirement applies for the time period of March 23, 2010 through September 30,
2019.
Consequently, during this time period, States which did not have an enrollment cap or
waiting list in effect as of March 23, 2010 may not impose an enrollment cap or waiting
list to categories of populations covered under their CHIP State Plan as of March 23,
2010.
TECHNICAL GUIDANCE
This template is broken down into the following sections:
Assurance
Application Processing
Screen and Enroll Process
Redetermination Processing
Screening by Other Insurance Affordability Programs
Limitation on Enrollment
Assurance
Template CS24 begins with the CHIP Agency being asked to provide assurance that it
meets all of the requirements of 42 CFR 457, subpart C for application processing,
eligibility screening and enrollment.
The State provides this affirmative assurance by checking the box next to the assurance
statement. If the State does not check this box, the system will not accept this template
for review and approval.
Application Processing
This section begins with the State being asked to indicate which application(s) the agency
uses for all insurance affordability programs. The options are:
1. The single, streamlined application developed by the Secretary
2. An alternative single, streamlined application developed by the State and
approved by the Secretary
3. An alternative application used to apply for multiple human service programs
approved by the Secretary
If the State selects option 2 (an alternative single, streamlined application developed by
the State and approved by the Secretary), it must attach a copy of the application via the
Upload function.
3

Validation: The system will not allow the selection of option 3 (an alternative application
used to apply for multiple human service programs approved by the Secretary), unless
the State selected either option 1 or 2 or both options 1 and 2 first. States selecting option
3 must also attach a copy of this application via the Upload function.
Next, the State is asked to provide assurance that the agency's procedures permit the
submittal of an application via the internet website described in CFR 457.340(a), by
telephone, via mail, in person and other commonly available electronic means.
The State provides this affirmative assurance by checking the box next to the assurance
statement. If the State does not check this box, the system will not accept this template
for review and approval.
The last part of this section asks the agency to indicate by what other electronic means
(i.e. other than the internet website) it accepts applications. The Agency would do so by
checking the box next to the ‘other electronic means’ option and then entering the name
and description of this other means of accepting applications. If the State has more than
one other electronic means, it can reselect ‘name of method’ until all other means are
entered.
Examples of other electronic means include: by fax or an attachment to an email.
Review Criteria
The description should be sufficiently clear, detailed and complete to permit the
reviewer to determine that the State’s election meets applicable federal
statutory, regulatory and policy requirements.
Screen and Enroll Process
This section begins with the State being asked to provide assurance that it has
coordinated eligibility and enrollment screening procedures in place that are applied at
time of initial application, periodic redeterminations, and follow-up eligibility
determinations.
The State provides this affirmative assurance by checking the box next to the assurance
statement. If the State does not check this box, the system will not accept this template
for review and approval.
This assurance is followed by a listing of three procedures which are pre-checked as they
are required by regulation of all States.
This is followed by a Y/N question asking if the CHIP agency has entered into an
arrangement with the Exchange to make eligibility determinations for advanced premium
tax credits in accordance with section 1943(b)(2) of the SSA. Regardless of whether the
State responds with a yes or no to this question, no additional data entry is required.
4

Redetermination Processing
This section consists or an assurance that redeterminations of eligibility for individuals
whose financial eligibility is based on the applicable modified adjusted gross income
standard are performed consistent with 42 CFR 457.343.
The State provides this affirmative assurance by checking the box next to the assurance
statement. If the State does not check this box, the system will not accept this template
for review and approval.
Screening by Other Insurance Affordability Programs
This section begins with the State being asked to provide assurance that it has adopted
procedures to accept and process electronic accounts of individuals screened as
potentially eligible for CHIP by other insurance affordability programs in accordance
with the requirements of 42 CFR 457.348(b) and to determine eligibility in accordance
with 42 CFR 457.340 in the same manner as if the application had been submitted
directly to, and processed by the State.
The State provides this affirmative assurance by checking the box next to the assurance
statement. If the State does not check this box, the system will not accept this template
for review and approval.
Immediately following the assurance, the CHIP Agency may indicate, by checking the
box next to the option, if it elects the option to accept CHIP eligibility decisions made by
another Insurance Affordability Program as provided in 42 CFR 457.348 and to furnish
CHIP in accordance with requirements of 42 CFR 457.340 to the same extent and in the
same manner as if the applicant had been determined by the State to be eligible for CHIP.
If the CHIP Agency checks this option, the State must then select from the three options
displayed as to which insurance affordability programs. One, two or all three of the
options may be selected.
If the State selects ‘Other Insurance Affordability Program’, it must enter the
name of the insurance affordability program in the text box provided. If there is
more than one other insurance affordability program, the State may re-select this
option until they have all been entered.

The last part of this section asks the Agency to provide assurance that it has entered into
an agreement with other insurance affordability programs to fulfill the requirements of
457.348(a) and will provide this agreement to the Secretary upon request.
The State provides this affirmative assurance by checking the box next to the assurance
statement. If the State does not check this box, the system will not accept this template
for review and approval.
Limitation on Enrollment
This section is broken down into the following subsections:
Background Information
Request for Placing Limitations on Enrollment
Background Information
This section begins with a Y/N question asking if the State had an approved plan
allowing for enrollment limits and the imposition of an enrollment freeze as of March 23,
2010.
If the answer is yes, the State must attach a copy of State's current approved State Plan
and letter from CMS granting approval for the enrollment cap and/or waiting list through
the Upload function before responding to the next question. See the next paragraph (If the
answer is no) for instructions related to this next question.
If the answer is no, a Y/N question is displayed asking if the State has expanded
eligibility after 3/23/10.
If the answer is no, there are no additional questions for the State.
If the answer is yes, another Y/N question is displayed asking if the State wants to
request approval for placing enrollment limitations to the expansion population.
If the answer is yes, the State must first describe the expansion population in the
text box provided before completing the ‘Request for Placing Limitations on
Enrollment’ section.
Note: In the description of the expansion population, States should be sure to only
include covered groups which were added to the State Plan after March 23, 2010.
Review Criteria
The description should be sufficiently clear, detailed and complete to permit the
reviewer to determine that the State’s election meets applicable federal
statutory, regulatory and policy requirements.

Request for Placing Limitations on Enrollment
This subsection is broken down into:
• Amendment Type
• Enrollment Cap
• Waiting List
Amendment Type
This section begins with the State selecting one of the two following options:
•

Specific state plan amendment indicating that a cap will be instituted as of a
specific date or enrollment number.

•

Amendment seeking general authority to implement a cap when needed without
specifying a date or enrollment number.

If the State selects ‘Specific state plan amendment indicating that a cap will be instituted
as of a specific date or enrollment number’, the State must then select from the following
options as to when enrollment becomes capped:
•

Enrollment reaches a certain level

•

Expenditures reach a certain level

•

Other

If the State selects ‘Enrollment reaches a certain level’, the State must then enter in
the enrollment cap number in the box provided.
If the State selects ‘Expenditures reach a certain level’, the State must then enter in
the dollar amount in the box provided.
If the State selects ‘Other’, it must enter a description in the text box provided. If
there is more than one other criterion, the State may reselect the ‘other ‘ option until
they have all been entered .
Review Criteria
The description should be sufficiently clear, detailed and complete to permit the
reviewer to determine that the State’s election meets applicable federal statutory,
regulatory and policy requirements.
Regardless of which option is selected, the CHIP Agency is asked to provide assurance
that it will provide to CMS, written advance notice of at least 30 days prior to
implementing an enrollment freeze.
7

The State provides this affirmative assurance by checking the box next to the assurance
statement. If the State does not check this box, the system will not accept this template
for review and approval.
Enrollment Cap
Following the assurance, the State must describe how it will notify applicants and the
public of the cap, in the text box provided. States should be sure to include of modes of
communication (e.g. written communication; print media, radio or TV ads or public
service announcements) as well as the schedule (e.g. written communication to applicants
at time of application, ads in local newspapers once a month for the duration of the
enrollment freeze).
Review Criteria
The description should be sufficiently clear, detailed and complete to permit the
reviewer to determine that the State’s election meets applicable federal statutory,
regulatory and policy requirements.
Next is a Y/N question asking if the enrollment cap can apply to individuals who do not
renew their eligibility at redetermination and who subsequently re-apply?
If the answer is yes, States must indicate how it will notify current enrollees from
a list of options provided.
If the State selects ‘other’, it must enter a description in the text box provided.
States should be sure to include modes of communication (e.g. written
communication; print media, radio or TV ads or public service announcements) as
well as the schedule (e.g. written communication to applicants at time of
application, ads in local newspapers once a month for the duration of the
enrollment freeze).
Review Criteria
The description should be sufficiently clear, detailed and complete to permit the
reviewer to determine that the State’s election meets applicable federal
statutory, regulatory and policy requirements.
Waiting List
The next Y/N question asks if the state will implement a waiting list.
If the answer is yes, The State is asked to provide assurance that applications are
screened for Medicaid or other insurance affordability programs and referred as
appropriate.

The State provides this affirmative assurance by checking the box next to the assurance
statement. If the State does not check this box, the system will not accept this template
for review and approval.
The first follow-up question asks how the State will provide public notice
of the waiting list. States must select one or both of the options listed.
Note: If the State selects ‘other’, it must enter a description in the text box
provided. States should be sure to include of modes of communication
(e.g. written communication; print media, radio or TV ads or public
service announcements) as well as the schedule (e.g. written
communication to applicants at time of application, ads in local
newspapers once a month for the duration of the enrollment freeze).
Review Criteria
The description should be sufficiently clear, detailed and complete to
permit the reviewer to determine that the State’s election meets
applicable federal statutory, regulatory and policy requirements.
The second follow-up question asks if there will be exceptions to the
waiting list. States must select one or all four of the options listed.
Note: If the State selects ‘other’, it must enter a description in the text box
provided. Examples of additional exceptions include: children with special
health care needs or high risk pregnancies.
Review Criteria
The description should be sufficiently clear, detailed and complete to
permit the reviewer to determine that the State’s election meets
applicable federal statutory, regulatory and policy requirements.
The third follow-up question asks how long after notification of removal
from the waiting list will a family have to enroll. States must select one of
the three options listed.
Note: States selecting ‘other’, should enter a number and the time period
to which that number applies, e.g. 100 days, 6 months along with any
other relevant information.
Review Criteria
The information should be sufficiently clear, detailed and complete to
permit the reviewer to determine that the State’s election meets
applicable federal statutory, regulatory and policy requirements.

The last follow-up question asks if the State will require updated or
additional information from the family after removal from the waiting list
and before enrolling children into CHIP.
If the answer is yes, the State is asked to provide a description in the text
box provided. The description should include the type of follow-up and
the time period applicants will be given to respond. An example of an
acceptable response is that the State may ask if there has been a change in
family circumstances for applicants who were on the waiting list for
longer than 3 months and applicants will be given 15 days to respond.
Review Criteria
The description should be sufficiently clear, detailed and complete to
permit the reviewer to determine that the State’s election meets
applicable federal statutory, regulatory and policy requirements.

If the answer to waiting list is no, the State must indicate whether it will
implement an open enrollment period.
If the answer is yes, the State is asked to provide an assurance that
applications are screened for Medicaid or other insurance affordability
programs and referred as appropriate.
The State provides this affirmative assurance by checking the box next to
the assurance statement. If the State does not check this box, the system
will not accept this template for review and approval.
The first follow-up question asks How the State will provide public notice
of the waiting list. States must select one or both of the options listed.
Note: If the State selects ‘other’, it must enter a description in the text box
provided. States should be sure to include modes of communication (e.g.
written communication; print media, radio or TV ads or public service
announcements) as well as the schedule (e.g. written communication to
applicants at time of application, ads in local newspapers once a month for
the duration of the enrollment freeze).
Review Criteria
The description should be sufficiently clear, detailed and complete to
permit the reviewer to determine that the State’s election meets
applicable federal statutory, regulatory and policy requirements.

The second follow-up question asks if there will be exceptions to the open
enrollment period. States must select one or all four of the options listed.
Note: If the State selects ‘other’, it must enter a description in the text box
provided. Examples of additional exceptions include: children with special
health care needs or high risk pregnancies.
Review Criteria
The description should be sufficiently clear, detailed and complete to
permit the reviewer to determine that the State’s election meets
applicable federal statutory, regulatory and policy requirements.
The third follow-up question asks how often will the State implement the
open enrollment period. The State must select on one of the options listed.
Note: If the State selects ‘as circumstances warrant’, it must then respond
in the text box provided to the following question: ‘On what will the state
base this decision?’. Examples include: enrollment will be opened when
enrollment reaches a certain level below the enrollment cap and re-frozen
when enrollment nears the cap again or that enrollment will opened if
expenditures increased at a slower pace than had been projected.
Review Criteria
The description should be sufficiently clear, detailed and complete to
permit the reviewer to determine that the State’s election meets
applicable federal statutory, regulatory and policy requirements.
If the State selects ‘other’, it must enter a description in the text box
provided. If the State intends to open enrollment based on a schedule,
other than once or twice a year, it should note timeframe in the
description.
Review Criteria
The description should be sufficiently clear, detailed and complete to
permit the reviewer to determine that the State’s election meets
applicable federal statutory, regulatory and policy requirements.
Validation: The system will check to ensure that the State responded with a yes to at least
one of the two questions regarding having a waiting list or open enrollment. If the
validation fails, an error message is displayed and the State is given the opportunity to
change its answer to one or both of those questions.

Template CS25 – General Eligibility - Beginning Date of Eligibility
Statute:
Regulation: 42 CFR 457.340(f)
INTRODUCTION
To be completed by States with separate child health assistance programs.
In template CS25, States provide information as to the methodology used in determining
the effective date of eligibility.
BACKGROUND
With the issuance of Final Rule Vol. 77, No 57, implementing provisions of the ACA, 42
CFR 457.340(f) was revised to require that States have a methodology for determining
effective date of eligibility that includes a coordinated transition of children between
CHIP and other insurance affordability programs to avoid gaps in coverage.
TECHNICAL GUIDANCE
This template is broken down into the following sections:
Assurance
Determination of Beginning Date of Eligibility
Exceptions
Assurance
Template CS25 begins with the State being asked to provide an assurance that it has a
method in place to determine the eligibility and/or enrollment effective dates that ensures
coordination between all the insurance affordability programs and avoids gaps or overlap
in coverage, including when changes in family circumstances lead to a change in
programs.
The State provides this affirmative assurance by checking the box next to the assurance
statement. If the State does not check this box, the system will not accept this template
for review and approval.
Determination of Beginning Date of Eligibility
The State must select from the 5 options listed as to how it determines the beginning date
of eligibility. Only one option may be selected.
If the State selects ‘Prospective effective date”, it must provide a description in the text
box provided. The description must include an explanation of the factors considered in

determining the prospective effective date, e.g. application date, eligibility determination
date, health plan selection and or health plan enrollment.
Review Criteria
The description should be sufficiently clear, detailed and complete to permit the
reviewer to determine that the State’s election meets applicable federal statutory,
regulatory and policy requirements.
If the State selects ‘Other‘, it must provide a description in the text box provided. The
description must include an explanation of the date (e.g. 15th of the month, any time
during the month), other factors considered (e.g. effective date of loss of coverage prior
to application) and rationale (e.g. avoid gaps in coverage).
Review Criteria
The description should be sufficiently clear, detailed and complete to permit the
reviewer to determine that the State’s election meets applicable federal statutory,
regulatory and policy requirements.
Exceptions
In this section, the State is asked to describe any exceptions to the CHIP Agency's
general rules for beginning dates of eligibility.
The State can skip this section if it does not allow any exceptions. If the State’s policy
allows exceptions to the general rules indicated in the previous section, then the State
must enter a description of its exception process along with a listing of acceptable
exceptions.
Review Criteria
The description should be sufficiently clear, detailed and complete to permit the
reviewer to determine that the State’s election meets applicable federal statutory,
regulatory and policy requirements.

Template CS26 – General Eligibility - Ending Dates of Eligibility
Statute:
Regulation:
INTRODUCTION
To be completed by States with separate child health assistance programs.
In template CS26, States provide information as to the methodology used in determining
the ending date of eligibility.
BACKGROUND
As with the beginning dates of eligibility, in determining the State’s methodology for the
effective date or eligibility termination, States should take into consideration the
coordinated transition of children between CHIP and other insurance affordability
programs to avoid gaps in coverage.
TECHNICAL GUIDANCE
This template is broken down into the following sections:
Assurance
Ending Date of Eligibility
Rules for Pregnant Women, if applicable
Assurance
Template CS26 begins with the State being asked to provide an assurance that it
determines the end date of eligibility in accordance with the provisions that follow.
The State provides this affirmative assurance by checking the box next to the assurance
statement. If the State does not check this box, the system will not accept this template
for review and approval
Ending Date of Eligibility
The State must select from the 5 options listed. Only one option may be selected.
If the State selects ‘Other‘, it must provide a description in the text box provided. The
description must include an explanation of the date (e.g. 15th of the month, any time
during the month), other factors considered (e.g. effective date new coverage) and
rationale (e.g. avoid gaps in coverage).
Review Criteria

The description should be sufficiently clear, detailed and complete to permit the
reviewer to determine that the State’s election meets applicable federal statutory,
regulatory and policy requirements.
Rules for Pregnant Women
This section displays only for States that offer coverage to targeted low-income pregnant
women.
This section consists of two policy statements and no entries are required by the State.

Template CS27 – General Eligibility - Continuous Eligibility
Statute: 2105(a)(4)(A)
Regulation:
INTRODUCTION
To be completed by States with separate child health assistance programs.
In template CS27, States indicate if they elect the option to provide continuous eligibility
(CE) coverage and if so, provide information as to the administration of continuous
eligibility.
BACKGROUND
States have the option to extend coverage to children for up to a full 12 month period if
certain conditions are met, although a change in family circumstances might otherwise
result in the termination of eligibility.
TECHNICAL GUIDANCE
This template is broken down into the following sections:
Policy Statement
Selection of Continuous Eligibility Option
Age and CE Period
Exceptions to CE

Policy Statement
Template CS27 begins with a policy statement that ‘ The CHIP Agency may provide that
children who have been determined eligible under the state plan, shall remain eligible
until either the end of a period (not to exceed 12 months) following determination, or the
time the child exceeds an age specified by the state (not to exceed 19), whichever is
earlier.’
Selection of Continuous Eligibility Option
In this section, States respond to a Y/N question as to whether it elects to provide
continuous eligibility.
If the answer is no, no additional entries are required by the State on this screen.
If the answer is yes, the State must complete the next two sections
Age and CE Period

For age, States must enter the age of children up to which the State will apply continuous
eligibility. .
Validation: The system will not accept a number for age that exceeds19.
For eligibility period, States must select one of the two options listed.
If the State selects the first option, it must then select the number of months from a drop
down list of the numbers 1 through 12 appearing in descending order.
Exceptions to CE
This section displays 6 options for exceptions to continuous eligibility, from which the
State can select none, one or more.

If the State selects ‘Other’, it must enter a description in the text box provided. States
should also include the rationale for the exception. If the State has more than one
additional exception, it can re-check the box next to other and repeat the process until all
exceptions have been entered.
Review Criteria
The description should be sufficiently clear, detailed and complete to permit the
reviewer to determine that the State’s election meets applicable federal statutory,
regulatory and policy requirements.

Template CS28 – General Eligibility – Presumptive Eligibility for Children
Statute: Sections 2107(e)(1)(L) and 1920A of the SSA
Regulation: 42 CFR 457.355
INTRODUCTION
To be completed by States with separate child health assistance programs.
In template CS28, States indicate if they elect the option to provide presumptive
eligibility (PE) for children and if so, provide information as to the administration of
presumptive eligibility. This template is used in conjunction with template CS(30)
Qualified Entities.
BACKGROUND
States may elect to apply presumptive eligibility for children provided that the
requirements of section 1920A of the SSA are satisfied.

Under presumptive eligibility States may pay costs of coverage under CHIP during a
period of presumptive eligibility for children applying for CHIP, pending the screening
process and a final determination of eligibility, provided that the PE determination was
made by a qualified entity. Section 1920A of the SSA defines certain types of entities
which may be used as qualified entities for the purpose of making determinations of
presumptive eligibility. Agencies must meet at least one of the requirements specified in
the Act.
TECHNICAL GUIDANCE
This template is broken down into the following sections:
Selection and Description of Presumptive Eligibility
Selection of Qualified Entities
Selection of Presumptive Eligibility Option
In this section, States respond to a Y/N question as to whether the CHIP Agency covers
children when determined presumptively eligible by a qualified entity.
If the answer is no, no additional entries are required by the State on this screen.
If the answer is yes, the State is then asked to:
•

Describe the population of children to whom presumptive eligibility applies.

•

Describe the duration of the presumptive eligibility period and any limitations.

•

Describe the application process and eligibility determination factors used.
1

Template CS29 – General Eligibility – Presumptive Eligibility for Pregnant Women
Statute: Sections 2112(c) of the SSA
Regulation:
INTRODUCTION
To be completed by States with separate child health assistance programs which also
provide coverage to pregnant women.
In template CS29, States indicate if they elect the option to provide presumptive
eligibility (PE) to pregnant women and if so, provide information as to the administration
of presumptive eligibility for pregnant women. This template is used in conjunction with
template CS(30) Qualified Entities.
BACKGROUND
States may elect to apply presumptive eligibility for pregnant women coverage
under CHIP, provided that the requirements of section 1920 of the SSA are satisfied.
Section 1920 of the SSA defines certain types of providers which may be used as
qualified providers for the purpose of making determinations of presumptive eligibility
for pregnant women. Since qualified entities are included in the definition of qualified
providers, States may also elect to use qualified entities to determine presumptive
eligibility for pregnant women.
Under presumptive eligibility, States may pay costs of coverage under CHIP during a
period of presumptive eligibility for pregnant women applying for CHIP, pending the
screening process and a final determination of eligibility, provided that the PE
determination was made by a qualified provider.
TECHNICAL GUIDANCE
This template is broken down into the following sections:
Selection and Description of Presumptive Eligibility
Selection of Qualified Entities
Selection and Description of Presumptive Eligibility
In this section, States respond to a Y/N question as to whether the CHIP Agency covers
pregnant women when determined presumptively eligible by a qualified entity.
If the answer is no, no additional entries are required by the State on this screen.
If the answer is yes, the State is then asked to:

•

Describe the population of pregnant women to whom presumptive eligibility
applies.

•

Describe the duration of the presumptive eligibility period and any limitations.

•

Describe the application process and eligibility determination factors used.

The State enters the requested information in the text boxes provided.
Review Criteria
The description should be sufficiently clear, detailed and complete to permit the
reviewer to determine that the State’s policies meet applicable federal statutory,
regulatory and policy requirements.
Selection of Qualified Entities
This section begins with a pre-checked statement that the CHIP Agency uses the
following entities to determine presumptive eligibility for pregnant women.
The State must then respond to a Y/N question as to whether the same qualified entities
are used to determine presumptive eligibility for pregnant women as used for children.
If the answer is no, template CS30 is displayed for the State to indicate which
types of organizations are used as qualified entities to determine presumptive
eligibility for pregnant women.
If the answer is yes, the State may view the list of qualified entities selected by
the State to determine presumptive eligibility for children.

Template CS30 – General Eligibility - List of Qualified Entities
Statute: Section 1920A
Regulation: 42CFR457.301
INTRODUCTION
This template applies only to States with separate child health assistance programs.
This template is not accessed directly. It is used in conjunction with templates CS28 (P.E
for children) or CS29 (P.E. for pregnant women) and is displayed for States to identify
the types of organizations it uses as qualified entities.
BACKGROUND
42 CFR457.301 defines Qualified Entities and identifies certain types of entities which
may be used for the purpose of making determinations of presumptive eligibility.
Agencies must meet the requirements specified in the Regulation.
TECHNICAL GUIDANCE
PREREQUISITE: States must have completed either template CS28 or CS29 through the
Qualified Entities section within which this template gets displayed.
In template CS30, States select one or more of the options listed as to the types of entities
used by the State to determine presumptive eligibility for children, if displayed within
template CS28 and for pregnant women if displayed within template CS29.
If the State selects ‘Any other entity the State so deems, as approved by the Secretary’, it must
enter the name and description of the entity in the text boxes provided. If there is more
than one other entity, the State can reselect this option until all the additional entities have
been entered.
Review Criteria
The description should be sufficiently clear, detailed and complete to permit the
reviewer to determine that the State’s election meets applicable federal
statutory, regulatory and policy requirements.
After the entities have been selected, the CHIP Agency must provide assurance that it has
communicated the requirements for qualified entities at 1920A(b)(3) of the Act, and
provided adequate training to the entities and organizations involved.
The State provides this affirmative assurance by checking the box next to the assurance
statement. If the State does not check this box, the system will not accept this template
for review and approval.

The State must then upload a copy of the training materials via the upload function.

Template CS32 – General Eligibility - Express Lane Eligibility
Statute: Sections 2107(e)(1)(E) and 1902(e)(13) of the SSA
Regulation:
Additional Reference: SHO # 10-003, February 4, 2010

INTRODUCTION

To be completed by States with separate child health assistance programs.
In template CS32, States indicate if they elect the option to use Express Lane agencies to
determine whether a child meets one or more of the requirements for CHIP eligibility and
if yes, provide information as to how Express Lane will be administered.
BACKGROUND
Express Lane Eligibility was enacted as part of the Children’s Health Insurance Program
Reauthorization Act of 2009 (CHIPRA). It permits states to use the findings of other
public agencies to conduct simplified eligibility determinations and facilitate enrollment
of children in Medicaid and CHIP by satisfying some or all of the eligibility requirements
for these programs. Express Lane agencies include those administering the TANF, Child
Support, CHIP, SNAP, School Lunch, WIC, Section 8 and other Federal housing
programs, Head Start, Child Care, Homeless Assistance, and Native American Housing
Assistance programs.
In addition the State may designate as Express Lane agencies and use the findings of
• Another governmental agency with fiscal liability or legal responsibility for the
accuracy of the eligibility determination findings relied on by the State, or
• Governmental agencies that are subject to an interagency agreement limiting the
disclosure and use of the information disclosed for purposes of determining
eligibility under the State plan.
Express Lane agencies may not include:
• Private, for profit organizations, or
• Agencies that only determine eligibility for programs under the title XX Social
Services Block Grant.
If the State elects to use the Express Lane Eligibility authority, it has a number of options
for how the Express Lane agency findings are used. It can elect to:
• Use it for applications, redeterminations, or both;
• Automatically enroll children based on the Express Lane agency’s data with the
family’s affirmative consent and/or automatically renew or continue eligibility;
• Use State income tax data to determine income eligibility;
• Use “screen and enroll” options to determine income eligibility for Medicaid and
CHIP by either establishing a screening threshold amount of income above the
Medicaid standard or by temporarily enrolling the child or children in CHIP while
1

determining if the child or children are eligible for Medicaid or CHIP based on a
full eligibility determination.
Additional information may be found in SHO # 10-003, dated February 4, 2010.

TECHNICAL GUIDANCE

This template is broken down into the following sections:
Selection of Express Lane Eligibility
Assurance
Provisions
Express Lane Agencies
Eligibility Components
Selection of Express Lane Eligibility
The State indicates whether or not it elects to rely on findings from Express Lane
agencies when determining Medicaid eligibility.
Assurance
If the State elects Express Lane eligibility, it must assure that it administers Express Lane
Eligibility as described in the template and consistent with section 2107(e)(1)(E) of the
Act.
The State provides this affirmative assurance by checking the box next to the assurance
statement. If the State does not check this box, the system will not accept this template
for review and approval.
Provisions
The first provision: ‘The Express Lane option is used for children under the age of 19’ is
pre-checked as it applies to all States.
Next, the State must indicate its selections of certain options:
• The State must indicate if the Express Lane option will be applied to initial
determinations (applications) or redeterminations of eligibility, or both.
• The State may elect to enroll children automatically, without an application, based
on data from Express Lane agencies and with the family’s or child’s affirmative
consent.
• The State may choose to use income eligibility findings from an Express Lane
agency that are based on State income tax data.
• The State must select an option for one of the Screen and Enroll requirements in
the Act. It must choose one of the following:
o One screening threshold
o More than one screening threshold, based on existing age-related income
standards for children in the State Plan
o Temporary enrollment, pending the full eligibility determination
2

o The State’s regular screening and enrollment process
If the State selects either ‘One screening threshold’ or ‘More than one screening
threshold, based on existing age-related income standards for children in the State
Plan’, the State must select whether it uses a threshold which exceeds the highest
applicable income standard for children (or for children in specific age-related
groups) by:
o 30 percentage points, or
o More than 30 percentage points.
If More than 30 percentage points is selected, the State must specify the
number of percentage points and provide a description of how this percentage
reflects the differences between the income methodologies of Medicaid the
Express Lane agency.
Express Lane Agencies
In addition to selecting the options for its Express Lane eligibility policy, the State must
indicate which types of public agencies are approved by the State as Express Lane
agencies. See implementation guidance for CS33 Express Lane Agencies.
Eligibility Components
The State must also indicate for each Express Lane Agency which eligibility components
are determined by that Express Lane Agency. See implementation guidance for CS34
Express lane Eligibility Components.

Template CS33 – General Eligibility - Express Lane Agencies
Statute: Sections 2107(e)(1)(E) and 1902(e)(13) of the SSA
Regulation:
INTRODUCTION
To be completed by States with separate child health assistance programs which elected
the option to use Express Lane agencies to determine whether a child meets one or more
of the requirements for CHIP eligibility in template CS32.
Template CS33 is used in conjunction with CS32 Express Lane Eligibility. States use
this template to designate which agencies will be used by the State as Express Lane
Agencies.
BACKGROUND
See implementation guidance for template CS32 for Background Information.
TECHNICAL GUIDANCE
PREREQUISITE: States must have completed template CS32 through the Express Lane
Agencies section within which this template gets displayed.
In this template, the State indicates which types of agencies it uses to determine
eligibility under the Express Lane option. It must select one or more of the four options
listed.
•

If ‘Public agencies that determine eligibility for assistance under any of the
following’ is selected, the State must check off one or more of the public agencies
from the list provided.

•

If ‘Other State-specified governmental agency that has fiscal liability or legal
responsibility for the accuracy of the eligibility determination findings relied on
by the State.’ is selected, the State must provide the name of the agency or
agencies. If there are multiple agencies, each agency must be entered separately.
This is done by re-checking the box next to the field named ‘Agency Name’.

•

If ‘A public agency that is subject to an interagency agreement limiting disclosure
and use of the information disclosed for the purposes of determining eligibility
under the Plan’ is selected, the State must provide the name of the agency. If there
are multiple agencies, each agency must be entered separately. This is done by rechecking the box next to the field named ‘Agency Name’.

Template CS34 – General Eligibility - Express Lane Eligibility Components
Statute: Sections 2107(e)(1)(E) and 1902(e)(13) of the SSA
Regulation:
INTRODUCTION
To be completed by States with separate child health assistance programs which elected
the option to use Express Lane agencies to determine whether a child meets one or more
of the requirements for CHIP eligibility in template CS32.
Template CS34 is used in conjunction with CS32 Express Lane Eligibility. States use
this template to specify the eligibility components used by each Express Lane Agency
used by the State.
BACKGROUND
States may vary which eligibility components are used by individual Express Lane
agencies provided that at a minimum, household income and household size are
used by all Express Lane agencies.

Additional background information may be found in the implementation guidance
for template CS32.
TECHNICAL GUIDANCE

PREREQUISITE: States must have completed template CS32 through the Express Lane
Eligibility Components section within which this template gets displayed and template
CS33 (Express Lane Agencies) before completing this template. This template will not
display if template CS33 has not been completed.
The system will display each agency that the State has designated as an Express Lane
Agency on the CS33 Express Lane Agencies template. For each agency, the State must
select from the list displayed, of eligibility findings which are determined by the Express
Lane Agency.
If the State selects ‘Other’, is must enter a name (this can be any name that relates to the
eligibility component and makes sense to the State) and description . If the Agency uses
more than one additional eligibility component, the State must reselect ‘Other’ until all
the eligibility components have been entered.
Review Criteria
The description should be sufficiently clear, detailed and complete to permit the
reviewer to determine that the State’s election meets applicable federal statutory,
regulatory and policy requirements.

For each eligibility component checked the State must select Y or N to indicate if the
methodology used under the Express Lane option is the same as it otherwise uses in
determining eligibility for CHIP.
•

If No, the State must describe any differences between the two methodologies in
the text box provided.

Review Criteria
The description should be sufficiently clear, detailed and complete to permit the
reviewer to determine that the State’s election meets applicable federal statutory,
regulatory and policy requirements.
There is a copy capability in this template so that the State may copy its response from
one Express Lane agency to another Express Lane agency and then, if necessary, modify
it to reflect any differences.

File Type	application/pdf
Author	Roy Trudel
File Modified	2019-08-30
File Created	2019-08-30