Form CMS-10434 #22 CMS-10434 #22 Health Homes

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

#22 Health Homes

GenIC #22 (Extension) - Health Home State Plan Amendment (SPA)

OMB: 0938-1188

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1188 can be found here:

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

Medicaid and CHIP Program (MACPro)
A1-Designation and Authority RU PRA document
Version 1.0
08/09/2017

Document Number: 162-QSSI-MACPro-PRA-A1-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. A1- Designation and Authority Screenshots ......................................................... 1
1.1
1.2

Section A. Single State Agency and Section B. Attorney General
Certification ..................................................................................................... 1
Section C. Administration of the Medicaid Program and D. Additional
information (optional) ...................................................................................... 2

List of Figures
Figure 1: Section A and B ............................................................................................... 1
Figure 2: Section C and D ............................................................................................... 2

List of Tables
No table of figures entries found.

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A1- Designation and Authority Screenshots

1. A1- Designation and Authority Screenshots
1.1

Section A. Single State Agency and Section B. Attorney General
Certification

Figure 1: Section A and B

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1.2

A1- Designation and Authority Screenshots

Section C. Administration of the Medicaid Program and D.
Additional information (optional)

Figure 2: Section C and D

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

Medicaid and CHIP Program (MACPro)
A2-Intergovernmental Cooperation Act Waivers
RU PRA document
Version 1.0
08/11/2017

Document Number: 163-QSSI-MACPro-PRA-A2-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. A2- Intergovernmental Cooperation Act Waivers Screenshots ........................... 1
1.1
1.2
1.3

Section A. Intergovernmental Cooperation Act Waivers ................................. 1
Add Waiver...................................................................................................... 2
Section B. Additional Information (optional) .................................................... 3

List of Figures
Figure 1: Section A .......................................................................................................... 1
Figure 2: Add Waiver....................................................................................................... 2
Figure 3: Section B .......................................................................................................... 3

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A2- Intergovernmental Cooperation Act Waivers Screenshots

1. A2- Intergovernmental Cooperation Act Waivers Screenshots
1.1

Section A. Intergovernmental Cooperation Act Waivers

Figure 1: Section A

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A2- Intergovernmental Cooperation Act Waivers Screenshots

Add Waiver

Figure 2: Add Waiver
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A2- Intergovernmental Cooperation Act Waivers Screenshots

Section B. Additional Information (optional)

Figure 3: Section B

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

Medicaid and CHIP Program (MACPro)
A3-Eligibility Determinations and Fair Hearings
RU PRA document
Version 1.0
08/21/2017

Document Number: 235-QSSI-MACPro-PRA-A3-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. A3- Eligibility Determinations and Fair Hearings Screenshots............................ 1
1.1
1.2
1.3

Section A. Eligibility Determinations (including any delegations) – Screenshot
1 ...................................................................................................................... 1
Section B. Fair Hearings (including any delegations) ...................................... 2
Section C. Evidentiary Hearings and Section D. Additional information
(optional) ......................................................................................................... 3

List of Figures
Figure 1: Section A Screenshot 1 .................................................................................... 1
Figure 2: Section A Screenshot 2 .................................................................................... 2
Figure 3: Section B .......................................................................................................... 2
Figure 4: Section C and D ............................................................................................... 3

List of Tables
No table of figures entries found.

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A3- Eligibility Determinations and Fair Hearings Screenshots

1. A3- Eligibility Determinations and Fair Hearings
Screenshots
1.1

Section A. Eligibility Determinations (including any delegations)

Figure 1: Section A Screenshot 1

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A3- Eligibility Determinations and Fair Hearings Screenshots

Figure 2: Section A Screenshot 2

1.2

Section B. Fair Hearings (including any delegations)

Figure 3: Section B

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A3- Eligibility Determinations and Fair Hearings Screenshots

Section C. Evidentiary Hearings and Section D. Additional
information (optional)

Figure 4: Section C and D

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

Medicaid and CHIP Program (MACPro)
A4-Organization and Administration RU PRA
document
Version 1.0
08/21/2017

Document Number: 242-QSSI-MACPro-PRA-A4-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. A4-Organization and Administration Screenshots ............................................... 1
1.1
1.2
1.3

1.4

Section A. Description of the Organization and Functions of the Single State
Agency ............................................................................................................ 1
Section B. Entities that Determine Eligibility or Conduct Fair Hearings Other
than the Medicaid Agency ............................................................................... 3
Section C. Supervision of the Administration of the State Plan through a State
Agency Other Than the Medicaid Agency and Section D. Supervision of the
Administration of the State Plan through Local Government Entities .............. 4
Section E. Coordination with Other Executive Agencies and Section F.
Additional information (optional) ...................................................................... 5

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

List of Tables
No table of figures entries found.

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A4-Organization and Administration Screenshots

1. A4-Organization and Administration Screenshots
1.1

Section A. Description of the Organization and Functions of the
Single State Agency

Figure 1: Section A Screenshot 1

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A4-Organization and Administration Screenshots

Figure 2: Section A Screenshot 2

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A4-Organization and Administration Screenshots

Section B. Entities that Determine Eligibility or Conduct Fair
Hearings Other than the Medicaid Agency

Figure 3: Section B

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A4-Organization and Administration Screenshots

Section C. Supervision of the Administration of the State Plan
through a State Agency Other Than the Medicaid Agency and
Section D. Supervision of the Administration of the State Plan
through Local Government Entities

Figure 4: Section C and D

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A4-Organization and Administration Screenshots

Section E. Coordination with Other Executive Agencies and
Section F. Additional information (optional)

Figure 5: Section E and F

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

Medicaid and CHIP Program (MACPro)
A5-Single State Agency Assurances RU PRA
document
Version 1.0
08/21/2017

Document Number: 240-QSSI-MACPro-PRA-A5-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. A5-Single State Agency Assurances Screenshots ............................................... 1
1.1

Section A. Assurances and Section B. Additional Information (optional) ........ 1

List of Figures
Figure 1: Section A and Section B .................................................................................. 1

List of Tables
No table of figures entries found.

A5-Single State Agency Assurances RU PRA document Version 1.0

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A5-Single State Agency Assurances Screenshots

1. A5-Single State Agency Assurances Screenshots
1.1

Section A. Assurances and Section B. Additional Information
(optional)

Figure 1: Section A and Section B

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

Medicaid and CHIP Program (MACPro)
HH1 - Health Homes Intro RU PRA document
Version 1.0
08/10/2017

Document Number: 167-QSSI-MACPro-PRA-HH1-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. HH1 – Health Homes Intro Screenshots ................................................................ 1
1.1

“Executive Summary” and “General Assurances” Sections............................. 1

List of Figures
Figure 1: Executive Summary and General Assurances ................................................. 1

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HH1 – Health Homes Intro Screenshots

HH1 – Health Homes Intro Screenshots
1.1

“Executive Summary” and “General Assurances” Sections

Figure 1: Executive Summary and General Assurances

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

Medicaid and CHIP Program (MACPro)
HH2 - Population and Enrollment PRA document
Version 1.0
08/10/2017

Document Number: 168-QSSI-MACPro-PRA-HH2-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. HH2 – Population and Enrollment Screenshots .................................................... 1
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8

“Categories of Individuals and Populations Provided Health Homes Services”
Section ............................................................................................................ 1
“Population Criteria” Section ........................................................................... 1
“Population Criteria” Section – Path 1 ............................................................. 2
“Population Criteria” Section – Path 2 ............................................................. 2
“Population Criteria” Section – Path 3 ............................................................. 2
“Enrollment of Participants” Section – Path 1 .................................................. 3
“Enrollment of Participants” Section – Path 2 .................................................. 3
“Enrollment of Participants” Section – Path 3 .................................................. 3

List of Figures
Figure 1: Categories of Individuals and Populations Provided Health Homes Services .. 1
Figure 2: Population Criteria ............................................................................................ 1
Figure 3: Population Criteria - 1 ...................................................................................... 2
Figure 4: Population Criteria - 2 ...................................................................................... 2
Figure 5: Population Criteria - 3 ...................................................................................... 2
Figure 6: Enrollment of Participants - 1 ........................................................................... 3
Figure 7: Enrollment of Participants - 2 ........................................................................... 3
Figure 8: Enrollment of Participants - 3 ........................................................................... 3

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HH2 – Population and Enrollment Screenshots

1. HH2 – Population and Enrollment Screenshots
1.1

“Categories of Individuals and Populations Provided Health
Homes Services” Section

Figure 1: Categories of Individuals and Populations Provided Health Homes Services

1.2

“Population Criteria” Section

Figure 2: Population Criteria

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HH2 – Population and Enrollment Screenshots

“Population Criteria” Section – Path 1

Figure 3: Population Criteria - 1

1.4

“Population Criteria” Section – Path 2

Figure 4: Population Criteria - 2

1.5

“Population Criteria” Section – Path 3

Figure 5: Population Criteria - 3

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HH2 – Population and Enrollment Screenshots

“Enrollment of Participants” Section – Path 1

Figure 6: Enrollment of Participants - 1

1.7

“Enrollment of Participants” Section – Path 2

Figure 7: Enrollment of Participants - 2

1.8

“Enrollment of Participants” Section – Path 3

Figure 8: Enrollment of Participants - 3

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

Medicaid and CHIP Program (MACPro)
HH3 – Geographic Limitations RU PRA document
Version 1.0
08/10/2017

Document Number: 172-QSSI-MACPro-PRA-HH3-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. HH3 – Geographic Limitations Screenshots ......................................................... 1
1.1
1.2
1.3
1.4
1.5

Geographic Limitations – Path 1 ..................................................................... 1
Geographic Limitations – Path 2 ..................................................................... 1
Geographic Limitations – Path 3 ..................................................................... 2
Geographic Limitations – Path 4 ..................................................................... 2
Geographic Limitations – Path 5 ..................................................................... 2

2. Geographic Limitations Add or Edit Phase Screenshots ..................................... 3
2.1
2.2
2.3
2.4
2.5

Geographic Limitations - Add or Edit Phase – Path 1 ..................................... 3
Geographic Limitations - Add or Edit Phase – Path 2 ..................................... 3
Geographic Limitations - Add or Edit Phase – Path 3 ..................................... 3
Geographic Limitations - Add or Edit Phase – Path 4 ..................................... 3
Geographic Limitations - Add or Edit Phase.................................................... 4

List of Figures
Figure 1: Geographic Limitations - 1 ............................................................................... 1
Figure 2: Geographic Limitations - 2 ............................................................................... 1
Figure 3: Geographic Limitations – 3............................................................................... 2
Figure 4: Geographic Limitations – 4............................................................................... 2
Figure 5: Geographic Limitations - 5 ............................................................................... 2
Figure 6: Geographic Limitations - Add or Edit Phase -1 ................................................ 3
Figure 7: Geographic Limitations - Add or Edit Phase – 2............................................... 3
Figure 8: Geographic Limitations - Add or Edit Phase – 3............................................... 3
Figure 9: Geographic Limitations - Add or Edit Phase - 4 ............................................... 3
Figure 10: Geographic Limitations - Add or Edit Phase – 5............................................. 4
Figure 11: Geographic Limitations - Add or Edit Phase - 6 ............................................. 4

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HH3 – Geographic Limitations Screenshots

1. HH3 – Geographic Limitations Screenshots
1.1

Geographic Limitations – Path 1

Figure 1: Geographic Limitations - 1

1.2

Geographic Limitations – Path 2

Figure 2: Geographic Limitations - 2

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HH3 – Geographic Limitations Screenshots

Geographic Limitations – Path 3

Figure 3: Geographic Limitations – 3

1.4

Geographic Limitations – Path 4

Figure 4: Geographic Limitations – 4

1.5

Geographic Limitations – Path 5

Figure 5: Geographic Limitations - 5

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Geographic Limitations Add or Edit Phase Screenshots

2. Geographic Limitations Add or Edit Phase Screenshots
2.1

Geographic Limitations - Add or Edit Phase – Path 1

Figure 6: Geographic Limitations - Add or Edit Phase -1

2.2

Geographic Limitations - Add or Edit Phase – Path 2

Figure 7: Geographic Limitations - Add or Edit Phase – 2

2.3

Geographic Limitations - Add or Edit Phase – Path 3

Figure 8: Geographic Limitations - Add or Edit Phase – 3

2.4

Geographic Limitations - Add or Edit Phase – Path 4

Figure 9: Geographic Limitations - Add or Edit Phase - 4

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Geographic Limitations Add or Edit Phase Screenshots

Geographic Limitations - Add or Edit Phase

Figure 10: Geographic Limitations - Add or Edit Phase – 5

Figure 11: Geographic Limitations - Add or Edit Phase - 6

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

Medicaid and CHIP Program (MACPro)
HH4 – Health Homes Services RU PRA document
Version 1.0
08/11/2017

Document Number: 165-QSSI-MACPro-PRA-HH4-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. HH4 – Health Homes Services Screenshots .......................................................... 1
1.1
1.2
1.3
1.4
1.5
1.6
1.7

“Service Definitions” Section – Comprehensive Care Management................ 1
“Service Definitions” Section – Care Coordination .......................................... 4
“Service Definitions” Section – Health Promotion ............................................ 6
“Service Definitions” Section – Comprehensive Transitional Care from
Inpatient to Other Settings............................................................................... 9
“Service Definitions” Section – Individual and Family Support ...................... 11
“Service Definitions” Section – Referral to Community and Social Support
Services ........................................................................................................ 14
“Health Homes Patient Flow” Section ........................................................... 17

List of Figures
Figure 1: Service Definitions - 1 ...................................................................................... 1
Figure 2: Service Definitions - 2 ...................................................................................... 1
Figure 3: Service Definitions - 3 ...................................................................................... 2
Figure 4: Service Definitions - 4 ...................................................................................... 2
Figure 5: Service Definitions - 5 ...................................................................................... 3
Figure 6: Service Definitions - 6 ...................................................................................... 3
Figure 7: Service Definitions - 7 ...................................................................................... 4
Figure 8: Service Definitions - 8 ...................................................................................... 4
Figure 9: Service Definitions - 9 ...................................................................................... 4
Figure 10: Service Definitions - 10 .................................................................................. 5
Figure 11: Service Definitions - 11 .................................................................................. 5
Figure 12: Service Definitions - 12 .................................................................................. 6
Figure 13: Service Definitions - 13 .................................................................................. 6
Figure 14: Service Definitions - 14 .................................................................................. 6
Figure 15: Service Definitions - 15 .................................................................................. 7
Figure 16: Service Definitions - 16 .................................................................................. 7
Figure 17: Service Definitions - 17 .................................................................................. 8

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List of Figures

Figure 18: Service Definitions - 18 .................................................................................. 8
Figure 19: Service Definitions - 19 .................................................................................. 9
Figure 20: Service Definitions - 20 .................................................................................. 9
Figure 21: Service Definitions - 21 .................................................................................. 9
Figure 22: Service Definitions - 22 ................................................................................ 10
Figure 23: Service Definitions - 23 ................................................................................ 10
Figure 24: Service Definitions - 24 ................................................................................ 11
Figure 25: Service Definitions - 25 ................................................................................ 11
Figure 26: Service Definitions - 26 ................................................................................ 11
Figure 27: Service Definitions - 27 ................................................................................ 12
Figure 28: Service Definitions - 28 ................................................................................ 12
Figure 29: Service Definitions - 29 ................................................................................ 13
Figure 30: Service Definitions - 30 ................................................................................ 13
Figure 31: Service Definitions - 31 ................................................................................ 14
Figure 32: Service Definitions - 32 ................................................................................ 14
Figure 33: Service Definitions - 33 ................................................................................ 14
Figure 34: Service Definitions - 34 ................................................................................ 15
Figure 35: Service Definitions - 35 ................................................................................ 15
Figure 36: Service Definitions - 36 ................................................................................ 16
Figure 37: Service Definitions - 37 ................................................................................ 16
Figure 38: Health Homes Patient Flow .......................................................................... 17

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HH4 – Health Homes Services Screenshots

1. HH4 – Health Homes Services Screenshots
1.1

“Service Definitions” Section – Comprehensive Care Management

Figure 1: Service Definitions - 1

Figure 2: Service Definitions - 2

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HH4 – Health Homes Services Screenshots

Figure 3: Service Definitions - 3

Figure 4: Service Definitions - 4

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HH4 – Health Homes Services Screenshots

Figure 5: Service Definitions - 5

Figure 6: Service Definitions - 6

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HH4 – Health Homes Services Screenshots

Figure 7: Service Definitions - 7

1.2

“Service Definitions” Section – Care Coordination

Figure 8: Service Definitions - 8

Figure 9: Service Definitions - 9

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HH4 – Health Homes Services Screenshots

Figure 10: Service Definitions - 10

Figure 11: Service Definitions - 11

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HH4 – Health Homes Services Screenshots

Figure 12: Service Definitions - 12

Figure 13: Service Definitions - 13

1.3

“Service Definitions” Section – Health Promotion

Figure 14: Service Definitions - 14

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HH4 – Health Homes Services Screenshots

Figure 15: Service Definitions - 15

Figure 16: Service Definitions - 16

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HH4 – Health Homes Services Screenshots

Figure 17: Service Definitions - 17

Figure 18: Service Definitions - 18

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HH4 – Health Homes Services Screenshots

Figure 19: Service Definitions - 19

1.4

“Service Definitions” Section – Comprehensive Transitional Care
from Inpatient to Other Settings

Figure 20: Service Definitions - 20

Figure 21: Service Definitions - 21

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HH4 – Health Homes Services Screenshots

Figure 22: Service Definitions - 22

Figure 23: Service Definitions - 23

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HH4 – Health Homes Services Screenshots

Figure 24: Service Definitions - 24

Figure 25: Service Definitions - 25

1.5

“Service Definitions” Section – Individual and Family Support

Figure 26: Service Definitions - 26

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HH4 – Health Homes Services Screenshots

Figure 27: Service Definitions - 27

Figure 28: Service Definitions - 28

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HH4 – Health Homes Services Screenshots

Figure 29: Service Definitions - 29

Figure 30: Service Definitions - 30

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HH4 – Health Homes Services Screenshots

Figure 31: Service Definitions - 31

1.6

“Service Definitions” Section – Referral to Community and Social
Support Services

Figure 32: Service Definitions - 32

Figure 33: Service Definitions - 33

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HH4 – Health Homes Services Screenshots

Figure 34: Service Definitions - 34

Figure 35: Service Definitions - 35

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HH4 – Health Homes Services Screenshots

Figure 36: Service Definitions - 36

Figure 37: Service Definitions - 37

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1.7

HH4 – Health Homes Services Screenshots

“Health Homes Patient Flow” Section

Figure 38: Health Homes Patient Flow

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

Medicaid and CHIP Program (MACPro)
HH5-Health Homes Providers RU PRA document
Version 1.0
08/11/2017

Document Number: 164-QSSI_MACPro-PRA-HH5-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. HH5 – Health Homes Providers Screenshots ........................................................ 1
1.1
1.2
1.3
1.4
1.5
1.6

“Types of Health Homes Providers” Section ................................................... 1
“Types of Health Homes Providers” Section – Path 1 ..................................... 1
“Types of Health Homes Providers” Section – Path 2 ..................................... 3
“Types of Health Homes Providers” Section – Path 3 ..................................... 5
“Provider Infrastructure” and “Supports for Health Homes Providers” Sections7
“Other Health Homes Provider Standards” Section ......................................... 7

List of Figures
Figure 1: Types of Health Homes Providers -1 ............................................................... 1
Figure 2: Types of Health Homes Providers -2 ............................................................... 1
Figure 3: Types of Health Homes Providers -3 ............................................................... 2
Figure 4: Types of Health Homes Providers -4 ............................................................... 2
Figure 5: Types of Health Homes Providers -5 ............................................................... 3
Figure 6: Types of Health Homes Providers -6 ............................................................... 3
Figure 7: Types of Health Homes Providers -7 ............................................................... 4
Figure 8: Types of Health Homes Providers -8 ............................................................... 4
Figure 9: Types of Health Homes Providers -9 ............................................................... 5
Figure 10: Types of Health Homes Providers -10 ........................................................... 5
Figure 11: Types of Health Homes Providers -11 ........................................................... 6
Figure 12: Types of Health Homes Providers -12 ........................................................... 6
Figure 13: Provider Infrastructure and Supports for Health Homes Providers................. 7
Figure 14: Other Health Homes Provider Standards ....................................................... 7

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HH5 – Health Homes Providers Screenshots

1. HH5 – Health Homes Providers Screenshots
1.1

“Types of Health Homes Providers” Section

Figure 1: Types of Health Homes Providers -1

1.2

“Types of Health Homes Providers” Section – Path 1

Figure 2: Types of Health Homes Providers -2

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HH5 – Health Homes Providers Screenshots

Figure 3: Types of Health Homes Providers -3

Figure 4: Types of Health Homes Providers -4

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HH5 – Health Homes Providers Screenshots

Figure 5: Types of Health Homes Providers -5

1.3

“Types of Health Homes Providers” Section – Path 2

Figure 6: Types of Health Homes Providers -6

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HH5 – Health Homes Providers Screenshots

Figure 7: Types of Health Homes Providers -7

Figure 8: Types of Health Homes Providers -8

HH5-Health Homes Providers RU PRA document Version 1.0

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CMS XLC

1.4

HH5 – Health Homes Providers Screenshots

“Types of Health Homes Providers” Section – Path 3

Figure 9: Types of Health Homes Providers -9

Figure 10: Types of Health Homes Providers -10

HH5-Health Homes Providers RU PRA document Version 1.0

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HH5 – Health Homes Providers Screenshots

Figure 11: Types of Health Homes Providers -11

Figure 12: Types of Health Homes Providers -12

HH5-Health Homes Providers RU PRA document Version 1.0

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CMS XLC

1.5

HH5 – Health Homes Providers Screenshots

“Provider Infrastructure” and “Supports for Health Homes
Providers” Sections

Figure 13: Provider Infrastructure and Supports for Health Homes Providers

1.6

“Other Health Homes Provider Standards” Section

Figure 14: Other Health Homes Provider Standards

HH5-Health Homes Providers RU PRA document Version 1.0

08/11/2017

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

Medicaid and CHIP Program (MACPro)
HH6-Health Homes Delivery Systems PRA
document
Version 1.0
08/16/2017

Document Number: 184-QSSI-MACPro-PRAHH6-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. HH6-Health Homes Service Delivery Systems – Screenshots ............................. 1
1.1
1.2
1.3
1.4
1.5
1.6
1.7

Health Homes Service Delivery Systems ........................................................ 1
Health Homes Service Delivery Systems – Path 1.......................................... 1
Health Homes Service Delivery Systems – Path 2.......................................... 2
Health Homes Service Delivery Systems – Path 3.......................................... 3
Health Homes Service Delivery Systems – Path 4.......................................... 4
Health Homes Service Delivery Systems – Path 5.......................................... 4
Health Homes Service Delivery Systems – Path 6.......................................... 5

List of Figures
Figure 1 : Health Homes Service Delivery - 1 ................................................................. 1
Figure 2: Health Homes Service Delivery - 2 .................................................................. 1
Figure 3: Health Homes Service Delivery - 3 .................................................................. 2
Figure 4: Health Homes Service Delivery – 4 .................................................................. 2
Figure 5: Health Homes Service Delivery – 5 .................................................................. 3
Figure 6: Health Homes Service Delivery – 6 .................................................................. 3
Figure 7: Health Homes Service Delivery – 7 .................................................................. 4
Figure 8: Health Homes Service Delivery – 8 .................................................................. 4
Figure 9: Health Homes Service Delivery – 9 .................................................................. 4
Figure 10: Health Homes Service Delivery – 10 .............................................................. 5

HH6-Health Homes Delivery Systems PRA document Version 1.0

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CMS XLC

HH6-Health Homes Service Delivery Systems – Screenshots

1. HH6-Health Homes Service Delivery Systems –
Screenshots
1.1

Health Homes Service Delivery Systems

Figure 1 : Health Homes Service Delivery - 1

1.2

Health Homes Service Delivery Systems – Path 1

Figure 2: Health Homes Service Delivery - 2

HH6-Health Homes Delivery Systems PRA document Version 1.0

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HH6-Health Homes Service Delivery Systems – Screenshots

Figure 3: Health Homes Service Delivery - 3

1.3

Health Homes Service Delivery Systems – Path 2

Figure 4: Health Homes Service Delivery – 4

HH6-Health Homes Delivery Systems PRA document Version 1.0

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1.4

HH6-Health Homes Service Delivery Systems – Screenshots

Health Homes Service Delivery Systems – Path 3

Figure 5: Health Homes Service Delivery – 5

Figure 6: Health Homes Service Delivery – 6

HH6-Health Homes Delivery Systems PRA document Version 1.0

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1.5

HH6-Health Homes Service Delivery Systems – Screenshots

Health Homes Service Delivery Systems – Path 4

Figure 7: Health Homes Service Delivery – 7

Figure 8: Health Homes Service Delivery – 8

1.6

Health Homes Service Delivery Systems – Path 5

Figure 9: Health Homes Service Delivery – 9

HH6-Health Homes Delivery Systems PRA document Version 1.0

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CMS XLC

1.7

HH6-Health Homes Service Delivery Systems – Screenshots

Health Homes Service Delivery Systems – Path 6

Figure 10: Health Homes Service Delivery – 10

HH6-Health Homes Delivery Systems PRA document Version 1.0

08/16/2017

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

Medicaid and CHIP Program (MACPro)
HH7-Health Homes Payment Methodologies PRA
document
Version 1.0
08/16/2017

Document Number: 185-QSSI-MACPro-PRA-HH7-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. HH7-Health Homes Payment Methodologies – Screenshots ............................... 1
1.1
1.2
1.3
1.4

“Payment Methodology” Section ..................................................................... 1
“Payment Methodology” Section – Path 1 ....................................................... 1
“Payment Methodology” Section – Path 2 ....................................................... 3
“Assurances” Section ...................................................................................... 3

List of Figures
Figure 1: Payment Methodology – 1 ............................................................................... 1
Figure 2: Payment Methodology – 2 ............................................................................... 1
Figure 3: Payment Methodology – 3 ............................................................................... 2
Figure 4: Payment Methodology – 4 ............................................................................... 2
Figure 5: Payment Methodology – 5 ............................................................................... 3
Figure 6: Assurances ...................................................................................................... 3

HH7-Health Homes Payment Methodologies PRA document Version 1.0

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CMS XLC

HH7-Health Homes Payment Methodologies – Screenshots

1. HH7-Health Homes Payment Methodologies –
Screenshots
1.1

“Payment Methodology” Section

Figure 1: Payment Methodology – 1

1.2

“Payment Methodology” Section – Path 1

Figure 2: Payment Methodology – 2

HH7-Health Homes Payment Methodologies PRA document Version 1.0

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CMS XLC

HH7-Health Homes Payment Methodologies – Screenshots

Figure 3: Payment Methodology – 3

Figure 4: Payment Methodology – 4

HH7-Health Homes Payment Methodologies PRA document Version 1.0

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CMS XLC

1.3

HH7-Health Homes Payment Methodologies – Screenshots

“Payment Methodology” Section – Path 2

Figure 5: Payment Methodology – 5

1.4

“Assurances” Section

Figure 6: Assurances

HH7-Health Homes Payment Methodologies PRA document Version 1.0

08/16/2017

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

Medicaid and CHIP Program (MACPro)
HH8-Health Homes Monitoring, Quality
Measurement and Evaluation PRA document
Version 1.0
08/16/2017

Document Number: 186-QSSI-MACPro-PRA-HH8-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. HH8-Health Homes Monitoring, Quality Measurement and Evaluation –
Screenshots ............................................................................................................. 1
1.1
1.2

“Monitoring” Section ........................................................................................ 1
“Quality Measurement and Evaluation” Section .............................................. 2

List of Figures
Figure 1: Monitoring – 1 .................................................................................................. 1
Figure 2: Monitoring - 2 ................................................................................................... 1
Figure 3: Quality Measurement and Evaluation .............................................................. 2

HH8-Health Homes Monitoring, Quality Measurement and Evaluation PRA document Version 1.0

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CMS XLC

HH8-Health Homes Monitoring, Quality Measurement and Evaluation – Screenshots

1. HH8-Health Homes Monitoring, Quality Measurement
and Evaluation – Screenshots
1.1

“Monitoring” Section

Figure 1: Monitoring – 1

Figure 2: Monitoring - 2

HH8-Health Homes Monitoring, Quality Measurement and Evaluation PRA document Version 1.0

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CMS XLC

1.2

HH8-Health Homes Monitoring, Quality Measurement and Evaluation – Screenshots

“Quality Measurement and Evaluation” Section

Figure 3: Quality Measurement and Evaluation

HH8-Health Homes Monitoring, Quality Measurement and Evaluation PRA document Version 1.0

08/16/2017

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

Medicaid and CHIP Program (MACPro)
HH9-Health Homes Program Termination PRA
document
Version 1.0
08/16/2017

Document Number: 187-QSSI-MACPro-PRA-HH9-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. HH8-Health Homes Program Termination – Screenshots .................................... 1
1.1
1.2
1.3

Health Homes Program Termination ............................................................... 1
Health Homes Program Termination – Path 1................................................. 1
Health Homes Program Termination – Path 2................................................. 2

List of Figures
Figure 1: Health Homes Program Termination – 1 .......................................................... 1
Figure 2: Health Homes Program Termination – 2 .......................................................... 1
Figure 3: Health Homes Program Termination – 3 .......................................................... 2

HH9-Health Homes Program Termination PRA document Version 1.0 i

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CMS XLC

HH8-Health Homes Program Termination – Screenshots

1. HH8-Health Homes Program Termination –
Screenshots
1.1

Health Homes Program Termination

Figure 1: Health Homes Program Termination – 1

1.2

Health Homes Program Termination – Path 1

Figure 2: Health Homes Program Termination – 2

HH9-Health Homes Program Termination PRA document Version 1.0 1

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1.3

HH8-Health Homes Program Termination – Screenshots

Health Homes Program Termination – Path 2

Figure 3: Health Homes Program Termination – 3

HH9-Health Homes Program Termination PRA document Version 1.0 2

08/16/2017

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

Medicaid and CHIP Program (MACPro)
I1-Submission Summary PRA document
Version 1.0
08/16/2017

Document Number: 189-QSSI-MACPro-PRA-I1-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. I1-Submission Summary – Screenshots................................................................ 1
1.1
1.2
1.3

Submission Summary ..................................................................................... 1
“Governor’s Office Review” Section – Path 1 .................................................. 2
“Governor’s Office Review” Section – Path 2 .................................................. 3

List of Figures
Figure 1: Submission Summary – 1 ................................................................................ 1
Figure 2: Submission Summary – 2 ................................................................................ 1
Figure 3: Submission Summary – 3 ................................................................................ 2
Figure 4: Submission Summary – 4 ................................................................................ 2
Figure 5: Governor’s Office Review - 1 ........................................................................... 2
Figure 6: Governor’s Office Review - 2 ........................................................................... 3

I1-Submission Summary PRA document Version 1.0

08/16/2017

CMS XLC

I1-Submission Summary – Screenshots

1. I1-Submission Summary – Screenshots
1.1

Submission Summary

Figure 1: Submission Summary – 1

Figure 2: Submission Summary – 2

I1-Submission Summary PRA document Version 1.0

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CMS XLC

I1-Submission Summary – Screenshots

Figure 3: Submission Summary – 3

Figure 4: Submission Summary – 4

1.2

“Governor’s Office Review” Section – Path 1

Figure 5: Governor’s Office Review - 1

I1-Submission Summary PRA document Version 1.0

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1.3

I1-Submission Summary – Screenshots

“Governor’s Office Review” Section – Path 2

Figure 6: Governor’s Office Review - 2

I1-Submission Summary PRA document Version 1.0

08/16/2017

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

Medicaid and CHIP Program (MACPro)
I2-Medicaid State Plan PRA document
Version 1.0
08/17/2017

Document Number: 192-QSSI-MACPro-PRA-I2-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. I2-Medicaid State Plan – Screenshots.................................................................... 1
1.1
1.2
1.3
1.4
1.5
1.6

Medicaid State Plan ........................................................................................ 1
Medicaid State Plan – Benefits and Payment – Path 1 ................................... 2
Medicaid State Plan – Benefits and Payment – Path 2 ................................... 2
Medicaid State Plan – Benefits and Payment – Path 3 ................................... 3
Medicaid State Plan – Benefits and Payment – Path 4 ................................... 3
Medicaid State Plan – Benefits and Payment – Path 5 ................................... 3

List of Figures
Figure 1: Medicaid State Plan – 1 ................................................................................... 1
Figure 2: Medicaid State Plan – 2 ................................................................................... 1
Figure 3: Medicaid State Plan – 3 ................................................................................... 2
Figure 4: Benefits and Payment – 1 ................................................................................ 2
Figure 5: Benefits and Payment – 2 ................................................................................ 2
Figure 6: Benefits and Payment – 3 ................................................................................ 3
Figure 7: Benefits and Payment – 4 ................................................................................ 3
Figure 8: Benefits and Payment – 5 ................................................................................ 3

I2-Medicaid State Plan PRA document Version 1.0

08/17/2017

CMS XLC

I2-Medicaid State Plan – Screenshots

1. I2-Medicaid State Plan – Screenshots
1.1

Medicaid State Plan

Figure 1: Medicaid State Plan – 1

Figure 2: Medicaid State Plan – 2

I2-Medicaid State Plan PRA document Version 1.0

08/17/2017

CMS XLC

I2-Medicaid State Plan – Screenshots

Figure 3: Medicaid State Plan – 3

1.2

Medicaid State Plan – Benefits and Payment – Path 1

Figure 4: Benefits and Payment – 1

1.3

Medicaid State Plan – Benefits and Payment – Path 2

Figure 5: Benefits and Payment – 2

I2-Medicaid State Plan PRA document Version 1.0

08/17/2017

CMS XLC

1.4

I2-Medicaid State Plan – Screenshots

Medicaid State Plan – Benefits and Payment – Path 3

Figure 6: Benefits and Payment – 3

1.5

Medicaid State Plan – Benefits and Payment – Path 4

Figure 7: Benefits and Payment – 4

1.6

Medicaid State Plan – Benefits and Payment – Path 5

Figure 8: Benefits and Payment – 5

I2-Medicaid State Plan PRA document Version 1.0

08/17/2017

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

Medicaid and CHIP Program (MACPro)
I3-Public Comment PRA document
Version 1.0
08/17/2017

Document Number: 193-QSSI-MACPro-PRA-I3-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. I3-Public Comment – Screenshots ......................................................................... 1
1.1
1.2

Public Comment – Path 1................................................................................ 1
Public Comment – Path 2................................................................................ 5

List of Figures
Figure 1: Public Comment – 1 ......................................................................................... 1
Figure 2: Public Comment – 2 ......................................................................................... 1
Figure 3: Public Comment – 3 ......................................................................................... 2
Figure 4: Public Comment – 4 ......................................................................................... 2
Figure 5: Public Comment – 5 ......................................................................................... 3
Figure 6: Public Comment – 6 ......................................................................................... 3
Figure 7: Public Comment – 7 ......................................................................................... 4
Figure 8: Public Comment – 8 ......................................................................................... 4
Figure 9: Public Comment – 9 ......................................................................................... 5
Figure 10: Public Comment – 10 ..................................................................................... 5
Figure 11: Public Comment – 11 ..................................................................................... 6
Figure 12: Public Comment – 12 ..................................................................................... 6
Figure 13: Public Comment – 13 ..................................................................................... 7
Figure 14: Public Comment – 14 ..................................................................................... 7
Figure 15: Public Comment – 15 ..................................................................................... 8

I3-Public Comment PRA document Version 1.0

08/17/2017

CMS XLC

I3-Public Comment – Screenshots

1. I3-Public Comment – Screenshots
1.1

Public Comment – Path 1

Figure 1: Public Comment – 1

Figure 2: Public Comment – 2

I3-Public Comment PRA document Version 1.0

08/17/2017

CMS XLC

I3-Public Comment – Screenshots

Figure 3: Public Comment – 3

Figure 4: Public Comment – 4

I3-Public Comment PRA document Version 1.0

08/17/2017

CMS XLC

I3-Public Comment – Screenshots

Figure 5: Public Comment – 5

Figure 6: Public Comment – 6

I3-Public Comment PRA document Version 1.0

08/17/2017

CMS XLC

I3-Public Comment – Screenshots

Figure 7: Public Comment – 7

Figure 8: Public Comment – 8

I3-Public Comment PRA document Version 1.0

08/17/2017

CMS XLC

1.2

I3-Public Comment – Screenshots

Public Comment – Path 2

Figure 9: Public Comment – 9

Figure 10: Public Comment – 10

I3-Public Comment PRA document Version 1.0

08/17/2017

CMS XLC

I3-Public Comment – Screenshots

Figure 11: Public Comment – 11

Figure 12: Public Comment – 12

I3-Public Comment PRA document Version 1.0

08/17/2017

CMS XLC

I3-Public Comment – Screenshots

Figure 13: Public Comment – 13

Figure 14: Public Comment – 14

I3-Public Comment PRA document Version 1.0

08/17/2017

CMS XLC

I3-Public Comment – Screenshots

Figure 15: Public Comment – 15

I3-Public Comment PRA document Version 1.0

08/17/2017

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

Medicaid and CHIP Program (MACPro)
I4-Tribal Input PRA document
Version 1.0
08/17/2017

Document Number: 194-QSSI-MACPro-PRA-I4-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. I4-Tribal Input – Screenshots .................................................................................. 1
1.1
1.2

Tribal Input – Path 1 ........................................................................................ 1
Tribal Input – Path 2 ........................................................................................ 4

List of Figures
Figure 1: Tribal Input – 1 ................................................................................................. 1
Figure 2: Tribal Input – 2 ................................................................................................. 1
Figure 3: Tribal Input – 3 ................................................................................................. 2
Figure 4: Tribal Input – 4 ................................................................................................. 2
Figure 5: Tribal Input – 5 ................................................................................................. 3
Figure 6: Tribal Input – 6 ................................................................................................. 3
Figure 7: Tribal Input – 7 ................................................................................................. 4
Figure 8: Tribal Input – 8 ................................................................................................. 4
Figure 9: Tribal Input – 9 ................................................................................................. 5
Figure 10: Tribal Input – 10 ............................................................................................. 5
Figure 11: Tribal Input – 11 ............................................................................................. 6
Figure 12: Tribal Input – 12 ............................................................................................. 6
Figure 13: Tribal Input – 13 ............................................................................................. 7
Figure 14: Tribal Input – 14 ............................................................................................. 7

I4-Tribal Input PRA document Version 1.0

08/17/2017

CMS XLC

I4-Tribal Input – Screenshots

1. I4-Tribal Input – Screenshots
1.1

Tribal Input – Path 1

Figure 1: Tribal Input – 1

Figure 2: Tribal Input – 2

I4-Tribal Input PRA document Version 1.0

08/17/2017

CMS XLC

I4-Tribal Input – Screenshots

Figure 3: Tribal Input – 3

Figure 4: Tribal Input – 4

I4-Tribal Input PRA document Version 1.0

08/17/2017

CMS XLC

I4-Tribal Input – Screenshots

Figure 5: Tribal Input – 5

Figure 6: Tribal Input – 6

I4-Tribal Input PRA document Version 1.0

08/17/2017

CMS XLC

I4-Tribal Input – Screenshots

Figure 7: Tribal Input – 7

1.2

Tribal Input – Path 2

Figure 8: Tribal Input – 8

I4-Tribal Input PRA document Version 1.0

08/17/2017

CMS XLC

I4-Tribal Input – Screenshots

Figure 9: Tribal Input – 9

Figure 10: Tribal Input – 10

I4-Tribal Input PRA document Version 1.0

08/17/2017

CMS XLC

I4-Tribal Input – Screenshots

Figure 11: Tribal Input – 11

Figure 12: Tribal Input – 12

I4-Tribal Input PRA document Version 1.0

08/17/2017

CMS XLC

I4-Tribal Input – Screenshots

Figure 13: Tribal Input – 13

Figure 14: Tribal Input – 14

I4-Tribal Input PRA document Version 1.0

08/17/2017

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

Medicaid and CHIP Program (MACPro)
I5-Other Comment PRA document
Version 1.0
08/17/2017

Document Number: 195-QSSI-MACPro-PRA-I5-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. I5-Other Comment – Screenshots .......................................................................... 1
1.1

Other Comment – “SAMHSA Consultation” Section ....................................... 1

List of Figures
Figure 1: Other Comment................................................................................................ 1

I5-Other Comment PRA document Version 1.0

08/17/2017

CMS XLC

I5-Other Comment – Screenshots

1. I5-Other Comment – Screenshots
1.1

Other Comment – “SAMHSA Consultation” Section

Figure 1: Other Comment

I5-Other Comment PRA document Version 1.0

08/17/2017

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

Medicaid and CHIP Program (MACPro)
S2 - Financial Eligibility Requirements for NonMAGI Groups RU PRA Document
Version 1.0
08/16/2017

Document Number: 181-QSSI-MACPro-R5.1-S2-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S2 - Financial Eligibility Requirements for Non-MAGI Groups Screenshots ...... 1
1.1
1.2

Package Header and A. Financial Eligibility Methodologies ............................ 1
B. Eligibility Determinations of Aged, Blind and Disabled Individuals, C.
Financial Responsibility of Relatives and D. Additional Information (optional) 2

List of Figures
Figure 1: Package Header and Section A ....................................................................... 1
Figure 2: Section B, Section C and Section D ................................................................. 2

List of Tables
No table of figures entries found.

S2 - Financial Eligibility Requirements for Non-MAGI Groups RU PRA Document Version
1.0
i

08/16/2017

CMS XLC

Package Header and A. Financial Eligibility Methodologies

1. S2 - Financial Eligibility Requirements for Non-MAGI
Groups Screenshots
1.1

Package Header and A. Financial Eligibility Methodologies

Figure 1: Package Header and Section A

S2 - Financial Eligibility Requirements for Non-MAGI Groups RU PRA Document Version
1.0
1

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CMS XLC
B. Eligibility Determinations of Aged, Blind and Disabled Individuals, C. Financial Responsibility of Relatives and D. Additional
Information (optional)

1.2

B. Eligibility Determinations of Aged, Blind and Disabled
Individuals, C. Financial Responsibility of Relatives and D.
Additional Information (optional)

Figure 2: Section B, Section C and Section D

S2 - Financial Eligibility Requirements for Non-MAGI Groups RU PRA Document Version
1.0
2

08/16/2017

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

Medicaid and CHIP Program (MACPro)
S2T-Financial Eligibility Requirements for NonMAGI Groups – Territories PRA document
Version 1.0
08/18/2017

Document Number: 214-QSSI-MACPro-PRA-S2T-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S2T-Financial Eligibility Requirements for Non-MAGI Groups – Territories –
Screenshots ............................................................................................................. 1
1.1

Financial Eligibility Requirements for Non-MAGI Groups – Territories ............ 1

List of Figures
Figure 1: Financial Eligibility Requirements for Non-MAGI Groups – Territories – 1 ....... 1
Figure 2: Financial Eligibility Requirements for Non-MAGI Groups – Territories – 2 ....... 1

S2T-Financial Eligibility Requirements for Non-MAGI Groups – Territories PRA document
Version 1.0
i

08/18/2017

CMS XLC

S2T-Financial Eligibility Requirements for Non-MAGI Groups – Territories – Screenshots

1. S2T-Financial Eligibility Requirements for Non-MAGI
Groups – Territories – Screenshots
1.1

Financial Eligibility Requirements for Non-MAGI Groups –
Territories

Figure 1: Financial Eligibility Requirements for Non-MAGI Groups – Territories – 1

Figure 2: Financial Eligibility Requirements for Non-MAGI Groups – Territories – 2

S2T-Financial Eligibility Requirements for Non-MAGI Groups – Territories PRA document
Version 1.0
1

08/18/2017

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

Medicaid and CHIP Program (MACPro)
S3 - Optional Eligibility Groups RU PRA
Document
Version 1.0
08/16/2017

Document Number: 178-QSSI-MACPro-R5.1-S3-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S3 - Optional Eligibility Groups Screenshots ........................................................ 1
1.1
1.2
1.3
1.4
1.5
1.6

Package Header ............................................................................................. 1
A. Options for Coverage – Part 1 .................................................................... 1
A. Options for Coverage – Part 2 .................................................................... 2
A. Options for Coverage – Part 3 .................................................................... 2
B. Medically Needy Options for Coverage –Part 1 .......................................... 3
B. Medically Needy Options for Coverage-Part 2, C. Additional Information
(optional) and Eligibility Groups Deselected from Coverage ........................... 4

List of Figures
Figure 1: Package Header .............................................................................................. 1
Figure 2: Section A-Part 1 ............................................................................................... 1
Figure 3: Section A-Part 2 ............................................................................................... 2
Figure 4: Section A-Part 3 ............................................................................................... 2
Figure 5: Section B-Part 1 ............................................................................................... 3

List of Tables
No table of figures entries found.

S3 - Optional Eligibility Groups RU PRA Document Version 1.0

08/16/2017

CMS XLC

Package Header

1. S3 - Optional Eligibility Groups Screenshots
1.1

Package Header

Figure 1: Package Header

1.2

A. Options for Coverage – Part 1

Figure 2: Section A-Part 1

S3 - Optional Eligibility Groups RU PRA Document Version 1.0

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CMS XLC

1.3

A. Options for Coverage – Part 2

Figure 3: Section A-Part 2

1.4

A. Options for Coverage – Part 3

Figure 4: Section A-Part 3

S3 - Optional Eligibility Groups RU PRA Document Version 1.0

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CMS XLC

1.5

B. Medically Needy Options for Coverage –Part 1

Figure 5: Section B-Part 1

S3 - Optional Eligibility Groups RU PRA Document Version 1.0

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Coverage”

B. Medically Needy Options for Coverage-Part 2, C. Additional Information (optional) and “Eligibility Groups Deselected from

1.6

B. Medically Needy Options for Coverage-Part 2, C. Additional
Information (optional) and “Eligibility Groups Deselected from
Coverage”

Figure 6: Section B-Part 2, Section C and Section “Eligibility Groups Deselected from
Coverage”

S3 - Optional Eligibility Groups RU PRA Document Version 1.0

08/16/2017

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

Medicaid and CHIP Program (MACPro)
S3a - De-selected RU PRA Document
Version 1.0
08/16/2017

Document Number: 188-QSSI-MACPro-R5.1-S3a-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S3a – De-selected RU Screenshots ........................................................................ 1
1.1
1.2

Package Header ............................................................................................. 1
Group No Longer Covered .............................................................................. 1

List of Figures
Figure 1: Package Header .............................................................................................. 1
Figure 2: Group No Longer Covered ............................................................................... 1

List of Tables
No table of figures entries found.

S3a - De-selected RU PRA Document Version 1.0

08/16/2017

CMS XLC

Package Header

1. S3a – De-selected RU Screenshots
1.1

Package Header

Figure 1: Package Header

1.2

Group No Longer Covered

Figure 2: Group No Longer Covered

S3a - De-selected RU PRA Document Version 1.0

08/16/2017

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

Medicaid and CHIP Program (MACPro)
S4 - Mandatory Eligibility Groups RU PRA
Document
Version 1.0
08/16/2017

Document Number: 190-QSSI-MACPro-R5.1-S4-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S4 - Mandatory Eligibility Groups Screenshots .................................................... 1
1.1
1.2
1.3
1.4

Package Header ............................................................................................. 1
Mandatory Coverage – Section A - Part 1 ....................................................... 1
Mandatory Coverage – Section A-Part 2 and Section B ................................. 2
Mandatory Coverage – Section C ................................................................... 2

List of Figures
Figure 1: Package Header .............................................................................................. 1
Figure 2: Section A-Part 1 ............................................................................................... 1
Figure 3: Section A-Part 2 and Section B ........................................................................ 2
Figure 4: Section C.......................................................................................................... 2

List of Tables
No table of figures entries found.

S4 - Mandatory Eligibility Groups RU PRA Document Version 1.0

08/16/2017

CMS XLC

Package Header

1. S4 - Mandatory Eligibility Groups Screenshots
1.1

Package Header

Figure 1: Package Header

1.2

Mandatory Coverage – Section A - Part 1

Figure 2: Section A-Part 1

S4 - Mandatory Eligibility Groups RU PRA Document Version 1.0

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CMS XLC

1.3

Mandatory Coverage – Section A-Part 2 and Section B

Figure 3: Section A-Part 2 and Section B

1.4

Mandatory Coverage – Section C

Figure 4: Section C

S4 - Mandatory Eligibility Groups RU PRA Document Version 1.0

08/16/2017

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

Medicaid and CHIP Program (MACPro)
S10-MAGI Based Methodologies RU PRA
document
Version 1.0
08/10/2017

Document Number: 166-QSSI-MACPro-PRA-S10-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S10- MAGI Based Methodologies Screenshots..................................................... 1
1.1
1.2
1.3
1.4
1.5

Section A. Household Composition ................................................................. 1
Section B. Household Income ......................................................................... 2
Section B. Household Income – Path 1 ........................................................... 3
Section B. Household Income – Path 2 ........................................................... 4
Section C. Resource Test and Section D. Additional Information (optional) ... 5

List of Figures
Figure 1: Section A- Household Composition.................................................................. 1
Figure 2: Section B .......................................................................................................... 2
Figure 3: Section B- Path 1 ............................................................................................. 3
Figure 4: Section B- Path 2 ............................................................................................. 4
Figure 5: Section C and Section D .................................................................................. 5

List of Tables
No table of figures entries found.

S10-MAGI Based Methodologies RU PRA document Version 1.0

08/10/2017

CMS XLC

Section A. Household Composition

1. S10- MAGI Based Methodologies Screenshots
1.1

Section A. Household Composition

Figure 1: Section A- Household Composition

S10-MAGI Based Methodologies RU PRA document Version 1.0

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CMS XLC

1.2

Section B. Household Income

Figure 2: Section B

S10-MAGI Based Methodologies RU PRA document Version 1.0

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CMS XLC

1.3

Section B. Household Income – Path 1

Figure 3: Section B- Path 1

S10-MAGI Based Methodologies RU PRA document Version 1.0

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CMS XLC

1.4

Section B. Household Income – Path 2

Figure 4: Section B- Path 2

S10-MAGI Based Methodologies RU PRA document Version 1.0

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CMS XLC

1.5

Section C. Resource Test and Section D. Additional Information (optional)

Section C. Resource Test and Section D. Additional Information
(optional)

Figure 5: Section C and Section D

S10-MAGI Based Methodologies RU PRA document Version 1.0

08/10/2017

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

Medicaid and CHIP Program (MACPro)
S10T-MAGI Based Methodologies - Territories RU
PRA document
Version 1.0
08/16/2017

Document Number: 176-QSSI-MACPro-R5.1-S10T-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S10T- MAGI Based Methodologies - Territories Screenshots.............................. 1
1.1
1.2
1.3
1.4

Section A. Household Composition ................................................................. 1
Section B. Household Income – Options 1-5................................................... 2
Section B. Household Income – Options 6-8................................................... 2
Section C. Resource Test and Section D. Additional Information (optional) ... 3

List of Figures
Figure 1: Section A- Household Composition.................................................................. 1
Figure 2: Section B-Options 1-5 ...................................................................................... 2
Figure 3: Section B- Options 6-8 ..................................................................................... 2
Figure 4: Section C and Section D .................................................................................. 3

List of Tables
No table of figures entries found.

S10T-MAGI Based Methodologies - Territories RU PRA document Version
1.0
i

08/16/2017

CMS XLC

Section A. Household Composition

1. S10T- MAGI Based Methodologies - Territories
Screenshots
1.1

Section A. Household Composition

Figure 1: Section A- Household Composition

S10T-MAGI Based Methodologies - Territories RU PRA document Version
1.0
1

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CMS XLC

1.2

Section B. Household Income – Options 1-5

Figure 2: Section B-Options 1-5

1.3

Section B. Household Income – Options 6-8

Figure 3: Section B- Options 6-8

S10T-MAGI Based Methodologies - Territories RU PRA document Version
1.0
2

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CMS XLC

1.4

Section C. Resource Test and Section D. Additional Information (optional)

Section C. Resource Test and Section D. Additional Information
(optional)

Figure 4: Section C and Section D

S10T-MAGI Based Methodologies - Territories RU PRA document Version
1.0
3

08/16/2017

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

Medicaid and CHIP Program (MACPro)
S11 - Reasonable Classification of Children - All
PRA Document
Version 1.0
08/21/2017

Document Number: 238-QSSI-MACPro-R5.1-S11-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S11 - Reasonable Classification Of Children – Limit Screenshots...................... 1
1.1
1.2
1.3

Reasonable Classification of Children – Limit – Screenshot 1 ........................ 1
Reasonable Classification of Children - Limit– Screenshot 2 .......................... 2
Reasonable Classification of Children - Limit– Screenshot 3 .......................... 2

List of Figures
Figure 1: Reasonable Classification of Children - Limit– Screenshot 1 ........................... 1
Figure 2: Reasonable Classification of Children - Limit– Screenshot 2 ........................... 2
Figure 3: Reasonable Classification of Children - Limit– Screenshot 3 ........................... 2

List of Tables
No table of figures entries found.

S11 - Reasonable Classification of Children - All PRA Document Version
1.0
i

08/21/2017

CMS XLC

Reasonable Classification of Children – Limit – Screenshot 1

1. S11 - Reasonable Classification of Children – All
Screenshots
1.1

Reasonable Classification of Children – Limit – Screenshot 1

Figure 1: Reasonable Classification of Children - All– Screenshot 1

S11 - Reasonable Classification of Children - All PRA Document Version
1.0
1

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CMS XLC

1.2

Reasonable Classification of Children - All– Screenshot 2

Figure 2: Reasonable Classification of Children - All– Screenshot 2

1.3

Reasonable Classification of Children - All– Screenshot 3

Figure 3: Reasonable Classification of Children - All– Screenshot 3

S11 - Reasonable Classification of Children - All PRA Document Version
1.0
2

08/21/2017

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

Medicaid and CHIP Program (MACPro)
S11a - Reasonable Classification of Children Limit PRA Document
Version 1.0
08/21/2017

Document Number: 239-QSSI-MACPro-R5.1-S11a-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S11a - Reasonable Classification of Children – Limit Screenshots .................... 1
1.1
1.2
1.3

List of Tables
No table of figures entries found.

S11a - Reasonable Classification of Children - Limit PRA Document Version
1.0
i

08/21/2017

CMS XLC

Reasonable Classification of Children – Limit – Screenshot 1

1. S11a - Reasonable Classification of Children – Limit
Screenshots
1.1

Reasonable Classification of Children – Limit – Screenshot 1

Figure 1: Reasonable Classification of Children - Limit– Screenshot 1

S11a - Reasonable Classification of Children - Limit PRA Document Version
1.0
1

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CMS XLC

1.2

Reasonable Classification of Children - Limit– Screenshot 2

Figure 2: Reasonable Classification of Children - Limit– Screenshot 2

1.3

Reasonable Classification of Children - Limit– Screenshot 3

Figure 3: Reasonable Classification of Children - Limit– Screenshot 3

S11a - Reasonable Classification of Children - Limit PRA Document Version
1.0
2

08/21/2017

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

Medicaid and CHIP Program (MACPro)
S13a - Income Standard PRA Document
Version 1.0
08/18/2017

Document Number: 219-QSSI-MACPro-R5.1-S13a-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S13a - Income Standard Screenshots .................................................................... 1
1.1
1.2
1.3
1.4

Income Standard – Path 1............................................................................... 1
Income Standard – Path 2............................................................................... 2
Income Standard – Path 3............................................................................... 2
Income Standard – Path 4............................................................................... 3

List of Figures
Figure 1: Income Standard – Path 1................................................................................ 1
Figure 2: Income Standard – Path 2................................................................................ 2
Figure 3: Income Standard – Path 3................................................................................ 2
Figure 4: Income Standard – Path 4................................................................................ 3

List of Tables
No table of figures entries found.

S13a - Income Standard PRA Document Version 1.0

08/18/2017

CMS XLC

Income Standard – Path 1

1. S13a - Income Standard Screenshots
1.1

Income Standard – Path 1

Figure 1: Income Standard – Path 1

S13a - Income Standard PRA Document Version 1.0

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CMS XLC

1.2

Income Standard – Path 2

Figure 2: Income Standard – Path 2

1.3

Income Standard – Path 3

Figure 3: Income Standard – Path 3

S13a - Income Standard PRA Document Version 1.0

08/18/2017

CMS XLC

1.4

Income Standard – Path 4

Figure 4: Income Standard – Path 4

S13a - Income Standard PRA Document Version 1.0

08/18/2017

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

Medicaid and CHIP Program (MACPro)
S14-AFDC Income Standards PRA document
Version 1.0
08/17/2017

Document Number: 205-QSSI-MACPro-PRA-S14-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S14-AFDC Income Standards – Screenshots ........................................................ 1
1.1

AFDC Income Standards ................................................................................ 1

List of Figures
Figure 1: AFDC Income Standards - 1 ............................................................................ 1
Figure 2: AFDC Income Standards – 2 ........................................................................... 2
Figure 3: AFDC Income Standards – 3 ........................................................................... 2

S14-AFDC Income Standards PRA document Version 1.0

08/17/2017

CMS XLC

S14-AFDC Income Standards – Screenshots

1. S14-AFDC Income Standards – Screenshots
1.1

AFDC Income Standards

Figure 1: AFDC Income Standards - 1

S14-AFDC Income Standards PRA document Version 1.0

08/17/2017

CMS XLC

S14-AFDC Income Standards – Screenshots

Figure 2: AFDC Income Standards – 2

Figure 3: AFDC Income Standards – 3

S14-AFDC Income Standards PRA document Version 1.0

08/17/2017

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

Medicaid and CHIP Program (MACPro)
S14a-Income Standards – Poverty Level Territories PRA document
Version 1.0
08/18/2017

Document Number: 210-QSSI-MACPro-PRA-S14a-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S14a- Income Standards – Poverty Level – Territories – Screenshots ............... 1
1.1

Income Standards – Poverty Level – Territories ............................................. 1

List of Figures
Figure 1: Income Standards – Poverty Level – Territories – 1 ........................................ 1
Figure 2: Income Standards – Poverty Level – Territories – 2 ........................................ 1

S14a-Income Standards – Poverty Level - Territories PRA document
Version 1.0

08/18/2017

CMS XLC

S14a- Income Standards – Poverty Level – Territories – Screenshots

1. S14a- Income Standards – Poverty Level – Territories
– Screenshots
1.1

Income Standards – Poverty Level – Territories

Figure 1: Income Standards – Poverty Level – Territories – 1

Figure 2: Income Standards – Poverty Level – Territories – 2

S14a-Income Standards – Poverty Level - Territories PRA document
Version 1.0
1

08/18/2017

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

Medicaid and CHIP Program (MACPro)
S14T- Income Standards - AFDC-related –
Territories PRA document
Version 1.0
08/18/2017

Document Number: 211-QSSI-MACPro-PRA-S14T-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S14T- Income Standards - AFDC-related – Territories – Screenshots ................ 1
1.1

Income Standards - AFDC-related – Territories .............................................. 1

List of Figures
Figure 1: Income Standards - AFDC-related – Territories – 1 ......................................... 1
Figure 2: Income Standards - AFDC-related – Territories – 2 ......................................... 1
Figure 3: Income Standards - AFDC-related – Territories – 3 ......................................... 2

S14T- Income Standards - AFDC-related – Territories PRA document
Version 1.0
i

08/18/2017

CMS XLC

S14T- Income Standards - AFDC-related – Territories – Screenshots

1. S14T- Income Standards - AFDC-related – Territories –
Screenshots
1.1

Income Standards - AFDC-related – Territories

Figure 1: Income Standards - AFDC-related – Territories – 1

Figure 2: Income Standards - AFDC-related – Territories – 2
S14T- Income Standards - AFDC-related – Territories PRA document
Version 1.0
1

08/18/2017

CMS XLC

S14T- Income Standards - AFDC-related – Territories – Screenshots

Figure 3: Income Standards - AFDC-related – Territories – 3

S14T- Income Standards - AFDC-related – Territories PRA document
Version 1.0
2

08/18/2017

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

Medicaid and CHIP Program (MACPro)
S16 - Presumptive Eligibility for Children under
Age 19 RU PRA Document
Version 1.0
08/16/2017

Document Number: 179-QSSI-MACPro-R5.1-S16-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S16 - Presumptive Eligibility for Children under Age 19 Screenshots ................ 1
1.1
1.2
1.3
1.4
1.5
1.6

Package Header ............................................................................................. 1
A. Presumptive Eligibility Income Standard, B. Presumptive Eligibility Age
Limit and C. Presumptive Eligibility Period ...................................................... 2
D. Application for Presumptive Eligibility–Part 1.............................................. 3
D. Application for Presumptive Eligibility–Part 2 and E. Presumptive Eligibility
Determination .................................................................................................. 4
F. Qualified Entities ......................................................................................... 4
G. Additional Information (optional) ................................................................. 5

List of Tables
No table of figures entries found.

S16 - Presumptive Eligibility for Children under Age 19 RU PRA Document Version
1.0
i

08/16/2017

CMS XLC

Package Header

1. S16 - Presumptive Eligibility for Children under Age 19
Screenshots
1.1

Package Header

Figure 1: Package Header

S16 - Presumptive Eligibility for Children under Age 19 RU PRA Document Version
1.0
1

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CMS XLC

1.2

A. Presumptive Eligibility Income Standard, B. Presumptive Eligibility Age Limit and C. Presumptive Eligibility Period

A. Presumptive Eligibility Income Standard, B. Presumptive
Eligibility Age Limit and C. Presumptive Eligibility Period

Figure 2: Section A, Section B and Section C

S16 - Presumptive Eligibility for Children under Age 19 RU PRA Document Version
1.0
2

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CMS XLC

1.3

D. Application for Presumptive Eligibility–Part 1

Figure 3: Section D-Part 1

S16 - Presumptive Eligibility for Children under Age 19 RU PRA Document Version
1.0
3

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CMS XLC

1.4

D. Application for Presumptive Eligibility–Part 2 and E. Presumptive Eligibility Determination

D. Application for Presumptive Eligibility–Part 2 and E.
Presumptive Eligibility Determination

Figure 4: Section D-Part 2 and Section E

1.5

F. Qualified Entities

Figure 5: Section F

S16 - Presumptive Eligibility for Children under Age 19 RU PRA Document Version
1.0
4

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CMS XLC

1.6

G. Additional Information (optional)

Figure 6: Section G

S16 - Presumptive Eligibility for Children under Age 19 RU PRA Document Version
1.0
5

08/16/2017

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

Medicaid and CHIP Program (MACPro)
S17 - Qualified Entities PRA Document
Version 1.0
08/16/2017

Document Number: 180-QSSI-MACPro-R5.1-S17-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S17 - Qualified Entities Screenshots ...................................................................... 1
1.1
1.2

Qualified Entities – Part 1 ................................................................................ 1
Qualified Entities – Part 2 ................................................................................ 1

List of Figures
Figure 1: Qualified Entities – Part 1 ................................................................................. 1
Figure 2: Qualified Entities – Part 2 ................................................................................. 1

List of Tables
No table of figures entries found.

S17 - Qualified Entities PRA Document Version 1.0

08/16/2017

CMS XLC

Qualified Entities – Part 1

1. S17 - Qualified Entities Screenshots
1.1

Qualified Entities – Part 1

Figure 1: Qualified Entities – Part 1

1.2

Qualified Entities – Part 2

Figure 2: Qualified Entities – Part 2

S17 - Qualified Entities PRA Document Version 1.0

08/16/2017

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

Medicaid and CHIP Program (MACPro)
S21-Presumptive Eligibility by Hospitals PRA
document
Version 1.0
08/21/2017

Document Number: 231-QSSI-MACPro-PRA-S21-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S21-Presumptive Eligibility by Hospitals – Screenshots ...................................................... 1
1.1

Presumptive Eligibility by Hospitals ................................................................. 1

List of Figures
Figure 1: Presumptive Eligibility by Hospitals – 1 ............................................................ 1
Figure 2: Presumptive Eligibility by Hospitals – 2 ............................................................ 2
Figure 3: Presumptive Eligibility by Hospitals – 3 ............................................................ 2
Figure 4: Presumptive Eligibility by Hospitals – 4 ............................................................ 3
Figure 5: Presumptive Eligibility by Hospitals – 5 ............................................................ 3
Figure 6: Presumptive Eligibility by Hospitals – 6 ............................................................ 4
Figure 7: Presumptive Eligibility by Hospitals – 7 ............................................................ 4

S21-Presumptive Eligibility by Hospitals PRA document Version 1.0

08/21/2017

CMS XLC

S21-Presumptive Eligibility by Hospitals – Screenshots

1. S21-Presumptive Eligibility by Hospitals – Screenshots
1.1

Presumptive Eligibility by Hospitals

Figure 1: Presumptive Eligibility by Hospitals – 1

S21-Presumptive Eligibility by Hospitals PRA document Version 1.0

08/21/2017

CMS XLC

S21-Presumptive Eligibility by Hospitals – Screenshots

Figure 2: Presumptive Eligibility by Hospitals – 2

Figure 3: Presumptive Eligibility by Hospitals – 3

S21-Presumptive Eligibility by Hospitals PRA document Version 1.0

08/21/2017

CMS XLC

S21-Presumptive Eligibility by Hospitals – Screenshots

Figure 4: Presumptive Eligibility by Hospitals – 4

Figure 5: Presumptive Eligibility by Hospitals – 5

S21-Presumptive Eligibility by Hospitals PRA document Version 1.0

08/21/2017

CMS XLC

S21-Presumptive Eligibility by Hospitals – Screenshots

Figure 6: Presumptive Eligibility by Hospitals – 6

Figure 7: Presumptive Eligibility by Hospitals – 7

S21-Presumptive Eligibility by Hospitals PRA document Version 1.0

08/21/2017

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

Medicaid and CHIP Program (MACPro)
S25-Parents and Other Caretaker Relatives PRA
document
Version 1.0
08/18/2017

Document Number: 212-QSSI-MACPro-PRA-S25-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S25-Parents and Other Caretaker Relatives – Screenshots ................................. 1
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9

Section A. “Characteristics” ............................................................................. 1
Section A. “Characteristics” Option C.ii – Path 1 ............................................. 2
Section A. “Characteristics” Option C.ii – Path 2 ............................................. 2
Section A. “Characteristics” Option C.ii – Path 3 ............................................. 2
Section C. “Income Standard Used” – Path 1 ................................................. 2
Section C. “Income Standard Used” – Path 2 ................................................. 3
Section D. “Basis for Income Standard” – Path 1 ............................................ 3
Section D. “Basis for Income Standard” – Path 2 ............................................ 4
Section E. “Additional Information” .................................................................. 4

List of Figures
Figure 1: Characteristics – 1 ........................................................................................... 1
Figure 2: Characteristics – 2 ........................................................................................... 1
Figure 3: Characteristics Option C.ii – 1 .......................................................................... 2
Figure 4: Characteristics Option C.ii – 2 .......................................................................... 2
Figure 5: Characteristics Option C.ii – 3 .......................................................................... 2
Figure 6: Income Standard Used – 1............................................................................... 2
Figure 7: Income Standard Used – 2............................................................................... 3
Figure 8: Basis for Income Standard – 1 ......................................................................... 3
Figure 9: Basis for Income Standard – 2 ......................................................................... 4
Figure 10: Additional Information .................................................................................... 4

S25-Parents and Other Caretaker Relatives PRA document
Version 1.0

08/18/2017

CMS XLC

S25-Parents and Other Caretaker Relatives – Screenshots

1. S25-Parents and Other Caretaker Relatives –
Screenshots
1.1

Section A. “Characteristics”

Figure 1: Characteristics – 1

Figure 2: Characteristics – 2

S25-Parents and Other Caretaker Relatives PRA document
Version 1.0

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CMS XLC

1.2

S25-Parents and Other Caretaker Relatives – Screenshots

Section A. “Characteristics” Option C.ii – Path 1

Figure 3: Characteristics Option C.ii – 1

1.3

Section A. “Characteristics” Option C.ii – Path 2

Figure 4: Characteristics Option C.ii – 2

1.4

Section A. “Characteristics” Option C.ii – Path 3

Figure 5: Characteristics Option C.ii – 3

1.5

Section C. “Income Standard Used” – Path 1

Figure 6: Income Standard Used – 1

S25-Parents and Other Caretaker Relatives PRA document
Version 1.0

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CMS XLC

1.6

S25-Parents and Other Caretaker Relatives – Screenshots

Section C. “Income Standard Used” – Path 2

Figure 7: Income Standard Used – 2

1.7

Section D. “Basis for Income Standard” – Path 1

Figure 8: Basis for Income Standard – 1

S25-Parents and Other Caretaker Relatives PRA document
Version 1.0

08/18/2017

CMS XLC

1.8

S25-Parents and Other Caretaker Relatives – Screenshots

Section D. “Basis for Income Standard” – Path 2

Figure 9: Basis for Income Standard – 2

1.9

Section E. “Additional Information”

Figure 10: Additional Information

S25-Parents and Other Caretaker Relatives PRA document
Version 1.0

08/18/2017

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

Medicaid and CHIP Program (MACPro)
S25a-Presumptive Eligibility for Parents and
Other Caretaker Relatives PRA document
Version 1.0
08/17/2017

Document Number: 206-QSSI-MACPro-PRA-S25a-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S25a-Parents and Other Caretaker Relatives – Screenshots ............................... 1
1.1

Parents and Other Caretaker Relatives .......................................................... 1

List of Figures
Figure 1: Parents and Other Caretaker Relatives – 1...................................................... 1
Figure 2: Parents and Other Caretaker Relatives – 2...................................................... 2
Figure 3: Parents and Other Caretaker Relatives – 3...................................................... 2
Figure 4: Parents and Other Caretaker Relatives – 4...................................................... 3
Figure 5: Parents and Other Caretaker Relatives – 5...................................................... 3

S25a-Presumptive Eligibility for Parents and Other Caretaker Relatives PRA document Version 1.0

08/17/2017

CMS XLC

S25a-Presumptive Eligibility for Parents and Other Caretaker Relatives – Screenshots

1. S25a-Presumptive Eligibility for Parents and Other
Caretaker Relatives – Screenshots
1.1

Presumptive Eligibility for Parents and Other Caretaker Relatives

Figure 1: Presumptive Eligibility for Parents and Other Caretaker Relatives – 1

S25a-Presumptive Eligibility for Parents and Other Caretaker Relatives PRA document Version 1.0

08/17/2017

CMS XLC

S25a-Presumptive Eligibility for Parents and Other Caretaker Relatives – Screenshots

Figure 2: Presumptive Eligibility for Parents and Other Caretaker Relatives – 2

Figure 3: Presumptive Eligibility for Parents and Other Caretaker Relatives – 3

S25a-Presumptive Eligibility for Parents and Other Caretaker Relatives PRA document Version 1.0

08/17/2017

CMS XLC

S25a-Presumptive Eligibility for Parents and Other Caretaker Relatives – Screenshots

Figure 4: Presumptive Eligibility for Parents and Other Caretaker Relatives – 4

Figure 5: Parents and Other Caretaker Relatives – 5

S25a-Presumptive Eligibility for Parents and Other Caretaker Relatives PRA document Version 1.0

08/17/2017

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

Medicaid and CHIP Program (MACPro)
S28-Pregnant Women PRA document
Version 1.0
08/18/2017

Document Number: 213-QSSI-MACPro-PRA-S28-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S28-Pregnant Women – Screenshot ...................................................................... 1
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9

Section A. “Characteristics” ............................................................................. 1
Section B. “Financial Methodologies” and Section C. “Income Standard Used”1
Section D. “Benefits for Pregnant Women” – Path 1 ....................................... 2
Section D. “Benefits for Pregnant Women” – Path 2 ....................................... 2
Section D. “Benefits for Pregnant Women” – Path 3 ....................................... 2
Section E. “Basis for Pregnant Women Income Standard” ............................. 3
Section F. “Basis for income limit for full Medicaid coverage for pregnant
women” – Path 1 ............................................................................................. 3
Section F. “Basis for income limit for full Medicaid coverage for pregnant
women” – Path 2 ............................................................................................. 4
Section G. “Additional Information” ................................................................. 4

List of Figures
Figure 1: Characteristics ................................................................................................. 1
Figure 2: Financial Methodologies and Income Standard Used ...................................... 1
Figure 3: Benefits for Pregnant Women – 1 .................................................................... 2
Figure 4: Benefits for Pregnant Women – 2 .................................................................... 2
Figure 5: Benefits for Pregnant Women – 3 .................................................................... 2
Figure 6: Basis for Pregnant Women Income Standard .................................................. 3
Figure 7: Basis for income limit for full Medicaid coverage for pregnant women – 1 ....... 3
Figure 8: Basis for income limit for full Medicaid coverage for pregnant women – 2 ....... 4
Figure 9: Additional Information ...................................................................................... 4

S28-Pregnant Women PRA document Version 1.0

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CMS XLC

S28-Pregnant Women – Screenshot

1. S28-Pregnant Women – Screenshot
1.1

Section A. “Characteristics”

Figure 1: Characteristics

1.2

Section B. “Financial Methodologies” and Section C. “Income
Standard Used”

Figure 2: Financial Methodologies and Income Standard Used

S28-Pregnant Women PRA document Version 1.0

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CMS XLC

1.3

S28-Pregnant Women – Screenshot

Section D. “Benefits for Pregnant Women” – Path 1

Figure 3: Benefits for Pregnant Women – 1

1.4

Section D. “Benefits for Pregnant Women” – Path 2

Figure 4: Benefits for Pregnant Women – 2

1.5

Section D. “Benefits for Pregnant Women” – Path 3

Figure 5: Benefits for Pregnant Women – 3

S28-Pregnant Women PRA document Version 1.0

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CMS XLC

1.6

S28-Pregnant Women – Screenshot

Section E. “Basis for Pregnant Women Income Standard”

Figure 6: Basis for Pregnant Women Income Standard

1.7

Section F. “Basis for income limit for full Medicaid coverage for
pregnant women” – Path 1

Figure 7: Basis for income limit for full Medicaid coverage for pregnant women – 1

S28-Pregnant Women PRA document Version 1.0

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CMS XLC

1.8

S28-Pregnant Women – Screenshot

Section F. “Basis for income limit for full Medicaid coverage for
pregnant women” – Path 2

Figure 8: Basis for income limit for full Medicaid coverage for pregnant women – 2

1.9

Section G. “Additional Information”

Figure 9: Additional Information

S28-Pregnant Women PRA document Version 1.0

08/18/2017

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

Medicaid and CHIP Program (MACPro)
S28a-Presumtpive Eligibility for Pregnant Women
PRA document
Version 1.0
08/17/2017

Document Number: 207-QSSI-MACPro-PRA-S28a-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S28a-Presumptive Eligibility for Pregnant Women – Screenshots ..................... 1
1.1

Presumptive Eligibility for Pregnant Women ................................................... 1

List of Figures
Figure 1: Presumptive Eligibility for Pregnant Women– 1 ............................................... 1
Figure 2: Presumptive Eligibility for Pregnant Women – 2 .............................................. 2
Figure 3: Presumptive Eligibility for Pregnant Women – 3 .............................................. 2
Figure 4: Presumptive Eligibility for Pregnant Women – 4 .............................................. 3

S28a-Presumtpive Eligibility for Pregnant Women PRA document Version 1.0

08/17/2017

CMS XLC

S28a-Presumptive Eligibility for Pregnant Women – Screenshots

1. S28a-Presumptive Eligibility for Pregnant Women –
Screenshots
1.1

Presumptive Eligibility for Pregnant Women

Figure 1: Presumptive Eligibility for Pregnant Women– 1

S28a-Presumtpive Eligibility for Pregnant Women PRA document Version 1.0

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CMS XLC

S28a-Presumptive Eligibility for Pregnant Women – Screenshots

Figure 2: Presumptive Eligibility for Pregnant Women – 2

Figure 3: Presumptive Eligibility for Pregnant Women – 3

S28a-Presumtpive Eligibility for Pregnant Women PRA document Version 1.0

08/17/2017

CMS XLC

S28a-Presumptive Eligibility for Pregnant Women – Screenshots

Figure 4: Presumptive Eligibility for Pregnant Women – 4

S28a-Presumtpive Eligibility for Pregnant Women PRA document Version 1.0

08/17/2017

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

Medicaid and CHIP Program (MACPro)
S28T-Presumptive Eligibility for Pregnant Women
PRA document
Version 1.0
08/21/2017

Document Number: 232-QSSI-MACPro-PRA-S28T-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S28T-Presumptive Eligibility for Pregnant Women – Screenshots ..................... 1
1.1

Presumptive Eligibility for Pregnant Women ................................................... 1

List of Figures
Figure 1: Presumptive Eligibility for Pregnant Women – 1 .............................................. 1
Figure 2: Presumptive Eligibility for Pregnant Women – 2 .............................................. 2
Figure 3: Presumptive Eligibility for Pregnant Women – 3 .............................................. 2
Figure 4: Presumptive Eligibility for Pregnant Women – 4 .............................................. 3

S28T-Presumptive Eligibility for Pregnant Women PRA document Version 1.0

08/21/2017

CMS XLC

S28T-Presumptive Eligibility for Pregnant Women – Screenshots

1. S28T-Presumptive Eligibility for Pregnant Women –
Screenshots
1.1

Presumptive Eligibility for Pregnant Women

Figure 1: Presumptive Eligibility for Pregnant Women – 1

S28T-Presumptive Eligibility for Pregnant Women PRA document Version 1.0

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CMS XLC

S28T-Presumptive Eligibility for Pregnant Women – Screenshots

Figure 2: Presumptive Eligibility for Pregnant Women – 2

Figure 3: Presumptive Eligibility for Pregnant Women – 3

S28T-Presumptive Eligibility for Pregnant Women PRA document Version 1.0

08/21/2017

CMS XLC

S28T-Presumptive Eligibility for Pregnant Women – Screenshots

Figure 4: Presumptive Eligibility for Pregnant Women – 4

S28T-Presumptive Eligibility for Pregnant Women PRA document Version 1.0

08/21/2017

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

Medicaid and CHIP Program (MACPro)
S30 – Infants and Children under Age 19 RU PRA
Document
Version 1.0
08/18/2017

Document Number: 209-QSSI-MACPro-R5.1-S30-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S30 - Infants and Children under Age 19 Screenshots ....................................................... 1
1.1
1.2
1.3
1.4
1.5
1.6
1.7

Package Header ............................................................................................. 1
A. Characteristics and B. Financial Methodologies and C. Income Standards
Used ................................................................................................................ 1
D. Basis for the Income Standard for Infants under Age 1 – Path 1 ................ 2
D. Basis for the Income Standard for Infants under Age 1 – Path 2 ................ 2
E. Basis for the Income Standard for Children Age One through Age Five ..... 3
F. Basis for the Income Standard for Children Age Six through Age Eighteen 3
G. Additional Information (optional) ................................................................. 4

List of Tables
No table of figures entries found.

S30 – Infants and Children under Age 19 RU PRA Document
Version 1.0

08/18/2017

CMS XLC

Package Header

1. S30 - Infants and Children under Age 19 Screenshots
1.1

Package Header

Figure 1: Package Header

1.2

A. Characteristics and B. Financial Methodologies and C. Income
Standards Used

Figure 2: Section A, Section B and Section C

S30 – Infants and Children under Age 19 RU PRA Document
Version 1.0

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CMS XLC

1.3

D. Basis for the Income Standard for Infants under Age 1 – Path 1

Figure 3: Section D-Path1

1.4

D. Basis for the Income Standard for Infants under Age 1 – Path 2

Figure 4: Section D-Path2

S30 – Infants and Children under Age 19 RU PRA Document
Version 1.0

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CMS XLC

1.5

E. Basis for the Income Standard for Children Age One through Age Five

E. Basis for the Income Standard for Children Age One through Age
Five

Figure 5 : Section E

1.6

F. Basis for the Income Standard for Children Age Six through Age
Eighteen

Figure 6 : Section F

S30 – Infants and Children under Age 19 RU PRA Document
Version 1.0

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CMS XLC

1.7

G. Additional Information (optional)

Figure 7 : Section G

S30 – Infants and Children under Age 19 RU PRA Document
Version 1.0

08/18/2017

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

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

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

CMS XLC

Table of Contents

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

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

List of Tables
No table of figures entries found.

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

08/16/2017

CMS XLC

Package Header

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

Package Header

Figure 1: Package Header

1.2

A. Characteristics and B. Financial Methodologies

Figure 2: Section A and Section B

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

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CMS XLC

1.3

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

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

Figure 3: Section C and Section D

1.4

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

Figure 4: Section E and Section F

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

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CMS XLC

1.5

G. Additional Information (optional)

Figure 5: Section G

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

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

Medicaid and CHIP Program (MACPro)
S32 - Adult Group RU PRA Document
Version 1.0
08/16/2017

Document Number: 183-QSSI-MACPro-R5.1-S32-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S32 - Adult Group Screenshots .............................................................................. 1
1.1
1.2
1.3

Package Header ............................................................................................. 1
A. Characteristics, B. Financial Methodologies, C. Income Standard Used and
D. Coverage of Dependent Children ............................................................... 1
E. Additional Information (optional) ................................................................. 2

List of Tables
No table of figures entries found.

S32 - Adult Group RU PRA Document Version 1.0

08/16/2017

CMS XLC

Package Header

1. S32 - Adult Group Screenshots
1.1

Package Header

Figure 1: Package Header

1.2

A. Characteristics, B. Financial Methodologies, C. Income Standard
Used and D. Coverage of Dependent Children

Figure 2: Section A, Section B, Section C and Section D

S32 - Adult Group RU PRA Document Version 1.0

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CMS XLC

1.3

E. Additional Information (optional)

Figure 3: Section E

S32 - Adult Group RU PRA Document Version 1.0

08/16/2017

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

Medicaid and CHIP Program (MACPro)
S32a-Adult Group - Presumptive Eligibility PRA
document
Version 1.0
08/18/2017

Document Number: 215-QSSI-MACPro-PRA-S32a-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S32a-Adult Group - Presumptive Eligibility ........................................................... 1
1.1

Adult Group - Presumptive Eligibility ............................................................... 1

List of Figures
Figure 1: Adult Group - Presumptive Eligibility – 1 .......................................................... 1
Figure 2: Adult Group - Presumptive Eligibility – 2 .......................................................... 2
Figure 3: Adult Group - Presumptive Eligibility – 3 .......................................................... 2
Figure 4: Adult Group - Presumptive Eligibility – 4 .......................................................... 3
Figure 5: Adult Group - Presumptive Eligibility – 5 .......................................................... 3

S32a-Adult Group - Presumptive Eligibility PRA document Version 1.0 i

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CMS XLC

S32a-Adult Group - Presumptive Eligibility - Screenshots

1. S32a-Adult Group - Presumptive Eligibility Screenshots
1.1

Adult Group - Presumptive Eligibility

Figure 1: Adult Group - Presumptive Eligibility – 1

S32a-Adult Group - Presumptive Eligibility PRA document Version 1.0 1

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CMS XLC

S32a-Adult Group - Presumptive Eligibility - Screenshots

Figure 2: Adult Group - Presumptive Eligibility – 2

Figure 3: Adult Group - Presumptive Eligibility – 3

S32a-Adult Group - Presumptive Eligibility PRA document Version 1.0 2

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CMS XLC

S32a-Adult Group - Presumptive Eligibility - Screenshots

Figure 4: Adult Group - Presumptive Eligibility – 4

Figure 5: Adult Group - Presumptive Eligibility – 5

S32a-Adult Group - Presumptive Eligibility PRA document Version 1.0 3

08/18/2017

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

Medicaid and CHIP Program (MACPro)
S32T-Adult Group - Presumptive Eligibility PRA
document
Version 1.0
08/21/2017

Document Number: 241-QSSI-MACPro-PRA-S32T-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S32T-Adult Group - Presumptive Eligibility – Screenshots ................................................... 1
1.1

Adult Group - Presumptive Eligibility ............................................................... 1

S32T-Adult Group - Presumptive Eligibility PRA document Version 1.0 i

08/21/2017

CMS XLC

S32T-Adult Group - Presumptive Eligibility – Screenshots

1. S32T-Adult Group - Presumptive Eligibility – Screenshots
1.1

Adult Group - Presumptive Eligibility

Figure 1: Adult Group - Presumptive Eligibility – 1

S32T-Adult Group - Presumptive Eligibility PRA document Version 1.0 1

08/21/2017

CMS XLC

S32T-Adult Group - Presumptive Eligibility – Screenshots

Figure 2: Adult Group - Presumptive Eligibility – 2

Figure 3: Adult Group - Presumptive Eligibility – 3

S32T-Adult Group - Presumptive Eligibility PRA document Version 1.0 2

08/21/2017

CMS XLC

S32T-Adult Group - Presumptive Eligibility – Screenshots

Figure 4: Adult Group - Presumptive Eligibility – 4

Figure 5: Adult Group - Presumptive Eligibility – 5

S32T-Adult Group - Presumptive Eligibility PRA document Version 1.0 3

08/21/2017

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

Medicaid and CHIP Program (MACPro)
S33-Former Foster Care Children PRA document
Version 1.0
08/18/2017

Document Number: 216-QSSI-MACPro-PRA-S33-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S33-Former Foster Care Children – Screenshots ................................................. 1
1.1

Former Foster Care Children .......................................................................... 1

List of Figures
Figure 1: Former Foster Care Children – 1 ..................................................................... 1
Figure 2: Former Foster Care Children – 2 ..................................................................... 1

S33-Former Foster Care Children PRA document Version 1.0

08/18/2017

CMS XLC

S33-Former Foster Care Children – Screenshots

1. S33-Former Foster Care Children – Screenshots
1.1

Former Foster Care Children

Figure 1: Former Foster Care Children – 1

Figure 2: Former Foster Care Children – 2

S33-Former Foster Care Children PRA document Version 1.0

08/18/2017

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

Medicaid and CHIP Program (MACPro)
S33a-Former Foster Care Children – Presumptive
Eligibility PRA document
Version 1.0
08/18/2017

Document Number: 217-QSSI-MACPro-PRA-S33a-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S33a-Former Foster Care Children – Presumptive Eligibility - Screenshots ...... 1
1.1

Former Foster Care Children – Presumptive Eligibility .................................... 1

List of Figures
Figure 1: Former Foster Care Children – Presumptive Eligibility – 1 ............................... 1
Figure 2: Former Foster Care Children – Presumptive Eligibility – 2 ............................... 2
Figure 3: Former Foster Care Children – Presumptive Eligibility – 3 ............................... 2
Figure 4: Former Foster Care Children – Presumptive Eligibility – 4 ............................... 3
Figure 5: Former Foster Care Children – Presumptive Eligibility – 5 ............................... 3

S33a-Former Foster Care Children – Presumptive Eligibility PRA document Version 1.0

08/18/2017

CMS XLC

S33a-Former Foster Care Children – Presumptive Eligibility - Screenshots

1. S33a-Former Foster Care Children – Presumptive
Eligibility - Screenshots
1.1

Former Foster Care Children – Presumptive Eligibility

Figure 1: Former Foster Care Children – Presumptive Eligibility – 1

S33a-Former Foster Care Children – Presumptive Eligibility PRA document Version 1.0

08/18/2017

CMS XLC

S33a-Former Foster Care Children – Presumptive Eligibility - Screenshots

Figure 2: Former Foster Care Children – Presumptive Eligibility – 2

Figure 3: Former Foster Care Children – Presumptive Eligibility – 3

S33a-Former Foster Care Children – Presumptive Eligibility PRA document Version 1.0

08/18/2017

CMS XLC

S33a-Former Foster Care Children – Presumptive Eligibility - Screenshots

Figure 4: Former Foster Care Children – Presumptive Eligibility – 4

Figure 5: Former Foster Care Children – Presumptive Eligibility – 5

S33a-Former Foster Care Children – Presumptive Eligibility PRA document Version 1.0

08/18/2017

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

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

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

CMS XLC

Table of Contents

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

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

S50 – Individuals above 133% FPL under Age 65 RU PRA Document Version
1.0
i

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CMS XLC

List of Tables

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

List of Tables
No table of figures entries found.

S50 – Individuals above 133% FPL under Age 65 RU PRA Document Version
1.0
ii

08/18/2017

CMS XLC

Package Header

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

Package Header

Figure 1: Package Header

1.2

A. Characteristics, B. Financial Methodologies,

Figure 2: Section A and Section B

S50 – Individuals above 133% FPL under Age 65 RU PRA Document Version
1.0
1

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CMS XLC

1.3

C. Individuals Covered

Figure 3: Section C

1.4

D. Income Standard Used – Path 1

Figure 4: Section D – Path 1

1.5

D. Income Standard Used – Path 2

Figure 5: Section D – Path 2
S50 – Individuals above 133% FPL under Age 65 RU PRA Document Version
1.0
2

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CMS XLC

1.6

D. Income Standard Used – Path 3 – Screenshot 1

Figure 6: Section D – Path 3 – Screenshot 1

1.7

D. Income Standard Used – Path 3 – Screenshot 2

Figure 7: Section D – Path 3 – Screenshot 2

S50 – Individuals above 133% FPL under Age 65 RU PRA Document Version
1.0
3

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CMS XLC

1.8

E. Coverage of Dependent Children

Figure 8: Section E

1.9

F. Phase-In

Figure 9: Section F – Phase-In

S50 – Individuals above 133% FPL under Age 65 RU PRA Document Version
1.0
4

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CMS XLC

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

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

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

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

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

S50 – Individuals above 133% FPL under Age 65 RU PRA Document Version
1.0
5

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CMS XLC

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

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

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

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

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

S50 – Individuals above 133% FPL under Age 65 RU PRA Document Version
1.0
6

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CMS XLC

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

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

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

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

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

S50 – Individuals above 133% FPL under Age 65 RU PRA Document Version
1.0
7

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CMS XLC

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

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

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

1.17 G. Additional Information (optional)

Figure 17: Section G

S50 – Individuals above 133% FPL under Age 65 RU PRA Document Version
1.0
8

08/18/2017

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

Medicaid and CHIP Program (MACPro)
S50a - Individuals above 133% FPL under Age 65
- Presumptive Eligibility RU PRA Document
Version 1.0
08/18/2017

Document Number: 221-QSSI-MACPro-R5.1-S50a-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S50a - Individuals above 133% FPL under Age 65 - Presumptive Eligibility
Screenshots ............................................................................................................. 1
1.1
1.2
1.3
1.4

Package Header ............................................................................................. 1
A. Presumptive Eligibility Period and B. Application for Presumptive Eligibility 2
C. Presumptive Eligibility Determination and D. Qualified Entities .................. 2
E. Additional Information (optional) ................................................................. 3

List of Tables
No table of figures entries found.

S50a - Individuals above 133% FPL under Age 65 - Presumptive Eligibility RU PRA Document Version
1.0
i

08/18/2017

CMS XLC

Package Header

1. S50a - Individuals above 133% FPL under Age 65 Presumptive Eligibility Screenshots
1.1

Package Header

Figure 1: Package Header

S50a - Individuals above 133% FPL under Age 65 - Presumptive Eligibility RU PRA Document Version
1.0
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CMS XLC

1.2

A. Presumptive Eligibility Period and B. Application for Presumptive Eligibility

A. Presumptive Eligibility Period and B. Application for
Presumptive Eligibility

Figure 2: Section A and Section B

1.3

C. Presumptive Eligibility Determination and D. Qualified Entities

Figure 3 : Section C and Section D

S50a - Individuals above 133% FPL under Age 65 - Presumptive Eligibility RU PRA Document Version
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1.4

E. Additional Information (optional)

Figure 4 : Section E

S50a - Individuals above 133% FPL under Age 65 - Presumptive Eligibility RU PRA Document Version
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Centers for Medicare & Medicaid
Services
CMS eXpedited Life Cycle (XLC)

Medicaid and CHIP Program (MACPro)
S51 - Optional Coverage of Parents and Other
Caretaker Relatives RU PRA Document
Version 1.0
08/15/2017

Document Number: 171-QSSI-MACPro-R5.1-S51-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S51- Optional Coverage of Parents and Other Caretaker Relatives Screenshots .................... 1
1.1
1.2
1.3
1.4
1.5

Package Header ............................................................................................. 1
A. Characteristics, B. Financial Methodologies, C. Coverage Prior to January
1, 2014 and D. Income Standard Used–Path 1 ............................................... 2
D. Income Standard Used – Path 2................................................................. 2
E. Basis for Income Standard.......................................................................... 3
F. Additional Information (optional) ................................................................. 3

List of Tables
No table of figures entries found.

S51 - Optional Coverage of Parents and Other Caretaker Relatives RU PRA Document Version
1.0
i

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CMS XLC

Package Header

1. S51- Optional Coverage of Parents and Other Caretaker Relatives
Screenshots
1.1

Package Header

Figure 1: Package Header

S51 - Optional Coverage of Parents and Other Caretaker Relatives RU PRA Document Version
1.0
1

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CMS XLC

1.2

A. Characteristics, B. Financial Methodologies, C. Coverage Prior to January 1, 2014 and D. Income Standard Used–Path 1

A. Characteristics, B. Financial Methodologies, C. Coverage Prior
to January 1, 2014 and D. Income Standard Used–Path 1

Figure 2: Section A, Section B, Section C and Section D-Path1

1.3

D. Income Standard Used – Path 2

Figure 3: Section D–Path 2

S51 - Optional Coverage of Parents and Other Caretaker Relatives RU PRA Document Version
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CMS XLC

1.4

E. Basis for Income Standard

Figure 4: Section E

1.5

F. Additional Information (optional)

Figure 5: Section F

S51 - Optional Coverage of Parents and Other Caretaker Relatives RU PRA Document Version
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Centers for Medicare & Medicaid
Services
CMS eXpedited Life Cycle (XLC)

Medicaid and CHIP Program (MACPro)
S52 – Reasonable Classification of Individuals
under Age 21 RU PRA Document
Version 1.0
08/21/2017

Document Number: 237-QSSI-MACPro-R5.1-S52-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S52 - Reasonable Classification of Individuals under Age 21 Screenshots ....... 1
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
1.11
1.12
1.13
1.14
1.15

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

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List of Tables

Figure 14: Section E ........................................................................................................ 7
Figure 15: Section F ........................................................................................................ 7

List of Tables
No table of figures entries found.

S52 – Reasonable Classification of Individuals under Age 21 RU PRA Document
Version 1.0
ii

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CMS XLC

Package Header

1. S52 - Reasonable Classification of Individuals under
Age 21 Screenshots
1.1

Package Header

Figure 1: Package Header

1.2

A. Characteristics, B. Financial Methodologies,

Figure 2: Section A and Section B

S52 – Reasonable Classification of Individuals under Age 21 RU PRA Document
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CMS XLC

1.3

C. Individuals Covered – Path 1 – Screenshot 1

Figure 3: Section C- Path 1– Screenshot 1

1.4

C. Individuals Covered – Path 1 – Screenshot 2

Figure 4 : Section C – Path 1 – Screenshot 2

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1.5

C. Individuals Covered – Path 2

Figure 5: Section C –Path 2

1.6

C. Individuals Covered – Path 3

Figure 6: Section C – Path 3

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1.7

C. Individuals Covered – Path 4

Figure 7: Section C – Path 4

1.8

C. Individuals Covered – Path 5

Figure 8: Section C – Path 5

1.9

C. Individuals Covered – Path 6

Figure 9: Section C – Path 6

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D. Income Standard Used – Path 1

1.10 D. Income Standard Used – Path 1

Figure 10: Section D – Path 1

1.11 D. Income Standard Used – Path 2

Figure 11: Section D – Path 2

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D. Income Standard Used – Path 3

1.12 D. Income Standard Used – Path 3

Figure 12 : Section D – Path 3

1.13 D. Income Standard Used – Path 4

Figure 13: Section D – Path 4

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1.14

E. Basis for Income Standard

Figure 14: Section E

1.15 F. Additional Information (optional)

Figure 15: Section F

S52 – Reasonable Classification of Individuals under Age 21 RU PRA Document
Version 1.0
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Centers for Medicare & Medicaid
Services
CMS eXpedited Life Cycle (XLC)

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

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

CMS XLC

Table of Contents

Table of Contents
1. S53 - Children with Non IV-E Adoption Assistance Screenshots ........................ 1
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
1.11
1.12

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

List of Tables
No table of figures entries found.

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

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CMS XLC

Package Header

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

Package Header

Figure 1: Package Header

1.2

A. Characteristics, B. Financial Methodologies,

Figure 2: Section A and Section B

S53 – Children with Non IV-E Adoption Assistance RU PRA Document
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1.3

C. Individuals Covered – Path 1

Figure 3: Section C- Path 1

1.4

C. Individuals Covered – Path 2 – Screenshot 1

Figure 4 : Section C – Path 2 – Screenshot 1

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1.5

C. Individuals Covered – Path 2 – Screenshot 2

Figure 5: Section C – Path 2 – Screenshot 2

1.6

D. Income Standard Used – Path 1 – Screenshot 1

Figure 6: Section D – Path 1 – Screenshot 1

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1.7

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

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

1.8

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

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

S53 – Children with Non IV-E Adoption Assistance RU PRA Document
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1.9

D. Income Standard Used – Path 2

Figure 9: Section D – Path 2

1.10 Income Standard Used – Path 3

Figure 10: Section D – Path 3

1.11

E. Basis for Income Standard - Maximum Income Standard

Figure 11: Section E

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F. Additional Information (optional)

1.12 F. Additional Information (optional)

Figure 12: Section F

S53 – Children with Non IV-E Adoption Assistance RU PRA Document
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Centers for Medicare & Medicaid
Services
CMS eXpedited Life Cycle (XLC)

Medicaid and CHIP Program (MACPro)
S54 - Optional Targeted Low Income Children RU
Document
Version 1.0
08/15/2017

Document Number: 175-QSSI-MACPro-R5.1-S54-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S54 - Optional Targeted Low Income Children Screenshots ............................... 1
1.1
1.2
1.3
1.4
1.5
1.6

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

List of Tables
No table of figures entries found.

S54 - Optional Targeted Low Income Children RU Document Version
1.0
i

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CMS XLC

Package Header

1. S54 - Optional Targeted Low Income Children
Screenshots
1.1

Package Header

Figure 1: Package Header

S54 - Optional Targeted Low Income Children RU Document Version
1.0
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CMS XLC

1.2

A. Characteristics, B. Financial Methodologies and C. Individuals Covered-Path 1

A. Characteristics, B. Financial Methodologies and C. Individuals
Covered-Path 1

Figure 2: Section A, Section B and Section C-Path1

1.3

C. Individuals Covered-Path 2

Figure 3: Section C-Path2

S54 - Optional Targeted Low Income Children RU Document Version
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1.4

D. Income Standard Used

Figure 4: Section D

1.5

E. Basis for Income Standard

Figure 5: Section E

S54 - Optional Targeted Low Income Children RU Document Version
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1.6

F. Additional Information (optional)

Figure 6: Section F

S54 - Optional Targeted Low Income Children RU Document Version
1.0
4

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

Medicaid and CHIP Program (MACPro)
S55-Individuals with Tuberculosis PRA document
Version 1.0
08/22/2017

Document Number: 243-QSSI-MACPro-PRA-S55-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S55-Individuals with Tuberculosis - Screenshots ............................................................... 1
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9

Section A. “Characteristics” ............................................................................. 1
Section B. “Financial Methodologies” .............................................................. 1
Section C. “Income Standard Used” – Path 1 ................................................. 1
Section C. “Income Standard Used” – Path 2 ................................................. 2
Section D. “Basis for Individuals with Tuberculosis Income Standard Maximum Income Standard” – Path 1 ............................................................. 2
Section D. “Basis for Individuals with Tuberculosis Income Standard Maximum Income Standard” – Path 2 ............................................................. 2
Section D. “Basis for Individuals with Tuberculosis Income Standard Maximum Income Standard” – Path 3 ............................................................. 3
Section D. “Basis for Individuals with Tuberculosis Income Standard Maximum Income Standard” – Path 4 ............................................................. 3
Section E. “Benefits for Individuals with Tuberculosis” and Section F.
“Additional Information” ................................................................................... 3

List of Figures
Figure 1: Section A .......................................................................................................... 1
Figure 2: Section B .......................................................................................................... 1
Figure 3: Section C. - 1 ................................................................................................... 1
Figure 4: Section C. – 2................................................................................................... 2
Figure 5: Section D – 1.................................................................................................... 2
Figure 6: Section D – 2.................................................................................................... 2
Figure 7: Section D – 3.................................................................................................... 3
Figure 8: Section D – 4.................................................................................................... 3
Figure 9: Sections E & F ................................................................................................. 3

S55-Individuals with Tuberculosis PRA document Version 1.0

08/22/2017

CMS XLC

S55-Individuals with Tuberculosis - Screenshots

1. S55-Individuals with Tuberculosis - Screenshots
1.1

Section A. “Characteristics”

Figure 1: Section A

1.2

Section B. “Financial Methodologies”

Figure 2: Section B

1.3

Section C. “Income Standard Used” – Path 1

Figure 3: Section C. - 1

S55-Individuals with Tuberculosis PRA document Version 1.0

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CMS XLC

1.4

S55-Individuals with Tuberculosis - Screenshots

Section C. “Income Standard Used” – Path 2

Figure 4: Section C. – 2

1.5

Section D. “Basis for Individuals with Tuberculosis Income
Standard - Maximum Income Standard” – Path 1

Figure 5: Section D – 1

1.6

Section D. “Basis for Individuals with Tuberculosis Income
Standard - Maximum Income Standard” – Path 2

Figure 6: Section D – 2

S55-Individuals with Tuberculosis PRA document Version 1.0

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CMS XLC

1.7

S55-Individuals with Tuberculosis - Screenshots

Section D. “Basis for Individuals with Tuberculosis Income
Standard - Maximum Income Standard” – Path 3

Figure 7: Section D – 3

1.8

Section D. “Basis for Individuals with Tuberculosis Income
Standard - Maximum Income Standard” – Path 4

Figure 8: Section D – 4

1.9

Section E. “Benefits for Individuals with Tuberculosis” and
Section F. “Additional Information”

Figure 9: Sections E & F

S55-Individuals with Tuberculosis PRA document Version 1.0

08/22/2017

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

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

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

CMS XLC

Table of Contents

Table of Contents
1. S57 - Independent Foster Care Adolescents Screenshots .................................. 1
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
1.11
1.12
1.13
1.14
1.15
1.16
1.17
1.18
1.19
1.20
1.21
1.22
1.23
1.24
1.25

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

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1.26
1.27
1.28
1.29
1.30
1.31
1.32

List of Figures

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

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

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

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

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

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

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List of Tables

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

List of Tables
No table of figures entries found.

S57 – Independent Foster Care Adolescents RU PRA Document Version
1.0
iii

08/18/2017

CMS XLC

Package Header

1. S57 - Independent Foster Care Adolescents
Screenshots
1.1

Package Header

Figure 1: Package Header

1.2

A. Characteristics, B. Financial Methodologies,

Figure 2: Section A and Section B

S57 – Independent Foster Care Adolescents RU PRA Document Version
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CMS XLC

1.3

C. Individuals Covered – Path 1 – Screenshot 1

Figure 3: Section C – Path 1 – Screenshot 1

1.4

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

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

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1.5

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

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

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

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1.6

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

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

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

1.7

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

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

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1.8

C. Individuals Covered – Path 2 – Screenshot 1

Figure 8: Section C– Path 2 – Screenshot 1

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1.9

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

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

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

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

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

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

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

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

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

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

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

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C. Individuals Covered– Path 3 – Screenshot 1

1.13 C. Individuals Covered– Path 3 – Screenshot 1

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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C. Individuals Covered– Path 4 – Screenshot 1

1.19 C. Individuals Covered– Path 4 – Screenshot 1

Figure 19 : Section C– Path 4 – Screenshot 1

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

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

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

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

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

1.22 C. Individuals Covered– Path 5 – Screenshot 1

Figure 22: Section C – Path 5 – Screenshot 1

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

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

Figure 23

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

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

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C. Individuals Covered– Path 6 – Screenshot 1

1.25 C. Individuals Covered– Path 6 – Screenshot 1

Figure 25 : Section C– Path 6 – Screenshot 1

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

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

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XLC

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

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

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

1.28 C. Individuals Covered– Path 7 – Screenshot 1

Figure 28: Section C– Path 7 – Screenshot 1

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

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

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

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

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

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

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

Figure 31: Section E

1.32 F. Additional Information (optional)

Figure 32: Section F

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

Medicaid and CHIP Program (MACPro)
S59 – Individuals Eligible for Family Planning
Services RU PRA Document
Version 1.0
08/20/2017

Document Number: 228-QSSI-MACPro-R5.1-S59-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S59 - Individuals Eligible for Family Planning Services Screenshots ................. 1
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
1.11

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

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

List of Tables
No table of figures entries found.

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Version 1.0
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CMS XLC

Package Header

1. S59 - Individuals Eligible for Family Planning Services
Screenshots
1.1

Package Header

Figure 1: Package Header

1.2

A. Characteristics, B. Individuals Covered – Path 1

Figure 2: Section A, Section B – Path 1

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1.3

B. Individuals Covered – Path 2

Figure 3: Section B – Path 2

1.4

C. Income Standard Used – Path 1

Figure 4: Section C - Path 1

1.5

C. Income Standard Used – Path 2

Figure 5: Section C - Path 2

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1.6

C. Income Standard Used – Path 3

Figure 6: Section C – Path 3

1.7

D. Financial Methodologies – Path 1

Figure 7: Section D – Path 1

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1.8

D. Financial Methodologies – Path 2

Figure 8: Section D - Path 2

1.9

D. Financial Methodologies – Path 3 – Screenshot 1

Figure 9 : Section D - Path 3 - Screenshot 1

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D. Financial Methodologies – Path 3 – Screenshot 2

1.10 D. Financial Methodologies – Path 3 – Screenshot 2

Figure 10 : Section D - Path 3 - Screenshot 2

1.11 E. Basis for Income Standard - Maximum Income Standard, F.
Family Planning Benefits and G. Additional Information (optional)

Figure 11 : Section E, Section F and Section G

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

Medicaid and CHIP Program (MACPro)
S59a - Individuals Eligible for Family Planning
Services - Presumptive Eligibility RU PRA
Document
Version 1.0
08/20/2017

Document Number: 229-QSSI-MACPro-R5.1-S59a-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S59a - Individuals Eligible for Family Planning Services - Presumptive
Eligibility Screenshots ............................................................................................ 1
1.1
1.2
1.3
1.4
1.5
1.6

Package Header ............................................................................................. 1
A. Presumptive Eligibility Period ...................................................................... 1
B. Application for Presumptive Eligibility – Screenshot 1. ............................... 2
B. Application for Presumptive Eligibility – Screenshot 2 ................................ 2
C. Presumptive Eligibility Determination and D. Qualified Entities .................. 3
E. Additional Information (optional) ................................................................. 3

List of Figures
Figure 1: Package Header .............................................................................................. 1
Figure 2: Section A .......................................................................................................... 1
Figure 3: Section B – Screenshot 1 ................................................................................. 2
Figure 4: Section B – Screenshot 2 ................................................................................. 2
Figure 5 : Section C and Section D ................................................................................. 3
Figure 6 : Section E ......................................................................................................... 3

List of Tables
No table of figures entries found.

S59a - Individuals Eligible for Family Planning Services - Presumptive Eligibility RU PRA Document Version
1.0
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Package Header

1. S59a - Individuals Eligible for Family Planning Services
- Presumptive Eligibility Screenshots
1.1

Package Header

Figure 1: Package Header

1.2

A. Presumptive Eligibility Period

Figure 2: Section A

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1.3

B. Application for Presumptive Eligibility – Screenshot 1.

Figure 3: Section B – Screenshot 1

1.4

B. Application for Presumptive Eligibility – Screenshot 2

Figure 4: Section B – Screenshot 2

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1.5

C. Presumptive Eligibility Determination and D. Qualified Entities

Figure 5 : Section C and Section D

1.6

E. Additional Information (optional)

Figure 6 : Section E

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

Medicaid and CHIP Program (MACPro)
S88-State Residency PRA document
Version 1.0
08/21/2017

Document Number: 233-QSSI-MACPro-PRA-S88-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S88-State Residency - Screenshots .................................................................................. 1
1.1

State Residency .............................................................................................. 1

List of Figures
Figure 1: State Residency – 1 ......................................................................................... 1
Figure 2: State Residency – 2 ......................................................................................... 2
Figure 3: State Residency – 3 ......................................................................................... 2
Figure 4: State Residency – 4 ......................................................................................... 3

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CMS XLC

S88-State Residency - Screenshots

1. S88-State Residency - Screenshots
1.1

State Residency

Figure 1: State Residency – 1

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CMS XLC

S88-State Residency - Screenshots

Figure 2: State Residency – 2

Figure 3: State Residency – 3

S88-State Residency PRA document Version 1.0

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CMS XLC

S88-State Residency - Screenshots

Figure 4: State Residency – 4

S88-State Residency PRA document Version 1.0

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

Medicaid and CHIP Program (MACPro)
S89-Citizenship and Non-Citizenship PRA
document
Version 1.0
08/22/2017

Document Number: 244-QSSI-MACPro-PRA-S89-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S89-Citizenship and Non-Citizenship – Screenshots ........................................... 1
1.1

Citizenship and Non-Citizenship ..................................................................... 1

List of Figures
Figure 1: Citizenship and Non-Citizenship – 1 ................................................................ 1
Figure 2: Citizenship and Non-Citizenship – 2 ................................................................ 2
Figure 3: Citizenship and Non-Citizenship – 3 ................................................................ 2
Figure 4: Citizenship and Non-Citizenship – 4 ................................................................ 3
Figure 5: Citizenship and Non-Citizenship – 5 ................................................................ 3

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CMS XLC

S89-Citizenship and Non-Citizenship – Screenshots

1. S89-Citizenship and Non-Citizenship – Screenshots
1.1

Citizenship and Non-Citizenship

Figure 1: Citizenship and Non-Citizenship – 1

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CMS XLC

S89-Citizenship and Non-Citizenship – Screenshots

Figure 2: Citizenship and Non-Citizenship – 2

Figure 3: Citizenship and Non-Citizenship – 3

S89-Citizenship and Non-Citizenship PRA document Version 1.0

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CMS XLC

S89-Citizenship and Non-Citizenship – Screenshots

Figure 4: Citizenship and Non-Citizenship – 4

Figure 5: Citizenship and Non-Citizenship – 5

S89-Citizenship and Non-Citizenship PRA document Version 1.0

08/22/2017

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

Medicaid and CHIP Program (MACPro)
S94-Eligibility Process PRA document
Version 1.0
08/21/2017

Document Number: 234-QSSI-MACPro-PRA-S94-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S94-Eligibility Process – Screenshots ................................................................... 1
1.1

Eligibility Process ............................................................................................ 1

List of Figures
Figure 1: Eligibility Process – 1 ....................................................................................... 1
Figure 2: Eligibility Process – 2 ....................................................................................... 2
Figure 3: Eligibility Process – 3 ....................................................................................... 2
Figure 4: Eligibility Process – 4 ....................................................................................... 3
Figure 5: Eligibility Process – 5 ....................................................................................... 3
Figure 6: Eligibility Process – 6 ....................................................................................... 4
Figure 7: Eligibility Process – 7 ....................................................................................... 4

S94-Eligibility Process PRA document Version 1.0

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CMS XLC

S94-Eligibility Process – Screenshots

1. S94-Eligibility Process – Screenshots
1.1

Eligibility Process

Figure 1: Eligibility Process – 1

S94-Eligibility Process PRA document Version 1.0

08/21/2017

CMS XLC

S94-Eligibility Process – Screenshots

Figure 2: Eligibility Process – 2

Figure 3: Eligibility Process – 3

S94-Eligibility Process PRA document Version 1.0

08/21/2017

CMS XLC

S94-Eligibility Process – Screenshots

Figure 4: Eligibility Process – 4

Figure 5: Eligibility Process – 5

S94-Eligibility Process PRA document Version 1.0

08/21/2017

CMS XLC

S94-Eligibility Process – Screenshots

Figure 6: Eligibility Process – 6

Figure 7: Eligibility Process – 7

S94-Eligibility Process PRA document Version 1.0

08/21/2017

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

Medicaid and CHIP Program (MACPro)
S94a-Application PRA document
Version 1.0
08/17/2017

Document Number: 208-QSSI-MACPro-PRA-S94a-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S94a-Application – Screenshots ............................................................................ 1
1.1

Application....................................................................................................... 1

List of Figures
Figure 1: Application - 1 .................................................................................................. 1
Figure 2: Application – 2.................................................................................................. 1
Figure 3: Application – 3.................................................................................................. 2
Figure 4: Application – 4.................................................................................................. 2
Figure 5: Application – 5.................................................................................................. 3
Figure 6: Application – 6.................................................................................................. 3
Figure 7: Application – 7.................................................................................................. 4
Figure 8: Application – 8.................................................................................................. 4

S94a-Application PRA document Version 1.0

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CMS XLC

S94a-Application – Screenshots

1. S94a-Application – Screenshots
1.1

Application

Figure 1: Application - 1

Figure 2: Application – 2

S94a-Application PRA document Version 1.0

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CMS XLC

S94a-Application – Screenshots

Figure 3: Application – 3

Figure 4: Application – 4

S94a-Application PRA document Version 1.0

08/17/2017

CMS XLC

S94a-Application – Screenshots

Figure 5: Application – 5

Figure 6: Application – 6

S94a-Application PRA document Version 1.0

08/17/2017

CMS XLC

S94a-Application – Screenshots

Figure 7: Application – 7

Figure 8: Application – 8

S94a-Application PRA document Version 1.0

08/17/2017

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File Modified	2019-08-30
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