CMS-10398 #17 Eligibility - Targeted Low-Income Pregnant Women

CHIP Eligibility
0MB Control Number 0938-1148

Separate Child Health Insurance Progra m
Eligibility - Targeted Low-Income Pregnant Women

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Section 2112 of the SSA
Targeted Low-Income Pregnant Women - Uninsured pregnant women who do not have access to public employee coverage and
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■ whose household income is within standards established by the state.

D The CHIP Agency operates this covered group in accordance with the following provisions:
Age Standards for Pregnant Women
The state provides coverage to pregnant women:
Select an age range:

r From age 19, up to the following age:
(' With no age restriction.
(' Another age range:
If there is no age restriction or if the age range overlaps with the qualifying ages for children, describe how the
determination is made as to whether the applicant will be provided coverage as a child or as a pregnant woman.

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Must be pregnant or post-partum

Income Standards
Pregnant women coverage may only be provided if children's qualifying income standard under the plan is at least up to 200% of FPL
for all age ranges.
Income standard is applied statewide

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PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid 0MB control number. The valid 0MB control number for this information collection is 0938-1148 (CMS-10398 #17). The time
required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions,
search existing data resources, gather the data needed, and complete and review the information collection. If you have comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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