CMS-10398 #17 Eligibility - Children Who Have Access to Public Employe

CHIP Eligibility
OMB Control Number: 0938‐1148

Separate Child Health Insurance Program
Eligibility - Children Who Have Access to Public Employee Coverage

CS10

Sec. 2110(b)(2)(B) and (b)(6) of the SSA

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Children Who Have Access to Public Employee Coverage - Otherwise eligible targeted low-income children who have access to
public employee coverage on the basis of a family member's employment.
The CHIP Agency operates this covered group in accordance with the following provisions:
Select one of the following conditions as described in Section 2110(b)(6) of the Social Security Act:
Maintenance of agency contribution as provided in 2110(b)(6)(B) of the SSA.
Hardship criteria as provided in section 2110(b)(6)(C) of the Social Security Act.
Coverage under this option is extended to children whose household income is:
Select one of the options for the income standard when compared to Targeted Low Income Children
The same as the standards for Targeted Low-Income Children
Lower than the income standards for Targeted Low-Income Children
Coverage under this option is extended to:
Select type of children covered:
All children who have access to public employee coverage
Children of:
Children considered to have access to public employee coverage, and therefore not excluded from CHIP through this option,
meet the definition provided at 42 CFR 457.310(c)(1).

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 OMB control number. The valid OMB 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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