CMS-10398 #17 Eligibility - Pregnant Women Who Have Access to Public E

CHIP Eligibility
OMB Control Number: 0938-1148

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

CS11

Sec. 2110(b)(2)(B) and (b)(6) of the SSA
Pregnant Women Who Have Access to Public Employee Coverage - Otherwise eligible targeted low-income pregnant women
who have access to public employee coverage on the basis oftheir, or a family member's employment.

The CHIP Agency operates this eligibility group in accordance with the following provisions:
Select one ofthe following conditions as described in Section 2110(b)(6) ofthe Social Security Act:
Maintenance of agency contribution as provided in 2110(b)(6)(B) ofthe SSA.
Hardship criteria as provided in section 2110(b)(6)(C) ofthe Social Security Act.
Coverage under this option is extended to pregnant women whose household income is:
Select one of the options for the income standard when compared to Targeted Low-Income Pregnant Women
The same as the standards for Targeted Low-Income Pregnant Women.
Lower than the income standards for Targeted Low-Income Pregnant Women.
Coverage under this option is extended to:
Select type of pregnant women covered:
All pregnant women who have access to public employee coverage.
Pregnant women who are employees or dependents of employees, limited to:
Age Standard
Select an age standard:
Same as the age criteria used for Targeted Low-Income Pregnant Women.
Different than the age criteria used for Targeted Low-Income Pregnant Women.
Must be pregnant or in a post-partum period.
Pregnant women considered to have access to public employee coverage, and therefore not excluded from CHIP through this
option, meet the definition provided at 457.3 l0(c)(l).

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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