CMS-10398 #17 Non-Financial Requirements - Other Eligibility Standards

OMB Control Number: 0938-1148

Separate Child Health Insurance Program

CS27

General Eligibility - Continuous Eligibility
2105(a)(4)(A) of the SSA and 42 CFR 457.342 and 435.926; 2107(e)(1)(J) and 1902(e)(16) of
the SSA
Mandatory 12-Month Postpartum Continuous Eligibility in CHIP for States Electing This
Option in Medicaid
At state option in Medicaid, states may elect to provide continuous eligibility for an
individual’s 12-month postpartum period consistent with section 1902(e)(16) of the SSA. If
elected under Medicaid, states are required to provide the same continuous eligibility and
extended postpartum period for pregnant individuals in its separate CHIP. A separate CHIP
cannot implement this option if not also elected under the Medicaid state plan.
State elected the Medicaid option to provide continuous eligibility through the 12month postpartum period
Yes/No
If YES, show rest of the Postpartum Section
The 12-month postpartum continuous eligibility applies for the period beginning on the
effective date of this SPA (no earlier than April 1, 2022) and is available through March 31,
2027.
□ The state assures the extended postpartum period available to pregnant targeted low-income
children or targeted low-income pregnant women under section 2107(e)(1)(J) of the SSA is
provided consistent with the following provisions:
□ Individuals who, while pregnant, were eligible and received services under the state
child health plan or waiver shall remain eligible throughout the duration of the
pregnancy (including any period of retroactive eligibility) and the 12-month
postpartum period, beginning on the last day the pregnancy ends and ending on the last
day of the 12th month consistent with paragraphs (5) and (16) of section 1902(e) of the
SSA
□ Continuous eligibility is provided to targeted low income children who are pregnant or
targeted low-income pregnant women (if applicable) who are eligible for and enrolled under
the state child health plan through the end of the 12-month postpartum period who would
otherwise lose eligibility because of a change in circumstances, unless:
□ The individual or representative requests voluntary disenrollment.
□ The individual is no longer a resident of the state.

□ The Agency determines that eligibility was erroneously granted at the most recent
determination or renewal of eligibility because of Agency error or fraud, abuse, or
perjury attributed to the individual.
□ The individual dies.
Unlike continuous eligibility for children, states providing the 12-month postpartum period
may not end an individual’s continuous eligibility due to non-payment of premiums or
becoming eligible for Medicaid.
□ Consistent with section 2107(e)(1)(J) of the SSA, the state assures that continuous
eligibility is provided through an individual’s pregnancy and 12-month postpartum
period regardless of non-payment of premiums, or an individual becoming eligible for
Medicaid.
□ Benefits provided during the 12-month postpartum period must be the same scope of
comprehensive services consistent with the benefit package elected by the state under section
2103(a) of the SSA that is available to targeted low income children and/or targeted lowincome pregnant women and may include additional benefits as described in Section 6 of the
CHIP state plan.
Optional Continuous Eligibility for Children
The CHIP Agency may provide that children who have been determined eligible under the
state plan shall remain eligible, regardless of any changes in the family’s circumstances,
during a continuous eligibility period up to 12 months, or until the time the child reaches an
age specified by the state (not to exceed age 19), whichever is earlier.
The CHIP Agency elects to provide continuous eligibility to children under this provision
YES/ NO
If YES, show rest of the children’s CE template.
□ For children up to age 19
□ For children up to age (drop down to select specific age)
The continuous eligibility period begins on the effective date of the child's most recent
determination or redetermination of eligibility, and ends: At the end of the (drop down
box max of 12) months continuous eligibility period
□ Please assure that a child’s eligibility is not terminated during a continuous eligibility
period, regardless of any changes in circumstances, unless:
□ The child attains the age specified by the state Agency or age 19.
□ The child or child's representative requests voluntary disenrollment.
□ The child is no longer a resident of the state.

□ The Agency determines that eligibility was erroneously granted at the most recent
determination or renewal of eligibility because of Agency error or fraud, abuse, or
perjury attributed to child or child's representative.
□ The child dies.
□ The child becomes eligible for Medicaid
□ There is a failure to pay required premiums or enrollment fees on behalf of a child,
as provided for in the state plan

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. The time required to complete this information collection is
estimated to average 50 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.