Track Change: IG_CS27

CS27 – General Eligibility - Continuous Eligibility

Statute: 2107(e)(1)(J), 2107(e)(1)(K), and 1902(e)(16) of the SSA

Regulation: 42 CFR 457.342 and 435.926

INTRODUCTION

This state plan page (fillable PDF) applies to states with separate child health assistance programs.

The state plan page CS27 captures two continuous eligibility policies for states’ separate CHIPs: 1) whether states provide continuous eligibility through a pregnant individual’s 12-month postpartum period and 2) states’ assurance that it provides continuous eligibility coverage for children.

This state plan page is required in the following scenarios:

1. When a state elects to provide continuous eligibility during an individual’s 12-month extended postpartum period in Medicaid if it has an approved CS7 and/or CS8

2. Effective January 1, 2024, when a state has an approved CS7 and/or CS9 (i.e., the state provides coverage to targeted low-income children), continuous eligibility coverage must be provided for 12 months.

For states that elect to cover only the from-conception-to-end-of-pregnancy population (otherwise known as the “unborn”) consistent with the CS9 through its separate CHIP, the 12-Month Postpartum Continuous Eligibility section of this template is not applicable; however, the Mandatory Continuous Eligibility for Children section is required.

BACKGROUND

12-Month Postpartum Period Continuous Eligibility

Section 2107(e)(1)(J) of the Social Security Act (the Act) requires that if states elect to provide continuous eligibility through an individual’s 12-month postpartum period in Medicaid, the state is also required to provide the same extended postpartum coverage in CHIP. Additionally, separate CHIPs cannot offer the 12-month postpartum period if the state does not elect to provide the same option in Medicaid.

Section 2107(e)(1)(J) applies section 1902(e)(16) equally to CHIP and allows individuals who were eligible for and enrolled in CHIP while pregnant to remain eligible regardless of changes in circumstance except for the following:

• The individual requests a 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; or

• The individual dies.

Unlike with continuous eligibility for children, states providing an extended postpartum period may not disenroll individuals during their pregnancy or 12-month postpartum period for becoming eligible for Medicaid.

While eligibility for Medicaid is not an exception to continuous eligibility in CHIP during pregnancy and the extended postpartum period under section 2107(e)(1)(J), it may be beneficial for a pregnant or postpartum individual to request voluntary termination of CHIP eligibility to enroll in Medicaid.  As such, beneficiaries who become Medicaid eligible need to be informed about the differences between the programs, including cost sharing, benefits, provider networks, and their eligibility for extended postpartum coverage, so they can make an informed decision.

States implementing the extended postpartum period in CHIP are required to provide the same scope of benefits provided to other targeted low-income children or targeted low-income pregnant women under the CHIP state plan.

Mandatory Continuous Eligibility Period for Children

Section 2107(e)(1)(K) of the Act requires states to provide coverage to children for a 12-month period, regardless of a change in family circumstances that might otherwise result in the termination of eligibility.

Under 42 CFR 457.342(a), states must apply the same exceptions to continuous eligibility for children in Medicaid consistent with §435.926. In addition, if a child becomes eligible for Medicaid, the state must transfer them to Medicaid.

The continuous eligibility period must begin on the effective date of the child’s most recent determination or renewal of eligibility and continue for a duration of 12-months, regardless of any changes in family’s circumstances, unless:

• The child attains 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 the child or the child’s representative.

• The child dies; or.

• The child becomes eligible for Medicaid.

TECHNICAL GUIDANCE

PREREQUISITES:

None

This state plan page is broken down into the following sections:

12-Month Postpartum Continuous Eligibility

• Policy statement

• Selection of 12-Month Postpartum Continuous Eligibility

• Eligible Individuals

• Exceptions to Continuous Eligibility

• Benefits During the 12-Month Postpartum Period

Mandatory Continuous Eligibility Period for Children

• Policy Statement

• Assurance of Continuous Eligibility and Exceptions

• Selection of From-Conception-to-End-of-Pregnancy Optional Coverage Group

• Assurance of Continuous Eligibility for From-Conception-to-End-of-Pregnancy Optional Coverage Group

12-Month Postpartum Continuous Eligibility

Policy Statement

This section begins with a policy statement that providing continuous eligibility through a pregnant individual’s 12-month postpartum period is required in CHIP if the state elects to provide the same option for pregnant individuals in the Medicaid state plan.

Selection of Continuous Eligibility Option

In this section, the state indicates whether it provides continuous eligibility during an individual’s 12-month postpartum period in Medicaid.

Review Criteria

If the state does not elect to provide continuous eligibility during an individual’s 12-month postpartum period in Medicaid, the state cannot provide the option under the CHIP state plan.

If the state has an approved CS7 or CS8, and the answer is yes, the state must complete the remainder of the Postpartum Section of the state plan page.

Eligible Individuals

This section provides a description of individuals who are eligible for continuous eligibility throughout their pregnancy and 12-month postpartum period. In addition to all pregnant applicants and all pregnant or postpartum enrollees in CHIP, states have the option to re-enroll individuals who were terminated from CHIP prior to the state implementing the extended postpartum option who would have otherwise been eligible for the extended postpartum period. These individuals who are re-enrolled are eligible for continuous eligibility through the remainder of their 12-month postpartum period.

Review Criteria

The state must check off the first assurance that the state will implement the extended postpartum period consistent with section 2107(e)(1)(J) of the Act, and the second assurance describing the required eligible individuals. If the state does not check off the assurances, this state plan page cannot be approved.

Exceptions to Continuous Eligibility

The first assurance in this section lists the permissible exceptions to continuous eligibility throughout an individual’s pregnancy and 12-month postpartum period. All of these exceptions are mandatory and are prechecked.

The second assurance specifies that states electing the extended postpartum option continue to provide continuous eligibility regardless of exceptions otherwise permitted in CHIP under §457.342(b). This includes becoming eligible for Medicaid.

Review Criteria

The state must check off both assurances in this section, otherwise the state plan pages cannot be approved.

Benefits

This section describes the benefit package states are required to provide individuals during their 12-month postpartum period.

Review Criteria

The state must check off the assurance in this section, otherwise the state plan pages cannot be approved.

If states want to provide additional benefits to individuals only during the 12-month postpartum period, the state should make the appropriate updates in Section 6 of the paper CHIP state plan.

Mandatory Continuous Eligibility Period for Children

Policy Statement

This section of the CS27 begins with a policy statement that “The CHIP Agency must provide that children who have been determined eligible under the state plan shall remain eligible, regardless of any changes in the family’s circumstances, for a 12-month continuous eligibility period.”

Assurance of Continuous Eligibility and Exceptions

In this section, the state assures that it provides continuous eligibility to its targeted low-income children for a duration of 12 months, regardless of any changes in circumstances. The CHIP regulations at §457.342 cross reference Medicaid regulations at §435.926(d) and permit the same Federal exceptions to the continuous eligibility process as Medicaid.

The assurance in this section lists the permissible exceptions to continuous eligibility. The mandatory exceptions are pre-checked.

Review Criteria

The state must check off the assurance in this section if the state has an approved CS7 and offers coverage to targeted low-income children, otherwise the state plan pages cannot be approved.

Selection of From-Conception-to-End-of-Pregnancy Optional Coverage Group

In this section, the state selects whether or not is has elected to provide coverage to the from-conception-to-end-of-pregnancy population (otherwise known as “unborn”). States that have elected to provide this coverage option must provide continuous eligibility to this population as well.

Review Criteria

The state must answer yes in this section if the state has an approved CS9 and offers coverage to the from-conception-to-end-of-pregnancy population, otherwise the state plan pages cannot be approved.

If the answer is yes, the state must complete the remainder of this section of the state plan page.

If the state does not have an approved CS9 and does not offer coverage to the from-conception-to-end of pregnancy population, the state must answer no and it does not need to complete the remainder of this section. The review is complete.

Assurance of Continuous Eligibility for the From-Conception-to-End-of-Pregnancy Optional Coverage Group

In this section, the state assures continuous eligibility for the from-conception-to-end-of-pregnancy group (otherwise known as “unborn”) is provided in the same manner as continuous eligibility for other targeted low-income children, except for the duration of the continuous eligibility period.

Unlike other targeted low-income children, the duration of the continuous eligibility period for the unborn will depend on how a state pays for labor and delivery services. The state may refer to the Continuous Eligibility for Children SHO #23-004 for more detailed information on payment information.

Following the initial assurance in this section, the state will answer the following “Yes/No” questions: 1) the state screens the child for potential eligibility for Medicaid upon birth, and 2) the state deems the newborn eligible for Medicaid and ends the continuous eligibility period in CHIP at birth.

Review Criteria

If the state offers coverage under the from-conception-to-end-of-pregnancy population, the state must select the assurance or this state plan page cannot be approved.

The state must select yes or no to screening the child for potential eligibility for Medicaid upon birth or this state plan page cannot be approved.

The state must select yes or no to deeming newborns eligible for Medicaid or this state plan page cannot be approved.

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