GenIC #17 (Revision): CHIP State Plan Eligibility

CS7 – Targeted Low-Income Children

Statute: 2102(b) of the SSA

Regulation: 42 CFR 457.310, 315 and 320

INTRODUCTION

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

This state plan page must be completed by states which currently have or elect to provide coverage to Targeted Low-Income Children.

In this state plan page, states provide information with regards to eligibility criteria specific to the targeted low-income children (TLIC) covered group. States are asked to provide income standards used for this covered group and information regarding their program for children with disabilities, if they have one.

BACKGROUND

Uninsured, low-income children in families with incomes too high to qualify for Medicaid, but too low to be able to afford private coverage are the original group of individuals for whom CHIP was created.

Section 2110(b) of the SSA and 42 CFR 457.310 provide the definition of TLIC, including income standards, age, health insurance status and other non-financial standards. Although this definition has been modified and expanded over the years, the core group of eligibles continues to be the original group of uninsured low-income children.

Many states adjust the qualifying income levels based on the age of the child, family income and/or geographic area, such as counties. Effective January 1, 2014, all states are required to use MAGI-based income methodologies to determine income eligibility for CHIP (42 CFR 457.315). Existing CHIP programs using a net income standard must convert their existing qualifying income standards (FPLs), to MAGI-equivalent standards.

Also effective January 1, 2014, the minimum qualifying income level for Medicaid is increased to 133% FPL for children ages 6 up to 19, making 133% FPL the minimum income level for all children under 19 (42 CFR 435.118). States with a separate CHIP program with income standards below 133% FPL must submit a state plan amendment to reflect revised income standards, with a lower level of no less than 133 percent of the FPL to be in compliance with this requirement. States may continue to receive title XXI funding for children transitioning to Medicaid and also receive title XXI funding for children newly eligible for Medicaid as a result of this requirement.

In order to address the special needs of targeted low-income children with disabilities, some states have also created a special program for children with disabilities. It is a program within a separate CHIP that has coverage criteria that are different than those for the rest of the population of targeted low-income children. Children with disabilities should be considered to include children with special health care needs.

TECHNICAL GUIDANCE

PREREQUISITES:

State plan page CS15 - MAGI-Based Income Methodologies must also have been submitted prior to or concurrently with state plan page CS7.

A Medicaid SPA for coverage of children - S30 (Mandatory - Infants and Children under Age 19) and/or S54 (Optional Targeted Low-Income Child) must also have been submitted prior to or on the same day as submittal of state plan page CS7.

Note that many states will also need to submit state plan page CS3 (Medicaid Expansion), though it is not a prerequisite for submission of this state plan page.

Review Criteria

If state plan pages CS15 (MAGI-Based Income Methodologies); S30 (Mandatory - Infants and Children under Age 19) and/or S54 (Optional Targeted Low-Income Child) are not approved, state plan page CS7 cannot be approved.

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

• Eligibility Determination Assurance

• Age Standard

• Income Standards

• Special Program for Children with Disabilities

Eligibility Determination Assurance

CS7 begins with the CHIP Agency being asked to provide assurance that it operates this eligibility group in accordance with the provisions that follow.

The state provides this affirmative assurance by checking the box next to the assurance statement.

Review Criteria

The state must check the assurance box or this state plan page cannot be approved.

Age Standard

This section consists of a statement that the child’s age must be under 19. Since this age standard is required of all states, it is pre-checked and does not require any action by the CHIP Agency.

Income Standards

States are asked to provide the income standards used by the state to determine eligibility for targeted low-income children, beginning with a Yes/No question as to whether income standards are applied statewide.

Review Criteria

The state must select either yes or no or this state plan page cannot be approved.

• If the answer is yes, the state then also responds to the next Yes/No question asking if there are any exceptions, e.g. populations in a county which may qualify either under a statewide income standard or a county income standard.

Review Criteria

The state must select either yes or no or this state plan page cannot be approved.

• If the answer to this second question is no, that is income standards are statewide with no exceptions, the state then enters the ages and income standards for each age range in the grid provided. See below for instructions on completing the age and income standards grid.

Review Criteria

The state must enter their statewide income standards (age and FPL levels) or this state plan page cannot be approved.

• If the answer to this second question is yes, the state then enters an explanation, including a description of the overlapping geographic area and the reason for having different income standards.

Review Criteria

The description should be sufficiently clear, detailed and complete to permit the reviewer to determine that the state’s election meets applicable federal statutory, regulatory and policy requirements.

• The state then enters both their statewide income standards as well as income standards which vary by geography (county, city or other geographic way) in the grids provided. See instructions below for completion of the age and income standards grid.

Review Criteria

The state must enter their statewide income standards (age and FPL levels) as well as selecting a geographic option and entering the income standards (age and FPL levels) for that geographic option or this state plan page cannot be approved.

• If the answer to whether income standards are applied statewide is no, the state must then select between the following two options:

  • Standard varies by county or city, or

  • Standard varies in some other geographic way

Review Criteria

The state must select a geographic option or this state plan page cannot be approved.

Standard varies by county or city

If the state selects “Standard varies by county or city”, it enters all the counties having the same age and income standards at one time and then enters the age and income standards for that set of counties in the grid provided. If there are additional counties with different age and income standards, repeat the process until all the counties with different standards have been entered. See instructions below on completing the income standards information.

Review Criteria

The state must enter the county names and their respective income standards (age and FPL levels) or this state plan page cannot be approved.

After completing the county standards, the state responds to the Y/N question asking if any cities within your state have their own separate income standards. If the answer is yes, the state enters the name of each city having the same age and income standards, and then enters the age and income standards for those cities. If there are additional cities with different age and income standards, repeat the process until all the cities with different standards have been entered. See instructions below on completing the income standards information.

Review Criteria

The state must enter the city names and their respective income standards (age and FPL levels) or this state plan page cannot be approved.

Standard varies in some other geographic way

If the state selects “Standard varies in some other geographic way”, it names and describes the geographic area(s) and then enters the age and income standards for that geographic area in the age and income standards grid. If there are additional geographic areas within the state with separate age and income standards, repeat the process until all the geographic areas with different standards have been entered. See instructions below on completing the age and income standards information.

Review Criteria

The state must enter the names and descriptions of the geographic areas and their respective income standards (age and FPL levels) or this state plan page cannot be approved.

Instructions for Completing the Age and Income Grid

States are asked to first provide the age range to which a qualifying income standard applies and then to enter the household income range that applies to the age range entered.

For “From Age” and “To Age”, states select ages from a drop down list of values from zero through 19.

Note: The “From Age” includes the child’s birthday. The “To Age” should be read as “up to, but not including”. That is, for example, up to age 6 means until the child’s sixth birthday but not including the child’s birthday.

Review Criteria

Unless the state includes an explanation with the reason for having age overlaps, there should not be overlaps from one age range to the next. There should also not be any gaps from one age range to the next. In order to avoid age gaps, the “To Age” of each age range should be the same as the “From Age” of the next age range (e.g., up to (but not including) age 6, and on the next line from age 6 up to…). Although the same number is entered for “To Age” as for “From Age” of the next age range, this does not constitute an overlap. However two age ranges that both include the same ages, such as the first two years of life (From age 0 up to (but not including) age 2 on one line and from age 0 up to (but not including) age 6) on the next line is an overlap and must include a description. The description must include a justification for the age overlap, e.g. a higher income standard is used for targeted populations, such as children with disabilities or children under a specified age born to mothers enrolled in a prenatal program.

Additionally, for each age range the number entered for “To Age” must be greater than the number entered for “From Age”.

There are two fields for household income ranges, labeled “Above” for the lower end of the income standard and “Up to and including” for the upper bound of the income standard. The state enters the Federal Poverty Level (FPL) percentages, applicable to the income standard used for the age range selected.

Note: The “Above” amount does not equal the actual dollar amount represented by the FPL percentage entered, but rather, it is equal to one cent above the dollar amount represented by the FPL percentage entered. However, “Up to and including” is inclusive of the actual dollar amount represented by the FPL percentage entered. Example: for income range of above 185% (dollar value = $1,850) up to and including 250% (dollar value = $2,500), the lower end equals $1,850.01 and the upper end equals $2,500 exactly).

If the state has different income standards for different age groups, the state reselects the button to the left of the age/income grid and repeats the process until all the income standards have been entered.

Review Criteria

Within each income range entered, the number for “Up to and including” must be greater than the number entered for “Above”. In order to avoid income gaps, the number entered for the lower end of each income range, which is the “Above” column, must be equal to the qualifying income standard used for Medicaid or Medicaid expansion for children of the same age. For example, if the applicable Medicaid or Medicaid expansion upper income limit is 133 percent of the FPL, then the number entered in CS7 for “Above” (i.e. the lower income for TLIC) would also be 133 percent FPL because the income standard is anything above 133 percent of the FPL.

Special Program for Children with Disabilities

This section begins with a question as to whether the state has a special program for children with disabilities.

Review Criteria

The state must select yes or no or this state plan page cannot be approved.

• If the answer is yes, the state also answers the next question as to whether the program is available to all eligible targeted low-income children.

Review Criteria

The state must select yes or no or this state plan page cannot be approved.

If the state applies the same age and income limits for its special program for children with disabilities as those for targeted low-income children, the state selects yes. The form skips the section on age and income limits, and goes to the next section where the state provides a program description consisting of two parts: disability criteria used and a description of the program, including additional benefits offered.

Review Criteria

The state must complete both parts of the program description or this state plan page cannot be approved. The description should be sufficiently clear, detailed and complete to permit the reviewer to determine that the state’s election meets applicable federal statutory, regulatory and policy requirements, and must include additional benefits offered.

States have flexibility in establishing age or income limits for their special program for children with disabilities which are different than those for targeted low-income children. If the state applies different age and income limits, the state selects no as the answer to this question and then provides information about those limits by selecting one or both from the following options:

• The program is limited to certain age groups

• The program is limited to TLIC under a certain income level

Review Criteria

The state must select at least one of the two options or this state plan page cannot be approved.

If the program is limited to certain age groups is selected, the state then selects the start and end of the age range from the drop down lists in each of the two fields that are provided.

Review Criteria

The start and end ages entered must fall within the qualifying age used for TLIC.

If the state selects that the program is limited to TLIC under a certain income level, the state is then asked to provide the income level up to which children can qualify. The state enters the FPL percentage in the space provided.

Review Criteria

The FPL percentage entered must be less than the highest income standard used for TLIC of the same age(s) as children eligible for enrollment in the state’s special program for children with disabilities.

This is followed by the state being asked to provide a program description consisting of two parts: disability criteria used and a description of the program, including additional benefits offered. The state enters the disability criteria and program description, including additional benefits offered, in the spaces provided.

Review Criteria

The state must complete both parts of the program description or this state plan page cannot be approved. The description should be sufficiently clear, detailed and complete to permit the reviewer to determine that the state’s election meets applicable federal statutory, regulatory and policy requirements, and must include additional benefits offered.

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