GenIC #17 (Revision): CHIP State Plan Eligibility

CS8 - Targeted Low-Income Pregnant Women

Statute: 2112 of the SSA

Formal Guidance: SHOL # 09-006, dated May 11, 2009

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 that currently have or elect to provide coverage to Targeted Low-Income Pregnant Women. States that do not elect to provide this coverage need not complete this state plan page.

In this state plan page, states provide information with regards to eligibility criteria, including income standards specific to the targeted low-income pregnant women (TLIPW) covered group.

BACKGROUND

Section 2112 of the Social Security Act was added by section 111 of the Children’s Health Insurance Reauthorization Act (CHIPRA) to give states the option to provide healthcare coverage for necessary prenatal, delivery, and postpartum care to uninsured, low-income pregnant women through an amendment to its state CHIP plan. Unlike prenatal coverage provided under the “Coverage from Conception to Birth” covered group, under this option, the pregnant woman is eligible for coverage rather than the unborn child.

Subject to the below criteria, states establish the qualifying income limits to be used under this option. 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.

In order to cover pregnant women through this option, states must meet certain criteria:

• Pregnant women must be covered under Medicaid up to an income level of at least 185% of the FPL.

• The income level for targeted low-income pregnant women may not be higher than for targeted low-income children.

• States must cover children, under CHIP (targeted low income children) or Medicaid, up to age 19 at an income level no lower than 200% of the FPL.

• The income level for pregnant women under CHIP cannot be lower than it is under the state’s Medicaid program.

• Higher income pregnant women cannot be covered without covering lower income pregnant women.

Additional information may be found in SHOL # 09-006, dated May 11, 2009

TECHNICAL GUIDANCE

PREREQUISITES:

• State plan pages CS3 (Medicaid Expansion) and/or CS7 (Targeted Low-Income Children), must have been submitted prior to or concurrently with state plan page CS8.

• State plan page CS15 - MAGI-Based Income Methodologies must have been submitted prior to or concurrently with state plan page CS8.

• A Medicaid SPA for pregnant women (state plan page S28) must have been submitted prior to or on the same day as submittal of state plan page CS3.

• State plan page CS13 – Deemed Newborns must be submitted concurrently with state plan page CS8.

Review Criteria

If either state plan pages CS7 (targeted low-income children) and/or CS3 (Medicaid expansion), and S28 (Medicaid for pregnant women) are not approved, state plan page CS8 cannot be approved. Approval for CS13 (Deemed Newborns) should be given concurrently with approval of CS8.

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

• Eligibility Determination Assurance

• Age Standard

• Pregnancy Status

• Income Standards

Eligibility Determination Assurance

State plan page CS8 begins with the state being asked to provide an 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

In this section states are asked to provide information about the age standard they apply to this group. The state does so by selecting one of the three options listed.

Review Criteria

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

• If the state selects “From age 19, up to the following age:”, it then enters the upper limit age.

• If the state selects “Another age range:”, it then enters the start and the end of the qualifying age range.

• If the state selects “With no age restriction” or “Another age range:” and the ages entered overlap with the qualifying ages for children, the state then enters a description of how the determination is made as to whether the applicant will be provided coverage as a child or as a pregnant woman.

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.

Pregnancy Status

A statement is displayed saying that a woman must be pregnant or post-partum. Since this criterion is required of all states providing coverage to this group, it is pre-checked and does not require any entry by the state.

Income Standards

In this section, states are asked to provide the income standards used by the state to determine eligibility for targeted low-income women.

This section begins with a policy statement that “Pregnant women coverage may only be provided if children’s qualifying income standard under the plan is at least up to 200% of FPL for all age ranges.”

Review Criteria

Qualifying income standards for targeted low-income children entered on state plan page CS7, must be at least up to (and including) 200% of the FPL for all the age ranges entered on CS7.

The state then indicates, by selecting Yes or No, whether the income standard is 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 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 statewide income standard. See instructions below on completing the income standards information.

Review Criteria

The state must enter their statewide income standards or this state plan page cannot be approved.

• If the answer to the second question is yes, that is there are exceptions to income standards being statewide, 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 standard (see instructions below on completing the income standards information) as well as income standards which vary by geography. See instructions below for completion of geographic standards (Standard varies by county or city, or Standard varies in some other geographic way).

Review Criteria

The state must enter their statewide income standards as well as selecting a geographic option and entering the income standards 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 then selects between 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 standard at one time and then enters the income standard for that set of counties. 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 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 standard, and then enters the income standard for those cities. If there are additional cities with different 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 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 income standard for that geographic area. If there are additional geographic areas within the state with different income standards, repeat the process until all the geographic areas with different standards have been entered. See instructions below on completing the income standards information.

Review Criteria

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

Instructions for Completing Income Standard Information

Two fields are displayed for the percentage of the Federal poverty level (FPL) 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 qualifying FPL amounts in both fields.

Note: The “Above” amount does not equal the actual dollar amount represented by the FPL percentage entered, but rather is equal to the dollar amount plus one cent of 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).

Review Criteria

The qualifying income standard under Medicaid for pregnant women must be at least up to and including 185% of the FPL. The value entered for “Above” must be the same as the qualifying income limit for pregnant women under Medicaid (amount entered on state plan page S28).

The value entered for “Up to and including” should be greater than the value entered for “Above” and the value entered for “Up to and including” cannot be greater than the highest income level used for targeted low-income children (amounts entered on state plan page CS7 for all the age ranges).

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