GenIC #17 (Revision): CHIP State Plan Eligibility

CS9 – Coverage from Conception to Birth

Regulation: 42 CFR 457.10

Formal Guidance: SHOL #02-004, dated November 12, 2002

INTRODUCTION

This state plan page (fillable PDF) applies to states providing coverage to children either under a separate child health assistance program or a Medicaid expansion, or a combination of both.

State plan page CS9 must be completed by states that currently have or elect the option to provide coverage from conception to birth. States that do not provide this coverage need not complete this state plan page.

In this state plan page, states provide information with regard to eligibility criteria, including income standards specific to the coverage from conception to birth option.

BACKGROUND

In the interest of providing necessary prenatal care and other health services to children, CMS promulgated a final rule on October 2, 2002 that revised the definition of “child” at 42 CFR 457.10 to clarify that “child” means an individual from conception up to age 19. This definitional change provided states with the option to make children eligible for coverage from conception to birth if other applicable state eligibility requirements are met, regardless of the mother’s eligibility status. The conception to birth option is available only under the separate child health assistance program.

This covered group is distinct from the option added by section 111 of the Children’s Health Insurance Reauthorization Act (CHIPRA), giving states the option to provide coverage to uninsured, low-income pregnant women under the CHIP plan (targeted low-income pregnant women). Under the targeted low-income pregnant women option, the pregnant woman is eligible for coverage, rather than her child. Therefore, states may elect one or both options, at their discretion.

Since this group is not covered under Medicaid, income eligibility for this group begins at zero and states then establish the highest income level to be used under this option. Many states adjust the qualifying income levels based on 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.

TECHNICAL GUIDANCE

PREREQUISITES:

State plan page S15 - MAGI-Based Income Methodologies must have been submitted prior to or concurrently with state plan page CS9, if the state currently covers the conception to birth optional covered group.

Review Criteria

For states with existing coverage from conception to birth, if state plan page CS15 (MAGI-Based Income Methodologies) is not approved, state plan page CS9 cannot be approved.

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

• Eligibility Determination Assurance

• Age Standard

• Income Standards

• Policy Exceptions

Eligibility Determination Assurance

State plan page CS9 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

The age standard section begins with a statement of the age standard being from conception through birth. This is followed by a Yes/No question asking if the state has additional age definition or other age-related conditions.

Review Criteria

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

• If the response if yes, the state enters a description of the additional definition or age-related conditions. States have flexibility in establishing eligibility guidelines, such as when coverage begins.

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.

Income Standards

The income standards section begins with a Yes/No question as to whether income standards are applied statewide.

Review Criteria

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

• If the answer is yes, the state also responds to the 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 enter their statewide income standards 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. Since Medicaid does not provide coverage for this group, the lower end of the income standard is pre-filled with zero. The state enters the upper income FPL level.

Review Criteria

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

• If the answer to this second question is yes, that is there are exceptions to income standards being statewide, the state then enters an explanation which includes 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 above) as well as income standards which vary by geography (county, city or other geographic way). See instructions below for completion of geographic standards.

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 income standards, repeat the process until all the counties with different standards have been entered. Since Medicaid does not provide coverage for this group, the lower end of the income standard is pre-filled with zero. The state enters the upper income FPL level.

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. Since Medicaid does not provide coverage for this group, the lower end of the income standard is pre-filled with zero. The state enters the upper income FPL level.

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. Since Medicaid does not provide coverage for this group, the lower end of the income standard is pre-filled with zero. The state enters the upper income FPL level.

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.

Policy Exceptions

The bottom of the state plan page contains two policy statements regarding exemptions from the requirements of applying for or providing a social security number and verification of citizenship. Since these apply to all states providing coverage to this group, they are pre-checked.

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