GenIC #17 (Revision): CHIP State Plan Eligibility

CS11 – Pregnant Women Who Have Access
to Public Employee Coverage

Statute: 2110(b)(2)(B) and (b)(6) of the SSA

Formal guidance: SHOL # 11-002, dated April4, 2011

INTRODUCTION

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

State plan page CS11 must be completed by states which currently have or elect to provide coverage to Pregnant Women Who Have Access to Public Employee Coverage. States that do not elect to provide coverage to pregnant women who have access to public employee 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 this population group.

BACKGROUND

Prior to passage of the Affordable Care Act, section 2110(b) of the Social Security Act excluded from CHIP eligibility children with access to a state employee health benefits plan. This exclusion also applied to targeted low-income pregnant women.

An individual is considered eligible for health benefits coverage under a state health benefits plan if a more than nominal contribution to the cost of health benefits coverage under a state health benefits plan is available from the state or public agency. A contribution is considered more than nominal if the state or public agency makes a contribution toward the cost of an employee's dependent(s) that is $10 per family, per month, more than the state or public agency’s contribution toward the cost of covering the employee only.

In response to concerns raised that some children of state employees did not have access to comprehensive, affordable coverage, the definition of a targeted low-income child in section 2110(b)(2)(B) of the Act was amended by the ACA to include children of state employees if one of two conditions is met. This option was also extended to pregnant women.

The conditions which must be met for pregnant women to qualify for this option are the same as those for children. One of the following conditions must be met.

Maintenance of Agency Contribution Condition

For this condition to be met, states must demonstrate that they have been consistently contributing to the cost of employee coverage, with increases for inflation, since 1997.

This condition is met when the public agency expenditures for health coverage for employees that have dependent coverage is not less than the amount of such expenditures in the 1997 state fiscal year, increased by the percentage increase of the medical care expenditure category of the Consumer Price Index. This does not require a case-by-case determination but can be calculated on an average basis for each public agency or it can be done in the aggregate for all multiple agencies having the same contribution rate structures.

Hardship Condition

For this condition to be met, states must demonstrate that the coverage currently available through the public employee system poses a financial hardship for families. In making a hardship determination, states would assess whether the annual aggregate premiums and cost-sharing imposed by the state health benefits plan would exceed 5 percent of a family’s income during the time period the pregnant woman would be enrolled in CHIP.

State Plan Options

States may offer this option to a subset of their population eligible for public employee coverage. For example, States may limit coverage under this option to pregnant women in families with family income under 250% of the FPL although coverage for targeted low-income pregnant women is offered up to 300% of the FPL. States also have the option of limiting coverage under this option to certain public agencies.

Additional information may be found in SHOL # 11-002, dated April 4, 2011.

Note: If states have questions or need technical assistance regarding the methodology for expanding CHIP to pregnant women who have access to public employee coverage, the CMS project officer may provide guidance.

TECHNICAL GUIDANCE

PREREQUISITES:

State plan page CS8 - Targeted Low-Income Pregnant Women must also have been submitted prior to or concurrently with state plan page CS8.

State plan page CS15 - MAGI-Based Income Methodologies must also have been submitted prior to or concurrently with state plan page CS11.

Review Criteria

If state plan pages CS8 (targeted low-income pregnant women) and CS15 (MAGI-Based Income Methodologies) are not approved, state plan page CS11 cannot be approved.

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

• Eligibility Determination Assurance

• Selection of Condition/Criteria

• Age Standards

• Pregnancy Status

• Additional Assurances

Eligibility Determination Assurance

State plan page CS11 begins with the state being asked to provide assurance that it determines eligibility for this 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.

Selection of Condition/Criteria

The state is then asked to select one of the following two options:

• Maintenance of agency contribution as provided in 2110(b)(6)(B) of the SSA

• Hardship criteria as provided in section 2110(b)(6)(C) of the Social Security Act

Review Criteria

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

For the option selected, states are asked to provide household income standards and to identify the population(s) to whom that option is offered.

Household Income

States are asked to choose between one of two options:

Review Criteria

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

• The same as the standards for Targeted Low Income Pregnant Women

• Lower than the income standards for Targeted Low Income Pregnant Women

If the state selects “The same as the standards for Targeted Low Income Pregnant Women”, no further entry is required in this section and the state moves on to the next section of state plan page CS11, labeled “Age Standards” (see instructions below).

If the state selects “Lower than the income standards for Targeted Low Income Pregnant Women”, the system displays a Y/N 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 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 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 which includes a description of the overlapping geographic area and the reason for having different income standards.

Review Criteria

The state must enter a 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.

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 (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 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. 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 value entered for the “Above” field must be equal to the qualifying income standard used in CS8 for targeted low-income pregnant women, and the value entered for “Up to and including” should be greater than the value entered for “Above”. The value entered for “Up to and including” cannot be greater than the income standard for targeted low-income pregnant women on CS8.

Population(s) to Whom this Option is Offered

States are asked to indicate the population(s) offered this option by checking one of the following options:

Review Criteria

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

• All pregnant women who have access to public employee coverage.

• Certain pregnant women who have access to public employee coverage.

If the second option is selected, then the state selects one or both of the following options:

Review Criteria

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

• Certain public agencies.

• Certain types of public employees or are dependents of certain types of public employees.

If the state selects “Certain public agencies”, the state enters the type of agencies. If this option is offered to multiple agencies, the state selects the button to the left of the “Type of Agency” field for entry of each agency type on a separate line.

Review Criteria

The state must enter the type of agencies or this state plan page cannot be approved.

If the state selects “Certain types of public employees or are dependents of certain types of public employees”, the state enters a description of the types of public employees. If this option is offered to multiple types of public employees, the state selects the button to the left of the “Describe type of public employees” field for entry of each type of public employee on a separate line.

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.

Documentation

After the state completes the income and population information, it attaches a copy of the documentation demonstrating that the state meets the conditions specific of the option selected. Please note that the button stating “An attachment is submitted” is an inactive button used as a reminder for the state to attach a document to the MMDL. Each state plan amendment submission includes an MMDL screen that provides an upload function for attachments.

Review Criteria

The state must attach the documentation or this state plan page cannot be approved.

Review Criteria

For maintenance of effort, the documentation should include the methodology the state used to calculate the maintenance of agency contribution. The documentation 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.

For technical assistance in developing the methodology, please contact CMS.

The state is then asked to provide assurance that it will, on an annual basis, recalculate expenditures for each participating public agency to determine if the maintenance of effort condition continues to be met.

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.

Review Criteria

For hardship, the documentation should include the methodology the state used to calculate the financial hardship. The documentation 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.

For technical assistance in developing the methodology, please contact CMS.

The state is then asked to provide assurance that it will, on an annual basis, recalculate the financial status to determine if the hardship condition continues to be met.

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, the state is asked to select one of the following options as to the age standard used:

• Same as the age criteria used for Targeted Low-Income Pregnant Women

• Different than the age criteria used for Targeted Low-Income Pregnant Women

Review Criteria

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

If the state selects “Different than the age criteria used for Targeted Low-Income Pregnant Women” the state then selects one of the three options listed.

Review Criteria

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

If the state selects “From age 19, up to age_”, the state then enters the upper age limit.

Review Criteria

The state must enter the upper age limit or this state plan page cannot

If the state selects “Another age range”, the state then enters the “Start of the age range…” and “End of the age range…”.

Review Criteria

The state must enter the start and end ages or this state plan page cannot be approved.

If the state selects either “With no age restriction” or entered ages, under “Another age range” which overlap with the qualifying ages for children, the state then describes 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 state must enter a 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.

Pregnancy Status

This section displays a statement that a woman must be pregnant or post-partum. Since this criterion is required of all states, it is pre-checked and does not require any action by the state.

Additional Assurances

Regardless of whether this option is offered to all or just a subset of pregnant women with access to public coverage, or which condition (maintenance of effort or hardship) is used by the state to offer this coverage, the state must provide assurance that “Pregnant women considered to have access to public employee coverage, and therefore not excluded from CHIP through this option, otherwise meet the definition of targeted low-income pregnant woman in accordance with section 2112(d)(2) of the SSA.”

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.

If the state does not cover all pregnant women, i.e. the state selected “Certain pregnant women who have access to public employee coverage”, the state must provide an additional assurance. Here, the state assures that “Pregnant women who are eligible for public employee health benefits coverage who are not described above are excluded from eligibility under the plan”.

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.

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