GenIC #17 (Revision): CHIP State Plan Eligibility

CS29 – General Eligibility –
Presumptive Eligibility for Pregnant Women

Statute: 2112(c) of the SSA

INTRODUCTION

This state plan page (fillable PDF) applies to states with separate child health assistance programs and which also provide coverage to targeted low-income pregnant women.

In state plan page CS29, states indicate if they elect the option to provide presumptive eligibility to targeted low-income pregnant women and, if so, provide information as to the administration of presumptive eligibility for pregnant women. States electing this option must also indicate the types of qualified entities used to make determinations of presumptive eligibility. This state plan page is required only of states which provide presumptive eligibility for pregnant women. States which do not provide presumptive eligibility for pregnant women need not submit this page.

BACKGROUND

States may elect to apply presumptive eligibility for pregnant women coverage under CHIP, provided that the requirements of section 1920 of the SSA are satisfied.

Under presumptive eligibility, states may use title XXI funds to pay costs of CHIP coverage during a period of presumptive eligibility, for pregnant women applying for CHIP, pending the screening process and a final determination of eligibility.

The determination of presumptive eligibility must be made by a qualified entity, on the basis of preliminary information, that the individual has gross income (or, at state option, a reasonable estimate of household income determined using simplified methods prescribed by the agency, to better approximate MAGI-based household income) at or below the income standard established by the state for pregnant women under the plan.

The state may require the attestation of citizenship, national or satisfactory immigration status, or state residency by the individual (applicant), or another person who attests to having reasonable knowledge of the individual’s status as a condition of presumptive eligibility.

The presumptive eligibility period begins with the date that the determination is made by a qualified entity, and ends on the day the determination is made with respect to the pregnant woman’s eligibility for CHIP pregnancy-related assistance under the state plan, or the last day of the month following the month during which the qualified entity makes the presumptive eligibility determination, if an application for CHIP pregnancy-related assistance is not filed within that time. Only one presumptive eligibility period per pregnancy is allowed.

42 CFR 457.301 defines certain types of entities which may be used as qualified entities for the purpose of making determinations of presumptive eligibility for CHIP. Agencies must meet at least one of the requirements specified in the regulations to be designated as a qualified entity.

The state may use the same qualified entities to determine presumptive eligibility for pregnant women as are used to determine presumptive eligibility for children, or it may designate specific agencies to determine presumptive eligibility for pregnant women. The state must provide qualified entities with adequate training, forms and other information necessary to assist pregnant women with completion and submittal of the application for coverage under the plan.

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 CS29.

Review Criteria

If state plan page CS8 (targeted low-income pregnant women) is not approved, state plan page CS29 cannot be approved.

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

• Selection and Description of Presumptive Eligibility

• Selection of Qualified Entities

Selection and Description of Presumptive Eligibility

In this section, states indicate that they offer presumptive eligibility to pregnant women by selecting “Yes” to the statement “The CHIP Agency covers pregnant women when determined presumptively eligible by a qualified entity.”

Review Criteria

If the state offers presumptive eligibility to pregnant women, it must select yes to this question.

If the answer is yes, the state is then asked to:

• Describe the population of pregnant women to whom presumptive eligibility applies.

The state enters the requested information in the space provided.

Review Criteria

The state must enter a description of the population of pregnant women to whom presumptive eligibility applies 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 policies meet applicable federal statutory, regulatory and policy requirements.

• Describe the duration of the presumptive eligibility period and any limitations.

The state enters the requested information in the space provided.

Review Criteria

The state must enter a description of the duration of the presumptive eligibility period and any limitations 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 policies meet applicable federal statutory, regulatory and policy requirements.

• Describe the application process and eligibility determination factors used.

The state enters the requested information in the space provided.

Review Criteria

The state must enter a description of the application process and eligibility determination factors used 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 policies meet applicable federal statutory, regulatory and policy requirements.

Selection of Qualified Entities

This section begins with a pre-checked statement “The CHIP Agency uses the following entities to determine presumptive eligibility for pregnant women.”

The state then responds by selecting yes or no to the following question: “The same qualified entities are used to determine presumptive eligibility for pregnant women as used for children.”

If the answer is yes, no additional information is needed.

If the answer if no, the state then completes the List of Qualified Entities (CS30), which gets displayed within CS29, to indicate which types of organizations the state uses as qualified entities to determine presumptive eligibility for pregnant women.

Review Criteria

The state must select at least one type of entity from the list or this state plan page cannot be approved.

If the state selects “Any other entity the state so deems, as approved by the Secretary”, it then enters the name(s) and description(s) of the entities. The state must enter at least one other entity name and corresponding description. If there is more than one other entity, the state reselects the button to the left of the name/description grid and repeats the process until all have been entered.

Review Criteria

If the state selects “Any other entity”, the state must enter at least one other entity name and corresponding description or state plan page CS29 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.

After completing the entities selection, the state is asked to provide assurance that it has communicated the requirements for qualified entities at 1920A(b)(3) of the Act, and provided adequate training to the entities and organizations involved.

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.

The state also submits a copy of the training materials used. 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 submit a copy of the training materials used or this state plan page cannot be approved.

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