Implementation Guides

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CS10 – Children Who Have Access to
Public Employee Coverage
Statute: 2110(b)(2)(B) and (b)(6) of the SSA
Formal Guidance: SHOL # 11-002, dated April 4, 2011

INTRODUCTION

This state plan page (fillable PDF) applies only to states with separate child health assistance
programs.
State plan page CS10 must be completed by states which currently have or elect to provide
coverage to Children Who Have Access to Public Employee Coverage. States that do not elect to
provide coverage to children 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.
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. Exclusion of children with access to public employee coverage does not
apply to coverage under a Medicaid expansion program.
For children of state employees to qualify under this option, 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.
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CS10 – Children Who Have Access to
Public Employee Coverage
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
year the child 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 children in families with family
income under 250% of the FPL although coverage for targeted low-income children 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 children who have access to public employee coverage, the CMS project
officer may provide guidance.

TECHNICAL GUIDANCE
PREREQUISITES:
State plan page CS7 - Targeted Low-Income Children must also have been submitted prior to
or concurrently with state plan page CS10.
State plan page CS15 - MAGI-Based Income Methodologies must also have been submitted
prior to or concurrently with state plan page CS10.
Review Criteria

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CS10 – Children Who Have Access to
Public Employee Coverage
If state plan pages CS7 (targeted low-income children) and CS15 (MAGI-Based Income
Methodologies) are not approved, state plan page CS10 cannot be approved.
This state plan page is broken down into the following sections:
Eligibility Determination

•
Assurance

Selection of Condition/Criteria
Additional Assurances

•
•

Eligibility Determination Assurance
State plan page CS10 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:
•
contribution as provided in 2110(b)(6)(B) of the SSA
•
section 2110(b)(6)(C) of the Social Security Act

Maintenance of agency
Hardship criteria as provided in

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:

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CS10 – Children Who Have Access to
Public Employee Coverage
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 Children

Lower than the income standards

•
for Targeted Low Income Children

If the state selects “The same as the standards for Targeted Low Income Children”, no
further entry is required in this section and the state moves on to the last section of state
plan page CS10, labeled “Additional Assurances” (see instructions below).
If the state selects “Lower than the income standards for Targeted Low Income
Children”, 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.
o

If the answer to this second
question is no, that is income standards are statewide with no exceptions, the
state 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
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CS10 – Children Who Have Access to
Public Employee Coverage
The state must enter their statewide income standards (age and FPL levels) or
this state plan page cannot be approved.
o

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 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 standards as well as income
standards which vary by geography (county, city or other geographic way) in the
grid 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 then selects between the following two
options:
o
o

Standard varies by county or city,

or

Standard varies in some other

geographic way
Review Criteria
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CS10 – Children Who Have Access to
Public Employee Coverage
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 different 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

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CS10 – Children Who Have Access to
Public Employee Coverage
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.

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CS10 – Children Who Have Access to
Public Employee Coverage
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”.
No matter how the state varies the income thresholds for this option, 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 in CS7 for targeted low-income
children of the same age. For example, if the applicable lower income limit (amount
entered in “Above”) for targeted low-income children is 133 percent of the FPL, then
the number entered for “Above” (i.e. the lower income for children with access to
public employee coverage) would also be 133 percent of the FPL.
Additionally, the number entered for the highest qualifying income limit, which is the
“Up to and including” column must not be greater than the highest income limit
entered for targeted low-income children in CS7 for children of the same age.
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 children who have access to

•
public employee coverage
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CS10 – Children Who Have Access to
Public Employee Coverage
Certain children who have access

•

to public employee coverage
If this 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.
o
o

Employees of certain public

agencies

Certain types of public employees

If the state selects “Employees of certain public agencies”, the state enters the
type of agency. 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”, 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
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CS10 – Children Who Have Access to
Public Employee Coverage
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.

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CS10 – Children Who Have Access to
Public Employee Coverage
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.
Additional Assurances
This section consists of two assurances:
•

•

Children who are eligible for
public employee health benefits coverage who are not described above are excluded from
eligibility under the plan.
Children 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 child provided at 457.310.

The state provides these affirmative assurances by checking the box next to each assurance
statement.
Review Criteria
The state must check both assurance boxes, or this state plan page cannot be approved.

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