Implementation Guides

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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.
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CS11 – Pregnant Women Who Have Access
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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
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CS11 – Pregnant Women Who Have Access
to Public Employee Coverage
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:

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CS11 – Pregnant Women Who Have Access
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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.
o 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.

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CS11 – Pregnant Women Who Have Access
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o 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:
o Standard varies by county or city, or
o 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
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CS11 – Pregnant Women Who Have Access
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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.

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CS11 – Pregnant Women 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 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.
o Certain public agencies.
o Certain types of public employees or are dependents of certain types of
public employees.

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CS11 – Pregnant Women Who Have Access
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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.
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CS11 – Pregnant Women Who Have Access
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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
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CS11 – Pregnant Women Who Have Access
to Public Employee Coverage
•

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.

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CS11 – Pregnant Women Who Have Access
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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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