Implementation Guides

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Download: pdf

CS12 – Dental Only Supplemental Coverage
Statute: 2110(b)(5) of the SSA
Formal Guidance: SHOL #09-012 dated October 7, 2009

INTRODUCTION

This state plan page (fillable PDF) applies only to states with separate child health assistance
programs.
State plan page CS12 must be completed by states which currently have or elect the option to
provide Dental Only Supplemental Coverage. States that do not elect to provide Dental Only
Supplemental 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 Dental Only Supplemental Coverage covered group.

BACKGROUND

The Children’s Health Insurance Reauthorization Act of 2009 (CHIPRA) added section
2103(c)(5) of the Social Security Act requiring coverage of dental services “necessary to prevent
disease and promote oral health, restore oral structures to health and function, and treat
emergency conditions” for children enrolled in CHIP.
CHIPRA also added section 2110(b)(5), which gives states with separate CHIP programs the
option to offer dental-only supplemental coverage to children who have health insurance
coverage through an employer but are uninsured or underinsured with respect to dental coverage.
States electing this option must provide the same coverage under the Dental Only Supplemental
Coverage as provided to other children enrolled in CHIP.
Children can enroll in the dental-only supplemental coverage even if their group health plan or
other health insurance coverage includes some dental benefits.
Children of state employees may qualify for Dental Only Supplemental Coverage if they meet
the exception under 42 CFR 457.310(c)(1), i.e. the state makes no more than a nominal payment
for the cost of their state employee coverage ($10 or less per month).
A state may limit coverage under this option to children whose family income does not exceed a
level specified by the state, so long as the specified level does not exceed the maximum income
level used by the state for other targeted low-income children.
In order to offer supplemental dental coverage, a state may not implement a waiting list for its
CHIP medical or CHIP dental program, and the CHIP plan must cover children to the highest
income eligibility standard permitted under title XXI (or a waiver) as of January 1, 2009 (i.e., if
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not under a waiver, 200 percent of the FPL or 50 percentage points above the applicable
Medicaid income level for the child’s age).
Additional information may be found in SHOL #09-012 dated October 7, 2009.

TECHNICAL GUIDANCE
PREREQUISITES:
State plan page CS7 - Targeted Low-Income Children must also have been submitted prior to
or concurrently with state plan page CS12.
State plan page CS15 - MAGI-Based Income Methodologies must also have been submitted
prior to or concurrently with state plan page CS12.
Review Criteria
If state plan pages CS7 (targeted low-income children) and CS15 (MAGI-Based Income
Methodologies) are not approved, state plan page CS12 cannot be approved.
This state plan page is broken down into the following sections:
•
•
•

Eligibility Determination Assurance
Income Standards
Additional Assurances

Eligibility Determination Assurance
State plan page CS12 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.

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CS12 – Dental Only Supplemental Coverage
Income Standards
The state is then asked to provide income standards, beginning with a Yes/No question as
whether the state uses the same income standards for Dental only supplemental coverage as are
used for other targeted low income children.
Review Criteria
The state must select either yes or no or this state plan page cannot be approved.
If the answer is yes, then no further entry is required in this section and the state moves on to the
last section of this state plan page labeled “Additional Assurances” (see instructions below).
If the answer is no, the state responds to the Yes/No 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 to this second question is yes, the state also 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 third question is no, that is income standards are statewide
with no exceptions, the state then 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
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 third question is yes, that is there are exceptions to income
standards being statewide, the state then enters an explanation which includes a
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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 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 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

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CS12 – Dental Only Supplemental Coverage
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
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.
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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.
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”.

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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 dental-only supplemental 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.
Additional Assurances
The income section is followed by the state being asked to provide two assurances:
•
•

That the state has the highest income eligibility standard permitted under Title XXI (or a
waiver) as of January 1, 2009; and
That the state does not limit the acceptance of applications for children or impose any
numerical limitation, waiting list, or similar limitation on the eligibility of children under
the state plan.

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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