[Medicaid] GenIC #17 (Revised): CHIP State Plan Eligibility

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The following guide provides useful information for completion of amendments to the eligibility section of the CHIP state plan using the MMDL PDF repository. The guide is intended to be used in conjunction with the eligibility state plan pages (fillable PDFs) and provides statutory and regulatory background, guidance regarding what information is to be provided by states, as well as minimum criteria for the review of state plan pages. 

The CHIP Eligibility state plan pages posted to MMDL fall into five state plan amendment (SPA) Groups: 

    1. MAGI Eligibility and Methods
    2. Title XXI Medicaid Expansion
    3. Establish 2101(f) Group
    4. Eligibility Processing
    5. Non-Financial Eligibility

Some of the SPA groups contain one state plan page and others are comprised of multiple pages; states have the flexibility to submit multiple pages, or PDF files, in one SPA submission. We strongly encourage states to group state plan pages according to SPA group (as above) and to enter each SPA group as separate SPA submissions. This will allow for CMS review teams to evaluate each submission in a more efficient and thorough manner, and help to ensure a timely decision. 

States need only to submit those state plan pages that apply to the state. We encourage states to reach out to CMS Central Office CHIP staff for guidance in completing the state plan pages and/or in determining which pages apply. In addition, some states may elect to cover a covered group for the first time through these state plan pages – for example, Targeted Low-Income Pregnant Women (CS8) or Children from Conception to Birth (CS9). If this is the case, the state should contact CMS CHIP staff for information about other possible state plan page requirements. Note that the foregoing does not apply to Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards (CS14) which does not require other state plan pages. The PDFs reflect policies which are effective January 1, 2014 and cannot be used to make state plan changes with an effective date prior to January 1, 2014.

Below are important guidelines to follow when completing the PDFs:

    • The PDFs are designed to reduce the number of questions states have to answer by presenting certain questions based on the answers to other questions.  In order to avoid having to answer unnecessary questions, make sure to answer all questions accurately, based on your state policy. Questions that appear due to the selection of an incorrect answer to a previous question become hidden again when the state changes the answer to the previous question.
    • The MMDL has limited functionality, therefore the attachment uploading buttons in the fillable PDF pages do not function. The MMDL web interface itself has an attachment function for states to upload needed supporting documents for each SPA submission. 
    • To the extent applicable, make sure to check the boxes that use the wording “assures,” “attests,” or “assurance.”  These are statements about which there is no choice, and by checking these, the state is confirming that it will follow the requirement described. The SPA cannot be approved unless you have checked all the applicable assurance boxes. When you check the box, a “check” will appear in the box, rather than an “X.”
    • Some state plan pages and corresponding guides contain information on optional provisions that do not apply to every state. If a statement does not apply to a state (such as provisions related to targeted low-income pregnant women, for example), the state may ignore the statement as not applicable. 
    • Throughout the state plan pages, states have various options of multiple entries in a table (for example, when entering age and income information or when entering text for “Other” with multiple entries). In this circumstance, the “+” button is for the addition of a new row and the “X” button is for the deletion of the row. In some other multiple entry sections, buttons with “Add” and “Delete” appear with the same functions for the section. 
    • We encourage states to share draft state plan pages with CMS through the MMDL. Follow this procedure after uploading the PDF to MMDL: From the Control Panel, select the Access tab, and then select “Allow CMS View” to allow CMS to view your draft PDF. Please notify CMS CHIP staff when you have done this for a prompt review. 

This implementation guide includes the following sections, consistent with the PDFs for each state plan page, and listed below by SPA Group: 

1. MAGI Eligibility and Methods

Targeted Low-Income Children (CS7) 
For states covering or electing to provide coverage to targeted low-income children, to provide information with regard to eligibility criteria, including income standards specific to this covered group.

Targeted Low-Income Pregnant Women (CS8)
For states covering or electing to provide coverage to targeted low-income pregnant women, to provide information with regard to eligibility criteria, including income standards specific to this covered group.

Coverage from Conception to Birth (CS9)
For states covering or electing to provide coverage to children from conception to birth, to provide information with regard to eligibility criteria, including income standards specific to this covered group.

Children Who Have Access to Public Employee Coverage (CS10)
For states covering or electing to provide coverage to children who have access to public employee coverage, to provide information with regard to covered population and qualifying income standards specific to this covered group.

Pregnant Women Who Have Access to Public Employee Coverage (CS11)
For states covering or electing to provide coverage to targeted low-income pregnant women who have access to public employee coverage, to provide information with regard to covered population and qualifying income standards specific to this covered group.

Dental Only Supplemental Coverage (CS12)
For states covering or electing to provide dental-only supplemental coverage, to provide information with regard to eligibility criteria, including income standards, specific to this covered group.

Deemed Newborns (CS13)
For states to provide deemed newborn coverage; describes the one-year coverage for infants born to targeted low-income pregnant women and options for additional deemed newborn coverage.

MAGI-Based Income Methodologies (CS15)
For states to provide information with regard to criteria used in the calculation of income for eligibility determination using MAGI-based income methodologies for their separate child health program.

Spenddown (CS16)
For states to indicate whether they apply spenddown and, if so, to provide information as to their application of spenddown for their separate child health program.

2. Title XXI Medicaid Expansion

Medicaid Expansion (CS3)
For states with Medicaid expansion programs to provide the qualifying ages for children and the income eligibility standards used by the state in determining eligibility under its Medicaid expansion program.

3. Establish 2101(f) Group

Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards (CS14)
For states to provide information as to how coverage will be provided for children subject to section 2101(f) protection or to provide assurance that there will be no children in the state subject to such protection. 

4. Eligibility Processing

General Eligibility-Eligibility Processing (CS24)
For states to provide information and assurances with respect to application and redetermination processing, eligibility screening and enrollment, and coordination with other insurance affordability programs. 

5. Non-Financial Eligibility

Residency (CS17)
For states to provide information with regard to residency requirements for their separate child health program.

Citizenship (CS18)
For states to provide information with regard to citizenship and non-citizenship requirements, and to provide the option for coverage of certain non-citizens lawfully present for less than five years, for their separate child health program.

Social Security Number (CS19)
For states to provide information with regard to social security number requirements for their separate child health program.

Substitution of Coverage (CS20)
For states to provide information about the state’s policies and procedures to prevent the substitution of group health coverage or other commercial health insurance with publicly-funded coverage for their separate child health program.

Non-Payment of Premiums (CS21)
For states to provide information about the state’s policies and procedures with respect to non-payment of premiums for their separate child health program.

Retroactive Eligibility for Children, From Conception to End of Pregnancy, and/or Pregnant Women (CS22)
For states to indicate if they elect the option to provide retroactive eligibility for children and/or pregnant women in their separate child health program.

Other Eligibility Standards (CS23)
For states to provide information in regard to additional eligibility standards, if any, used in their state’s separate child health program.

General Eligibility-Continuous Eligibility (CS27)
For states to elect the option to provide continuous eligibility (CE) coverage and, if elected, to provide information as to the administration of continuous eligibility for their separate child health program.

General Eligibility–Presumptive Eligibility for Children (CS28)
For states to elect the option to provide presumptive eligibility (PE) for children and, if elected, to provide information as to the administration of presumptive eligibility for their separate child health program.

General Eligibility–Presumptive Eligibility for Pregnant Women (CS29)
For states to elect the option to provide presumptive eligibility (PE) to pregnant women and, if elected, to provide information as to the administration of presumptive eligibility for pregnant women for their separate child health program. 

General Eligibility—Incarcerated CHIP Beneficiaries (CS31)
For states to provide information about the state’s policies and procedures with respect to incarcerated children and pregnant women who are enrolled in or found eligible for CHIP, and the services available to children prior to their release from a carceral facility.