Form CMS-10398 #33 CMS-10398 #33 FOA Preprint

ATTACHMENT 2.2-A PAGE 23e

Revision:

State/Territory:

_{Citation Groups Covered}

B. Optional Groups Other Than the Medically Needy (Continued)

1902(a)(10)(A) [ ] 26. Family Opportunity Act – (ii)(XIX) of the Act

Children who have not attained 19 years of age, who would be considered disabled under Section 1614(a)(3)(C) of the Act, and whose family income meets the standard described on Page 12p of Attachment 2.6-A.

_{Income Standards}

The agency uses the family income standard of 300% of federal poverty level;

The agency uses the family income standard of less than 300% of the federal poverty level. Specify the income standard

The agency uses a family income standard higher than 300% of the federal poverty level, (no federal financial participation is provided for benefits to families above 300% FPL). Specify the income standard

Resource Standards

Under this provision agencies may not impose resource standards or asset tests in determining eligibility.

TN No. Supersedes

TN No.

Approval Date

Effective Date

_{Citation Condition or Requirement}

1902(a)(10)(A)(ii)(XIX) of the Act Income Methodologies

In determining whether a family meets the income standard described above, the agency uses the following methodologies.

The income methodologies of the SSI

_program.

The agency uses methodologies for treatment of income that are more restrictive than the SSI program. These more restrictive methodologies are described in Supplement 4 to Attachment 2.6-A

The agency uses more liberal income methodologies than the SSI program. More liberal income methodologies are described in Supplement 8a to Attachment 2.6-A.

1902(cc) and 1903(a) Interaction with Employer Sponsored Family of the Act Coverage

For individuals eligible under the FOA eligibility group described in No. 26 on page 23e of Attachment 2.2-A:

The agency requires parents to enroll in available group health plans through their employers if the plan qualifies under Section

2791(a) of the Public Health Service Act and the employer contributes at least 50 percent of the total cost of annual premiums for such coverage.

TN No. Supersedes

TN No.

Approval Date

Effective Date

Revision: ATTACHMENT 2.6-A Page 12r

_{State/Territory:}

_{Citation Condition or Requirement}

1902(cc) and 1903(a) Interaction with Employer Sponsored Family of the Act Coverage (Continued)

If such coverage is obtained, the agency (subject to the payment of premiums described in Attachment 2.6-A, pages 12r and s) reduces any premium imposed by the State by an amount that reasonably reflects the premium contribution made by the parent for private coverage on behalf of a child with a disability; and treats such coverage as a third party liability.

The agency provides for payment of all or some portion of the annual premium for the employer-provided private family coverage that the parent is required to pay. Any payments made by the State are considered, for purposes of section

1903(a), to be payments for medical assistance. The agency pays percent of the premium.

1902(a)(10)(A)(ii)(XIX), Payment of Premiums

1902(cc)(2)(A)(ii)(I) and 1916(i)

of the Act For individuals eligible under the FOA eligibility group described in No. 26 on page 23e of Attachment 2.2-A:

The agency does not require the payment of premiums for Medicaid coverage.

The agency requires payment of premiums on a sliding scale based on income. The premiums and how they are applied are described below:

TN No. Supersedes

TN No.

Approval Date Effective Date

Revision: ATTACHMENT 2.6-A Page 12s

_{State/Territory:}

_{Citation Condition or Requirement}

1902(a)(10)(A)(ii)(XIX), Payment of Premiums (Continued)

1902(cc)(2)(A)(ii)(I) and 1916(i)

of the Act NOTE: Amounts paid for premiums for Medicaid, required family coverage, and other cost- sharing may not exceed 5% of a family’s income for families with income up to and including 200% FPL and 7.5% of a family’s income for families above

200% and up to 300% FPL.

NOTE: A State may not require prepayment of premiums and may not terminate eligibility of a child for medical assistance on the basis of failure to

pay a premium until the failure to pay continues for at least 60 days from the date on which the premium was past due.

NOTE: The State may waive payment of any such premium in any case where the State determines that requiring payment would create an undue hardship.

TN No. Supersedes

_{TN No.}

Approval Date Effective Date

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 6 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

CMS-10398 #33 (OCN 0938-1148)

Expiration date: 10/31/2014

(formerly CMS-10232, OCN 0938-1045)