Form CMS-10398 Federally Facilitated Marketplace and State Based Rules

---

Overview

Staff Contact
Customer Service
Medicaid State Based Rules
CHIP Program
Sheet3

---

Sheet 1: Staff Contact

Federally Faciliated Exchange and State Based Rules Intergration Plan
Contact information
State/Territory
Contact Name 1 (First Last)
Title
Email
Phone Number
Contact 2 (First Last)
Title
Email
Phone Number

---

Sheet 2: Customer Service

Federally Facilitated Exchange and State Based Rules Integration Plan
Customer Service Information
State/Territory
Customer Service Contact 1
Type of Customer Service	(For example, General, Application Assistance, Plan Enrollment, Renewal, RAI follow up, Application Tracking, Appeals)
Agency Name
Address
Hotline for assistance (toll free number)
Hours of Operation
Holiday Hours
State Agency Website
Coverage Areas
Language Access hotline
Language Capacity(s)
Hours of Operations
Customer Service Contact 2 (if applicable)
Type of Customer Service	(For example, General, Application Assistance, Plan Enrollment, Renewal, RAI follow up, Application Tracking, Appeals)
Agency Name
Address
Hotline for assistance (toll free number)
Hours of Operation
Holiday Hours
State Agency Website
Coverage Areas
Language Access hotline
Language Capacity(s)
Hours of Operations
Customer Service Contact 3 (if applicable)
Type of Customer Service	(For example, General, Application Assistance, Plan Enrollment, Renewal, RAI follow up, Application Tracking, Appeals )
Agency Name
Address
Hotline for assistance (toll free number)
Hours of Operation
Holiday Hours
State Agency Website
Coverage Areas
Language Access hotline
Language Capacity(s)
Hours of Operations
Customer Service Contact 4 (if applicable)
Type of Customer Service	(For example, General, Application Assistance, Plan Enrollment, Renewal, RAI follow up, Application Tracking, Appeals)
Agency Name
Address
Hotline for assistance (toll free number)
Hours of Operation
Holiday Hours
State Agency Website
Coverage Areas
Language Access hotline
Language Capacity(s)
Hours of Operations
Customer Service Contact 5 (if applicable)
Type of Customer Service	(For example, General, Application Assistance, Plan Enrollment, Renewal, RAI follow up, Application Tracking, Appeals)
Agency Name
Address
Hotline for assistance (toll free number)
Hours of Operation
Holiday Hours
State Agency Website
Coverage Areas
Language Access hotline
Language Capacity(s)
Hours of Operations
PRA Disclosure Statement
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 20 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.

---

Sheet 3: Medicaid State Based Rules

	Federally Facilitated Marketplace and State Based Rules Integration Plan (Medicaid)
	Medicaid State Agency Name
	State/Territory
	Date of Submission
#	Data Elements	Data Points	Valid Data Points	Description/Instructions
	General Questions
1	Medicaid determination or assessment		Y/N	Indicate if the State as elected to allow the Federally Facilitated Market to conduct Medicaid determinations (this includes determination based on MAGI and determinations for Refugee Medical Assistance and Emergency Medicaid) on behalf of the state Medicaid agency.
2	Effective date of coverage		Drop down	Indicate if the states has elected to start coverage at the date of application or the 1st of the month of the date of application
	PARENTS AND OTHER CARETAKER RELATIVES
3	Parents and other caretaker relatives - Medicaid eligibility level		%	Indicate the FPL the State has elected to apply to this category. 42 CFR 453.110
4	Optional expanded definition of parents and other caretaker relatives		Y/N	Indicate if the State has elected the option to expand the definition of parents and other caretaker relatives. If the State is ONLY applying the standard definition, fill in "N" for "No". 42 CFR 435.4
5	Dependent Child Age		Y/N	Indicate if the State has elected the option to expand the definition of dependent child to include individuals who are age 18 AND a full time student. Select "N" for "No" if the State has ONLY elected the standard definition of a dependent child as an individual up to age 18. 42 CFR 435.4
6	Retained the deprivation requirement for a parent or caretaker relative		Y/N	Indicate if the State has elected to retain the deprivation requirement for parent caretaker relative category. 42 CFR 435.4
6a	a. State unemployment Standard for Parent Caretaker Category		Y/N	If the State has retained the deprivation requirement, indicate if the State has elected to include the unemployment standard for fulfilling this requirement, in addition to the standard deprivation elements. Standard deprivation elements include absent parent or deceased parent.
6a(i)	i. Minimum number of hours worked		Integer, must be greater than 100	If the State has elected the unemployment standard, enter the minimum number of hours worked to meet the state's definition of unemployment for the deprivation requirement.
PREGNANT WOMEN
7	Pregnant women - Medicaid eligibility level		%	Indicate the FPL the State has elected for this population. 42 CFR 435.116
	MEDICAID CHILD CATEGORY
8	Children under age 1 - Medicaid eligibility level		%	Indicate the FPL the State has elected for this population. This includes children covered in CFR 42 435.118
9	Children ages 1-5 - Medicaid eligibility level		%	Indicate the FPL the State has elected for this population. This includes children covered in CFR 42 435.118
10	Children ages 6-18 - Medicaid eligibility level		%	Indicate the FPL the State has elected for this population. This includes children covered in CFR 42 435.118
11	Include individuals under age 20 (19 year olds) and/or under age 21 (20 year olds)	Y1-Include under age 20 year old in Child category	Y/N	Indicate whether the State has elected to include individuals under age 20 (19 year olds) and/or under age 21 (20 year olds) in the Medicaid child category. Do not provide information in this section on subsets covered under reasonable classifications of children.
11a	a. FPL threshold		%	If State elected to expand coverage to children aged 19 and/or 20, enter the FPL threshold the State has applied to this group.
	ADULT GROUP AND OPTIONAL XX GROUP CATEGORY
12	Adult Group		Y/N	Indicate whether the State has elected to cover the Adult group. 42 CFR 435.119
13	Optional XX Group		Y/N	Indicate whether the State has elected to cover the optional XX group. (42 CFR 435.218)
13a	a. FPL threshold		%	Indicate the FPL the State has elected for this group.
13b	b. Phase-in plan (if applicable)		free text	If this group will be phased in, please describe the phase-in plan.
	OPTIONAL TARGETED LOW-INCOME CHILD CATEGORY
14	Optional Targeted Low-Income Child Group		Y/N	Indicate if the State has elected to cover the Optional Targeted Low Income Child group. This does not include children who will be covered under other Medicaid eligibility groups described above. (42 CFR 435.229)
14a	a. Child Age Range 1		(min age)	If yes, indicate the minimum age the State has elected for this population. If different age groups are covered at different levels, please describe other age ranges in spaces below.
			(max age)	Indicate the maximum age range the State has elected for this population.
14a(i)	i. FPL threshold		%	Indicate the FPL the State has elected for this population.
14b	b. Child Age Range 2 (if applicable)		(min age)	If yes, indicate the minimum age the State has elected for this population.
			(max age)	Indicate the maximum age the State has elected for this population.
14b(i)	i. FPL threshold		%	Indicate the FPL the State has elected for this population.
14c	c. Child Age Range 3 (if applicable)		(min age)	If yes, indicate the minimum age the State has elected for this population.
			(max age)	Indicate the maximum age the State has elected for this population.
14c(i)	i. FPL threshold		%	Indicate the FPL the State has elected for this population.
	HOUSEHOLD COMPOSITION
15	Count full-time students under age 20 (19 year olds) and under age 21 (20 year olds) as children for purposes of household composition		drop down for standard/ expanded	Indicate if the State has elected to count full time students age 19 and 20 as children for purposes of household composition. 42 CFR 435.603 (f)(iv).
16	Count pregnant family members as one, or one plus number of expected children, for purposes of household composition		drop down with applicable options	Indicate whether the state has elected to count a pregnant family member (other than the applicant) as one individual or one individual plus the number of children she is expected to deliver, for purposes of household composition. 42 CFR 435.603(b) Note: this standard will apply to both the Medicaid and CHIP programs.
	CASH SUPPORT AND INCOME
17	Include nominal cash support as income		Y/N	When determining the income of an individual, who is claimed as a tax dependent by someone other than a parent or a spouse, indicate whether the State has elected to include cash support provided by the taxpayer, if such cash support exceeds a nominal amount. 42 CFR 435.603(d)(3)
17a	a. Nominal Amount		Dollar Amount $	If yes, enter the nominal threshold established by the state
18	Account for reasonably predictable increases AND decreases in future income		drop down menu with options	Indicate if the State has elected the option to account for reasonably predictable increases AND decreases in future income. The FFM will not support the option to consider ONLY increases or ONLY decreases in future income. 42 CFR 435.603(h)(3)
	RESIDENCY OPTION
20	Elect Medicaid student residency option		Y/N	State considers an applicant, aged 18-22 and a full time student in the state, to not be a resident of the state, if (1) neither parent lives in the state, (2) the student is claimed as a tax dependent by someone in another state, and (3) the student is applying on his or her own behalf.  NOTE: if this option is elected, and an applicant meets these criteria, his/her Medicaid residency will be set to pend to allow the applicant to provide evidence of state residency. 42 CFR 435.403(i)(2)
	IMMIGRATION ELIGIBILITY OPTIONS
21	Provide coverage for non-citizen, lawfully present children and/or pregnant women otherwise not eligible for Medicaid		Y/N	Indicate if the State has elected the option to provide coverage for non-citizen, lawfully present children and/or pregnant women who would otherwise not be considered eligible for Medicaid. SS 1903(v)(4)
21a	Age threshold for children under CHIPRA 214		Drop down max age threshold	Enter age threshold for this category. Note: this threshold will apply for both Medicaid and CHIP.
22	Seven year limit for refugees, asylees, non-citizens whose deportation is withheld, Cuban and Haitian Entrants, and Amerasians		Y/N	Indicate if the State has elected the option to limit Medicaid eligibility to seven years for refugees, asylees, non-citizens whose deportation is withheld, Cuban and Haitian Entrants, and Amerasians. 8 USC SS 1612(b)(2)(A)(i)
23	Requirement that lawful permanent residents also have 40 Title II Work Quarters		Y/N	Indicate if the State has elected the option to limit Medicaid eligibility for lawful permanent residents to those who have 40 Title II work quarters. 8 USC SS 1612(b)(2)(B)
	REFUGEE MEDICAL ASSISTANCE OPTION
24	Provides Refugee Medical Assistance		Y/N	Indicate if the State has elected the option to provide medical assistance to refugees 45 CFR subpart G
24a	Percent FPL Refugee Medical Assistance Limit		%	If yes, enter the FPL threshold the State has applied to this group.
	FORMER FOSTER CARE GROUP
25	Foster Care Age Threshold		Age	Indicate the age at which individuals become ineligible for Title IV-E foster care assistance. In other words, when an individual turns XX years old, he/she stops receiving Title IV-E foster care assistance. Proposed 42 CFR 435.150
26	In-State Foster Care Required		Y/N	In determining eligibility for the former foster care group, indicate whether the State covers only those individuals who aged out of foster care assistance in their state or also covers individuals who aged out of foster care in other states.
PRA Disclosure Statement
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 20 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.

---

Sheet 4: CHIP Program

	Federally Facilitated Marketplace and State Based Rules Integration Plan (CHIP)
	CHIP State Agency Name
	State/Territory
	Date of Submission
		Data Elements	Valid data points	Description/Instructions
	GENERAL
1	CHIP Determination or Assessment		Y/N	Indicate if the state as elected to allow the Federally Facilitated Market to conduct determination of CHIP eligibility. If
	CHIP TARGETED LOW-INCOME CHILD CATEGORY
2	CHIP targeted low-income child group		Y/N	Indicate if the State has elected the option to include the CHIP Targeted Low Income Child category in its program.
2a	a. CHIP Targeted Low-Income Child Group Age Range 1		(min age)	If yes, indicate the minimum age the State elected for this population.
			(max age)	Indicate the maximum age the State elected for this population.
2a(i)	i. FPL threshold		(min%-max%)	Indicate the FPL the State elected for this population.
2b	b. CHIP Targeted Low-Income Child Group Age Range 2 (if applicable)		(min age)	If yes, indicate the minimum age the State elected for this population.
			(max age)	Indicate the maximum age the State elected for this population.
2b(i)	i. FPL threshold		(min%-max%)	Indicate the FPL the State elected for this population.
2c	c. CHIP Targeted Low-Income Child Group Age Range 3 (if applicable)		(min age)	If yes, indicate the age range the State elected for this population.
			(max age)	Indicate the maximum age the State elected for this population.
2c(i)	i. FPL threshold		(min%-max%)	Indicate the FPL the State elected for this population.
	PREGNANT WOMEN
3	Pregnant Women Category		Y/N	Indicate if the State has elected the option to provide CHIP coverage for pregnant women.
3a	Pregnant women - CHIP eligibility level		%	If yes, Indicate the FPL the State has elected for this population.
	CHIP SPECIFIC STATE PROGRAM ELIGIBILITY
4	Option to Provide CHIP to individuals with access to state health benefits	All individuals	Drop down menu	Indicate if State has elected the option to provide CHIP coverage to individuals who have access to a state health benefits plan based on a family member's employment with a public agency. SS2110(b)(2)(B) of the Act.
4a	a. If household FPL threshold applies, enter the FLP threshold		%	Enter FPL level if State has elected to apply a household FPL threshold that is lower than for the threshold for the targeted low-income children group
5	Option to cover unborn children of pregnant women who are not otherwise eligible for CHIP or Medicaid		Y/N	Indicate if the State has elected to provide coverage to unborn children of pregnant women who are not otherwise eligible for CHIP or Medicaid. 42 CFR 457.10
5a	a. FPL standard for Unborn Child Category		%	Enter FPL level if State has elected to cover unborn children in this category. Otherwise, enter N/A for "not applicable"
	IMMIGRATION ELIGIBILITY (CHIPRA 214)
7	Provide coverage for non-citizen, lawfully present child and/or pregnant women otherwise eligible for CHIP		Y/N	Indicate if the State has elected the option to provide coverage to non-citizen, lawfully present children and/or pregnant women who would otherwise be considered eligible for CHIP. SS 2107(e)(1)(J) of the Act
	WAITING PERIODS
8	Length of CHIP waiting period		Number of days or N/A	If State has elected to apply waiting periods in program, Indicate the length of waiting period. If states did not elect to apply waiting periods, enter "N/A". SS 2102(b)(3)©
PRA Disclosure Statement
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 20 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.

---

Sheet 5: Sheet3

Y1-Count Pregnant Woman as 1					N/A		Medicaid Only		Effective Date of Application
Y2-Count Pregnant Woma as 2					19		CHIP Only		Effective 1st day of month of date of application
Y3-Count Pregnant Woman as 1 + babies due					20		Medicaid and CHIP
N-No, State did not elect this option					21		Neither
Other							Y1-Children Only
No Coverage (Rule does not apply)							Y2-Pregnant Women Only
All individuals							Y3-Children and Pregnant Women
Household FPL must be below a state threshold							N-No, State did not elect this option
Other
							Y-Consider increases AND decreases
							N-Consider increases ONLY
Y1- Applied Standard and Any Relatives of the child based on blood, adoption, or marriage (beyond those included in the standard definition)
Y2- Applied Standard and Domestic partner of the parent or other caretaker relative
Y3- Applied Standard and Any Relative and Domestic Partner (Option Y1 & Y2)
Y4- Applied Standard and Any adult with whom the child is living and who assumes primary responsibility for the dependent child's care
N-Applied Standard Definition to Parent Caretaker Relative ONLY
						N-Consider decreases ONLY
						N-Do not consider increases or decreases
Y- Depend child is up to age 18 and a full time student
N-Depend child is up to age 18 ONLY						Y- Student is not considered a state resident if all criterion are met
						N- Student is considered a state resident
Y- Retained deprivation requirement
N-Eliminated deprivation requirement						Y- Only covers indivduals who received Title IV-E in State
						N-Covers indivduals who received Title IV-E in another State
Y- Applied standard deprivation elements and elected unemployment requirement
N- Applied standard deprivation elements ONLY
						Y- Allow FFM to Determine MAGI, Refugee Medical Assistance and Emergency Medicaid eligibility
Y1-Include under age 20 year old in Child category						N-Allow FFM to Assess MAGI, Refugee Medical Assistance and Emergency Medicaid eligibility
Y2-Include under age 21 year old in Child category
N-Applied standard definition to Child category ONLY (under age 19)
						Y- Allow FFM to Determine CHIP eligibility
						N-Allow FFM to Assess CHIP eligibility