Apply the CHIP no-other-coverage test to pregnancy pathways in every state

changelog.d/chip-pregnant-coverage-test.fixed.md

@@ -0,0 +1 @@
+Exclude pregnant people with other health coverage from standard pregnancy CHIP and from the unborn-child (FCEP) option in every state, not only California.

policyengine_us/parameters/gov/hhs/chip/disqualifying_health_coverage.yaml

@@ -1,4 +1,4 @@
-description: Health coverage sources that disqualify a child from CHIP eligibility.
+description: Health coverage sources that disqualify a child or a pregnant person from Children's Health Insurance Program eligibility.
 values:
   0000-01-01:
     - has_health_coverage_other_than_chip
@@ -18,9 +18,13 @@ metadata:
   period: year
   label: CHIP disqualifying health coverage sources
   reference:
-    - title: 42 CFR § 457.310(b)(2) - Health benefits coverage
+    - title: 42 CFR § 457.310(b)(2) - No other coverage standard
       href: https://www.ecfr.gov/current/title-42/section-457.310#p-457.310(b)(2)
+    - title: 42 CFR § 457.320(a)(7) - Other eligibility standards
+      href: https://www.ecfr.gov/current/title-42/section-457.320#p-457.320(a)(7)
     - title: 42 CFR § 457.320(b)(5) - Other eligibility standards
       href: https://www.ecfr.gov/current/title-42/section-457.320#p-457.320(b)(5)
-    - title: 45 CFR § 146.113(a)(1) - Excepted benefits
+    - title: 42 U.S.C. § 1397ll(d)(2)(C) - Targeted low-income pregnant woman
+      href: https://www.law.cornell.edu/uscode/text/42/1397ll#d_2_C
+    - title: 45 CFR § 146.113(a)(1) - Creditable coverage
       href: https://www.ecfr.gov/current/title-45/section-146.113#p-146.113(a)(1)

policyengine_us/tests/policy/baseline/gov/hhs/chip/is_chip_eligible_fcep.yaml

@@ -333,7 +333,10 @@
 # California's FCEP population above the Medi-Cal pregnancy limit is the Medi-Cal
 # Access Program. WIC § 15833 excludes applicants eligible for no-cost Medi-Cal
 # or Medicare and WIC § 15834 excludes services already covered by private
-# coverage, so the CHIP disqualifying coverage list applies in California only.
+# coverage. The CHIP disqualifying coverage list applies to FCEP in every
+# state and carries these exclusions: 42 CFR 457.310(b)(2) excludes group
+# health plan and health insurance coverage, and 42 CFR 457.320(a)(7) lets a
+# state also exclude other coverage, such as Medicare.
 - name: California MCAP applicant without other coverage is eligible
   period: 2025
   input:
@@ -448,15 +451,16 @@
     is_chip_fcep_eligible_person: true
     chip_category: PREGNANT_FCEP
 
-- name: The California MCAP insurance exclusion does not reach Texas FCEP
+- name: Texas FCEP excludes a pregnant applicant with employer coverage (42 CFR 457.310(b)(2))
   period: 2025
   input:
     people:
       head:
         age: 30
         is_pregnant: true
         is_medicaid_eligible: false
-        medicaid_income_level: 2
+        # Above Texas Medicaid's 203% FPL pregnancy limit, within the 207% FCEP limit.
+        medicaid_income_level: 2.05
         has_esi: true
     tax_units:
       tax_unit:
@@ -468,7 +472,8 @@
         - head
         state_code: TX
   output:
-    is_chip_fcep_eligible_person: true
+    is_chip_fcep_eligible_person: false
+    chip_category: NONE
 
 # FCEP covers the unborn child regardless of the parent's immigration status.
 # https://www.medicaid.gov/chip/chip-eligibility-enrollment

policyengine_us/tests/policy/baseline/gov/hhs/chip/is_chip_eligible_pregnant.yaml

@@ -37,3 +37,103 @@
         is_chip_fcep_eligible_person: False
   output:
     is_chip_eligible_pregnant: False
+
+- name: Case 5, pregnant woman with employer coverage is not eligible for standard pregnancy CHIP.
+  period: 2026
+  input:
+    people:
+      head:
+        age: 30
+        is_pregnant: true
+        immigration_status: CITIZEN
+        is_medicaid_eligible: false
+        medicaid_income_level: 2
+        has_esi: true
+    tax_units:
+      tax_unit:
+        members: [head]
+    households:
+      household:
+        members: [head]
+        state_code: NJ
+  output:
+    # New Jersey covers pregnant women up to 205% FPL through CHIP and has no
+    # FCEP option, but a targeted low-income pregnant woman must be uninsured
+    # (42 USC 1397ll(d)(2)(C)).
+    is_chip_eligible_standard_pregnant_person: false
+    is_chip_fcep_eligible_person: false
+    is_chip_eligible_pregnant: false
+
+- name: Case 6, an insured pregnant applicant in a state with both CHIP pregnancy options gets neither option.
+  period: 2025
+  input:
+    people:
+      # person1 has employer coverage; person2 is the uninsured control.
+      person1:
+        age: 30
+        is_pregnant: true
+        immigration_status: CITIZEN
+        is_medicaid_eligible: false
+        medicaid_income_level: 2.3
+        has_esi: true
+      person2:
+        age: 30
+        is_pregnant: true
+        immigration_status: CITIZEN
+        is_medicaid_eligible: false
+        medicaid_income_level: 2.3
+    tax_units:
+      tax_unit1:
+        members: [person1]
+      tax_unit2:
+        members: [person2]
+    households:
+      household1:
+        members: [person1]
+        state_code: CO
+      household2:
+        members: [person2]
+        state_code: CO
+  output:
+    # Colorado offers the standard and FCEP options up to 265% FPL; 230% FPL
+    # is above its 200% Medicaid pregnancy limit and within both CHIP limits.
+    is_chip_eligible_standard_pregnant_person: [false, true]
+    is_chip_fcep_eligible_person: [false, true]
+    is_chip_eligible_pregnant: [false, true]
+    chip_category: [NONE, PREGNANT_STANDARD]
+
+- name: Case 7, other coverage reported through the aggregate input excludes pregnant applicants from both CHIP pregnancy options.
+  period: 2026
+  input:
+    people:
+      # person1: New Jersey (standard option only); person2: Texas (FCEP only).
+      person1:
+        age: 30
+        is_pregnant: true
+        immigration_status: CITIZEN
+        is_medicaid_eligible: false
+        medicaid_income_level: 2
+        has_health_coverage_other_than_chip: true
+      person2:
+        age: 30
+        is_pregnant: true
+        is_medicaid_eligible: false
+        medicaid_income_level: 2.05
+        has_health_coverage_other_than_chip: true
+    tax_units:
+      tax_unit1:
+        members: [person1]
+      tax_unit2:
+        members: [person2]
+    households:
+      household1:
+        members: [person1]
+        state_code: NJ
+      household2:
+        members: [person2]
+        state_code: TX
+  output:
+    is_chip_eligible_standard_pregnant_person: [false, false]
+    is_chip_fcep_eligible_person: [false, false]
+    is_chip_eligible_pregnant: [false, false]
+    chip_category: [NONE, NONE]

policyengine_us/tests/policy/baseline/gov/states/ca/dhcs/medi_cal/mixed_households.yaml

@@ -1,5 +1,6 @@
-# Mixed-state populations: California's pregnancy counting and MCAP insurance
-# exclusion must apply only to California persons within one simulation.
+# Mixed-state populations: California's pregnancy counting must apply only to
+# California persons, and the CHIP no-other-coverage exclusion must apply per
+# person, within one simulation.
 - name: Case 1, California pregnancy counting remains isolated in a mixed-state population.
   period: 2025
   input:
@@ -59,12 +60,12 @@
     medicaid_household_size: [5, 5, 5, 3, 4, 3]
     ca_medicaid_household_pregnancies: [2, 2, 2, 0, 0, 0]
 
-- name: Case 2, California MCAP insurance exclusion is applied per person in a mixed-state population.
+- name: Case 2, CHIP no-other-coverage exclusion is applied per person in a mixed-state population.
   period: 2025
   input:
     people:
-      # person1: insured Californian; person2: insured Texan control;
-      # person3: uninsured Californian.
+      # person1: insured Californian; person2: uninsured Texan above Texas
+      # Medicaid's 203% FPL pregnancy limit; person3: uninsured Californian.
       person1:
         age: 30
         is_pregnant: true
@@ -74,8 +75,7 @@
       person2:
         age: 30
         is_pregnant: true
-        has_esi: true
-        medicaid_income_level: 2
+        medicaid_income_level: 2.05
         is_medicaid_eligible: false
       person3:
         age: 30

policyengine_us/variables/gov/hhs/chip/is_chip_eligible_standard_pregnant_person.py

@@ -13,6 +13,7 @@ class is_chip_eligible_standard_pregnant_person(Variable):
     reference = (
         "https://www.ssa.gov/OP_Home/ssact/title21/2110.htm",
         "https://www.medicaid.gov/medicaid/national-medicaid-chip-program-information/medicaid-childrens-health-insurance-program-basic-health-program-eligibility-levels",
+        "https://www.law.cornell.edu/uscode/text/42/1397ll#d_2_C",
         "https://www.law.cornell.edu/uscode/text/8/1611#a",
         "https://www.law.cornell.edu/uscode/text/8/1641#b",
         "https://www.law.cornell.edu/cfr/text/45/155.20",
@@ -46,10 +47,18 @@ def formula(person, period, parameters):
             person, period, parameters, income_limit
         )
 
+        # A targeted low-income pregnant woman must not be covered under a
+        # group health plan or health insurance coverage, in the same manner
+        # as a child (42 USC 1397ll(d)(2)(C) and 1397jj(b)(1)(C)).
+        has_disqualifying_coverage = person(
+            "has_chip_disqualifying_health_coverage", period
+        )
+
         return (
             is_pregnant
             & state_has_pregnant_chip
             & immigration_eligible
             & ~medicaid_eligible
             & income_eligible
+            & ~has_disqualifying_coverage
         )

policyengine_us/variables/gov/hhs/chip/is_chip_fcep_eligible_person.py

@@ -22,6 +22,7 @@ class is_chip_fcep_eligible_person(Variable):
         # 42 CFR 457.10 defines "child" to include the period from conception to
         # birth, so the unborn child (not the parent) is the CHIP beneficiary.
         "https://www.law.cornell.edu/cfr/text/42/457.10",
+        "https://www.ecfr.gov/current/title-42/section-457.310#p-457.310(b)(2)",
         "https://www.kff.org/affordable-care-act/state-indicator/medicaid-and-chip-income-eligibility-limits-for-pregnant-women-as-a-percent-of-the-federal-poverty-level",
         # California's FCEP population is the Medi-Cal Access Program. WIC
         # § 15833 excludes applicants eligible for no-cost Medi-Cal or Medicare
@@ -77,17 +78,16 @@ def formula(person, period, parameters):
             person, period, parameters, income_limit
         )
 
-        # California's FCEP population above the Medi-Cal pregnancy limit is the
-        # Medi-Cal Access Program (MCAP). MCAP turns away applicants who are
-        # eligible for no-cost Medi-Cal or Medicare (WIC § 15833) and applicants
-        # whose private coverage already covers its services (WIC § 15834), which
-        # the CHIP disqualifying coverage list captures. The former AIM rule at
-        # 10 CCR § 2699.200(b)(1)(F)-(G) states the same two exclusions; its
-        # (b)(1)(G) exception for private plans that omit maternity benefits, or
-        # carry a maternity-only deductible or copayment above $500, is not
-        # modeled.
-        in_california = state_code == StateCode.CA
-        ca_has_disqualifying_coverage = in_california & person(
+        # The unborn child is a targeted low-income child, so it must not be
+        # covered under a group health plan or health insurance coverage
+        # (42 CFR 457.310(b)(2)). The pregnant person's coverage stands in for
+        # the unborn child's. California's FCEP population above the Medi-Cal
+        # pregnancy limit is the Medi-Cal Access Program (MCAP), which states
+        # the same exclusions (WIC §§ 15833-15834; former AIM rule 10 CCR
+        # § 2699.200(b)(1)(F)-(G)). MCAP's exception for private plans that
+        # omit maternity benefits, or carry a maternity-only deductible or
+        # copayment above $500, is not modeled.
+        has_disqualifying_coverage = person(
             "has_chip_disqualifying_health_coverage", period
         )
 
@@ -97,5 +97,5 @@ def formula(person, period, parameters):
             & fcep_geographic_eligible
             & ~medicaid_eligible
             & income_eligible
-            & ~ca_has_disqualifying_coverage
+            & ~has_disqualifying_coverage
         )