lib/libs/webforms/ABP2B/v202401.ts
import { FormSchema } from "shared-types";
import { noLeadingTrailingWhitespace } from "shared-utils/regex";
export const v202401: FormSchema = {
header:
"ABP 2b: Voluntary enrollment assurances for eligibility groups other than the “adult” group under Section 1902(a)(10)(A)(i)(VIII) of the Act",
formId: "abp2b",
sections: [
{
title: "Assurances",
sectionId: "addurances",
form: [
{
slots: [
{
rhf: "Checkbox",
name: "adult-eligibility-included",
descriptionClassName: "text-black text-base",
descriptionAbove: true,
description: [
{
text: "These assurances must be made by the state/territory if the Alternative Benefit Plan (ABP) population includes any eligibility groups other than or in addition to the “adult” eligibility group.",
type: "default",
classname: "block pb-4",
},
{
text: "When offering voluntary enrollment in an ABP (benchmark or benchmark-equivalent), prior to enrollment, the state/territory will:",
type: "default",
classname: "font-bold block pt-2",
},
],
rules: { required: "* Required" },
props: {
options: [
{
label:
"Inform individuals they are exempt and comply with all requirements related to voluntary enrollment",
value:
"inform_exempt_and_comply_with_requirements_related_to_voluntary_enrollment",
},
{
styledLabel: [
{
text: "Effectively inform individuals who voluntarily enroll:",
type: "default",
classname: "block pb-1",
},
{
text: "A. That enrollment is voluntary",
type: "default",
classname: "block py-1",
},
{
text: "B. That they may disenroll from the ABP at any time and regain immediate access to full standard state/territory plan coverage",
type: "default",
classname: "block py-1",
},
{
text: "C. What the process is for disenrolling",
type: "default",
classname: "block pt-1",
},
],
value:
"effectively_inform_voluntarily_enroll_and_may_disenroll",
},
{
styledLabel: [
{
text: "Inform individuals of:",
type: "default",
classname: "block pb-1",
},
{
text: "A. The benefits available under the ABP",
type: "default",
classname: "block py-1",
},
{
text: "B. The costs of the different benefit packages and a comparison of how the ABP differs from the approved Medicaid state/territory plan",
type: "default",
classname: "block pt-1",
},
],
value:
"inform_individuals_of_abp_benefits_and_costs_of_different_packages",
},
],
},
},
],
},
],
},
{
title: "Delivery of information",
sectionId: "delivery-of-info",
form: [
{
description:
"How will the state/territory inform individuals about their options for enrollment?",
slots: [
{
rhf: "Checkbox",
name: "assurances",
rules: { required: "* Required" },
props: {
options: [
{
label: "Letter",
value: "letter",
},
{
label: "Email",
value: "email",
},
{
label: "Other",
value: "other",
slots: [
{
rhf: "Textarea",
name: "describe-other-enrollment",
label: "Describe",
labelClassName: "font-bold",
rules: {
required: "* Required",
pattern: {
value: noLeadingTrailingWhitespace,
message:
"Must not have leading or trailing whitespace.",
},
},
},
],
},
],
},
},
{
rhf: "Upload",
name: "provide-copy",
description:
"Provide a copy of the letter, email, or other communication.",
descriptionAbove: true,
descriptionClassName: "font-bold text-black",
rules: {
required: "* Required",
},
props: { maxFiles: 3 },
},
{
rhf: "Input",
name: "when-to-inform",
descriptionAbove: true,
description:
"When did/will the state/territory inform the individuals?",
rules: {
required: "* Required",
pattern: {
value: /^\S(.*\S)?$/,
message: "Must not have leading or trailing whitespace.",
},
},
descriptionClassName: "font-bold text-black",
},
{
rhf: "Textarea",
name: "process-for-allow-voluntarily-enrolled-to-disenroll",
descriptionAbove: true,
description:
"What is the state/territory's process for allowing voluntarily enrolled individuals to disenroll?",
descriptionClassName: "font-bold text-black",
rules: {
required: "* Required",
pattern: {
value: noLeadingTrailingWhitespace,
message: "Must not have leading or trailing whitespace.",
},
},
},
{
rhf: "Checkbox",
name: "state-territory-assures-it-will-document-exempt-individuals",
formItemClassName: "whitespace-pre-wrap",
rules: {
required: "* Required",
},
props: {
options: [
{
styledLabel: [
{
text: "The state/territory assures it will document in the exempt individual's eligibility file that the individual:",
type: "default",
classname: "block pb-1",
},
{
text: "A. Was informed in accordance with this section prior to enrollment",
type: "default",
classname: "block py-1",
},
{
text: "B. Was given ample time to arrive at an informed choice",
type: "default",
classname: "block py-1",
},
{
text: " C. Chose to enroll in ABP coverage subject to Section 1937 requirements or defined as the state/territory's approved Medicaid state plan not subject to Section 1937 requirements",
},
],
value:
"state_territory_will_document_exempt_individuals_eligibility",
},
],
},
},
{
rhf: "Checkbox",
name: "where-will-info-be-doc",
descriptionAbove: true,
descriptionClassName: "font-bold text-black",
description: "Where will the information be documented?",
rules: {
required: "* Required",
},
props: {
options: [
{
label: "In the eligibility system",
value: "in_eligibility_system",
},
{
label: "In the hard copy of the case record",
value: "hard_copy_of_case_record",
},
{
label: "Other",
value: "other",
slots: [
{
rhf: "Textarea",
name: "where-will-info-be-doc-describe-other",
label: "Describe",
labelClassName: "font-bold",
rules: {
required: "* Required",
pattern: {
value: noLeadingTrailingWhitespace,
message:
"Must not have leading or trailing whitespace.",
},
},
},
],
},
],
},
},
{
rhf: "Checkbox",
name: "what-docu-will-be-maintained",
descriptionAbove: true,
descriptionClassName: "font-bold text-black",
description:
"What documentation will be maintained in the eligibility file?",
formItemClassName: "pb-6 border-b-[1px] border-[#AEB0B5]",
rules: {
required: "* Required",
},
props: {
options: [
{
label: "Copy of correspondence sent to the individual",
value: "copy_of_correspondence_sent_to_the_individual",
},
{
label:
"Signed documentation from the individual consenting to enrollment in the ABP",
value:
"signed_documentation_from_individual_consenting_enrollment_ABP",
},
{
label: "Other",
value:
"what_documentation_will_be_maintained_in_the_eligibility_file_other",
slots: [
{
rhf: "Textarea",
name: "describe-other-maintained",
label: "Describe",
labelClassName: "font-bold",
rules: {
required: "* Required",
pattern: {
value: noLeadingTrailingWhitespace,
message:
"Must not have leading or trailing whitespace.",
},
},
},
],
},
],
},
},
{
rhf: "Checkbox",
name: "state-territory-assures-maintain-data",
rules: {
required: "* Required",
},
props: {
options: [
{
label:
"The state/territory assures it will maintain data that tracks the total number of individuals who have voluntarily enrolled in an ABP and the total number who have disenrolled.",
value: "state_territory_assures_it_will_maintain_data",
},
],
},
},
],
},
],
},
{
title: "Additional information",
sectionId: "addtnl-info",
form: [
{
description:
"Other information about enrollment assurances for voluntary participants (optional)",
slots: [
{
rhf: "Textarea",
name: "other-info-about-enroll-assurance",
rules: {
pattern: {
value: noLeadingTrailingWhitespace,
message: "Must not have leading or trailing whitespace.",
},
},
},
],
},
],
},
],
};