lib/libs/webforms/ABP2C/v202401.ts
import { FormSchema } from "shared-types";
import { noLeadingTrailingWhitespace } from "shared-utils/regex";
export const v202401: FormSchema = {
header: "ABP 2c: Enrollment assurances - Mandatory participants",
formId: "abp2c",
sections: [
{
title: "Assurances",
sectionId: "assurances",
form: [
{
slots: [
{
name: "mandatory-identify-exempt",
rhf: "Checkbox",
descriptionAbove: true,
labelClassName: "text-black text-base",
styledLabel: [
"These assurances must be made by the state/territory if enrollment is mandatory for any of the target populations or subpopulations.",
{
type: "br",
classname: "font-bold block pt-4",
text: "When mandatorily enrolling eligibility groups in an Alternative Benefit Plan (ABP) (benchmark or benchmark-equivalent plan) that could have exempt individuals, prior to enrollment:",
},
],
rules: { required: "* Required" },
props: {
options: [
{
value: "assure_individuals_in_egroup_exempt_section_1937",
styledLabel: [
{
text: "The state/territory assures it will appropriately identify any individuals in the eligibility groups who:",
classname: "block pb-1",
},
{
text: "A. Are exempt from mandatory enrollment in an ABP",
classname: "block py-1",
},
{
text: "B. Meet the exemption criteria and are given a choice of ABP coverage defined using Section 1937 requirements or ABP coverage defined as the state/territory’s approved Medicaid state plan not subject to Section 1937 requirements",
classname: "block py-1",
},
],
},
],
},
},
{
name: "how-identify",
rhf: "Checkbox",
label: "How will the state/territory identify these individuals?",
labelClassName: "font-bold text-black",
rules: { required: "* Required" },
props: {
options: [
{
label:
"Review of eligibility criteria (e.g., age, disorder, diagnosis, condition)",
value: "review_of_eligibility_criteria",
slots: [
{
name: "how-id-review-eligible-crit-desc",
rhf: "Textarea",
label: "Describe",
labelClassName: "font-bold text-black",
rules: {
required: "* Required",
pattern: {
value: noLeadingTrailingWhitespace,
message:
"Must not have leading or trailing whitespace.",
},
},
},
],
},
{
label: "Self-identification",
value: "self_identification",
slots: [
{
name: "how-id-self-id-desc",
rhf: "Textarea",
label: "Describe",
labelClassName: "font-bold text-black",
rules: {
required: "* Required",
pattern: {
value: noLeadingTrailingWhitespace,
message:
"Must not have leading or trailing whitespace.",
},
},
},
],
},
{
label: "Other",
value: "other",
slots: [
{
name: "how-id-other-desc",
rhf: "Textarea",
label: "Describe",
labelClassName: "font-bold text-black",
rules: {
required: "* Required",
pattern: {
value: noLeadingTrailingWhitespace,
message:
"Must not have leading or trailing whitespace.",
},
},
},
],
},
],
},
},
],
},
],
},
{
title: "Exemptions",
sectionId: "exemptions",
form: [
{
slots: [
{
name: "mandatory-inform-current-exempt",
rhf: "Checkbox",
rules: { required: "* Required" },
props: {
options: [
{
label:
"The state/territory must inform the individual they are exempt or meet the exemption criteria, and the state/territory must comply with all requirements related to voluntary enrollment or, for beneficiaries in the “individuals age 19 or older and under age 65 at or below 133% FPL” eligibility group, optional enrollment in ABP coverage defined using Section 1937 requirements or ABP coverage defined as the state/territory's approved Medicaid state plan.",
value:
"state_must_inform_current_exemptions_comply_volunteer_enroll_between_19_and_65_or_133_FPL_optional_enroll_coverage_section_1937",
},
],
},
},
{
name: "madatory-inform-future-exempt",
rhf: "Checkbox",
rules: { required: "* Required" },
props: {
options: [
{
label:
"The state/territory assures that for individuals who have become exempt from enrollment in an ABP, the state/territory must inform them they are now exempt. The state/territory must comply with all requirements related to voluntary enrollment or, for beneficiaries in the “individuals age 19 or older and under age 65 at or below 133% FPL” eligibility group, optional enrollment in ABP coverage defined using Section 1937 requirements or ABP coverage defined as the state/territory's approved Medicaid state plan.",
value:
"state_assures_individuals_future_exempt_informedcomply_volunteer_enroll_between_19_and_65_or_133_FPL_optional_enroll_coverage_section_1937",
},
],
},
},
{
name: "how-id-become-exempt",
rhf: "Checkbox",
label:
"How will the state/territory identify if an individual becomes exempt?",
labelClassName: "font-bold text-black",
rules: { required: "* Required" },
props: {
options: [
{
label: "Review of claims data",
value: "review_of_claims_data",
},
{
label: "Self-identification",
value: "self_identification",
},
{
label: "Review at the time of eligibility redetermination",
value: "review_eligibility_redetermination",
},
{
label: "Provider identification",
value: "provider_identification",
},
{
label: "Change in eligibility group",
value: "change_in_eligibility_group",
},
{
label: "Other",
value: "other",
slots: [
{
name: "how-id-exempt-other-desc",
rhf: "Textarea",
label: "Describe",
labelClassName: "font-bold text-black",
rules: {
required: "* Required",
pattern: {
value: noLeadingTrailingWhitespace,
message:
"Must not have leading or trailing whitespace.",
},
},
},
],
},
],
},
},
{
name: "freq-determine-exemptions",
rhf: "Radio",
rules: { required: "* Required" },
labelClassName: "font-bold text-black",
label:
"How frequently will the state/territory review the ABP population to determine if individuals are exempt from mandatory enrollment or meet the exemption criteria?",
props: {
options: [
{
label: "Monthly",
value: "monthly",
},
{
label: "Quarterly",
value: "quarterly",
},
{
label: "Annually",
value: "annually",
},
{
label: "On an as-needed basis",
value: "as_needed_basis",
},
{
label: "Other",
value: "other",
slots: [
{
name: "freq-determine-ex-other-desc",
rhf: "Textarea",
label: "Describe",
labelClassName: "font-bold text-black",
rules: {
required: "* Required",
pattern: {
value: noLeadingTrailingWhitespace,
message:
"Must not have leading or trailing whitespace.",
},
},
},
],
},
],
},
},
{
name: "assure-disenroll-process",
rhf: "Checkbox",
rules: { required: "* Required" },
props: {
options: [
{
label:
"The state/territory assures that it will promptly process all requests made by exempt individuals for disenrollment from the ABP and has in place a process that ensures exempt individuals have access to all standard state/territory plan services or, for beneficiaries in the “individuals age 19 or older and under age 65 at or below 133% FPL” eligibility group, optional enrollment in ABP coverage defined using Section 1937 requirements or ABP coverage defined as the state/territory's approved Medicaid state plan.",
value:
"state_assures_prompt_disenrollment_request_process_for_exempt_and_ensure_services_available",
},
],
},
},
{
name: "desc-disenroll-process",
rhf: "Textarea",
rules: {
required: "* Required",
pattern: {
value: noLeadingTrailingWhitespace,
message: "Must not have leading or trailing whitespace.",
},
},
props: {
className: "min-h-[114px]",
},
label: "Describe the process for processing requests.",
labelClassName: "font-bold text-black",
formItemClassName: "pl-8",
},
],
},
],
},
{
title: "Additional Information",
sectionId: "addtnl-info",
form: [
{
slots: [
{
name: "description",
rhf: "Textarea",
label:
"Other information about enrollment assurances for mandatory participants (optional)",
labelClassName: "font-bold text-black",
props: {
className: "min-h-[114px]",
},
rules: {
pattern: {
value: noLeadingTrailingWhitespace,
message: "Must not have leading or trailing whitespace.",
},
},
},
],
},
],
},
],
};