lib/libs/webforms/ABP3/v202401.ts
import { FormSchema } from "shared-types";
import { noLeadingTrailingWhitespace } from "shared-utils/regex";
export const v202401: FormSchema = {
header:
"ABP 3: Selection of benchmark or benchmark-equivalent benefit package",
formId: "abp3",
sections: [
{
title: "Benefit package details",
sectionId: "benefit-package",
form: [
{
description:
"For the population defined in section 1, the state/territory wants to:",
slots: [
{
rhf: "Radio",
name: "details",
rules: { required: "* Required" },
props: {
options: [
{
label: "Amend one existing benefit package",
value: "amend_existing",
},
{
label: "Create a single new benefit package",
value: "create_new_benefit_package",
},
],
},
},
{
rhf: "Input",
name: "name",
label: "Benefit package name",
labelClassName: "font-bold",
props: {
className: "w-[355px]",
},
rules: {
required: "* Required",
pattern: {
value: /^\S(.*\S)?$/,
message: "Must not have leading or trailing whitespace.",
},
},
},
],
},
],
},
{
title: "Selection of Section 1937 coverage option",
sectionId: "select-of-sect-1937-cov-opt",
form: [
{
description:
"The state/territory selects as its Section 1937 coverage option the following type of benchmark or benchmark-equivalent benefit package under this Alternative Benefit Plan (ABP):",
slots: [
{
rhf: "Radio",
name: "type",
rules: { required: "* Required" },
props: {
options: [
{
label: "Benchmark benefit package",
value: "benchmark_benefit_package",
form: [
{
slots: [
{
rhf: "Radio",
name: "benchmark-benefit-package-options",
rules: { required: "* Required" },
props: {
options: [
{
label:
"The standard Blue Cross Blue Shield preferred provider option offered through the Federal Employee Health Benefit Program (FEHBP)",
value: "blue_cross_blue_shield",
},
{
label:
"State employee coverage that is offered and generally available to state employees (state employee coverage)",
value: "state_employee_coverage",
form: [
{
slots: [
{
rhf: "Input",
label: "Plan name",
labelClassName: "font-bold",
name: "state-employee-coverage-plan-name",
props: {
className: "w-[658px]",
},
rules: {
required: "* Required",
pattern: {
value: /^\S(.*\S)?$/,
message:
"Must not have leading or trailing whitespace.",
},
},
},
],
},
],
},
{
label:
"A commercial HMO with the largest insured commercial, non-Medicaid enrollment in the state/territory (commercial HMO)",
value: "commercial_hmo",
form: [
{
slots: [
{
rhf: "Input",
label: "Plan name",
labelClassName: "font-bold",
name: "commercial-hmo",
props: {
className: "w-[658px]",
},
rules: {
required: "* Required",
pattern: {
value: /^\S(.*\S)?$/,
message:
"Must not have leading or trailing whitespace.",
},
},
},
],
},
],
},
{
label: "Secretary-approved coverage",
value: "secretary_approved_coverage",
form: [
{
slots: [
{
rhf: "Radio",
name: "secretary-approved",
rules: {
required: "* Required",
pattern: {
value: /^\S(.*\S)?$/,
message:
"Must not have leading or trailing whitespace.",
},
},
props: {
options: [
{
label:
"The state/territory offers the following benefits based on the approved state plan:",
value: "approved_state_plan",
form: [
{
slots: [
{
rhf: "Radio",
name: "approved-state-plan-opts",
rules: {
required:
"* Required",
},
props: {
options: [
{
label:
"Benefits provided in the approved state plan",
value:
"approved_state_plan",
},
{
label:
"All benefits provided in the approved state plan plus additional benefits",
value:
"additional_benefits",
},
{
label:
"Benefits provided in the approved state plan but in a different amount, duration, and/or scope",
value:
"different_amount_duration_scope",
},
{
label:
"A partial list of benefits provided in the approved state plan",
value:
"partial_list_of_benefits",
},
{
label:
"A partial list of benefits provided in the approved state plan plus additional benefits",
value:
"partial_list_of_benefits_plus_additional_benefits",
},
],
},
},
],
},
],
},
{
label:
"The state/territory offers an array of benefits from the Section 1937 coverage option and/or base benchmark plan benefit packages, the approved state plan, or a combination of these benefit packages.",
value: "array_of_benefits",
},
],
},
},
{
rhf: "Textarea",
name: "benefits-and-limits",
props: {
className: "min-h-[114px]",
},
rules: {
required: "* Required",
pattern: {
value:
noLeadingTrailingWhitespace,
message:
"Must not have leading or trailing whitespace.",
},
},
labelClassName: "font-bold",
label:
"Describe the benefits, source of benefits, and any limitations.",
},
],
},
],
},
],
},
},
],
},
],
},
{
label: "Benchmark-equivalent benefit package",
value: "benchmark_equivalent_benefit_package",
form: [
{
slots: [
{
rhf: "Radio",
name: "bench-equivalent",
rules: { required: "* Required" },
props: {
options: [
{
label:
"The standard Blue Cross Blue Shield preferred provider option offered through the Federal Employee Health Benefit Program (FEHBP)",
value: "blue_cross_blue_shield",
},
{
label:
"State employee coverage that is offered and generally available to state employees (state employee coverage)",
value: "state_employee_coverage",
form: [
{
slots: [
{
rhf: "Input",
name: "state-employee-coverage-plan-name",
label: "Plan name",
props: {
className: "w-[658px]",
},
labelClassName: "font-bold",
rules: {
required: "* Required",
pattern: {
value: /^\S(.*\S)?$/,
message:
"Must not have leading or trailing whitespace.",
},
},
},
],
},
],
},
{
label:
"A commercial HMO with the largest insured commercial, non-Medicaid enrollment in the state/territory (commercial HMO)",
value: "commercial_hmo",
form: [
{
slots: [
{
rhf: "Input",
name: "commercial-hmo-plan-name",
label: "Plan name",
props: {
className: "w-[658px]",
},
labelClassName: "font-bold",
rules: {
required: "* Required",
pattern: {
value: /^\S(.*\S)?$/,
message:
"Must not have leading or trailing whitespace.",
},
},
},
],
},
],
},
{
label:
"The Medicaid state plan coverage provided to categorically needy (mandatory and options for coverage) eligibility groups.",
value: "medicaid_categorically_needy",
},
],
},
},
],
},
],
},
],
},
},
],
},
],
},
{
title: "Selection of base benchmark plan",
sectionId: "select-of-base-bench-plan",
form: [
{
description:
"The state/territory must select a base benchmark plan as the basis for providing essential health benefits in its benchmark or benchmark-equivalent package.",
descriptionClassName: "font-normal",
slots: [
{
rhf: "Select",
label:
"Is the base benchmark plan the same as the Section 1937 coverage option?",
labelClassName: "font-bold",
name: "same-as-sect-1937",
rules: { required: "* Required" },
props: {
className: "w-[150px]",
options: [
{ label: "Yes", value: "yes" },
{ label: "No", value: "no" },
],
},
},
{
rhf: "Radio",
label:
"The state/territory will use the following as its base benchmark plan as described at 45 CFR 156.100(a):",
labelClassName: "font-bold",
name: "base-benchmark-plan",
rules: { required: "* Required" },
props: {
options: [
{
label:
"The largest plan by enrollment of the three largest small group insurance products in the state's small group market",
value: "largest_plan_by_enrollment",
},
{
label:
"Any of the largest three state employee health benefit plans by enrollment",
value: "any_of_largest_three_state",
},
{
label:
"Any of the largest three national FEHBP plan options open to federal employees in all geographies by enrollment",
value: "any_of_largest_three_national_fehbp_plan_options",
},
{
label: "The largest insured commercial non-Medicaid HMO",
value: "largest_insured_commercial_hmo",
},
],
},
},
{
rhf: "Input",
label: "Plan name",
labelClassName: "font-bold",
name: "name",
props: {
className: "w-[527px]",
},
rules: {
required: "* Required",
pattern: {
value: /^\S(.*\S)?$/,
message: "Must not have leading or trailing whitespace.",
},
},
},
],
},
],
},
{
title: "Additional information",
sectionId: "addtnl-info",
form: [
{
description:
"Other information about selection of the Section 1937 coverage option and the base benchmark plan (optional)",
slots: [
{
rhf: "Textarea",
name: "description",
props: {
className: "min-h-[114px]",
},
rules: {
pattern: {
value: noLeadingTrailingWhitespace,
message: "Must not have leading or trailing whitespace.",
},
},
},
],
},
],
},
],
};