lib/libs/webforms/ABP3_1/v202401.ts
import { FormSchema } from "shared-types";
import { noLeadingTrailingWhitespace } from "shared-utils/regex";
export const v202401: FormSchema = {
header:
"ABP 3.1 Selection of benchmark or benchmark-equivalent benefit package",
formId: "abp3-1",
sections: [
{
title: "Benefit package details",
sectionId: "benefit-package-details",
form: [
{
description:
"For the population defined in Section 1, the state/territory wants to:",
slots: [
{
rhf: "Radio",
name: "amending-benefit",
rules: {
required: "* Required",
},
props: {
options: [
{
label: "Amend one existing benefit package",
value: "existing_package",
},
{
label: "Create a single new benefit package",
value: "new_package",
},
],
},
},
],
},
{
description: "Benefit package name",
slots: [
{
rhf: "Input",
name: "name",
props: {
className: "w-[355px]",
},
rules: {
required: "* Required",
pattern: {
value: /^\S(.*\S)?$/,
message: "Must not have leading or trailing whitespace.",
},
},
},
],
},
],
},
{
title: "Selection of Section 1937 coverage option",
sectionId: "select-of-sect-1937-coverage-op",
form: [
{
description:
"The state/territory selects as its Section 1937 coverage option the following type of benchmark or benchmark-equivalent benefit package under this Alternative Benefit Plan (ABP):",
slots: [
{
name: "benchmark",
rhf: "Radio",
rules: {
required: "* Required",
},
props: {
options: [
{
label: "Benchmark benefit package",
value: "benefit_package",
form: [
{
slots: [
{
name: "state-territory-bench",
rhf: "Radio",
rules: {
required: "* Required",
},
props: {
options: [
{
label:
"The standard Blue Cross Blue Shield preferred provider option offered through the Federal Employee Health Benefit Program (FEHBP)",
value: "blue_cross_blue_shield",
},
{
label:
"State employee coverage that is offered and generally available to state employees",
value: "state_employee_coverage",
slots: [
{
rhf: "Input",
name: "state-territory-bench-plan-name",
label: "Plan name",
labelClassName: "font-bold",
props: {
className: "w-[658px]",
},
rules: {
required: "* Required",
pattern: {
value: /^\S(.*\S)?$/,
message:
"Must not have leading or trailing whitespace.",
},
},
},
],
},
{
label:
"A commercial HMO with the largest insured commercial, non-Medicaid enrollment in the state/territory",
value: "commerical_HMO",
slots: [
{
rhf: "Input",
name: "bench-hmo-plan-name",
label: "Plan name",
labelClassName: "font-bold",
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",
form: [
{
slots: [
{
name: "benefits-based-on",
rhf: "Radio",
rules: {
required: "* Required",
},
props: {
options: [
{
label:
"The state/territory offers the following benefits based on the approved state plan:",
value: "state_plan",
form: [
{
slots: [
{
rhf: "Radio",
name: "state-plan-benefits",
props: {
options: [
{
label:
"Benefits provided in the approved state plan",
value:
"provided_in_approved_state_plan",
},
{
label:
"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",
},
{
label:
"A partial list of benefits provided in the approved state plan plus additional benefits",
value:
"partial_list_plus_additional_benefits",
},
],
},
rules: {
required:
"* Required",
},
},
],
},
],
},
{
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-description",
label:
"Describe the benefits, source of benefits, and any limitations.",
labelClassName: "font-bold",
props: {
className: "h-[114px]",
},
rules: {
required: "* Required",
pattern: {
value:
noLeadingTrailingWhitespace,
message:
"Must not have leading or trailing whitespace.",
},
},
},
],
},
],
},
],
},
},
],
},
],
},
{
label: "Benchmark-equivalent benefit package",
value: "equivalent",
form: [
{
slots: [
{
rhf: "Radio",
name: "geographic-variation",
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",
value: "state_employee_coverage",
slots: [
{
rhf: "Input",
name: "bench-equivalent-state-coverage-plan-name",
label: "Plan name",
labelClassName: "font-bold",
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",
value: "commerical_HMO",
slots: [
{
rhf: "Input",
name: "bench-equivalent-hmo-plan-name",
label: "Plan name",
labelClassName: "font-bold",
props: {
className: "w-[658px]",
},
rules: {
required: "* Required",
pattern: {
value: /^\S(.*\S)?$/,
message:
"Must not have leading or trailing whitespace.",
},
},
},
],
},
{
label:
"The Medicaid state plan coverage provided to categorically needy (mandatory and options for coverage) eligibility groups",
value: "state_plan_to_categorically_needy",
},
],
},
},
],
},
],
},
],
},
},
],
},
],
},
{
title: "Selection of EHB-benchmark plan",
sectionId: "select-of-ehb-bench-plan",
form: [
{
description:
"The state or territory must select an EHB-benchmark plan as the basis for providing essential health benefits in its benchmark or benchmark-equivalent package.",
descriptionClassName: "text-base",
slots: [
{
name: "plan-name",
rhf: "Input",
label: "EHB-benchmark plan name",
labelClassName: "font-bold",
props: {
className: "w-[355px]",
},
rules: {
required: "* Required",
pattern: {
value: /^\S(.*\S)?$/,
message: "Must not have leading or trailing whitespace.",
},
},
},
{
name: "is-ehb-bench-plan-same-section-1937",
rhf: "Select",
label:
"Is the EHB-benchmark plan the same as the Section 1937 coverage option?",
labelClassName: "font-bold",
rules: {
required: "* Required",
},
props: {
className: "w-[150px]",
options: [
{ label: "Yes", value: "yes" },
{ label: "No", value: "no" },
],
},
},
{
label:
"The state/territory will use the following as its EHB-benchmark option as described at 45 CFR 156.111(b)(2)(B), in compliance with the individual insurance market under 45 CFR 156.100 through 156.125:",
labelClassName: "font-bold",
name: "ehb-bench-option",
rhf: "Radio",
descriptionAbove: true,
descriptionClassName: "text-base text-black",
rules: {
required: "* Required",
},
dependency: {
conditions: [
{
name: "abp3-1_select-of-ehb-bench-plan_is-ehb-bench-plan-same-section-1937",
type: "expectedValue",
expectedValue: "no",
},
],
effect: { type: "show" },
},
props: {
options: [
{
label:
"The EHB-benchmark plan used by the state/territory for the 2017 plan year",
value: "EHB_benchmark_2017_plan_year",
},
{
label:
"One of the EHB-benchmark plans used for the 2017 plan year by another state/territory",
value: "another_state_EHB_benchmark_plan_year",
slots: [
{
rhf: "Select",
name: "is-geo-area",
label: "State/territory",
labelClassName: "font-bold",
formItemClassName: "flex-row",
props: {
className: "w-[256px]",
options: [
{ label: "Alabama", value: "AL" },
{ label: "Alaska", value: "AK" },
{
label: "American Samoa",
value: "AS",
},
{ label: "Arizona", value: "AZ" },
{ label: "Arkansas", value: "AR" },
{ label: "California", value: "CA" },
{ label: "Colorado", value: "CO" },
{ label: "Connecticut", value: "CT" },
{ label: "Delaware", value: "DE" },
{
label: "District of Columbia",
value: "DC",
},
{ label: "Florida", value: "FL" },
{ label: "Georgia", value: "GA" },
{ label: "Guam", value: "GU" },
{ label: "Hawaii", value: "HI" },
{ label: "Idaho", value: "ID" },
{ label: "Illinois", value: "IL" },
{ label: "Indiana", value: "IN" },
{ label: "Iowa", value: "IA" },
{ label: "Kansas", value: "KS" },
{ label: "Kentucky", value: "KY" },
{ label: "Louisiana", value: "LA" },
{ label: "Maine", value: "ME" },
{ label: "Maryland", value: "MD" },
{
label: "Massachusetts",
value: "MA",
},
{ label: "Michigan", value: "MI" },
{ label: "Minnesota", value: "MN" },
{ label: "Mississippi", value: "MS" },
{ label: "Missouri", value: "MO" },
{ label: "Montana", value: "MT" },
{ label: "Nebraska", value: "NE" },
{ label: "Nevada", value: "NV" },
{
label: "New Hampshire",
value: "NH",
},
{ label: "New Jersey", value: "NJ" },
{ label: "New Mexico", value: "NM" },
{ label: "New York", value: "NY" },
{
label: "North Carolina",
value: "NC",
},
{
label: "North Dakota",
value: "ND",
},
{
label: "Northern Mariana Islands",
value: "MP",
},
{ label: "Ohio", value: "OH" },
{ label: "Oklahoma", value: "OK" },
{ label: "Oregon", value: "OR" },
{
label: "Pennsylvania",
value: "PA",
},
{ label: "Puerto Rico", value: "PR" },
{
label: "Rhode Island",
value: "RI",
},
{
label: "South Carolina",
value: "SC",
},
{
label: "South Dakota",
value: "SD",
},
{ label: "Tennessee", value: "TN" },
{ label: "Texas", value: "TX" },
{ label: "Utah", value: "UT" },
{ label: "Vermont", value: "VT" },
{
label: "Virgin Islands",
value: "VI",
},
{ label: "Virginia", value: "VA" },
{ label: "Washington", value: "WA" },
{
label: "West Virginia",
value: "WV",
},
{ label: "Wisconsin", value: "WI" },
{ label: "Wyoming", value: "WY" },
],
},
rules: {
required: "* Required",
},
},
{
rhf: "Radio",
name: "indicate-ehb-bench-plan",
label: "Type of EHB-benchmark plan",
labelClassName: "font-bold",
props: {
options: [
{
label:
"The largest plan by enrollment of the three largest small group insurance products in the state's small group market",
value: "three_largest_small_group_insurance",
},
{
label:
"Any of the largest three state employee health benefit plans by enrollment",
value: "largest_three_state_employee_plans",
},
{
label:
"Any of the largest three national Federal Employee Health Benefit Program (FEHBP) plan options open to federal employees in all geographies by enrollment",
value: "largest_three_state_FEHBP_plans",
},
{
label:
"The largest insured commercial, non-Medicaid HMO",
value: "larged_insured_commercial",
},
],
},
rules: {
required: "* Required",
},
},
],
},
{
label:
"The following EHB-benchmark plan used for the 2017 plan year but replacing coverage of one or more EHB categories with coverage of the same category from the 2017 EHB-benchmark plan of one or more other states",
value: "EHB_benchmark_2017_plan_year_but_replace_coverage",
form: [
{
description: "Type of EHB-benchmark plan",
slots: [
{
rhf: "Radio",
name: "EHB-bench-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: "three_largest_small_group_insurance",
},
{
label:
"Any of the largest three state employee health benefit plans by enrollment",
value: "largest_three_state_employee_plans",
},
{
label:
"Any of the largest three national Federal Employee Health Benefit Program (FEHBP) plan options open to federal employees in all geographies by enrollment",
value: "largest_three_state_FEHBP_plans",
},
{
label:
"The largest insured commercial, non-Medicaid HMO",
value: "larged_insured_commercial",
},
],
},
},
{
rhf: "Checkbox",
name: "one-or-more-EHBs-other-states",
label:
"Select one or more essential health benefits (EHBs) from other states.",
labelClassName: "font-bold border-t-[1px] pt-5",
rules: { required: "* Required" },
props: {
options: [
{
label: "Ambulatory patient services",
value: "ambulatory_patient_services",
slots: [
{
rhf: "Select",
name: "ambulatory-patient-services-state-territory",
label: "From state/territory",
labelClassName: "font-bold",
formItemClassName: "flex-row",
props: {
className: "w-[256px]",
options: [
{ label: "Alabama", value: "AL" },
{ label: "Alaska", value: "AK" },
{
label: "American Samoa",
value: "AS",
},
{ label: "Arizona", value: "AZ" },
{ label: "Arkansas", value: "AR" },
{ label: "California", value: "CA" },
{ label: "Colorado", value: "CO" },
{ label: "Connecticut", value: "CT" },
{ label: "Delaware", value: "DE" },
{
label: "District of Columbia",
value: "DC",
},
{ label: "Florida", value: "FL" },
{ label: "Georgia", value: "GA" },
{ label: "Guam", value: "GU" },
{ label: "Hawaii", value: "HI" },
{ label: "Idaho", value: "ID" },
{ label: "Illinois", value: "IL" },
{ label: "Indiana", value: "IN" },
{ label: "Iowa", value: "IA" },
{ label: "Kansas", value: "KS" },
{ label: "Kentucky", value: "KY" },
{ label: "Louisiana", value: "LA" },
{ label: "Maine", value: "ME" },
{ label: "Maryland", value: "MD" },
{
label: "Massachusetts",
value: "MA",
},
{ label: "Michigan", value: "MI" },
{ label: "Minnesota", value: "MN" },
{ label: "Mississippi", value: "MS" },
{ label: "Missouri", value: "MO" },
{ label: "Montana", value: "MT" },
{ label: "Nebraska", value: "NE" },
{ label: "Nevada", value: "NV" },
{
label: "New Hampshire",
value: "NH",
},
{ label: "New Jersey", value: "NJ" },
{ label: "New Mexico", value: "NM" },
{ label: "New York", value: "NY" },
{
label: "North Carolina",
value: "NC",
},
{
label: "North Dakota",
value: "ND",
},
{
label: "Northern Mariana Islands",
value: "MP",
},
{ label: "Ohio", value: "OH" },
{ label: "Oklahoma", value: "OK" },
{ label: "Oregon", value: "OR" },
{
label: "Pennsylvania",
value: "PA",
},
{ label: "Puerto Rico", value: "PR" },
{
label: "Rhode Island",
value: "RI",
},
{
label: "South Carolina",
value: "SC",
},
{
label: "South Dakota",
value: "SD",
},
{ label: "Tennessee", value: "TN" },
{ label: "Texas", value: "TX" },
{ label: "Utah", value: "UT" },
{ label: "Vermont", value: "VT" },
{
label: "Virgin Islands",
value: "VI",
},
{ label: "Virginia", value: "VA" },
{ label: "Washington", value: "WA" },
{
label: "West Virginia",
value: "WV",
},
{ label: "Wisconsin", value: "WI" },
{ label: "Wyoming", value: "WY" },
],
},
},
],
},
{
label: "Emergency services",
value: "emergency_services",
slots: [
{
rhf: "Select",
name: "emergency-services-state-territory",
label: "From state/territory",
labelClassName: "font-bold",
formItemClassName: "flex-row",
rules: {
required: "* Required",
},
props: {
className: "w-[256px]",
options: [
{ label: "Alabama", value: "AL" },
{ label: "Alaska", value: "AK" },
{
label: "American Samoa",
value: "AS",
},
{ label: "Arizona", value: "AZ" },
{ label: "Arkansas", value: "AR" },
{ label: "California", value: "CA" },
{ label: "Colorado", value: "CO" },
{ label: "Connecticut", value: "CT" },
{ label: "Delaware", value: "DE" },
{
label: "District of Columbia",
value: "DC",
},
{ label: "Florida", value: "FL" },
{ label: "Georgia", value: "GA" },
{ label: "Guam", value: "GU" },
{ label: "Hawaii", value: "HI" },
{ label: "Idaho", value: "ID" },
{ label: "Illinois", value: "IL" },
{ label: "Indiana", value: "IN" },
{ label: "Iowa", value: "IA" },
{ label: "Kansas", value: "KS" },
{ label: "Kentucky", value: "KY" },
{ label: "Louisiana", value: "LA" },
{ label: "Maine", value: "ME" },
{ label: "Maryland", value: "MD" },
{
label: "Massachusetts",
value: "MA",
},
{ label: "Michigan", value: "MI" },
{ label: "Minnesota", value: "MN" },
{ label: "Mississippi", value: "MS" },
{ label: "Missouri", value: "MO" },
{ label: "Montana", value: "MT" },
{ label: "Nebraska", value: "NE" },
{ label: "Nevada", value: "NV" },
{
label: "New Hampshire",
value: "NH",
},
{ label: "New Jersey", value: "NJ" },
{ label: "New Mexico", value: "NM" },
{ label: "New York", value: "NY" },
{
label: "North Carolina",
value: "NC",
},
{
label: "North Dakota",
value: "ND",
},
{
label: "Northern Mariana Islands",
value: "MP",
},
{ label: "Ohio", value: "OH" },
{ label: "Oklahoma", value: "OK" },
{ label: "Oregon", value: "OR" },
{
label: "Pennsylvania",
value: "PA",
},
{ label: "Puerto Rico", value: "PR" },
{
label: "Rhode Island",
value: "RI",
},
{
label: "South Carolina",
value: "SC",
},
{
label: "South Dakota",
value: "SD",
},
{ label: "Tennessee", value: "TN" },
{ label: "Texas", value: "TX" },
{ label: "Utah", value: "UT" },
{ label: "Vermont", value: "VT" },
{
label: "Virgin Islands",
value: "VI",
},
{ label: "Virginia", value: "VA" },
{ label: "Washington", value: "WA" },
{
label: "West Virginia",
value: "WV",
},
{ label: "Wisconsin", value: "WI" },
{ label: "Wyoming", value: "WY" },
],
},
},
],
},
{
label: "Hospitalization",
value: "hospitalization",
slots: [
{
rhf: "Select",
name: "hospital-state-territory",
label: "From state/territory",
labelClassName: "font-bold",
formItemClassName: "flex-row",
rules: {
required: "* Required",
},
props: {
className: "w-[256px]",
options: [
{ label: "Alabama", value: "AL" },
{ label: "Alaska", value: "AK" },
{
label: "American Samoa",
value: "AS",
},
{ label: "Arizona", value: "AZ" },
{ label: "Arkansas", value: "AR" },
{ label: "California", value: "CA" },
{ label: "Colorado", value: "CO" },
{ label: "Connecticut", value: "CT" },
{ label: "Delaware", value: "DE" },
{
label: "District of Columbia",
value: "DC",
},
{ label: "Florida", value: "FL" },
{ label: "Georgia", value: "GA" },
{ label: "Guam", value: "GU" },
{ label: "Hawaii", value: "HI" },
{ label: "Idaho", value: "ID" },
{ label: "Illinois", value: "IL" },
{ label: "Indiana", value: "IN" },
{ label: "Iowa", value: "IA" },
{ label: "Kansas", value: "KS" },
{ label: "Kentucky", value: "KY" },
{ label: "Louisiana", value: "LA" },
{ label: "Maine", value: "ME" },
{ label: "Maryland", value: "MD" },
{
label: "Massachusetts",
value: "MA",
},
{ label: "Michigan", value: "MI" },
{ label: "Minnesota", value: "MN" },
{ label: "Mississippi", value: "MS" },
{ label: "Missouri", value: "MO" },
{ label: "Montana", value: "MT" },
{ label: "Nebraska", value: "NE" },
{ label: "Nevada", value: "NV" },
{
label: "New Hampshire",
value: "NH",
},
{ label: "New Jersey", value: "NJ" },
{ label: "New Mexico", value: "NM" },
{ label: "New York", value: "NY" },
{
label: "North Carolina",
value: "NC",
},
{
label: "North Dakota",
value: "ND",
},
{
label: "Northern Mariana Islands",
value: "MP",
},
{ label: "Ohio", value: "OH" },
{ label: "Oklahoma", value: "OK" },
{ label: "Oregon", value: "OR" },
{
label: "Pennsylvania",
value: "PA",
},
{ label: "Puerto Rico", value: "PR" },
{
label: "Rhode Island",
value: "RI",
},
{
label: "South Carolina",
value: "SC",
},
{
label: "South Dakota",
value: "SD",
},
{ label: "Tennessee", value: "TN" },
{ label: "Texas", value: "TX" },
{ label: "Utah", value: "UT" },
{ label: "Vermont", value: "VT" },
{
label: "Virgin Islands",
value: "VI",
},
{ label: "Virginia", value: "VA" },
{ label: "Washington", value: "WA" },
{
label: "West Virginia",
value: "WV",
},
{ label: "Wisconsin", value: "WI" },
{ label: "Wyoming", value: "WY" },
],
},
},
],
},
{
label: "Maternity and newborn care",
value: "maternity_and_newborn_care",
slots: [
{
rhf: "Select",
name: "maternity-and-newborn-care-state-territory",
label: "From state/territory",
labelClassName: "font-bold",
formItemClassName: "flex-row",
rules: {
required: "* Required",
},
props: {
className: "w-[256px]",
options: [
{ label: "Alabama", value: "AL" },
{ label: "Alaska", value: "AK" },
{
label: "American Samoa",
value: "AS",
},
{ label: "Arizona", value: "AZ" },
{ label: "Arkansas", value: "AR" },
{ label: "California", value: "CA" },
{ label: "Colorado", value: "CO" },
{ label: "Connecticut", value: "CT" },
{ label: "Delaware", value: "DE" },
{
label: "District of Columbia",
value: "DC",
},
{ label: "Florida", value: "FL" },
{ label: "Georgia", value: "GA" },
{ label: "Guam", value: "GU" },
{ label: "Hawaii", value: "HI" },
{ label: "Idaho", value: "ID" },
{ label: "Illinois", value: "IL" },
{ label: "Indiana", value: "IN" },
{ label: "Iowa", value: "IA" },
{ label: "Kansas", value: "KS" },
{ label: "Kentucky", value: "KY" },
{ label: "Louisiana", value: "LA" },
{ label: "Maine", value: "ME" },
{ label: "Maryland", value: "MD" },
{
label: "Massachusetts",
value: "MA",
},
{ label: "Michigan", value: "MI" },
{ label: "Minnesota", value: "MN" },
{ label: "Mississippi", value: "MS" },
{ label: "Missouri", value: "MO" },
{ label: "Montana", value: "MT" },
{ label: "Nebraska", value: "NE" },
{ label: "Nevada", value: "NV" },
{
label: "New Hampshire",
value: "NH",
},
{ label: "New Jersey", value: "NJ" },
{ label: "New Mexico", value: "NM" },
{ label: "New York", value: "NY" },
{
label: "North Carolina",
value: "NC",
},
{
label: "North Dakota",
value: "ND",
},
{
label: "Northern Mariana Islands",
value: "MP",
},
{ label: "Ohio", value: "OH" },
{ label: "Oklahoma", value: "OK" },
{ label: "Oregon", value: "OR" },
{
label: "Pennsylvania",
value: "PA",
},
{ label: "Puerto Rico", value: "PR" },
{
label: "Rhode Island",
value: "RI",
},
{
label: "South Carolina",
value: "SC",
},
{
label: "South Dakota",
value: "SD",
},
{ label: "Tennessee", value: "TN" },
{ label: "Texas", value: "TX" },
{ label: "Utah", value: "UT" },
{ label: "Vermont", value: "VT" },
{
label: "Virgin Islands",
value: "VI",
},
{ label: "Virginia", value: "VA" },
{ label: "Washington", value: "WA" },
{
label: "West Virginia",
value: "WV",
},
{ label: "Wisconsin", value: "WI" },
{ label: "Wyoming", value: "WY" },
],
},
},
],
},
{
label:
"Mental health and substance use disorders",
value:
"mental_health_and_substance_use_disorders",
slots: [
{
rhf: "Select",
name: "mental-health-and-substance-use-disorders-state-territory",
label: "From state/territory",
labelClassName: "font-bold",
formItemClassName: "flex-row",
rules: {
required: "* Required",
},
props: {
className: "w-[256px]",
options: [
{ label: "Alabama", value: "AL" },
{ label: "Alaska", value: "AK" },
{
label: "American Samoa",
value: "AS",
},
{ label: "Arizona", value: "AZ" },
{ label: "Arkansas", value: "AR" },
{ label: "California", value: "CA" },
{ label: "Colorado", value: "CO" },
{ label: "Connecticut", value: "CT" },
{ label: "Delaware", value: "DE" },
{
label: "District of Columbia",
value: "DC",
},
{ label: "Florida", value: "FL" },
{ label: "Georgia", value: "GA" },
{ label: "Guam", value: "GU" },
{ label: "Hawaii", value: "HI" },
{ label: "Idaho", value: "ID" },
{ label: "Illinois", value: "IL" },
{ label: "Indiana", value: "IN" },
{ label: "Iowa", value: "IA" },
{ label: "Kansas", value: "KS" },
{ label: "Kentucky", value: "KY" },
{ label: "Louisiana", value: "LA" },
{ label: "Maine", value: "ME" },
{ label: "Maryland", value: "MD" },
{
label: "Massachusetts",
value: "MA",
},
{ label: "Michigan", value: "MI" },
{ label: "Minnesota", value: "MN" },
{ label: "Mississippi", value: "MS" },
{ label: "Missouri", value: "MO" },
{ label: "Montana", value: "MT" },
{ label: "Nebraska", value: "NE" },
{ label: "Nevada", value: "NV" },
{
label: "New Hampshire",
value: "NH",
},
{ label: "New Jersey", value: "NJ" },
{ label: "New Mexico", value: "NM" },
{ label: "New York", value: "NY" },
{
label: "North Carolina",
value: "NC",
},
{
label: "North Dakota",
value: "ND",
},
{
label: "Northern Mariana Islands",
value: "MP",
},
{ label: "Ohio", value: "OH" },
{ label: "Oklahoma", value: "OK" },
{ label: "Oregon", value: "OR" },
{
label: "Pennsylvania",
value: "PA",
},
{ label: "Puerto Rico", value: "PR" },
{
label: "Rhode Island",
value: "RI",
},
{
label: "South Carolina",
value: "SC",
},
{
label: "South Dakota",
value: "SD",
},
{ label: "Tennessee", value: "TN" },
{ label: "Texas", value: "TX" },
{ label: "Utah", value: "UT" },
{ label: "Vermont", value: "VT" },
{
label: "Virgin Islands",
value: "VI",
},
{ label: "Virginia", value: "VA" },
{ label: "Washington", value: "WA" },
{
label: "West Virginia",
value: "WV",
},
{ label: "Wisconsin", value: "WI" },
{ label: "Wyoming", value: "WY" },
],
},
},
],
},
{
label: "Prescription drugs",
value: "prescription_drugs",
slots: [
{
rhf: "Select",
name: "prescription-drugs-state-territory",
label: "From state/territory",
labelClassName: "font-bold",
formItemClassName: "flex-row",
rules: {
required: "* Required",
},
props: {
className: "w-[256px]",
options: [
{ label: "Alabama", value: "AL" },
{ label: "Alaska", value: "AK" },
{
label: "American Samoa",
value: "AS",
},
{ label: "Arizona", value: "AZ" },
{ label: "Arkansas", value: "AR" },
{ label: "California", value: "CA" },
{ label: "Colorado", value: "CO" },
{ label: "Connecticut", value: "CT" },
{ label: "Delaware", value: "DE" },
{
label: "District of Columbia",
value: "DC",
},
{ label: "Florida", value: "FL" },
{ label: "Georgia", value: "GA" },
{ label: "Guam", value: "GU" },
{ label: "Hawaii", value: "HI" },
{ label: "Idaho", value: "ID" },
{ label: "Illinois", value: "IL" },
{ label: "Indiana", value: "IN" },
{ label: "Iowa", value: "IA" },
{ label: "Kansas", value: "KS" },
{ label: "Kentucky", value: "KY" },
{ label: "Louisiana", value: "LA" },
{ label: "Maine", value: "ME" },
{ label: "Maryland", value: "MD" },
{
label: "Massachusetts",
value: "MA",
},
{ label: "Michigan", value: "MI" },
{ label: "Minnesota", value: "MN" },
{ label: "Mississippi", value: "MS" },
{ label: "Missouri", value: "MO" },
{ label: "Montana", value: "MT" },
{ label: "Nebraska", value: "NE" },
{ label: "Nevada", value: "NV" },
{
label: "New Hampshire",
value: "NH",
},
{ label: "New Jersey", value: "NJ" },
{ label: "New Mexico", value: "NM" },
{ label: "New York", value: "NY" },
{
label: "North Carolina",
value: "NC",
},
{
label: "North Dakota",
value: "ND",
},
{
label: "Northern Mariana Islands",
value: "MP",
},
{ label: "Ohio", value: "OH" },
{ label: "Oklahoma", value: "OK" },
{ label: "Oregon", value: "OR" },
{
label: "Pennsylvania",
value: "PA",
},
{ label: "Puerto Rico", value: "PR" },
{
label: "Rhode Island",
value: "RI",
},
{
label: "South Carolina",
value: "SC",
},
{
label: "South Dakota",
value: "SD",
},
{ label: "Tennessee", value: "TN" },
{ label: "Texas", value: "TX" },
{ label: "Utah", value: "UT" },
{ label: "Vermont", value: "VT" },
{
label: "Virgin Islands",
value: "VI",
},
{ label: "Virginia", value: "VA" },
{ label: "Washington", value: "WA" },
{
label: "West Virginia",
value: "WV",
},
{ label: "Wisconsin", value: "WI" },
{ label: "Wyoming", value: "WY" },
],
},
},
],
},
{
label:
"Rehabilitative and habilitative services and devices",
value:
"rehabilitative_and_habilitative_services_and_devices",
slots: [
{
rhf: "Select",
name: "rehab-and-habilitative-services-and-devices-state-territory",
label: "From state/territory",
labelClassName: "font-bold",
formItemClassName: "flex-row",
rules: {
required: "* Required",
},
props: {
className: "w-[256px]",
options: [
{ label: "Alabama", value: "AL" },
{ label: "Alaska", value: "AK" },
{
label: "American Samoa",
value: "AS",
},
{ label: "Arizona", value: "AZ" },
{ label: "Arkansas", value: "AR" },
{ label: "California", value: "CA" },
{ label: "Colorado", value: "CO" },
{ label: "Connecticut", value: "CT" },
{ label: "Delaware", value: "DE" },
{
label: "District of Columbia",
value: "DC",
},
{ label: "Florida", value: "FL" },
{ label: "Georgia", value: "GA" },
{ label: "Guam", value: "GU" },
{ label: "Hawaii", value: "HI" },
{ label: "Idaho", value: "ID" },
{ label: "Illinois", value: "IL" },
{ label: "Indiana", value: "IN" },
{ label: "Iowa", value: "IA" },
{ label: "Kansas", value: "KS" },
{ label: "Kentucky", value: "KY" },
{ label: "Louisiana", value: "LA" },
{ label: "Maine", value: "ME" },
{ label: "Maryland", value: "MD" },
{
label: "Massachusetts",
value: "MA",
},
{ label: "Michigan", value: "MI" },
{ label: "Minnesota", value: "MN" },
{ label: "Mississippi", value: "MS" },
{ label: "Missouri", value: "MO" },
{ label: "Montana", value: "MT" },
{ label: "Nebraska", value: "NE" },
{ label: "Nevada", value: "NV" },
{
label: "New Hampshire",
value: "NH",
},
{ label: "New Jersey", value: "NJ" },
{ label: "New Mexico", value: "NM" },
{ label: "New York", value: "NY" },
{
label: "North Carolina",
value: "NC",
},
{
label: "North Dakota",
value: "ND",
},
{
label: "Northern Mariana Islands",
value: "MP",
},
{ label: "Ohio", value: "OH" },
{ label: "Oklahoma", value: "OK" },
{ label: "Oregon", value: "OR" },
{
label: "Pennsylvania",
value: "PA",
},
{ label: "Puerto Rico", value: "PR" },
{
label: "Rhode Island",
value: "RI",
},
{
label: "South Carolina",
value: "SC",
},
{
label: "South Dakota",
value: "SD",
},
{ label: "Tennessee", value: "TN" },
{ label: "Texas", value: "TX" },
{ label: "Utah", value: "UT" },
{ label: "Vermont", value: "VT" },
{
label: "Virgin Islands",
value: "VI",
},
{ label: "Virginia", value: "VA" },
{ label: "Washington", value: "WA" },
{
label: "West Virginia",
value: "WV",
},
{ label: "Wisconsin", value: "WI" },
{ label: "Wyoming", value: "WY" },
],
},
},
],
},
{
label: "Laboratory services",
value: "laboratory_services",
slots: [
{
rhf: "Select",
name: "laboratory-services-state-territory",
label: "From state/territory",
labelClassName: "font-bold",
formItemClassName: "flex-row",
rules: {
required: "* Required",
},
props: {
className: "w-[256px]",
options: [
{ label: "Alabama", value: "AL" },
{ label: "Alaska", value: "AK" },
{
label: "American Samoa",
value: "AS",
},
{ label: "Arizona", value: "AZ" },
{ label: "Arkansas", value: "AR" },
{ label: "California", value: "CA" },
{ label: "Colorado", value: "CO" },
{ label: "Connecticut", value: "CT" },
{ label: "Delaware", value: "DE" },
{
label: "District of Columbia",
value: "DC",
},
{ label: "Florida", value: "FL" },
{ label: "Georgia", value: "GA" },
{ label: "Guam", value: "GU" },
{ label: "Hawaii", value: "HI" },
{ label: "Idaho", value: "ID" },
{ label: "Illinois", value: "IL" },
{ label: "Indiana", value: "IN" },
{ label: "Iowa", value: "IA" },
{ label: "Kansas", value: "KS" },
{ label: "Kentucky", value: "KY" },
{ label: "Louisiana", value: "LA" },
{ label: "Maine", value: "ME" },
{ label: "Maryland", value: "MD" },
{
label: "Massachusetts",
value: "MA",
},
{ label: "Michigan", value: "MI" },
{ label: "Minnesota", value: "MN" },
{ label: "Mississippi", value: "MS" },
{ label: "Missouri", value: "MO" },
{ label: "Montana", value: "MT" },
{ label: "Nebraska", value: "NE" },
{ label: "Nevada", value: "NV" },
{
label: "New Hampshire",
value: "NH",
},
{ label: "New Jersey", value: "NJ" },
{ label: "New Mexico", value: "NM" },
{ label: "New York", value: "NY" },
{
label: "North Carolina",
value: "NC",
},
{
label: "North Dakota",
value: "ND",
},
{
label: "Northern Mariana Islands",
value: "MP",
},
{ label: "Ohio", value: "OH" },
{ label: "Oklahoma", value: "OK" },
{ label: "Oregon", value: "OR" },
{
label: "Pennsylvania",
value: "PA",
},
{ label: "Puerto Rico", value: "PR" },
{
label: "Rhode Island",
value: "RI",
},
{
label: "South Carolina",
value: "SC",
},
{
label: "South Dakota",
value: "SD",
},
{ label: "Tennessee", value: "TN" },
{ label: "Texas", value: "TX" },
{ label: "Utah", value: "UT" },
{ label: "Vermont", value: "VT" },
{
label: "Virgin Islands",
value: "VI",
},
{ label: "Virginia", value: "VA" },
{ label: "Washington", value: "WA" },
{
label: "West Virginia",
value: "WV",
},
{ label: "Wisconsin", value: "WI" },
{ label: "Wyoming", value: "WY" },
],
},
},
],
},
{
label:
"Preventive and wellness services and chronic disease management",
value:
"preventive_and_wellness_services_and_chronic_disease_management",
slots: [
{
rhf: "Select",
name: "prevent-and-well-services-and-chronic-disease-management-state-territory",
label: "From state/territory",
labelClassName: "font-bold",
formItemClassName: "flex-row",
rules: {
required: "* Required",
},
props: {
className: "w-[256px]",
options: [
{ label: "Alabama", value: "AL" },
{ label: "Alaska", value: "AK" },
{
label: "American Samoa",
value: "AS",
},
{ label: "Arizona", value: "AZ" },
{ label: "Arkansas", value: "AR" },
{ label: "California", value: "CA" },
{ label: "Colorado", value: "CO" },
{ label: "Connecticut", value: "CT" },
{ label: "Delaware", value: "DE" },
{
label: "District of Columbia",
value: "DC",
},
{ label: "Florida", value: "FL" },
{ label: "Georgia", value: "GA" },
{ label: "Guam", value: "GU" },
{ label: "Hawaii", value: "HI" },
{ label: "Idaho", value: "ID" },
{ label: "Illinois", value: "IL" },
{ label: "Indiana", value: "IN" },
{ label: "Iowa", value: "IA" },
{ label: "Kansas", value: "KS" },
{ label: "Kentucky", value: "KY" },
{ label: "Louisiana", value: "LA" },
{ label: "Maine", value: "ME" },
{ label: "Maryland", value: "MD" },
{
label: "Massachusetts",
value: "MA",
},
{ label: "Michigan", value: "MI" },
{ label: "Minnesota", value: "MN" },
{ label: "Mississippi", value: "MS" },
{ label: "Missouri", value: "MO" },
{ label: "Montana", value: "MT" },
{ label: "Nebraska", value: "NE" },
{ label: "Nevada", value: "NV" },
{
label: "New Hampshire",
value: "NH",
},
{ label: "New Jersey", value: "NJ" },
{ label: "New Mexico", value: "NM" },
{ label: "New York", value: "NY" },
{
label: "North Carolina",
value: "NC",
},
{
label: "North Dakota",
value: "ND",
},
{
label: "Northern Mariana Islands",
value: "MP",
},
{ label: "Ohio", value: "OH" },
{ label: "Oklahoma", value: "OK" },
{ label: "Oregon", value: "OR" },
{
label: "Pennsylvania",
value: "PA",
},
{ label: "Puerto Rico", value: "PR" },
{
label: "Rhode Island",
value: "RI",
},
{
label: "South Carolina",
value: "SC",
},
{
label: "South Dakota",
value: "SD",
},
{ label: "Tennessee", value: "TN" },
{ label: "Texas", value: "TX" },
{ label: "Utah", value: "UT" },
{ label: "Vermont", value: "VT" },
{
label: "Virgin Islands",
value: "VI",
},
{ label: "Virginia", value: "VA" },
{ label: "Washington", value: "WA" },
{
label: "West Virginia",
value: "WV",
},
{ label: "Wisconsin", value: "WI" },
{ label: "Wyoming", value: "WY" },
],
},
},
],
},
{
label:
"Pediatric services, including oral and vision care",
value:
"pediatric_services_including_oral_and_vision_care",
slots: [
{
rhf: "Select",
name: "pediatric-services-including-oral-and-vision-care-state-territory",
label: "From state/territory",
labelClassName: "font-bold",
formItemClassName: "flex-row",
rules: {
required: "* Required",
},
props: {
className: "w-[256px]",
options: [
{ label: "Alabama", value: "AL" },
{ label: "Alaska", value: "AK" },
{
label: "American Samoa",
value: "AS",
},
{ label: "Arizona", value: "AZ" },
{ label: "Arkansas", value: "AR" },
{ label: "California", value: "CA" },
{ label: "Colorado", value: "CO" },
{ label: "Connecticut", value: "CT" },
{ label: "Delaware", value: "DE" },
{
label: "District of Columbia",
value: "DC",
},
{ label: "Florida", value: "FL" },
{ label: "Georgia", value: "GA" },
{ label: "Guam", value: "GU" },
{ label: "Hawaii", value: "HI" },
{ label: "Idaho", value: "ID" },
{ label: "Illinois", value: "IL" },
{ label: "Indiana", value: "IN" },
{ label: "Iowa", value: "IA" },
{ label: "Kansas", value: "KS" },
{ label: "Kentucky", value: "KY" },
{ label: "Louisiana", value: "LA" },
{ label: "Maine", value: "ME" },
{ label: "Maryland", value: "MD" },
{
label: "Massachusetts",
value: "MA",
},
{ label: "Michigan", value: "MI" },
{ label: "Minnesota", value: "MN" },
{ label: "Mississippi", value: "MS" },
{ label: "Missouri", value: "MO" },
{ label: "Montana", value: "MT" },
{ label: "Nebraska", value: "NE" },
{ label: "Nevada", value: "NV" },
{
label: "New Hampshire",
value: "NH",
},
{ label: "New Jersey", value: "NJ" },
{ label: "New Mexico", value: "NM" },
{ label: "New York", value: "NY" },
{
label: "North Carolina",
value: "NC",
},
{
label: "North Dakota",
value: "ND",
},
{
label: "Northern Mariana Islands",
value: "MP",
},
{ label: "Ohio", value: "OH" },
{ label: "Oklahoma", value: "OK" },
{ label: "Oregon", value: "OR" },
{
label: "Pennsylvania",
value: "PA",
},
{ label: "Puerto Rico", value: "PR" },
{
label: "Rhode Island",
value: "RI",
},
{
label: "South Carolina",
value: "SC",
},
{
label: "South Dakota",
value: "SD",
},
{ label: "Tennessee", value: "TN" },
{ label: "Texas", value: "TX" },
{ label: "Utah", value: "UT" },
{ label: "Vermont", value: "VT" },
{
label: "Virgin Islands",
value: "VI",
},
{ label: "Virginia", value: "VA" },
{ label: "Washington", value: "WA" },
{
label: "West Virginia",
value: "WV",
},
{ label: "Wisconsin", value: "WI" },
{ label: "Wyoming", value: "WY" },
],
},
},
],
},
],
},
},
],
},
],
},
{
label:
"A set of benefits consistent with the 10 EHB categories to become the new EHB-benchmark plan (Submit ABP 5: Benefits description)",
value: "10_EHB_categories_new_EHB_benchmark",
},
],
},
},
],
},
],
},
{
title: "Assurances",
sectionId: "assurances",
dependency: {
conditions: [
{
name: "abp3-1_select-of-ehb-bench-plan_is-ehb-bench-plan-same-section-1937",
type: "expectedValue",
expectedValue: "no",
},
],
effect: { type: "show" },
},
form: [
{
slots: [
{
name: "meets-scope",
rhf: "Checkbox",
rules: {
required: "* Required",
},
props: {
options: [
{
label:
"The state/territory assures the EHB plan meets the scope of benefits standards at 45 CFR 156.111(b), does not exceed generosity of most generous among a set of comparison plans, provides appropriate balance of coverage among 10 EHB categories, and the scope of benefits is equal to or greater than the scope of benefits provided under a typical employer plan as defined at 45 CFR 156.111(b)(2).",
value: "meets_scope",
},
{
label:
"The state/territory assures that actuarial certification and an associated actuarial report from an actuary, who is a member of the American Academy of Actuaries, in accordance with generally accepted actuarial principles and methodologies, has been completed and is available upon request.",
value: "assures_from_acturial_certification",
dependency: {
conditions: [
{
name: "abp3-1_select-of-ehb-bench-plan_ehb-bench-option",
type: "expectedValue",
expectedValue: "EHB_benchmark_2017_plan_year",
},
],
effect: { type: "hide" },
},
},
{
label:
"The state/territory assures that all services in the EHB-benchmark plan have been accounted for throughout the benefit chart found in ABP 5.",
value: "assures_EHB_benchmark_throughout_abp5_benefit",
},
{
label:
"The state/territory assures the accuracy of all information in ABP 5 depicting amount, duration, and scope parameters of services authorized in the currently approved Medicaid state plan.",
value: "assures_abp5_amount_duration_scope",
},
],
},
},
],
},
],
},
{
title: "Additional information",
sectionId: "addtnl-info",
form: [
{
description:
"Other information about selection of the Section 1937 coverage option and the EHB-benchmark plan (optional)",
slots: [
{
name: "description",
rhf: "Textarea",
props: {
className: "h-[114px]",
},
rules: {
pattern: {
value: noLeadingTrailingWhitespace,
message: "Must not have leading or trailing whitespace.",
},
},
},
],
},
],
},
],
};