lib/libs/webforms/CS11/v202401.ts
import { FormSchema } from "shared-types";
import { noLeadingTrailingWhitespace } from "shared-utils";
export const v202401: FormSchema = {
header:
"CS 11: Separate CHIP eligibility—Pregnant women who have access to public employee coverage",
subheader:
"Sections 2110(b)(2)(B) and (b)(6) of the Social Security Act (SSA)",
formId: "cs11",
sections: [
{
title: "Overview",
sectionId: "overview",
form: [
{
slots: [
{
rhf: "Checkbox",
name: "chip-cover-group-follow-provisions",
styledLabel: [
{
text: "Otherwise eligible",
type: "default",
classname: "text-black",
},
{
text: " targeted low-income pregnant women who have access to public employee coverage",
type: "bold",
classname: "text-black",
},
{
text: " on the basis of their own or a family member's employment",
type: "default",
classname: "text-black",
},
],
rules: {
required: "* Required",
},
props: {
options: [
{
label:
"The CHIP agency operates this covered group in accordance with the following provisions.",
value: "true",
},
],
},
},
],
},
],
},
{
title: "Conditions",
sectionId: "conditions",
subsection: true,
form: [
{
slots: [
{
rhf: "Radio",
label: "Conditions as described in Section 2110(b)(6) of the SSA",
labelClassName: "font-bold text-black",
name: "conditions",
rules: {
required: "* Required",
},
props: {
options: [
{
label:
"Maintenance of agency contribution as provided in Section 2110(b)(6)(B)",
value: "maintenance",
slots: [
{
rhf: "Upload",
name: "maintenance-upload",
description:
"Attach the state’s methodology for calculating the maintenance of agency contribution.",
descriptionAbove: true,
descriptionClassName: "font-bold text-black",
rules: {
required: "* Required",
},
},
{
rhf: "Checkbox",
name: "state-assures-recalculate-maintenance",
props: {
options: [
{
label:
"The state assures it will recalculate expenditures for each participating public agency on an annual basis to determine if the maintenance of agency contribution continues to be met.",
value: "true",
},
],
},
rules: {
required: "* Required",
},
},
],
},
{
label:
"Hardship criteria as provided in Section 2110(b)(6)(C)",
value: "hardship-criteria",
slots: [
{
rhf: "Upload",
name: "hardship-criteria-upload",
description:
"Attach the state's methodology for calculating the hardship condition.",
descriptionAbove: true,
descriptionClassName: "font-bold text-black",
rules: {
required: "* Required",
},
},
{
rhf: "Checkbox",
name: "state-assures-recalculate-hardship",
props: {
options: [
{
label:
"The state assures it will recalculate the financial status on an annual basis to determine if the hardship condition continues to be met.",
value: "true",
},
],
},
rules: {
required: "* Required",
},
},
],
},
],
},
},
],
},
],
},
{
title: "Household income standards",
subsection: true,
sectionId: "household-income-standards",
form: [
{
slots: [
{
rhf: "Radio",
label:
"Coverage under this option is extended to pregnant women whose household income is:",
labelClassName: "font-bold text-black",
name: "household-income-is",
rules: {
required: "* Required",
},
props: {
options: [
{
label:
"The same as the income standards for targeted low-income pregnant women",
value: "same",
},
{
label:
"Lower than the income standards for targeted low-income pregnant women",
value: "lower",
},
],
},
},
],
},
],
},
{
title: "Statewide income standards",
subsection: true,
sectionId: "statewide-income-standards",
form: [
{
slots: [
{
rhf: "Select",
label: "Are income standards applied statewide?",
labelClassName: "font-bold text-black",
name: "standards-applied-statewide",
props: {
className: "w-[125px]",
options: [
{
label: "Yes",
value: "yes",
},
{
label: "No",
value: "no",
},
],
},
rules: {
required: "* Required",
},
},
{
rhf: "WrappedGroup",
name: "wrapped",
label: "Statewide income standards",
labelClassName: "font-bold text-black",
description:
"The upper end of an income range cannot be more than the highest income level for targeted low-income pregnant women.",
descriptionAbove: true,
props: {
wrapperClassName: "flex-row flex gap-5",
},
fields: [
{
rhf: "Input",
name: "above",
rules: {
pattern: {
value: /^[0-9]\d*$/,
message: "Must be a positive integer value",
},
required: "* Required",
},
label: "Above",
labelClassName: "font-bold text-black",
props: {
className: "w-[159px]",
icon: "% FPL",
iconRight: true,
},
},
{
rhf: "Input",
name: "up-to-and-including",
rules: {
pattern: {
value: /^[0-9]\d*$/,
message: "Must be a positive integer value",
},
required: "* Required",
},
label: "Up to and including",
labelClassName: "font-bold text-black",
props: {
icon: "% FPL",
iconRight: true,
className: "w-[159px]",
},
},
],
},
],
},
],
},
{
title: "Income standard exceptions",
subsection: true,
sectionId: "income-standard-exceptions",
form: [
{
slots: [
{
rhf: "Select",
label:
"Are there any income standard exceptions, such as populations in a county that may qualify under either a statewide income standard or a county income standard?",
labelClassName: "font-bold text-black",
name: "are-there-exceptions",
props: {
className: "w-[125px]",
options: [
{
label: "Yes",
value: "yes",
},
{
label: "No",
value: "no",
},
],
},
rules: {
required: "* Required",
},
},
{
rhf: "Textarea",
name: "explain-overlap-diff-income-standards",
rules: {
required: "* Required",
pattern: {
value: noLeadingTrailingWhitespace,
message: "Must not have leading or trailing whitespace.",
},
},
label:
"Explain, including a description of the overlapping geographic area and the reason for having different income standards.",
labelClassName: "font-bold text-black",
props: {
className: "w-[696px]",
},
formItemClassName:
"ml-[0.6rem] px-4 border-l-4 border-l-primary mb-4",
dependency: {
conditions: [
{
type: "expectedValue",
name: "cs11_income-standard-exceptions_are-there-exceptions",
expectedValue: "yes",
},
],
effect: { type: "show" },
},
},
{
rhf: "Checkbox",
name: "method-of-geographic-variation",
label: "Method of geographic variation",
labelClassName: "font-bold text-black",
rules: {
required: "* Required",
},
props: {
options: [
{
label: "By county",
value: "by-county",
slots: [
{
rhf: "WrappedGroup",
name: "wrapped",
styledLabel: [
{
text: "Enter one county if the county has a unique income standard. If multiple counties share the same income standard, enter all the counties, then enter the income standard that applies to those counties.",
type: "paragraph",
},
{
text: "The upper end of the income range cannot be more than the highest income level for targeted low-income pregnant women.",
type: "paragraph",
},
{
text: "The highest income level for pregnant women cannot be more than the highest income level for children.",
type: "paragraph",
},
],
fields: [
{
rhf: "FieldArray",
name: "county-info",
props: { appendText: "Add county" },
fields: [
{
rhf: "Input",
name: "county-name",
rules: {
required: "* Required",
pattern: {
value: noLeadingTrailingWhitespace,
message:
"Must not have leading or trailing whitespace.",
},
},
label: "County",
labelClassName: "font-bold text-black",
props: {
className: "w-[229px]",
},
},
{
rhf: "Input",
name: "county-above",
rules: {
pattern: {
value: /^[0-9]\d*$/,
message: "Must be a positive integer value",
},
required: "* Required",
},
label: "Above",
labelClassName: "font-bold text-black",
props: {
className: "w-[159px]",
icon: "% FPL",
iconRight: true,
},
},
{
rhf: "Input",
name: "county-up-to-and-including",
rules: {
pattern: {
value: /^[0-9]\d*$/,
message: "Must be a positive integer value",
},
required: "* Required",
},
label: "Up to and including",
labelClassName: "font-bold text-black",
props: {
icon: "% FPL",
iconRight: true,
className: "w-[159px]",
},
},
],
},
],
},
],
},
{
label: "By city",
value: "by-city",
slots: [
{
rhf: "WrappedGroup",
name: "wrapped",
styledLabel: [
{
text: "Enter one city if the city has a unique income standard. If multiple cities share the same income standard, enter all the cities, then enter the income standard that applies to those cities.",
type: "paragraph",
},
{
text: "The upper end of the income range cannot be more than the highest income level for targeted low-income pregnant women.",
type: "paragraph",
},
{
text: "The highest income level for pregnant women cannot be more than the highest income level for children.",
type: "paragraph",
},
],
fields: [
{
rhf: "FieldArray",
name: "city-info",
props: { appendText: "Add city" },
fields: [
{
rhf: "Input",
name: "city-name",
rules: {
required: "* Required",
pattern: {
value: noLeadingTrailingWhitespace,
message:
"Must not have leading or trailing whitespace.",
},
},
label: "City",
labelClassName: "font-bold text-black",
props: {
className: "w-[229px]",
},
},
{
rhf: "Input",
name: "city-above",
rules: {
pattern: {
value: /^[0-9]\d*$/,
message: "Must be a positive integer value",
},
required: "* Required",
},
label: "Above",
labelClassName: "font-bold text-black",
props: {
className: "w-[159px]",
icon: "% FPL",
iconRight: true,
},
},
{
rhf: "Input",
name: "city-up-to-and-including",
rules: {
pattern: {
value: /^[0-9]\d*$/,
message: "Must be a positive integer value",
},
required: "* Required",
},
label: "Up to and including",
labelClassName: "font-bold text-black",
props: {
icon: "% FPL",
iconRight: true,
className: "w-[159px]",
},
},
],
},
],
},
],
},
{
label: "Other geographic area",
value: "other-geo-area",
slots: [
{
rhf: "WrappedGroup",
name: "wrapped",
styledLabel: [
{
text: "Enter each geographic area with a unique income standard.",
type: "paragraph",
},
{
text: "The upper end of the income range cannot be more than highest income level for targeted low-income pregnant women.",
type: "paragraph",
},
{
text: "The highest income level for pregnant women cannot be more than the highest income level for children.",
type: "paragraph",
},
],
fields: [
{
rhf: "FieldArray",
name: "other-geo-area",
props: { appendText: "Add geographic area" },
fields: [
{
rhf: "WrappedGroup",
name: "wrapped",
props: {
wrapperClassName:
"flex flex-col gap-7 ml-[0.6rem] px-4 border-l-4 border-l-primary mb-4",
},
fields: [
{
rhf: "Input",
name: "other-geo-var",
rules: {
required: "* Required",
pattern: {
value: noLeadingTrailingWhitespace,
message:
"Must not have leading or trailing whitespace.",
},
},
label: "Geographic Area",
labelClassName: "font-bold text-black",
props: {
className: "w-[527px]",
},
},
{
rhf: "Textarea",
name: "other-geo-area-describe",
rules: {
required: "* Required",
pattern: {
value: noLeadingTrailingWhitespace,
message:
"Must not have leading or trailing whitespace.",
},
},
label: "Describe",
labelClassName: "font-bold text-black",
props: {
className: "w-[527px]",
},
},
{
rhf: "WrappedGroup",
name: "wrapped",
props: {
wrapperClassName: "flex-row flex gap-5",
},
fields: [
{
rhf: "Input",
name: "other-above-geo-var",
rules: {
pattern: {
value: /^[0-9]\d*$/,
message:
"Must be a positive integer value",
},
required: "* Required",
},
label: "Above",
labelClassName: "font-bold text-black",
props: {
className: "w-[159px]",
icon: "% FPL",
iconRight: true,
},
},
{
rhf: "Input",
name: "up-to-and-including-other-geo-var",
rules: {
pattern: {
value: /^[0-9]\d*$/,
message:
"Must be a positive integer value",
},
required: "* Required",
},
label: "Up to and including",
labelClassName: "font-bold text-black",
props: {
icon: "% FPL",
iconRight: true,
className: "w-[159px]",
},
},
],
},
],
},
],
},
],
},
],
},
],
},
},
],
},
],
},
{
title: "Access to public employee coverage",
subsection: true,
sectionId: "access-to-public-employee-coverage",
form: [
{
slots: [
{
rhf: "Radio",
label: "Coverage under this option is extended to:",
labelClassName: "font-bold text-black",
name: "coverage-extended-to",
rules: {
required: "* Required",
},
props: {
options: [
{
label:
"All pregnant women who have access to public employee coverage",
value: "all-pregnant-women",
},
{
label:
"Certain pregnant women who have access to public employee coverage",
value: "certain-pregnant-women",
slots: [
{
rhf: "Checkbox",
name: "type-of-employee-coverage",
rules: {
required: "* Required",
},
props: {
options: [
{
label: "Employees of certain public agencies",
value: "employees-of-certain-public-agencies",
slots: [
{
rhf: "FieldArray",
name: "agencies",
props: { appendText: "Add type" },
fields: [
{
rhf: "Input",
label: "Type of agency",
labelClassName: "font-bold text-black",
name: "agency-type",
props: {
className: "w-[527px]",
},
rules: {
required: "* Required",
pattern: {
value: noLeadingTrailingWhitespace,
message:
"Must not have leading or trailing whitespace.",
},
},
},
],
},
],
},
{
label:
"Certain types of public employees or dependents of certain types of public employees",
value: "certain-types-of-public-employees",
slots: [
{
rhf: "FieldArray",
name: "types-of-public-employees",
props: { appendText: "Add type" },
fields: [
{
rhf: "Input",
label: "Type of public employee",
labelClassName: "font-bold text-black",
name: "public-employee-type",
props: {
className: "w-[527px]",
},
rules: {
pattern: {
value: noLeadingTrailingWhitespace,
message:
"Must not have leading or trailing whitespace.",
},
required: "* Required",
},
},
],
},
],
},
],
},
},
],
},
],
},
},
],
},
],
},
{
title: "Age standard",
subsection: true,
sectionId: "age-standard",
form: [
{
slots: [
{
rhf: "Radio",
label: "Age standard",
name: "age-standard-select",
labelClassName: "font-bold text-black",
rules: {
required: "* Required",
},
props: {
options: [
{
label:
"Same as the age criteria used for targeted low-income pregnant women",
value: "same-as-targeted",
},
{
label:
"Different than the age criteria used for targeted low-income pregnant women",
value: "different-than-targeted",
slots: [
{
rhf: "Radio",
label: "Age range",
labelClassName: "font-bold text-black",
name: "age-range",
rules: {
required: "* Required",
},
props: {
options: [
{
label: "From age 19, up to specific age",
value: "from-19",
slots: [
{
rhf: "Input",
label: "End of age range",
labelClassName: "font-bold text-black",
name: "end-of-age-range",
rules: {
required: "* Required",
pattern: {
value: /^(2[0-9]|[3-9]\d|\d{3,})$/,
message:
"Must be a positive integer value greater than 19",
},
},
props: {
className: "w-[125px]",
},
},
],
},
{
label: "No age restriction",
value: "no-age-restriction",
slots: [
{
rhf: "Textarea",
label:
"Describe how it’s determined whether the applicant will be provided coverage as a child or as a pregnant woman.",
labelClassName: "font-bold text-black",
name: "describe-determination",
rules: {
pattern: {
value: noLeadingTrailingWhitespace,
message:
"Must not have leading or trailing whitespace.",
},
required: "* Required",
},
},
],
},
{
label: "Another age range",
value: "another-age-range",
slots: [
{
rhf: "WrappedGroup",
name: "wrapped",
fields: [
{
rhf: "WrappedGroup",
name: "wrapped",
props: {
wrapperClassName: "flex-row flex gap-5",
},
fields: [
{
rhf: "Input",
name: "start-age-range",
rules: {
pattern: {
value: /^[0-9]\d*$/,
message:
"Must be a positive integer value",
},
required: "* Required",
},
label: "Start of age range",
labelClassName:
"font-bold text-black",
props: {
className: "w-[125px]",
},
},
{
rhf: "Input",
name: "end-age-range",
rules: {
pattern: {
value: /^[0-9]\d*$/,
message:
"Must be a positive integer value",
},
required: "* Required",
},
addtnlRules: [
{
type: "greaterThanField",
strictGreater: true,
fieldName:
"cs11_age-standard_start-age-range",
message:
"Must be greater than start of age range",
},
],
label: "End of age range",
labelClassName:
"font-bold text-black",
props: {
className: "w-[125px]",
},
},
],
},
{
rhf: "Select",
label:
"Does the age range for targeted low-income pregnant women overlap with the age range for targeted low-income children?",
labelClassName:
"font-bold text-black mt-4",
name: "age-range-overlap",
rules: {
required: "* Required",
},
props: {
className: "w-[125px]",
options: [
{
label: "Yes",
value: "yes",
},
{
label: "No",
value: "no",
},
],
},
},
{
rhf: "Textarea",
label:
"Describe how it's determined whether the applicant will be provided coverage as a child or as a pregnant woman.",
labelClassName: "font-bold text-black",
name: "describe-determination",
formItemClassName:
"ml-[0.6rem] pl-6 mt-4 border-l-4 border-l-primary",
rules: {
pattern: {
value: noLeadingTrailingWhitespace,
message:
"Must not have leading or trailing whitespace.",
},
required: "* Required",
},
dependency: {
conditions: [
{
name: "cs11_age-standard_age-range-overlap",
type: "expectedValue",
expectedValue: "yes",
},
],
effect: { type: "show" },
},
},
],
},
],
},
],
},
},
],
},
],
},
},
],
},
],
},
{
title: "Assurances",
subsection: true,
sectionId: "assurances",
form: [
{
slots: [
{
rhf: "Checkbox",
name: "public-employee-coverage-assurances",
props: {
options: [
{
label:
"Pregnant women considered to have access to public employee coverage, and therefore not excluded from CHIP through this option, otherwise meet the definition of targeted low-income pregnant woman in accordance with Section 2112(d)(2) of the SSA.",
value: "meet-definition",
},
{
label:
"Pregnant women who are eligible for public employee health benefits coverage who are not described above are excluded from eligibility under the plan.",
value: "excluded-from-eligibility",
dependency: {
conditions: [
{
name: "cs11_access-to-public-employee-coverage_coverage-extended-to",
type: "expectedValue",
expectedValue: "certain-pregnant-women",
},
],
effect: { type: "show" },
},
},
],
},
rules: {
required: "* Required",
},
},
],
},
],
},
],
};