lib/libs/webforms/G2B/v202401.ts
import { FormSchema, DefaultFieldGroupProps } from "shared-types";
import { noLeadingTrailingWhitespace } from "shared-utils/regex";
export const v202401: FormSchema = {
header:
"Premiums and cost sharing G2b: Cost-sharing amounts—Medically needy individuals",
subheader: "1916 | 1916A | 42 CFR 447.52 through 447.54",
formId: "g2b",
sections: [
{
title: "Overview",
sectionId: "overview",
form: [
{
slots: [
{
name: "state-charge-cost-sharing",
rhf: "Select",
rules: { required: "* Required" },
label:
"Does the state charge cost sharing to all medically needy individuals?",
labelClassName: "font-bold text-[#212121]",
props: {
className: "w-[125px]",
options: [
{
value: "yes",
label: "Yes",
},
{
value: "no",
label: "No",
},
],
},
},
{
name: "cost-share-same-charge-as-needy",
rhf: "Select",
rules: { required: "* Required" },
label:
"Is the cost sharing charged to medically needy individuals the same as that charged to categorically needy individuals?",
labelClassName: "font-bold text-[#212121]",
props: {
className: "w-[125px]",
options: [
{
value: "yes",
label: "Yes",
},
{
value: "no",
label: "No",
},
],
},
},
],
},
],
},
{
title:
"Services or items with the same cost-sharing amount for all incomes",
sectionId: "services-same-all-incomes",
subsection: true,
form: [
{
slots: [
{
rhf: "FieldArray",
name: "service-item",
props: {
...DefaultFieldGroupProps,
appendText: "Add service or item",
removeText: "Remove",
},
fields: [
{
rhf: "Input",
name: "service-item-name",
rules: { required: "* Required" },
props: { className: "w-96" },
labelClassName: "text-black font-bold",
label: "Service or Item",
},
{
rhf: "WrappedGroup",
name: "wrapped",
props: {
wrapperClassName: "flex-row flex w-full gap-5",
},
fields: [
{
rhf: "Input",
name: "amount",
rules: {
pattern: {
value: /^[0-9]\d*$/,
message: "Must be a positive integer value",
},
required: "* Required",
},
formItemClassName: "w-48",
labelClassName: "text-black font-bold",
label: "Amount",
},
{
rhf: "Select",
name: "dollar-or-percent",
rules: { required: "* Required" },
formItemClassName: "w-56",
labelClassName: "text-black font-bold",
label: "Dollars or percentage",
props: {
options: [
{
label: "Dollar",
value: "dollar",
},
{
label: "Percentage",
value: "percentage",
},
],
},
},
{
rhf: "Select",
name: "unit",
rules: { required: "* Required" },
labelClassName: "text-black font-bold",
label: "Unit",
formItemClassName: "w-48",
props: {
customSort: "noSort",
options: [
{ label: "Day", value: "Day" },
{ label: "Month", value: "Month" },
{ label: "Visit", value: "Visit" },
{ label: "Prescription", value: "Prescription" },
{ label: "15 minute", value: "15 minute" },
{ label: "30 minute", value: "30 minute" },
{ label: "Hour", value: "Hour" },
{ label: "Trip", value: "Trip" },
{ label: "Encounter", value: "Encounter" },
{ label: "Pair", value: "Pair" },
{ label: "Item", value: "Item" },
{ label: "Procedure", value: "Procedure" },
{ label: "Entire Stay", value: "Entire Stay" },
{ label: "Other", value: "Other" },
],
},
},
],
},
{
rhf: "Textarea",
name: "explanation",
labelClassName: "text-black font-bold",
label: "Explanation (optional)",
rules: {
pattern: {
value: noLeadingTrailingWhitespace,
message: "Must not have leading or trailing whitespace.",
},
},
},
],
},
],
},
],
},
{
title: "Services or items with cost-sharing amounts that vary by income",
sectionId: "services-vary-by-income",
subsection: true,
form: [
{
slots: [
{
name: "service-item",
rhf: "FieldArray",
props: {
...DefaultFieldGroupProps,
appendText: "Add service or item",
removeText: "Remove",
},
fields: [
{
rhf: "Input",
rules: { required: "* Required" },
name: "service-item-name",
props: { className: "w-96" },
labelClassName: "text-black font-bold",
label: "Service or Item",
},
{
name: "array-label-non-child-style",
rhf: "TextDisplay",
text: "Income ranges for cost-sharing amount",
props: { className: "text-black font-bold" },
},
{
rhf: "FieldArray",
name: "inc-range-cost-share-amount",
props: {
appendText: "Add range",
fieldArrayClassName:
DefaultFieldGroupProps.fieldArrayClassName +
"space-y-6 " +
"ml-[0.6rem] px-4 border-l-4 border-l-primary mb-4",
divider: true,
},
fields: [
{
rhf: "WrappedGroup",
name: "wrapped",
props: {
wrapperClassName:
"space-between flex-row flex w-full gap-5",
},
fields: [
{
rhf: "Input",
rules: {
pattern: {
value: /^\d*(?:\.\d{1,2})?$/,
message:
"Must be a positive number, maximum of two decimals, no commas. e.g. 1234.56",
},
required: "* Required",
},
name: "income-greater-than",
formItemClassName: "w-48",
labelClassName: "text-black font-bold",
label: "Income greater than ($)",
},
{
rhf: "Input",
rules: {
pattern: {
value: /^\d*(?:\.\d{1,2})?$/,
message:
"Must be a positive number, maximum of two decimals, no commas. e.g. 1234.56",
},
required: "* Required",
},
name: "income-lesser-than",
labelClassName: "text-black font-bold",
label: "Income less than or equal to ($)",
},
],
},
{
rhf: "WrappedGroup",
name: "wrapped",
props: {
wrapperClassName:
"space-between flex-row flex w-full gap-5",
},
fields: [
{
rhf: "Input",
rules: {
pattern: {
value: /^[0-9]\d*$/,
message: "Must be a positive integer value",
},
required: "* Required",
},
name: "amount",
formItemClassName: "w-48",
labelClassName: "text-black font-bold",
label: "Amount",
},
{
rhf: "Select",
rules: { required: "* Required" },
name: "dollar-or-percent",
formItemClassName: "w-56",
labelClassName: "text-black font-bold",
label: "Dollars or percentage",
props: {
options: [
{
label: "Dollar",
value: "dollar",
},
{
label: "Percentage",
value: "percentage",
},
],
},
},
{
rhf: "Select",
rules: { required: "* Required" },
name: "unit",
formItemClassName: "w-48",
labelClassName: "text-black font-bold",
label: "Unit",
props: {
customSort: "noSort",
options: [
{ label: "Day", value: "Day" },
{ label: "Month", value: "Month" },
{ label: "Visit", value: "Visit" },
{ label: "Prescription", value: "Prescription" },
{ label: "15 minute", value: "15 minute" },
{ label: "30 minute", value: "30 minute" },
{ label: "Hour", value: "Hour" },
{ label: "Trip", value: "Trip" },
{ label: "Encounter", value: "Encounter" },
{ label: "Pair", value: "Pair" },
{ label: "Item", value: "Item" },
{ label: "Procedure", value: "Procedure" },
{ label: "Entire Stay", value: "Entire Stay" },
{ label: "Other", value: "Other" },
],
},
},
],
},
{
rhf: "Textarea",
name: "explanation",
labelClassName: "text-black font-bold",
label: "Explanation (optional)",
rules: {
pattern: {
value: noLeadingTrailingWhitespace,
message:
"Must not have leading or trailing whitespace.",
},
},
},
],
},
],
},
],
},
],
},
{
title:
"Cost sharing for non-preferred drugs charged to otherwise exempt individuals",
sectionId: "cost-share-charge-otherwise-exempt",
subsection: true,
form: [
{
slots: [
{
rhf: "Select",
rules: { required: "* Required" },
name: "charge-otherwise-exempt",
labelClassName: "text-black font-bold",
label:
"Does the state charge cost sharing for non-preferred drugs (entered above) to otherwise exempt individuals?",
props: {
className: "w-48",
options: [
{ label: "Yes", value: "yes" },
{ label: "No", value: "no" },
],
},
},
{
rhf: "Select",
rules: { required: "* Required" },
name: "charges-same-as-non-exempt",
labelClassName: "text-black font-bold",
label:
"Are the cost-sharing charges for non-preferred drugs imposed on otherwise exempt individuals the same as the charges imposed on non-exempt individuals?",
props: {
className: "w-48",
options: [
{ label: "Yes", value: "yes" },
{ label: "No", value: "no" },
],
},
dependency: {
conditions: [
{
type: "expectedValue",
name: "g2b_cost-share-charge-otherwise-exempt_charge-otherwise-exempt",
expectedValue: "yes",
},
],
effect: { type: "show" },
},
},
{
name: "charge-rate",
rhf: "FieldArray",
props: {
appendText: "Add charge",
fieldArrayClassName:
DefaultFieldGroupProps.fieldArrayClassName +
"space-y-6 " +
"ml-[0.6rem] px-4 border-l-4 border-l-primary mb-4",
divider: true,
},
dependency: {
conditions: [
{
type: "expectedValue",
name: "g2b_cost-share-charge-otherwise-exempt_charges-same-as-non-exempt",
expectedValue: "no",
},
],
effect: { type: "show" },
},
fields: [
{
rhf: "WrappedGroup",
name: "rateWrapper",
props: {
wrapperClassName:
"space-between flex-row flex w-full gap-5",
},
fields: [
{
rhf: "Input",
rules: {
pattern: {
value: /^[0-9]\d*$/,
message: "Must be a positive integer value",
},
required: "* Required",
},
name: "amount",
formItemClassName: "w-48",
labelClassName: "text-black font-bold",
label: "Amount",
},
{
rhf: "Select",
rules: { required: "* Required" },
name: "dollar-or-percent",
formItemClassName: "w-56",
labelClassName: "text-black font-bold",
label: "Dollars or percentage",
props: {
options: [
{
label: "Dollar",
value: "dollar",
},
{
label: "Percentage",
value: "percentage",
},
],
},
},
{
rhf: "Select",
name: "unit",
rules: { required: "* Required" },
formItemClassName: "w-48",
labelClassName: "text-black font-bold",
label: "Unit",
props: {
customSort: "noSort",
options: [
{ label: "Day", value: "Day" },
{ label: "Month", value: "Month" },
{ label: "Visit", value: "Visit" },
{ label: "Prescription", value: "Prescription" },
{ label: "15 minute", value: "15 minute" },
{ label: "30 minute", value: "30 minute" },
{ label: "Hour", value: "Hour" },
{ label: "Trip", value: "Trip" },
{ label: "Encounter", value: "Encounter" },
{ label: "Pair", value: "Pair" },
{ label: "Item", value: "Item" },
{ label: "Procedure", value: "Procedure" },
{ label: "Entire Stay", value: "Entire Stay" },
{ label: "Other", value: "Other" },
],
},
},
],
},
{
rhf: "Textarea",
name: "explanation",
labelClassName: "text-black font-bold",
label: "Explanation (optional)",
rules: {
pattern: {
value: noLeadingTrailingWhitespace,
message: "Must not have leading or trailing whitespace.",
},
},
},
],
},
],
},
],
},
{
title:
"Cost sharing for non-emergency services provided in the hospital emergency department charged to otherwise exempt individuals",
sectionId: "cost-share-hospital-emergency-charge-otherwise-exempt",
subsection: true,
form: [
{
slots: [
{
rhf: "Select",
rules: { required: "* Required" },
name: "charge-otherwise-exempt",
labelClassName: "text-black font-bold",
label:
"Does the state charge cost sharing for non-emergency services provided in the hospital emergency department (entered above) to otherwise exempt individuals?",
props: {
className: "w-48",
options: [
{ label: "Yes", value: "yes" },
{ label: "No", value: "no" },
],
},
},
{
rhf: "Select",
rules: { required: "* Required" },
name: "charges-same-as-non-exempt",
labelClassName: "text-black font-bold",
label:
"Are the cost-sharing charges for non-emergency services provided in the hospital emergency department imposed on otherwise exempt individuals the same as the charges imposed on non-exempt individuals?",
props: {
className: "w-48",
options: [
{ label: "Yes", value: "yes" },
{ label: "No", value: "no" },
],
},
dependency: {
conditions: [
{
type: "expectedValue",
name: "g2b_cost-share-hospital-emergency-charge-otherwise-exempt_charge-otherwise-exempt",
expectedValue: "yes",
},
],
effect: { type: "show" },
},
},
{
name: "charge-rate",
rhf: "FieldArray",
rules: { required: "* Required" },
props: {
appendText: "Add charge",
fieldArrayClassName:
DefaultFieldGroupProps.fieldArrayClassName +
"space-y-6 " +
"ml-[0.6rem] px-4 border-l-4 border-l-primary mb-4",
divider: true,
},
dependency: {
conditions: [
{
type: "expectedValue",
name: "g2b_cost-share-hospital-emergency-charge-otherwise-exempt_charges-same-as-non-exempt",
expectedValue: "no",
},
],
effect: { type: "show" },
},
fields: [
{
rhf: "WrappedGroup",
name: "rateWrapper",
props: {
wrapperClassName:
"space-between flex-row flex w-full gap-5",
},
fields: [
{
rhf: "Input",
rules: {
pattern: {
value: /^[0-9]\d*$/,
message: "Must be a positive integer value",
},
required: "* Required",
},
formItemClassName: "w-46",
name: "amount",
labelClassName: "text-black font-bold",
label: "Amount",
},
{
rhf: "Select",
rules: { required: "* Required" },
name: "dollar-or-percent",
formItemClassName: "w-56",
labelClassName: "text-black font-bold",
label: "Dollars or percentage",
props: {
options: [
{
label: "Dollar",
value: "dollar",
},
{
label: "Percentage",
value: "percentage",
},
],
},
},
{
rhf: "Select",
rules: { required: "* Required" },
name: "unit",
formItemClassName: "w-40",
labelClassName: "text-black font-bold",
label: "Unit",
props: {
customSort: "noSort",
options: [
{ label: "Day", value: "Day" },
{ label: "Month", value: "Month" },
{ label: "Visit", value: "Visit" },
{ label: "Prescription", value: "Prescription" },
{ label: "15 minute", value: "15 minute" },
{ label: "30 minute", value: "30 minute" },
{ label: "Hour", value: "Hour" },
{ label: "Trip", value: "Trip" },
{ label: "Encounter", value: "Encounter" },
{ label: "Pair", value: "Pair" },
{ label: "Item", value: "Item" },
{ label: "Procedure", value: "Procedure" },
{ label: "Entire Stay", value: "Entire Stay" },
{ label: "Other", value: "Other" },
],
},
},
],
},
{
rhf: "Textarea",
name: "explanation",
labelClassName: "text-black font-bold",
label: "Explanation (optional)",
rules: {
pattern: {
value: noLeadingTrailingWhitespace,
message: "Must not have leading or trailing whitespace.",
},
},
},
],
},
],
},
],
},
],
};