DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
 
Center for Medicaid, CHIP, and Survey & Certification 
 
CMCS Informational Bulletin 
  
 
DATE:  March 3, 2011 
 
FROM:  Cindy Mann, JD 
  Director 
  Center for Medicaid, CHIP and Survey and & Certification (CMCS) 
 
SUBJECT:  Technical Assistance for CHIPRA Performance Bonuses for FY 2011   
 
This Informational Bulletin is to remind States of technical assistance opportunities available and 
upcoming deadlines for applying for performance bonuses for Federal fiscal year (FY) 2011 under 
section 2105(a)(3) to the Social Security Act (the Act), as amended by section 104 of the Childrens 
Health Insurance Program Reauthorization Act of 2009 (CHIPRA).  Performance bonuses provide 
additional Federal funding for qualifying States that have taken specific steps to simplify Medicaid and 
CHIP enrollment and renewal procedures and have also increased Medicaid enrollment of children 
above a baseline level.  In FY 2010, the Centers for Medicare & Medicaid Services (CMS) awarded 
$206 million in performance bonuses to 15 States. 
 
Applications for FY 2011 
 
In order for a State to claim credit for one the 8 Performance Bonus program features for FY 2011, 
that program feature must be operational no later than April 1, 2011.  Also, in order for a State to 
qualify for a new program feature that is a required element of the Medicaid/CHIP State plan, the State 
must have submitted the necessary State Plan Amendment with an effective date of April 1 of the FY 
in question.   
 
In order to clarify which State Plan pages and other supporting documentation are required for each 
program feature, we have attached a revised Bonus Payment Request Template for States use in FY 
2011.  We also have a performance bonus calculator that is available and will be updated for FY 2011 
in the near future.  These additions are intended to provide more clarity and consistency regarding the 
supporting documentation that States must submit along with the Performance Bonus Request 
Template, such as State Plan pages, copies of application and renewal forms, and additional sources 
such as State Manual pages or Administrative Memoranda.   
 
Performance bonus applications for FY 2011 will be due October 15, 2011.  In general, we will be 
following the same timeframes established for the review of performance bonuses in FY 2010, which 
were outlined in the CMS State Health Official letter released on October 1, 2010  (available at 
http://www.cms.gov/smdl/downloads/SHO10008.pdf).   
 
 
 
  Page 2  CMCS Informational Bulletin 
In addition, based on our experience from FY 2010 performance bonus reviews, we offer the following 
clarifications regarding two of the Performance Bonus program features: 
 
  Liberalization of asset requirements. States that wish to receive credit for this program feature 
by eliminating asset tests in Medicaid and CHIP need to formally document in their State Plans 
the elimination of the asset test for all Medicaid children in categories for which being a child 
is a condition of eligibility, including section 1931 children, mandatory qualified children, and 
all other Medicaid child eligibility groups listed in Appendix II of the CMS State Health 
Official Letter released on December 16, 2009 (available at 
http://www.cms.gov/smdl/downloads/SHO09015.pdf).  CMCS staff are available to offer 
technical assistance to States interested in discussing this program feature. 
 
  Same application and renewal forms. To document implementation of this program feature, 
States need to submit copies of application, renewal, and supplemental forms that request 
additional information needed to establish or verify one or more factors of eligibility (for 
example, forms used to verify employment, income, or residency).  States should also submit a 
description of its consumer-facing information verification processes.  We note that if the forms 
are not the same, a State can also meet the requirements of this program feature by 
demonstrating that their forms are interchangeable.  At a minimum, interchangeable forms 
should be accepted by either Medicaid or CHIP, and ideally, interchangeable forms should help 
coordinate enrollment between programs without requiring additional information from 
applicants.          
 
Full descriptions of all of the Performance Bonus program features can be found in the CMS State 
Health Official letter released on December 16, 2009  (available at 
http://www.cms.gov/smdl/downloads/SHO09015.pdf), and additional guidance can be found in the 
CMS State Health Official letter released on October 1, 2010  (available at 
http://www.cms.gov/smdl/downloads/SHO10008.pdf).    
 
Technical Assistance Team 
 
Performance Bonuses offer an open opportunity for States to leverage additional federal funds --   FY 
2010 Performance Bonuses ranged from $3 million to $55 million per State.  In order to help States 
that are interested in applying for Performance Bonuses in FY 2011 and subsequent years, CMS has 
established a performance bonus technical assistance team and will be holding office hours with 
States during the month of March in anticipation of the April 1 deadline. The technical assistance team 
can help States calculate the bonus amount that they have the potential to qualify for, share best 
practices from the implementation of program features in other States, provide technical assistance on 
necessary State Plan Amendments, and answer other questions related to the Performance Bonus 
process.   
 
If your State is interested in discussing the possibility of a CHIPRA Performance Bonus for FY 2011, 
please contact my staff via email at CHIPRAbonuspayments@cms.hhs.gov with a copy to your 
servicing CMS Regional Office, and we will follow up with you to schedule an appointment.   
 
 
ATTACHMENTS 
2 
  State Request for  
Childrens Health Insurance Program Reauthorization Act (CHIPRA) Performance Bonus  
Federal Fiscal Year 2011 
 
State: ____(please fill in)_ 
Contact Name: ___(please fill in)___ Telephone: _(please fill in)_  Email: _(please fill in)______  Date: MM/DD/YYYY 
 
This template represents this State's request for a determination of eligibility for a CHIP Performance Bonus Payment for Federal fiscal year 2011 
under the provisions of section 2105(a)(3) and (4) of the Social Security Act and provides the States certification of the indicated program features. 
 
A.   B.  C.  D.  E. 
Qualifying Criteria  Criteria  Supporting Documentation  Additional Information/ Program Limitations   Effective 
Met  (If attached, please mark with an x)   Date  
(Y/N) 
1.  Continuous   [   ]  State Plan Attachment 2.2-A     
Eligibility    [   ]  Other State Plan page with 
 
   Title XIX  1902(e)(12) of the Social Security Act 
  Citation 
   Title XXI    [   ]   State Plan Section 4.1.8     
2.  Liberalization of  If eliminating asset test:   [   ]  The State has eliminated the Asset Test for   
Asset (or    all required groups; or 
Resource)  [   ]  State Plan Attachment 2.2-A   
Requirements   [   ]  The State allows self-declaration of assets 
[   ]  State Plan Attachment 2.6-A  
   Title XIX    for some or all required groups. 
[   ]  Supplements to State Plan   
If allowing self-declaration of assets, please 
Attachment 2.6-A 
specify the States process for each eligibility 
group: 
   Title XXI  If eliminating asset test:   [   ]  The State has eliminated the Asset Test for   
  CHIP; or 
[   ]  Section 4.1.4   
  [   ]  The State allows self-declaration of assets 
  for CHIP. 
 
If allowing self-declaration of assets, please 
specify the States process for each eligibility 
group:  Page 2  Performance Bonus FY 2011 
 
A.   B.  C.  D.  E. 
Qualifying Criteria  Criteria  Supporting Documentation  Additional Information/ Program Limitations   Effective 
Met  (If attached, please mark with an x)   Date  
(Y/N) 
3.  Elimination of       
In-Person     
Interview    
   Title XIX   
 
   Title XXI 
 
 
 
4.  Use of Same  [   ]  The same application form   Please describe the States information   
Application and  [   ]  The same renewal form  verification process for Medicaid and CHIP. 
Renewal Form   
[   ]  The same supplemental form(s) 
and Procedures  If forms are different between Medicaid and 
   
for Medicaid and  CHIP, please describe how they are 
CHIP   interchangeable. 
Title XIX  and   
Title XXI   
5.  Automatic/Admi   [   ]  If administrative renewal, a  Please describe the States standard renewal   
nistrative  copy of the preprinted renewal form   process, and any limitations to its application. 
Renewal      
   Title XIX     
 
   Title XXI    [   ]  If administrative renewal, a  Please describe the States standard renewal 
copy of the preprinted renewal form   process, and any limitations to its application. 
 
 
6.  Presumptive  [   ]  State Plan Page with Citation of  The following qualified entities conduct   
Eligibility for  1920A of the Social Security Act  presumptive eligibility: 
Children       
   Title XIX     
 
   Title XXI  [   ]  State Plan Section 4.3  The following qualified entities conduct 
  presumptive eligibility: 
 
  Page 3  Performance Bonus FY 2011 
 
A.   B.  C.  D.  E. 
Qualifying Criteria  Criteria  Supporting Documentation  Additional Information/ Program Limitations   Effective 
Met  (If attached, please mark with an x)   Date  
(Y/N) 
7.  Express Lane    [   ]  State Plan Section 2.1 pages 11b- Which Agency is the designated Express Lane   
   Title XIX  11d of the State plan.  Agency? 
     
    What finding is used from the Express Lane 
    Agency? 
     
 
   Title XXI  [   ]  State Plan Section 4.3  Which Agency is the designated Express Lane 
  Agency? 
 
What finding is used from the Express Lane 
Agency? 
 
8.  Premium  [   ]  State Plan Enclosure 4 page 29d     
Assistance   
Subsidies    
 
   Title XIX or   
   Title XXI  [   ]    State Plan Sections 1.4 and 6.4.3 
 
  Page 4  Performance Bonus FY 2011 
 
Template Instructions for Line Entries in Each Column 
 
A.  Qualifying Criteria  Lines 1 through 8 in Column A  lists the eight program features identified in section 2105(a)(4).  In order to get credit 
for a program feature, a State must identify information for both its title XIX and XXI programs for all program features except Premium 
Assistance Subsidies.  A State may qualify for the Premium Assistance Subsidy program feature if it meets the criteria for either title XIX or 
title XXI. 
 
B.  Criteria Met  In Column B each State should indicate a Y or N with respect to each of the program features in Column A for which it 
believes it meets the respective criteria for such program feature.  A State must meet the criteria for at least 5 of 8 of the program features to 
qualify for a bonus payment. 
 
C.  Required Documents:  State must check the appropriate box to indicate the location within its approved State plan(s), if the program feature 
is authorized through the respective XIX or XXI approved State plan.  If located elsewhere, State should write in the section and page 
number.   States should submit copies of the State plan page with the template as supporting documentation.   If not in State Plan, the State 
should submit other documentation.  Examples of the types of additional documentation a State should submit would be:  program 
application(s) for eligibility in Medicaid and CHIP, redetermination forms, income and asset instruction forms, process descriptions including 
time frames used to receive and process information for Medicaid and CHIP, instruction manuals provided to eligibility intake/determination 
employees regarding state policy for the program feature.  In Column C, the State should identify the supporting documentation it submitted 
to demonstrate it has met the requirements for the program feature in Column A. 
 
D.  Additional Information /Program Limitations  In Column D, each State should answer any questions listed.  The description may be 
provided either in the template or in an attachment if additional space is needed.  Each State should also identify any limitations associated 
with the program feature referenced in Column A.  In particular, identify any categories or groups of children to which the program feature 
does not apply (such as age limitations) or any income level to which the program feature does not apply (income limitations).  States should 
identify any other type of program feature limitation that would limit the availability of the program feature only to certain beneficiaries. 
 
E.  Effective Date  In Column E each State should indicate the date the program feature became operational in the each of the applicable 
programs, Medicaid or CHIP.