~+"y._9VIt:£f.~ { · ~ DEPARTMENT OF HEALTH & HUMAN SERVICES '<S'r Centers for Medicare & Medicaid Services APR 2 0 2009 William H. Hogan, Commissioner Department of Health and Social Services Post Office Box 110601 Juneau, Alaska 99811-0601 Region 10 2201 Sixth Avenue, MSIAX 43 Seattle, Washington 98121 RE: Alaska State Plan Amendment Transmittal Number #09-003 Dear Mr. Hogan: The Centers for Medicare & Medicaid Services' Seattle Regional Office has completed its review of State Plan Amendment (SPA) Transmittal Number 09-003. This amendment lengthens the continuous eligibility period for children under age 19 from 6 months to 12 months in Alaska. These changes are reflected in Attachment 2.2-A, page 23d. This SPA is approved effective April 1, 2009. If you have additional questions or require further assistance, please contact Maria Garza at (206) 615-2542 or Maria.Garza@cms.hhs.gov. cc: William Streur, Deputy Commissioner Jerry Fuller, Medicaid Director Sincerely, ~7Cv7VLJ2 Barbara K. Richards Associate Regional Administrator Division of Medicaid and Children's Health Operations Michelle Lyons-Brown, State Plan Coordinator

State Plan for Title XIX State of Alaska ATTACHMENT 2.2-A Page 23d Citation Groups Covered 1920A of the Act 21. 1902(a)(IO)(A) 1902(a)(l 0) (A)(ii)(XIH) _X_22. a total not to exceed _lL_ months, regardless of changes in circumstances other than attainment of the maximum age stated above. Children under age 19 who are determined by a "qualified entity" (as defined in 1920A(b)(3)(A)) based on preliminary information, to meet the highest applicable income criteria specified in this plan. The presumptive period begins on the day that the determination is made. If an application for Medicaid is filed on the child's behalf by the last day of the month following the month in which the determination of presumptive eligibility was made, the presumptive period ends on the day that the State agency makes a determination of eligibility based on that application. If an application is not filed on the child's behalf by the last day of the month following the month the determination of presumptive eligibility was made, the presumptive period ends on that last day. Working Disabled individuals whose net family income is below 250 percent of the federal poverty guideline for Alaska for a family of the size involved and who, except for earned income, meet all criteria for receiving the optional state supplement to SSI. See page 12c of ATTACHMENT 2.6-A TN No. 09-03 Approval DateAPR 2 0 2009 Effective Date April. 1, 2009 Supersedes TN No. ----"9'-"'9--0=0=8'-----

DEI'ARTM91T OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION FORM APPROVED OMB NO 0938..0193 TRANSMITTAL AND NOTICE OF APPROVAL OF L TRANSMITI AL NUMBER: 2.STATE Alaska STATE PLAN MATERIAL 09-03 FOR: HEALTH CARE FINANCING ADMINISTRATION TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 3. PROORAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFF.ECTIVE DATE April t, 2009 0 Nl:W STATE PLAN 0 AMENDMENT TO BE CONSIUERl:D AS NEW PLAN [81 AM.ENlJMENT 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SU ERSEDED PLAN SECTION OR ATTACHMENT ({( Applic<Jble): Attachment 2.2-A. Page 23d Attachment 2.2-A, Page 23d 10. SUBJECT OF AMENDMENT: DKC 12-month Continuous Eligibility II. GOVERNOR'S REVIEW (Check Om~): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT t8'J OTHER. AS SPECIFIED: Does not wish to c::omment. 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS Of SUBMrtTAL Alaska Oepartment of Health at~d Social Services ~~=-:::~~~~-------------! PO Box 110601 14. TTfLE: Medicaid Director, Juneau, AK 99~n 1-0601 Alaska D t. of Health and Social Services 15. DATE SUBMITTED:March 25,2009 17. DATE RECETVED: FORM HCFA-179 (07-92) APR 2 0 2009 Associate Re ional Administrator Division of Medicaid & Children's Health

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare 8 Medicaid Services Region 10 2201 Sixth Avenue, MSlRX 43 Seattle, Washington 98121 NOV 5 2009 William Hogan, Commissioner Department of Health and Social Services Post Office Box 1 10601 Juneau, Alaska 998 1 1-060 1 RE: Alaska State Plan Amendment (SPA) Transmittal Number #09-005 Dear Mr. Hogan: The Centers for Medicare & Medicaid Services' Seattle Regional Office has completed its review of State Plan Amendment (SPA) Transmittal Number #09-005. This amendment implements changes in deemed eligibility of children born to mothers covered by Medicaid for the date of the child's birth for a period of one year from birth, as required by section 11 3 of the Children's Health Insurance Program Reauthorization Act of 2009. This change is reflected in Attachment 2.2-A pages 6 and 25. This SPA is approved effective October 1,2009. If you have additional questions or require further assistance, please coiltact me or have your staff contact Maria Garza at (206) 615-2542 or .Marii~.(~ia~:za(uicn_l_s.I~hs.g~~v. Sincerely, Barbara K. Richards Associate Regional Administrator Division of Medicaid and Children's Health Operations CC : William Streur, Deputy Commissioner Jerry Fuller, Medicaid Director Vichelle Lyons-Brown, State Plan Coordinator

Revision: HCFA-PM-92-1 (MB) ATTACHMENT 2.2-A FEBRUARY 1992 Page 6 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: ALASKA COVERAGE AND CONDITIONS OF ELIGIBILITY Citation (s) Groups Covered A.Mandatory Coverage - Categorically Needy and Other Required Special Groups (Continued) 42 CFR 435.117, 12. A c h i l d born i n t h e United S t a t e s t o a 1902 ( e ) (4) woman who was e l i g i b l e f o r and of t h e Act r e c e i v i n g Medicaid ( i n c l u d i n g coverage of an a l i e n f o r l a b o r and d e l i v e r y a s emergency medical s e r v i c e s ) f o r t h e d a t e of t h e c h i l d ' s b i r t h , i n c l u d i n g r e t r o a c t i v e l y . The c h i l d is deemed e l i g i b l e f o r one year from b i r t h . 42 CFR 435.120 13.Aged, Blind and Disabled Individuals receiving Cash Assistance /x/ a.Individua1.s receiving SSI. - This includes beneficiaries' eligible spouses and persons receiving SSI benefits pending a final determination of blindness or disability or pending disposal of excess resources under an agreement with the Social Security Administration; and beginning January 1, 1981 persons receiving SSI under section 1619(a) of the Act or considered to be receiving SSI under section 1619(b) of the Act. X Aged X Blind X Disabled TN No. 09-05 Approval DateoCT - I mgective Date October 1, 2009 Su~ersedes 92 -0 1 HCFA ID: 7983E

Revision: HCFA-PM-91-4 (BPD) ATTACHMENT 2.2-A AUGUST 1991 Page 25 OMB NO.: 0938- State: Alaska Agency* Citation (s) Groups Covered The Department of Health and Social Services C.Optiona1 Coverage of Medically Needy (Continued) 1902 (e) (4) of 4. Newborn children born on or after the Act October 1, 1984 to a woman who is eligible as medically needy and is receiving Medicaid on the date of the child's birth. Please note: for medically needy coverage, deemed newborn eligibility is obsolete as of April 1, 2009. Please see Attachment 2.2-A, page 6, of this Plan for current policy on mandatory deemed newborn coverage. 42 CFR 435.308 5 - / a. Financially eligible individuals who are not described in section C.3. above and who are under the age of-- 21 - 20 19 - 18 or under age 19 who are full-time - students in a secondary school or in the equivalent level of vocational or technical training / / b. Reasonable classifications of financially - eligible individuals under the ages of 21, 20, 19, or 18 as specified below: (1)Individuals for whom public agencies are - assuming full or partial financial responsibility and who are: (a) In foster homes (and are under the age - of - (b)In private institutions (and are under - the age of ) . TN NO. 09-05 Supersedes 91-13 Approval Date QCT - I m g c t i v e Date October 1, 2009 HCFA ID: 7984E

I ~ I - ~i -- ~ I I < .IIU I ~ K ~ I N V I V ( ; f\r?\11xr5 I lo# -- - O\li+VO O ' J ~ S - ~ ! \JL TRANSMITTAI, AND NOTICE OF APYROvAI, 6% ' 1 TF<i\hSllIlT,\L K[lbt13l it ---" - 2 -- - -- FOR: HEA1,'I'H CARE FINANC'IYt; AI)\IINISI K,Z i'IOh / : I'RO(JRI\\I II)I K HTICI I IOV 'l'lrl.l E xl<Ok' I'HF / hO('1,ZL S1.('1Jl<J 1'J7 ,21*1 (~lk'l)J(l~flD) - -- - -- "" ""-" - - * -- 1'0 KliGlUh~lL AL)M[I\I[S I K h 1 O R 1.1 Pl,<'l EVE !>4'rF litA1,'f ti CARE FT?;ANC'IUCi ,21>W IN IS 1 R.Z7I'I0h October 1 , 2009 - -* - " - -- - - -

- 5 I YPIJ OF 1'1 AN MATERIAL (Clrrr X U;;L,) -- - i o S~VRJEC'I'OF A M E ~ D X I E N I CCj IPRA Dcc~ncd Ncwboms ." .- . .. ." . . . , . .... • (.iOVF:KNOR'S OFFICE KEP(3RTED SO COMh~1T'N'l El O'n-lKR. :IS SPLCiFIl,sO. DOCS [lot wish to comnicnr. n ('OMMENTS OF (jOVFRNOR'S 0FFIC:E ENC'LCjSED NO IUiPI..Y RECETVED WlTliIK 45 DAYS OF SII'U\1I'I'T,\I, PI I J ~ I ~ R O \ -- F I ~ o d ( (jn, I 1 I A L 1i1 i~ - -- -- - - 10 <F~;ECII\'I: l ) , ~ l l l ~ O k \ l ~ l l l < O i 1.1) kl 1 I l.l<l,Il 2 0 S l ( @ j O # y , ~ f+lC 1," ,. OCT - I 2009, -- - - . - -- -- - - - - - - ----- - - 21 TYPED NAME: -12 l I I 1 i *cr A;;[_?.\iC'Y Or I.kl,~\l. - I ? CI(;NATl'RE OT-A ir t , \ -&-- *=LL---- - 13 r ~ e 6 P ~ r . . 7 ~ ~ 1 ~ ~ u l l c l - - a

- - 11 1 1'11 R Xieii~caid D~cclor, - - - Alaska Dcpt of I icaltll ~ n d Socl 31 Scrv ices - - I5 DATE SUBhlITTET) Scptcn~bcr 7S 2009 ~ssociate Regiooiat Administrator ' 16. IXLT17Rh f 0 Alaska I)cpa~-tnient of tlcalth 'ind Soci,~l Sen ices PO nok I 1000 1 duncau. 4 K 908 l 1 0601 Division of Medicaid & byl I O / ~ ~ / W Children's Health

_____________________________________________________________________________

Table of Contents State/Territory Name: State Plan Amendment This file contains the following documents in the order listed:

(SPA) #: Alaska 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages 09-06

Sh RVICE: co 8.64

~ om

C DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

%,

oF HEALTH g

x

4, "hv 140 Region 10 2201 Sixth Avenue, MS/RX 43 Seattle, Washington 98121

WAR 18 2010

William Hogan, Commissioner Department of Health and Social Services Post Office Box 110601

Juneau, Alaska 99811-0601

RE: Alaska State Plan Amendment (SPA) Transmittal Number #09-006 Dear Mr. Hogan:

The Centers for Medicare & Medicaid Services’ Seattle Regional Office has completed its review of State Plan Amendment (SPA) Transmittal Number (TN) #09-006. This amendment implements more liberal disregards of Americorps payments for purpose of determining eligibility for individuals in the AFDC-related eligibility groups. The disregard for the SSI- related eligibility groups is already exempt during the SSI determination process; therefore, it is not necessary in the State plan. The changes are in Supplement 8a to Attachment 2.6-A page 4 and Supplement 14 to Attachment 2.6-A, page 2a.

This SPA is approved effective July 1, 2009.

If you have additional questions or require further assistance, please contact me, or have your staff contact Maria Garza at (206) 615-2542 or Maria.Garza@ems.hhs.gov.

Sincerely,

a . _

Barbara K. Richards

Associate Regional Administrator

Division of Medicaid and Children’s Health Operations

ce: William Streur, Deputy Commissioner

Jerry Fuller, Medicaid Director

Michelle Lyons-Brown, State Plan Coordinator

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION

FORM APPROVED OMB NO. 0938-0195

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION

1. TRANSMITTAL NUMBER: 09-06

2. STATE | Alaska

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES

4, PROPOSED ‘EFFECTIVE DATE July 1, 2009

5. TYPE OF PLAN MATERIAL (Check One):

_CJNEW STATE PLAN

im AMENDMENT TO BE CONSIDERED AS NEW PLAN

[| AMENDMENT _

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMEN

DMENT (Separate Transmittal for each amendment)

“6. FEDERAL STATUTE/REGULATION CITATION: ARRA of 2009 P.L. 111-5 Section 5004 1902(r)(2) of the Act

| 7. FEDERAL BUDGET IMPACT:

a FRY 167 OF Cre) $0) vb. FFY H” 1O Upti) $0

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Supplement 8a to Attachment 2.6-A, Page Z 4 pri) Supplement Id to Attodument Lle-Pe 9 LO

(pit

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATLTACHMEN! (if Applicable):

N/A

10. SUBJECT OF AMENDMENT:

More Liberal Methods of Treating Americorps Income Under Section 1902(r) (2) of the Act

“11. GOVERNOR’S REVIEW (Check One): (J GOVERNOR’S OFFICE REPORTED NO COMMENT oO COMMENTS OF GOVERNOR'S OFFICE ENCLOSED (J NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

(X] OTHER. AS SPECIFIED: Does not wish to comment.

INCY OFFICIAL:

12. SIGNATURE OE. STATE 4

1B. TYPEDAAME: Jerry Fuller

14. TITLE: Medicaid Director, Alaska Dept. of Health and Social Services _ 15. DATE SUBMITTED: September 28, 2009

16. RETURN TO:

| Alaska Department of Health and Social Services

PO Box 110601 Juneau, AK 99811-0601

FOR REGIONAL, OFFICE USE ONLY

17, DATE RECEIVED:

SEP 28 2009

[18 DATE APPROVED: MAR 18 2010

PLAN APPROVED ~ ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL: J

ee LAL:

21. TYPED NAME;

22. TITLE: Associate Regional Administrator

DAC BARA Ie. RIS KUDS

~ 23. REMARKS:

Division of Medicaid & Children’s Health

3) 05/2010 - Kate Authoruspypim trite Changer,

FORM HCFA-179 (07-92)

STATE PLAN for Title XIX Supplement 8a to ATTACHMENT 2.6-A State of Alaska Page 4

VI. —_ Beginning July 1, 2009, all AmeriCorps payments, including living stipends, are disregarded as income for purposes of determining eligibility for individuals in the all AFDC-related eligibility groups as outlined below: 1902(a)(10)(A)(i)(IID) qualified pregnant women and infants, 1902(a)(10)(A)(i)(IV) poverty-level related pregnant women and infants, 1902(a)(10)(A)(i)(VI) poverty-level related children aged 1 up to 6, 1902(a)(10)(A)(i)(VID poverty-level related children aged 6 up to 19,

1902(a)(10)(A)(ii)(1) and (IV) for children under 1905(a)(i), parents/caretaker relatives under 1905(a)(ii), and pregnant women under 1905(a)(viii),

1902(a)(10)(A)(ii)(VIID State subsidized adoption children,

1902(a)(10)(A)(ii)(IX) optional poverty-level related pregnant women and infants,

1902(a)(10)(A)(ii)(XIV) optional targeted low-income children.

wRTS2

TN No. __09-06 Approval Date: Effective Date: July 1, 2009 Supersedes TN No: __ N/A

STATE PLAN for Title XIX Supplement 14 to ATTACHMENT 2.6-A State of Alaska Page 2a

Less Restrictive Income Standards —con’t:

j. Beginning July 1, 2009, all AmeriCorps payments, including living stipends, are disregarded as income for purposes of determining eligibility.

TN No. _09-06 Approval Date: Effective Date: July 1, 2009 Supersedes TN No. N/A

_____________________________________________________________________________

Table of Contents

State/Territory Name: Alaska

State Plan Amendment (SPA) #: AK-13-0001

(In addition to the SPA noted above, this package contains other state plan amendment approvals)

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

The complete title XXI state plan for Alaska consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Seattle Regional Office 2201 Sixth Avenue, Mail Stop 43 Seattle, Washington 98121 CENTERS FOR MEDICARE & MEDICAID SERVICES D IVISION OF M EDICAID & CHILDREN'S HEALTH OPERATIONS APR 2 9 2013 William J. Streur, Commissioner Department of Health and Social Services Post Office Box 110601 Juneau, Alaska 99811-0601 RE: Alaska State Plan Amendment (SPA) Transmittal Number 13-001 Dear Mr. Streur: The Centers for Medicare & Medicaid Services (CMS) Seattle Regional Office has completed its review of State Plan Amendment (SPA) Transmittal Number 13-001. This transmittal updates the optional state supplement standards for special income level groups consistent with the published 2013 federal poverty levels. This SPA is approved effective January 1, 2013. If you have any additional questions or require any further assistance, please contact me or have your staff contact Maria Garza at (206) 615-2542 or maria.garza@cms.hhs.gov. Sincerely, C::J.~ (\)~ Associate Regional Administrator Division ofMedicaid and Children's Health Operations

DEPARTMENT OF HEALTH & HUMAN SERVICES a Centers for Medicare & Medicaid Services (CMS 7500 Security Boulevard, Mail Stop: S2-26-12

‘CENTERS FOR MEDICARE & MEDICAID SERVICES:

Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

Ms. Barbara Hale FEB 0 6 2014

Medical Assistance Administrator/CHIP Medicaid and Health Care Policy

P.O. Box 110660

Juneau, AK 99811-0660

Dear Ms. Hale:

Iam pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) numbers AK-13-0002 and AK-13-0001, related to Modified Adjusted Gross Income (MAGD Eligibility, have been approved with an effective date of January 1, 2014.

Establish 2101(f) Group:

SPA number AK-13-0002 describes the state’s plan to maintain Medicaid eligibility for children who would otherwise be subject to Section 2101(f) of the Affordable Care Act, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is attached, and should be incorporated within a separate subsection under Section 4.1 of Alaska’s approved CHIP state plan.

XXI Medicaid Expansion

SPA number AK-13-0001 converts the state’s existing income eligibility standards to modified adjusted gross income (MAGI)-equivalent standards, by age group, for children covered in its title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into the state’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section (4.0) of the current CHIP state plan.

Your title XX] project officer is Ms. Victoria Collins. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Collins’ contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services Mail Stop S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-2167

Facsimile: (410) 786-5943

Page 2 — Ms. Barbara Hale

E-mail: Victoria.Collins@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Collins and to Ms. Carol Peverly, Associate Regional Administrator (ARA) in our Seattle Regional Office. Ms. Peverly’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations 2201 6" Avenue, Mail Stop RX-43

Seattle, Washington 98121

If you have additional questions, please contact Ms. Linda Nablo, Director, Division of State Coverage Programs, at (410) 786-5143. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs.

Sincerely,

Eliot Fishman Director

Enclosures ce: Ms. Carol Peverly, ARA, CMS Region X, Seattle

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility AK.0632.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Alaska State Funds: $ Federal Funds: $ Submitted By: Barbara Hale Last Revision Date: Dec 19, 2013 Submit Date: Dec 19, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. AK-13-0001 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457.320(a)(2) and (3) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:150 out of 2000 Set MAGI-based income standards for the following Title XXI funded CHIP age groups: from age 0 to age 1; from age 1 to age 6 and from age 6 to age 19. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/16/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/16/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

Cems. CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Section 2101(f) of the ACA and 42 CFR 457.310(d)

{li Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards The CHIP agency provides coverage for this group of children as follows:

The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to “ Section 2101(f) such that no child in the state will be subject to this provision.

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected ~ from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage in a

separate CHIP (expected to be no later than April 1, 2016 ).

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance

Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Approval Date: FEB 0 6 2014 Effective Date: January 1, 2014 Page 1 of 1

SPA# AK-13-0002

ccCmMs CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

42 CFR 457.320(a)(2) and (3)

Income eligibility for children under the Medicaid Expansion is determined in accordance with the following income standards: There should be no overlaps or gaps for the ages entered.

Age and Household Income Ranges

From Age To Age Above (% FPL) Up to & including (% FPL) 1 159 203 6 159 203 19 124 203

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA# AK-13-0001 Approval Date: FEB 0 6 2014

Effective Date: January 1, 2014

Page 1 of I

State Plan for Title XIX State of Alaska Supplement 6 to A TI ACHMENT 2.6-A (as required by Attachment 2.2-A) Page I Standards for Optional State Supplementary Payments AGED Payment Category Administered Income Level Maximum Payment Notes by Gross Net Level (Reasonable Classification) (Fed/State) 1 Person Couple I Person Couple 1 Person Couple Non-Institutionalized, living State $2130 $4260 $1319 $1954 $1072 $1594 1/ 2/ independently. Non-Institutionalized, living in 1/ 2/ another individuals home and State $2130 $4260 $1090 $1626 $841 $1253 receiving in-kind income in the form of both food and shelter. Institutionalized in a hospital, State $2130 $4260 $199 $399 $200 $400 1/ 2/ SNF, ICF, or ICF/MR In Assisted Living Home State $2130 $4260 $1319 $1954 $810 $1266 II 2/ 1/ Income Disregard: Alaska Native Land Claims Settlement 2/ Additional Eligibility Criteria: Individual must be age 18 or older. TN No. 13-001 Approval Date April 29, 2013 Effective Date January 1, 2013 Supersedes TN No. 12-003

State Plan for Title XIX State of Alaska Supplement 6 to A IT ACHMENT 2.6-A (as required by Attachment 2.2-A) Page2 Standards for Optional State Supplementary Payments BLIND Payment Category Administered Income Level Maximum Payment Notes by Gross Net Level (Reasonable Classification) (Fed/State) 1 Person Couple 1 Person Couple 1 Person Couple Non-Institutionalized, living State $2130 $4260 $1 319 $1954 $1072 $1594 1/ 2/ independently. Non-Institutionalized, living in 1/ 2/ another individuals home and State $2130 $4260 $1090 $1626 $841 $1253 receiving in-kind income in the form of both food and shelter. Institutionalized in a hospital, SNF, State $2 130 $4260 $199 $399 $200 $400 1/ 2/ ICF, or ICF/MR In Assisted Living Home State $2130 . $4260 $1319 $1954 $810 -- $1266 1/ 2/ I/ Income Disregard: Alaska Native Land Claims Settlement 2/ Additional Eligibility Criteria: Individual must be age 18 or older. TN No. 13-001 Approval Date April 29, 2013 Effective Date January 1. 20 13 Supersedes TN No. 12-003

State Plan for Title XIX State of Alaska Supplement 6 to ATTACHMENT 2.6-A (as required by Attachment 2.2-A) Page 3 Standards for Optional State Supplementary Payments DISABLED Payment Category Administered Income Level Maximum Payment Notes by Gross Net Level (Reasonable Classification) (Fed/State) 1 Person Couple 1 Person Couple 1 Person Couple Non-Institutionalized, living State $2130 $4260 $1319 $1954 $1072 $1594 1/ 21 independently. Non-Institutionalized, living in 1/ 2/ another individuals home and State $2130 $4260 $1090 $1626 $841 $1253 receiving in-kind income in the form of both food and shelter. Institutionalized in a hospital, SNF, State $2130 $4260 $199 $399 $200 $400 11 21 ICF, or lCF/MR In Assisted Living Home State $2130 $4260 $1 319 $1954 $810 $1266 1/ 21 1/ Income Disregard: Alaska Native Land Claims Settlement 21 Additional Eligibility Criteria: Individual must be age 18 or older. TN No. 13- 001 Approval Date April 29, 2013 Effective Date January l. 2013 Supersedes TN No. 12-003

L>t::PARTMENT OF llf:ALTII AND HUMAN SERVICES IIJ:/\I.TII CARt:: 1-'INANCINU AOMINI!-.TRATJON FORM APPROVED OMB NO. 0938..()193 TRANSMIIT ALAND NOTICE OF APPROVAL OF I. TRANSMIITAL NUMBER: STATE PLAN MATERIAL I 3 - 00 I 2. STATE Alaska FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF IlEAL TH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 4. PROPOSED EFFECTIVE DATE January I, 20 13 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN 181 AMENDMENT COMPLETE BLOCKS 6 THRlJ 10 IF THIS IS AN AMENDMENT (Se araze Transmilla/ or each amendment) 6. FEDERAL STATUTE/REG LATION CITATION: 7. FEDERAL BUDGET IMPACT: 42 CFR 435.232 a. FFY 13 SO b. FFY 14 $0 8. PAGE NUMBER OF THE PLAN SECTION OR ATI"ACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR A IT ACHMENT (If Applicable): upplemcnt 6 to Attachment 2.6-A, Page J-3 Supplement 6 to Attachment 2.6-A, Page 1-3 10. SUBJECT OF AMENDMENT: Income eligibility standards for ptional state supplementary payments to the aged, blind and disabled 11. GOVERNOR'S VIEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUDMI1TAL 181 OTHER, AS SPECIFIED: Does not wish to comment 12. SIGNAT~E:__.~ - 16. RETURN TO: ~"' ~ Alaska Department of Health and Social Services -,-,,.....,.,.,~,./!;-~~:--::~-----=---:::-------------i 450 I Business Park Blvd., Suite 24, Dldg L 13. TYPED NAME: Margaret Brodie Anchorage, Alaska 99503-7167 14. TITLE: Director Division Health Services, Department of llealth and Social Services, State of Alaska 15. DATESUBMITIED: March 12,2013 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVE 18.DATEAPPROVED: April 29,2013 21 . TYPED NAME: Carol J.C. Peverly 23. REMARKS: FORM HCFA-179 (07-92) tor

_____________________________________________________________________________

Table of Contents

State/Territory Name: Alaska

State Plan Amendment (SPA) #: AK-13-0002

(In addition to the SPA noted above, this package contains other state plan amendment approvals)

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

The complete title XXI state plan for Alaska consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES a Centers for Medicare & Medicaid Services (CMS 7500 Security Boulevard, Mail Stop: S2-26-12

‘CENTERS FOR MEDICARE & MEDICAID SERVICES:

Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

Ms. Barbara Hale FEB 0 6 2014

Medical Assistance Administrator/CHIP Medicaid and Health Care Policy

P.O. Box 110660

Juneau, AK 99811-0660

Dear Ms. Hale:

Iam pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) numbers AK-13-0002 and AK-13-0001, related to Modified Adjusted Gross Income (MAGD Eligibility, have been approved with an effective date of January 1, 2014.

Establish 2101(f) Group:

SPA number AK-13-0002 describes the state’s plan to maintain Medicaid eligibility for children who would otherwise be subject to Section 2101(f) of the Affordable Care Act, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is attached, and should be incorporated within a separate subsection under Section 4.1 of Alaska’s approved CHIP state plan.

XXI Medicaid Expansion

SPA number AK-13-0001 converts the state’s existing income eligibility standards to modified adjusted gross income (MAGI)-equivalent standards, by age group, for children covered in its title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into the state’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section (4.0) of the current CHIP state plan.

Your title XX] project officer is Ms. Victoria Collins. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Collins’ contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services Mail Stop S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-2167

Facsimile: (410) 786-5943

Page 2 — Ms. Barbara Hale

E-mail: Victoria.Collins@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Collins and to Ms. Carol Peverly, Associate Regional Administrator (ARA) in our Seattle Regional Office. Ms. Peverly’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations 2201 6" Avenue, Mail Stop RX-43

Seattle, Washington 98121

If you have additional questions, please contact Ms. Linda Nablo, Director, Division of State Coverage Programs, at (410) 786-5143. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs.

Sincerely,

Eliot Fishman Director

Enclosures ce: Ms. Carol Peverly, ARA, CMS Region X, Seattle

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility AK.0633.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Alaska State Funds: $ Federal Funds: $ Submitted By: Barbara Hale Last Revision Date: Dec 19, 2013 Submit Date: Dec 19, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. AK-13-0002 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Section 2101(f) of the ACA and 42 CFR 457.310(d) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:305 out of 2000 Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. Department has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to Section 2101(f) h th t hild i th t t ill b bj t t thi Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/16/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/16/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

Cems. CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Section 2101(f) of the ACA and 42 CFR 457.310(d)

{li Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards The CHIP agency provides coverage for this group of children as follows:

The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to “ Section 2101(f) such that no child in the state will be subject to this provision.

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected ~ from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage in a

separate CHIP (expected to be no later than April 1, 2016 ).

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance

Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Approval Date: FEB 0 6 2014 Effective Date: January 1, 2014 Page 1 of 1

SPA# AK-13-0002

ccCmMs CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

42 CFR 457.320(a)(2) and (3)

Income eligibility for children under the Medicaid Expansion is determined in accordance with the following income standards: There should be no overlaps or gaps for the ages entered.

Age and Household Income Ranges

From Age To Age Above (% FPL) Up to & including (% FPL) 1 159 203 6 159 203 19 124 203

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA# AK-13-0001 Approval Date: FEB 0 6 2014

Effective Date: January 1, 2014

Page 1 of I

_____________________________________________________________________________

Table of Contents State/Territory Name: Alaska State Plan Amendment (SPA) #: 13-0027-MM1 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice (delete if not applicable) 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Seattle Regional Office 2201 Sixth Avenue, MS/RX -43 Seattle, WA 98121 Cl\tS CENTERS FOR MEDICARE & MEDICAID SERVICES DIVISION OF MEDICAID & CHILDREN'S HEALTH OPERATIONS William J. Streur, Commissioner Department of Health and Social Services Post Office Box 110601 Juneau, Alaska 99811-0601 }AN 3 1 2014 RE: Alaska State Plan Amendment (SPA) Transmittal Number 13-0027-MMl Dear Mr. Streur: The Centers for Medicare & Medicaid Services (CMS) has completed its review of State Plan Amendment (SPA) Transmittal Number 13-0027-MMl. This SPA incorporates mandatory and optional Modified Adjusted Gross Income (MAGI) based eligibility groups into the Medicaid State Plan in accordance with the Affordable Care Act. This SPA is approved effective January 1, 2014. The new pages listed below should be placed in a separate section at the back of the state plan: • S14, Pages 1-6 • S25, Pages 1-5 • S28, Pages 1-2 • S30, Pages 1-5 • S32, Page 1 • S33, Page 1 • S50, Page 1 • S51, Page 1 • S52, Pages 1-7 • S53, Page 1 • S54, Pages 1-3 • S55, Page 1 • S57, Page 1 • S59, Page 1 Also, the new page titled, "Superseding Pages of the State Plan Material", should be placed in a separate section in front of the state plan. If you have any additional questions or require further assistance, please contact me or have your staff contact Janice Adams at (206) 615-2541 or janice.adams@cms.hhs.gov.

cc: Sincerely,

Associate Regional Administrator Division of Medicaid and Children's Health Operations Craig J. Christensen, DPM, CEM, Deputy Administrator Gennifer Moreau-Johnson, State Plan Coordinator

State/Territory name: Alaska Submitted By: Gennifer Moreau Last Revision Date: Jan 29, 2014 Submit Date: Dec 24, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. AK-13-0027 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 1902(a)(10)(A)(i)(I) and 1913 (b) and (d) 42 CFR 435.1110 1902 (a)(10)(A)(i)(III) and (IV) and (IX) 42 CFR 43 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 275000.00 Second Year 2015 $ 1100000.00 Subject of Amendment MAGI realted SPA's MAGI based eligibity groups Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Does not wish to comment. Signature of State Agency Official TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

1

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

13-0027-MM

STATE:

Alaska

Pages or sections of pages being superseded by S25, S28, S30, S52, S53, S54, and S14 and related pages or sections of pages being deleted as obsolete

State Plan Section

Complete Pages Removed

Partial Pages Removed Attachment 2.2-A

Page 1 Page 3 Page 3a Page 4 Page 4a Page 12 Page 13 Page 13a Page 14 Page 14a Page 21 Page 23 Page 23b

Page 2, A.2.b Page 2, A.2.c Page 2a, A.3 Page 5, A.10 Page 9c, B.1 for “Caretaker relatives” and “Pregnant women” Page 20, B.14 Page 23c, B.19 Page 23d, B.21 Page 25, C.4

Supplement 1 to Attachment 2.2-A

Page 1

Attachment 2.6-A

Page 3b Page 11a Page 19 Page 19a Page 19b Page 21

Page 1, A.2.a(i) and (iii) Page 6 related to AFDC recipients, pregnant women, infants, and children Page 7, 1.a(1) and (2) Page 12, C.1.e(2) Page 18, C.5.e Page 25, C.11.a(3) Supplement 1 to Attachment 2.6-A Pages 1- 3, 4

Supplement 2 to Attachment 2.6-A

Pages 1-5

Supplement 8a to Attachment 2.6-A Page 5 Page 1, II for AFDC- related groups, III Page 2, V TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

2

Page 3, f. for AFDC- related groups, g., and h. Page 4 for AFDC- related groups Supplement 8b to Attachment 2.6-A

Page 1, IIPage 2, II for AFDC-related groups, III

Supplement 14 to Attachment 2.6-A Page 1-4

TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 1 of 6 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 AFDC Income Standards S14 Enter the AFDC Standards below. All states must enter: MAGI-equivalent AFDC Payment Standard in Effect As of May 1, 1988 and AFDC Payment Standard in Effect As of July 16, 1996 Entry of other standards is optional. MAGI-equivalent AFDC Payment Standard in Effect As of May 1, 1988 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the statewide standard Household size Standard ($) + 1 446 x + 2 995 x + 3 1,214 x + 4 1,433 x + 5 1,653 x + 6 1,872 x + 7 2,091 x Additional incremental amount Yes No Increment amount $ 216 The dollar amounts increase automatically each year Yes No AFDC Payment Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 2 of 6 Medicaid Eligibility The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the standard by living arrangement Remove Living Arrangement Name of living arrangement Adult Not Included Description Adult Not Included Household size Standard ($) + 1 452 x + 2 554 x + 3 656 x + 4 758 x Additional incremental amount Yes No Increment amount $ 102 Remove Living Arrangement Name of living arrangement Adult Included Description Adult Included Household size Standard ($) + 1 x + 2 821 x + 3 923 x + 4 1,025 x + 5 1,127 x Additional incremental amount Yes No Increment amount $ 102 Remove Living Arrangement TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 3 of 6 Medicaid Eligibility Name of living arrangement Single Adult Description Single Adult Household size Standard ($) + 1 514 x Additional incremental amount Yes No Increment amount $ Add Living Arrangement The dollar amounts increase automatically each year Yes No MAGI-equivalent AFDC Payment Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the standard by living arrangement Remove Living Arrangement Name of living arrangement Adult Not Included Description Adult Not Included Household size Standard ($) + 1 640 x + 2 880 x + 3 1,121 x TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 4 of 6 Medicaid Eligibility + 4 1,361 x Additional incremental amount Yes No Increment amount $ 235 Remove Living Arrangement Name of living arrangement Adult Included Description Adult Included Household size Standard ($) + 1 x + 2 1,174 x + 3 1,421 x + 4 1,668 x + 5 1,916 x Additional incremental amount Yes No Increment amount $ 352 Remove Living Arrangement Name of living arrangement Single Adult Description Single Adult Household size Standard ($) + 1 692 x Additional incremental amount Yes No Increment amount $ Add Living Arrangement The dollar amounts increase automatically each year Yes No AFDC Need Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 5 of 6 Medicaid Eligibility Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date. Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No MAGI-equivalent AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 6 of 6 Medicaid Eligibility TANF payment standard Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No MAGI-equivalent TANF payment standard Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 1 of 5 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Parents and Other Caretaker Relatives S25 42 CFR 435.110 1902(a)(10)(A)(i)(I) 1931(b) and (d) Parents and Other Caretaker Relatives - Parents and other caretaker relatives of dependent children with household income at or below a standard established by the state. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ Are parents or other caretaker relatives (defined at 42 CFR 435.4), including pregnant women, of dependent children (defined at 42 CFR 435.4) under age 18. Spouses of parents and other caretaker relatives are also included. ■ The state elects the following options: This eligibility group includes individuals who are parents or other caretakers of children who are 18 years old, provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training. Options relating to the definition of caretaker relative (select any that apply): The definition of caretaker relative includes the domestic partner of the parent or other caretaker relative, even after the partnership is terminated. Definition of domestic partner: The definition of caretaker relative includes other relatives of the child based on blood (including those of half-blood), adoption or marriage. Description of other relatives: DEFINITION OF A CARETAKER RELATIVE

A caretaker relative is a person in one of the following groups:

A person who is related to the dependent child by full or half-blood and who is within the fifth degree of kinship to the child as follows: Relative Degree of Relative Kinship 1st degree: Mother, Father 2nd degree: Sister, Brother, Grandparent 3rd degree: Great-grandparent, Uncle or Aunt, Nephew or Niece 4th degree: Great-great-grandparent, Great uncle or great aunt, First cousin 5th degree: Great-great-great grandparent, Great-great uncle or great-great aunt, First cousin once removed (child of First cousin)

Stepfather, stepmother, stepbrother, or stepsister. TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 2 of 5 Medicaid Eligibility Persons who legally adopt a child or his parent as well as the natural and other legally adopted children of such persons, and other relatives of the adoptive parents in accordance with state law. Spouses of any persons named above, even after the marriage is terminated by death or divorce. Biological relatives, whose legal and financial relationship to the dependent child that has been severed through an adoption, may still be considered as caretaker relatives. Note:

A caretaker relative does not include a guardian, friend, neighbor, non-related godparent, second cousin, or a person who has been given a dependent child. The definition of caretaker relative includes any adult with whom the child is living and who assumes primary responsibility for the dependent child's care. Options relating to the definition of dependent child (select the one that applies): The state elects to eliminate the requirement that a dependent child must be deprived of parental support or care by reason of the death, physical or mental incapacity, or absence from the home or unemployment of at least one parent. The child must be deprived of parental support or care, but a less restrictive standard is used to measure unemployment of the parent (select the one that applies): Have household income at or below the standard established by the state. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ Income standard used for this group ■ Minimum income standard ■ The minimum income standard used for this group is the state's AFDC payment standard in effect as of May 1, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in S14 AFDC Income Standards. The state certifies that it has submitted and received approval for its converted May 1, 1988 AFDC payment standard. ✔ An attachment is submitted. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for parents and other caretaker relatives to MAGI-equivalent standards and the determination of the maximum income standard to be used for parents and other caretaker relatives under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this eligibility group is: TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 3 of 5 Medicaid Eligibility The state's effective income level for section 1931 families under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for section 1931 families under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date, converted to a MAGI- equivalent standard. The standard is described in S14 AFDC Income Standards. The state's TANF payment standard, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. Other dollar amount % Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the statewide standard TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 4 of 5 Medicaid Eligibility Household size Standard ($) + 1 1,333 x + 2 2,082 x + 3 2,492 x + 4 2,902 x + 5 3,312 x + 6 3,722 x + 7 4,131 x + 8 4,541 x + 9 4,951 x + 10 5,361 x Additional incremental amount Yes No Increment amount $ 385 The dollar amounts increase automatically each year Yes No The basis of the increase is CPI-U Other basis Name: CPI-U plus adjustment for annual dividend payment to Alaska residents The annual increase occurs in the month and day indicated: Every Month : January Day : 1 Income standard chosen: ■ Indicate the state's income standard used for this eligibility group: The minimum income standard The maximum income standard The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in S14 AFDC Income Standards. Another income standard in-between the minimum and maximum standards allowed There is no resource test for this eligibility group. ■ TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 5 of 5 Medicaid Eligibility Presumptive Eligibility ■ The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Pregnant Women S28 42 CFR 435.116 1902(a)(10)(A)(i)(III) and (IV) 1902(a)(10)(A)(ii)(I), (IV) and (IX) 1931(b) and (d) 1920 Pregnant Women - Women who are pregnant or post-partum, with household income at or below a standard established by the state. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must be pregnant or post-partum, as defined in 42 CFR 435.4. ■ Pregnant women in the last trimester of their pregnancy without dependent children are eligible for full benefits under this group in accordance with section 1931 of the Act, if they meet the income standard for state plan Parents and Other Caretaker Relatives at 42 CFR 435.110. Yes No MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI-Based Income Methodologies, completed by the state. ■ Income standard used for this group ■ Minimum income standard (Once entered and approved by CMS, the minimum income standard cannot be changed.) ■ The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for pregnant women, or as of July 1, 1989, had authorizing legislation to do so. Yes No The minimum income standard for this eligibility group is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for pregnant women to MAGI-equivalent standards and the determination of the maximum income standard to be used for pregnant women under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this eligibility group is: The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10) (A)(ii)(I) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 2 of 2 Medicaid Eligibility The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10) (A)(ii)(I) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 185% FPL The amount of the maximum income standard is: 200 % FPL Income standard chosen ■ Indicate the state's income standard used for this eligibility group: The minimum income standard The maximum income standard Another income standard in-between the minimum and maximum standards allowed. There is no resource test for this eligibility group. ■ Benefits for individuals in this eligibility group consist of the following: ■ All pregnant women eligible under this group receive full Medicaid coverage under this state plan. Pregnant women whose income exceeds the income limit specified below for full coverage of pregnant women receive only pregnancy-related services. Presumptive Eligibility ■ The state covers ambulatory prenatal care for individuals under this group when determined presumptively eligible by a qualified entity. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 1 of 5 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Infants and Children under Age 19 S30 42 CFR 435.118 1902(a)(10)(A)(i)(III), (IV), (VI) and (VII) 1902(a)(10)(A)(ii)(IV) and (IX) 1931(b) and (d) Infants and Children under Age 19 - Infants and children under age 19 with household income at or below standards established by the state based on age group. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Children qualifying under this eligibility group must meet the following criteria: ■ Are under age 19 ■ Have household income at or below the standard established by the state. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ Income standard used for infants under age one ■ Minimum income standard ■ The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for infants under age one, or as of July 1, 1989, had authorizing legislation to do so. Yes No The minimum income standard for infants under age one is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for infants under age one to MAGI-equivalent standards and the determination of the maximum income standard to be used for infants under age one. ✔ An attachment is submitted. The state's maximum income standard for this age group is: The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 2 of 5 Medicaid Eligibility The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 185% FPL Enter the amount of the maximum income standard: 177 % FPL Income standard chosen ■ The state's income standard used for infants under age one is: The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10) (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10) (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. Income standard for children age one through age five, inclusive ■ Minimum income standard ■ TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 3 of 5 Medicaid Eligibility The minimum income standard used for this age group is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for children age one through five to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age one through five. ✔ An attachment is submitted. The state's maximum income standard for children age one through five is: The state's highest effective income level for coverage of children age one through five under sections 1931 (low- income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's highest effective income level for coverage of children age one through five under sections 1931 (low- income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. Enter the amount of the maximum income standard: 177 % FPL Income standard chosen ■ The state's income standard used for children age one through five is: The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 4 of 5 Medicaid Eligibility If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. Income standard for children age six through age eighteen, inclusive ■ Minimum income standard ■ The minimum income standard used for this age group is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for children age six through eighteen to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age six through age eighteen. ✔ An attachment is submitted. The state's maximum income standard for children age six through eighteen is: The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 133% FPL Enter the amount of the maximum income standard: 177 % FPL Income standard chosen ■ TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 5 of 5 Medicaid Eligibility The state's income standard used for children age six through eighteen is: The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. There is no resource test for this eligibility group. ■ Presumptive Eligibility ■ The state covers children when determined presumptively eligible by a qualified entity. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Adult Group S32 1902(a)(10)(A)(i)(VIII) 42 CFR 435.119 The state covers the Adult Group as described at 42 CFR 435.119. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Former Foster Care Children S33 42 CFR 435.150 1902(a)(10)(A)(i)(IX) Former Foster Care Children - Individuals under the age of 26, not otherwise mandatorily eligible, who were on Medicaid and in foster care when they turned age 18 or aged out of foster care. ■ The state attests that it operates this eligibility group under the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ Are under age 26. ■ Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. ■ Were in foster care under the responsibility of the state or Tribe and were enrolled in Medicaid under the state's state plan or 1115 demonstration when they turned 18 or at the time of aging out of that state's or Tribe's foster care program. ■ The state elects to cover children who were in foster care and on Medicaid in any state at the time they turned 18 or aged out of the foster care system. Yes No The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Individuals above 133% FPL S50 1902(a)(10)(A)(ii)(XX) 1902(hh) 42 CFR 435.218 Individuals above 133% FPL - The state elects to cover individuals under 65, not otherwise mandatorily or optionally eligible, with income above 133% FPL and at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.218. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Optional Coverage of Parents and Other Caretaker Relatives S51 42 CFR 435.220 1902(a)(10)(A)(ii)(I) Optional Coverage of Parents and Other Caretaker Relatives - The state elects to cover individuals qualifying as parents or other caretaker relatives who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.220. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 1 of 7 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Reasonable Classification of Individuals under Age 21 S52 42 CFR 435.222 1902(a)(10)(A)(ii)(I) 1902(a)(10)(A)(ii)(IV) Reasonable Classification of Individuals under Age 21 - The state elects to cover one or more reasonable classifications of individuals under age 21 who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.222. Yes No The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must qualify under a reasonable classification by meeting the following criteria: ■ Be under age 21, or a lower age, as defined within the reasonable classification. ■ Have household income at or below the standard established by the state, if the state has an income standard for the reasonable classification. ■ Not be eligible and enrolled for mandatory coverage under the state plan. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ The state covered at least one reasonable classification under this eligibility group under its Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013, with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age. Yes No The state also covered at least one reasonable classification under this group in the Medicaid state plan as of March 23, 2010 with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age. Yes No Reasonable Classifications Covered in the Medicaid State Plan as of March 23, 2010 The state attaches the approved pages from the Medicaid state plan as of March 23, 2010 to indicate the age groups, reasonable classifications, and income standards used at that time for this eligibility group. ✔ An attachment is submitted. Current Coverage of All Children under a Specified Age TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 2 of 7 Medicaid Eligibility The state covers all children under a specified age limit, equal to or higher than the age limit and/or income standard used in the Medicaid state plan as of March 23, 2010, provided the income standard is higher than the current mandatory income standard for the individual's age. The age limit and/or income standard used must be no higher than any age limit and/or income standard covered in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Higher income standards may include the disregard of all income. Yes No Indicate below the age under which all children are covered under this eligibility group, based on a specific age group used previously in the Medicaid state plan or under a Demonstration, which is equal to or higher than the age group for coverage of all children in the Medicaid state plan as of March 23, 2010. Under age 21 Under age 20 Under age 19 Under age 18 Enter the income standard used for this age group. The standard must be higher than the mandatory income standard for the individual's age, not more restrictive than that used in the Medicaid state plan as of March 23, 2010 and not less restrictive than that used in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Income standard used ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state certifies that it has submitted and received approval for its converted income standards for this classification of children to MAGI-equivalent standards and the determination of the maximum income standard to be used for this classification of children under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: The state's effective income level for this classification of children under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 3 of 7 Medicaid Eligibility The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI- equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. Other dollar amount % Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the statewide standard TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 4 of 7 Medicaid Eligibility Household size Standard ($) + 1 1,333 x + 2 2,082 x + 3 2,492 x + 4 2,902 x + 5 3,312 x + 6 3,722 x + 7 4,131 x + 8 4,541 x + 9 4,951 x + 10 5,361 x Additional incremental amount Yes No Increment amount $ 385 The dollar amounts increase automatically each year Yes No The basis of the increase is CPI-U Other basis Name: CPI-U plus adjustment for annual dividend payment to Alaska residents The annual increase occurs in the month and day indicated: Every Month : January Day : 1 Income standard chosen ■ Individuals qualify under this classification under the following income standard: The minimum standard. The maximum income standard. If not chosen as the maximum income standard, the state's effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 5 of 7 Medicaid Eligibility If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. Current Coverage of Reasonable Classifications Covered in the Medicaid State Plan as of March 23, 2010 The state covers reasonable classifications of children previously covered in the Medicaid state plan as of March 23, 2010, with income standards higher than the current mandatory income standard for the age group. Age limits and income standards are equal to or higher than the Medicaid state plan as of March 23, 2010, but no higher than any age limit and/or income standard for this classification covered in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Higher income standards may include the disregard of all income. Yes No Other Reasonable Classifications Previously Covered The state covers reasonable classifications of children not covered in the Medicaid state plan as of March 23, 2010, but covered under the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013 with an income standard higher than the current mandatory income standard for the age group. Yes No The additional previously covered reasonable classifications to be included are: Additional Previously Covered Reasonable Classifications Included Reasonable Classifications of Children S11 Individuals for whom public agencies are assuming full or partial financial responsibility. Individuals in adoptions subsidized in full or part by a public agency Individuals in nursing facilities, if nursing facility services are provided under this plan TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 6 of 7 Medicaid Eligibility Individuals receiving active treatment as inpatients in psychiatric facilities or programs, if such services are provided under this plan Other reasonable classifications Name of classification Description Age Limit + 2101(f)-Like Children Children under age 19 who were enrolled in Medicaid on 12/31/2013 and would otherwise become ineligible for Medicaid at their first redetermination using MAGI methodologies solely due to the loss of income disregards will remain Medicaid eligible until their next redetermination using MAGI methodologies. Under age 19 x Enter the income standard used for these classifications (which must be higher than the mandatory standard for the child's age but may be no higher than the highest standard used in the state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013). Click here once S11 form above is complete to view the income standards form. 2101(f)-Like Children Income standard used ■ Minimum income standard ■ The minimum income standard for this classification of children must exceed the lowest income standard chosen for children under this age under the Infants and Children under Age 19 eligibility group. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No No income test was used (all income was disregarded) for this classification under: ■ (check all that apply) The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. A Medicaid 1115 Demonstration as of March 23, 2010. A Medicaid 1115 Demonstration as of December 31, 2013. TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 7 of 7 Medicaid Eligibility The state's maximum standard for this classification of children is no income test (all income is disregarded). Income standard chosen ■ Individuals qualify under this classification under the following income standard: This classification does not use an income test (all income is disregarded). Another income standard higher than both the minimum income standard and the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. Additional new age groups or reasonable classifications covered If the state has not elected to cover the Adult Group (42 CFR 435.119), it may elect to cover additional new age groups or reasonable classifications that have not been covered previously. If the state covers the Adult Group, this additional option is not available, as the standard for the new age groups or classifications is lower than that used for mandatory coverage. The state does not cover the Adult Group and elects the option to include in this eligibility group additional age groups or reasonable classifications that have not been covered previously in the state plan or under a Medicaid 1115 Demonstration. Any additional age groups or reasonable classifications not previously covered are restricted to the AFDC income standard from July 16, 1996, not converted to a MAGI-equivalent standard. Yes No There is no resource test for this eligibility group. ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Children with Non IV-E Adoption Assistance S53 42 CFR 435.227 1902(a)(10)(A)(ii)(VIII) Children with Non IV-E Adoption Assistance - The state elects to cover children with special needs for whom there is a non IV-E adoption assistance agreement in effect with a state, who were eligible for Medicaid, or who had income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.227. Yes No The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ The state adoption agency has determined that they cannot be placed without Medicaid coverage because of special needs for medical or rehabilitative care; ■ Are under the following age (see the Guidance for restrictions on the selection of an age): ■ Under age 21 Under age 20 Under age 19 Under age 18 MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ The state covered this eligibility group in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. Yes No Individuals qualify under this eligibility group if they were eligible under the state's approved state plan prior to the execution of the adoption agreement. ■ The state used an income standard or disregarded all income for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No There is no resource test for this eligibility group. ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 1 of 3 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Optional Targeted Low Income Children S54 1902(a)(10)(A)(ii)(XIV) 42 CFR 435.229 and 435.4 1905(u)(2)(B) Optional Targeted Low Income Children - The state elects to cover uninsured children who meet the definition of optional targeted low income children at 42 CFR 435.4, who have household income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.229. Yes No The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must not be eligible for Medicaid under any mandatory eligibility group. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ The state covered this eligibility group in the state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state also covered this eligibility group in the state plan as of March 23, 2010. Yes No Until October 1, 2019, states must include at least those individuals covered as of March 23, 2010, but may cover additional individuals. Effective October 1, 2019, states may reduce or eliminate coverage for this group. ■ Individuals are covered under this eligibility group, as follows: ■ All children under age 18 or 19 are covered: The reasonable classification of children covered is: Under age 19 Under age 18 Income standard used for this classification ■ Minimum income standard ■ The income standard for this classification of children must exceed the lowest income standard chosen for children in the age group selected above, under the mandatory Infants and Children under Age 19 eligibility group. Maximum income standard ■ TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 2 of 3 Medicaid Eligibility The state certifies that it has submitted and received approval for its converted income standard(s) for this classification of children to MAGI-equivalent standards and the determination of the maximum income standard to be used for this classification of children under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: The state's effective income level for this classification of children under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for this classification of children under the Medicaid State Plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for this classification of children under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for this classification of children under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 200% FPL. A percentage of the FPL which may exceed the Medicaid Applicable Income Level, defined in section 2110(b)(4) of the Act, but by no more than 50 percentage points. The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: ■ % FPL 203 Income standard chosen, which must exceed the minimum income standard ■ Individuals qualify under the following income standard: The maximum income standard. The state's effective income level for this eligibility group under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the effective income level used under the state plan as of March 23, 2010, the state's effective income level for this eligibility group under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the effective income level used under the state plan as of March 23, 2010, the state's effective income level for this eligibility group under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the effective income level used under the state plan as of March 23, 2010, the state's effective income level for this eligibility group under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the effective income level used under the state plan as of March 23, 2010, 200% FPL. TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 3 of 3 Medicaid Eligibility If higher than the effective income level used under the state plan as of March 23, 2010, a percentage of the FPL which may exceed the Medicaid Applicable Income Level, defined in section 2110(b)(4) of the Act, but by no more than 50 percentage points. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income level for this eligibility group in the state plan as of March 23, 2010. The income standard for this eligibility group is: 203 % FPL There is no resource test for this eligibility group. ■ Presumptive Eligibility ■ Presumptive eligibility for this group depends upon the selection of presumptive eligibility for the Infants and Children under Age 19 eligibility group. If presumptive eligibility is done for that group, it is done for this group under the same provisions. ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Individuals with Tuberculosis S55 1902(a)(10)(A)(ii)(XII) 1902(z) Individuals with Tuberculosis - The state elects to cover individuals infected with tuberculosis who have income at or below a standard established by the state, limited to tuberculosis-related services. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Independent Foster Care Adolescents S57 42 CFR 435.226 1902(a)(10)(A)(ii)(XVII) Independent Foster Care Adolescents - The state elects to cover individuals under an age specified by the state, less than age 21, who were in state-sponsored foster care on their 18th birthday and who meet the income standard established by the state and in accordance with the provisions described at 42 CFR 435.226. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Individuals Eligible for Family Planning Services S59 1902(a)(10)(A)(ii)(XXI) 42 CFR 435.214 Individuals Eligible for Family Planning Services - The state elects to cover individuals who are not pregnant, and have household income at or below a standard established by the state, whose coverage is limited to family planning and related services and in accordance with provisions described at 42 CFR 435.214. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN NO: 13-0027-MM1 Approval Date: 1/31/2014 Effective Date: 1/01/2014

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Table of Contents State/Territory Name: Alaska State Plan Amendment (SPA) #: 13-0028 This file contains the following documents in the order listed: 1) Approval Letter 2) Additional Companion letter (delete if not applicable) 3) CMS 179 Form/Summary Form (with 179-like data) 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Seattle Regional Office 2201 Sixth A venue, Mail Stop 43 Seattle, Washington 98121 DIVISION OF MEDICAID & CHILDREN'S HEALTH OPERATIONS William J. Streur, Commissioner Department of Health and Social Services Post Office Box 110601 Juneau,AJaska 99811-0601 CENTERS FOR MEDICARE & MEDICAID SERVICES FEB 0 5 2014 RE: Alaska State Plan Amendment (SPA) Transmittal Number 13-0028-MM Dear Mr. Streur: The Centers for Medicare & Medicaid Services (CMS) has completed its review of State Plan Amendment (SPA) Transmittal Number 13-0028-MM. This transmittal incorporates the Modified Adjusted Gross Income (MAGI)-Based eligibility process requirements, including the single streamlined application, into the Medicaid State Plan in accordance with the Affordable Care Act. This SPA is approved effective October 1, 2013. The approval of SPA 13-0028-MM includes the state's use of the single streamlined paper application developed by the Secretary in accordance with section 1413(b)(l)(A) of the Affordable Care Act, as well as the full approval of your state's paper alternative application used to apply for multiple human service programs. Until April1, 2014, the state will use an interim online alternative single streamlined application and will submit a revised alternative single streamlined online application that will address CMS concerns outlined in the companion letter issued with this SPA approval. The new state plan pages for the S94 amendment and attachments should be incorporated within a separate section at the end of Alaska's approved state plan: • Alaska's S94, pages S94-1 and S94-2 • Attachment 1 -Paper application used to apply for multiple human service programs: GenSOc-redesign-09-18-13. • Attachment 2- Statement of use with respect to the alternative single streamlined online application - AK Online Interim Application Placeholder Doc.doc

CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this SPA, please contact me, or have your staff contact Maria Garza at (206) 615-2542 orMaria.Garza@cms.hhs.gov. cc: Sincerely, 21~<V~ Associate Regional Administrator Division of Medicaid and Children's Health Operations Brodie, Margaret C (HSS) ~llmodie@ala.skagov Steele, Jim E (HSS) jjinnm.~~gmr Etheridge, Deb J (HSS)«ftdl».dllmiidge@a.Jaska..gov

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Seattle Regional Office 2201 Sixth A venue, Mail Stop 43 Seattle, Washington 98121 ONJERS FOR MEDICARE & MEDICAID SERVICES DIVISION OF MEDICAID & CHILDREN'S HEALTH OPERATIONS William J. Streur, Commissioner Department ofHealth and Social Services Post Office Box 110601 Juneau,AJaska 99811-0601 FEB 0 5 2014 RE: Companion Letter for Alaska State Plan Amendment (SPA) Transmittal Number 13-0028-MM Dear Mr. Streur: This letter is being sent as a companion to the Centers for Medicare & Medicaid Services' (CMS) letter dated February 5, 2014, which approved State Plan Amendment (SPA) Transmittal Number 13-0028- MM, Eligibility Process. Our review of this submission included a review of the state's use of the single streamlined paper application developed by the Secretary in accordance with section 1413(b)(l)(A) of the Affordable Care Act, as well as the full approval of your state's paper alternative application used to apply for multiple human service programs. Until April 1, 2014, the state is authorized to use an interim alternative single streamlined online application. This interim application needs to be revised to reflect the following changes: Necessary changes: Completion Date 1. Remove citizenship, immigration status, and residency questions for April 1,2014 non-applicant household members. 2. Remove income questions regarding the amount of SSI income, April 1, 2014 child support income, worker's compensation, VA, and gifts received. 3. Remove absent parent questions. April 1, 2014

4. Update the application to allow for individuals to identify themselves as American Indians and Alaska Natives for the purpose of cost-sharing protections, and specifically identify American April 1, 2014 Indian and Alaska Native income not countable for Medicaid and CHIP income determinations. 5. Questions regarding "other health coverage:" Please revise questions to inquire about offers of coverage from an April 1, 2014 employer, even if not currently enrolled. In addition, for individuals who are currently enrolled in health coverage, revise the application to include what type of coverage the individual currently has. Options such as- COBRA, retiree, Peace Corps, VA, among other choices, will be included as answer choices for this question. Please submit the revised alternative online applications to CMS for review no later than March 1, 2014 to ensure approval by April 1, 2014. We continue to be available to provide technical assistance. If you have any questions about your application, please contact Dena Greenblum at IIDmm .<G'tnmlllibi~<tlllll5.~ or ( 41 0) 786-8684. If you have any questions about this letter or need any additional information, please contact me, or have your staff contact Maria Garza either by phone at 206-615-2542 or by email at h\1blrim~<tlllll5..1hihB. .g,w~ . Sincerely, ~0~~~ Associate Regional Administrator Division of Medicaid and Children's Health Operations cc: Brodie, Margaret C (HSS) ~llmodie@alaskagov Steele, Jim E (HSS)jjinnm.~~gov Etheridge, Deb J (HSS)«<kW .. ~:znl! gov

State/Territory name: Alaska Submitted By: Gennifer Moreau Last Revision Date: Jan 17, 2014 Submit Date: Nov 12, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. AK-13-0028 Proposed Effective Date 10/01/2013 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 435.10 42 CFR 435, subpart J and subpart M Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment Single Streamlined Application Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Does not wish to comment Signature of State Agency Official

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 General Eligibility Requirements Eligibility Process S94 42 CFR 435, Subpart J and Subpart M Eligibility Process The state meets all the requirements of 42 CFR 435, Subpart J for processing applications, determining and verifying eligibility, and furnishing Medicaid. ✔ Application Processing Indicate which application the agency uses for individuals applying for coverage who may be eligible based on the applicable modified adjusted gross income standard. The single, streamlined application for all insurance affordability programs, developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act An alternative single, streamlined application developed by the state in accordance with section 1413(b)(1)(B) of the Affordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary. An attachment is submitted. An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs. An attachment is submitted. Indicate which application the agency uses for individuals applying for coverage who may be eligible on a basis other than the applicable modified adjusted gross income standard: The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary. An attachment is submitted. An application designed specifically to determine eligibility on a basis other than the applicable MAGI standard which minimizes the burden on applicants, submitted to the Secretary. An attachment is submitted. The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in 42 CFR 435.1200(f), by telephone, via mail, and in person. The agency also accepts applications by other electronic means: Yes No TN No: 13-0028-MM Approval Date:2/5/14 Effective Date: 10/01/13

Page 2 of 2 Medicaid Eligibility Indicate the other electronic means below: Name of Method Description + Fax Document received via facsimile. x + Scan Application received via e-mail. x The agency has procedures to take applications, assist applicants and perform initial processing of applications for the eligibility groups listed below at locations other than those used for the receipt and processing of applications for the title IV-A program, including Federally-qualified health centers and disproportionate share hospitals. ✔ Parents and Other Caretaker Relatives Pregnant Women Infants and Children under Age 19 Redetermination Processing Redeterminations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 435.916: ✔ Once every 12 months ■ Without requiring information from the individual if able to do so based on reliable information contained in the individual's account or other more current information available to the agency ■ If the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available. ■ Redeterminations of eligibility for individuals whose financial eligibility is not based on the applicable modified adjusted gross income standard are performed, consistent with 42 CFR 435.916 (check all that apply): ■ Once every 12 months Once every 6 months Other, more often than once every 12 months Coordination of Eligibility and Enrollment The state meets all the requirements of 42 CFR 435, Subpart M relative to coordination of eligibility and enrollment between Medicaid, CHIP, Exchanges and other insurance affordability programs. The single state agency has entered into agreements with the Exchange and with other agencies administering insurance affordability programs. ✔ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No: 13-0028-MM Approval Date:2/5/14 Effective Date: 10/01/13

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Table of Contents State/Territory Name: Alaska State Plan Amendment (SPA) #: 13-0029-MM3 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Seattle Regional Office 2201 Sixth A venue, Mail Stop 43 Seattle, Washington 98121 CENTERS FOR MEDICARE & MEDICAID SERVICES DIVISION OF MEDICAID & CHILDREN'S HEALTH OPERATIONS William J. Streur, Commissioner Department of Health and Social Services Post Office Box 110601 Juneau, Alaska 99811-0601 .JAN 1 0 2014 RE: Alaska State Plan Amendment (SPA) Transmittal Number 13-0029-MM3 Dear Mr. Streur: The Centers for Medicare & Medicaid Services (CMS) Seattle Regional Office has completed its review of State Plan Amendment (SPA) Transmittal Number 13-0029-MM3. This transmittal incorporates the Modified Adjusted Gross Income (MAGI)-Based Methodologies into the Medicaid State Plan in accordance with the Affordable Care Act. This SPA is approved effective January 1, 2014. The new pages, S 10-1 and S 10-2, should be placed in a separate section at the back of the state plan. Also, the new page titled, Superseding Pages of State Plan Material, should be placed in a separate section in the front of the state plan. This page incorporates the following statement into the Alaska State Plan: "Notwithstanding any other provisions of the Alaska Medicaid State Plan, the financial eligibility methodologies described in State Plan Amendment, AK-13-0029-MM3 will apply to all MAGI-based eligibility groups covered under Alaska's Medicaid State Plan. The MAGI financial methodologies set forth in 42 CFR § 435.603 apply to everyone except those individuals described at 42 CFR § 435.603(j) for whom MAGI-based methods do not apply. This State Plan Amendment supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI-based eligibility groups." If you have any additional questions or require any further assistance, please contact me or have your staff contact Maria Garza at (206) 615-2542 or maria.garza@cms.hhs.gov. Sincerely,

Associate Regional Administrator Division of Medicaid and Children's Health Operations

cc: Craig, J. Christenson DPM,CEM, Deputy Commissioner Gennifer Moreau-Johnson, State Plan Manager

State/Territory name: Alaska Submitted By: Gennifer Moreau Last Revision Date: Jan 7, 2014 Submit Date: Dec 24, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. AK-13-0029 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 1902(e)(14) Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment MAGI Income Methodology Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Does not wish to comment Signature of State Agency Official

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date· 10/31/2014 !MAGI-Based Income Methodologies 1902(e)( 14) 42 CFR 435.603 ~ The state will apply Modified Adjusted Gross Income (MAG I)-based methodologies as described below, and consistent with • 42 CFR 435.603. In the case of determining ongoing eligibility for beneficiaries determined eligible for Medicaid on or before December 3 1, 2013, MAGI-based income methodologies will not be applied until March 31, 2014, or the next regularly-scheduled renewal of eligibility, whichever is later, if application of such methods results in a determination of ineligibility prior to such date. ln determining family size for the eligibility determination of a pregnant woman, she is counted as herself plus each of the children she is expected to deliver. In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: l- The pregnant woman is counted just as herself. l" The pregnant woman is counted as herself, plus one. l The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: l- Current monthly household income and family size l" Projected annual household income and fami ly size for the remaining months of the current calendar year In determining current monthly or projected annual household income, the state will use reasonable methods to: ~ Include a prorated portion of a reasonably predictable increase in future income and/or family size. ~ Account for a reasonably predictable decrease in future income and/or family size. Except as provided at 42 CFR 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household. ln determining eligibility for Medicaid, an amount equivalent to 5 percentage points of the FPL for the applicable family size will be deducted from household income in accordance with 42 CFR 435.603(d). Household income includes actually available cash support, exceeding nominal amounts, provided by the person claiming an individual described at §435.603(t)(2)(i) as a tax dependent. l Yes l- No SlO Page I of2 TN NO: 13-0029-MM3 Approval Date 01/10/2014 Effective Date: 01/01/2014 Superseds TN:

Medicaid Eligibility 00 The age used for children with respect to 42 CFR 435.603(t)(3)(iv) is: (e Age 19 (' Age 19, or in the case of full-time students, age 21 PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Page 2 of2 TN NO: 13-0029-MM3 Approval Date 01/10/2014 Effective Date: 01/01/2014 Superseds TN:

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Table of Contents State/Territory Name: Alaska State Plan Amendment (SPA) #: 13-0030-MM This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice (delete if not applicable) 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Seattle Regional Office 2201 Sixth Avenue, Mail Stop 43 Seattle, Washington 98121 CENTERS FOR MEDICARE & MEDICAID SERVICES DIVISION OF MEDICAID & CHILDREN'S HEALTH OPERATIONS William J. Streur, Commissioner Department of Health and Social Services Post Office Box 11 0601 Juneau, Alaska 99811-0601 RE: Alaska State Plan Amendment (SPA) Transmittal Number 13-030-MMS Dear Mr. Streur: The Centers for Medicare & Medicaid Services (CMS) Seattle Regional Office has completed its review of State Plan Amendment (SPA) Transmittal Number 13-030-MM5. This transmittal incorporates the residency requirements into the Medicaid State Plan in accordance with the Affordable Care Act. This SPA is approved effective January 1, 2014. The new pages, S88-1 through S88-4, should be placed in a separate section at the back of the state plan. Also, the new page titled, "Superseding Pages of the State Plan Material", should be placed in a separate section in front of the state plan. If you have any additional questions or require any further assistance, please contact me, or have your staff contact Maria Garza at (206) 615-2542 or maria.garza@cms.hhs.gov. cc: c:1i. c. ~ Carol J.C. Peverly ~ 1., Associate Regional Administrator Division of Medicaid and Children's Health Operations Gennifer Moreau-J ohnson, gennifer.moreau-j ohnson@alaska.gov Brodie, Margaret C (HSS) margaret.brodie@alaska.gov Steele, Jim E (HSS) jim.steele@alaska.gov 3/21/14

State/Territory name: Alaska Submitted By: Gennifer Moreau Last Revision Date: Mar 18, 2014 Submit Date: Dec 27, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. AK-13-0030 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 1902(b)(2) Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment State affirms residency regulations Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Does not wish to comment. Signature of State Agency Official

SUPERSEDING PAGES OF

STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 13-0030 MMS5 Alaska PAGE NUMBER OF THE PLAN SECTION OR PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT (If Applicable): $88 Non-Financial Eligibility- State Residency Section 2.3: Page 13, TN 87-4 Attachment 2.6-A: Page 3, Item 4, TN 13-031 MM6

Page 1 of 4 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Non-Financial Eligibility State Residency S88 42 CFR 435.403 State Residency The state provides Medicaid to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions. ✔ Individuals are considered to be residents of the state under the following conditions: Non-institutionalized individuals age 21 and over, or under age 21, capable of indicating intent and who are emancipated or married, if the individual is living in the state and: ■ Intends to reside in the state, including without a fixed address, or ■ Entered the state with a job commitment or seeking employment, whether or not currently employed. ■ Individuals age 21 and over, not living in an institution, who are not capable of indicating intent, are residents of the state in which they live. ■ Non-institutionalized individuals under 21 not described above and non IV-E beneficiary children: ■ Residing in the state, with or without a fixed address, or ■ The state of residency of the parent or caretaker, in accordance with 42 CFR 435.403(h)(1), with whom the individual resides. ■ Individuals living in institutions, as defined in 42 CFR 435.1010, including foster care homes, who became incapable of indicating intent before age 21 and individuals under age 21 who are not emancipated or married: ■ Regardless of which state the individual resides, if the parent or guardian applying for Medicaid on the individual's behalf resides in the state, or ■ Regardless of which state the individual resides, if the parent or guardian resides in the state at the time of the individual's placement, or ■ If the individual applying for Medicaid on the individual's behalf resides in the state and the parental rights of the institutionalized individual's parent(s) were terminated and no guardian has been appointed and the individual is institutionalized in the state. ■ Individuals living in institutions who became incapable of indicating intent at or after age 21, if physically present in the state, unless another state made the placement. ■ Individuals who have been placed in an out-of-state institution, including foster care homes, by an agency of the state. ■ Any other institutionalized individual age 21 or over when living in the state with the intent to reside there, and not placed in the institution by another state. ■ IV-E eligible children living in the state, or ■ TN No. 13-0030 Approval Date: 3/21/14 Effective Date: January 1, 2014

Page 2 of 4 Medicaid Eligibility Otherwise meet the requirements of 42 CFR 435.403. ■ TN No. 13-0030 Approval Date: 3/21/14 Effective Date: January 1, 2014

Page 3 of 4 Medicaid Eligibility Meet the criteria specified in an interstate agreement. Yes No The state has interstate agreements with the following selected states: ■ Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming The interstate agreement contains a procedure for providing Medicaid to individuals pending resolution of their residency status and criteria for resolving disputed residency of individuals who (select all that apply): ■ Are IV-E eligible Are in the state only for the purpose of attending school Are out of the state only for the purpose of attending school Retain addresses in both states Other type of individual The state has a policy related to individuals in the state only to attend school. Yes No Provide a description of the policy: Alaska considers an applicant, aged 18-22 and a full time student in the state, to not be a resident of the state, if (1) neither parent lives in the state, (2) the student is claimed as a tax dependent by someone in another state, and (3) the student is applying on his or her own behalf. Otherwise meet the criteria of resident, but who may be temporarily absent from the state. ■ TN No. 13-0030 Approval Date: 3/21/14 Effective Date: January 1, 2014

Page 4 of 4 Medicaid Eligibility The state has a definition of temporary absence, including treatment of individuals who attend school in another state. Yes No Provide a description of the definition: Medicaid may not be denied or terminated because an individual is temporarily absent from the state if that individual intends to return to the state when the purpose of the absence has been accomplished, unless another state has determined that the individual is a resident for the purposes of receiving Medicaid. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. TN No. 13-0030 Approval Date: 3/21/14 Effective Date: January 1, 2014

Table of Contents State/Territory N arne: Alaska State Plan Amendment (SPA) #: 13-0031 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Seattle Regional Office 70 1 Fifth Avenue, Suite 1600, MS/RX-200 Seattle, Washington 98 104 Cl\tiS CENTERS FOR MEDICARE & MEDICAID SERVICES Division of Medicaid & Children's Health Operations Valerie Davidson, Commissioner Department of Health and Social Services Post Office Box 110601 Juneau, AJaska 99811-0601 - - JAN 2 7 2015 RE: Alaska State Plan Amendment (SPA) Transmittal Number 13-0031-MM6 Dear Ms. Davidson: The Centers for Medicare & Medicaid Services (CMS) Seattle Regional Office has completed its review of State Plan Amendment (SPA) Transmittal Number 13-0031-MM6. This transmittal incorporates the citizen and non-citizen eligibility requirements into the Medicaid State Plan in accordance with the Affordable Care Act. This SPA is approved effective January 1, 2014. The new pages, S89-l through S89-3, should be placed in a separate section at the back of the state plan. Also, the new page titled, "Superseding Pages of the State Plan Material", should be placed in a separate section in front of the state plan. If you have any additional questions or require any further assistance, please contact me, or have your staff contact Maria Garza at (206) 615-2542 or maria.garza@cms.hhs.gov. cc: Jon Sherwood, Deputy Commissioner Sincerely, Carol J.C. Peverly Associate Regional Administrator Division of Medicaid and Children's Health Operations Gennifer Moreau-Johnson, gennifer.moreau-johnson@alaska.gov Margaret C. Brodie, Margaret.brodie@alaska.gov Deb J Etheridge, deb.etheridge@alaska.gov

Medicaid State Plan Eligibility: Summary Page (CMS 179) State/Territory name: Alaska Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY =the last two digits of the submission year, and 0000 =a four digit number with leading zeros. The dashes must also be entered. AK-13-0031 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 1902(a)(46)(8), and 1903(v)(2), (3) and ( 4) Federal Budget Impact Federal Fiscal Year First Year 2014 $0.00 Second Year 2015 $0.00 Subject of Amendment Affirms citizenship and immigration policies Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Does not wish to com ment Signature of State Agency Official Submitted By: Last Revision Date: Submit Date: Gennifer Moreau Jan 9, 2015 Dec 27, 2013 Amount

SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 13-003 1 MM6 Alaska PACE NUMBER OF THE PLAN SECTION OR PACE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT (If Applicable): 1 589 Non-Financial Eligibility- Citizenship and Non-citizen Eligibility None (new) Attachment 2.6-A: Page 2 Attachment 2.6-A: Page 2, TN 91-13 I Attachment 2.6-A: Page 3 Attachment 2.6-A: Page 3, TN 13-0030 MM5

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date· 10/31/2014 Non-Financial Eligibility Citizenship and Non-Citizen Eligibility 1902(a)(46)(B) 8 U.S.C. 1611, 1612, 1613, and 1641 1903(v)(2),(3) and (4) 42 CFR435.4 42 CFR 435.406 42 CFR 435.956 Citizenship and Non-Citizen Eligibility I il II The state provides Medicaid to citizens and nationals of the United States and certain non-citizens consistent with requirements of 42 IZJ CFR 435.406, including during a reasonable opportunity period pending verification of their citizenship, national status or satisfactory immigration status. ~ The state provides Medicaid eligibility to otherwise eligible individuals: ~ Who are citizens or nationals of the United States; and Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity ~Reconci liation Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) ofPRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 ofPRWORA (8 U.S.C. §1613); and Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality or ~ satisfactory immigration status consistent with requirements of 1903(x), 1137( d), 1902( ee) of the SSA and 42 CFR 435.406, and 956. The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual. The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the verification process. ('Yes r. No The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date earlier than the date the notice is received by the individual. r. Yes ('No The date benefits are furnished is: le' The date of application containing the declaration of citizenship or immigration status. (' The date the reasonable opportunity notice is sent. ('Other date, as described: TN NO: 13 -0 031 Approval Date 1/27/15 Effective Date: January 1, 2014 Supersedes TN: N/A Alaska Page I of3

Medicaid Eligibility The state provides Medicaid coverage to all Qualified Non-Citizens whose eligibility is not prohibited by section 403 ofPRWORA (8 U.S.C. §1613). (i' Yes (' No The state elects the option to provide Medicaid coverage to otherwise eligible individuals under 21 and pregnant women, lawfully residing in the United States, as provided in section 1903(v)(4) of the Act. (' Yes (i' No ~ An individual is considered to be lawfully residing in the United States if he or she is lawfully present and otherwise meets the eligibility requirements in the state plan. ~ An individual is considered to be lawfully present in the United States if he or she: 1. Is a qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c); 2. Is a non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17)); 3. Is a non-citizen who has been paroled into the United States in accordance with 8 U.S.C. 1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings; 4. Is a non-citizen who belongs to one of the following classes: ~ Granted temporary resident status in accordance with 8 U.S.C. 1160 or 1255a, respectively; ~ Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization; ~ Granted employment authorization under 8 CFR 274a.12(c); ~ Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended; ~ Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; ~ Granted Deferred Action status; ~ Granted an administrative stay of removal under 8 CFR 241; ~ Beneficiary of approved visa petition who has a pending application for adjustment of status; 5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231 , or under the Convention Against Torture who - ~ Has been granted employment authorization; or ~ Is under the age of 14 and has had an application pending for at least 180 days; 6. Has been granted withholding of removal under the Convention Against Torture; 7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C. 1101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or 9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b)); TN NU: 1 3 -UU.:Ll Approval Date 1/27/15 Ettectlve Date: January 1, 2014 Supersedes TN: N/A Alaska P~e2~3

Medicaid Eligibility 10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15,2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition. D Other The state assures that it provides limited Medicaid services for treatment of an emergency medical condition, not related to an organ transplant procedure, as defined in 1903(v)(3) of the SSA and implemented at 42 CFR 440.255, to the following [Z] individuals who meet all Medicaid eligibility requirements, except documentation of citizenship or satisfactory immigration status and/or present an SSN: ~ Qualified non-citizens subject to the 5 year waiting period described in 8 U.S.C. 1613; ~ Non-qualified non-citizens, unless covered as a lawfully residing child or pregnant woman by the state under the option in • accordance with 1903(v)(4) and implemented at 435.406(b). PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN NO: 13-0031 Approval Date 1/27/15 Effective Date: January 1, 2014 Supersedes TN: N/A Alaska Page 3 of3

Table of Contents State/Territory N arne: Alaska State Plan Amendment (SPA) #: 13-0031 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Seattle Regional Office 70 1 Fifth Avenue, Suite 1600, MS/RX-200 Seattle, Washington 98 104 Cl\tiS CENTERS FOR MEDICARE & MEDICAID SERVICES Division of Medicaid & Children's Health Operations Valerie Davidson, Commissioner Department of Health and Social Services Post Office Box 110601 Juneau, AJaska 99811-0601 - - JAN 2 7 2015 RE: Alaska State Plan Amendment (SPA) Transmittal Number 13-0031-MM6 Dear Ms. Davidson: The Centers for Medicare & Medicaid Services (CMS) Seattle Regional Office has completed its review of State Plan Amendment (SPA) Transmittal Number 13-0031-MM6. This transmittal incorporates the citizen and non-citizen eligibility requirements into the Medicaid State Plan in accordance with the Affordable Care Act. This SPA is approved effective January 1, 2014. The new pages, S89-l through S89-3, should be placed in a separate section at the back of the state plan. Also, the new page titled, "Superseding Pages of the State Plan Material", should be placed in a separate section in front of the state plan. If you have any additional questions or require any further assistance, please contact me, or have your staff contact Maria Garza at (206) 615-2542 or maria.garza@cms.hhs.gov. cc: Jon Sherwood, Deputy Commissioner Sincerely, Carol J.C. Peverly Associate Regional Administrator Division of Medicaid and Children's Health Operations Gennifer Moreau-Johnson, gennifer.moreau-johnson@alaska.gov Margaret C. Brodie, Margaret.brodie@alaska.gov Deb J Etheridge, deb.etheridge@alaska.gov

Medicaid State Plan Eligibility: Summary Page (CMS 179) State/Territory name: Alaska Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY =the last two digits of the submission year, and 0000 =a four digit number with leading zeros. The dashes must also be entered. AK-13-0031 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 1902(a)(46)(8), and 1903(v)(2), (3) and ( 4) Federal Budget Impact Federal Fiscal Year First Year 2014 $0.00 Second Year 2015 $0.00 Subject of Amendment Affirms citizenship and immigration policies Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Does not wish to com ment Signature of State Agency Official Submitted By: Last Revision Date: Submit Date: Gennifer Moreau Jan 9, 2015 Dec 27, 2013 Amount

SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 13-003 1 MM6 Alaska PACE NUMBER OF THE PLAN SECTION OR PACE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT (If Applicable): 1 589 Non-Financial Eligibility- Citizenship and Non-citizen Eligibility None (new) Attachment 2.6-A: Page 2 Attachment 2.6-A: Page 2, TN 91-13 I Attachment 2.6-A: Page 3 Attachment 2.6-A: Page 3, TN 13-0030 MM5

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date· 10/31/2014 Non-Financial Eligibility Citizenship and Non-Citizen Eligibility 1902(a)(46)(B) 8 U.S.C. 1611, 1612, 1613, and 1641 1903(v)(2),(3) and (4) 42 CFR435.4 42 CFR 435.406 42 CFR 435.956 Citizenship and Non-Citizen Eligibility I il II The state provides Medicaid to citizens and nationals of the United States and certain non-citizens consistent with requirements of 42 IZJ CFR 435.406, including during a reasonable opportunity period pending verification of their citizenship, national status or satisfactory immigration status. ~ The state provides Medicaid eligibility to otherwise eligible individuals: ~ Who are citizens or nationals of the United States; and Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity ~Reconci liation Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) ofPRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 ofPRWORA (8 U.S.C. §1613); and Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality or ~ satisfactory immigration status consistent with requirements of 1903(x), 1137( d), 1902( ee) of the SSA and 42 CFR 435.406, and 956. The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual. The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the verification process. ('Yes r. No The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date earlier than the date the notice is received by the individual. r. Yes ('No The date benefits are furnished is: le' The date of application containing the declaration of citizenship or immigration status. (' The date the reasonable opportunity notice is sent. ('Other date, as described: TN NO: 13 -0 031 Approval Date 1/27/15 Effective Date: January 1, 2014 Supersedes TN: N/A Alaska Page I of3

Medicaid Eligibility The state provides Medicaid coverage to all Qualified Non-Citizens whose eligibility is not prohibited by section 403 ofPRWORA (8 U.S.C. §1613). (i' Yes (' No The state elects the option to provide Medicaid coverage to otherwise eligible individuals under 21 and pregnant women, lawfully residing in the United States, as provided in section 1903(v)(4) of the Act. (' Yes (i' No ~ An individual is considered to be lawfully residing in the United States if he or she is lawfully present and otherwise meets the eligibility requirements in the state plan. ~ An individual is considered to be lawfully present in the United States if he or she: 1. Is a qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c); 2. Is a non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17)); 3. Is a non-citizen who has been paroled into the United States in accordance with 8 U.S.C. 1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings; 4. Is a non-citizen who belongs to one of the following classes: ~ Granted temporary resident status in accordance with 8 U.S.C. 1160 or 1255a, respectively; ~ Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization; ~ Granted employment authorization under 8 CFR 274a.12(c); ~ Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended; ~ Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; ~ Granted Deferred Action status; ~ Granted an administrative stay of removal under 8 CFR 241; ~ Beneficiary of approved visa petition who has a pending application for adjustment of status; 5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231 , or under the Convention Against Torture who - ~ Has been granted employment authorization; or ~ Is under the age of 14 and has had an application pending for at least 180 days; 6. Has been granted withholding of removal under the Convention Against Torture; 7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C. 1101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or 9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b)); TN NU: 1 3 -UU.:Ll Approval Date 1/27/15 Ettectlve Date: January 1, 2014 Supersedes TN: N/A Alaska P~e2~3

Medicaid Eligibility 10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15,2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition. D Other The state assures that it provides limited Medicaid services for treatment of an emergency medical condition, not related to an organ transplant procedure, as defined in 1903(v)(3) of the SSA and implemented at 42 CFR 440.255, to the following [Z] individuals who meet all Medicaid eligibility requirements, except documentation of citizenship or satisfactory immigration status and/or present an SSN: ~ Qualified non-citizens subject to the 5 year waiting period described in 8 U.S.C. 1613; ~ Non-qualified non-citizens, unless covered as a lawfully residing child or pregnant woman by the state under the option in • accordance with 1903(v)(4) and implemented at 435.406(b). PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN NO: 13-0031 Approval Date 1/27/15 Effective Date: January 1, 2014 Supersedes TN: N/A Alaska Page 3 of3

Table of Contents State/Territory Name: Alaska State Plan Amendment (SPA) #: 13-0036 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Seattle Regional Office 701 5th Avenue, Suite 1600, MS/RX-200 Seattle, Washington 98104 Cl\,tS CENTERS FOR MEDICARE & MEDICAID SERVICES DIVISION OF MEDICAID & CHILDREN'S HEALTH OPERATIONS William J. Streur, Commissioner Department of Health and Social Services Post Office Box 110601 Juneau, Alaska 99811-0601 MAY 2 7 2014 RE: Alaska State Plan Amendment (SPA) Transmittal Number 13-0036-MM1 Dear Mr. Streur: The Centers for Medicare & Medicaid Services (CMS) has completed its review of State Plan Amendment (SPA) Transmittal Number 13-0036-MM1, submitted on May 12, 2014. This SPA updates the income level for inflation in PDF S52 for optional reasonable classifications of individuals under the age of 21 in the Medicaid State Plan. This SPA is approved effective April1, 2014. If you have any additional questions or require further assistance, please contact me or have your staff contact Janice Adams at (206) 615-2541 or janice.adams@cms.hhs.gov. cc: Margaret Brodie, Director Sincerely,

Carol J.C. Peverly Associate Regional Administrator Division of Medicaid and Children's Health Operations Gennifer Moreau-Johnson, State Plan Coordinator

Medicaid State Plan Eligibility: Summary Page (CMS 179) State!Territory name: Alaska Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST =the state abbreviation, YY =the last two digits of the submission ear, and 0000 =a four digit number with leading zeros. The dashes must also be entered. AK-13-0036 Proposed E.f!.~!)ve Date_.~ 04/01/2014 (mm/dd/yyyy) Feder:_al Statute/ Reg!.:::u::: la:,:,: ti:::: on :_:_;:;;C~it:::::a:.:: ti:::: o :.n:_ ___________________ ~· 1902(a)(1 O)(A)(ii)(l), 1902(a)(1 O)(A)(ii)(IV) and 42 CFR 435.222 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $0.00 Second Year 2015 $0.00 Subject of Amendment MAGI related SPA's MAGI based eligibity groups -this is an amendment to S 52 to update the income standards for 2014. Governor's Office Review Governor's office reported no comment Comments of Governor's office received No reply received within 45 days of submittal Other, as specified Describe: Does not wish to comment. Signature of State Agency Official Submitted By: Last Revision Date: Submit Date: Gennifer Moreau May 15, 2014 May 12,2014

Medicaid Eligibility OMB Control Number 0938-1.148 42 CFR 435.222 1902(a)(lO)(A)(ii)(J) 1902(a)(JO)(A)(ii}(IV) Reasonnblc Classification of Individuals under Age 21 • The state elects to cover one or more reasonable classifications of individuals under age 21 who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.222. t. Yes (' No Alaska 0 The state attests that it operates this eligibility group in accordance with the following provisions: ~ Individuals qualifYing under this eligibility group must qualifY under a reasonable classification by meeting the following criteria: 00 Be under age 21, or a lower age, as defined within the. reasonable clijSsitication, ~ Have household income at or below the standard established by the state, if the state has an iitcome standard tbr the • reasonable classification. ~ Not be eligible and ertrolled for mandatory coverage under the state plan. ~ MAGI-based income methodologies are used in calculating household income. Please refer as necessal)' to S 10 MAGI- Based Income l\·1cthodologies, completed by the state. The state covered at least one reasonable classification under this eligibility group under its Medicaid state plan as of December 31, 2{)13, or under a Medicaid J 115 Demonstration as of March 23, 2010 or December 31, 2013, with income standards higher (including disregarding all income) than tlre current mandatory income st~ndargs for the individval's age. (i' Yes C No The state also covered at least one reasonable classification under this group in the Medicaid state plan as of March 23, 201 0 with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age. (it: Yes C No RG.~.Qnable Classifiq_ations Cover~£ in the Medicaid SJpte Plan as of Mar<;.h.l.J..2Q.lQ The state attaches the approved -pages from the Medicaid state plan as of March 23, 2010 to indicate the age 0 gmups, reasonable classifications, and income standards used at that time for this eligibility group. D!Jrent Coverag_c of All Children under a Specified Age TN NO: 13-0036 Supersedes 13-0027 Approval Date 5/27/14 Effective April 1, 2014 Pall.e I of7

Alaska Medicaid Eligibility The state covers all children under a specified age limit, equal to or higher than the age limit and/or income standard used in the Medicaid state plan as ofMarch 23, 20'1 0, provided the income standard is higher than the current mandatory income standard for the individual's age. The age limit and/or income standard used must be no higher than any age limit and/or income standard covered in the Menicaid state,plan as of December 31, 20 13 or under a Medicaid 1115 Demonstration as ofMarch 23, 2010 or December 31, 20n. Higher income standards may include the disregard of all incomt!. (e' Yes ('No Indicate below the age under which all children are covered under this eligibility group, based on a specific age group used previously in the Medicaid state plan or under a Demonstration, which is equal to or higher than the age group for coverage of aU children in the Medicaid state pJan as of March 23,2010. (e' Under age 2 I (' Under age 20 ('. Under age 19 0 Under age 18 Enter the income standard used for this age group. The standard must b~ higher than the mandatoty income standard for the individual's age, not more restrictive than that used in the Medicaid state plan as of March 23, 20 l 0 and not less restrictive than that used in the Medicaid state plan as ofDecember 31,2013 or under a Medicaid 1115 Demonstration as of March 23,2010 or December 31, 2013. !!] Income standard used !!] Minimum income standard The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S I 4 AFDC lncome Standards. !!] Maximum income standard No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31,2013, or under a Medicaid 1115 Demonstration as of March 23, 20!0 or December31, 2013. (' Yes {.'; No The state certifies that it has submitted and .received approval for its converted income standards for this classification of children to MAGI-equivalent standards and the detem1ination of the 0 maximum income standard to be used for this classification of children under this eligibility group. The state's maximum incQme standard for this classification of children (which must exceed the minimum for the classification) is: The state's effective income level for this classification of children under the Medicaid state plan (' as of March 23, 20 lO, conve1ted to a MAGI-equivalent percent of fPL or amounts by household size. The state's effective income level for this classificati<m of children under the Medicaid state plan ,@ as of December 31, 2013, converted to a MAGI-equivalent_perccnt ofFPL or amounts by household size. Page 2 of7 TN NO: 13-0036 Supersedes 13···0027 Approval Date 5/27/14 Effective April 1, 2014

Alaska Medicaid Eligibility The state's effective income !~vel for this classificatiQn of children under a Me-dicaid 1115 { Demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income lcvet for this classification of children under a Medicaid lll5 C· Demonstration as of December 31, 2013, converted to a MAGI-eqtjivalcnt percent ofFPL or amounts by household size. Enter the amount of the maximum income standard: C A percentage of the federal poverty level; D % The state's AFDC payment standard in effect as of Juiy 16, 1996, converted to a MAGI- equivalent standard. This standard is described in Sl4 AFDC Income Standards. This option 0 should only be selected tor children 19 and older, and only if the state has not elected to cover the Adult Group. The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is (' described in Sl4 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. (tJ: Other dollar amount TI1e standard is as follows: @ Statewide standard C Standard varies by region C Standard varies by living arrangeri1ent C Standard varies in some other way TN NO: 13-0036 Supersedes 13-0027 Approval Date 5/27/14 Effective April l, 2014 Page 3 of7

Medicaid Eligibility Additional incremental amount Household size Standar<l ($) (;; Yes (';No }:~ + 1 1,352 Increment amount $1390 I -;;, + 2 2,.110 -~- 3 2,525 + 4 2,939 + 5 3,354 + 6 3,768 X + 7 4,182 X '2 . + 8 4,596 + 9 5,011 + 10 5,425 The dollar amounts increase automatically each year ~Yes C No The basis of the increase is CCPI-U le'· Other basis N ·I:Pl-U plus adjust111ent for annual dividend payment to Ala~ka rune. residents. j The annual incre.ase ()cc.urs in the month and day indicated: Every Month : I January I Day :II l ~ Income standard chosen Individuals qualify under this classification under the following income standard: (' The minimum standard. r. The maximum income standard. Tf not chosen as the maximum income standard, the·state's effective income level for this (' classification under the Medicaid state plan as of March 23, 20.1 0, converted to a MAGI-equivalent percent of FPL or anlQUJllS by household size. Alaska TN NO: 13-0036 Supersedes 13-0027 Approval Date 5/27/14 Effective April 1, 2014 Page 4 of7

Alaska Medicaid Eligibility lf not chosen as the maximum income standard, and if higher than the effective income level used (' under the Medicaid state plan as ofMarch 23, 2010, the state's effective income level for this classification under the Medicaid state plan as of December 31 , 2013, converted to a MAGI- equivalent percent ofFPL or amounts byhQusehold size. If not chosen as the maximum income standard, and if higher than the effective income level used r under the Medicaid state plan as ofMarch 23, 2010, th~ State's effective income level for this classification under a Medicaid lll5 Demonstratio.n as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by. household size. If not chosen as the maximum income standard, and if higher than the effective income level used (' under the Medicaid state plan as of March 23,2010, the state's effective income leveJ for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a !VlAGl- equivalent percent of FPL or amounts by household size. Another income standard in-between the minimum and maximum st<mdards aUow(:d, provided it is (' higher than the effective income level for this classification in d1e state plan as of March 23, 2010, converted to a MAGI equivalent. The state covers reasonable classifications of children previously covered i.n the Medicaid state plan as of March 23, 2010, with income standards higher than the current mandatory income standard for the age group. Age limits and income standards are equal to or higher than the Medicaid state plan as of March 23, 2010, but no higher than any age limit and/or income standard tor this classification covered in the· Medicaid state plan as of December 3 I, 20 13 or under a Medicaid IllS Demonstration as of March 23,2010 or December 31,2013. Higher income standards may include the disregard of all income. (' Yes r. No The state covers reasonable classifications of children Dill covered in the Medicaid state plan as of March 23, 2010, but covered under ihe Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 20 J 0 or December 31, 2013 with an iJ1come standard higher than the current mandatory income standard for the age group. r. Yes (' No The additional previously covered reasonable classifications to be included are: AQ_dj1im.lill..Eill!imtsJy Cover~d.Rcasonable C!as,'iillcations Included Sll 0 lndividuals for whom public agencies are assuming full or partial fioancial responsibility. 0 lndrviduals in adoptions subsidized in full or part by a public agency 0 Individuals in nursing facilities, if nursing facility ~ervic~s are provided under this plan TN NO: 13-0036 Supersedes 13-0027 Approval Date 5/27/14 Ef f ect ive April 1 , 2014 Page 5 of7

Alaska Medicaid Eligibility O lndividu~ls receiving active treatment as inpatients in psychiatric facilities or programs, if such services are provided under this plan ~ Other reasonable classifications Name of classification Description Age Limit ~~ Children under age 19 who were } enrolled in Medicaid on 12/31/2013 and would otherwise become ineligible for Medicaid at their first + 210 l(f}Like Children. redetermination using MAGI Under age 19 methodologies solely due to the Joss of income disregards will remain Medicaid eligible until their next redetermination, using MAGI methodol.ogies. -----·--··- ~- tX '!' 0 ;, Enter the income standard use9 for these classifications (which must lYe higher than the mandatory standard for the child's age but may be no higher than the highest standard used in the state plan as of December 31 , 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013). ~~~~~~~r-~----~~~~~F=~~ ·~ vi~the il)come standardsJo~m: :o,~:w- · *"-• ":\ I!] Income standard used [!) Minimum income standard The minimum income standard for this classificatiOJi of children must exceed the lowest income standard chosen for children under this age under the Infants and Children under Age 19 eligibility group. I!] Maximum 'income standard No income test was used (aU income was disreg;rrded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 20 I 0 or December 31, 201 J. te Yes (" No [!) o income test was used (all income was disregarded) for this classification under: (check all that apply) 0 The Medicaid state plan as of March 23, 2010. [gJ ·n1e Medicaid state plan as of December 31, 2'013. 0 A Medicaid 1115 Demonstration as ofMarch 23, 2010. 0 A Medicaid I 115 Demonstration as of December 31 ,~ 2013. TN NO: 13 -0036 Supersedes 13-0027 Approval Date 5/27/14 Eff ective April l , 2014 Page 6 of7

Medicaid Eligibility The state's maximum standard for this classification of children is no income test (all income is disregarded). [!J l.ncomc standard chosen Individuals qualify under this classification under the following income standard: r. This classification does not use an income test.( all income is disregarded). ("' Another income standard higher than both the minimum income standard and the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. Additional new age_ groups or r.~asonable classifications covered If the state has not elected to cover the Adult Group (42 CFR 43 5 .119), it may elect to cover additional new age groups or reasonable classifications that have not been covered previously. If the state covers the Adult Group, this additional option is not available, as the standard for the new age groups or classifications is lower than that used for mandatory coverage. The state docs not cover the Adult Group and elects the option to include in this eligibility group additional age groups or reasonable classifications that have not been covered previously in the state plan dr under a Medicaid 1115 Demonstration. Any additional age groups or reasonable classifications not previously covered are restricted to the AFDC income standard from July !6, 1996, not converted to a MAGI-equivalent standard. C Yes ~No [!J There is no resource test for this eligibility group. PRA Disclosure Statement Accotding to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including th,e time to review instructions, search existing data resources, gather the data needed, and complete and review the in.fbrmation coHection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this fonn, please write to: CMS~ 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Alaska TN NO: 13···0036 Supersedes 13 -· 0027 Approval Date 5/27/1.4 Effective April 1., 2014 Page 7 of?

Table of Contents State/Territory N arne: Alaska State Plan Amendment (SPA) #: 14-003 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

DEPARTM ENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Seattle Regional Office 701 Fifth Avenue, Suite 1600, MS/RX-200 Seattle, W A 98 104 Division of Medicaid & Children's Health Operations William J. Streur, Commissioner Department of Health and Social Services Post Office Box 110601 Juneau, AJaska 99811-0601 CMS CENTERS FOR MEDICARE & MEDICAID SERVICES JUN 0 3 2014 RE: Alaska State Plan Amendment (SPA) Transmittal Number 14-003-MM4 Dear Mr. Streur: The Centers for Medicare & Medicaid Services (CMS) Seattle Regional Office has completed its review of State Plan Amendment (SPA) Transmittal Number 14-003-MM4. This transmittal describes the single state agency's delegation of appeals and determinations in accordance with the Affordable Care Act and updates the state's organizational structure. This SPA is approved effective January 1, 2014. The new pages, A-1 through A-3, should be placed in a separate section at the back of the state plan. Also, the new page titled, "Superseding Pages of the State Plan Material", should be placed in a separate section in front of the state plan. If you have any additional questions or require any further assistance, please contact me or have your staff contact Maria Garza at (206) 615-2542 or maria.garza@cms.hhs.gov. cc: Sincerely, Q Associate Regional Administrator Division of Medicaid and Children's Health Operations Gennifer Moreau-J ohnson, gennifer.moreau-johnson@alaska. gov Margaret Brodie, margaret.brodie@alaska.gov

Medicaid State Plan Eligibility: Summary Page (CMS 179) --------------------~------~~~------~--------------------- State/Territory name: Alaska Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY =the last two digits of the submission year, and 0000 =a four digit number with leading zeros. The dashes must also be entered. 14-003 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 431 .10 Federal Budget Impact Federal Fiscal Year First Year 2014 Second Year 2015 Subject of Amendment Administration of Medicaid Governor's Office Review $0.00 $0.00 Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal _ Other, as specified Describe: Did not wish to comment. Signature of State Agency Official Submitted By: Last Revision Date: Submit Date: Gennifer Moreau May 23, 2014 Mar 18, 2014 Amount

SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 14 -003 Alaska PAGE NUMBER OF THE PLAN SECTION OR COMPLETE PAGES PARTIAL PAGES ATTACHMENT: SUPERSEDED: SUPERSEDED: A1-A3 Page 1 Section 1.4 (page 9)(State Medical Care Advisory Section 1.1 (pages 2-6) Committee only. Tribal consultation will remain in the Section 1.2 (page 7) state plan.) Section 1.3 (page 8) Attachment 1.1-A (Attorney General certification) Attachment 1.2-A (Organizational chart) Attachment 1.2-B (Description of the functions of the single state agency) Attachment 1.2-C (Description of professional medical and supporting staff)

Medicaid Administration OMB Control Number0938-1148 OMB Expiration date· 10/31/2014 State Plan Administration Designation and Authority 42CFR431.10 Designation and Authority State Name: !Alaska II .f As a condition for receipt of Federal funds under title XIX of the Social Security Act, the single state agency named below submits the following state plan for the medical assistance program, and hereby agrees to administer the program in accordance with the provisions of this state plan, the requirements of titles XI and XIX of the Act, and all applicable Federal regulations and other official issuances of the Department. Name of single state agency: Type of Agency: (' Title IV-A Agency (' Health (' Human Resources le' Other jDepartment of Health and Social Services Type of Agency !Health and Title IV -A l The above named agency is the single state agency designated to administer or supervise the administration of the Medicaid program under title XIX of the Social Security Act. (All references in this plan to "the Medicaid agency" mean the agency named as the single state agency.) The state statutory citation for the legal authority under which the single state agency administers the state plan is: !Alaska Statute 47.07.040 The single state agency supervises the administration of the state plan by local political subdivisions. (' Yes le' No [{] The certification signed by the state Attorney General identifying the single state agency and citing the legal authority under ./ which it administers or supervises administration of the program has been provided. An attachment is submitted. The state plan may be administered solely by the single state agency, or some portions may be administered by other agencies. The single state agency administers the entire state plan under title XIX (i.e., no other agency or organization administers any portion of it). le' Yes (' No Alaska TN NO: 14-003 Supersedes N/A Approval Date:06/03/2014 Effective Date: January 1, 2014 Page 1 of 5

Medicaid Administration The entity or entities that have responsibility for determinations of eligibility for families, adults, and for individuals under 21 are: [gJ The Medicaid agency O Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands 0 An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The entity that has responsibility for determinations of eligibility for the aged, blind, and disabled are: [gJ The Medicaid agency O Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands 0 An Exchange that is a government agency established under sections 1.311(b)(l) or 132l(c)(l) of the Affordable Care Act 0 The Federal agency administering the SSI program The entity or entities that have responsibility for conducting fair hearings with respect to denials of eligibility based on the applicable modified adjusted gross income standard are: [gJ Medicaid agency 0 An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act 0 An Exchange appeals entity, including an entity established under section 1411 (f) of the Affordable Care Act The agency has established a review process whereby the agency reviews appeals decisions made by the Exchange or Exchange appeals entity or other state agency, but only with respect to conclusions of law, including interpretations of state or federal policies. (' Yes r. No State Plan Administration Organization and Administration 42 CFR431.10 42 CFR 431.11 Organization and Administration Provide a description of the organization and functions of the Medicaid agency. The following divisions within the Department of Health and Social Services play a role in administering the Medicaid program. The Office of the Commissioner includes two Deputy Commissioners, and an Assistant Commissioner, supporting staff and additional units. A2 The Commissioner's Office is responsible for providing the leadership and direction to ensure an efficient and effect1ve organization that is capable of fulfilling the functions and responsibilities designated by law. Reporting directly to the Commissioner is the Division of Public Health, which administers and enforces State health regulations. Within the Office of the Deputy Commissioner for Medicaid and Health Care Policy is the Division of Health Care Services, which has been designated as the medical assistance unit. The Office of Medicaid Policy and Planning includes Program Review, which provides quality assurance and handles intergovernmental relations. The Office of Rate and Review makes recommendations to the Commissioner on all rates paid to providers. The Division of Senior and Disability Services provides the full range of care for seniors and the disabled in one agency through the administration of state and federal grant programs and all Medicaid Home and Community Based Waivers. The Division of Behavioral Health assumes all policy, program and administrative responsibility for mental health and substance abuse services. Alaska TN NO: 14-003 Supersedes N/A Approval Date:06/03/2014 Effective Date: January 1, 2014 Page 2 of 5

Medicaid Administration i Withm the Uttlce ot the Deputy Commissioner tor Family, Commumty and integrated :Services IS the DIVISIOn ot Public Assistance and the Office of Children's Services. The Division of Public Assistance develops health care eligibility policy for Medicaid, Chronic and Acute Medical Assistance (CAMA) programs, and Aid to the Blind, Disabled, and Old Age Assistance. Except for children in state custody, the Division of Public Assistance makes all eligibility determinations for Medicaid. The Office of Children's Services determines Medicaid eligibility for children in state custody. DHSS role and responsibility in Administrative Hearings: The review done by DHSS Commissioner's office is a de novo review that is based upon facts and conclusions of law including the appropriate application offederal and state Medicaid law regulations or policies. An individual does have the ability to ask for "review" or comment on an OAH decision through the proposal for action process. What that means is that every party to the OAH decision, including consumers, has the ability to submit a \\-ritten brief in support of, or in opposition of the OAH decision raising questions of both law and fact. This is not an appeal per se, but rather an ability to file objections or statement in support of findings of fact and conclusions of law made by the hearing officer, that are submitted to the Commissioner's office along with the proposed decision and any other documents or evidence submitted in the hearing process for final decision. The proposal for action is optional, if either party submits a proposal for action it must be submitted to the Commissioner's office for decision, if neither party present a proposal for action the OAH decision is final under operation of law. If the Commissioner's office or the OAH rules in favor of the department the consumer has the abi lity to appeal that decision to the Superior Court. If the OAH rules in favor of the consumer that is the end of the line there is no nght for the department to appeal it's own decision. There is no difference in the "standard of review" all matters are reviewed de novo at all levels of the administrative process. A de novo review can also be requested at the Superior Court appeal level although that is the exception not the rule. Upload an organizational chart of the Medicaid agency. An attachment is submitted. Provide a description of the structure of the state's executive branch which includes how the Medicaid agency fits in with other health, human service and public assistance agencies. All State health, human service, and public assistance agencies are housed within the single state agency, the Department of Health and Social Services. The Office of Administrative Hearings, an independent office within the Department of Administration charged with providing adjudication services, regulatory review and training, provides Administrative Law Judges to conduct hearings in accordance with 7 AAC 49.010 - 7 AAC 49.180, 7 AAC 49.220 and 7 AAC 49.240. This office makes recommendations to the Department of Health and Social Services after considering hearings and appeals, on behalf of the Commissioner, regarding Medicaid applicants, recipients, or providers. The Administrative Law Judge would hear a case in accordance with 7 AAC 49.010 - 7 AAC 49.180, 7 AAC 49.220 and 7 AAC 49.240, and would prepare draft findings, conclusions, and order for the Commissioner of the Department of Health and Social Services. The Commissioner of the Department has final authority in deciding cases. Entities that determine eligibility other than the Medicaid Agency (if entities are described under Designation and Authority) •I Alaska I Remove Type of entity that determines eligibility: (' Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands (' An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act (' The Federal agency administering the SSI program Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility. TN NO: 14-003 Supersedes N/A Approval Date:06/03/2014 Effective Date: January 1, 2014 Page 3 of 5

Alaska Medicaid Administration I Add Entities that conduct fair hearings other than the Medicaid Agency (if are described under Designation and Authority) L I Remove Type of entity that conducts fair hearings: (' An Exchange that is a government agency established under sections 13ll(b)(l) or 1321 (c)(l) of the Affordable Care Act (' An Exchange appeals entity, including an entity established under section 1411(f) of the Affordable Care Act Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility. II I Supervision of state plan administration by local political subdivisions (if described under Designation and Authority) Is the supervision of the administration done through a state-wide agency which uses local political subdivisions? (' Yes (' No State Plan Administration Assurances 42 CFR 431.10 42 CFR 431.12 42 CFR 431.50 Assurances 0 The state plan is in operation on a statewide basis, in accordance with all the requirements of 42 CFR 431.50. 0 All requirements of 42 CFR 431.10 are met. !l II Add 0 There is a Medical Care Advisory Committee to the agency director on health and medical services established in accordance with meeting all the requirements of 42 CFR 431 .12. 0 The Medicaid agency does not delegate, to other than its own officials, the authority to supervise the plan or to develop or issue policies, rules, and regulations on program matters. Assurance for states that have delegated authority to determine eligibility: D There is a written agreement between the Medicaid agency and the Exchange or any other state or local agency that has been delegated authority to determine eligibility for Medicaid eligibility in compliance with 42 CFR 431.10(d). Assurances for states that have delegated authority to conduct fair hearings: D There is a written agreement between the Medicaid agency and the Exchange or Exchange appeals entity that has been delegated authority to conduct Medicaid fair hearings in compliance with 42 CFR 431.10(d). D When authority is delegated to the Exchange or an Exchange appeals entity, individuals who have requested a fair hearing are given the option to have their fair hearing conducted instead by the Medicaid agency. Assurance for states that have delegated authority to determine eligibility and/or to conduct fair hearings: I TN NO: 14-003 Supersedes N/A Approval Date:06/03/2014 Effective Date: January 1, 2014 Page 4 of5

Medicaid Administration D The Medicaid agency does not delegate authority to make eligibility determinations or to conduct fair hearings to entities other than government agencies which maintain personnel standards on a merit basis. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collecHon is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20 130917 Alaska TN NO: 14-003 Supersedes N/A Approval Date:06/03/2014 Effective Date: January 1, 2014 Page 5 of 5

Table of Contents State/Territory Name: Alaska State Plan Amendment (SPA) #: 14-004-MMl This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Seattle Regional Office 2201 Sixth Avenue, MS/RX -43 Seattle, WA 98121 DIVISION OF MEDICAID & CHILDREN'S HEALTH OPERATIONS William J. Streur, Commissioner Department of Health and Social Services Post Office Box 110601 Juneau, Alaska 99811-0601 c~s CENTERS FOR MEDICARE & MEDICAID SERVICES APR 0 2 20f~ RE: Alaska State Plan Amendment (SPA) Transmittal Number 14-004-MM1 Dear Mr. Streur: The Centers for Medicare & Medicaid Services (CMS) has completed its review of State Plan Amendment (SPA) Transmittal Number 14-004-MMl. This SPA updates the income level for inflation in PDF S25 for the mandatory eligibility group for parents and other caretaker relatives in the Medicaid State Plan. This SPA is approved effective January 1, 2014. If you have any additional questions or require further assistance, please contact me or have your staff contact Janice Adams at (206) 615-2541 or janice.adams@cms.hhs.gov. Sincerely, Carol J.C. Peverly Associate Regional Administrator Division of Medicaid and Children's Health Operations cc: Margaret Brodie, Director Gennifer Moreau-Johnson, State Plan Coordinator

- Medicaid State Plan Eligibility: Summary Page (CMS 179) Statefferritory name: Alaska Transmittal Number: Please enter tile Transmittal Number (TN) in tile format ST- YY-0000 where ST= tile state abbreviation, YY =tile last two digits of tile submission year, and 0000 =a four digit number with leading zeros. Tile dashes must also be entered. 14-004 Proposed Effective Dat_e_ 01/01/2014 (mm/ dd/ yyyy) Federal Statute/Regulation Citation 42 CFR 435.110 1902(a)(l O)(A)(i)(I) 1931 (b) and (d) Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $0.00 Second Year 2015 $0.00 Subject of Amendment This SPA is superseding section S 13a of S25 witht he same effective date. Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal _ 1 Other, as specified Describe: Does not wish to comment. Signature of State Agency Official Submitted By: Last Revision Date: Submit Date: Gennifer Moreau Mar20, 2014 Mar 19,2014 ------------~ -

Medicaid ,Eligibility OMB Control Number 0938-1148 OMB date: 10/31/2014 42 CFR 435,110 1902( a )(10)(A)(i)(I) 1931(b) and (d) r.oJ Parents and Other Caretaker Relatives - Parents and other caretaker relatives of dependent children with household income at or ~ below a standard established by the state. 0 The state attests that it operates this eligibility group in acc0rdance with the following provisions: ~ Individuals qualifying under this eligibility group must meet the following criteria: ~ Are parents or other caretaker relatives (defined at 42 CFR 435.4), including pregnant women, of dependent children (defined at 42 CFR 435.4) under age 18. Spouses of parents and other caretaker relatives are also included. TN No:14-004 The state elects the following options: This eligibility group includes individuals who are parents or other caretakers of children who are 18 years old, !Zl provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training. !Zl Options relating to the definition of caretaker relative (select any that apply): The definition of caretaker relative includes the domestic partner of the parent or other caretaker relative, 0 even after the partnership is terminated. Definition of domestic partner: IZl The definition of caretaker relative includes other relatives of the child based on blood (including those of half-blood), adoption or marriage. Description of other relatives: DEFINITION OF A CARETAKER RELATIVE A caretaker relative is a person in one of the following groups: A person who is related to the dependent child by full or half-blood and who is within the fifth degree of kinship to the child as follows: Relative Degree of Relative Kinship 1st degree: Mother, Father 2nd degree: Sister, Brother, Grandparent 3rd degree: Great-grandparent, Uncle or Aunt, Nephew or Niece 4th degree: Great-great-grandparent, Great uncle or great aunt, First cousin 5th degree: Great-great-great grandparent, Great-great uncle or great-great aunt, First cousin once removed (child of First cousin) Stepfather, stepmother, stepbrother, or stepsister. Approval Date:4/02/14 Ef f ect i ve Date : 1/01/14 Page 1 of 5

Medicaid Eligibility Persons who legally adopt a child or his parent as well as the natural and other legally adopted children of such persons, and other relatives of the adoptive parents in accordance with state law. Spouses of any persons named above, even after the marriage is terminated by death or divorce. Biological relatives, whose legal and financial relationship to the dependent child that has been severed through an adoption, may still be considered as caretaker relatives. Note: A caretaker relative does not include a guardian, friend, neighbor, non-related godparent, second cousin, or a person who has been given a dependent child. D The definition of caretaker relative includes any adult with whom the child is living and who assumes primary responsibility for the dependent child's care. IZ] Options relating to the definition of dependent child (select the one that applies): The state elects to eliminate the requirement that a dependent child must be deprived of parental support or @ care by reason of the death, physical or mental incapacity, or absence from the home or unemployment of at least one parent. ( ) The child must be deprived of parental support or care, but a less restrictive standard is used to measure ~· unemployment of the parent (select the one that applies): ~ Have household income at or below the standard established by the state. ~ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to SlO MAGI- Based Income Methodologies, completed by the state. ~ Income standard used for this group ~ Minimum income standard The minimum income standard used for this group is the state's AFDC payment standard in effect as of May 1, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in S14 AFDC Income Standards. [Zl The state certifies that it has submitted and received approval for its converted May 1, 1988 AFDC payment standard. ~ Maximum income standard TN No:14 - 004 The state certifies that it has submitted and received approval for its converted income standard(s) for parents and [Zl other caretaker relatives to MAGI-equivalent standards and the determination of the maximum income standard to be used for parents and other caretaker relatives under this eligibility group. The state's maximum income standard for this eligibility group is: Approval Date:4/02/14 Effect i ve Date:1/01/14 Page 2 of 5

Medicaid Eligibility C' The state's effective income level for section 1931 families under the Medicaid state plan as of March 23, 2010, _i converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for section 1931 families under the Medicaid state plan as of December 31, (!'! 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 0 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 Ci demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: () A percentage of the federal poverty level: D % 0 The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage O increase in the Consumer Price Index for urban consumers (CPI-U) since such date, converted to a MAGI- equivalent standard. The standard is described in S14 AFDC Income Standards. The state's TANF payment standard, converted to a MAGI-equivalent standard. The standard is described in S14 0 AFDC Income Standards. (!'1 Other dollar amount In,fome Standard Entry · Dollar Amount - ~utomatic Increase Optioq S13a The standard is as follows: @ Statewide standard 0 Standard varies by region C Standard varies by living arrangement 0 Standard varies in some other way !enter the statewide standard I TN No:14-004 Approval Date :4/02/14 Effect i ve Dat e:1/01/ 14 Page 3 of 5

Medicaid Eligibility Additional incremental amount Household size Standard ($) @Yes 0 No ·+ 1 1,352 X Increment amount $1390 I ' IL + 2 2,110 rK fl+ 3 2,525 X + 4 2,939 IX ~+ 5 3,354 X I!'W + 6 3,768 X ~ 7 4,182 "X it.: + 8 4,596 X ~t1Wi -, + 9 5,011 'X + 10 5,425 c¥ The dollar amounts increase automatically each year @Yes 0 No The basis of the increase is OCPI-U @Other basis N : ICPI-U plus adjustment for annual dividend payment to Alaska arne. residents I The annual increase occurs in the month and day indicated: Every Month :!January I Day :11 I ~ Income standard chosen: Indicate the state's income standard used for this eligibility group: 0 The minimum income standard @ The maximum income standard The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage Ci increase in the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in S14 AFDC Income Standards. 0 Another income standard in-between the minimum and maximum standards allowed ~ There is no resource test for this eligibility group. TN No:14-004 Approval Date:4/02/14 Ef f ective Date : 1/01/14 Page 4 of 5

Medicaid Eligibility [!] Presumptive Eligibility The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible. 0 Yes @No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No : 14-004 Approval Date :4 / 02/ 14 Effectiv e Date: 1/0 1 / 14 Page 5 of 5

Table of Contents State/Territory Name: Alaska State Plan Amendment (SPA)#: 14-005 This file contains the following documents in the order listed: 1) Approval Letter 2) Additional Companion letter 3) CMS 179 Form/Summary Form (with 179-like data) 4) Approved SPA Pages

DEPARTMENT OF HEA LTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Seattle Regional Office 70! Fifth Avenue, Suite !600, MS/RX-200 Seattle, Washington 98 ! 04 CI\4S CENTERS FOR MEDICARE & MEDICAID SERVICES Division of Medicaid & Children's Health Operations Valerie Davidson, Commissioner Department of Health and Social Services Post Office Box 110601 Juneau, Alaska 99811-0601 DEr. 1 · f 20f4 RE: Alaska State Plan Amendment (SPA) Transmittal Number 14-005-MM7 Dear Ms. Davidson: The Centers for Medicare & Medicaid Services (CMS) Seattle Regional Office has completed its review of State Plan Amendment (SPA) Transmittal Number 14-005-MM?, implementing Hospital Presumptive Eligibility (HPE). This amendment provides Medicaid coverage for individuals determined presumptively eligible under 42 CFR 435.1110 and in accordance with the Affordable Care Act. This SPA is approved effective January 1, 2014. This SPA approval and accompanying companion letter reflects the acceptance of the paper application for HPE submitted and reviewed at the time of the submission of AK-14-005-MM?. The State of Alaska has informed CMS that it plans to implement an electronic HPE online application process in 2015, pending system design and completion. By way of this approval letter, CMS is notifying Alaska that it will need to submit an updated SPA with the electronic application screen captures when this system is complete and ready for implementation. The new pages, S21-1 through S21-3, should be placed in a separate section at the back of the state plan. If you have any additional questions or require any further assistance, please contact me or have your staff contact Maria Garza at (206) 615-2542 or maria.garza@cms.hhs.gov. cc: Sincerely, Associate Regional Administrator Division ofMedicaid and Children's Health Operations Gennifer Moreau, SPA Coordinator, gennifer.moreau-johnson@alaska.gov Margaret Brodie, Director of Health Care Services, margaret.brodie@alaska.gov

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Seattle Regional Office 70 1 Fifth Avenue, Suite 1600, MS/RX-200 Seattle, Washington 98 1 04 Division of Medicaid & Children's Health Operations Valerie Davidson, Commissioner Department of Health and Social Services Post Office Box 11 0601 Juneau, Alaska 99811-0601 CENTERS FOR MEDICARE & MEDICAID SERVICES RE: Alaska State Plan Amendment (SPA) Transmittal Number 14-005-MM7 Dear Ms. Davidson: This letter is being sent as a companion to our approval of Alaska State Plan Amendment (SPA) AK-14-005-MM?, which specifies options for presumptive eligibility conducted by hospitals into the Medicaid state plan in accordance with the Affordable Care Act. This amendment was submitted on March 28, 2014, with an effective date ofJanuary 1, 2014. Section 1902(a) of the Social Security Act (the Act) requires that states have a State Plan for medical assistance that meets certain Federal requirements that set out a framework for the State program. Implementing regulations at 42 CFR 430.10 require that the State Plan be a comprehensive written statement describing the nature and scope of the state's Medicaid program and that it contain all information necessary for the Centers for Medicare & Medicaid Services (CMS) to determine whether the plan can be approved to serve as the basis for Federal Financial Participation in the state program. The CMS' analysis determined that additional changes related to the state's implementation of the hospital presumptive eligibility provision are needed in the Alaska Medicaid State Plan as specifically indicated below. 1. Implementation date: In reviewing the state plan pages, CMS found issues related to the State's proposed implementation date of the hospital presumptive eligibility provision. As set forth in Section 1902(a)(47)(B) of the Social Security Act, states must provide a program for hospitals that choose to provide hospital presumptive eligibility determinations, effective January 1, 2014, as codified in the Section 2202 of the Affordable Care Act. Alaska has provided sufficient SPA pages and supporting materials in the AK-14-005-MM? submission to show that it has policies in place and can begin to train providers as qualified entities allowing CMS to approve this SPA. CMS also acknowledges that systems limitations are preventing the state from fully implementing its hospital presumptive eligible program, so we are giving the State time to come into compliance with its approved state plan, which has an effective date of January 1, 2014. We understand that the state is still in the process of finalizing its system to support hospital presumptive eligibility and is in discussion with its system integrator to revise an implementation date, after recently learning that the original effective date of December

20, 2014, is no longer feasible. Within 30 days of this letter, please reply to CMS with an update on the state's continuing implementation efforts, including the revised timeline, if changed from December 20, 2014. If the program is not yet implemented by that time, please include in your reply a corrective action plan to comply with requirements of 42 CFR 430.10 and 42 CFR 440.167, which outlines a timeline and the steps the state will take to finalize the implementation of the program and come into compliance with the January 1, 2014, effective date in statute and in the state's approved SPA. During the 30 days, CMS will remain available to provide technical assistance, as requested or required. 2. Period of presumptive eligibility: The state has indicated that, at the present time, it is not able to automatically end hospital presumptive eligibility in the middle of the month for those individuals who have been found not eligible for full Medicaid. Pursuant to 42 CFR § 435.1101, a period of presumptive eligibility means a period that begins on the date on which a qualified entity determines that an individual is presumptively eligible and ends with the earlier of: (a) In the case of an individual on whose behalf a Medicaid application has been filed, the day on which a decision is made on that application; or (b) In the case of an individual on whose behalf a Medicaid application has not been filed, the last day of the month following the month in which the determination of presumptive eligibility was made. Per this requirement, a state cannot extend hospital presumptive eligibility to the end of the month if an individual is found not eligible for full Medicaid before then (i.e., in the middle of the month). Alaska has infonned CMS that it continues to pursue changes to its eligibility system and Medicaid Management Information System (MMIS). We understand that the state is working with its system integrator to revise an implementation date, after recently learning that the originally projected date of December 20, 2014, is no longer feasible. Within 30 days of this letter, please reply to CMS with an update on these system changes. If the changes are not yet operational, please describe the state's plan to finalize the changes, including the revised timelines. If you have questions concerning this letter, please contact me, or have your staff contact Maria Garza at (206) 615-2542 or via email at maria.garza@cms.hhs.gov. cc: Carol J.C. Peverly Associate Regional Administrator Division ofMedicaid and Children's Health Operations Gennifer Moreau, SPA Coordinator, gennifer.moreau-johnson@alaska.gov Margaret Brodie, Director of Health Care Services, margaret.brodie@alaska.gov

Medicaid State Plan Eligibility: Summary Page (CMS 179) State{Territory name: Alaska Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST =the state abbreviation, YY =the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. AK-14-005 Prop()seg .E!!.~~~~~-9~!.~- __ 01 /01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 435.1110 Federal Budget Impact Federal Fiscal Year First Year 2014 Second Year 2015 Subject of Amendment Hospital Presumptive Eligibility Governor's Office Review $0.00 $0.00 Governor's office reported no comment Comments of Governor's office received No reply received within 45 days of submittal @ Other, as specified Describe: Does not wish to comment. Signature of State Agency Official Submitted By: Last Revision Date: Submit Date: Gennifer Moreau Nov20, 2014 Mar 28,2014 Amount Date Received: Date Approved: PLAN APPROVED- ONE COPY ATTACHED DEC 1 · 1 201't Effective Date of Approved Material: Signature of Regional Official: /- o l- I Typed Name: Title:

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date· 10/31/2014 Presumptive Eligibility by Hospitals S21 42 CFR 435.1110 One or more qualified hospitals are determining presumptive eligibility under 42 CFR 435.1110, and the state is providing Medicaid coverage for individuals determined presumptively eligible under this provision. le' Yes (No [Z] The state attests that presumptive eligibility by hospitals is administered in accordance with the following provisions: ~ A qualified hospital is a hospital that: Participates as a provider under the Medicaid state plan or a Medicaid 1115 Demonstration, notifies the Medicaid agency of ~ its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with state policies and procedures. Has not been disqualified by the Medicaid agency for failure to make presumptive eligibility determinations in accordance ~ with applicable state policies and procedures or for failure to meet any standards that may have been established by the Medicaid agency. Assists individuals in completing and submitting the full application and understanding any documentation requirements. le' Yes (No ~ The eligibility groups or populations for which hospitals determine eligibility presumptively are: ~ Pregnant Women ~ Infants and Children under Age 19 ~ Parents and Other Caretaker Relatives ~ Adult Group, if covered by the state ~ Individuals above 133% FPL under Age 65, if covered by the state ~ Individuals Eligible for Family Planning Services, if covered by the state ~ Former Foster Care Children ~ Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state 0 Other Family/Adult groups: 0 Eligibility groups for individuals age 65 and over 0 Eligibility groups for individuals who are blind 0 Eligibility groups for individuals with disabilities 0 Other Medicaid state plan eligibility groups 0 Demonstration populations covered under section 1115 The state establishes standards for qualified hospitals making presumptive eligibility determinations. TN NO: 14- 005 Approval Date: 12/ 11/ 14 Effective Dare: 1/ 01 / 2014 Supersede d TN NO: N/A Alaska Page 1 of3

Medicaid Eligibility (i' Yes ('No Select one or both: IZJ The state has standards that relate to the proportion of individuals determined presumptively eligible who submit a regular application, as described at 42 CFR 435.907, before the end of the presumptive eligibility period. D . . f d d 1:80% of the individuals determined to be presumptively eligible will submit a regular application I escnpt10n o stan ar s: .- M d. .db .- h d f h · · 1· ·b·1· · d ,or e ICai e1ore t e en o t e1r presumptive e 1g1 1 1ty peno . D The state has standards that relate to the proportion of individuals who are determined eligible for Medicaid based on the submission of an application before the end of the presumptive eligibility period. ~ The presumptive period begins on the date the determination is made. ~ The end date of the presumptive period is the earlier of: The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. ~Periods of presumptive eligibility are limited as follows: ('No more than one period within a calendar year. ('No more than one period within two calendar years. (i' No _more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility penod. ('Other reasonable limitation: The state requires that a written application be signed by the applicant, parent or representative, as appropriate. (i' Yes (' No (' The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS. (i' The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the application form is • included. I An attachment is submitted. I TN NO : 14- 0 0 5 Approval Date: 12/11/14 Effective Dare: 1/01/2014 Superseded TN NO: N/A Alaska Page 2 of3

Medicaid Eligibility ~ The presumptive eligibility determination is based on the following factors: The individual's categorical or non-financial eligibility for the group for which the individual's presumptive eligibility is ~ being determined (e.g., based on age, pregnancy status, status as a parent/caretaker relative, disability, or other requirements specified in the Medicaid state plan or a Medicaid 1115 demonstration for that group) ~ Household income must not exceed the applicable income standard for the group for which the individual's presumptive • eligibility is being determined, if an income standard is applicable for this group. ~ State residency ~ Citizenship, status as a national, or satisfactory immigration status [{] The state assures that it has communicated the requirements for qualified hospitals, and has provided adequate training to the ./ hospitals. A copy of the training materials has been included. I An attachment is submitted. I PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN NO: 14-005 Approval Date: 12/11/14 Effective Dare: 1/01/2014 Superseded TN NO: N/A Alaska Page 3 of3

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Table of Contents

State/Territory Name: Alaska

State Plan Amendment (SPA) #: 15-0006

This file contains the following documents in the order listed:

1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Seattle Regional Office 701 Fifth Avenue, Suite 1600, MS/RX-200 Seattle, WA 98104 Division of Medicaid & Children’s Health Operations September 24, 2015 Jon Sherwood, Deputy Commissioner Department of Health and Social Services PO Box 110601 Juneau, AK 99811-0601 RE: Alaska State Plan Amendment (SPA) Transmittal Number 15-0006-MM1 Dear Mr. Sherwood: The Centers for Medicare & Medicaid Services (CMS) has completed its review of State Plan Amendment (SPA) Transmittal Number 15-0006-MM1. In this SPA, Alaska elects to cover the adult eligibility group under the Medicaid State Plan in accordance with section 1902(a)(10)(A)(i)(VIII) of the Affordable Care Act. This SPA is approved effective September 1, 2015. If you have any additional questions or require further assistance, please contact me or have your staff contact Maria Garza at (206) 615-2542 or maria.garza@cms.hhs.gov. Sincerely, David L. Meacham Associate Regional Administrator cc: Gennifer Moreau-Johnson, State Plan Coordinator Digitally signed by David L. Meacham -S Date: 2015.09.25 10:45:06 -07'00'

Medicaid State Plan Eligibility: Summary Page (CMS 179) State/Territory name: Alaska Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. Proposed Effective Date (mm/dd/yyyy) Federal Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First Year Second Year $ 12000000.00 $ 145000000.00 Adding new adult group. Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Submitted By: Gennifer Moreau Last Revision Date: Sep 22, 2015 Submit Date: Jul 21, 2015 AK-15-0006 g 1902(a)(10)(A)(i)(VIII) 42 CFR 435.119 09/01/2015 2015 2016 Date Received: 09/21/2015 Date Approved: 09/24/2015 PLAN APPROVED- ONE COPY ATTACHED Effective Date of Approved Material: 09/1/2015 Signature of Regional Official: /s/ Typed Name: David L. Meacham Title: Associate Regional Administrator General Information: PDF(s) superseded by this SPA (Include Transmittal Number): Adult Group S 32 AK SPA 13- 0027 Description: Eligibility SPA Adult Group S 32 Subject of Amendment Transmittal Number: AK-15-0006 Supersedes TN: AK-13-0027 Approval Date: 9/24/2015 Effective Date: 9/1/2015

Page 1 of 2 Medicaid Eligibility Transmittal Number: AK State Name: Alaska OMB Control Number: 0938‐1148 Expiration date: 10/31/2014 - 15 - 0006 Eligibility Groups - Mandatory Coverage Adult Group S32 1902(a)(10)(A)(i)(VIII) 42 CFR 435.119 The state covers the Adult Group as described at 42 CFR 435.119. Yes No Adult Group - Non-pregnant individuals age 19 through 64, not otherwise mandatorily eligible, with income at or below 133% FPL. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ Have attained age 19 but not age 65. ■ Are not pregnant. ■ Are not entitled to or enrolled for Part A or B Medicare benefits. ■ Are not otherwise eligible for and enrolled for mandatory coverage under the state plan in accordance with 42 CFR 435, subpart B. ■ Note: In 209(b) states, individuals receiving SSI or deemed to be receiving SSI who do not qualify for mandatory Medicaid eligibility due to more restrictive requirements may qualify for this eligibility group if otherwise eligible. Have household income at or below 133% FPL. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI-Based Income Methodologies, completed by the state. ■ There is no resource test for this eligibility group. ■ Parents or other caretaker relatives living with a child under the age specified below are not covered unless the child is receiving benefits under Medicaid, CHIP or through the Exchange, or otherwise enrolled in minimum essential coverage, as defined in 42 CFR 435.4. ■ Under age 19, or A higher age of children, if any, covered under 42 CFR 435.222 on March 23, 2010: Under age 20 Under age 21 Presumptive Eligibility ■ The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible. Yes No Transmittal Number: AK-15-0006 Supersedes TN: AK-13-0027 Approval Date: 9/24/2015 Effective Date: 9/1/2015

Page 2 of 2 Medicaid Eligibility PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. V.20140415 Transmittal Number: AK-15-0006 Supersedes TN: AK-13-0027 Approval Date: 9/24/2015 Effective Date: 9/1/2015

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Table of Contents

State/Territory Name: Alaska

State Plan Amendment (SPA) #: 15-0009

This file contains the following documents in the order listed:

1) Approval Letter 2) CMS 179 Form/Summary Page 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Seattle Regional Office 701 Fifth Avenue, Suite 1600, MS/RX-200 Seattle, WA 98104 Division of Medicaid & Children’s Health Operations December , 2015 Valerie Davidson, Commissioner Department of Health and Social Services 3601 C Street, Suite 902 Anchorage, AK 99503-7167 RE: Alaska State Plan Amendment (SPA) Transmittal Number 15-0009 Dear Ms. Davidson: The Centers for Medicare & Medicaid Services (CMS) has completed its review of Alaska State Plan Amendment (SPA) Transmittal Number 15-0009. This SPA changes the state from accepting eligibility assessment to accepting eligibility determination for Medicaid made by the Federally Facilitated Marketplace. In addition, the transmittal describes the single state agency’s delegation of appeals and determinations in accordance with the Affordable Care Act. This SPA is approved effective November 1, 2015, as requested by the state. If there are additional questions please contact me, or your staff may contact Maria Garza at maria.garza@cms.hhs.gov or at (206) 615-2542. Sincerely, David L. Meacham Associate Regional Administrator Enclosure cc: Jon Sherwood, DHSS Digitally signed by David L. Meacham -S DN: c=US, o=U.S. Government, ou=HHS, ou=CMS, ou=People, 0.9.2342.19200300.100.1.1=2000041858, cn=David L. Meacham -S Date: 2015.12.18 11:04:39 -08'00'

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Page 1 of 5 Medicaid Administration Transmittal Number: AK State Name: Alaska OMB Control Number: 0938‐1148 Expiration date: 10/31/2014 - 15 - 0009 State Plan Administration Designation and Authority A1 42 CFR 431.10 Designation and Authority State Name: Alaska As a condition for receipt of Federal funds under title XIX of the Social Security Act, the single state agency named below submits the following state plan for the medical assistance program, and hereby agrees to administer the program in accordance with the provisions of this state plan, the requirements of titles XI and XIX of the Act, and all applicable Federal regulations and other official issuances of the Department. Name of single state agency: Department of Health and Social Services Type of Agency: Title IV-A Agency Health Human Resources Other Type of Agency Health and Title IV-A The above named agency is the single state agency designated to administer or supervise the administration of the Medicaid program under title XIX of the Social Security Act. (All references in this plan to "the Medicaid agency" mean the agency named as the single state agency.) The state statutory citation for the legal authority under which the single state agency administers the state plan is: Alaska Statute 47.07.040 The single state agency supervises the administration of the state plan by local political subdivisions. Yes No The certification signed by the state Attorney General identifying the single state agency and citing the legal authority under which it administers or supervises administration of the program has been provided. ✔ An attachment is submitted. The state plan may be administered solely by the single state agency, or some portions may be administered by other agencies. The single state agency administers the entire state plan under title XIX (i.e., no other agency or organization administers any portion of it). Yes No 71 $.  $SSURYDO'DWH  (IIHFWLYH'DWH  6XSHUVHGHV71 $.00 

Page 2 of 5 Medicaid Administration The entity or entities that have responsibility for determinations of eligibility for families, adults, and for individuals under 21 are: The Medicaid agency Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The entity that has responsibility for determinations of eligibility for the aged, blind, and disabled are: The Medicaid agency Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The Federal agency administering the SSI program The entity or entities that have responsibility for conducting fair hearings with respect to denials of eligibility based on the applicable modified adjusted gross income standard are: Medicaid agency An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act An Exchange appeals entity, including an entity established under section 1411(f) of the Affordable Care Act Name of entity: HHS appeals entity The agency has established a review process whereby the agency reviews appeals decisions made by the Exchange or Exchange appeals entity or other state agency, but only with respect to conclusions of law, including interpretations of state or federal policies. Yes No State Plan Administration Organization and Administration A2 42 CFR 431.10 42 CFR 431.11 Organization and Administration Provide a description of the organization and functions of the Medicaid agency. The following divisions within the Department of Health and Social Services play a role in administering the Medicaid program. The Office of the Commissioner includes two Deputy Commissioners, and an Assistant Commissioner, supporting staff and additional units. The Commissioner's Office is responsible for providing the leadership and direction to ensure an efficient and effective organization that is capable of fulfilling the functions and responsibilities designated by law. Reporting directly to the Commissioner is the Division of Public Health, which administers and enforces State health regulations. Within the Office of the Deputy Commissioner for Medicaid and Health Care Policy is the Division of Health Care Services, which has been designated as the medical assistance unit. The Office of Medicaid Policy and Planning includes Program Review, which provides quality assurance and handles intergovernmental relations. The Office of Rate and Review makes recommendations to the Commissioner on all rates paid to providers. The Division of Senior and Disability Services provides the full range of care for seniors and the disabled in one agency through the administration of state and federal grant programs and all Medicaid Home and 71 $.   $SSURYDO'DWH  (IIHFWLYH'DWH  6XSHUVHGHV71 $.00 

Page 3 of 5 Medicaid Administration Community Based Waivers. The Division of Behavioral Health assumes all policy, program and administrative responsibility for mental health and substance abuse services. The Division of Alaska Pioneer Homes provides residential and pharmaceutical services in Sitka, Fairbanks, Anchorage, Ketchikan, Palmer, and Juneau for qualified Alaska seniors. Within the Office of the Deputy Commissioner for Family, Community and Integrated Services is the Division of Public Assistance, the Division of Juvenile Justice, and the Office of Children’s Services. The Division of Public Assistance develops health care eligibility policy for Medicaid, Chronic and Acute Medical Assistance (CAMA) programs, and Aid to the Blind, Disabled, and Old Age Assistance. Except for children in state custody, the Division of Public Assistance makes all eligibility determinations for Medicaid other than those eligibility determinations made by the Exchange. The Office of Children’s Services determines Medicaid eligibility for children in state custody. DJJ is responsible for juveniles adjudicated under the criminal justice system in Alaska, including juveniles in parole status. DHSS role and responsibility in Administrative Hearings: The DHSS Commissioner’s, through a statutory delegation, tasks Administrative Law Judges at the Office of Administrative Hearings (OAH) to conduct a de novo review that is based upon facts and conclusions of law including the appropriate application of federal and state Medicaid law regulations or policies. An individual does have the ability to ask for "review" or comment on an OAH decision through the proposal for action process. What that means is that every party to the OAH decision, including consumers, has the ability to submit a written brief in support of, or in opposition of the OAH decision raising questions of both law and fact. This is not an appeal per se, but rather an ability to file objections or statement in support of findings of fact and conclusions of law made by the hearing officer, that are submitted to the Commissioner’s office along with the proposed decision and any other documents or evidence submitted in the hearing process for final decision. The proposal for action is optional, if either party submits a proposal for action it must be submitted to the Commissioner’s office for decision, if neither party present a proposal for action the OAH decision is final under operation of law. If the Commissioner’s office or the OAH rules in favor of the department the consumer has the ability to appeal that decision to the Superior Court. If the OAH rules in favor of the consumer that is the end of the line there is no right for the department to appeal it's own decision. There is no difference in the "standard of review" all matters are reviewed de novo at all levels of the administrative process. A de novo review can also be requested at the Superior Court appeal level although that is the exception not the rule. Upload an organizational chart of the Medicaid agency. An attachment is submitted. Provide a description of the structure of the state's executive branch which includes how the Medicaid agency fits in with other health, human service and public assistance agencies. All State health, human service, and public assistance agencies are housed within the single state agency, the Department of Health and Social Services. The Office of Administrative Hearings, an independent office within the Department of Administration charged with providing adjudication services, regulatory review and training, provides Administrative Law Judges to conduct hearings in accordance with 7 AAC 49.010 – 7 AAC 49.180, 7 AAC 49.220 and 7 AAC 49.240. This office makes recommendations to the Department of Health and Social Services after considering hearings and appeals, on behalf of the Commissioner, regarding Medicaid applicants, recipients, or providers. The Administrative Law Judge would hear a case in accordance with 7 AAC 49.010 – 7 AAC 49.180, 7 AAC 49.220 and 7 AAC 49.240, and would prepare draft findings, conclusions, and order for the Commissioner of the Department of Health and Social Services. The Commissioner of the Department has final authority in deciding cases. Entities that determine eligibility other than the Medicaid Agency (if entities are described under Designation and Authority) Remove Type of entity that determines eligibility: Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The Federal agency administering the SSI program 71 $.   $SSURYDO'DWH  (IIHFWLYH'DWH  6XSHUVHGHV71 $.00 

Page 4 of 5 Medicaid Administration Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility. The Federally-Facilitated Marketplace (FFM) will be determining eligibility for Medicaid for groups of individuals whose income eligibility is determined based on MAGI income methodology and who apply through the FFM. The FFM will not be assigning an individual who is determined eligible for Medicaid whose income eligibility is determined using MAGI methodology to a specific eligibility group, determining cost-sharing (if applicable), or assigning a benefit package – functions that will be performed by the single state agency. Add Entities that conduct fair hearings other than the Medicaid Agency (if are described under Designation and Authority) Remove Type of entity that conducts fair hearings: An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act An Exchange appeals entity, including an entity established under section 1411(f) of the Affordable Care Act Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility. The HHS appeals entity will conduct Medicaid fair hearings for individuals whose Medicaid eligibility has been determined and found ineligible for Medicaid by the Federally-facilitated Marketplace (FFM). These will be individuals whose income eligibility is determined based on MAGI income methodology and who applied for health coverage through the FFM. Add Supervision of state plan administration by local political subdivisions (if described under Designation and Authority) Is the supervision of the administration done through a state-wide agency which uses local political subdivisions? Yes No State Plan Administration Assurances A3 42 CFR 431.10 42 CFR 431.12 42 CFR 431.50 Assurances The state plan is in operation on a statewide basis, in accordance with all the requirements of 42 CFR 431.50. ✔ All requirements of 42 CFR 431.10 are met. ✔ There is a Medical Care Advisory Committee to the agency director on health and medical services established in accordance with meeting all the requirements of 42 CFR 431.12. ✔ The Medicaid agency does not delegate, to other than its own officials, the authority to supervise the plan or to develop or issue policies, rules, and regulations on program matters. ✔ Assurance for states that have delegated authority to determine eligibility: 71 $.   $SSURYDO'DWH  (IIHFWLYH'DWH  6XSHUVHGHV71 $.00 

Page 5 of 5 Medicaid Administration There is a written agreement between the Medicaid agency and the Exchange or any other state or local agency that has been delegated authority to determine eligibility for Medicaid eligibility in compliance with 42 CFR 431.10(d). ✔ Assurances for states that have delegated authority to conduct fair hearings: There is a written agreement between the Medicaid agency and the Exchange or Exchange appeals entity that has been delegated authority to conduct Medicaid fair hearings in compliance with 42 CFR 431.10(d). ✔ When authority is delegated to the Exchange or an Exchange appeals entity, individuals who have requested a fair hearing are given the option to have their fair hearing conducted instead by the Medicaid agency. ✔ Assurance for states that have delegated authority to determine eligibility and/or to conduct fair hearings: The Medicaid agency does not delegate authority to make eligibility determinations or to conduct fair hearings to entities other than government agencies which maintain personnel standards on a merit basis. ✔ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20141203 71 $.   $SSURYDO'DWH  (IIHFWLYH'DWH  6XSHUVHGHV71 $.00 

___________________________________________________________________________________ Table of Contents State/Territory Name: Alaska State Plan Amendment (SPA) #: 17-0010 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Seattle Regional Office 701 Fifth Avenue, Suite 1600, MS/RX-200 Seattle, WA 98104 Division of Medicaid & Children’s Health Operations February 12, 2018 Valerie Davidson, Commissioner Department of Health and Social Services PO Box 110601 Anchorage, AK 99503-7167 RE: Alaska State Plan Amendment (SPA) Transmittal Number 17-0010 Dear Ms. Davidson: The Centers for Medicare & Medicaid Services (CMS) has completed its review of State Plan Amendment (SPA), Transmittal Number 17-0010. This SPA provides for the verification of assets for the purposes of determining and re-determining Medicaid eligibility for aged, blind and disabled Medicaid applicants and recipients using an Asset Verification System (AVS). This SPA is approved effective October 1, 2017. CMS approves this SPA and the implementation timeline dated February 12, 2018. If the timeline changes by more than 30 days, please submit any changes to the Seattle Regional Office for review. Enclosed is a copy of the CMS-179 summary form and the approved pages for incorporation into the Alaska State Plan. If there are any questions concerning this approval, please contact me or your staff may contact Maria Garza at maria.garza@cms.hhs.gov or at (206) 615-2541. Sincerely, David L. Meacham Associate Regional Administrator Enclosure cc: Jon Sherwood, DHSS Courtney King, DHSS Digitally signed by David L. Meacham -S

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State Plan for Title XIX Attachment 4.32-A State of Alaska Page 1 TN No. 17-0010 Approval Date: Effective Date October 1, 2017 Supersedes TN No. 10-06 INCOME AND ELIGIBILITY VERIFICATION SYSTEM PROCEDURES – REQUESTS TO OTHER STATE AGENCIES The State of Alaska conducts a data match with the Public Assistance Reporting Information System (PARIS) for public assistance recipients on at least an annual basis. The PARIS match helps the state maintain program integrity by detecting and deterring improper payments. The PARIS match collects data from three separate data matches – federal, Veteran’s Affairs (VA), and interstate. The federal match provides information about recipient’s military and civil service benefits. The VA match provides information about veteran pension and compensation benefits. The interstate provides information about recipients’ possible receipt of duplicative TANF, Medicaid, and food stamp benefits issues by the 50 states, Washington D.C., and Puerto Rico. ASSET VERIFICATION SYSTEM I. The agency will provide for the verification of assets for the purposes of determining or re-determining Medicaid eligibility for aged, blind, and disabled Medicaid applicants and recipients using an Asset Verification System (AVS) that meets the following minimum requirements. A. The request and response system must be electronic: 1. Verification inquiries must be sent electronically via the internet or similar means from the agency to the financial institution (FI). 2. The system cannot be based on mailing paper-based requests. 3. The system must have the capability to accept responses electronically. B. The system must be secure, based on a recognized industry standard of security (e.g., as defined by the U.S. Commerce Department’s National Institute of Standard and Technology (NIST). C. They system must establish and maintain a database of FIs that participate in the agency’s AVS. D. Verification requests also must be sent to FIs other than those identified by applicants and recipients, based on some logic such as geographic proximity to the applicant’s home address, or other reasonable factors whenever the agency determines that such requests are needed to determine or re-determine the individual’s eligibility. E. The verification requests must include a request for information on both open and closed accounts, going back up to 5 years as determined by the state. II. System Development A. The agency itself will develop an AVS. In #3 below, provide any additional information the agency wants to include. B. The agency will hire a contractor to develop an AVS. In #3 below, provide any additional information the agency wants to include. C. The agency will be joining a consortium to develop an AVS. In #3 below, identify the state participating in the consortium. Also, provide any other information the agency wants to include pertaining to how the consortium will implement the AVS requirements. D. The agency already has a system in place that meets the requirements for an acceptable AVS. In #3 below, describe how the existing system meets the requirements in Section 1. E. Other alternative not included in A – D above. In #3 below, describe this alternative approach and how it will meet the requirements in Section 1. &ĞďƌƵĂƌLJϭϮ͕ϮϬϭϴ

State Plan for Title XIX Attachment 4.32-A State of Alaska Page 2 TN No. 17-0010 Approval Date: Effective Date October 1, 2017 Supersedes TN No. New III. Provide the AVS implementation information requested for the implementation approach checked in Section 2, and any other information the agency may want to include. In order to implement the requirements of an Asset Verification System (AVS), the state will be contracting with New England States Consortium Systems Organization (NESCO). The contractor has the capacity, requisite experience, and expertise to procure the AVS services for the state, in accordance with the provisions and requirement set forth in Section 1940 of P.L. 110-252. NESCO will contribute to the development of project documents, timely communicate with, and submit materials to, all entities, ensure compliance with procurement processes, procedures and requirements, and timely execute a contract with the selected vendor(s). The system will comply with the national standards prescribed by the Health Insurance Portability and Accountability Act of 1996 and the Balanced Budget Act of 1997, and kept in compliance with new and modified requirements. &ĞďƌƵĂƌLJϭϮ͕ϮϬϭϴ

___________________________________________________________________________________ Table of Contents State/Territory Name: Alaska State Plan Amendment (SPA) #: 19-0002 This file contains the following documents in the order listed: 1) Approval Letter 2) Companion Letter 3) Summary Page (with 179 like page data) 4) Approved SPA Reviewable Units from MACPRO

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Seattle Regional Office 701 Fifth Avenue, Suite 1600, MS/RX-200 Seattle, WA 98104 Western Division - Regional Operations Group Adam Crum, Commissioner Department of Health and Social Services 3601 C Street, Suite 902 Anchorage, AK 99503-7167 RE: Alaska State Plan Amendment (SPA) Transmittal Number 19-0002 Dear Mr. Crum: This letter is being sent as a companion to the Centers for Medicare & Medicaid Services (CMS) approval of Alaska State Plan Amendment (SPA) AK-19-0002, which was submitted on March 29, 2019. Alaska submitted this SPA to update the income standards for recipients of its optional state supplement program Adult Public Assistance (APA) in accordance with the 2019 cost of living adjustments for the supplemental security income (SSI) federal benefit rate (FBR), consistent with section 1902(a)(10)(A)(ii)(XI) of the Social Security Act (the Act) and the implementing regulations at 42 CFR 435.232 and 435.234. During the review of SPA AK-19-0002, CMS learned that Alaska is not operating its optional state supplement program consistent with the requirements in applicable statute and regulations. Specifically, the state is not in all circumstances making payments under its APA program that are equal to the difference between the income standard used to determine eligibility for the APA program and an individual’s countable income. The State has committed to full compliance with statute and federal regulations by January 1, 2020, by ensuring that the APA program’s optional state supplement payment is equal to the difference between the income standard and the individual’s countable income. Alaska has memorialized this commitment within the substance of AK 19-0002, and it will submit a state plan amendment, the proposed effective date of which will be January 1, 2020, that will conform the state’s operation of the APA program with federal Medicaid statutory and regulatory requirements. We continue to be available to provide technical assistance. If you have any questions about this companion letter, please contact Maria Garza at maria.garza@hhs.gov or at (206) 615-2542.

In addition Stephanie Kaminsky, Director, Division of Medicaid Eligibility Policy at Stephanie.Kaminsky@cms.hhs.gov will remain available for further discussion related to technical assistance and to address concerns related to the companion letter. Sincerely, / s / David L. Meacham Deputy Director cc: Courtney King, SPA Coordinator Albert Wall, DHSS Renee Gayhart, DHSS, HCS

Records / Submission Packages AK - Submission Package - AK2019MS0002O - (AK-19-0002) - Eligibility CMS-10434 OMB 0938-1188 Package Information Package ID AK2019MS0002O Program Name N/A SPA ID AK-19-0002 Version Number 6 Submitted By Courtney King Package Disposition Priority Code P2 Submission Type Official State AK Region Seattle, WA Package Status Approved Submission Date 3/29/2019 Approval Date 11/1/2019 4:49 PM EDT Summary Reviewable Units Versions Correspondence Log Analyst Notes Review Assessment Report Approval Letter RAI Transaction Logs News Related Actions

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Seattle Regional Office 701 Fifth Avenue, Suite 1600, MS/RX-200 Seattle, WA 98104 Division of Medicaid and Children's Health Operations November 01, 2019 Adam Crum Commissioner Department of Health and Social Services 3601 C Street Suite 902 Anchorage, AK 99503 Re: Approval of State Plan Amendment AK-19-0002 Dear Adam Crum: On March 29, 2019, the Centers for Medicare and Medicaid Services (CMS) received Alaska State Plan Amendment (SPA) AK-19-0002 to updates the income standards for recipients of its optional state supplement program (Adult Public Assistance, hereafter APA) in accordance with the 2019 cost of living adjustments for the supplemental security income (SSI) federal benefit rate (FBR), consistent with section 1902(a)(10)(A)(ii)(XI) of the Social Security Act (the Act) and the implementing regulations at 42 CFR 435.232 and 435.234.. We approve Alaska State Plan Amendment (SPA) AK-19-0002 on November 01, 2019 with an effective date(s) of January 01, 2019. Name Date Created COMPANION Letter AK19-0002 10/30/2019 5:51 PM EDT If you have any questions regarding this amendment, please contact MARIA GARZA at maria.garza@cms.hhs.gov. Sincerely, David L. Meacham Deputy Director Division of Medicaid and Children's Health Operations Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | AK2019MS0002O | AK-19-0002 Package Header Package ID AK2019MS0002O Submission Type Official Approval Date 11/1/2019 Superseded SPA ID N/A SPA ID AK-19-0002 Initial Submission Date 3/29/2019 Effective Date N/A State Information State/Territory Name: Alaska Medicaid Agency Name: Department of Health and Social Services Submission Component State Plan Amendment Medicaid CHIP

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | AK2019MS0002O | AK-19-0002 Package Header Package ID AK2019MS0002O Submission Type Official Approval Date 11/1/2019 Superseded SPA ID N/A SPA ID AK-19-0002 Initial Submission Date 3/29/2019 Effective Date N/A SPA ID and Effective Date SPA ID AK-19-0002 Reviewable Unit Proposed Effective Date Superseded SPA ID Eligibility Determinations of Individuals Age 65 or Older or Who Have Blindness or a Disability 1/1/2019 NA Non-MAGI Methodologies 1/1/2019 NA Mandatory Eligibility Groups 1/1/2019 NA Optional Eligibility Groups 1/1/2019 NA Optional State Supplement Beneficiaries 1/1/2019 18-001 Page Number of the Superseded Plan Section or Attachment (If Applicable): Elig. Det. of Ind. Age 65 or Older or Who Have Blindness or a Disability: correction to AK-13-0036 from migration. Optional State Supplement Beneficiaries: Supplement 6 to Att 2.6-A, pages 1-3; Att 2.2-A, page 17, 18; Att 2.6-A, page 4b, 6

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | AK2019MS0002O | AK-19-0002 Package Header Package ID AK2019MS0002O Submission Type Official Approval Date 11/1/2019 Superseded SPA ID N/A SPA ID AK-19-0002 Initial Submission Date 3/29/2019 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives The SPA updates the income standards for recipients of Alaska's Optional State Supplement Payments. In Alaska, individuals are able to qualify for Medicaid by reducing their countable gross income through the use of approved Medicaid Qualifying Trusts. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2019 $0 Second 2020 $0 Federal Statute / Regulation Citation 42 CFR 435.232 Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | AK2019MS0002O | AK-19-0002 Package Header Package ID AK2019MS0002O Submission Type Official Approval Date 11/1/2019 Superseded SPA ID N/A SPA ID AK-19-0002 Initial Submission Date 3/29/2019 Effective Date N/A Governor's Office Review No comment Comments received No response within 45 days Other

Submission - Public Comment MEDICAID | Medicaid State Plan | Eligibility | AK2019MS0002O | AK-19-0002 Package Header Package ID AK2019MS0002O Submission Type Official Approval Date 11/1/2019 Superseded SPA ID N/A SPA ID AK-19-0002 Initial Submission Date 3/29/2019 Effective Date N/A Indicate whether public comment was solicited with respect to this submission. Public notice was not federally required and comment was not solicited Public notice was not federally required, but comment was solicited Public notice was federally required and comment was solicited

Submission - Tribal Input MEDICAID | Medicaid State Plan | Eligibility | AK2019MS0002O | AK-19-0002 Package Header Package ID AK2019MS0002O Submission Type Official Approval Date 11/1/2019 Superseded SPA ID N/A SPA ID AK-19-0002 Initial Submission Date 3/29/2019 Effective Date N/A One or more Indian Health Programs or Urban Indian Organizations furnish health care services in this state Yes No This state plan amendment is likely to have a direct effect on Indians, Indian Health Programs or Urban Indian Organizations, as described in the state consultation plan. Yes No Explain why this SPA is not likely to have a direct effect on Indians, Indian Health Programs or Urban Indian Organizations: Alaska did not conduct tribal consultation on this SPA, as the only change involved was updating charts in the State Plan to reflect increases in the State Supplement income standards. These are not changes made by the Medicaid program (governed by separate state statute and regulation for the SSP, known as Adult Public Assistance in Alaska) and the standards are not set through the Medicaid program.

Medicaid State Plan Eligibility Income/Resource Methodologies Eligibility Determinations of Individuals Age 65 or Older or Who Have Blindness or a Disability MEDICAID | Medicaid State Plan | Eligibility | AK2019MS0002O | AK-19-0002 Package Header Package ID AK2019MS0002O Submission Type Official Approval Date 11/1/2019 Superseded SPA ID NA User-Entered SPA ID AK-19-0002 Initial Submission Date 3/29/2019 Effective Date 1/1/2019 A. Eligibility Determinations of Individuals Who Are Age 65 or Older or Who Have Blindness or a Disability Eligibility determinations of individuals who are age 65 or older or who have blindness or a disability are based on one of the following: 1. SSA Eligibility Determination State (1634 State) The state has an agreement under section 1634 of the Social Security Act for the Social Security Administration to determine Medicaid eligibility of SSI beneficiaries. For all other individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, the state requires a separate Medicaid application and determines financial eligibility based on SSI income and resource methodologies. 2. State Eligibility Determination (SSI Criteria State) The state requires all individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, including SSI beneficiaries, to file a separate Medicaid application, and determines financial eligibility based on SSI income and resource methodologies. 3. State Eligibility Determination (209(b) State) The state requires all individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, including SSI beneficiaries, to file a separate Medicaid application, and determines financial eligibility using income and resource methodologies more restrictive than SSI. B. Additional information (optional)

Medicaid State Plan Eligibility Income/Resource Methodologies Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | AK2019MS0002O | AK-19-0002 Package Header Package ID AK2019MS0002O Submission Type Official Approval Date 11/1/2019 Superseded SPA ID NA User-Entered SPA ID AK-19-0002 Initial Submission Date 3/29/2019 Effective Date 1/1/2019 The state will apply the methodologies as described below, and consistent with 42 CFR 435.601, 435.602, and 435.831. A. Basic Financial Methodology 1. The state applies the income and resource methodologies of the SSI program when determining eligibility for a population based on age (65 or older) or having blindness or a disability, with the exceptions described below in B. through G. 2. The state applies the financial methodologies of either the SSI program or the AFDC program in effect as of July 16, 1996 (whichever is most closely related) when determining eligibility for a population based on age (as a child), pregnancy, or status as a caretaker relative, with the exceptions described below in B. through G. B. Use of Less Restrictive Methodologies 1. The state elects to apply income and/or resources methodologies that are less restrictive than those used under the cash assistance programs, in accordance with 42 CFR 435.601(d). Yes No 2. The less restrictive income and resource methodologies are described on the RU for each applicable eligibility group.

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | AK2019MS0002O | AK-19-0002 Package Header Package ID AK2019MS0002O Submission Type Official Approval Date 11/1/2019 Superseded SPA ID NA User-Entered SPA ID AK-19-0002 Initial Submission Date 3/29/2019 Effective Date 1/1/2019 C. Financial Responsibility of Relatives 1. In determining financial eligibility for an individual, the state does not include income and resources from anyone other than the individual's spouse, and for individuals under age 21 or who have blindness or disability, the individual's parent. a.The state includes the income and resources of a spouse or parent only when they are living with the individual in the same household, except as follows: i. In the case of spouses who are age 65 or older or who have blindness or disability and who share the same room in a Medicaid institution, the state: (1) Considers these couples either as living together or as living separately for the purpose of counting income and resources, whichever is more advantageous to the couple. (2) Considers these couples as living separately for the purpose of counting income and resources. ii. Where applicable, the state determines income and resource eligibility consistent with the spousal impoverishment rules of section 1924 of the Act, as described in the Resource Assessment and Eligibility reviewable unit. b. In the case of individuals under age 21 for whom AFDC is the most closely related cash assistance program, the income and resources of parents and spouses are included only if the individual would have been considered a dependent under the state's approved AFDC state plan in effect as of July 16, 1996.

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | AK2019MS0002O | AK-19-0002 Package Header Package ID AK2019MS0002O Submission Type Official Approval Date 11/1/2019 Superseded SPA ID NA User-Entered SPA ID AK-19-0002 Initial Submission Date 3/29/2019 Effective Date 1/1/2019 D. Family Size 1. The family size of an individual for whom the SSI income and resource methodologies are used (as described in section A) includes the persons identified below: a. The individual applying, or b. If the individual lives together with his or her spouse, the individual applying and the spouse, or c. If the individual lives together with his or her parent(s) and the individual is under 21 or has blindness or a disability, the individual applying and the parent(s). 2. The family size of an individual for whom the AFDC income and resource methodologies are used (as described in section A.), includes the persons who would have been included in the family under the state's July 16, 1996 AFDC state plan, except where the state has elected to use the MAGI-like methodologies (as described in section E). 3. The state defines family size for one or more of the following FPL eligibility groups to include others beyond those identified in D.1. and D.2. Yes No

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | AK2019MS0002O | AK-19-0002 Package Header Package ID AK2019MS0002O Submission Type Official Approval Date 11/1/2019 Superseded SPA ID NA User-Entered SPA ID AK-19-0002 Initial Submission Date 3/29/2019 Effective Date 1/1/2019 E. Use of MAGI-like Methodologies 1. The state uses MAGI-like methodologies for one or more populations for whom the most closely related cash assistance program would be the AFDC program in effect as of July 16, 1996. Yes No

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | AK2019MS0002O | AK-19-0002 Package Header Package ID AK2019MS0002O Submission Type Official Approval Date 11/1/2019 Superseded SPA ID NA User-Entered SPA ID AK-19-0002 Initial Submission Date 3/29/2019 Effective Date 1/1/2019 F. Countable Income Deductions for the Medically Needy In determining countable income for individuals who are age 65 or older or who have blindness or a disability, the state deducts: 1. Amounts that would be deducted in determining eligibility under SSI. 2. The highest amounts that would be deducted in determining eligibility for optional state supplements if these supplements are paid to all individuals who are receiving SSI or would be eligible for SSI except for their income.

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | AK2019MS0002O | AK-19-0002 Package Header Package ID AK2019MS0002O Submission Type Official Approval Date 11/1/2019 Superseded SPA ID NA User-Entered SPA ID AK-19-0002 Initial Submission Date 3/29/2019 Effective Date 1/1/2019 G. Additional Information (optional)

Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | AK2019MS0002O | AK-19-0002 Package Header Package ID AK2019MS0002O Submission Type Official Approval Date 11/1/2019 Superseded SPA ID NA User-Entered SPA ID AK-19-0002 Initial Submission Date 3/29/2019 Effective Date 1/1/2019 Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package ? Included in Another Submission Package Source Type ? Infants and Children under Age 19 CONVERTED Parents and Other Caretaker Relatives CONVERTED Pregnant Women CONVERTED Deemed Newborns NEW Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care NEW Former Foster Care Children NEW Transitional Medical Assistance NEW Extended Medicaid due to Spousal Support Collections NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package ? Included in Another Submission Package Source Type ? SSI Beneficiaries NEW Closed Eligibility Groups NEW Individuals Deemed To Be Receiving SSI NEW NEW            

Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Working Individuals under 1619(b) Qualified Medicare Beneficiaries NEW Qualified Disabled and Working Individuals NEW Specified Low Income Medicare Beneficiaries NEW Qualifying Individuals NEW     TN: AK-19-0002 Supersedes TN: NA Approval Date: 11/1/2019 Effective Date: 1/1/2019

Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | AK2019MS0002O | AK-19-0002 Package Header Package ID AK2019MS0002O Submission Type Official Approval Date 11/1/2019 Superseded SPA ID NA User-Entered SPA ID AK-19-0002 Initial Submission Date 3/29/2019 Effective Date 1/1/2019 B. The state elects the Adult Group, described at 42 CFR 435.119. Yes No Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Adult Group NEW C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: • N/A 

Medicaid State Plan Eligibility Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | AK2019MS0002O | AK-19-0002 Package Header Package ID AK2019MS0002O Submission Type Official Approval Date 11/1/2019 Superseded SPA ID NA User-Entered SPA ID AK-19-0002 Initial Submission Date 3/29/2019 Effective Date 1/1/2019 A. Options for Coverage The state provides Medicaid to specified optional groups of individuals. Yes No The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper-based state plan to MACPro): Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Optional Coverage of Parents and Other Caretaker Relatives NEW Reasonable Classifications of Individuals under Age 21 CONVERTED Children with Non- IV-E Adoption Assistance CONVERTED Independent Foster Care Adolescents NEW Optional Targeted Low Income Children CONVERTED Individuals above 133% FPL under Age 65 NEW Individuals Needing Treatment for Breast or Cervical Cancer NEW Individuals Eligible for Family Planning Services NEW Individuals with Tuberculosis NEW Individuals Electing COBRA Continuation Coverage NEW Aged, Blind and Disabled    

Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Individuals Eligible for but Not Receiving Cash Assistance NEW Individuals Eligible for Cash Except for Institutionalization NEW Individuals Receiving Home and Community- Based Waiver Services under Institutional Rules NEW Optional State Supplement Beneficiaries APPROVED Individuals in Institutions Eligible under a Special Income Level NEW PACE Participants NEW Individuals Receiving Hospice NEW Children under Age 19 with a Disability NEW Age and Disability- Related Poverty Level NEW Work Incentives NEW Ticket to Work Basic NEW Ticket to Work Medical Improvements NEW Family Opportunity Act Children with a Disability NEW Individuals Receiving State Plan Home and Community-Based Services NEW Individuals Receiving State Plan Home and Community-Based Services Who Are Otherwise Eligible for HCBS Waivers NEW         TN: AK-19-0002 Supersedes TN: NA Approval Date: 11/1/2019 Effective Date: 1/1/2019

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | AK2019MS0002O | AK-19-0002 Package Header Package ID AK2019MS0002O Submission Type Official Approval Date 11/1/2019 Superseded SPA ID NA User-Entered SPA ID AK-19-0002 Initial Submission Date 3/29/2019 Effective Date 1/1/2019 B. Medically Needy Options for Coverage The state provides Medicaid to specified groups of individuals who are medically needy. Yes No

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | AK2019MS0002O | AK-19-0002 Package Header Package ID AK2019MS0002O Submission Type Official Approval Date 11/1/2019 Superseded SPA ID NA User-Entered SPA ID AK-19-0002 Initial Submission Date 3/29/2019 Effective Date 1/1/2019 C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: • N/A

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Optional State Supplement Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | AK2019MS0002O | AK-19-0002 Individuals who receive an optional state supplementary payment. Package Header Package ID AK2019MS0002O Submission Type Official Approval Date 11/1/2019 Superseded SPA ID 18-001 User-Entered SPA ID AK-19-0002 Initial Submission Date 3/29/2019 Effective Date 1/1/2019 The state covers the Optional State Supplement Beneficiaries eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Receive an optional state supplement that meets the conditions described in sections C and D. 2. Except for income, would be eligible for SSI. 3. Do not have gross income exceeding 300% of the SSI Federal Benefit Rate (FBR).

Optional State Supplement Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | AK2019MS0002O | AK-19-0002 Package Header Package ID AK2019MS0002O Submission Type Official Approval Date 11/1/2019 Superseded SPA ID 18-001 User-Entered SPA ID AK-19-0002 Initial Submission Date 3/29/2019 Effective Date 1/1/2019 B. Individuals Covered 1. The state covers all individuals who meet the characteristics described in section A. Yes No

Optional State Supplement Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | AK2019MS0002O | AK-19-0002 Package Header Package ID AK2019MS0002O Submission Type Official Approval Date 11/1/2019 Superseded SPA ID 18-001 User-Entered SPA ID AK-19-0002 Initial Submission Date 3/29/2019 Effective Date 1/1/2019 C. Optional State Supplement Program 1. The optional state supplement program is administered: a. Solely by the federal government. The state has an agreement with the Social Security Administration under section 1616 of the Act regarding the administration of optional state supplementary payments. b. By a combination of federal and state administration. The state has an agreement with the Social Security Administration under section 1616 of the Act regarding the administration of optional state supplementary payments for some classifications of individuals, while state supplementary payments for other classifications of individuals are administered by the state. c. Solely by the state. 2. Payments under the optional state supplement program are: a. Based on need and paid in cash on a regular basis; b. Equal to the difference between the individual's countable income and the income standard used to determine eligibility for supplement; and c. Available to all individuals in each population selected in section B.

Optional State Supplement Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | AK2019MS0002O | AK-19-0002 Package Header Package ID AK2019MS0002O Submission Type Official Approval Date 11/1/2019 Superseded SPA ID 18-001 User-Entered SPA ID AK-19-0002 Initial Submission Date 3/29/2019 Effective Date 1/1/2019 D. Income Standard of Optional State Supplement Program 1. The income standard for the optional state supplement: a. Varies by political subdivision. Yes No b. Varies by payment classification. Yes No The payment classifications used are: i. All individuals age 65 or older, regardless of living arrangement. ii. All individuals who have blindness, regardless of living arrangement. iii. All individuals who have a disability, regardless of living arrangement.  iv. Independent living. Income Standard I n d i v i d u a l $ 1 4 3 2 . 0 0 C o u p l e $ 2 1 2 1 . 0 0  v. Living in household of another. Income Standard I n d i v i d C o u p l e

u a l $ 1 1 8 3 . 0 0 $ 1 7 6 5 . 0 0 vi. Independent living and receiving non-medical care outside the home. vii. Living in household of another and receiving non-medical care outside the home. viii. Living in a domiciliary facility or other group living arrangement.  ix. Other payment classification. Name of Classification Independent Living Description: Independent Living Individual $1432.00 Couple $2121.00 Name of Classification Living in a Household of Another Description: Living in a Household of Another Individual $1183.00 Couple $1765.00 Name of Classification Institutionalized Description: Institutionalized Individual $200.00 Couple $400.00 Name of Classification Assisted Living Home Description: Assisted Living Home Individual $1432.00 Couple $2121.00 TN: AK-19-0002 Supersedes TN: AK-18-001 Approval Date: 11/1/2019 Effective Date: 1/1/2019

Optional State Supplement Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | AK2019MS0002O | AK-19-0002 Package Header Package ID AK2019MS0002O Submission Type Official Approval Date 11/1/2019 Superseded SPA ID 18-001 User-Entered SPA ID AK-19-0002 Initial Submission Date 3/29/2019 Effective Date 1/1/2019 E. Additional Information (optional) The 2019 maximum payment standards for each payment classification are as follows: HOUSEHOLD TYPE - MAXIMUM PAYMENT Individual, Independent living 1,133 Individual, Living in a household of another 882 Individual, Assisted Living Home 871 Couple, Independent living (one eligible) 1,292 Couple, Living in a household of another (one eligible) 978 Couple, Assisted Living Home (one eligible) 871 Couple, Independent Living (both eligible) 1,685 Couple, Living in a household of another (both eligible) 1,314 Couple, Assisted Living Home (both eligible) 1,357 Individual, Institutionalized 200 The State is taking the necessary actions to come into compliance with 42 CFR 435.232 starting with the benefit month of January 2020.

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 11/4/2019 12:14 PM EST TN: AK-19-0002 Supersedes TN: AK-18-001 Approval Date: 11/1/2019 Effective Date: 1/1/2019

Table of Contents State/Territory Name: Alaska State Plan Amendment (SPA) #: 20-0003 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 May , 2020 Adam Crum, Commissioner Department of Health and Social Services 3601 C Street, Suite 902 Anchorage, AK 99503-7167 Re: Alaska State Plan Amendment (SPA) Transmittal Number 20-0003 Dear Mr. Crum: We have reviewed the proposed amendment to add section 7.4 Medicaid Disaster Relief for the COVID-19 National Emergency to your Medicaid state plan, as submitted under transmittal number (TN) 20-0003. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID- 19 outbreak (or any renewals thereof). On March 13, 2020, the President of the United States issued a proclamation that the COVID- 19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency, including any extensions. Pursuant to section 1135(b)(5) of the Act, for the period of the public health emergency, CMS is modifying, the requirement at 42 C.F.R. 430.20 that the state submit SPAs related to the COVID- 19 public health emergency by the final day of the quarter, to obtain a SPA effective date during the quarter, enabling SPAs submitted after the last day of the quarter to have an effective date in a previous quarter, but no earlier than the effective date of the public health emergency.

The State of Alaska also requested a waiver of public notice requirements applicable to the SPA submission process. Pursuant to section 1135(b)(1)(C) of the Act, CMS is also waiving public notice requirements applicable to the SPA submission process. Public notice for SPAs is required under 42 C.F.R. §447.205 for changes in statewide methods and standards for setting Medicaid payment rates, 42 C.F.R. §447.57 for changes to premiums and cost sharing, and 42 C.F.R. §440.386 for changes to Alternative Benefit Plans (ABPs). Pursuant to section 1135(b)(1)(C) (to waive), CMS is approving the state’s request to waive these notice requirements otherwise applicable to SPA submissions. The State of Alaska also requested a waiver to modify the tribal consultation timeline applicable to this SPA submission process. Pursuant to section 1135(b)(5) of the Act, CMS is also allowing states to modify the timeframes associated with tribal consultation required under section 1902(a)(73) of the Act, including shortening the number of days before submission or conducting consultation after submission of the SPA. These waivers or modifications of the requirements related to SPA submission timelines, public notice, and tribal consultation apply only with respect to SPAs that meet the following criteria: (1) the SPA provides or increases beneficiary access to items and services related to COVID-19 (such as by waiving or eliminating cost sharing, increasing payment rates or amending ABPs to add services or providers); (2) the SPA does not restrict or limit payment or services or otherwise burden beneficiaries and providers; and (3) the SPA is temporary, with a specified sunset date that is not later than the last day of the declared COVID-19 public health emergency (or any extension thereof). We nonetheless encourage states to make all relevant information about the SPA available to the public so they are aware of the changes. We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that Alaska’s Medicaid SPA Transmittal Number 20-0003 is approved effective March 1, 2020. Enclosed is a copy of the CMS-179 summary form and the approved state plan pages. Please contact Maria Garza at (206) 615-2542 or by email at Maria.Garza@cms.hhs.gov if you have any questions about this approval. We appreciate the efforts of you and your staff in responding to the needs of the residents of the State of Alaska and the health care community. Sincerely, Anne Marie Costello Deputy Director Center for Medicaid & CHIP Services Enclosures Anne M. Costello -S Digitally signed by Anne M. Costello -S Date: 2020.05.07 08:18:25 -04'00'

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION

FORM APPROVED OMB NO. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

1. TRANSMITTAL NUMBER: 20-0003

2. STATE AK

FOR: HEALTH CARE FINANCING ADMINISTRATION

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE March 1, 2020

5. TYPE OF PLAN MATERIAL (Check One):

[_] NEW STATE PLAN

[|] AMENDMENT TO BE CONSIDERED AS NEW PLAN

[X] AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION: Section 1135 of the SSA & Title 19 of the Act (P&I)

7. FEDERAL BUDGET IMPACT: a. FFY 2020 $ 4,023,900 P&I b. FFY 2021 $0 $988,900

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Section 7.4, pages 90-98

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): N/A

10. SUBJECT OF AMENDMENT:

Disaster Relief SPA #1 (P&I)

11. GOVERNOR’S REVIEW (Check One): {-] GOVERNOR’S OFFICE REPORTED NO COMMENT [_] COMMENTS OF GOVERNOR’S OFFICE ENCLOSED (_] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

IX] OTHER. AS SPECIFIED: Does not wish to comment

12. SIGNATURE OF STATE AGENCY OFFICIAL:

13. TYPED NAME: Al Wall

14. TITLE: Deputy Commissioner, DHSS

15. DATE SUBMITTED: 4/17/20

16. RETURN TO:

Department of Health and Social Services Office of the Commissioner

3601 “C” Street, suite 902

Anchorage, AK 99503

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED: April 17, 2020

18. DATE APPROVED: May 7. 2020

PLAN APPROVED — ONE COPY ATTACHED

19, EFFECTIVE DATE OF APPROVED MATERIAL:

March 1, 2020 Costello S— —Date: 2020.05.07 21. TYPED NAME: 22. TITLE: Deputy Director Anne Marie Costello Center for Medicaid & CHIP Services

23. REMARKS: 4/28/20 P&I authorized by state to Box 6 & Box 10 4/29/20 P&I authorized by state to Box 7 fiscal impact

FORM HCFA-179 (07-92)

State/Territory: __Alaska________ Page 90 TN: 20-0003 Supersedes TN: NEW Section 7 – General Provisions 7.4. Medicaid Disaster Relief for the COVID-19 National Emergency On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and waivers will no longer be available, upon termination of the public health emergency, including any extensions. The State Medicaid agency (agency) seeks to implement the policies and procedures described below, which are different than the policies and procedures otherwise applied under the Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof), or for any shorter period described below: Describe shorter period here. NOTE: States may not elect a period longer than the Presidential or Secretarial emergency declaration (or any renewal thereof). States may not propose changes on this template that restrict or limit payment, services, or eligibility, or otherwise burden beneficiaries and providers. Request for Waivers under Section 1135 _ X__ The agency seeks the following under section 1135(b)(1)(C) and/or section 1135(b)(5) of the Act: a. __X _ SPA submission requirements – the agency requests modification of the requirement to submit the SPA by March 31, 2020, to obtain a SPA effective date during the first calendar quarter of 2020, pursuant to 42 CFR 430.20. b. __X__ Public notice requirements – the agency requests waiver of public notice requirements that would otherwise be applicable to this SPA submission. These requirements may include those specified in 42 CFR 440.386 (Alternative Benefit Plans), 42 CFR 447.57(c) (premiums and cost sharing), and 42 CFR 447.205 (public notice of changes in statewide methods and standards for setting payment rates). Approval Date: ___ DĂLJ ϳ͕ __ _ __ ϮϬϮϬ _ Effective Date: March 1, 2020

State/Territory: __Alaska________ Page 91 TN: 20-0003 Supersedes TN: NEW c. _ X__ Tribal consultation requirements – the agency requests modification of tribal consultation timelines specified in Alaska Medicaid state plan, as described below: The state requests approval to conduct tribal consultation concurrent to the SPA submission - disseminating a written notice via e-mail upon submission of the SPA and utilizing a shortened timeframe for a meeting and comment. Section A – Eligibility 1. The agency furnishes medical assistance to the following optional groups of individuals described in section 1902(a)(10)(A)(ii) or 1902(a)(10)(c) of the Act. This may include the new optional group described at section 1902(a)(10)(A)(ii)(XXIII) and 1902(ss) of the Act providing coverage for uninsured individuals. 2. _____ The agency furnishes medical assistance to the following populations of individuals described in section 1902(a)(10)(A)(ii)(XX) of the Act and 42 CFR 435.218: a. _ _ All individuals who are described in section 1905(a)(10)(A)(ii)(XX) Income standard: -or-

b. _____ Individuals described in the following categorical populations in section 1905(a) of the Act: Income standard: _____________ 3. The agency applies less restrictive financial methodologies to individuals excepted from financial methodologies based on modified adjusted gross income (MAGI) as follows. Less restrictive income methodologies: Approval Date: _DĂLJ ϳ͕ ϮϬϮϬ Effective Date: March 1, 2020

State/Territory: __Alaska________ Page 92 TN: 20-0003 Approval Date: _ Supersedes TN: NEW Effective Date: March 1, 2020 Less restrictive resource methodologies: 4. ____ The agency considers individuals who are evacuated from the state, who leave the state for medical reasons related to the disaster or public health emergency, or who are otherwise absent from the state due to the disaster or public health emergency and who intend to return to the state, to continue to be residents of the state under 42 CFR 435.403(j)(3). 5. X _ The agency provides Medicaid coverage to the following individuals living in the state, who are non-residents: Non-residents of the state who otherwise meet eligibility requirements and are in the state temporarily. The state will work with the individual’s home state to prevent duplicate coverage. 6. __X__ The agency provides for an extension of the reasonable opportunity period for non- citizens declaring to be in a satisfactory immigration status, if the non-citizen is making a good faith effort to resolve any inconsistences or obtain any necessary documentation, or the agency is unable to complete the verification process within the 90-day reasonable opportunity period due to the disaster or public health emergency. Section B – Enrollment 1. The agency elects to allow hospitals to make presumptive eligibility determinations for the following additional state plan populations, or for populations in an approved section 1115 demonstration, in accordance with section 1902(a)(47)(B) of the Act and 42 CFR 435.1110, provided that the agency has determined that the hospital is capable of making such determinations. 2. _____ The agency designates itself as a qualified entity for purposes of making presumptive eligibility determinations described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. 3. The agency designates the following entities as qualified entities for purposes of making presumptive eligibility determinations or adds additional populations as described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Indicate if any designated entities are permitted to make presumptive eligibility determinations only for specified populations. DĂLJ ϳ͕ ϮϬϮϬ

State/Territory: __Alaska________ Page 93 TN: 20-0003 Supersedes TN: NEW 4. _____ The agency adopts a total of _____ months (not to exceed 12 months) continuous eligibility for children under age enter age _____ (not to exceed age 19) regardless of changes in circumstances in accordance with section 1902(e)(12) of the Act and 42 CFR 435.926. 5. _ _ The agency conducts redeterminations of eligibility for individuals excepted from MAGI- based financial methodologies under 42 CFR 435.603(j) once every months (not to exceed 12 months) in accordance with 42 CFR 435.916(b). 6. _____ The agency uses the following simplified application(s) to support enrollment in affected areas or for affected individuals (a copy of the simplified application(s) has been submitted to CMS). a. _____ The agency uses a simplified paper application. b. _____ The agency uses a simplified online application. c. _____ The simplified paper or online application is made available for use in call-centers or other telephone applications in affected areas. Section C – Premiums and Cost Sharing 1. __X__ The agency suspends deductibles, copayments, coinsurance, and other cost sharing charges as follows: Alaska will not impose cost-sharing for testing services (including in vitro diagnostic products, and including test administration), testing-related services, and treatments for COVID-19, including vaccines, pharmaceuticals, specialized equipment, and therapies, for any quarter in which the increased FMAP is claimed. 2. __X__ The agency suspends enrollment fees, premiums and similar charges for: a. _____ All beneficiaries b. __X The following eligibility groups or categorical populations: Qualified Working Disabled eligibility category under 1902(a)(1O)(A)(ii)(XIII) of the Act 3. _____ The agency allows waiver of payment of the enrollment fee, premiums and similar charges for undue hardship. Approval Date: DĂLJ ϳ͕ ϮϬϮϬ Effective Date: March 1, 2020

State/Territory: __Alaska________ Page 94 TN: 20-0003 Supersedes TN: NEW Section D – Benefits Benefits: 1. ____ The agency adds the following optional benefits in its state plan (include service descriptions, provider qualifications, and limitations on amount, duration or scope of the benefit): 2. _ X__ The agency makes the following adjustments to benefits currently covered in the state plan: x Temporarily revise state plan provisions at Attachment 3.1-K, page six, to allow the provision of Community First Choice Personal Care services to a recipient in an acute care hospital as long as the services are identified in an individual’s personal plan of care, address needs that are not met through the provision of hospital services, are not duplicative of services the hospital is obligated to provide, and are designed to ensure smooth transitions between acute care settings and home and community-based settings, and preserve the individual’s functional abilities. x Temporarily waive provider requirements as follows: o revise provisions located in Attached Sheet to Attachment 3.1, pages 4b (i) and 4c (bullet #1) to allow students who have completed all required coursework with the exception of a practicum and/or internship hours to practice as unlicensed mental health professionals o revise provisions located in attached sheet to Attachment 3.1-A page 11a, and Attachment 3.1-K, page 7 to remove the requirement for certifications in First Aid and CPR. x Temporarily expand state plan provisions regarding pharmacists under the OLP benefit at Attached Sheet to Attachment 3.1-A, page 2, item 6 (d.3) to allow service provision and reimbursement of services provided by qualified and enrolled State Licensed Pharmacists practicing within their authorized scope practice, statewide standing orders authorized by the Alaska Chief Medical Officer, and the HHS Office of the Assistant Secretary for Health guidance memo dated April 8, 2020. 3. __X__ The agency assures that newly added benefits or adjustments to benefits comply with all applicable statutory requirements, including the statewideness requirements found at 1902(a)(1), comparability requirements found at 1902(a)(10)(B), and free choice of provider requirements found at 1902(a)(23). 4. X _ Application to Alternative Benefit Plans (ABP). The state adheres to all ABP provisions in 42 CFR Part 440, Subpart C. This section only applies to states that have an approved ABP(s). a. __X _ The agency assures that these newly added and/or adjusted benefits will be made available to individuals receiving services under ABPs. b. _____ Individuals receiving services under ABPs will not receive these newly added and/or adjusted benefits, or will only receive the following subset: Approval Date: ___DĂLJ ϳ͕ ϮϬϮϬ

ffective Date: March 1, 2020

State/Territory: __Alaska________ Page 95 TN: 20-0003 Supersedes TN: NEW Telehealth: 5. _____ The agency utilizes telehealth in the following manner, which may be different than outlined in the state’s approved state plan: Drug Benefit: 6. __X__ The agency makes the following adjustments to the day supply or quantity limit for covered outpatient drugs. The agency should only make this modification if its current state plan pages have limits on the amount of medication dispensed. (1) Temporarily revise state plan provision at Attached Sheet to Attachment 3.1-A, page 4 (3.b) to read: Claims for medications with days’ supply up to 68 days shall be permitted unless medication is on the 90-day list, then 90-days will be permitted. (2) Temporarily revise state plan provisions at Attached Sheet to Attachment 3.1-A, page 3b, (4) to waive the requirement for the return of unused unit dose medications dispensed to a LTC facility due to infection control considerations. 7. _____ Prior authorization for medications is expanded by automatic renewal without clinical review, or time/quantity extensions. 8. __X__ The agency makes the following payment adjustment to the professional dispensing fee when additional costs are incurred by the providers for delivery. States will need to supply documentation to justify the additional fees. (1) Temporarily revise state plan provisions at Attachment 4.19-B, page 8 (K&L) to allow for a professional dispensing fee to be reimbursed no more than every 14-days per individual at $15.86 for pharmacies located on the road system and $23.78 for pharmacies not located on the road system. Shipping will be reimbursed regardless of the location of the pharmacy or beneficiary. (2) Covered outpatient drugs dispensed by a retail-based pharmacy (non-physician administered drugs), when a medication’s acquisition cost exceeds the standard “lesser of” payment methodology logic, providers may petition for reimbursement at Wholesale Acquisition Cost (WAC) + 1% on a claim-level basis through the point-of-sale and bypass the Federal Upper Limit (FUL) and National Average Drug Acquisition Cost (NADAC). 9. __X__ The agency makes exceptions to their published Preferred Drug List if drug shortages occur. This would include options for covering a brand name drug product that is a multi-source drug if a generic drug option is not available. Approval Date: DĂLJ ϳ͕ ϮϬϮϬ Effective Date: March 1, 2020

State/Territory: __Alaska________ Page 96 TN: 20-0003 Supersedes TN: NEW Section E – Payments Optional benefits described in Section D: 1. __ _ Newly added benefits described in Section D are paid using the following methodology: a. _____ Published fee schedules – Effective date (enter date of change): _____________ Location (list published location): _____________ b. _ _ Other: Increases to state plan payment methodologies: 2. __X _ The agency increases payment rates for the following services: Targeted Case Management (ILP & LTSS) a. __X__ Payment increases are targeted based on the following criteria: Modify the reimbursement of ILP and LTSS Targeted Case Management to reflect a per episode rate equal to the existing monthly rate, this increase is reflective of the increased requirements for TCM providers during the PHE. b. Payments are increased through: i. _____ A supplemental payment or add-on within applicable upper payment limits: ii. _____ An increase to rates as described below. Rates are increased: _____ Uniformly by the following percentage: _____________ _____ Through a modification to published fee schedules – Effective date (enter date of change): _____________ Location (list published location): _____________ _____ Up to the Medicare payments for equivalent services. _____ By the following factors: Approval DaƚĞ͗ DĂLJ ϳ͕ ϮϬϮϬ Effective Date: March 1, 2020

State/Territory: __Alaska________ Page 97 TN: 20-0003 Supersedes TN: NEW Payment for services delivered via telehealth: 3. _____ For the duration of the emergency, the state authorizes payments for telehealth services that: a. _____ Are not otherwise paid under the Medicaid state plan; b. _____ Differ from payments for the same services when provided face to face; c. _____ Differ from current state plan provisions governing reimbursement for telehealth; d. _____ Include payment for ancillary costs associated with the delivery of covered services via telehealth, (if applicable), as follows: i. _____ Ancillary cost associated with the originating site for telehealth is incorporated into fee-for-service rates. ii. _____ Ancillary cost associated with the originating site for telehealth is separately reimbursed as an administrative cost by the state when a Medicaid service is delivered. Other: 4. _____ Other payment changes: Section F – Post-Eligibility Treatment of Income 1. The state elects to modify the basic personal needs allowance for institutionalized individuals. The basic personal needs allowance is equal to one of the following amounts: a. _____ The individual’s total income b. _____ 300 percent of the SSI federal benefit rate c. _____ Other reasonable amount: _________________ 2. _____ The state elects a new variance to the basic personal needs allowance. (Note: Election of this option is not dependent on a state electing the option described the option in F.1. above.) The state protects amounts exceeding the basic personal needs allowance for individuals who have the following greater personal needs: Approval Date: DĂLJ ϳ͕ ϮϬϮϬ Effective Date: March 1, 2020

State/Territory: __Alaska________ Page 98 TN: 20-0003 Supersedes TN: NEW Section G – Other Policies and Procedures Differing from Approved Medicaid State Plan /Additional Information PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148 (Expires 03/31/2021). The time required to complete this information collection is estimated to average 1 to 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Your response is required to receive a waiver under Section 1135 of the Social Security Act. All responses are public and will be made available on the CMS web site. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ***CMS Disclosure*** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the Centers for Medicaid & CHIP Services at 410-786-3870. Approval Date: DĂLJ ϳ͕ ϮϬϮϬ Effective Date: March 1, 2020

___________________________________________________________________________________ Table of Contents State/Territory Name: Alaska State Plan Amendment (SPA) #: 20-0006 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106

Medicaid and CHIP Operations Group

November 23, 2020

Adam Crum, Commissioner Department of Health and Social Services 3601 C Street, Suite 902 Anchorage, AK 99503

Re: Alaska State Plan Amendment (SPA) AK-20-0006

Dear Mr. Crum:

The Centers for Medicare and Medicaid Services (CMS) has reviewed the state’s proposed Medicaid State Plan Amendment (SPA) submitted under transmittal number AK-20-0006. This amendment proposes to add chore services to the 1915(k) Community First Choice (CFC) state plan benefit. CMS conducted the review of the state’s submittal according to statutory requirements in Title XIX of the Social Security Act and relevant federal regulations.

This letter is to inform you that AK-20-0006 is approved on November 19, 2020, with an effective date of January 01, 2021. Enclosed is the approved CMS Form 179 and the following approved SPA pages to incorporate into the state’s approved state plan:

• Attachment 3.1-K, pages 1-30 • Attachment 4.19-B, page 5b

It is important to note that CMS’ approval of this change to the state’s 1915(k) CFC state plan benefit solely addresses the state’s compliance with the applicable Medicaid authorities. CMS’ approval does not address the state’s independent and separate obligations under federal laws including, but not limited to, the Americans with Disabilities Act, §504 of the Rehabilitation Act, or the Supreme Court’s Olmstead decision. Guidance from the Department of Justice concerning compliance with the Americans with Disabilities Act and the Olmstead decision is available at http://www.ada.gov/olmstead/q&a_olmstead.htm.

If you have any questions concerning this information, please contact me at (206) 615-2356, or your staff may contact Shante Shaw at shante.shaw@cms.hhs.gov or (206) 615-2346.

Sincerely,

Division of HCBS Operations and Oversight

Mr. Crum – Page 2 cc: John Lee, HSS Renee Gayhart, HSS Anthony Newman, HSS Jetta Whittaker, SDS Dominique Mathurin, CMS

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 FORM HCFA-179 (07-92) TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION 1. TRANSMITTAL NUMBER: 20-0006 2. STATE AK 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE January 1, 2021 5. TYPE OF PLAN MATERIAL (Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: Title XIX of the SSA 7. FEDERAL BUDGET IMPACT: a. FFY 2021 $ 88,495 b. FFY 2022 $ 88,495 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Attachment 3.1-K, pages 1-29 30 Attachment 4.19-B, page 5b 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Attachment 3.1-K, pages 1-29 30 Attachment 4.16 9-B, page 5b 10. SUBJECT OF AMENDMENT: This SPA effects the move of chore services from 1915(c) waivers to the 1915(k) Community First Choice Option. 11. GOVERNOR’S REVIEW (Check One): GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR’S OFFICE ENCLOSED Does not wish to comment NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: /s/ 16. RETURN TO: Courtney O’Byrne King 3601 C Street, Suite 907 Anchorage, AK 99503 13. TYPED NAME: Albert E. Wall 14. TITLE: Deputy Commissioner, DHSS; Medicaid Director 15. DATE SUBMITTED: September 2, 2020 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: PLAN APPROVED – ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: 21. TYPED NAME: 22. TITLE: David L. Meacham Director, Division of HCBS Operations and Oversight 09/02/2020 01/01/2021 23. REMARKS: 11/10/202: The state authorizes a P&I change to reflect the submission of Attachment 3.1 k pages 1-30 instead of pages 1-29, as stated initially on the Form 179. 09/08/2020:The state authorizes a P&I change to reflect the accurate number in Block 7 and to reflect Attachment 4.19-B in Block 9 $66,371.25 $66,371.25 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 1 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 Please provide a brief general overview of the state's proposed Community First Choice (CFC) benefit, including but not limited to an overview of services, delivery method, impact on other long-term services and supports (LTSS) programs, and how services will be coordinated between the CFC program and other state services provided: Services and delivery method: Alaska’s Community First Choice (CFC) option offers personal attendant services, known as Community First Choice Personal Care Service (CFC-PCS), Chore Services, and Emergency Response Systems. These services are offered using provider agencies as the delivery method, including an option to select an agency with choice model for PCS (called Consumer Directed PCS) that allows participants to have more control over their services. The CFC-PCS package also includes services to assist individuals in acquiring, enhancing, and/or maintaining skills necessary for the individual to accomplish ADLs, IADLs, and health-related tasks, and a voluntary option for training on how to select, manage, and dismiss attendants. Impact on other LTSS programs: The state makes the following alterations to current Long Term Supports and Services (LTSS) to prevent duplication of services: 1) the current State Plan PCS benefit is modified so that participants choose between CFC PCS and the State Plan PCS benefit. 2) The current 1915(c) waivers are amended to ensure there is not duplication. Coordination between CFC and other State Services: The state coordinates CFC with other services by using: 1) integrated intake, triage, and assessment processes that allow all individuals potentially eligible for CFC to make an informed choice and experience a single assessment that determines eligibility for CFC and other state services; and 2) a person-centered support plan that includes all LTSS services, including Medicaid State Plan services. Community First Choice Development Implementation Council Name of State Development and Implementation Council: Inclusive Community Choices (ICC) Council Date of first Council meeting: October 28, 2015 The state has consulted with its Development and Implementation Council before submitting its CFC State Plan amendment. The state has consulted with its Development and Implementation Council on its assessment of compliance with home and community-based settings requirements, including on the settings the state believes overcome the presumption of having institutional qualities. The state has sought public input on home and community-based settings compliance beyond the Development and Implementation Council. If yes, please describe. Since its first ICC meeting in October, 2015, the department coordinated monthly meetings of the ICC through 2016; the ICC agreed to meet quarterly in 2017 and into the future. Voting membership includes representatives from various affected constituencies across the state, including traumatic brain injury; senior citizens; people with intellectual and developmental disabilities; family members and caregivers; and the drug and alcohol advisory board. The ICC also includes non-voting representatives from affected provider groups. In addition to learning about and advising SDS on long term care reform initiatives, including the CFC State Plan Amendment, the state has consulted with ICC regarding provider compliance with home and community based settings requirements. In addition to conducting regular briefings with the Inclusive Community Choices Council (ICC), the Division of Senior and Disabilities Services (SDS) meets monthly with several partners, including provider and advocacy 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 2 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 associations, to update each on settings compliance and other CFC activities. These partners then share the information with their respective memberships to keep them apprised of CFC topics and issues. The department also sought public input on multiple versions of its Settings Transition Plan (STP), using a variety of outreach methods. CMS awarded initial approval of the state’s STP in December 2016 and final approval in August, 2018. As part of the systemic analysis contained in the STP, the department participated in meetings with external stakeholder workgroups comprised of provider and advocacy agencies. This group reviewed and suggested settings-related amendments to applicable regulations and Conditions of Participation, which detail the standards for each service. These amended regulations utilized a mandatory public comment period, which was announced using the approved outreach methods for amendments to regulations, primarily the state’s Online Public Notice system and newspaper advertisements. In addition to the outreach methods required of regulations amendments, the department also regularly solicits public comments on waiver amendments via its E-Alert system, which reaches over 1700 providers and participants. These E-Alerts are frequently forwarded to the mailing lists of the advisory groups, reaching many more consumers, family caregivers, and advocates. E-Alerts include information on updates and changes to the CFC program and other Medicaid reform goals, such as moving the chore services from 1915(c) waivers into the CFC program. The department has a Communication Plan for the CFC program. The Communication Plan includes talking points and a list of “frequently asked questions and responses” for the governor, the commissioner of the Department of Health and Social Services (DHSS), and DHSS staff, to ensure a consistent message is shared with interested parties. The department continues to hold webinars to explain how the CFC operates and how it affects both participants and providers. These webinars are advertised through the E-Alert system. And, to ensure the information is available at all times, the department updates its web page dedicated to the CFC program, which contains the department contact information if readers have questions or want to comment on the content. Community First Choice Eligibility Individuals are eligible for medical assistance under an eligibility group identified in the state plan. Categorically Needy Individuals Medically Needy Individuals Medically Needy individuals receive the same services that are provided to Categorically Needy individuals Different services than those provided to Categorically Needy individuals are provided to Medically Needy individuals. (If this box is checked, a separate template must be submitted to describe the CFC benefits provided to Medically Needy individuals) The state assures the following: Individuals are in eligibility groups in which they are entitled to nursing facility services, or 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 3 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 If individuals are in an eligibility group under the state plan that does not include nursing facility services, and to which the state has elected to make CFC services available (if not otherwise required), such individuals have an income that is at or below 150 percent of the Federal poverty level (FPL) Level of Care The state assures that absent the provision of home and community based attendant services and supports provided under CFC, individuals would require the level of care furnished in a long-term care hospital, a nursing facility, an intermediate care facility for individuals with intellectual disabilities, an institution providing inpatient psychiatric services for individuals under age 21, or an institution for mental diseases for individuals age 65 or over. Recertification No The state has chosen to permanently waive the annual recertification of level of care requirement for individuals in accordance with 441.510(c)(1) & (2). Please indicate the levels of care that are being waived Long-term care hospital Nursing facility Intermediate care facility for individuals with intellectual disabilities Institution providing psychiatric services for individuals under age 21 Institution for mental diseases for individual age 65 and over Describe the state process for determining an individual's level of care: • Nursing Facility Level of Care (NFLOC) determinations: Potential participants seeking a NFLOC determination are assessed, using the standardized Consumer Assessment Tool (CAT) tool by a qualified department assessor. The CAT is conducted in person when possible and at a time and place convenient to the participant. The participant may also be assessed using secure telehealth technology when appropriate. In addition to the CAT, the assessor also collects supporting documentation, such as components of the medical record, to determine NFLOC. • Intermediate Care Facility for Individuals with Intellectual Disabilities Level of Care (ICF-IID LOC) determinations: Potential participants seeking an ICF-IID LOC determination are assessed using the Inventory for Client and Agency Planning (ICAP) adaptive behavior tool by a qualified department ICAP assessor. Whenever possible, the ICAP observation is conducted in person and at a time and place convenient to the participant. The department conducts a limited number of assessments using secure telehealth technology, to more quickly assess participants in remote locations. In addition to a qualifying score on the ICAP, the department must also have documentation that the participant has a qualifying intellectual or developmental disability diagnosis. • Institution providing inpatient psychiatric services for individuals under age 21, or an institution for mental diseases for individuals age 65 or over: the department contracts with Comagine Health to gather documentation and make recommendations about the participant’s eligibility, and the department reviews the recommendations and provides final approval. To meet this criterion, the participant must be in imminent risk of being placed in an institution because of a danger to the participant or others. If a participant does not meet either the NFLOC or ICF-IID LOC and the assessment indicates that there is a concern about a danger to the participant or others, the participant is referred to Qualis for a review to determine if he or she meets the IMD LOC. 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 4 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 Informing Individuals Potentially Eligible for the Community First Choice Option Indicate how the state ensures that individuals potentially eligible for CFC services and supports are informed of the program's availability and services: Letter Email Other describe: Agencies serving as access points for publicly funded LTSS Please describe the process used for informing beneficiaries: For the initial implementation of CFC, the department sent letters and emails to the following individuals informing them about CFC: 1) participants currently enrolled in State Plan PCS services for whom their most recent CAT assessment indicates that they meet an institutional LOC (which includes those individuals already enrolled on a waiver); and 2) participants on a waiver program who currently receive emergency response services. These letters provided information about the enrollment process, program benefits, and the assessment process. The department also provided briefings about CFC to other state agencies and stakeholders via emails, in person monthly meetings with the Provider Association, and the ICCs. As a waiver service is transitioned from the 1915(c) waivers into the CFC program, participants receiving that waiver service are notified by email and letter about transitioning to CFC in order to continue to receive that service. The letters and emails state that the agency provider and the direct care worker providing that service will continue to serve the recipient; the only change will be that the provider will bill a different code once the service is a CFC service. The state’s Aging and Disability Resource Centers (ADRCs), Developmental Disability Resource Centers (DDRCs), care coordinators, and intake staff at agencies providing HCB waiver services are given CFC program information to share with beneficiaries to ensure that all individuals seeking LTSS can make an informed decision about CFC regardless of where they enter the system. Beneficiaries seeking LTSS have an opportunity to receive Person-centered Intake (PCI) from the State’s ADRC and DDRC programs. Assurances (All assurances must be checked). Services are provided on a statewide basis. Individuals make an affirmative choice to receive services through the CFC option. Services are provided without regard to the individual’s age, type, or nature of disability, severity of disability, or the form of home and community-based attendant services and supports that the individual needs to lead an independent life. Individuals receiving services through CFC will not be precluded from receiving other home and community- based long-term care services and supports through other Medicaid state plan, waiver, grant, or demonstration authorities. 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 5 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 During the five-year period that begins January 1, 2014, spousal impoverishment rules are used to determine the eligibility of individuals with a community spouse who seek eligibility for HCB waiver services provided under 1915(k). CFC Service Models Indicate which service models are used in the state's CFC program to provide consumer-directed home and community-based attendant services and supports (Select all that apply): Agency-Provider Model Self-Directed Model with Service Budget Other Service Model. Describe: Provider agency and provider agency with choice model, with different provider qualifications. Please complete the following section if the state is using the Self-Directed Model with Service Budget or the Other Service Model if it includes a Service Budget Financial Management Services • The state must make available financial management services to all individuals with a service budget. The state will claim costs associated with financial management services as: A Medicaid Service An Administrative Activity The state assures that financial management service activities will be provided in accordance with 42 CFR 441.545(B)(1). (Must check) If applicable, please describe the types of activities that the financial management service entity will be providing, in addition to the regulatory requirements at 42 CFR 441.545(B)(1). Specify the type of entity that provides financial management services: State Medicaid Agency Another State Agency – Specify ________________________ Vendor organization, describe _________________________ Other Payment Methods The state also provides for the payment of CFC services through the following methods: Use of Direct Cash Payments - The state elects to disburse cash prospectively to CFC participants. The state assures that all Internal Revenue Service (IRS) requirements regarding payroll/tax filing functions will be followed, including when participants perform the payroll/tax filing functions themselves. Describe: 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 6 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 Vouchers- Describe: Service Budget Methodology Describe the budget methodology the state uses to determine the individual's service budget amount. Also, describe how the state assures that the individual's budget allocation is objective and evidence-based utilizing valid, reliable cost data and can be applied consistently to individuals: Describe how the state informs the individual of the specific dollar amount they may use for CFC services and supports before the person-centered service plan is finalized: Describe how the individual may adjust the budget, including how he or she may freely change the budget and the circumstances, if any, which may require prior approval of the budget change from the state: Describe the circumstances that may require a change in the person-centered service plan: Describe how the individual requests a fair hearing if his or her request for a budget adjustment is denied or the amount of the budget is reduced: Describe the procedures used to safeguard individuals when the budgeted service amount is insufficient to meet the individual's needs: Describe how the state notifies individuals of the amount of any limit to the individual's CFC services and supports: Describe the process for making adjustments to the individual's budget when a reassessment indicates there has been a change in his or her medical condition, functional status, or living situation: Mandatory Services and Supports a. Assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), and health -related tasks through hand-on assistance, supervision, and/or cueing. Identify the activities to be provided by applicable provider type and describe any service limitations related to such activities. 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 7 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 Personal Attendant Services - Describe: Personal Attendant Services, known as Community First Choice Personal Care Services (CFC-PCS) under CFC, provides in-home personal care services to qualified Alaskan seniors and individual with disabilities. CFC-PCS is defined as providing assistance with Activities of Daily Living (ADL), such as eating, dressing, toileting, and Instrumental Activities of Daily Living (IADL), such as light meal preparation, main meal preparation in the individual’s home in order to meet the health needs of the individual, housework in the individual’s home to maintain a safe and sanitary environment, laundry services, shopping for items required for the health and maintenance of the individual, assistance with self-administration of medications, minor maintenance of respiratory equipment, dressing changes and wound care, and escorting an individual to and from medical appointments if the individual requires assistance with locomotion. Provider type: Agency-Based and Consumer-Directed Personal Care Services Agencies that are certified by the department and enrolled with Conduent to bill Medicaid, employing Personal Care Attendants (each with individual billing numbers issued by Conduent). Personal care services may be provided through two different qualified Personal Care Agency Models: Agency Based Personal Care Services (ABPCS): The beneficiary may choose a personal care agency in the agency- based program, which provides services through an agency that oversees, manages, and supervises the beneficiary’s care. The ABPCS agency hires, trains, schedules, develops a backup plan if the regularly scheduled personal care assistant (PCA) is unavailable, and dispatches PCAs. Consumer Directed Personal Care Services (CDPCS): Under the agency with choice model, the beneficiary may choose a consumer directed personal services program, which provides administrative support to the participant who manages his or her own care, or the participant’s representative who manages the recipient’s care, by hiring, firing, and supervising the PCA. The CDPCS administers payroll and Medicaid billing support. License required No Certification required Yes Describe: To qualify for certification as a PCS agency, the agency must meet the applicable certification criteria set out in the department's Personal Care Assistant Agency Certification Application packet. Both Agency Based Personal Care Services (ABPCS) and Consumer Directed Personal Care Services (CDPCS) agencies must employ a program administrator who has attended mandatory division training. For the ABPCS agency type only, the agency must employ a registered nurse. Education-Based Standard: No Describe: Other qualifications required for this provider type: Yes Describe: At both CDPCS and ABPCS agencies, the personal care assistant must be at least 18 years of age, must be able to meet all the requirements of the program as described in state regulations, including successful completion of First Aid and CPR training within the last two years, must be individually enrolled to bill Medicaid, must pass a criminal background check, must not have been denied a health care provider license or certification for a reason related to patient services, and must be able independently to assist the participant with the specific Activity of 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 8 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 Daily Living (ADL), Instrumental Activity of Daily Living (IADL), and services. To be a personal care assistant for an ABPCS, the assistant must be a licensed nurse, CNA, a community health aide, or have successfully completed a training approved by the state, or completed an equivalent training five years prior to applying to be employed as a PCA. In addition to the mandatory First Aid and CPR certification, training requirements for PCAs working in ABPCS agencies include at least 40 hours of instruction, given by a nurse licensed by the State of Alaska, in infection control, bowel and bladder care, nutrition and food planning and preparation, physical transfers, assistance with self-administration of medication, blood pressure, temperature, respiration, developmental disabilities and physical and mental illnesses, body systems, mechanics and disorders, death and dying, use of equipment necessary to perform the tasks of a PCA, universal precautions, and affecting PCAs such as record keeping, confidentiality, reporting Medicaid fraud. For CDPCS, the agency must provide its personal care assistants information regarding the responsibilities of the recipient for training the PCA and management of his/her personal care services. Both types of agencies must provide all personal care attendants training on critical incident reporting, restrictive interventions and assistance with self-administration of medication. Additionally, both types of agencies must also attest to providing training to staff on acquiring and maintaining skills necessary for a participant to independently complete activities of daily living (ADLs), instrumental activities of daily living (IADLs) and health related tasks. Companion Services Provider type License required No Describe Certification required No Describe

Education-Based Standard: No Describe

Other qualifications required for this provider type: No Describe Homemaker/Chore Services: (describe) All services funded by the Division of Senior and Disabilities Services fall within the umbrella term “long term services and supports”. This term includes Medicaid waiver services, Community First Choice services, Medicaid State Plan personal care services, Medicaid State Plan targeted case management services, and grant services. Agencies providing any, or all, of these services are considered to be providing long term services and supports. Chore services assist the participant to maintain a clean, sanitary and safe environment. Chore services consist of regular cleaning of the residence used by the participant including washing floors, windows and walls, tacking down loose rugs and tiles, moving heavy items of furniture, snow shoveling or snow plowing 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 9 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 in order to provide safe access and egress, hauling water, hauling or disposing of human excreta, collecting and chopping firewood, if firewood is used as a heat source for the participant’s home, and other services that the state determines necessary to maintain a healthy and safe residence. Payment for chore services will not be made if any other relative or caregiver, or any community or volunteer agency or third-party payer is capable of or responsible for the provision of chore services, or if the participant’s residence is a rental property, and the state determines those services to be the responsibility of the landlord under the lease or applicable law. In addition, the state will not authorize chore services if the certified chore provider resides in the same residence as the recipient of chore services. The definition of Chore does not change as the service transfers from being a 1915(c) waiver service to a Community First Choice service. Conversion to CFC Chore will not affect current recipients of waiver Chore services, unless they opt not to be part of CFC, in which case they will not receive Chore services. Agencies currently certified to provide Chore as a waiver service will continue certification as CFC Chore providers; direct service workers for waiver Chore will continue to provide CFC Chore. A modifier will be used with the billing procedure code when providers submit a claim, to indicate that Chore expenditures are now part of CFC. If an agency certified to provide CFC Personal Care Services (either agency-based or consumer-directed) wishes to add Chore to the array of services offered to recipients of PCS, that agency needs to separately certify as an HCBS Agency in order to provide CFC Chore. If an HCBS agency certified to provide Chore services wishes to provide either agency-based or consumer-directed personal care services, that agency will need to separately certify as a PCS/CFC PCS agency. All chore services must be prior authorized. Provider type: Describe: HCBS Agency License required No Describe Certification required Yes Describe: To qualify for certification as a provider of CFC chore services, the agency must meet the applicable certification criteria set out in the department’s Chore Services Certification Application Packet. The HCBS agency must employ a program administrator who has attended mandatory division training. HCBS agencies do not certify as agency-based or consumer-directed (those designations are specific to agencies providing personal care services. Education-Based Standard: No Describe: Other qualifications required for this provider type: Yes Describe: 1) Chore services workers must be at least 18 years of age; qualified through education or experience; and possess, or develop before providing services, the skills necessary to perform, as requested by the 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 10 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 recipient, the tasks included in the chore services plan. 2) Required education and alternatives to formal education: A) high school or general education development (GED) diploma; or B) demonstration to the provider of the ability to read written instructions and to make entries regarding services in the recipient record or file. Other Services. Describe: Provider type: License required: No Describe: Certification required: No Describe: Education-Based Standard: No Describe:

Other qualifications required for this provider type: Describe: 2. The acquisition, maintenance, and enhancement of skills necessary for the individual to accomplish ADLs, IADLs, and health-related tasks. Identify the activities to be provided by applicable provider type and any describe any service limitations related to such activities: To foster greater independence among the participants enrolled in CFC, the program supports the acquisition, maintenance, and enhancement of skills that allow participants to be more independent in completing ADLs, IADLs, and health related tasks. This support includes the following: • The participant’s person-centered support plan will identify skills the participant would like to address and the plan for addressing them: This section of the Support Plan includes any ADLs, IADLs, or health-related tasks that the participant or the participant’s representative chooses. Provider type: Skill Building Personal Care Attendant Services (SB-PCA) SB-PCA providers are certified PCA providers who have been trained on acquiring and maintaining skills necessary for a participant to independently complete activities of daily living (ADLs), instrumental activities of daily living (IADLs), and health related tasks. License required: No Describe:

11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 11 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 Certification required: Yes Describe: Qualifications required for this provider SB-PCA are the same as required for PCAs. Education-Based Standard: Yes Describe: Qualifications required for this provider SB-PCA are the same as required for PCAs. Other qualifications required for this provider type: Yes Describe: Qualifications required for this provider SB-PCA are the same as required for PCAs. 3. Individual back-up systems or mechanisms to ensure continuity of services and supports. Identify the systems or mechanisms to be provided and limitations for: Identify the systems or mechanisms to be provided and limitations for: Personal emergency response systems Pagers Other mobile electronic devices Other, describe: The department will consider an item to be an emergency response system if that item is: 1) A device, control, or appliance that summon help in the event of an emergency; and 2) Identified in the department's Specialized Medical Equipment Fee Schedule. Describe any limitations for the systems or mechanisms provided: Under CFC, the department pays for emergency response systems that: 1) are supported by a prescription or other written documentation required by the department’s Specialized Medical Equipment Fee Schedule A) from an individual with an active license under AS 08 to practice as i) a physician, including an osteopath; ii) a physician assistant; iii) an advanced nurse practitioner; iv) an occupational therapist; or v) a physical therapist; and B) stating that the emergency response system requested is appropriate for the recipient and consistent with the person-centered support plan; 2) is supported by a written cost estimate; and 3) is approved as part of the participant’s person-centered support plan. The department will pay under this section subject to the following: 1) the unit cost of equipment is determined by including the cost of A) training in the equipment's proper use; and B) routine fitting of and maintenance on the equipment necessary to meet applicable standards of manufacture, design, and installation; 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 12 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 2) the department will not pay, as a CFC service, the cost of any medical equipment or supplies payable under 7 AAC 120.200 - 7 AAC 120.299; 3) emergency response systems shall be rented unless the department determines that purchasing the equipment is more cost-effective than renting it; 4) once purchased, specialized medical equipment becomes the property of the participant; 5) the department does not give prior authorization to replace emergency response systems before the expiration of the time period identified in the department's Specialized Medical Equipment Fee Schedule unless the department determines that replacement is more cost-effective than repairing that equipment. Provider type: Medical Supply Provider License required Yes Describe: Alaska business license under AS 43.70 and 7 AAC 12 Certification required No Describe: Education-Based Standard: No Describe: Other qualifications required for this provider type: Yes Describe: Medical supply provider enrolled with the State Medicaid Agency Claims Payment System. 4. Voluntary training on how to select, manage, and dismiss attendants. The state will claim costs associated with voluntary training as (check one): Medicaid Service An Administrative Activity Describe the voluntary training program the state will provide to individuals on selecting, managing, and dismissing attendants: Individuals receive a brochure that includes website links that direct them to training resources on how to select, manage, and dismiss PCAs. They will be given this information again by care coordinators, when their person- centered support plan is updated or renewed. The department training staff provides electronic training videos on the department website via YouTube/Vimeo. The modules are designed to teach CFC participants how to select, manage, and dismiss attendants. Provider type: License required No Describe: Certification required No Describe: 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 13 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 Education-Based Standard: No Describe: Other qualifications required for this provider type: No Describe: Operational Services and Supports Indicate which of the following optional services and supports the state provides and provide a detailed description of these benefits and any limitations applicable to them. Transition Costs (Provided to individuals transitioning from a nursing facility, Institution for Mental Disease, Intermediate care facility for Individuals with Intellectual Disabilities to a community based home setting) – Check all of the following costs that apply: Rental and Security Deposits- Description and Limitations: Utility Security Deposits Description and Limitations: First Month’s Rent Description and Limitations: First Month’s Utilities Description and Limitations: Basic Kitchen Supplies Description and Limitations: Bedding and Furniture- Description and Limitations: Other Household Items – Description and Limitations: Other coverable necessities linked to an assessed need to enable transition from an institution to the community Description and Limitations: Goods and Services - Services or supports for a need identified in the individual's person-centered plan of services that increase an individual's independence or substitute for human assistance, to the extent that 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 14 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 expenditures would otherwise be made for the human assistance. Include a service description including provider type and any limitations for each service provided. Home and Community Based Settings Each individual receiving CFC services and supports must reside in a home or community-based setting and receive CFC services in community settings that meet the requirements of 42 CFR 441.530. Setting Types (check all that apply): CFC services are only provided in private residences and are not provided in provider - owned or controlled settings. CFC services may be provided in private residences and in provider owned or controlled settings. The CFC benefit includes settings that have been determined home and community-based through the heightened scrutiny process. Provider –owned or controlled settings: 1. Please identify all residential setting types in which an individual may receive services under the CFC benefit. 2. Please identify all non-residential setting types in which a person may receive services under the CFC benefit. Setting Assurances – The state assures the following: CFC services will be furnished to individuals who reside in a home or community setting, which does not include a nursing facility, institution for mental diseases, an intermediate care facility for individuals with intellectual disabilities, or a hospital providing long-term care services. Any permissible modifications of rights within a provider owned and controlled setting is incorporated into an individual’s person-centered service plan and meets the requirements of 42 CFR 441.530(a)(vi)(F). Additional state assurances: CFC Support Systems, Assessment, and Service Plan Support System The support system is provided in accordance with the requirements of §441.555. Provide a description of how the support system is implemented and identify the entity or entities responsible for performing support activities: The state provides the following supports to each CFC participant: 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 15 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 1) Each applicant for CFC services is assessed by a qualified assessor employed by the department, using the appropriate assessment tool. Applicants that are eligible for CFC services are notified and receive pre- enrollment counseling from a care coordinator. 2) Each applicant is provided pre-enrollment counseling; information is communicated in a manner that is understandable to the participant and in a manner sensitive to the participant’s culture. A) Pre-enrollment counseling includes the following topics: i) a review of all Medicaid services available to the participant; ii) discussion of the participant’s right to choose services, providers, or no services; iii) the responsibilities of the participant when choosing an agency with choice approach for PCS, (including the responsibility to participate in risk management [Quality Assurance] plans) and the risks associated with those responsibilities; iv) an explanation of the participant’s right of freedom of choice, rights to control information rights to reasonable accommodation when accessing information and rights to appeal; v) ways to identify and access services, supports and resources including a printed list of all CFC service providers and their contact information and information on the advocacy systems and groups including a printed list of each advocacy group and their contact information. 3) All participants choosing to enroll in CFC must work with a care coordinator to develop the person-centered support plan and to initiate services. The support planning conference is conducted as directed by the participant with the assistance and oversight of the care coordinator, who ensures that all communications take place in a manner that is understandable to the participant and in a manner that is sensitive to the participant’s culture. A) The support planning conference establishes: i) the participant’s choices of services and supports specific to the participant’s needs and will set goals and expected outcomes for each service and support; ii) a personal safety and backup plan, including information on the participant’s responsibility for reporting critical incidents and the method by which critical incidences are reported; iii) a schedule for reassessment and revision of the person-centered support plan. Specify any tools or instruments used as part of the risk management system to identify and mitigate potential risks to the individual receiving CFC services: The department’s risk management approach for CFC includes the following components: • The care coordinator reviews the assessment for information and documents any potential risks in the person- centered support plan. This plan also documents plans for mitigating those risks. The participant and/or her or his representatives than acknowledge that they understand and accept the risks and this is documented in the plan. • The care coordinator, as part of the person-centered planning process, is responsible for discussing with the participant whether the level of risk in the plan indicates that more frequent monitoring by the care coordinator should be part of the risk mitigation strategy. • Mandatory reporting of suspected cases of abandonment, exploitation, abuse, neglect, or self-neglect of vulnerable adults pursuant to AS 47.24 and mandatory reporting of suspected cases of child abuse and neglect pursuant to AS 47.14 through the Alaska State Centralized Reporting system. • Maltreatment reports and provider complaints received by Centralized Reporting are routed to the unit or program (Adult Protective Services, Program Integrity and Licensing unit) that is relevant to the report or complaint. The Harmony Centralized Reporting electronic portal captures and stores information for each entity. This information can be analyzed to identify prevalence and patterns of adverse events. All units 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 16 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 collaborate on investigations when needed, and may refer to other investigative authorities such as law enforcement, Medicaid Fraud Control Unit, Elder Fraud, and Program Integrity. • Adult Protective Services is responsible for the protection of vulnerable adults from abuse, neglect, and exploitation. Investigation findings may lead to appointing a surrogate decision maker, a petition for services, conservator or guardian, and applying for benefits or providing protective placement. • Quality Assurance, in collaboration with Provider Certification and Compliance, is responsible for ensuring quality providers are certified and enrolled and maintain ongoing compliance. Investigation findings may result in providing technical assistance, requiring corrective actions, and imposing sanctions up to and including termination from the Medicaid program. • Residential Licensing is responsible for oversight of facilities that serve adult populations, however, State Plan services are not allowed in those facilities. Licensed foster homes for children are overseen by the Office of Children’s Services (OCS). OCS conducts investigations into any allegations of the licensed entity, or any harm reported for recipients. OCS issues plans of corrections and sanctions, up to and including termination from the program for providers, and protective placements for children at risk for harm. Provide a description of the conflict of interest standards that apply to all individuals and entities, public or private to ensure that a single entity does not provide the assessments of functional need and/or the person-centered service plan development process along with direct CFC service provision to the same individual: The individual conducting the level of care assessment is a state employee. The care coordinators helping to support the development of the person-centered support plan are conflict-free. The state assures that conflict of interest standards required in CFR 441.555(c), for the functional needs assessment and development of the person-centered support plan applies to all individuals and entities, both public and private. The state ensures that the individual conducting the functional needs assessment and person-centered service plan is not: A) related by blood or marriage to the participant, or to any paid caregiver of the participant; B) financially responsible for the participant; C) empowered to make financial or health-related decisions on behalf of the participant; D) someone who would benefit financially from the provision of assessed needs and services; E) a provider of state-funded services for the participant, or has an interest in or is employed by, a provider of state funded services for the participant. Conflict of Interest Exception: The only willing and qualified entity performing assessments of functional need and or developing the person-centered service plan also provide home and community based waiver services. Provide a description, including firewalls, to be implemented within the entity to protect against conflict of interest, such as separation of assessment and/or planning functions from direct service provision functions, and a description of the alternative dispute resolution process: The state adheres to the CFC regulations conflict of interest standard. Individuals or entities conducting the assessment of functional need and person-centered service plan development process are not: 1) related by blood or marriage to the individual, or to any paid caregiver of the individual. 2) financially responsible for the individual. 3) empowered to make financial or health-related decisions on behalf of the individual. 4) individuals who would benefit financially from the provision of assessed needs and services. 5) providers of State Plan home and community-based services for the individual, or those how have an interest in or are employed by a provider of State Plan home and community-based services for the individual, except when the state demonstrates that the only willing and qualified entity/entities to perform assessments of 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 17 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 functional need and develop person-centered service plans in a geographic area also provides home and community-based services. The state will grant exceptions to the conflict-free requirements for care coordinators, who conduct person- centered service plan development, in areas of the state for which no willing and qualified conflict-free care coordinator is available. In these cases, the state will verify that a) no conflict-free care coordinator is enrolled as a Medicaid provider [other than for the service of care coordination] and serves that geographic area, or b) if a conflict-free case manager is enrolled and serves that geographic area, that provider has indicated that it is not willing or able to serve the individual. If an exception is granted, the agency receiving the exception must demonstrate it has conflict of interest protections by submitting the following documentation: 1) description of the administrative separation of State Plan home and community-based services from care coordination that includes a description of the duties of the State Plan home and community-based services supervisor(s) and the care coordination supervisor(s) and explains how the agency ensures that the care coordinator is free from influence of direct service providers regarding participant care plans. 2) evidence of administrative separation on organizational chart that includes position titles and names of staff. 3) the plan/policy/procedure used to ensure administrative separation of State Plan home and community-based services from care coordination. This plan/policy/procedure ensures that choice of all available State Plan home and community-based services providers. Assessment of Need Describe the assessment process or processes the state will use to obtain information concerning the individual's needs, strengths, preferences, and goals: Department staff currently conducts a level of care assessment using the Alaska Consumer Assessment Tool (CAT) or the Inventory for Client and Agency Planning (ICAP), both of which collect information on functioning, behavior issues, medical concerns, and other needs. The participant’s care coordinator reviews this information and collects additional information about the participant’s strengths and preferences to assess functional need, then works with the participant and her or his representative to identify needed and preferred services and person-centered goals. CAT and ICAP assessments are conducted face-to-face or by telehealth as described in the section below. The state will allow the use of telemedicine or other information technology medium in lieu of a face-to-face assessment in accordance with §441.535. The individual is provided with the opportunity for an in-person assessment in lieu of one performed via telemedicine. Include a description about how an individual receives appropriate support including access to on-site support staff during the assessment: The state has developed telehealth policy for conducting level of care assessments and reassessments, using video conference technology. These assessments occur where signed agreements with approved conferencing centers exist. The agreements outline the procedures and secure technology requirements for all parties. The state may conduct assessments and reassessments, and to allow care coordinators to conduct functional assessments, in a participant’s own home using telehealth methods once secure technology and connectivity is in place. Following person-centered practices, the individual being assessed or reassessed is offered a choice of a face-to- face assessment in lieu of a telehealth assessment. If all parties agree to a telehealth assessment, the individual must sign the Consent for Telehealth Assessment form prior to the scheduled assessment. The individual is involved in the scheduling of the assessment and may choose a date and time that is best for them from a list of available dates and times offered by the state. Individuals may choose to invite their care coordinator, direct care provider, service agency representative, family member, or friends to be present during the assessment. This is especially 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 18 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 important if the individual requires assistance or support with locomotion, transferring and/or other activities of daily living that are a vital part of the assessment process. The state’s pre-assessment protocol includes contacting the participant, caregiver, and rural health clinic at least one week prior to the scheduled assessment to coordinate an escort or other assistance needed for the individual to access the assessment. The state assessor explains to the individual that the telehealth assessment may be stopped at any time if the participant or any family member becomes uncomfortable with the video assessment process, and allows the individual or family members to ask questions before and after the assessment. The state will claim costs associated with CFC assessment activities as: A Medicaid Service An Administrative Activity Indicate who is responsible for completing the assessment prior to developing the CFC person-centered service plan. Also, specify their qualifications: Social work. Specify qualifications: Bachelor or Master’s prepared Registered Nurse, licensed to practice in the state, acting within scope of practice under state law. Licensed Practical Nurse or Vocational Nurse, acting within scope of practice under state law. Licensed Physician (M.D. or O.D.), acting within scope of practice under state law. Case manager. Specify qualifications: ___________________________________________ Other. Specify provider type and qualifications: 1) Licensed, psychologist (Master's prepared); licensed physician (MD or DO); 2) occupational therapist; 3) physical therapist; 4) speech pathologist or audiologist; 5) professional recreation staff (an individual with a Bachelor's in a recreation specialty (art, music, physical education); 6) individual with a Bachelor's in a human services field (sociology, special education, rehabilitation, counseling, psychology); 7) professional that holds a Master's degree from an accredited college in health, public health, behavioral health, health care services, health practice, senior health care, developmental disabilities, health sciences, health care administration, or a closely related field and has at least one year of advanced professional level experience performing health program planning, development, coordination, evaluation, or implementation, technical health care assistance and consultation; health care utilization or quality assurance examination; and/or health care service delivery; 8) Bachelor's degree from an accredited college in biological, health or behavioral science; health practice; education; public, healthcare, or business administration; or a closely related field with two years of advanced professional level experience performing health program planning, development, coordination, evaluation, or implementation; technical health care assistance and consultation; health care utilization or quality assurance examination; and/or health care service delivery; or 9) diploma or associate's degree from a school of nursing accredited by the National League for Nursing and has four years of advanced professional level experience performing health program planning, development, coordination, evaluation; or implementation; technical health care assistance and 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 19 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 consultation; health care utilization or quality assurance examination; and/or health care service delivery. The reassessment process is conducted every: 12 months Other (must be in increments of time less than 12 months) Describe the reassessment process the state will use when there is a significant change in the individual's needs or the individual requests a reassessment. Indicate if this process is conducted in the same manner and by the same entity as the initial assessment process or if different procedures are followed: When there is significant change in the individual’s needs or the individual requests a reassessment, the reassessment process is conducted in the same manner and by the same entity as the initial assessment process. Person-centered Service Plan The CFC service plan must be developed using a person-centered and person-directed planning process. This process is driven by the individual and includes people chosen by the individual to participate. The state will claim costs associated with CFC person-centered planning process as: A Medicaid Service An Administrative Activity Indicate who is responsible for completing the Community First Choice person-centered service plan. Case manager. Specify qualifications: Case management is provided by conflict-free care coordinators employed by a certified care coordination agency. Care coordination may be provided by an agency employing multiple care coordinators or an agency that is a sole practitioner; however, both must meet the certification requirements and be enrolled with Medicaid as a care coordination agency. Every care coordination agency must have a qualified program administrator to manage the day to day operations of the agency’s services. A care coordinator must be at least 18 years of age. All care coordinators must complete the department’s Basic Care Coordination training course, and demonstrate comprehension of course content prior to certification. Training may be completed up to two years prior to application. To maintain or renew certification, a care coordinator must attend the department’s care coordination training every two years. Social work. Specify qualifications: BA, BS, or AA degree from accredited college or university Registered Nurse, licensed to practice in the state, acting within scope of practice under state law. Licensed Practical Nurse or Vocational Nurse, acting within scope of practice under state law. Licensed Physician (M.D. or O.D.), acting within scope of practice under state law. Other. Specify provider type and qualifications: Have one of the following combinations of education or experience: 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 20 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 1) BA, BS, or AA degree from an accredited college or university in psychology, rehabilitation, or a closely related human services field, and one year of full-time, paid experience working with human services participants; or 2) Two years of course credits from an accredited college or university in social work, psychology, rehabilitation, nursing, or a closely related human services field, and one year of full-time, paid experience working with human services participants; or 3) Three years of full-time paid experience working with human services participants in social work, psychology, rehabilitation, nursing, or a closely related human services field or setting; or 4) Certification of a rural community health aide or practitioner and one year of full-time, paid experience working with human services participants. Person-centered Service Plan Development Process: Use the section below to describe the process that is used to develop the person-centered service plan. Specify the supports and information that are made available to the individual (and/or family or authorized representative, as appropriate) to direct and be actively engaged in the person-centered service plan development process and the individual’s authority to determine who is included in the process: The following processes help the individual (and/or family or authorized representatives) direct and be actively engaged in the development of the person-center support plan: • The care coordinator is trained to ask the individual (and/or family authorized representatives as appropriate) who should be included in the process. The care coordinator documents who was included and verifies this choice was given. • The care coordinator educates the individual (and/or family authorized representatives as appropriate) about person-centered support plan process. This includes discussing the Participant Rights and Responsibilities form with the individual/representative and obtaining the recipient’s signature during the initial development of the support plan and when plans are updated. The form explains the right to participate in planning and making choices about services received from all sources. • The state has prepared handouts and other training materials to assist individuals in taking a leading role in the process. • The state has structured the support plan so that the individual’s personal goals will play a central role in designing supports. • The support plan format addresses whether the individual would like to make changes to his or her living situation, employment, and/or ability to perform tasks more independently. Indicate who develops the person-centered service plan. Identify what individuals, other than the individual receiving services or their authorized representative, are expected to participate in the person-centered service plan development process. Please explain how the state assures that the individual has the opportunity to include participants of their choice: The participant can include any individuals they choose in the planning process according to the Participant Rights and Responsibilities form and the choice statement in the person-centered support plan. The care coordinator facilitates this involvement. The care coordinator develops the person-centered service plan with the individual. All service providers agreeing to give service are expected to participate in the plan development. All certified CFC service providers must sign the plan document. Other supports as invited by the individual to participate also sign. 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 21 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 Describe the timing of the person-centered service plan development to assure the individual has access to services as quickly as possible; describe how and when it is updated, including mechanisms to address changing circumstances and needs or at the request of the individual: After an initial Level of Care and program eligibility is established, care coordinators have 60 days to submit, via the state’s database, a person-centered support plan. Care coordinators can submit a plan any time prior to that deadline. The state has 30 days to notify the participant of approval or disapproval once a complete plan is received. The person-centered service plan is reviewed, and revised upon reassessment of functional need, at least every 12 months. The person-centered service plan is reviewed, and revised when the individual’s circumstances or needs change significantly, and at the request of the individual. Any support plan review or revision request that addresses health and safety concerns can receive expedited review of the person-centered support plan changes. The department will respond within 10 days of receiving and expedited request and complete the person-centered support plan or amendment. Regulations ensure the department responds in a timely manner. Fair hearing rights are provided to participants on all disapproval of person-centered support plans. Describe the state's expectations regarding the scheduling and location of meetings to accommodate individuals receiving services and how cultural considerations of the individual are reflected in the development of the person- centered service plan: Care Coordinator (CC) Conditions of Participation (COP) require that the care coordinator maintain contact with the individual in a timely manner and frequency appropriate to the individual’s needs and that the meeting times and locations be acceptable for the individual. The care coordinator must communicate in a method appropriate to the abilities of the individual and representative to assure contend is understood. These expectations are included in the required care coordinator training curriculum. Care coordinators must attend training before certification and renewal. Describe how the service plan development process ensures that the person-centered service plan addresses the individual's goals, needs (including health care needs), and preferences and offers choices regarding the services and supports they receive and from whom. Please include a description of how the state records in the person- centered service plan the alternative home and community based settings that were considered by the individual: A person-centered support plan document is required for each participant. The support plan includes a segment to identify the individual’s personal goal(s) and to document that services are requested that match those goals. The person-centered support plan documents the outcomes of a structured discussion that addresses the participant’s personal goals, needs, including health care needs, and preferences and how services and other supports will help achieve those goals. The document captures information regarding the participant’s preference for skills training to acquire, maintain, or enhance their ability to perform ADLs, IADLs, and health related tasks; the participant’s or a representative’s desire to receive training on how to manage direct care workers; the participant’s preferences related to employment; and alternative home and community based settings available to the participant that were considered by the individual. Describe the strategies used for resolving conflict or disagreements within the process: The care coordinator is required to submit in writing, within the person-centered support plan, information about any disagreement in the kind of services, frequency, scope, or duration of service among individuals who participate in the support planning process. 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 22 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 Department staff reviews the person-centered support plan and work with the care coordinator to resolve any disagreements or conflicts, then approve the plan and issue prior authorizations for billing. In addition, the participant must initial and sign the department’s Participant Rights and Responsibilities form that outlines participant’s rights including the right to make choices about their care, to participate in support planning and to receive a copy of the person-centered support plan, to change providers at any time, and to submit a complaint through a grievance procedure established by the service provider. Fair hearing rights are provided to participants on all disapproval of person-centered support plans. All participants receive a written denial or decision of conflict resolution plan of care notice (POC) informing them of actions taken by the department. The notice is sent via certified mail with the accompanying fair hearing rights enclosed. Please describe how the person-centered service plan development process provides for the assignment of responsibilities for the development of the plan and to implement and monitor the plan. The state encourages the participant and/or her or his representative to take the lead in developing the Person- centered Support Plan. This is achieved by: A) educating the participant/representative about the process. B) identifying supports or accommodations the participant may need to play a more active role in the process. C) the care coordinator will coach the participant throughout the process. D) department staff reviews the person-centered support plan and obtains feedback from the participant or representative about his or her perception about being involved in the process. A conflict-free care coordinator facilitates the support planning process to ensure that the person-centered support plan is completed according to the state’s requirements, including reflecting the participant’s person-centered goals and preferences. If the participant or a representative cannot or prefers not to lead the process, the care coordinator will assume the lead. The care coordinator will file all necessary documents with the department and track their status. The care coordinator works with the participant and/or representative to select service providers. The care coordinator translates these selections into requests for services, which are then prior authorized if approved by the state. Department staff then review all person-centered support plans to ensure compliance, including addressing person-centered requirements. The case manager has the responsibility to monitor the plan according to the schedule included in the support plan. The participant may contact the department or care coordinator at any time if she or he has a concern about services. The department may proactively contact individuals for whom overbilling or chronic under billing is noted or in response to a critical incident. If these contacts suggest the need for ongoing monitoring, the support plan may be adjusted or the participant will be offered enrollment in a program that provides more care coordination. The state assures that assessment and service planning will be conducted according to 441.540(B) 1-12. The person-centered service plan is reviewed and updated every: 3 months 6 months 12 months 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 23 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 Other:

(must be less than 12 months) AND When an individual's circumstances or needs change significantly or at the individuals request. Describe the person-centered service plan review process the state will use. In the description, please indicate if this process is conducted in the same manner and by the same entity as the initial service plan review process or if different procedures are followed: Updates to the person-centered support plan will follow the same development and review process as described for the initial plan. CFC Service Delivery System Identify the service delivery system(s) that will be used for individuals receiving CFC services: Traditional State-Managed Fee-for-Service (4.19(b) page is required) Managed Care Organization Other: Quality Assurance System Please describe the state's quality improvement strategy: The department Continuous Quality Improvement plan (CQI) is one element of the department’s Quality Improvement Strategy (QIS) that provides for systematic evaluation of department activities to ensure health, safety, and welfare of participants, facilitates discovery activities through collection of data necessary for remediating individual problems and implementing system improvements, and provides a reporting mechanism for department performance to the DHSS leadership. Work involved in the implementation of the CQI plan is done within Quality Improvement Task Committees, comprised of department Unit Managers and the Quality Improvement Workgroup (QIW) comprised of department Unit Managers and the Division’s Executive Team. Activities of the QWI are overseen by the DHSS Quality Improvement Steering Committee (QISC) led by the department’s commissioner and deputy commissioner. The CQI plan incorporates input from stakeholders, participants, providers and the public as necessary. The Department holds occasional information sharing teleconferences open to all stakeholders and covering a variety of topics and issues impacting CFC participants and CFC services, specifically when changes are made to operations or there are noted issues to address. The department uses these opportunities to report department performance status, changes in CFC program administration and anticipated system changes resulting from discovery activities. The department also gathers and shares information regularly at meetings of provider professional associations. The QIS and Task Committees perform discovery and remediation activities for CFC. Data is separately aggregated and analyzed for CFC. The QIW establishes Task Committees charged with discovery and remediation responsibilities associated with operation of CFC and measured by established performance measures. Task Committees meet monthly to review performance measure data, identify performance deficiencies, implement and report on corrective action on 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 24 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 individual cases, and recommend system improvement to QIW. The following Task Committees are currently in operation: • Mortality Review Team- the Mortality Review Team identifies and reviews all deaths reported throughout the centralized intake reporting system. Membership includes the Quality Assurance Unit Manager (Chair) and department staff including a Qualified Intellectual Disability Professional (QIDP), a Registered Nurse (RN), the department Mortality Review Coordinator, an Adult Protective Services (APS) Unit representative, a Residential Licensing Unit representative, and an Office of Long Term Care Ombudsman(OLTCO) representative. The team reviews information on participant deaths obtained through the department critical incident reporting process, medical records, vital statistics, Medical Examiner’s office and law enforcement reports and determines if the death is the result of an action or omission (or inaction) on the part of a provider agency or the department. The team also compares department findings with information obtained from the Bureau of Vital Statistics to discover additional deaths not reported by providers. Untimely deaths, or deaths involving unusual circumstances of CFC service participants, are vetted carefully by the committee and may trigger an investigation. • Level of Care Review Task Committee- the Level of Care Review Task Committee discovers and remediates department performance including timeliness of initial and annual assessments and LOC determinations and other administrative factors identified in the department’s LOC performance measures. On a weekly basis, the unit manager’s review LOC status reports generated by the Research and Analysis Unit, identifies deficiencies in performance and plans and implements remediation activities. On a monthly basis, the committee reviews, aggregated monthly, quarterly and annual data, analyzes trends, and makes recommendations for systems improvement to the QIW. • Qualified Providers Review Task Committee- the Qualified Providers Task Committee gathers and reviews data from department performance measures regarding provider qualifications to determine whether certification standards, including required training, are met. Membership includes the Managers of the Provider Certification and Compliance Unit (Chair), Research and Analysis Unit, Operations Integrity Unit (OIU), Policy and Program Development, Grants, Certification Unit staff, and the department Training Coordinator. On a monthly basis, the committee reviews certification and training records and aggregated data to discover the status of provider compliance with certification standards, and plans and implements remediation activities. • Service Plan Review Task Committee- the Service Plan Review Task Committee gathers and reviews data from department performance measures that reveal if service plans are timely, person centered, identify personal goals and address needs identified in the assessments and provide choices to the participant. The committee reviews results of monthly service plan record reviews and reports findings to the manager of the CFC program services unit. The manager identifies and initiates remediation activities needed to cure identified deficiencies. The committee also submits reports on remediation completed to the Quality Assurance unit for inclusion in the monthly QIW meetings and makes system improvement recommendations to QIW. • Policy and Procedure Task Committee- the Policy and Procedure Task Committee develops and reviews department policies and procedures with input from department staff content experts.” Before finalizing, all department policies are reviewed by participants, stakeholders, providers and the public. Input is collected and analyzed by the committee, and incorporated whenever possible. The committee also oversees policy implementation including staff and provider training and communication plans pertaining to new or revised policy and procedures. • Health and Welfare Review Task Committee- the Health and Welfare Review Task Committee monitors performance measures related to reports of harm and other critical incidents. The committee reviews reports of harm, critical incident and complaint reports, discovers deficiencies and plans, and conducts individual and system remediation. 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 25 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 • Information Technology Task Committee- the Information Technology (IT) Task Committee monitors the coordination and integration of department information technology and supports data collection and analysis activities of all the task committees. The committee supports and coordinates development and functionality of the department management information system, Harmony, including identification of system performance enhancements and coordination with other DHSS and partner systems. • Financial Accountability Task Committee- the Financial Accountability Task Committee ensures that CFC services claims for reimbursement are coded and paid in accordance with the reimbursement methodology. The committee monitors regulations, policy, and procedure regarding claims and service utilization, and reviews DHSS audit reports and other surveillance reports generated by the department to discover deficiencies in provider billing compliance. The committee addresses deficiencies that can be remediated at the department level, and supports the department efforts to recoup overpayments and sanction providers as needed to maintain the financial integrity of the CFC program. • Quality Improvement Workgroup (QIW) - The QIW reviews and analyzes aggregated data collected through activities of Task Committees and determines if system changes are necessary to meet performance targets. The QIW drafts the CQI plan and performance measures, reviews findings and first level remediation activities, and determines the need for remediation. QIW meets monthly to develop plans of action that include a statement of the problems/risk to be corrected, desired results/changes, specific action steps, identification of person/s responsible, timeframe for completion of the corrective action plan, and plans for monitoring the effectiveness. Additional responsibilities include comparison of monthly, quarterly, and annually aggregated data to identify trends or potential system changes and recommendations for system change activities. The CQI plan also includes requirements for providers including submitting to independent audits conducted by the department. In addition, CFC services providers are expected to perform an internal evaluation including client satisfaction surveys, which are reviewed by department QA staff and considered when the agency seeks recertification. Describe the methods the state will use to continuously monitor the health and welfare of each individual who receives home and community-based attendant services and supports, including a process for the mandatory reporting, investigation, and resolution of allegations of neglect, abuse, or exploitation in connection with the provision of such services and supports: The state operates a formal, comprehensive system that includes an ongoing process of discovery, remediation, and improvement. The state assures the health and welfare of participants by monitoring: a) LOC determinations; b) individual plans and services delivery; c) provider qualifications; d) participant health and welfare; e) financial oversight; and f) administrative oversight. The state further assures that all problems identified through its discovery processes are addressed in an appropriate and timely manner, consistent with the severity and nature of the problem. This system will be integrated with the CQI system for the state’s CFC program. All service providers are mandatory reporters for abuse, neglect, or exploitation and are required to report these types of incidents in accordance with AS 47.17.010 for children and AS 47.24.010 for adults. For incidents of abuse, neglect, or exploitation in an assisted living home, service providers are required to report these incidents to the department pursuant to AS 47.24.013. 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 26 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 All providers are required to report critical incidents. Within 24 hours or one business day of observing or learning of an incident involving a participant for whom services are provided under a service plan, the provider agency, or the incident reporter is required to file a department Critical Incident Report (CIR). For medication errors, this timeframe must be met only when the error results in the need for medical intervention; all other medical errors must be reviewed and documented by the provider on a quarterly basis, and submitted to the department upon request. The department’s Central Intake Unit receives and routes all reports of physical and sexual abuse, neglect, self- neglect, exploitation, including financial exploitation, and abandonment as well as critical incidents involving CFC participants. Providers, participants, care coordinators, family members, advocates or any citizen may submit a “report of harm” through the department-sponsored “Centralized Reporting” electronic portal accessed through the department web at http://dhss.alaska.gov/dsds/Pages/CentralizedReporting.aspx. APS reviews all reports of harm and critical incidents within 24 hours of receipt and investigates allegations of abuse neglect or exploitation. Describe how the state measures individual outcomes associated with the receipt of home and community-based attendant services and supports as set forth in the person-centered service plan, particularly for the health and welfare of individuals receiving such services and supports. (These measures must be reported to CMS upon request.) Care coordinators have responsibility for implementation and ongoing monitoring of the participant’s person- centered support plan. Using telephonic and in-person contacts, the care coordinator ensures that services are provided as identified in the person-centered support plan, monitors the effectiveness and quality of services received from providers, evaluates the need for specific services or changes in services, and, with the participant, revises the person-centered support plan as needed. In addition, the care coordinator coordinates multiple services and providers, including non-CFC services, such as primary health care. The care coordinator also reviews and modifies the participant’s service back-up plan as needed to ensure participant health, safety and welfare, and to ensure that participants have free choice of providers, responds to participant requests for changes in providers by providing service options, linking the participant with a new provider, and facilitating the transition as needed. The state also takes a role in monitoring implementation of the person-centered support plan through a review of the care coordinator’s efforts. After each visit with a participant, the care coordinator completes a provider “record of service” as required by regulations that include annotated case notes signed and dated by the care coordinator. The department Provider Quality Assurance Unit requests the participant contact form when needed in response to a participant complaint, when the state’s discovery efforts reveal problems with a participant’s care, or for safety investigations and/or audit and program integrity reviews. When a care coordinator is identified as deficient in any of these areas, the department remediates the problem by providing training and technical assistance. If the care coordinator’s performance does not improve, the department will respond with progressive disciplinary actions, culminating in loss of provider certification. The department uses the same performance indicators, including the health and welfare performance indicators. The department collects and aggregates data for these measures for a statistically significant and representative sample of individuals enrolled in CFC. For CFC, the department supplements these indicators with performance indicators utilizing data collected directly from participants after the support planning process. These indicators monitor the participant’s experience with services and the assessment and support planning process. Describe the standards for all service delivery models for training, appeals for denials and reconsideration procedures for an individual’s person-centered service plan: 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 27 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 Training: Training standards for individual services, care coordinators, and department staff are discussed in the earlier sections, as is the voluntary training being offered to participants and/or representatives. The department Training Unit will oversee compliance with all training standards. Denials and Fair Hearings: Alaska’s Administrative Code at 7 AAC 49 provides applicants and participants in programs the right to notice of adverse actions, an appeal of such adverse actions, and a fair hearing. A notice of adverse action must be given to individuals when their request for services is not acted upon with reasonable promptness, if not given the choice of CFC services as an alternative to institutional care, are denied the service(s) of their choice or the provider(s) of their choice; or, whose services are denied, suspended, reduced or terminated. During the initial application process, an applicant for CFC services is informed of their rights to dispute, through the fair hearing process, any adverse action from the state. This information is given to the individual by the care coordinator assisting them with the application process in the Notice of Adverse Actions, Hearings and Appeals information sheet. The department ensures that the applicant receives the Notice of Adverse Action by requiring the department’s Program Participant Rights form as part of the complete application. The form requires the applicant to read and initial 18 statements attesting to the fact that they understand their rights under the program. The final statement confirms that they have received a copy of the Notice of Adverse Actions, Hearings and Appeals information sheet. The state offers a process for mediation in advance of fair hearing to address disputes in regards to all services provided through the department. All fair hearings in the State of Alaska are centralized and conducted by the Alaska Department of Administration and heard before an administrative law judge. Fair hearing representatives are responsible for preparing the case for adverse action and representing the department at the hearing. The applicant or participant may choose to represent him or herself at the fair hearing, or may choose representation by a guardian, attorney, friend, or family member. Due to conflict of interest concerns the participant's care coordinator or other service providers may not represent the participant at the fair hearing, but may accompany the participant to the hearing, act as an advocate, offer assistance throughout the process, and refer the participant to additional sources of assistance as appropriate. In addition, upon oral or written request from the applicant or participant, the department will provide assistance in obtaining representation, preparing the case, and gathering witnesses and/or documents to be used in presenting the claim. Describe the methods used to monitor provider qualifications: Alaska monitors provider qualifications using the certification process and ongoing provider monitoring. Provider Certification: the provider choosing to offer Medicaid-reimbursable CFC services must be certified as a provider of those services and operate in compliance with the State’s certification criteria. The provider must demonstrate, through documents describing provider operations, readiness to provide services and comprehension of Medicaid regulations, Community First Choice regulation and the Provider Conditions of Participation. Provider Monitoring: As part of monthly discovery activities, the Provider Certification and Compliance Unit manager reviews the department training database against a list of certified CFC services providers. For those providers who are out of compliance with department training requirements, including Critical Incident Reporting training, the manager directs staff to issue a “report of findings”. The report must include a description of the evidence supporting the finding of noncompliance as well as the specific standard, policy, regulation, or statute that is the basis for the finding. In addition, the report specifies the remediation action required to achieve compliance, the date by which compliance is required and the method of provider confirmation of compliance. The department may also perform targeted reviews and conduct agency onsite visits, including document reviews and participant or provider staff interviews. The department then monitors remediation requirements through review and analysis of provider reports, information provided by participants, and reviews of complaints. The department continues to 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 28 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 review progress until the deficiencies are corrected, and reports on the performance of department certification and oversight process activities to the departmental Quality Improvement Steering Committee on a quarterly basis. Describe the methods for assuring that individuals are given a choice between institutional and community based services: The person-centered support plan includes a section called Participant Choice of Services that requires the participant or legal representative to initial a series of statements indicating that they understand the choices available– either receiving Medicaid funded care in an institution, through state funded community based services, only non-Medicaid services, or receiving no services at all. The section also outlines the assistance the department and/or the participant’s care coordinator provide after a choice is made. Finally, the section requires the participant and/or their legal representative to indicate their choice. The person-centered support plan is then signed by everyone involved in the planning effort. The Participant Choice of Services section of the person-centered support plan is updated and reviewed with the participant at least annually. Participants are also given materials listing all the Medicaid LTSS available to them. Describe the methods for assuring that individuals are given a choice of services, supports, and providers: Prior to person-centered support plan development, the care coordinator, chosen by the participant from an official list of care coordinators (provided after a person-centered intake by the Aging and Disability Resource Center or Developmental Disability Resource Center specialist) in their geographic area, provides a list of CFC, relevant HCB waiver services, and State plan LTSS. The care coordinator then assists the participant to explore the range of services offered, and to make decisions regarding which services meet their person-centered goals, needs, preferences, and desires. Participants take the lead in their person-centered support plan development, may refuse services, and are given information on how to contact the department for more information or to lodge complaints regarding services, service providers, or any other aspect of CFC participation. Participants sign the Participant Rights and Responsibilities form at time of application, and sign annual service plans and when needed changes are identified, plan amendments. The department Standards for Care Coordinators requires care coordinators to help participants explore options when choosing service providers. The care coordinator provides the participant with a list of certified and enrolled providers who offer services in their area and the participant picks those providers that fit her or his needs as outlined in the person-centered support plan and have the capacity to serve them. The Participant Choice of Service section of the person-centered support plan confirms that the care coordinator fulfilled these requirements. If the care coordinator has been granted an exemption by the department and is not conflict-free, the care coordinator is required to disclose this conflict of interest and ensure that the participant understands that they still have the right to choose a provider other than the care coordinator’s agency. The department reviews the person-centered support plans to ensure these requirements are met. In addition, the department will be surveying participants to ensure they believed they were given a choice of services, supports, and providers. Describe the methods for monitoring that the services and supports provided to each individual are appropriate: The department ensures that services and supports provided under CFC are appropriate by: 1. issuing guidance and training to care coordinators that require that all services and supports must be related to a documented assessed need or person-centered goal. 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 29 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 2. reviewing all person-centered support plans to ensure that services and supports are appropriate given assessed needs and person-centered goals. 3. ensuring that the care coordinator discusses the provision of services with the participant or the participant's legal representative telephonically or during participant requested contact and reports to department staff. 4. ensuring that the person-centered support plan is updated annually or when needed to reflect changes in the participant's condition, desires, goals, or needs. Annual updates take place after the reassessment and redetermination of the participant’s Institutional LOC. Describe the state process for ongoing monitoring of compliance with the home and community-based setting requirements, including systemic oversight and individual outcomes: Services are only provided to individuals living in private residences and not in provider owned or controlled settings. Services are not provided in any residential foster care for children. The department has incorporated settings compliance into its existing monitoring processes. Choice and Control Describe the quality assurance system's methods to (1) maximize consumer independence and control, (2) provide information about the provisions of quality improvement to each individual receiving CFC services and supports The department’s CQI process, which is described in greater detail in earlier sections, includes the following components that help maximize participant independence and control: 1. Department staff monitors data collected by the ADRCs during the person-centered intake to ensure that individuals are able to make an informed choice about whether to enroll in CFC. 2. Department staff review all the person-centered support plans to ensure that care coordinators followed the proscribed policies and procedures designed to maximize participant independence and control. 3. Department staff will review the results of a survey of all participants regarding their experience in completing a person-centered support plan. This survey, the Questionnaire for Initial and Renewal Plans of Care, includes items addressing independence and control. These reviews result in interventions both at the individual and programmatic level. Each CFC participant receives a document that explains how the CFC quality management strategy works. The care coordinator explains this document when initial and annual person-centered support plan updates are finalized. Stakeholder Feedback Describe how the state will elicit feedback from key stakeholders to improve the quality of the community-based attendant services and supports benefit: The department elicits and incorporates stakeholder feedback into its quality improvement strategy in the following ways: 1. The department elicits feedback from all CFC participants during the support planning process using the “Questionnaire for Initial and Renewal Plans of Care”. This questionnaire collects information about services and the support planning process and is used as a key data source in the department’s quality management strategy that was described earlier. 2. The department holds at least quarterly meetings of the Inclusive Community Choices Council (ICC) to present information about CFC and HCB waiver services and elicit feedback from program participants. The ICC includes individuals with disabilities, older adults, their advocates, and providers and other stakeholders who impact 11/19/2020

1915(k) State Plan for Title XIX 42 CFR 441 Subpart K Attachment 3.1-K State of Alaska Community First Choice Page 30 TN No. 20-0006 Approval Date: Effective Date January 1, 2021 Supersedes TN No. 17-0011 and/or are impacted by CFC and HCB waiver services. During these meetings, summary information from the Questionnaire and other key CQI information is presented. 3. The department participates in meetings held by associations and other groups, such as the Governor’s Council on Disabilities and Special Education and the Alaska Commission on Aging, to inform them about how CFC and HCB waiver services are working and to obtain input. 4. The department makes summary information about the program available on its website. 5. The department also holds webinars and community forums when major changes are being considered or are in the process of being implemented. Identify the stakeholders from whom the state will elicit feedback: The state will elicit feedback from the following stakeholders: (1) Individuals receiving CFC services and, if applicable, their representatives, (2) disability organizations, (3) providers, (4) families of elderly individuals or individuals with disabilities, (5) and members of the community Other, describe: State Assurances The state assures there are necessary safeguards in place to protect the health and welfare of individuals provided services under this state Plan Option, and to assure financial accountability for funds expended for CFC services. With respect to expenditures during the first full year in which the state plan amendment is implemented, the state will maintain or exceed the level of state expenditures for home and community-based attendant services and supports provided under section 1905(a), section 1915, section 1115, or otherwise to individuals with disabilities or elderly individuals attributable to the preceding year. The state assures the collection and reporting of information, including data regarding how the state provides home and community-based attendant services and supports and other HCB WAIVER SERVICES , the cost of such services and supports, and how the state provides individuals with disabilities who otherwise qualify for institutional care under the state plan or under a waiver the choice to instead receive HCB WAIVER SERVICES in lieu of institutional care, and the impact of CFC on the physical and emotional health of individuals. The state shall provide the Secretary with the following information regarding the provision of home and community-based attendant services and supports under this subsection for each fiscal year such services and supports are provided: (i) The number of individuals who are estimated to receive home and community-based attendant services and supports under this option during the fiscal year. (ii) The number of individuals that received such services and supports during the preceding fiscal year. (iii) The specific number of individuals served by type of disability, age, gender, education level, and employment status. (iv) Whether the specific individuals have been previously served under any other home and community based services and support program under the state plan or under a waiver. The state assures that home and community-based attendant services and supports are provided in accordance with the requirements of the Fair Labor Standards Act of 1938 and applicable Federal and state laws. 11/19/2020

State Plan for Title XIX Attachment 4.19-B State of Alaska Page 5b TN No.: 20-0006 Approval Date: _ __ Effective Date: January 1, 2021 Supersedes TN No.: 20-0005 Personal Care Services Services are reimbursed at the lesser of the amount billed the general public or the state maximum allowable. Except as otherwise noted in the plan, payment for these services is based on state-developed fee schedule rates, which are the same for both governmental and private providers of personal care services. The agency’s rate for personal care services updated on 7/1/2019, are effective for services rendered on or after 07/01/19. The fee schedule, including any annual/periodic adjustments to the fee schedule based on the CMS Home Health Agency Market Basket, and its effective dates are included in the fee schedule for personal care services published at http://dhss.alaska.gov/dsds/Pages/info/costsurvey.aspx. For SFY20, July 1, 2019 through June 30, 2020, the payment rates will be 95% of the SFY19 rates. Personal Care Services for Community First Choice Option Effective for services provided on or after January 1, 2018, providers of Personal Care Services for Community First Choice eligible recipients will be reimbursed at fee for service rates built on the base rate of the Personal Care Assistant adjusted to include: • Salaries for Personal Care Supervisors and Personal Care Assistants • Fringe Benefits for Personal Care Supervisors and Personal Care Assistants • Training time for Personal Care Supervisors and Personal Care Assistants Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers. The fee schedule, and effective date is published at http://dhss.alaska.gov/dsds/Pages/info/costsurvey.aspx. Chore Services for Community First Choice Option Effective for services provided on or after January 1, 2021, the State Medicaid Program reimburses providers of Chore Services for Community First Choice eligible recipients at the lesser of the amount billed to the general public or the state maximum allowable. Except as otherwise noted in the plan, payment for these services is based on state-developed fee schedule rates, which are the same for both governmental and private providers. The agency’s rates for CFC chore services are effective January 1, 2021, for services provided on or after January 1, 2021. The fee schedule, including any annual/periodic adjustments to the fee schedule based on the CMS Home Health Agency Market Basket, and its effective date is included in the fee schedule for chore services published at http://dhss.alaska.gov/dsds/Pages/info/costsurvey.aspx. Physical and Occupational Therapy Services Payment is made at the lesser of billed charges, 85 percent of the Resource Based Relative Value Scale methodology used for the physicians, the provider’s lowest charge, or the maximum allowable for procedures that do not have an established RVU. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of physical and occupational therapy services. The fee schedule and its effective dates are available at http://manuals.medicaidalaska.com/medicaidalaska/providers/FeeSchedule.asp. Physician Assistants Payment is made at the lesser of billed charges, 85 percent of the Resource Based Relative Value Scale methodology used for physicians, the provider’s lowest charge, or the maximum allowable for procedures that do not have an established RVU. State developed fee schedules are the same for both public and private providers. The fee schedule and effective date are available at: http://manuals.medicaidalaska.com/medicaidalaska/providers/FeeSchedule.asp. 11/19/2020

Table of Contents State/Territory Name: Alaska State Plan Amendment (SPA) #: 22-0005 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group August , 2022 Adam Crum, Commissioner Alaska Department of Health 3601 C Street, Suite 902 Anchorage, AK 99503-7167 Re: Alaska State Plan Amendment (SPA) Transmittal Number 22-0005 Dear Mr. Crum: The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) 22-0005. This amendment updates third-party liability and payment of claims in accordance with requirements in the Bipartisan Budget Act (BBA) of 2018 and the Medicaid Services Investment and Accountability Act (MSIAA) of 2019. Specifically, updating third party liability and related Medicaid payments associated with prenatal care, preventative pediatric services and medical child support. We conducted our review of your submittal according to statutory requirements in Title XIX of the Social Security Act and implementing regulations 42 CFR § 435.733. This letter is to inform you that Alaska Medicaid SPA 22-0003 was approved on August 19, 2022, with an effective date of July 1, 2022. If you have any questions, please contact Maria Garza at 206-615-2542 or via email at maria.garza@cms.hhs.gov. Sincerely, James G. Scott, Director Division of Program Operations cc: Al Wall, Deputy Commissioner, a.wall@alaska.gov Courtney King, SPA Coordinator, courtney.king@alaska.gov Digitally signed by James G. Scott -S Date: 2022.08.22 12:07:30 -05'00'




  

 



  


  

 
 

   

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 Digitally signed by James G. Scott -S Date: 2022.08.22 12:09:00 -05'00'

69 Revision: HCFA-PM-94-1 (MB) February 1994 State/Territory: Alaska TN No.: 22-0005 Approval Date: ƵŐƵƐƚϭϵ͕ϮϬϮϮ Effective Date: July 1, 2022 Supersedes TN No.: 94-10 Citation 4.22 Third Party Liability 42 CFR §433.137 A. The Medicaid agency meets all the requirements of 1902 (a)(25)(B),(E), (F), (H), and (I) of the Act 1. 42 CFR 433.138 and 433.139 2. 42 CFR 433.145 through 433.148 3. 42 CFR 433.151 through 433.154 4. Section 1902 (a)(25)(B), (E), (F), (H), and (I) of the Act 42 CFR §433.138(f) B. Attachment 4.22-A 1. Specifies the frequency with which the data exchanges required in §433.138(d)(1), (d)(3), and (d)(4), and the diagnosis and trauma code edits required in §433.138(e) conducted; 42 CFR §433.138(g)(1)(ii) and (2)(ii) 2. Describes the methods the agency uses for meeting the follow-up requirements contained in §433.138(g)(1)(i) and (g)(2)(i); 42 CFR §433.138(g)(3)(i) and (iii) 3. Describes the methods the agency uses for following up on information obtained through the state motor vehicle accident report file data exchange required under §433.138(d)(4)(ii) and specifies the time frames for incorporation into the eligibility case file and into its third party database and third party recovery unit of all information obtained through the follow-up that identifies legally liable third party resources; and 42 CFR §433.138(g)(4)(i) through (iii) 4. Describes the methods the agency uses for following up on paid claims identified under §433.138(e) (methods include a procedure for periodically identifying those trauma codes that yield the highest third party collections and giving priority to following up on those codes) and specifies the time frames for incorporation into the eligibility case file and into its third party database and third party recovery unit of all information obtained through the follow-up that identifies legally liable third party resources. 42 CFR §433.139(b)(3)(ii)(A) C. Providers are required to bill liable third parties when furnishing services covered under the plan to an individual on whose behalf the state IV-D agency carries out child support enforcement.

69a Revision: HCFA-PM-94-1 (MB) February 1994 State/Territory: Alaska TN No.: 22-0005 Approval Date: ƵŐƵƐƚϭϵ͕ϮϬϮϮ Effective Date: July 1, 2022 Supersedes TN No.: 94-10 4.22 (continued) D. Attachment 4.22-B specifies the following: 42 CFR §433.139(b)(3)(i) and (ii)(C) 1. The method used in determining a provider’s compliance with the third-party billing requirements at §433.139(b)(3)(ii)(C); 42 CFR §433.139(f)(2) 2. The threshold amount or other guideline used in determining whether to seek recovery of reimbursement from a liable third party or the process by which the agency determines that seeking recovery of reimbursement would not be cost-effective; 42 CFR §433.139(f)(3) 3. The dollar amount or time period the state uses to accumulate billings from a particular liable third party in deciding to seek recovery of reimbursement. 42 CFR §447.20 E. The Medicaid agency ensures that the provider furnishing a service for which a third party is liable follows the restrictions spe3cified in 42 CFR §447.20. 42 CFR §433.151(a) F. The Medicaid agency has written cooperative agreements for the enforcement of rights to and collection of third party benefits assigned to the state as a condition of eligibility for medical assistance with the following: State title IV-D agency. The state meets the requirements of 42 CFR §433.152(b). Other appropriate state agency(s) Other appropriate agencies of another state Courts and law enforcement officials 1902(a)(60) of the Act G. The Medicaid agency assures that the state has in effect the laws relating to medical child support under section 1908 of the Act 1906 of the Act H. The Medicaid agency specifies the guidelines used in determining the cost-effectiveness of an employer- based group health plan by selecting one of the following: The Secretary’s method, as provided in the state Medicaid manual, section 3910. The state provides methods for determining cost- effectiveness in attachment 4.22-C.

70 Revision: HCFA-PM-94-1 (MB) February 1994 State/Territory: Alaska TN No.: 22-0005 Approval Date: ƵŐƵƐƚϭϵ͕ϮϬϮϮ Effective Date: July 1, 2022 Supersedes TN No.: 01-011 This page is intentionally left blank

State Plan for Title XIX Attachment 4.22-B State of Alaska Page 1 Requirements for Third Party Liability Payment of Claims TN No. 22-0005 Approval Date͗ƵŐƵƐƚϭϵ͕ϮϬϮϮ Effective Date: July 1, 2022 Supersedes TN No. 97-006 Providers of medical services have the primary responsibility for assuring the application of third-party resources to the cost of care before billing Medicaid. Unless excluded by federal law, claims for medical services are cost-avoided when a third-party liability policy exists within the claims payment system. The Medicaid agency applies cost avoidance procedures to claims for prenatal services, including labor, delivery, and postpartum care services. The Medicaid agency or its third-party liability (TPL) contractor pursues claims paid before the inclusion of third-party coverage information in the claims system, as described in this attachment. I. Monitoring Provider Compliance – 42 CFR § 433.139(b)(3)(ii)(C) A provider submitting a claim for a recipient with a third-party resource must include with the claim an explanation of benefits (EOB) from each known third-party resource. The provider must indicate the amount of payment received from each third-party resource on the claim. If payment was unavailable from a third-party resource, the provider must document the attempt to collect payment by attaching an EOB or other documentation showing denial of payment by the third-party resource. Exceptions exist for those claims specified in 42 CFR § 433.139(b)(3)(i) and (ii) and any approved cost avoidance waivers. The Medicaid agency monitors provider compliance with insurance billing requirements through post-payment recovery responses to the TPL vendor. If the provider or the insured person receives a report of prior payment, the amount paid by the insurer is subject to recoupment from the provider. II. Guidelines Used to Determine When to Seek Reimbursement from a Liable Third-Party – 42 CFR § 433.139(f)(2) Providers must bill liable third parties when providing services to an individual on whose behalf the Title IV-D agency carries out medical support enforcement unless the provider certifies that before billing Medicaid, the provider (1) billed the third party, (2) waited 100 days from the date of the service provision, and (3) has not received payment from the third-party in compliance with 1902(a)(25)(F) of the SSA. The state makes payments without regard to potential TPL for pediatric preventive services unless it determines cost-effectiveness and access to care issues warrant cost avoidance for up to 90 days in compliance with 1902(a)(25)(E) of the SSA. A. Health Insurance For medical claims paid before the inclusion of the relevant TPL policy information in the eligibility or claims systems, a vendor pursues recovery from the provider within one year of the date of service for amounts greater than $0.01 once combined charges for all recipients from the provider equal or exceed $50.00. For medical claims with a date of service greater than one year and paid before the inclusion of the relevant TPL policy information in the eligibility or claims systems, a vendor pursues recovery from the liable third-party payor for amounts greater than $0.01 within three years of the date the provider furnished the item or service. Any action by the Medicaid agency to enforce its rights with respect to the claim commences within six years of claim submission.

State Plan for Title XIX Attachment 4.22-B State of Alaska Page 2 Requirements for Third Party Liability Payment of Claims TN No. 22-0005 Approval Date͗ƵŐƵƐƚϭϵ͕ϮϬϮϮ Effective Date: July 1, 2022 Supersedes TN No. 97-006 B. Casualty Recovery The threshold for casualty-related claims is $250.00 per individual claim, with no time limit on accumulating outstanding charges. The Medicaid agency complies with Section 1902(a)(25)(B) of the Social Security Act, using the following factors and guidelines when determining whether or not to pursue recovery of benefits from a liable party after deduction of its proportionate share of attorney’s fees and costs. 1. Ascertain the amount of Medicaid lien and the amount of the gross settlement; 2. Determine whether the Medicaid lien plus attorney’s fees and costs will exhaust or exceed the settlement funds; 3. If the answer to (b) is yes, and if the Medicaid agency a. is informed that the client will not pursue the claim; or b. cannot handle the case once it is tendered to the Medicaid agency by the client or the client’s attorney to pursue on behalf of the client; or c. has made a reasonable effort to ascertain the client’s intention regarding the claim but could not obtain a response; then the Medicaid agency shall follow the procedure in (4) below. 4. The Medicaid agency shall consider the cost-effectiveness principle in determining the estimated net recovery amount based on the likelihood of collections. The Medicaid agency defines the net recovery amount as recovered dollars applicable to Medicaid costs. In determining the net recovery amount, the Medicaid agency considers the following factors: a. The settlement as it may be affected by insurance coverage or other factors relating to the liable party; b. The factual and legal issues of liability as they may exist between the client and the liable party; c. Any problems of proof in obtaining the award or settlement; and d. The estimated attorney’s fee and costs as required for the Medicaid agency to pursue the claim. 5. After considering the above factors, the Medicaid agency may pursue a lesser recovery amount to the extent that the Medicaid agency determines it is cost-effective to do so. III. Dollar Amount or Timeframe for Seeking Recovery – 42 CFR § 433.139(f)(3) Health insurance recovery action on claim types likely to be covered by insurance occurs when payments made by the Medicaid agency are greater than $0.01. Casualty recovery for personal injury investigative action occurs when hospital bills with trauma diagnoses for which the billed amounts are equal to or greater than $250.00

Table of Contents State/Territory Name: Alaska State Plan Amendment (SPA) #: 22-0013 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

Records / Submission Packages - View All

AK - Submission Package - AK2022MS00050 - (AK-22-0013) - Eligibility

Summary Reviewable Units Versions Analyst Notes

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group

601 E. 12th St., Room 355

Kansas City, MI 64106

Center for Medicaid & CHIP Services

December 06, 2022

Emily Ricci Commissioner Department of Health 3601 C Street

Suite 902

Anchorage, AK 99503

Re: Approval of State Plan Amendment AK-22-0013

Dear Emily Ricci,

Approval Letter Transaction Logs News Related Actions v

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

On November 01, 2022, the Centers for Medicare and Medicaid Services (CMS) received Alaska State Plan Amendment (SPA) AK-22-0013, which proposed to update the income standards for Alaska's optional state supplement program, the beneficiaries of which are eligible for Medicaid.

We approve Alaska State Plan Amendment (SPA) AK-22-0013 with an effective date(s) of January 01, 2023.

If you have any questions regarding this amendment, please contact MARIA GARZA at maria.garza@cms.hhs.gov

Sincerely, James G. Scott Director

Center for Medicaid & CHIP Services

Records / Submission Packages - View All

AK - Submission Package - AK2022MS00050 - (AK-22-0013) - Eligibility

Summary Reviewable Units Versions Analyst Notes Approval Letter Transaction Logs News Re tions

Submission - Summary

MEDICAID | Medicaid State Plan | Eligibility | AK2022MS00050 | AK-22-0013 CMS-10434 OMB 0938-1188

Package Header

Package ID AK2022MS0005O0 SPAID AK-22-0013 Submission Type Official Initial Submission Date 11/1/2022 Approval Date 12/6/2022 Effective Date N/A

Superseded SPAID N/A State Information State/Territory Name: Alaska Medicaid Agency Name: Department of Health

Submission Component

State Plan Amendment Medicaid

CHIP

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | AK2022MS00050 | AK-22-0013 Package Header

Package ID AK2022MS0005O SPAID AK-22-0013 Submission Type Official Initial Submission Date 11/1/2022 Approval Date 12/6/2022 Effective Date N/A

Superseded SPAID N/A

SPA ID and Effective Date

SPAID AK-22-0013

Reviewable Unit Proposed Effective Date Superseded SPA ID Optional Eligibility Groups 1/1/2023 AK-22-0002

Individuals Eligible for but Not Receiving Cash

- 1/1/2023 AK-22-0002 Assistance

Optional State Supplement Beneficiaries 1/1/2023 AK-22-0002

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | AK2022MS00050 | AK-22-0013 Package Header

Package ID AK2022MS0005O SPAID AK-22-0013 Submission Type Official Initial Submission Date 11/1/2022 Approval Date 12/6/2022 Effective Date N/A

Superseded SPAID N/A

Executive Summary

Summary Description Including The SPA updates the income standards for recipients of Alaska's Optional State Supplemental Payments. In Alaska, Goals and Objectives individuals are able to qualify for Medicaid by reducing their countable gross income through the use of approved Medicaid Qualifying Trusts

Federal Budget Impact and Statute/Regulation Citation

Federal Budget Impact

Federal Fiscal Year Amount First 2023 $0 Second 2024 $0

Federal Statute / Regulation Citation 42 CFR 435.234 and 42 CFR 435.210

Supporting documentation of budget impact is uploaded (optional).

Name Date Created

No items available

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | AK2022MS0005O | AK-22-0013 Package Header

Package ID AK2022MS00050 SPAID AK-22-0013 Submission Type Official Initial Submission Date 11/1/2022 Approval Date 12/6/2022 Effective Date N/A

Superseded SPAID N/A

Governor's Office Review

© No comment

© Comments received

CONo response within 45 days © Other

PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state's program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

This view was generated on 12/12/2022 6:14 PM EST

Records / Submission Packages - View All

AK - Submission Package - AK2022MS00050 - (AK-22-0013) - Eligibility

Summary Reviewable Units Versions Analyst Notes Approval Letter Transaction Logs News 1 Actions

v CMS-10434 OMB 0938-1188 Medicaid State Plan Eligibility Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | AK2022MS00050 | AK-22-0013 Package Header Package ID AK2022MS00050 SPAID AK-22-0013 Submission Type Official Initial Submission Date 11/1/2022 Approval Date 12/6/2022 Effective Date 1/1/2023

Superseded SPAID AK-22-0002

System-Derived

A. Options for Coverage

The state provides Medicaid to specified optional groups of individuals. Yes No

The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper- based state plan to MACPro):

Families and Adults

Include RU In Package Included in Another

Eligibility Group Name Covered In State Plan e Submission Package

Source Type @

Optional Coverage of Parents and Other [P| O NEW Caretaker Relatives

Reasonable Classifications of Individuals under Age 21

CONVERTED

Children with Non-IV-E CONVERTED Adoption Assistance Independent Foster NEW Care Adolescents

Optional Targeted Low

Income Children CONVERTED

Individuals above 133% FPL under Age 65 NEW Individuals Needing Treatment for Breast or Cervical Cancer

NEW

Individuals Eligible for Family Planning Services

NEW

Individuals with NEW Tuberculosis Individuals Electing COBRA Continuation Coverage

NEW

Oo 0000000 0

[P| [P| [P| [P| [P|

Aged, Blind and Disabled Eligibility Group Name

Individuals Eligible for but Not Receiving Cash Assistance

Individuals Eligible for Cash Except for Institutionalization

Individuals Receiving Home and Community- Based Waiver Services under Institutional Rules

Optional State Supplement Beneficiaries

Individuals in Institutions Eligible under a Special Income Level

PACE Participants

Individuals Receiving Hospice

Children under Age 19 with a Disability

Age and Disability- Related Poverty Level

Work Incentives Ticket to Work Basic

Ticket to Work Medical Improvements

Family Opportunity Act Children with a Disability

Individuals Receiving State Plan Home and Community-Based Services

Individuals Receiving State Plan Home and Community-Based Services Who Are Otherwise Eligible for HCBS Waivers

VHeeeeheeeee wo w & & PB

[2]

Covered In State Plan

Include RU In Package (2)

Included in Another Submission Package

O

O

Oo OO00OO00O00 0 O O

O

Source Type @

APPROVED

NEW

NEW

APPROVED.

NEW

NEW

NEW

NEW

NEW

NEW

NEW

NEW

NEW

NEW

NEW

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | AK2022MS00050 | AK-22-0013 Package Header

Package ID AK2022MS0005O0 SPAID AK-22-0013 Submission Type Official Initial Submission Date 11/1/2022 Approval Date 12/6/2022 Effective Date 1/1/2023

Superseded SPAID AK-22-0002

System-Derived

B. Medically Needy Options for Coverage

The state provides Medicaid to specified groups of individuals who are medically needy. Yes No

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | AK2022MS00050 | AK-22-0013 Package Header

Package ID AK2022MS0005O SPAID AK-22-0013 Submission Type Official Initial Submission Date 11/1/2022 Approval Date 12/6/2022 Effective Date 1/1/2023

Superseded SPAID AK-22-0002

System-Derived

C. Additional Information (optional)

Eligibility Groups Deselected from Coverage

The following eligi submission package:

lity groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this

« N/A

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage

Individuals Eligible for but Not Receiving Cash Assistance MEDICAID | Medicaid State Plan | Eligibility | AK2022MS00050 | AK-22-0013

Individuals who are eligible for but not receiving federal cash assistance or an optional state supplement.

Package Header Package ID Submission Type Approval Date Superseded SPA ID

AK2022MS0005O0 SPAID AK-22-0013 Official Initial Submission Date 11/1/2022 12/6/2022 Effective Date 1/1/2023 AK-22-0002

System-Derived

The state covers the optional Individuals Eligible for but Not Receiving Cash Assistance eligibility group in accordance with the following provisions:

A. Characteristics

Individuals qualifying under this eligibility group must meet the following criteria:

1. Meet the eligibility requirements of at least one of the following cash assistance programs:

a. SSI b. Optional State Supplement c, AFDC

2. Do not receive cash assistance under these programs.

Individuals Eligible for but Not Receiving Cash Assistance

MEDICAID | Medicaid State Plan | Eligibility | AK2022MS00050 | AK-22-0013

Package Header Package ID Submission Type Approval Date Superseded SPA ID

B. Individuals Covered

AK2022MS00050, SPAID AK-22-0013 Official Initial Submission Date 11/1/2022 12/6/2022 Effective Date 1/1/2023 AK-22-0002

System-Derived

1. The state covers all individuals who meet the characteristics described in section A.

Yes

No

Individuals Eligible for but Not Receiving Cash Assistance

MEDICAID | Medicaid State Plan | Eligibility | AK2022MS00050 | AK-22-0013

Package Header Package ID Submission Type Approval Date Superseded SPA ID

AK2022MS00050 SPAID AK-22-0013 Official Initial Submission Date 11/1/2022 12/6/2022 Effective Date 1/1/2023 AK-22-0002

System-Derived

C. Financial Methodologies

1. In calculating household income and resources for individuals who are seeking eligibility on the basis of being age 65 or older or having blindness or disability, SSI methodologies are used. Please refer as necessary to Non-MAGI Methodologies, completed by the state.

3. Less restrictive methodologies are used in calculating countable income.

Yes No

The less restrictive income methodologies are:

General income disregard:

Name of disregard: Description:

In 2023, for individuals, countable income between $1,276 and $1,697 is disregarded, and, for couples, countable income between $1,889 and $2,513 is disregarded

2023 Income Disregard

A specified type of income is disregarded:

Specific income changes are disregarded between redeterminations.

Name of income type: Description:

(1) AK annual Permanent Fund Dividend benefit payments are excluded from consideration as income for all mandatory and optional Medicaid eligibility categories; (2) Cash distributions from Alaska Native Claims Settlement Act corporations are excluded from income to the

Specified income changes are disregarded:

(1) Alaska Permanent Fund Dividend; (2) Alaska Native Claims Settlement Act; (3) AmeriCorps.

Name of disregard:

AK Permanent Fund Dividend

extent that the distributions do not exceed $2,000 per individual per calendar year. When an individual receives more than $2,000 from all ANCSA corporations in a single calendar year, any amounts exceeding $2,000 are considered countable income in the month of receipt. (3) All AmeriCorps payments, including living stipends, are disregarded as income for the purposes of determining eligibility.

Description:

Changes in income related to the receipt of the Alaska Permanent Fund Dividend are disregarded.

Name of disregard:

Alaska Native Claims Settlement Act

4. Less restrictive methodologies are used in calculating countable resources.

Yes No

The less restrictive resource methodologies are:

A specified type of resource is disregarded:

Name of resource type:

Alaska Native Claims Settlement Act

Permanent Fund Dividend Program

Description:

Cash distributions from Alaska Native Claims Settlement Act corporations up to $2,000 per individual per calendar year are excluded as a cash resource each year, are excluded indefinitely, and do not affect the exclusion of cash distributions made in subsequent years.

Description:

Cash distributions from Alaska Native Claims Settlement Act corporations up to $2,000 per individual per calendar year are excluded as a cash resource each year, are excluded indefinitely, and do not affect the exclusion of cash distributions made in subsequent years.

Dividend and benefit payments received from the Alaska Permanent Fund Dividend Program are excluded from consideration as countable resources.

Individuals Eligible for but Not Receiving Cash Assistance

MEDICAID | Medicaid State Plan | Eligibility | AK2022MS00050 | AK-22-0013

Package Header Package ID Submission Type Approval Date Superseded SPA ID

AK2022MS00050 SPAID AK-22-0013 Official Initial Submission Date 11/1/2022 12/6/2022 Effective Date 1/1/2023 AK-22-0002

System-Derived

D. Income Standard Used

The income standard used is the standard of the most closely related cash assistance program.

E. Resource Standard Used

The resource standard used is the standard of the most closely related cash assistance program.

Individuals Eligible for but Not Receiving Cash Assistance MEDICAID | Medicaid State Plan | Eligibility | AK2022MSO0005O | AK-22-0013 Package Header

Package ID AK2022MS0005O SPAID AK-22-0013 Submission Type Official Initial Submission Date 11/1/2022 Approval Date 12/6/2022 Effective Date 1/1/2023

Superseded SPAID AK-22-0002

System-Derived

F. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Optional State Supplement Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | AK2022MS0005O | AK-22-0013

Individuals who receive an optional state supplementary payment.

Package Header

Package ID AK2022MS0005O SPAID AK-22-0013 Submission Type Official Initial Submission Date 11/1/2022 Approval Date 12/6/2022 Effective Date 1/1/2023

Superseded SPAID AK-22-0002

System-Derived

The state covers the Optional State Supplement Beneficiaries eligibility group in accordance with the following provisions:

A. Characteristics

Individuals qualifying under this eligibility group must meet the following criteria: 1. Receive an optional state supplement that meets the conditions described in sections C and D. 2. Except for income, would be eligible for SSI.

3. Do not have gross income exceeding 300% of the SSI Federal Benefit Rate (FBR).

Optional State Supplement Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | AK2022MS00050 | AK-22-0013 Package Header

Package ID AK2022MS0005O SPAID AK-22-0013 Submission Type Official Initial Submission Date 11/1/2022 Approval Date 12/6/2022 Effective Date 1/1/2023

Superseded SPAID AK-22-0002

System-Derived

B. Individuals Covered

1. The state covers all individuals who meet the characteristics described in section A. Yes

No

Optional State Supplement Beneficiaries

MEDICAID | Medicaid State Plan | Eligibility | AK2022MS00050 | AK-22-0013

Package Header Package ID Submission Type Approval Date Superseded SPA ID

AK2022MS00050 SPAID AK-22-0013 Official Initial Submission Date 11/1/2022 12/6/2022 Effective Date 1/1/2023 AK-22-0002

System-Derived

C. Optional State Supplement Program

1. The optional state supplement program is administered:

a. Solely by the federal government. The state has an agreement with the Social Security Administration under section 1616 of the Act regarding the administration of optional state supplementary payments.

b. By a combination of federal and state administration. The state has an agreement with the Social Security Administration under section 1616 of the Act regarding the administration of optional state supplementary payments for some classifications of individuals, while state supplementary payments for other classifications of individuals are administered by the state.

c. Solely by the state.

2. Payments under the optional state supplement program are:

a. Based on need and paid in cash on a regular basis;

b. Equal to the difference between the individual's countable income and the income standard used to determine eligibility for supplement; and

c. Available to all individuals in each population selected in section B.

Optional State Supplement Beneficiaries

MEDICAID | Medicaid State Plan | Eligibility | AK2022MS00050 | AK-22-0013

Package Header Package ID Submission Type Approval Date Superseded SPA ID

D. Income Standard of Optional State Supplement Program

AK2022MS00050 Official 12/6/2022 AK-22-0002

System-Derived

1. The income standard for the optional state supplement:

a. Varies by political subdivision. Yes

No

b. Varies by payment classification.

Yes

No

SPAID AK-22-0013

Initial Submission Date 11/1/2022

The payment classifications used are:

Effective Date 1/1/2023

i. All individuals age 65 or older, regardless of living arrangement.

ii, All individuals who have blindness, regardless of living arrangement.

iii. All individuals who have a disability, regardless of living arrangement.

iv. Independent living.

Income Standard

Indi vidu al $12

76.0 0

v. Living in household of another.

Cou ple

$18 89.0 0

Income Standard

Indi vidu al

$97 7.00

Cou ple $14

57.0 (0)

vi. Independent living and receiving non-medical care outside the home.

vii. Living in household of another and receiving non-medical care outside the home.

viii. Living in a domiciliary facility or other group living arrangement.

ix. Other payment classification.

Name of Classification Description: Institutionalized Institutionalized Individual Couple

$200.00 $400.00

Name of Classification Description: Assisted Living Home Assisted Living Home

Individual Couple

$1014.00

$1571.00

Optional State Supplement Beneficiaries

MEDICAID | Medicaid State Plan | Eligibility | AK2022MSO005O | AK-22-0013

Package Header Package ID Submission Type Approval Date Superseded SPA ID

AK2022MS00050 Official 12/6/2022 AK-22-0002

System-Derived

E. Additional Information (optional)

SPAID AK-22-0013 Initial Submission Date 11/1/2022 Effective Date 1/1/2023

PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state's program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

This view was generated on 12/12/2022 6:15 PM EST

Table of Contents State/Territory Name: Alaska State Plan Amendment (SPA) #: 23-0002 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

Records / Submission Packages - View All AK - Submission Package - AK2023MS0002O - (AK-23-0002) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter .... Transaction Logs News Related Actions DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group 601 East 12th Street; Suite 0300 CMS I Kansas City , MO 64106 Cfr-.'TEIIS FOR MEDICARE &MEDICAID SE.IMCES 1 Center for Medicaid & CHIP Services June 27, 2023 Heidi Hedberg Commissioner Department of Health 3601 C Street Suite 902 Anchorage, AK 99503 Re: Approval of State Plan Amendment AK-23-0002 Dear Heidi Hedberg, On March 31, 2023, the Centers for Medicare & Medicaid Services (CMS) received Alaska State Plan Amendment (SPA) AK-23-0002, in which the state proposed to adopt the changes to the eligibility rules for the Former Foster Care Children eligibility group, as enacted by the Substance Use-Disorder Prevention that promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORD Act, Pub. L. No. 115-217, section 1002. We approve Alaska State Plan Amendment (SPA) AK-23-0002 with an effective date of January 01, 2023. If you have any questions regarding this amendment, please contact MARIA GARZA at (206) 615-2542 or via email at maria.garza@cms.hhs.gov. Sincerely, James G. Scott Director, Division of Program Operations Center for Medicaid & CHIP Services _J

Records I Submission Packages - View All AK - Submission Package - AK2023MS0002O - (AK-23-0002) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions CMS-10434 0MB 0938-1188 Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I AK2023MS0002O I AK-23-0002 Package Header Package ID AK2023MS0002O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID NIA State Information State/Territory Name: Alaska Submission Component 0 State Plan Amendment SPA ID AK-23-0002 Initial Submission Date 3/31/2023 Effective Date N/ A Medicaid Agency Name: Department of Health 0 Medicaid Q CHIP

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I AK2023MS0002O I AK-23-0002 Package Header Package ID AK2023MS0002O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID N/A SPA ID and Effective Date SPA ID AK-23-0002 Reviewable Unit Mandatory Eligibility Groups Former Foster Care Children Proposed Effective Date 1/1/2023 1/1/2023 Page Number of the Superseded Plan Section or Attachment (If Applicable): 533 SPA ID AK-23-0002 Initial Submission Date 3/31/2023 Effective Date N/ A Superseded SPA ID AK-19-0002 AK-13-0027-MM1

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I AK2023MS0002O I AK-23-0002 Package Header Package ID AK2023MS0002O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID N/A Executive Summary SPA ID AK-23-0002 Initial Submission Date 3/31/2023 Effective Date N/ A Summary Description Including Alaska will cover individuals who aged out of state or Tribal foster care any state effective January 1, 2023. Goals and Objectives Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact First Second Federal Fiscal Year 2023 2024 Federal Statute / Regulation Citation Section 1002(a) of the SUPPORT Act Amount $0 $0 Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I AK2023MS0002O I AK-23-0002 Package Header Package ID AK2023MS0002O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID N/A Governor's Office Review 0 Nocomment 0 Comments received 0 No response within 45 days Q other SPA ID AK-23-0002 Initial Submission Date 3/31/2023 Effective Date N/ A

PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children's Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state's program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children's Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 6128/2023 12: 16 PM EDT

Records / Submission Packages - View All AK - Submission Package - AK2023MS0002O - (AK-23-0002) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions CMS-10434 0MB 0938-1188 Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID I Medicaid State Plan I Eligibility I AK2023MS0002O I AK-23-0002 Package Header Package ID AK2023MS0002O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID AK-19-0002 User-Entered Mandatory Coverage SPA ID AK-23-0002 Initial Submission Date 3/31/2023 Effective Date 1/1/2023 A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package Included in Another 0 Submission Package Infants and Children [!] C □ 0 under Age 19 Parents and Other [!] C □ 0 Caretaker Relatives Pregnant Women [!] C □ 0 Deemed Newborns [!] C □ 0 Children with Title IV-E Adoption Assistance, [!] □ 0 Foster Care or Guardianship Care Former Foster Care [!] C C 0 Children Transitional Medical [!] C □ 0 Assistance Extended Medicaid due [!] to Spousal Support □ 0 Collections Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package Included in Another 0 Submission Package SSI Beneficiaries [!] C □ 0 Closed Eligibility [!] C □ 0 Groups Individuals Deemed To [!] C □ 0 Be Receiving SSI ... Source Type 0 CONVERTED CONVERTED CONVERTED NEW NEW APPROVED NEW NEW Source Type 0 NEW NEW NEW

Eligibility Group Name Covered In State Plan Include RU In Package Included in Another Source Type 9 9 Submission Package Working Individuals [!] C: □ 0 NEW under 1619(b) Qualified Medicare [!] C: □ 0 NEW Beneficiaries Qualified Disabled and [!] C: □ 0 NEW Working Individuals Specified Low Income [!] C: □ 0 NEW Medicare Beneficiaries Qualifying Individuals [!] C: □ 0 NEW

Mandatory Eligibility Groups MEDICAID I Medicaid State Plan I Eligibility I AK2023MS0002O I AK-23-0002 Package Header Package ID AK2023MS0002O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID AK-19-0002 User-Entered B. The state elects the Adult Group. described at42 CFR 435.119. 0 Yes Q No Families and Adults Eligibility Group Name Covered In State Plan Adult Group C: c. Additional Information (optional) Eligibility Groups Deselected from Coverage SPA ID AK-23-0002 Initial Submission Date 3/31/2023 Effective Date 1/1/2023 Include RU In Package 0 □ Included in Another Submission Package 0 Source Type 0 NEW The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: • N/A

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Former Foster Care Children MEDICAID I Medicaid State Plan I Eligibility I AK2023MS0002O I AK-23-0002 Individuals under the age of 26, who were in foster care and on Medicaid when they turned age 18 or aged out of foster care. Package Header Package ID AK2023MS0002O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID AK-13-0027-MM1 User-Entered SPA ID AK-23-0002 Initial Submission Date 3/31/2023 Effective Date 1/1/2023 The state covers the mandatory former foster care children group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are under age 26 2. Were in foster care upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21 ). 3. Are described under either Section B. or C. B. Individuals Covered For individuals who turn 18 before January 1, 2023: 1. The state covers individuals who: a. Upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21) were: i. In foster care under the responsibility of the state or a Tribe within the state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program); and ii. Enrolled in Medicaid under the state's Medicaid state plan or 111 S demonstration; and b. Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. 2. In addition to 8.1., the state elects to cover individuals who were in foster care under the responsibility of the state or a Tribe within the state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program) when they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act, and meet the following criteria: D a. They were enrolled in Medicaid under the state's Medicaid state plan or 1115 demonstration at any time during the foster care period in which they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. D b. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state's Medicaid state plan or 1115 demonstration project when they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. D c. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state's Medicaid state plan or 1115 demonstration project at any time during the foster care period in which they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. C. Individuals Covered For individuals who turn 18 on or after January 1, 2023: 1. The state covers individuals who: a. Upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21) were: i. In foster care under the responsibility of any state or a Tribe within any state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program); and ii. Enrolled in Medicaid under a state's Medicaid state plan or 1115 demonstration; and b. Are not enrolled in mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. 2. In addition to C.1., the state elects to cover individuals who were in foster care under the responsibility of any state or a Tribe within any state (including children who were cared for through a grant to a state under the unaccompanied refugee minor program) when they turned 18 or a higher age at which that state's or Tribe's foster care assistance ends under title IV-E of the Act, and meet the following criteria: D a. They were enrolled in Medicaid under a state's Medicaid state plan or 1115 demonstration at any time during the foster care period in which they turned 18 or a higher age at which a state's or Tribe's foster care assistance ends. D b. They were placed by a state or Tribe in another state and were enrolled in Medicaid under the other state's Medicaid state plan or 1115 demonstration project when they turned 18 or a higher age at which a state's or Tribe's foster care assistance ends. D c. They were placed by a state or Tribe in another state and were enrolled in Medicaid under the other state's Medicaid state plan or 1115 demonstration project at any time during the foster care period in which they turned 18 or a higher age at which a state's or Tribe's foster care assistance ends.

Former Foster Care Children MEDICAID I Medicaid State Plan I Eligibility I AK2023MS0002O I AK-23-0002 Package Header Package ID AK2023MS0002O Submission Type Official Approval Date 06/27/2023 Superseded SPA ID AK-13-0027-MM1 User-Entered D. Additional Information (optional) SPA ID AK-23-0002 Initial Submission Date 3/31/2023 Effective Date 1/1/2023

PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children's Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state's program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children's Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 6/28/2023 12: 19 PM EDT

Table of Contents State/Territory Name: Alaska State Plan Amendment (SPA) #: 23-0011 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

Records / Submission Packages - View All AK - Submission Package - AK2023MS0004O - (AK-23-0011) - Eligibility Summary Reviewable Units Versions Analyst Notes Approval Letter Transaction Logs News Related Actions DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group 601 E. 12th St., Room 355 Kansas City , MI 64106 Center for Medicaid & CHIP Services January 05, 2024 Heidi Hedberg Commissioner Department of Health 3601 C Street Suite 902 Anchorage, AK 99503 Re: Approval of State Plan Amendment AK-23-0011 Dear Heidi Hedberg, On December 01, 2023, the Centers for Medicare and Medicaid Services (CMS) received Alaska State Plan Amendment (SPA) AK-23-0011, in which the state proposed to memorialize the new income standards for its optional state supplement program, the beneficiaries of which are eligible for Medicaid under Alaska's state plan, and make related changes to other eligibility groups covered under its state plan. We approve Alaska State Plan Amendment (SPA) AK-23-0011 with an effective date(s) of January 01, 2024. If you have any questions regarding this amendment, please contact MARIA GARZA at maria.garza@cms.hhs.gov. Sincerely, James G. Scott Director Center for Medicaid & CHIP Services

Records / Submission Packages - View All AK - Submission Package - AK2023MS0004O - (AK-23-0011) - Eligibility Summary Reviewable Units Versions Analyst Notes Approval Letter Transaction Logs News Related Actions CMS-10434 OMB 0938-1188 Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | AK2023MS0004O | AK-23-0011 Package Header Package ID AK2023MS0004O Submission Type Official Approval Date 01/05/2024 Superseded SPA ID N/A SPA ID AK-23-0011 Initial Submission Date 12/1/2023 Effective Date N/A State Information State/Territory Name: Alaska Medicaid Agency Name: Department of Health Submission Component State Plan Amendment Medicaid CHIP 0 0 0

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | AK2023MS0004O | AK-23-0011 Package Header Package ID AK2023MS0004O Submission Type Official Approval Date 01/05/2024 Superseded SPA ID N/A SPA ID AK-23-0011 Initial Submission Date 12/1/2023 Effective Date N/A SPA ID and Effective Date SPA ID AK-23-0011 Reviewable Unit Proposed Effective Date Superseded SPA ID Optional Eligibility Groups 1/1/2024 AK-22-0013 Individuals Eligible for but Not Receiving Cash Assistance 1/1/2024 AK-22-0013 Optional State Supplement Beneficiaries 1/1/2024 AK-22-0013

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | AK2023MS0004O | AK-23-0011 Package Header Package ID AK2023MS0004O Submission Type Official Approval Date 01/05/2024 Superseded SPA ID N/A SPA ID AK-23-0011 Initial Submission Date 12/1/2023 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives The SPA updates the income standards for recipients of Alaska's optional state supplemental payments. In Alaska, individuals are able to qualify for Medicaid by reducing their countable gross income through the use of approved Medicaid Qualifying Trusts. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2024 $0 Second 2025 $0 Federal Statute / Regulation Citation 42 CFR 435.234 and 42 CFR 435.210 Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | AK2023MS0004O | AK-23-0011 Package Header Package ID AK2023MS0004O Submission Type Official Approval Date 01/05/2024 Superseded SPA ID N/A SPA ID AK-23-0011 Initial Submission Date 12/1/2023 Effective Date N/A Governor's Office Review No comment Comments received No response within 45 days Other 0 0 0 0

PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 1/5/2024 5:23 PM EST

Records / Submission Packages - View All AK - Submission Package - AK2023MS0004O - (AK-23-0011) - Eligibility Summary Reviewable Units Versions Analyst Notes Approval Letter Transaction Logs News Related Actions CMS-10434 OMB 0938-1188 Medicaid State Plan Eligibility Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | AK2023MS0004O | AK-23-0011 Package Header Package ID AK2023MS0004O Submission Type Official Approval Date 01/05/2024 Superseded SPA ID AK-22-0013 System-Derived SPA ID AK-23-0011 Initial Submission Date 12/1/2023 Effective Date 1/1/2024 A. Options for Coverage The state provides Medicaid to specified optional groups of individuals. The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper- based state plan to MACPro): Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Optional Coverage of Parents and Other Caretaker Relatives NEW Reasonable Classifications of Individuals under Age 21 CONVERTED Children with Non-IV-E Adoption Assistance CONVERTED Independent Foster Care Adolescents NEW Optional Targeted Low Income Children CONVERTED Individuals above 133% FPL under Age 65 NEW Individuals Needing Treatment for Breast or Cervical Cancer NEW Individuals Eligible for Family Planning Services NEW Individuals with Tuberculosis NEW Individuals Electing COBRA Continuation Coverage NEW Yes No

0 0 [!] □ □ 0 [!] □ 0 [!] C □ 0 [!] □ □ 0 [!] C □ 0 [!] □ □ • [!] □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0

Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Individuals Eligible for but Not Receiving Cash Assistance APPROVED Individuals Eligible for Cash Except for Institutionalization NEW Individuals Receiving Home and Community- Based Waiver Services under Institutional Rules NEW Optional State Supplement Beneficiaries APPROVED Individuals in Institutions Eligible under a Special Income Level NEW PACE Participants NEW Individuals Receiving Hospice NEW Children under Age 19 with a Disability NEW Age and Disability- Related Poverty Level NEW Work Incentives NEW Ticket to Work Basic NEW Ticket to Work Medical Improvements NEW Family Opportunity Act Children with a Disability NEW Individuals Receiving State Plan Home and Community-Based Services NEW Individuals Receiving State Plan Home and Community-Based Services Who Are Otherwise Eligible for HCBS Waivers NEW

[!] [!] [!] □ [!] □ [!] C [!] □ [!] C [!] □ [!] □ [!] □ [!] □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | AK2023MS0004O | AK-23-0011 Package Header Package ID AK2023MS0004O Submission Type Official Approval Date 01/05/2024 Superseded SPA ID AK-22-0013 System-Derived SPA ID AK-23-0011 Initial Submission Date 12/1/2023 Effective Date 1/1/2024 B. Medically Needy Options for Coverage The state provides Medicaid to specified groups of individuals who are medically needy. Yes No 0 0

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | AK2023MS0004O | AK-23-0011 Package Header Package ID AK2023MS0004O Submission Type Official Approval Date 01/05/2024 Superseded SPA ID AK-22-0013 System-Derived SPA ID AK-23-0011 Initial Submission Date 12/1/2023 Effective Date 1/1/2024 C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Individuals Eligible for but Not Receiving Cash Assistance MEDICAID | Medicaid State Plan | Eligibility | AK2023MS0004O | AK-23-0011 Individuals who are eligible for but not receiving federal cash assistance or an optional state supplement. Package Header Package ID AK2023MS0004O Submission Type Official Approval Date 01/05/2024 Superseded SPA ID AK-22-0013 System-Derived SPA ID AK-23-0011 Initial Submission Date 12/1/2023 Effective Date 1/1/2024 The state covers the optional Individuals Eligible for but Not Receiving Cash Assistance eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Meet the eligibility requirements of at least one of the following cash assistance programs: 2. Do not receive cash assistance under these programs. a. SSI b. Optional State Supplement c. AFDC □ C □

Individuals Eligible for but Not Receiving Cash Assistance MEDICAID | Medicaid State Plan | Eligibility | AK2023MS0004O | AK-23-0011 Package Header Package ID AK2023MS0004O Submission Type Official Approval Date 01/05/2024 Superseded SPA ID AK-22-0013 System-Derived SPA ID AK-23-0011 Initial Submission Date 12/1/2023 Effective Date 1/1/2024 B. Individuals Covered 1. The state covers all individuals who meet the characteristics described in section A. Yes No 0 0

Individuals Eligible for but Not Receiving Cash Assistance MEDICAID | Medicaid State Plan | Eligibility | AK2023MS0004O | AK-23-0011 Package Header Package ID AK2023MS0004O Submission Type Official Approval Date 01/05/2024 Superseded SPA ID AK-22-0013 System-Derived SPA ID AK-23-0011 Initial Submission Date 12/1/2023 Effective Date 1/1/2024 C. Financial Methodologies 1. In calculating household income and resources for individuals who are seeking eligibility on the basis of being age 65 or older or having blindness or disability, SSI methodologies are used. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 3. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Name of disregard: Description: 2024 Income Disregard In 2024, for individuals, countable income between $1,305 and $1,751 is disregarded, and, for couples, countable income between $1,943 and $2,593 is disregarded. Name of income type: Description: (1) Alaska Permanent Fund Dividend; (2) Alaska Native Claims Settlement Act; (3) AmeriCorps (1) AK annual Permanent Fund Dividend benefit payments are excluded from consideration as income for all mandatory and optional Medicaid eligibility categories; (2) Cash distributions from Alaska Native Claims Settlement Act corporations are excluded from income to the extent that the distributions do not exceed $2,000 per individual per calendar year. When an individual receives more than $2,000 from all ANCSA corporations in a single calendar year, any amounts exceeding $2,000 are considered countable income in the month of receipt. (3) All AmeriCorps payments, including living stipends, are disregarded as income for the purposes of determining eligibility. Name of disregard: Description: AK Permanent Fund Dividend Changes in income related to the receipt of the Alaska Permanent Fund Dividend are disregarded. Yes No General income disregard: A specified type of income is disregarded: Specific income changes are disregarded between redeterminations. Specified income changes are disregarded: C:

Name of disregard: Description: Alaska Native Claims Settlement Act Cash distributions from Alaska Native Claims Settlement Act corporations up to $2,000 per individual per calendar year are excluded as a cash resource each year, are excluded indefinitely, and do not affect the exclusion of cash distributions made in subsequent years. 4. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Name of resource type: Description: Alaska Native Claims Settlement Act Cash distributions from Alaska Native Claims Settlement Act corporations up to $2,000 per individual per calendar year are excluded as a cash resource each year, are excluded indefinitely, and do not affect the exclusion of cash distributions made in subsequent years. Permanent Fund Dividend Program Dividend and benefit payments received from the Alaska Permanent Fund Dividend Program are excluded from consideration as countable resources. Yes No A specified type of resource is disregarded: 0 0 C:

Individuals Eligible for but Not Receiving Cash Assistance MEDICAID | Medicaid State Plan | Eligibility | AK2023MS0004O | AK-23-0011 Package Header Package ID AK2023MS0004O Submission Type Official Approval Date 01/05/2024 Superseded SPA ID AK-22-0013 System-Derived SPA ID AK-23-0011 Initial Submission Date 12/1/2023 Effective Date 1/1/2024 D. Income Standard Used The income standard used is the standard of the most closely related cash assistance program. E. Resource Standard Used The resource standard used is the standard of the most closely related cash assistance program.

Individuals Eligible for but Not Receiving Cash Assistance MEDICAID | Medicaid State Plan | Eligibility | AK2023MS0004O | AK-23-0011 Package Header Package ID AK2023MS0004O Submission Type Official Approval Date 01/05/2024 Superseded SPA ID AK-22-0013 System-Derived SPA ID AK-23-0011 Initial Submission Date 12/1/2023 Effective Date 1/1/2024 F. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Optional State Supplement Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | AK2023MS0004O | AK-23-0011 Individuals who receive an optional state supplementary payment. Package Header Package ID AK2023MS0004O Submission Type Official Approval Date 01/05/2024 Superseded SPA ID AK-22-0013 System-Derived SPA ID AK-23-0011 Initial Submission Date 12/1/2023 Effective Date 1/1/2024 The state covers the Optional State Supplement Beneficiaries eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Receive an optional state supplement that meets the conditions described in sections C and D. 2. Except for income, would be eligible for SSI. 3. Do not have gross income exceeding 300% of the SSI Federal Benefit Rate (FBR).

Optional State Supplement Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | AK2023MS0004O | AK-23-0011 Package Header Package ID AK2023MS0004O Submission Type Official Approval Date 01/05/2024 Superseded SPA ID AK-22-0013 System-Derived SPA ID AK-23-0011 Initial Submission Date 12/1/2023 Effective Date 1/1/2024 B. Individuals Covered 1. The state covers all individuals who meet the characteristics described in section A. Yes No 0 0

Optional State Supplement Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | AK2023MS0004O | AK-23-0011 Package Header Package ID AK2023MS0004O Submission Type Official Approval Date 01/05/2024 Superseded SPA ID AK-22-0013 System-Derived SPA ID AK-23-0011 Initial Submission Date 12/1/2023 Effective Date 1/1/2024 C. Optional State Supplement Program 1. The optional state supplement program is administered: 2. Payments under the optional state supplement program are: a. Based on need and paid in cash on a regular basis; b. Equal to the difference between the individual's countable income and the income standard used to determine eligibility for supplement; and c. Available to all individuals in each population selected in section B. a. Solely by the federal government. The state has an agreement with the Social Security Administration under section 1616 of the Act regarding the administration of optional state supplementary payments. b. By a combination of federal and state administration. The state has an agreement with the Social Security Administration under section 1616 of the Act regarding the administration of optional state supplementary payments for some classifications of individuals, while state supplementary payments for other classifications of individuals are administered by the state. c. Solely by the state. 0 0 0

Optional State Supplement Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | AK2023MS0004O | AK-23-0011 Package Header Package ID AK2023MS0004O Submission Type Official Approval Date 01/05/2024 Superseded SPA ID AK-22-0013 System-Derived SPA ID AK-23-0011 Initial Submission Date 12/1/2023 Effective Date 1/1/2024 D. Income Standard of Optional State Supplement Program 1. The income standard for the optional state supplement: a. Varies by political subdivision. b. Varies by payment classification. The payment classifications used are: Income Standard Indi vidu al $13 05.0 0 Cou ple $19 43.0 0 Income Standard Indi vidu al $99 7.00 Cou ple $14 86.0 0 Name of Classification Institutionalized Description: Institutionalized Individual $200.00 Couple $400.00 Name of Classification Assisted Living Home Description: Assisted Living Home Individual Couple Yes No Yes No i. All individuals age 65 or older, regardless of living arrangement. ii. All individuals who have blindness, regardless of living arrangement. iii. All individuals who have a disability, regardless of living arrangement. iv. Independent living. v. Living in household of another. vi. Independent living and receiving non-medical care outside the home. vii. Living in household of another and receiving non-medical care outside the home. viii. Living in a domiciliary facility or other group living arrangement. ix. Other payment classification. 0 0 0 0 □ □ □ C □ □ □ C

Optional State Supplement Beneficiaries MEDICAID | Medicaid State Plan | Eligibility | AK2023MS0004O | AK-23-0011 Package Header Package ID AK2023MS0004O Submission Type Official Approval Date 01/05/2024 Superseded SPA ID AK-22-0013 System-Derived SPA ID AK-23-0011 Initial Submission Date 12/1/2023 Effective Date 1/1/2024 E. Additional Information (optional)

PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 1/5/2024 5:25 PM EST

Table of Contents State/Territory Name: Alaska State Plan Amendment (SPA) #: 24-0001 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

Records / Submission Packages - View All AK - Submission Package - AK2023MS000SO - (AK-24-0001) - Eligibility Summary Reviewable Units Versions DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group 601 East 12th Street; Suite 355 Kansas , MO 64106 Correspondence Log I Center for Medicaid & CHIP Services February 23, 2024 Heidi Hedberg Commissioner Department of Health 3601 C Street Suite 902 Anchorage, AK 99503 Re: Approval of State Plan Amendment AK-24-0001 Dear Heidi Hedberg, Analyst Notes Approval Letter .., Transaction Logs News Related Actions Ms l CfN EIS FOR MEDICARE & MEDICAlO SEA\'1C£S On January 04, 2024, the Centers for Medicare and Medicaid Services (CMS) received Alaska State Plan Amendment (SPA) AK-24-0001, in which the state proposed to: 1) elect the option described in section 1902(e)(16) of the Social Security Act to provide 12 months of postpartum coverage to Medicaid-eligible pregnant individuals; and 2) increase income eligibility for pregnant individuals to 225 percent of the federal poverty level. We approve Alaska State Plan Amendment (SPA) AK-24-0001 with an effective date(s) of February 01, 2024. If you have any questions regarding this amendment, please contact MARIA GARZA at maria.garza@cms.hhs.gov Sincerely, James G. Scott Director Center for Medicaid & CHIP Services

Records / Submission Packages - View All AK - Submission Package - AK2023MS000SO - (AK-24-0001) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions CMS-10434 0MB 0938-1188 Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I AK2023MS0005O I AK-24-0001 Package Header Package ID AK2023MS000SO Submission Type Official Approval Date 02/23/2024 Superseded SPA ID N/A State Information State/Territory Name: Alaska Submission Component O State Plan Amendment SPA ID AK-24-0001 Initial Submission Date 1/4/2024 Effective Date N/A Medicaid Agency Name: Department of Health 0 Medicaid Q CHIP ....

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I AK2023MS0005O I AK-24-0001 Package Header Package ID AK2023MS000SO Submission Type Official Approval Date 02/23/2024 Superseded SPA ID N/A SPA ID and Effective Date SPA ID AK-24-0001 Reviewable Unit Optional Eligibility Groups Individuals above 133% FPL under Age 65 Continuous Eligibility for Pregnant Women and Extended Postpartum Coverage Proposed Effective Date 2/1/2024 2/1/2024 2/1/2024 Page Number of the Superseded Plan Section or Attachment (If Applicable): SPA ID AK-24-0001 Initial Submission Date 1/4/2024 Effective Date N/A Superseded SPA ID AK-23-0011 AK-13-0027-MM1 new

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I AK2023MS0005O I AK-24-0001 Package Header Package ID AK2023MS0005O Submission Type Official Approval Date 02/23/2024 Superseded SPA ID N/A Executive Summary SPA ID AK-24-0001 Initial Submission Date 1/4/2024 Effective Date N/A Summary Description Including 1. Extension of postpartum coverage for pregnant women from sixty (60) days to 12 months. Goals and Objectives 2. Add new optional Pregnant Women eligibility category for eligible individuals with income between 201 % - 225% of the Federal Poverty Level (FPL) Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year First 2024 Second 2025 Federal Statute I Regulation Citation 1. Section 1902(e)(16) of the Social Security Act 2. Section 1902(a)(10)(A)(ii)(XX) of the Social Security Act; 42 CFR435.218 Amount $6825051 $10237577 Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I AK2023MS0005O I AK-24-0001 Package Header Package ID AK2023MS000SO Submission Type Official Approval Date 02/23/2024 Superseded SPA ID N/A Governor's Office Review 0 Nocomment 0 Comments received 0 No response within 45 days Q Other SPA ID AK-24-0001 Initial Submission Date 1/4/2024 Effective Date N/A

PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.5.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children's Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state's program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children's Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 2/23/2024 8:38 AM EST

Records / Submission Packages - View All AK - Submission Package - AK2023MS000SO - (AK-24-0001) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions CMS-10434 0MB 0938-1188 Medicaid State Plan Eligibility Optional Eligibility Groups MEDICAID I Medicaid State Plan I Eligibility I AK2023MS0005O I AK-24-0001 Package Header Package ID AK2023MS000SO Submission Type Official Approval Date 02/23/2024 Superseded SPA ID AK-23-0011 User-Entered A. Options for Coverage The state provides Medicaid to specified optional groups of individuals. 0 Yes Q No SPA ID AK-24-0001 Initial Submission Date 1/4/2024 Effective Date 2/1/2024 .... The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper- based state plan to MACPro): Families and Adults Eligibility Group Name Optional Coverage of Parents and Other Caretaker Relatives Reasonable Classifications of Individuals under Age 21 Children with Non-lV-E Adoption Assistance Independent Foster Care Adolescents Optional Targeted Low Income Children Individuals above 133% FPL under Age 65 Individuals Needing Treatment for Breast or Cervical Cancer Individuals Eligible for Family Planning Services Individuals with Tuberculosis Individuals Electing COBRA Continuation Coverage Covered In State Plan [!] □ [!] [!] C [!] □ [!] C [!] C [!] C [!] □ [!] □ [!] □ Include RU In Package G □ □ □ □ □ C □ □ □ □ Included in Another Submission Package 0 0 0 0 0 0 0 0 0 0 Source Type G NEW CONVERTED CONVERTED NEW CONVERTED APPROVED NEW NEW NEW NEW

Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package Included in Another Source Type G G Submission Package Individuals Eligible for [!] 0 but Not Receiving Cash C: □ APPROVED Assistance Individuals Eligible for [!] 0 Cash Except for □ NEW Institutionalization Individuals Receiving Home and Community- [!] 0 Based Waiver Services C: □ NEW under Institutional Rules Optional State [!] 0 Supplement C: □ APPROVED Beneficiaries Individuals in Institutions Eligible [!] □ 0 NEW under a Special Income Level PACE Participants [!] □ □ 0 NEW Individuals Receiving [!] □ □ 0 NEW Hospice Children under Age 19 [!] C: □ 0 NEW with a Disability Age and Disability- [!] □ □ 0 NEW Related Poverty Level Work Incentives [!] C: □ 0 NEW Ticket to Work Basic [!] □ □ 0 NEW Ticket to Work Medical [!] □ □ 0 NEW Improvements Family Opportunity Act [!] 0 Children with a □ □ NEW Disability Individuals Receiving State Plan Home and [!] □ □ 0 NEW Community-Based Services Individuals Receiving State Plan Home and Community-Based [!] □ □ 0 NEW Services Who Are Otherwise Eligible for HCBS Waivers

Optional Eligibility Groups MEDICAID I Medicaid State Plan I Eligibility I AK2023MS0005O I AK-24-0001 Package Header Package ID AK2023MS000SO Submission Type Official Approval Date 02/23/2024 Superseded SPA ID AK-23-0011 User-Entered B. Medically Needy Options for Coverage The state provides Medicaid to specified groups of individuals who are medically needy. 0 Yes 0 No SPA ID AK-24-0001 Initial Submission Date 1/4/2024 Effective Date 2/1/2024

Optional Eligibility Groups MEDICAID I Medicaid State Plan I Eligibility I AK2023MS0005O I AK-24-0001 Package Header Package ID AK2023MS000SO Submission Type Official Approval Date 02/23/2024 Superseded SPA ID AK-23-0011 User-Entered C. Additional Information (optional) Eligibility Groups Deselected from Coverage SPA ID AK-24-0001 Initial Submission Date 1/4/2024 Effective Date 2/1/2024 The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: • N/A

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Individuals above 133% FPL under Age 65 MEDICAID I Medicaid State Plan I Eligibility I AK2023MS0005D I AK-24-0001 Individuals under 65, not otherwise mandatorily or optionally eligible, with income above 133% FPL and at or below a standard established by the state. Package Header Package ID AK2023M500050 Submission Type Official Approval Date 02/23/2024 Superseded SPA ID AK-13-0027-MM1 User-Entered SPA ID AK-24-0001 Initial Submission Date 1/4/2024 Effective Date 2/1/2024 The state covers the optional individuals above 133% FPL group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are under age 65 2. Are not otherwise eligible for and enrolled in mandatory coverage under the state plan 3. Are not otherwise eligible for and enrolled in optional full Medicaid coverage under the state plan 4. Have household income that exceeds 133% FPL but is at or below the standard set by the state B. Financial Methodologies MAGI-based methodologies are used in calculating household income. Please refer as necessary to MAGI-Based Methodologies, completed by the state.

C. Individuals Covered 1. The state covers all individuals who meet the characteristics described in section A. Q Yes 0 No 2. The state covers the following populations: D a. All children under a specified age limit D b. Reasonable classifications of children D c. Parents and other caretaker relatives as defined in the Parents and Other Caretaker Relatives eligibility group, except for with respect to income C d. Pregnant women D e. Other

D. Income Standard Used 1. The state uses the same income standard for all individuals covered. Oves Q No 2. The income standard for this eligibility group is: 0 a. Percentage of the federal poverty level. 0 b. No income test (the income standard is infinite). 225.00% FPL

E. Coverage of Dependent Children Parents or caretaker relatives living with a child under the age specified below are not covered unless the child is receiving benefits under Medicaid, CHIP or through the Exchange or otherwise enrolled in minimum essential coverage, as defined in 42 CFR 435.4. 0 1. Under age 19, or 0 2. A higher age of children, if any covered under the Reasonable Classifications of Children eligibility group (42 CFR 435.222) on March 23, 201 0: 0 a. Under age 20 0 b. Under age 21

F. Phase-In The state elects to phase-in coverage to individuals in this group. Q Yes 0 No

G. Additional Information {optional)

Medicaid State Plan Eligibility Eligibility and Enrollment Processes Continuous Eligibility for Pregnant Women and Extended Postpartum Coverage MEDICAID I Medicaid State Plan I Eligibility I AK2023MS0005D I AK-24-0001 Package Header Package ID AK2023MS00050 Submission Type Official Approval Date 02/23/2024 Superseded SPA ID new User-Entered SPA ID AK-24-0001 Initial Submission Date 1/4/2024 Effective Date 2/1/2024 The state provides continuous eligibility for pregnant individuals and extended postpartum coverage in accordance with the following provisions: A. Mandatory Continuous Eligibility for Pregnant Women The state provides continuous eligibility to pregnant individuals who were eligible and enrolled under the state plan, without regard to any changes in income that otherwise would result in ineligibility, through the last day of the month in which a 60-day postpartum period (beginning on the last day of the pregnancy) ends. This extension does not apply to pregnant individuals eligible only during a period of presumptive eligibility. B. Optional 12-Month Postpartum Continuous Eligibility for Pregnant Women The state provides continuous eligibility to pregnant individuals who were eligible and enrolled under the state plan while pregnant (including during a period of retroactive eligibility) through the last day of the month in which a 12-month postpartum period (beginning on the last day of the pregnancy) ends. The 12-month postpartum continuous eligibility option applies for the period beginning on the effective date of this reviewable unit and is available through March 31, 2027 (or other date as specified by law). 0 Yes Q No 1. This extension does not apply to pregnant individuals eligible only during a period of presumptive eligibility. 2. Full benefits are provided for a pregnant or postpartum individual under this option. This includes all items and services covered under the state plan (or waiver) that are not less in amount, duration, or scope than, or are determined by the Secretary to be substantially equivalent to, the medical assistance available for an individual described in subsection 1902 (a)(1 O)(A)(i) of the Act. 3. Continuous eligibility is provided to pregnant individuals eligible and enrolled under the state plan through the end of the 12-month postpartum period who would otherwise lose eligibility because of a change in circumstances, unless: a. The individual requests voluntary termination of eligibility; b. The individual ceases to be a resident of the state; c. The Medicaid agency determines that eligibility was determined incorrectly at the most recent determination or redetermination of eligibility because of agency error or fraud, abuse or perjury attributed to the individual; or d. The individual dies. C. Additional Information (optional) Section 5113 of the Consolidated Appropriations Act, 2023, eliminated, without replacement, the March 31, 2027, sunset date of the 12-month postpartum continuous eligibility option. Therefore, the durational limit of the option that is described in Section B. does not apply. PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children's Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state's program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children's Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid DMB control number. The valid DMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 2/23/2024 8:39 AM EST

 



  



  

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 July16, 2024 Heidi Hedberg Commissioner Department of Health 2601 C Street, Suite 902 Anchorage, AK 99503-5923 Re: Alaska State Plan Amendment (SPA) 24-0006 Dear Commissioner Hedberg: The Centers for Medicare & Medicaid Services (CMS) reviewed the proposed Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) 24-0006. This amendment proposes to temporarily suspend behavioral health services prior/service authorizations originally approved in Disaster Relief SPA 23-0007 with the following modification to extend the provision an additional 12 months through June 30, 2025. CMS conducted our review of your submittal according to statutory requirements in Title XIX of the Social Security Act and implementing regulations. This letter is to inform you that Alaska’s Medicaid SPA Transmittal Number 24-0006 is approved effective May 13, 2024. If you have any questions, please contact Maria Garza at 206-615-2542 or via email at maria.garza@cms.hhs.gov. Sincerely, Courtney / Miller On Behalf of Anne Marie Costello, Deputy Director Center for Medicaid and CHIP Services Enclosures CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICE§

DEPARTMENT OF HEAL TH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEAL TH AND HUMAN SERVICES 1. TRANSMITTAL NUMBER L f<24 (~ _Q_ _Q_ _Q_ ~ 2. STATE AK 3. PROGRAM IDENTIFICATION: TITLE OF THE SOCIAL SECURITY ACT (e_) XIX O XXI 4. PROPOSED EFFECTIVE DATE May 13, 2024 FORM APPROVED 0MB No. 0938--0193 5. FEDERAL STATUTE/REGULATION CITATION 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) a FFY 24 $_0=------- seetiol I I 19, elf ti ,e SSA Section XIX of the SSA (P&I) 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT Section 7.4-C, page 1 9. SUBJECT OF AMENDMENT b. FFY 25 $ 0 8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) AK 23-0007, Section 7.4-C, page 1 This SPA seeks to suspend behavioral health services prior/service authorizations from May 13, 2024 to June 30, 2025. This flexbility was first approved under the 1135 waiver authority during the PHE. 10. GOVERNOR'S REVIEW (Check One) 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED W ITHIN 45 DAYS OF SUBMITTAL AGENCY OFFICIAL ® OTHER, AS SPECIFIED: 15. RETURN TO Dept of Health Commissioner's Office 12. TYPED NAME -------------c/o Emily Beaulieu Emily Ricci 3601 C Street, Suite 902 ---------------------Anchorage, AK 99503 13. TITLE Deputy Commissioner & Medicaid Director 14. DATE SUBMITTED 6/24/2024 16. DATE RECEIVED June 24, 2024 FOR CMS USE ONLY 17. DATE APPROVED July 16, 2024 PLAN APPROVED· ONE COPY ATTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL May 13, 2024 20. TYPED NAME OF APPROVING OFFICIAL Courtney L. Miller 22. REMARKS 19. SIGNATURE OF APPROVING OFFICIAL 21. TITLE OF APPROVING OFFICIAL On Behalf of Anne Marie Costello, Deputy Director for the Center for Medicaid & CHIP Services 7/8/24 State authorizes P&I changes to Box1 adjusting the transmittal number and Box 5 updating the citation to Title XIX FORM CMS-179 (09/24) Instructions on Back

  State Plan for Title XIX State of Alaska Attachment 7.4-C Page 1 7.4.C-Temporary Extension to the Disaster Relief Policies for the COVID-19 National Emergency Effective the day after the end of the PHE until June 30, 2025, the Medicaid agency temporarily implements the following change to the state plan: Section D - Benefit 1. X Suspends Medicaid fee-for-service prior/service authorization requirements in the behavioral health Medicaid program. 2. X The agency assures that newly added benefits or adjustments to benefits comply with all applicable statutory requirements, including the statewideness requirements found at 1902{a)(l), comparability requirements found at 1902{a)(10)(B), and free choice of provider requirements found at 1902{a)(23). 3. X Application to Alternative Benefit Plans (ABP). The state adheres to all ABP provisions in 42 CFR Part 440, Subpart C. This section only applies to states that have an approved ABP(s). a. _X_ The agency assures that these newly added and/or adjusted benefits will be made available to individuals receiving services under ABPs. b. __ Individuals receiving services under ABPs will not receive these newly added and/or adjusted benefits, or will only receive the following subset: TN No. 24-0006 Approval Date: __ _ Effective Date: May 13, 2024 Supersedes TN No. 23-0007

Table of Contents State/Territory Name: Alaska State Plan Amendment (SPA) #: 26-0001 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages



  

 

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This amendment updates the language of categorical determinations under the Pre-Admission Screening and Resident Review (PASRR) program and removes outdated language.

Approval Document

This SPA updates the Wholesale Acquisition Cost (WAC) rate for out-of-state providers.

Approval Document

This SPA was submitted to create a frontis page and update the effective dates of several Medicaid services.

Approval Document

This amendment aligns the Alternative Benefit Plan (ABP5) with the Medicaid State Plan to expand on the Advisory Committee on Immunization Practices (ACIP) recommendation for the administration of vaccines to include other governing bodies or professional organizations in the administration of vaccines.

Approval Document

This Amendment covers select prescribed drugs that are not covered outpatient drugs when medically necessary during drug shortages.

Approval Document

This amendment extends the state's exception to the Recovery Audit Contractor requirements under section 1902(a)(42)(B) of the Act through June 30, 2028.

Approval Document

Alaska updated income standards for their optional state supplement program for individuals eligible but not receiving cash assistance and other optional eligibility groups in the state plan.

Approval Document

This Amendment Plan updates Alaska's online alternative single, streamlined application.

Approval Document

This amendment aligns the Alternative Benefit Plan (ABP) with the Medicaid State Plan by removing the September 30, 2025, sunset date for the Medication-Assisted Treatment (MAT) benefit making the MAT benefit permanent for expansion group.

Approval Document

This amendment removes the September 30, 2025, sunset date for the Medication Assisted Treatment (MAT) benefit making the MAT benefit permanent under the Medicaid State Plan in accordance with federal statue.

Approval Document

This amendment provides Alaska expansion population coverage of screening, diagnostic, and targeted case management services for eligible juveniles who are inmates of a public institution in accordance with Section 5121 of the Consolidated Appropriations Act of 2023.

Approval Document

This amendment provides coverage of screening, diagnostic, and targeted case management services for eligible juveniles who are inmates of a public institution in accordance with Section 5121 of the Consolidated Appropriations Act of 2023.

Approval Document

This amendment expands transportation services allowed under administrative case management for tribal health organizations.

Approval Document

This SPA removes prior authorization requirements for rehabilitative behavioral health services, as well as services provided by community behavioral health service (CBHS) clinics and mental health physician clinics.

Approval Document

This SPA updates the state’s professional dispensing fees, as well as to update the excluded drug listing.

Approval Document

This SPA complies with the mandatory exception to the Medicaid clinic services benefit "four walls" requirement for Indian Health Services (HIS) and Tribal clinics.

Approval Document

This Alternative Benefit Plan amendment aligns with Medicaid State Plan to exempt general acute hospitals, reimbursed under the diagnosed related group (DRG) payment methodology, from continued stay service authorizations.

Approval Document

This amendment exempts general acute care, reimbursed under the diagnosed related group (DRG) payment methodology, from continued stay service authorizations.

Approval Document

This SPA allows Alaska to enter into value/outcome-based contracts with pharmaceutical manufacturers on a voluntary basis.

Approval Document

This SPA is to memorialize the new income standards for its optional state supplement program, the beneficiaries of which are eligible for Medicaid under Alaska's state plan, and make related changes to other eligibility groups covered under its state plan.

Approval Document

This plan amendment provides an annual update to fee schedule dates, links and clarifies fee-schedule language to License Behavior Analysts.

Approval Document

This SPA is to update state plan assurances in accordance with the federally mandated quality reporting requirements for the Child Core Set and the behavioral health quality measures on the Adult Core Set.

Approval Document

CMS is approving this time-limited state plan amendment to allow the state to implement temporary policies while returning to normal operations after the COVID-19 national emergency. The purpose of this amendment is to extend SPA AK-23-0003 pharmacy dispensing fee rates after the end of the COVID-19 Public Health Emergency, through May 11, 2024.

Approval Document

This amendment is to update the state plan to waive the Recovery Audit Contractor (RAC) Program.

Approval Document

CMS is approving this time-limited state plan amendment to allow the state to implement temporary policies while returning to normal operations after the COVID-19 national emergency. The purpose of this amendment is to extend the waiver of premiums for the Buy-In program for Working Adults with Disabilities and the Buy-In program for Children with Disabilities.

Approval Document

This Alternative Benefit Plan (ABP) aligns the Advanced Practice Dental Hygienist approved under the Alaska State Plan as a Medicaid billing provider for the expansion population.

Approval Document

This amendment adds Advanced Practice Dental Hygienist to the Alaska State Plan under the other licensed practitioner benefit.

Approval Document

The purposed amendment will add the current process of implementing updated inpatient and outpatient hospital per diem rates published by the by Indian Health Services (IHS) in the Federal Register.

Approval Document

This SPA provides Alaska with approval to provide 12 months of continuous postpartum coverage to women enrolled in its Medicaid program and increases the income eligibility for pregnant women up to 225 percent of the FPL.

Approval Document

This Alternative Benefit Plan (ABP) amendment complies with Section 11405 of the Inflation Reduction Act (IRA) aligning the new mandatory coverage of Medicaid adult vaccinations and the administration of vaccines for the expansion population under ABP5 benefit, without cost-sharing.

Approval Document

This Medicaid State Plan amendment complies with Section 11405 of the Inflation Reduction Act (IRA) aligning the new mandatory coverage of Medicaid adult vaccinations and the administration of the vaccines without cost-sharing.

Approval Document

The addition of diagnosis-related groups and a new disproportionate share hospital (DSH) category; and

Removal of outdated language, grammar revisions, and updated organization structure.

Approval Document

This SPA is to memorialize the new income standards for its optional state supplement program, the beneficiaries of which are eligible for Medicaid under Alaska's state plan, and make related changes to other eligibility groups covered under its state plan.

Approval Document

This SPA updates the effective date and fee-schedules for Ambulatory Surgical Clinic Services, In-home Peritoneal Services, Physician Services, Licensed Behavior Analysts, Substance Use Rehabilitation Services, Personal Care Services, Personal Care Services for Community First Choice Option, Chore Services for Community First Choice Option, and Long Term Services and Supports (LTSS) Targeted Case Management.

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Adds Licensed Marriage and Family Therapists, as Medicaid practitioners eligible to receive reimbursement

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Brings the state into compliance with the 21st Century Cures Act regarding the limit on federal financial participation for durable medical equipment prosthetics orthotics and supplies in Medicaid.

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This SPA revises Alaska's Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) to clarify private-duty nursing, hospice, chiropractic, and podiatry services available to individuals under 21 years of age.

Approval Document

This SPA expands Medicaid reimbursement for certified community health aides, levels I-II, behavioral health aides, levels I-IV and practitioners.

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Approval Document

Approval Document

Approval Document

Approval Document

This SPA describes the methodology used by the state for determining the appropriate FMAP rates, including the increased FMAP rates, available under the provision of the Affordable Care Act applicable for the medical assistance expenditures under the Medicaid program associated with enrollees in the new adult group adopted by the state.

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Incorporates the Modified Adjusted Gross Income (MAGI)-Based Eligibility Requirements Including the Single Streamlined Application.

Approval Document

Approval Document

Approval Document

Transfers the state Medicaid fair hearings and appeals process to the Office of Administrative Hearings and defines the role and responsibility of the Commissioners Office in the administrative appeals process.

Approval Document

Provides Medicaid Coverage of comprehensive tobacco cessation services for pregnant women, for both counseling and pharmacotherapy without cost sharing.

Approval Document

Approval Document

Approval Document

Approval Document

Attachment

Form CMS-179

Approval Document

Attachment

Form CMS-179

Approval Document

Attachment

Form CMS-179

Approval Document

Attachment

Form CMS-179

Approval Document

Attachment

Form CMS-179

Approval Document

Approval Document

Approval Document

Attachment

Form CMS-179

Approval Document

Attachment

Form CMS-179

Approval Document

Attachment

Form CMS-179

Approval Document

Attachment

Form CMS-179

Approval Document

Companion Letter

Attachment

Form CMS-179

Approval Document

Approval Document

Approval Document

Approval Document

Approval Document

Attachment

Form CMS-179

Approval Document

Companion Letter

Attachment

Form CMS-179

Approval Document

Attachment

Form CMS-179

Approval Document

Attachment

Form CMS-179

Approval Document

Form CMS-179

Form CMS-179

Form CMS-179

Approval Document

Form CMS-179

Approval Document

Companion Letter

Attachment

Form CMS-179

Approval Document

Attachment

Form CMS-179

Approval Document

Approval Document

Approval Document

Attachment

Form CMS-179

Form CMS-179

Approval Document

Attachment

Form CMS-179

Approval Document

Form CMS-179

Approval Document

Attachment