Model Application Template for the State Children’s Health Insurance Program

Effective Date: October 1, 2009

1 Approval Date: November 19, 2010 OMB #: 0938-0707 Exp. Date:

MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

Preamble

Section 4901 of the Balanced Budget Act of 1997 (BBA) amended the Social Security Act (the Act) by adding a new title XXI, the State Children’s Health Insurance Program (SCHIP). Title XXI provides funds to states to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner. To be eligible for funds under this program, states must submit a state plan, which must be approved by the Secretary. A state may choose to amend its approved state plan in whole or in part at any time through the submittal of a plan amendment.

This model application template outlines the information that must be included in the state child health plan, and any subsequent amendments. It has been designed to reflect the requirements as they exist in current regulations, found at 42 CFR part 457. These requirements are necessary for state plans and amendments under Title XXI.

The Department of Health and Human Services will continue to work collaboratively with states and other interested parties to provide specific guidance in key areas like applicant and enrollee protections, collection of baseline data, and methods for preventing substitution of Federal funds for existing state and private funds. As such guidance becomes available, we will work to distribute it in a timely fashion to provide assistance as states submit their state plans and amendments.

Form CMS-R-211

Model Application Template for the State Children’s Health Insurance Program

Effective Date: October 1, 2009

2 Approval Date: November 19, 2010 MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory:__________Alabama__________________________________________ (Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b))

________________________________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed)

submits the following State Child Health Plan for the State Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved State Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name: Donald E. Williamson, M.D.

Position/Title: State Health Officer Name: Reuben E. Davidson

Position/Title: Public Health

Administrative Officer Name: Cathy Caldwell

Position/Title: CHIP Director

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 0938-0707. The time required to complete this information collection is estimated to average 160 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 any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, N2-14-26, Baltimore, Maryland 21244.

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

October 1, 2009 3 Approval Date: November 19, 2010 Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101)

1.1 The state will use funds provided under Title XXI primarily for (Check appropriate box) (42 CFR 457.70):

1.1.1 X* Obtaining coverage that meets the requirements for a separate child health program (Section 2103); OR

1.1.2. ∼ Providing expanded benefits under the State’s Medicaid plan (Title XIX); OR

1.1.3. ∼ A combination of both of the above.

* Until October 1, 2002, Alabama’s CHIP was a combination program. With the mandated gradual increase of Medicaid coverage at higher income levels for children born after September 30, 1983, the Medicaid expansion portion of CHIP was subsumed, on October 1, 2002, by the Alabama Medicaid SOBRA Program for Pregnant Women and Children.

1.2 X Please provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d)) Alabama has not and will not claim expenditures for child health assistance prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS.

1.3 X Please provide an assurance that the state complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130) Assurances are on file with DHHS. The Alabama Department of Public Health continues to assure that compliance with all applicable civil rights requirements.

1.4

Please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment (42 CFR 457.65):

Model Application Template for the State Children’s Health Insurance Program

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October 1, 2009 4 Approval Date: November 19, 2010 Effective date: Original State Plan – February 1, 1998 Amendment 1 – Establishment of ALL Kids: October 1, 1998 Amendment 2 – Establishment of ALL Kids PLUS: October 1, 1999 Amendment 3 – Disregards: June 1, 2001 Amendment 4 - Compliance: August 24, 2001 Amendment 5 – Waiting List, Cost Sharing, Benefit Changes: October 1, 2003 Amendment 6 – Discontinuance of the Waiting List and other Clean-Up changes

November 23, 2004 Amendment 7 – Raise the upper income eligibility limit to 300% of FPL and

other minor changes: October 1, 2009 Amendment 8 – Include a private foundation grant as an additional source of state funding: October 27, 2009 Amendment 9 – Establishment of a Prospective Payment System for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs): October 1, 2009; Addendum on Dental Benefits Under Title XXI: October 1, 1998

Implementation date: Original State Plan – February 1, 1998 Amendment 1 – Establishment of ALL Kids: October 1, 1998 Amendment 2 – Establishment of ALL Kids PLUS: October 1, 1999 Amendment 3 – Disregards: June 1, 2001 Amendment 4 - Compliance: August 24, 2001 Amendment 5 – Waiting List, Cost Sharing, Benefit Changes: October 1, 2003 Amendment 6 – Discontinuance of the Waiting List and other Clean-Up changes

November 23, 2004 Amendment 7 – Raise the upper income eligibility limit to 300% of FPL and

other minor changes: October 1, 2009 Amendment 8 – Include a private foundation grant as an additional source of state funding: October 27, 2009

Amendment 9 – Establishment of a Prospective Payment System for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs): August 25, 2010; Addendum on Dental Benefits Under Title XXI: October 1, 1998

Model Application Template for the State Children’s Health Insurance Program

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October 1, 2009 5 Approval Date: November 19, 2010 Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)-(3)) and (Section 2105)(c)(7)(A)-(B))

2.1.Describe the extent to which, and manner in which, children in the state including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (42 CFR 457.80(a)) Prior to CHIP, the only two programs offering health insurance to low-income children were Medicaid and the Alabama Child Caring Foundation (ACCF). Medicaid served children at the minimum income levels required by federal law. This meant that Medicaid coverage was available to children at three different levels of income and age: - Those under the age of six (6) years with incomes up to 133% FPL; - Those children six (6) through 14 years of age who were born after September 30, 1983 with incomes up to 100%FPL; and, - Those remaining children through the age of 18 years (middle and older teens) with incomes at the TANF assistance level (below approximately 13% FPL). The ACCF served children (birth through 18 years) with incomes from the Medicaid levels up to 200% FPL.

From February 2, 1998 through September 30, 2002, Phase I of CHIP, a Medicaid expansion was in existence. On October 1, 2002, Phase I of Alabama’s CHIP was subsumed by the Alabama SOBRA Medicaid Program.

Originally, CHIP used a baseline number of uninsured children derived from the Current Population Survey (CPS). This baseline including the following chart was derived from a study by Winterbottom et.al. based on a three year merged Current Population Survey, or CPS, (1990-92), which showed over 200,000 children, in Alabama, under 18 years to be uninsured.

Employer Medicaid Other Coverage Uninsured Percent 59.3 17.2 5.1 18.4 Number 652,300 189,200 110,000 202,400

However, due to concerns about the CPS regarding potential problems with subjects’ abilities to recall information, Alabama changed its baseline estimate to reflect data from the 1997 round of the Urban Institute’s National Survey of America’s Families (NSAF). The NSAF indicated that there were 173,012 uninsured children in Alabama. Of these, 91,209 were < 100% Federal Poverty Level (FPL), 49,579 were above 100 up to 200% FPL and 32,223 were >200% FPL.

In its first 4 years of implementation (October 1, 1998 – September 30, 2002), Phase II, ALL

Model Application Template for the State Children’s Health Insurance Program

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October 1, 2009 6 Approval Date: November 19, 2010 Kids, enrolled over 80,000 children. It is estimated that 52,000 children have current enrollment in ALL Kids at the end of FY 2002.

ALL Kids PLUS, added as a third amendment to the CHIP State Plan (October, 1999), serves as a mechanism by which children with special health care needs/conditions (CSHCN/C), who are enrolled in ALL Kids, may receive health and health related services which are beyond the scope of the basic ALL Kids package. ALL Kids PLUS was designed so that it serves as a funding source for CHIP state match and as a funding mechanism for state agencies who serve CSHCN/C with state funds. State agencies participating in ALL Kids PLUS supply the state match, provide the service, and receive full reimbursement. It was originally estimated that approximately 9% of these enrollees would also receive at least one service under ALL Kids PLUS. However because the basic benefit package is so comprehensive, a much lower percentage of children are receiving PLUS services. It is expected that this percentage will increase as more state agencies contract with CHIP to become ALL Kids PLUS providers.

With the advent of ALL Kids, the ACCF has changed its income eligibility criteria to serve children who are not eligible for Medicaid or ALL Kids and who have incomes up to 235% FPL. Because, the ACCF has no enrollment restriction regarding immigrants, this program has seen a dramatic increase in its Hispanic enrollment.

2.2. Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42CFR 457.80(b))

2.2.1. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e. Medicaid and state-only child health insurance): In Alabama, thanks to outreach efforts of a variety of public and private agencies and organizations, there is a high awareness level of children’s health insurance programs and their eligibility requirements. Over one-fourth of children under the age of 19 in Alabama are covered by Medicaid or ALL Kids. The programs are reaching children who might not otherwise have access to the health care they need.

Prior to CHIP, the Medicaid Program was the only public health insurance program for children in Alabama. Health services are provided in Alabama to uninsured and Medicaid enrolled children by private physicians, the 67 Alabama Department of Public Health (ADPH) county health departments, 16 primary care centers (including Federally Qualified Health Centers), two children’s hospitals (The Children’s Hospital of Alabama and Women’s and Children’s Hospital at the University of South Alabama) school health nurses, and one Indian Health Service Clinic. In addition to the two children’s hospitals, Alabama Department of Rehabilitation Services, Children’s Rehabilitation Services (CRS) provides specialty care to uninsured and Medicaid enrolled children with special health care needs. As lead agency for Alabama’s Early Intervention System, this agency coordinates services for infants and toddlers

Model Application Template for the State Children’s Health Insurance Program

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October 1, 2009 7 Approval Date: November 19, 2010 eligible for IDEA (Individuals with Disabilities Education Act), part C. This section describes the current efforts made by the ADPH to provide health care services, and to identify and enroll uncovered children in the Medicaid and ALL Kids programs. This section also describes the efforts made by CRS, the Alabama Medicaid Agency, the Alabama Department of Human Resources, and the Alabama Department of Mental Health and Mental Retardation to identify and enroll all uncovered children who are eligible to participate in the Medicaid and ALL Kids programs.

Alabama Department of Public Health As the CHIP lead agency, the ADPH is actively involved in all aspects of identification and enrollment of children who are eligible to participate in public health insurance programs and health insurance programs that involve public-private partnerships. Activities include the creation, publication, and distribution of marketing materials, management of the ALL Kids enrollment process, and targeted outreach activities for specific populations such as faith-based organizations, etc. A more detailed description of current outreach activities can be found in Section 5 of this document.

The Alabama Department of Public Health provides some direct as well as support patient care for uninsured and Medicaid enrolled children and adolescents. Direct services for this population include: preventive child health services (well-child check-ups), prenatal services, Women Infants and Children Supplemental Nutrition [WIC] program services, preventive health education, immunizations, and Family Planning program services. Support services include case management services, the provision of information and referral via toll-free telephone lines, and laboratory services. These services are funded through federal Title V Maternal and Child Health Block Grant funds, federal Title X Family Planning program funds, federal WIC Program funds, Medicaid program reimbursements, federal immunization funds, state legislative appropriations, some local government appropriations, and a small amount of patient fee revenue. A variety of the above direct and support services are provided within ADPH county health departments. In fiscal year 2001, 34,664 children (birth through age 18 years) received health services in local county health departments. (This number excludes single service patients [STD-only, Immunization-only, WIC-only].) The Alabama Department of Public Health is the state’s Title V agency. Additionally, there are approximately 512 school health nurses, R.N.s and L.P.N.s, (working under the auspices of the ADPH, private hospitals, the Alabama State Department of Education, and/or local education agencies) in the state who provide a variety of health screening services, primary care and emergency services, Medicaid/ALL Kids enrollment facilitation, etc.

Income assessments are performed on all patients enrolled in ADPH clinics. The income assessments are reviewed for possible Medicaid eligibility. Beginning in FY 1991, Medicaid eligibility workers were out-stationed in health departments and other health care facilities to accept applications and complete Medicaid eligibility determinations at the time of health visits. A streamlined, four-page expanded Medicaid eligibility form, which was implemented in FY 1991, has been revised into a joint application with CHIP and the Alabama Child Caring Foundation (ACCF) and is available at county health departments. Out-stationed Medicaid

Model Application Template for the State Children’s Health Insurance Program

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October 1, 2009 8 Approval Date: November 19, 2010 eligibility personnel currently assist patients in completing the forms and data is put into an automated Medicaid system on-site. Final determination for Medicaid can then be made immediately. If the children appear to be ALL Kids or ACCF eligible the application is forwarded to the appropriate program.

New applications, as well as annual reviews of established patients, are assessed by ADPH intake staff and/or care coordinators for possible referral for medical assistance through Medicaid, ACCF, or SSI. When appropriate, staff assist families in completing the application forms, making appointments, and gathering medical information. Out-stationed Medicaid eligibility workers are based in many ADPH clinics, hospitals, and primary care centers across the state. Additionally, two Medicaid outstationed workers and a clerk are now located in the CHIP office who process many ALL Kids referrals. A third worker will be added in FY 2003.

Cross training sessions with staff at many levels has improved interagency communication at the community level.

In order to provide additional outreach, the ADPH operates two toll-free telephone lines for use by the general public. The toll-free telephone lines (established prior to the implementation of CHIP and continued to the present) are known as Healthy Beginnings and Info Connection. Two integral parts of the information provided to callers, via these telephone lines, are information on Medicaid, ALL Kids, and ACCF eligibility and referrals to health providers who accept Medicaid-eligible children and Medicaid-eligible pregnant women. Referral services provided by the Healthy Beginnings and Info Connection staff members are expanded through consultation supplied by a host of additional professionals located within the ADPH. The toll-free number for Healthy Beginnings is 1-800-654-1385. The Info Connection number is 1-800-545-1098. Both lines are operational 24 hours a day, seven (7) days a week; office hours are from 8:30 A.M. to 4:30 P.M. each week day. The Healthy Beginnings and Info Connection lines are publicized statewide through newspapers, television, posters, and pamphlets. Presentations regarding the lines are conducted statewide to various organizations and agencies. The numbers are also published in Alabama South Central Bell telephone books. Additionally, with the implementation of CHIP, the CHIP unit maintains two toll-free telephone lines (888-373-5437 for enrollment and eligibility issues and 877-774-9521 for administrative issues). Finally, in addition to the above efforts, ALL Kids, Medicaid, and the Alabama Child Caring Foundation have developed a joint application and renewal form for use by all three programs. This enables families to be screened for eligibility for all three programs and facilitates referrals and timely enrollment in the appropriate program. See section 5 for additional outreach efforts.

Alabama Department of Economic and Community Affairs (ADECA) ADECA notifies the ALL Kids regional staff when a plant or large business plans to close in the near future. ALL Kids regional staff present ALL Kids information and materials at employee meetings prior to the plant/business closing. In order to prevent gaps in health insurance coverage for the children of the employees of the plant/business, an ALL Kids policy was developed which provides for beginning ALL Kids coverage (for eligible children) the day after

Model Application Template for the State Children’s Health Insurance Program

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October 1, 2009 9 Approval Date: November 19, 2010 employer sponsored coverage ends if an application is received by the ALL Kids enrollment unit within 30 days after the plant/business closing.

Alabama Department of Rehabilitation Services Children’s Rehabilitation Service Children’s Rehabilitation Service (CRS) also has coordination agreements with the Alabama Medicaid Agency. (These contracts existed prior to CHIP and have continued to be in effect.) The Alabama Medicaid Agency contracted with CRS for the provision of specialty medical services, specialized therapy (such as physical, occupational, speech, etc) services, and case management services to children with special health care needs. With the implementation of ALL Kids, CRS clinics were added as preferred providers under the ALL Kids basic benefits package and the ALL Kids PLUS package.

New applications, as well as annual reviews of established patients, are assessed by CRS intake staff and/or care coordinators for possible referral for medical assistance through Medicaid, ALL Kids, ACCF, or SSI. When appropriate, staff assist families in completing the application forms, making appointments, and gathering medical information. Joint Medicaid/ALL Kids/ACCF eligibility forms are available in all CRS offices and clinics. As in the ADPH, cross training sessions with staff at many levels has improved interagency communication at the community level. Medicaid and ALL Kids information and outreach brochures and posters are available in every CRS office throughout the state.

Additionally, like the ADPH, CRS operates toll-free telephone lines for use by the general public. One line is operated at the state level in Montgomery and additional lines are located in each CRS district office. An integral part of the information provided to callers, via these telephone lines, is Medicaid, ALL Kids, and ACCF eligibility and referral information. CRS and Early Intervention (EI) have both completed database matches with ALL Kids files to identify children known to both programs. CHIP staff have participated in many staff trainings throughout the state to assist CRS and EI staff in outreach for ALL Kids, Medicaid, and ACCF.

Division of Early Intervention As the lead agency for Alabama’s early intervention system for infants and toddlers with developmental disabilities and their families, this unit provides a toll free Child Find telephone number for use by the general public and primary referral sources. Additional efforts for coordination are described in the PLUS sections of this document.

Medicaid Agency The Alabama Medicaid Agency has 135 eligibility workers in over 170 locations to enroll children eligible for SOBRA Medicaid whose the family’s income is at or below 100 percent of FPL (for children born after September 30, 1983) or 133 percent of the FPL (for children

Model Application Template for the State Children’s Health Insurance Program

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October 1, 2009 10 Approval Date: November 19, 2010 through age five). With the implementation of CHIP, 23 workers were added throughout the state. In March, 2002, two eligibility workers and a clerk were housed in the ALL Kids central office to review applications referred from the ALL Kids eligibility workers. In addition to the CHIP office, these workers are located in places children are likely to go to receive health care - - county health departments, Federally Qualified Health Centers and hospitals. Because workers are in the community, they can and do establish working relationships with public and private providers, social service agencies and others. For example, supervisors provide in- service training and education on Medicaid, ALL Kids, and ACCF eligibility to physicians, Head Start workers, day care centers, Human Resources staff and others. The Alabama Medicaid Agency also has 10 district offices located throughout the state that process applications for the elderly and the disabled population. The 80 eligibility workers and 20 supervisors advise applicants about other programs and refer the applicants to the proper office when they do not qualify for a disabled program. They also advise about programs for which other family members may be eligible. These district offices work closely with providers to keep them informed of all programs available through the Medicaid Agency.

Applications for Medicaid, ALL Kids, and ACCF are easily available to anyone who needs one. Applications are available not only from Medicaid workers but also at physicians’ offices, county offices of the Department of Human Resources and hospitals. All sources of the joint application (i.e., ADPH, CRS, etc.) allow a “mail-in” application process thereby allowing Medicaid to complete a phone interview instead of a face-to-face interview. Medicaid has a toll- free number for anyone to call to ask questions about Medicaid eligibility and find out where and how to apply. The number is 1-800-362-1504. Medicaid’s Web site contains information on Medicaid eligibility and is used by advocates to assist people who want to apply for Medicaid.

Through its Medical Care Advisory Committee and its Physicians Task Force, Medicaid receives guidance on ways to reach potential Medicaid eligibles. Medicaid staff regularly brief these groups, who represent both providers and consumers, on all facets of the Medicaid program, including eligibility. Both groups are kept informed of upcoming changes in the Medicaid program and encouraged to provide comments and suggestions. With welfare reform and the separation of Medicaid eligibility from eligibility for public assistance, the Alabama Medicaid Agency and the Department of Human Resources have developed new cooperative arrangements to assure that children in the state’s lowest income families have access to Medicaid. Applications may be completed through the mail with a telephone interview, thus eliminating the need for a face-to-face contact. Currently DHR workers assess their clients to determine whether they might be eligible for any Medicaid, ALL Kids, or ACCF program. Workers help to complete forms, gather information and make appointments as necessary. However, the enrollment function for this Medicaid program will be transferred from DHR to the Medicaid Agency within the coming year.

Outreach occurs after the birth of an infant to a Medicaid recipient. Following the birth of each newborn whose mother is a Medicaid recipient, the Alabama Medicaid Agency sends the infant's parent or guardian a pamphlet on the Early Periodic Screening, Diagnosis, and

Model Application Template for the State Children’s Health Insurance Program

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October 1, 2009 11 Approval Date: November 19, 2010 Treatment (EPSDT) program as well as a pamphlet on immunizations. When children are enrolled in the SSI Program, they are automatically enrolled in the Medicaid Program. Additionally, a brochure is sent to parents/guardians of all new SSI eligible children encouraging them to participate in the EPSDT program. In addition to these efforts, social workers within the ADPH conduct patient recruitment as a part of their case management activities. These recruitment efforts are conducted through community presentations and professional relationships with other State and local agencies which serve mothers and children.

The Alabama Department of Human Resources and the Alabama Department of Mental Health and Mental Retardation also provide case management services for Medicaid children known to their agencies, in order to facilitate their enrollment in health services particularly mental health services through the Rehabilitation Option.

Through CHIP Phase I, the Alabama Medicaid Agency, working with the Alabama Department of Public Health, took several major steps to identify and enroll all uncovered children who were eligible to participate in this public health insurance program. New eligibility workers were hired and they, plus existing eligibility workers, were trained in CHIP eligibility criteria as well as other Medicaid eligibility criteria. These eligibility workers are outstationed in health departments, hospitals, community health centers, CHIP office, etc.

In order to streamline the CHIP/Medicaid enrollment process, the Alabama Medicaid Agency initiated continuous eligibility for all Medicaid children under the age of 19 years, on April 1, 1998. Continuous eligibility means that Medicaid enrolled children maintain their Medicaid coverage continuously for one year from enrollment or re-determination.

Additionally, numerous presentations, regarding CHIP, have been made by knowledgeable professionals who are members of the broad based CHIP Workgroup and CHIP staff. These presentations include addresses to education professionals, rural health groups, child care management agencies, parents of children with special health care needs, Indian Health Service staff, the general public, etc. Some specific activities include:

Notice to all Medicaid providers News releases and camera-ready materials for newspapers Articles published in newsletters of health care provider associations–Medical Association of the State of Alabama, Alabama Hospital Association, Alabama Dental Association, and others Television commercials Radio spots Brochures have been distributed to date for outstationed Medicaid workers, public health workers, county human resources workers, Early Intervention Coordinating Councils, Mental Health Centers, family services centers, primary health care centers, hospitals, advocacy and professional organization, and in the school system, principles and guidance counselors

Model Application Template for the State Children’s Health Insurance Program

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October 1, 2009 12 Approval Date: November 19, 2010 Brochures distributed at state meetings of Alabama Conference of Social Work, Medical Association, American Academy of Pediatrics-Alabama Chapter, Alabama Dental Association, Family Practice doctors, and others

Satellite conferences to provide information about the basic ALL Kids Program and instruction in completing the application. Distribution of applications and brochures to all public school systems, local health departments, welfare offices, hospitals, community health centers, physician and dentist offices, pharmacies, WIC clinics, and family law attorneys, etc. Public forums for parents and advocates of CSHCC/N (Children with Special Health Care Conditions/Needs)

In addition to the above, the state has engaged in the following particular activities to promote ALL Kids PLUS. Originally, it was anticipated that ALL Kids PLUS would involve four state programs, Children’s Rehabilitation Service, Early Intervention, Mental Health/Mental Retardation, and Civitan International Research Center Sparks Clinics. After conducting database matches, reviews of Pediatric Health History information, claims data, through mutual agreement, Sparks determined that their services were being adequately reimbursed through the ALL Kids basic benefit package. Therefore, attention was focused on the remaining three agencies. Since that time, CHIP has entered into discussions with the Alabama Institute for the Deaf and Blind with regard to becoming an ALL Kids PLUS provider. CRS has had an active contract for the provision of PLUS services since October, 2000 and has served as a valuable partner in establishing protocols for the identification of ALL Kids enrollees in need of PLUS services and the identification of current clients in need of insurance coverage.

Initially it was anticipated that children would be identified for the PLUS program through an in-depth analysis of the Pediatric Health History and chart reviews. Practical experience has shown that this was not the most productive method of identification. Database matches were necessary as a first action to even identify ALL Kids enrollees who were being served by CRS. After this baseline was established, claims reviews were shown to be a more valuable mechanism in identifying children eligible for PLUS services than were chart reviews. This claims review revealed that a much smaller percentage of ALL Kids enrollees, than originally projected, were in need of services beyond those available in the basic benefits package. Program staff continually monitor feedback from providers and families regarding the need for additional services. This type of feedback and analysis has influenced the approaches that have been used with the other potential ALL Kids PLUS agencies. Through the activities of the regional ALL Kids staff, central office social work consultant, and customer service staff, ALL

Kids enrollees in need of these specialized services provided by ALL Kids PLUS agencies have been identified and referred as appropriate.

In August of 1999, the ADPH broadcasted a nationwide satellite conference to educate the provider community and other concerned individuals regarding ALL Kids PLUS. In addition, CHIP staff provided training on the PLUS program to CRS staff at regional meetings.

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October 1, 2009 13 Approval Date: November 19, 2010

Alabama Department of Human Resources (DHR) The DHR has continued to partner with the ADPH to communicate ALL Kids information to their county staffs. They have provided initial and continuing updates to county DHR staff as well as provided periodic shipments of applications, posters, etc. The DHR has also assisted with outreach efforts through its childcare management agencies and facilitated communication with licensed child day-care homes and centers.

2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership: There is only one health insurance program for children in Alabama that resembles a public- private partnership. This program is known as the Alabama Child Caring Foundation (ACCF) and is a part of Blue Cross Blue Shield. The Alabama Child Caring Foundation provides limited ambulatory health insurance to low income, non-Medicaid/non-ALL Kids, uninsured children under the age of 19 years who remain full-time students through grade 12. The program is funded through private donations and matching funds from Blue Cross Blue Shield. Outreach for this program is conducted through articles in Blue Cross Blue Shield publications and public service announcements in local newspapers, via television, and radio stations. The University of Alabama and Auburn University coaches’ television shows expressly advertise the Foundation. Case finding is conducted by school administrators, school nurses, day care operators, and others. Additionally referrals to the Foundation are received from the ALL Kids program, local offices of the ADPH, the Alabama Medicaid Agency, the Alabama Department of Human Resources, the Alabama Department of Industrial Relations Dislocated Workers program, individual health care providers, civic organizations, churches, Sunday School classes, other religious organizations, and from Foundation participants.

2.3. Describe the procedures the state uses to accomplish coordination of SCHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low-income children to increase the number of children with creditable health coverage. (Previously 4.4.5.) (Section 2102)(a)(3) and 2102(c)(2) and 2102(b)(3)(E)) (42CFR 457.80(c)) The State of Alabama assures coordination with other public and private programs providing creditable coverage for low-income children. The SOBRA Medicaid program, ALL Kids, and the Alabama Child Caring Foundation have developed and use joint application and renewal forms.

All applications received by the ALL Kids enrollment unit are screened for Medicaid eligibility. When a child is identified by an ALL Kids enrollment worker as potentially eligible for Medicaid, the family’s application is sent to a Medicaid enrollment worker. Medicaid then processes it. As stated previously, two Medicaid enrollment workers and one clerical worker are physically located within the ALL Kids enrollment unit. This process also works in the reverse (applications are sent from Medicaid to ALL Kids).

Model Application Template for the State Children’s Health Insurance Program

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October 1, 2009 14 Approval Date: November 19, 2010 When a child is identified by an ALL Kids enrollment worker as not potentially eligible for the Medicaid or ALL Kids but potentially eligible for the Alabama Child Caring Foundation (ACCF), the family’s application is sent to ACCF which then processes it and the opposite is also true.

Because it is recognized that the eligibility and enrollment systems of these three programs are not as seamless as needed, ALL Kids employs a full time MSW staff person. This staff person has responsibility to assist families in overcoming obstacles related to eligibility, enrollment, claims, and referral for specialty services as needed. Additional responsibilities include development and maintenance of the ALL Kids policy manual.

In addition, the State coordinates with the ALL Kids PLUS authorizing agencies. See the previous section for a broader description of the collaboration.

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October 1, 2009 15 Approval Date: November 19, 2010 Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4))

∼ Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 4.

3.1.Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42CFR 457.490(a)) Phase I - Medicaid Expansion From February 2, 1998 through September 30, 2002, Phase I of CHIP, a Medicaid expansion was in existence. On October 1, 2002, Phase I of Alabama’s CHIP was subsumed by the Alabama SOBRA Medicaid Program.

ALL Kids: Program Operation–Administration From inception of the program in 1998 through May, 2001, ALL Kids contracted with the State Employee’s Insurance Board (SEIB) to serve as its enrollment and premium billing/receiving office. As enrollment grew, ALL Kids staff increased, and the need for data management grew, the ADPH CHIP unit and SEIB jointly decided to move the enrollment and premium billing/receiving functions to the CHIP unit. The Alabama Department of Public Health (Department) now manages all enrollment aspects of the ALL Kids program and utilizes other contractors to administer certain aspects of the ALL Kids program including, but not limited to, the following:

1. Providing all eligible persons involved in ALL Kids an individual policy or certificate that states the insurance protection provided, the method and place of filing claims, and to whom benefits are payable. The policy or certificate indicates that coverage was obtained through CHIP; 2. Maintenance of a claims database for the purpose of program management. 3. Management of evaluation surveillance procedures. 4. Consultation for actuarial services 5. Consultation for development of data systems 6. Consultation for development of specialized outreach plans

Program Operation-Benefits and Services The ALL Kids program is a self-funded, discounted fee-for-service*, PPO, delivery system. In order to assure delivery of the insurance product(s), the Department utilizes a private health care delivery organization(s) to provide benefits and services. Both indemnity plan(s) and or managed care plans(s) are acceptable and have been used. The selected vendor(s) is required to perform, including but not limited to, the following:

1. Furnishing coverage information and ID cards;

Model Application Template for the State Children’s Health Insurance Program

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October 1, 2009 16 Approval Date: November 19, 2010 2. Member service responses to claims inquiries; 3. Claims certification, investigation, adjudication, and internal appeals process; 4. Processing and distribution of benefit payments to providers; 5. Appropriate and accurate fee administration; 6. Strict financial accounting and reconciliation; 7. Effective management of networks (if applicable); 8. Demonstrated capability to serve Alabama membership; 9. Effective medical, pharmacy and dental management including medical review of claims decisions; 10. Production of claims, contract, and other legal forms as required; 11. Establishment and maintenance of appropriate banking arrangements; 12. Continuous and accurate electronic transmission of all data; 13. Production of reports that capture claim and utilization experience and trends; 14. Other special services as may be requested from time to time 15. Have a network of physicians, dentists, pharmacies, and other providers capable of meeting the demands of the ALL Kids Program. 16. Facilitation of a medical home for each enrollee.

*The exception to the fee-for-service payment system is the method of reimbursement to federally qualified health centers (FQHCs) and rural health clinics (RHCs) based on a prospective payment system (PPS). This is in compliance with section 503 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA). In accordance with this provision of CHIPRA, ALL Kids has elected to adopt the Medicaid PPS Rates effective October 1, 2009. This method of payment will be implemented August 25, 2010 for all qualifying services rendered on or after October 1, 2009.

In the past, ALL Kids has used three (3) insurance venders, Blue Cross Blue Shield of Alabama (statewide), Prime Health (in 10 southwestern counties from 10/98-9/00) and United Healthcare (14 counties from 10/01-7/02) for the above services. However, due to low enrollment in Prime Health and United Healthcare (which was due to patient choice), each of those programs elected, with the mutual consent of the ALL Kids program, to discontinue serving as an ALL Kids vendor. Currently, the only ALL Kids vendor for the above services is Blue Cross Blue Shield of Alabama. This vendor provides services statewide.

CHIP makes health care coverage available to all individuals eligible for ALL Kids on a “guaranteed issue” basis with no exclusions of coverage for pre-existing conditions, and on a “guaranteed renewable” basis for those eligible.

ALL Kids PLUS Program Operation-Administration For this addition to the program, the Alabama Department of Public Health has partnered (and seeks to partner) with other governmental agencies (which serve special needs children) to provide the state match, provide or provide for covered ALL Kids PLUS services, to authorize

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October 1, 2009 17 Approval Date: November 19, 2010 case by case reimbursement for ALL Kids PLUS services, to notify ALL Kids PLUS families of their approval for services, and select one case manager per child so as to minimize duplication and gaps in services. PLUS services became available through CRS as of October 1, 2000. An ALL Kids PLUS contract was signed with the Department of Mental Health and Mental Retardation effective October 1, 2002.

Several state agencies, other provider entities, and advocates within the state have met to develop the concept and plan of operation for ALL Kids PLUS.

At the present time, the list of ALL Kids PLUS authorizing agencies is restricted to those governmental agencies supplying the state match money. If other state or appropriated matching funds become available, this restriction may be modified or eliminated. A child must be enrolled in ALL Kids to qualify for PLUS services. When a child is identified with a special condition or need that a participating agency serves, he/she is referred to that agency based on that special condition/need. This agency will, based on the availability of funds, assign a case manager to the child, authorize needed services within the agency, and make referrals to other authorizing agencies for additional services if needed. All agencies authorizing PLUS services for a child notify the child’s case manager and referral site (if different) for approval of services. Each child will only have one ALL Kids PLUS case manager. The decision as to which agency will provide the case management will be determined by the agencies involved in the child’s care and will be based on what makes the best practice sense and is in the best interest of the child.

Authorizing agencies bill the insurance vendor(s) for any authorized PLUS services that the agencies have provided directly or indirectly. The Alabama Department of Public Health reimburses the insurance vendor(s) in the same manner that reimbursement for the basic ALL Kids program is handled. At this time, the participating PLUS agencies do not utilize a central integrated data system. However, their day-to-day practice involves coordination through the case manager with other agencies to avoid duplication. Each agency submits all claims/data to the insurance vendor (BCBS) for adjudication and reimbursement. While a child may have claims submitted by more than one agency, only one agency may be reimbursed for case management services.

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42CFR 457.490(b)) Utilization control mechanisms are in place for the ALL Kids program to ensure that children use only health care that is appropriate, medically necessary, and/or approved by the State or the participating health plan. In addition, policies are in place to assure that necessary care is delivered in a cost-effective and efficient manner according to the vendors’ medical necessity definition. The current Blue Cross Blue Shield policies are available upon request.

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October 1, 2009 18 Approval Date: November 19, 2010 Before being approved for participation in the ALL Kids program, health plan vendors must develop and have in place utilization review policies and procedures, demand management, and disease state management mechanisms. Provider networks approved for the ALL Kids program are accepted based on evidence of the vendors’ provider credentialing policies, provider accessibility, cost-effectiveness, and efficiency.

Each ALL Kids PLUS authorizing state agency has a utilization review mechanism particular to that agency. Services approved for ALL Kids PLUS are those which are developmentally necessary and/or physically necessary. Reviewing the appropriate use of services is part of the case manager’s duties. Section 4. Eligibility Standards and Methodology. (Section 2102(b))

∼ Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 5.

4.1. The following standards may be used to determine eligibility of targeted low-income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102)(b)(1)(A)) (42CFR 457.305(a) and 457.320(a))

4.1.1. X Geographic area served by the Plan: Statewide 4.1.2. X Age: A child is eligible for ALL Kids if the date of birth on the application indicates that the child is less than 19 years of age. 4.1.3. X Income: Income eligibility is defined as above 133% of the Federal Poverty Level (FPL) for children less than six years of age and above 100% of FPL for those aged 6-18. It is the State’s intent to cover as many children as possible up to 300% of the FPL. If during the year State matching funds are not available at sufficient levels for coverage of all children to this income level and funding is depleted before the end of the fiscal year, it is the State’s intent to place eligible children on a waiting list until adequate funding becomes available to resume enrollment. Alabama will provide prior public notice and will notify CMS when placing applicants on a waiting list.

The definition of household size is the same as that for children under the Medicaid poverty level definition which includes the biological or adoptive parent(s) in the home, unborn children, and sibling children under 19. Income will be determined by totaling all earned and unearned income of family members included in the family size received on a monthly basis. Like Alabama Medicaid, certain income disregards will be considered under ALL Kids. Specific amounts will be deducted from gross monthly income when determining ALL Kids financial eligibility. The deductions used will be the standard Alabama Medicaid disregards which are: $90 for each wage earner, up to $50 child support received, up to $200 child care expenses for a child up to 24 months of age and up to $175 for child care expenses for a child 24 months of age and over (or incapacitated

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October 1, 2009 19 Approval Date: November 19, 2010 adult). If the income, after these standard disregards are made, is equal to or less than 300%FPL but over the Medicaid income eligibility limit and the applicant is otherwise eligible, the applicant will be enrolled in ALL Kids. The Department and Medicaid will collaborate closely to assure coverage through the appropriate program (i.e., Medicaid or CHIP) for those children whose incomes fall near the low-end threshold.

Income is based on self-declaration as recorded on the application.

4.1.4. ∼ Resources (including any standards relating to spend downs and disposition of resources): 4.1.5. X Residency (so long as residency requirement is not based on length of time in state) : A child must be a resident of the State of Alabama to be eligible for ALL Kids. Residency will be based on self- declaration as recorded on the application. 4.1.6. X Disability Status (so long as any standard relating to disability status does not restrict eligibility): Children will be eligible for ALL Kids regardless of disability. ALL Kids PLUS is available to children with special conditions/needs who are enrolled in ALL Kids. ALL Kids PLUS enrollment is restricted to services authorized and financed by PLUS participating agencies. However, if access to additional matching funds becomes available and/or the health needs of CSHCC/N change, authorized services will be revised to reflect these changes.

4.1.7. X Access to or coverage under other health coverage: A child is not eligible for ALL Kids if s/he has any other health insurance coverage or is found eligible or potentially eligible for Medicaid. Health insurance coverage is considered coverage under any group plan, and includes eligibility for state subsidized group health insurance (state employees, public school employees) whether or not the parent opts for the coverage.

Alabama uses several measures to minimize the effects of crowd- out in the ALL Kids program. The application form contains a statement asking about current health insurance coverage and coverage terminated within the past 90 days. Effective October 1, 2003, the ALL Kids program also requires a premium contribution for all children except Native Americans and Alaskan Natives. This family contribution is a disincentive for families to drop group employer coverage for the ALL Kids program. Additionally, since the ALL Kids package was designed to be similar to the standard benefit levels offered through most employers, there is no incentive to drop employer-based dependent coverage in favor of ALL Kids

Model Application Template for the State Children’s Health Insurance Program

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October 1, 2009 20 Approval Date: November 19, 2010 based on benefit levels alone. The ALL Kids program has a waiting period policy to deter crowd-out. Children, whose private coverage is voluntarily dropped, have to serve a 3-month waiting period before they can enroll in ALL Kids. The CHIP Data unit monitors the percentage of enrollees who have served the three- month waiting period due to voluntary termination of other coverage. There are four (4) exceptions to the waiting period policy: (1) children whose previous private coverage is through an individual policy; (2) children whose previous private coverage is through COBRA; (3) children whose previous private coverage is through the Alabama Child Caring Foundation; (4) children whose previous private coverage lifetime limits have been met. Exceptions 1, 2, and 3 were effective January 1, 2002 and exception 4 was effective July 1, 2002. The reasoning behind these exceptions is: these insurance situations are usually extremely expensive and therefore pose a true financial burden to the families (1 and 2), Child Caring insurance is very limited (3), there is essentially no real insurance coverage available to the child (4).

Applications which meet all eligibility criteria are subjected to a final review through Blue Cross Blue Shield of Alabama to check for other current insurance coverage or coverage terminated within the last 90 days. Since Blue Cross Blue Shield of Alabama covers 85% of the covered lives in Alabama, it is believed that this final review finds most of the applications where information about other insurance coverage is uncertain.

The enrollment or use of services in ALL Kids PLUS is restricted to children who are enrolled in the basic ALL Kids Program. Therefore, the information in the above three paragraphs will apply to the entire ALL Kids Program.

4.1.8. X Duration of eligibility: Eligibility for ALL Kids will commence on the first day of the month following the month of receipt of the application. An exception to this is allowed for newborns for whom coverage begins at birth when applications are received within 60 days after the birth. Two other exceptions are when Medicaid coverage ends or private insurance is involuntarily terminated. In these cases, ALL Kids coverage begins when the other insurance(s) ends so that there is no lapse in coverage for the child. Coverage for all ALL Kids enrollees is continuous for one year unless the child moves out of state or reaches the age of 19 years. Consistent with industry standards, children who become 19 years of age

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October 1, 2009 21 Approval Date: November 19, 2010 prior to the end of the year’s enrollment will have coverage through the end of the month of birth.

Children must have their eligibility redetermined each year. If more than one insurance vendor is available to an applicant, an individual will be “locked in” to the plan s/he chooses for enrollment (after the first month of enrollment) for a period of one year. Exceptions will be made for those children whose parent(s)/guardians(s) move from one provider region to another or if provider networks change significantly.

If an individual is pregnant at the time of annual renewal, her eligibility extends to 60 days post-partum unless she is or will the renewal process is initiated and eligibility is re-determined.

4.1.9. X Other standards (identify and describe): The only other eligibility disqualification is being the dependent of an employee whose children are eligible for state health benefits coverage under a state health benefits plan on the basis of a family member’s employment with a public agency in the state. This disqualification includes children of state employees, children of K-12 public school employees, children of all community colleges, trade and technical schools, and one four-year college (Jacksonville State).

Social Security number is requested of all individuals listed on the application. Non-applicants are not required to supply social security numbers. Social Security numbers are required for all applicant children. If the parent/guardian refuses or is unable to supply a Social Security number for an applicant child and citizenship can be otherwise established, a pseudo-Social Security number is given to the child. Parents are offered assistance in obtaining Social Security numbers as necessary.

4.2. The state assures that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102)(b)(1)(B)) (42CFR 457.320(b))

4.2.1. X These standards do not discriminate on the basis of diagnosis. 4.2.2. X Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. 4.2.3. X These standards do not deny eligibility based on a child having a pre- existing medical condition.

Model Application Template for the State Children’s Health Insurance Program

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October 1, 2009 22 Approval Date: November 19, 2010

4.3. Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2)) (42CFR 457.350) Applying the ALL Kids Eligibility Standards The eligibility standards for initial enrollment are as follows:

Under 19 years of age From just above the upper Medicaid income eligibility level (133% of FPL for children under 6 years old and 100% of FPL for children aged 6-18) to and including 300% FPL

Not be enrolled in or eligible for Medicaid Not covered by another group health insurance policy or have had coverage voluntarily terminated within the last 90 days (exceptions to this can be found in Sections 4.1.7 and in 4.4.4.3)

Not eligible for state health benefits coverage under a state health benefits plan

Not in an institution

Resident of Alabama Citizen of the US or an eligible “immigrant” child (The definition of an eligible immigrant child is the definition described in the January 14, 1998 “Dear State Health Official” letter from HCFA and HRSA. This letter indicates that any child born in the United States is a citizen and eligible to receive services funded by CHIP in addition to: • All legal immigrant children who were in the US before August 22, 1996, • Refugees, asylees and certain Cuban, Haitian and Amerasian immigrants, • Unmarried, dependent children of veterans and active duty service members of the Armed Forces, and • Legal immigrants arriving on or after August 22, 1996, and in continuous residence for 5 years. Applying the ALL Kids PLUS Eligibility Standards The eligibility standards for initial enrollment are as follows:

Be enrolled in the basic ALL Kids Program

Have a condition for which a PLUS service is available Be in need of a PLUS agency authorized ALL Kids PLUS service for which the participating agency has funds available

Redetermination Process Redetermination (renewal) is completed every 12 months. For renewal, all of the preceding standards apply and in addition, the family must be current with any outstanding premium balances. In order to facilitate continuous coverage, notices of any premium balances owed are sent to the family periodically throughout the year including a premium notice sent with the renewal form. A “coming soon” postcard is sent to the family ten weeks prior to the renewal date. The preprinted renewal form is sent to the family eight weeks prior to renewal, and a second postcard is sent as a reminder notice at six weeks prior to the renewal date. Once the renewal form is received, it is processed in exactly the same way as a new application is processed, including a check on Medicaid status and insurance coverage with Blue Cross Blue

Model Application Template for the State Children’s Health Insurance Program

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October 1, 2009 23 Approval Date: November 19, 2010 Shield of Alabama (current and in the past three months.)

Organization and Infrastructure Responsible for Making and Reviewing Eligibility Determinations The CHIP enrollment unit is responsible for making and reviewing eligibility determinations for ALL Kids. See Attachment C for a description of the CHIP enrollment unit. For ALL Kids PLUS, the Department will contract with the state agencies who serve CSHCN/C not only to supply the financial match but also to conduct ALL Kids PLUS enrollment procedures and to annually redetermine authorization for ALL Kids PLUS benefits the child is receiving.

Process for Enrollment The ALL Kids enrollment unit receives ALL Kids applications from numerous sources (families, hospitals, doctors’ offices, etc.). The enrollment unit staff review and input data from the application into an automated system which reviews the data for eligibility and, if appropriate, prompts the staff to enroll the child in the ALL Kids system. If an incomplete application is received, the staff contacts the family (by telephone and/or letter) in an attempt to obtain the necessary information. The enrollment unit sends enrollment notification to the insurance plan which the family/child has chosen. Once the enrollment transaction has been completed, the vendor supplies the family with enrollment materials including an insurance card, explanation of benefits, and information on locating providers. The enrollment unit also sends the family premium payment information as appropriate.

If the child is thought to be ineligible for ALL Kids due to possible eligibility for Medicaid or the Alabama Child Caring Foundation, the enrollment unit staff sends the application and/or automated data to the Alabama Medicaid Agency or Alabama Child Caring Foundation, as appropriate. Medicaid or the Alabama Child Caring Foundation assumes processing of the application following their usual rules and procedures. The CHIP enrollment unit notifies the family of its actions. This process works in the reverse if the application is processed initially

through Medicaid or the Alabama Child Caring Foundation. If the child is found to be ineligible for any other reason, the CHIP enrollment unit notifies the family.

ALL Kids PLUS enrollment procedures are conducted by each participating PLUS agency which serves or potentially serves the child. Enrollment procedures will consist of two elements - financial and health-need-based. When a child is referred to an authorizing agency, that agency determines whether or not funds are available to serve the child’s need. If funds are available and the child’s need(s) can be met by that agency, the child may be enrolled in ALL Kids PLUS through that agency and a case manager is assigned to the child. If the child needs services provided by another authorizing agency, the case manager makes a referral for enrollment with the second agency. The case manager may change depending upon the child’s needs.

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October 1, 2009 24 Approval Date: November 19, 2010

ALL Kids uses the same application form as SOBRA Medicaid and the Alabama Child Caring Foundation.

4.3.1 Describe the state’s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b)) Check here if this section does not apply to your state. There are no public notice state laws regarding enrollment caps and waiting lists in SCHIP. Due to insufficient state funds, ALL Kids initiated a waiting list beginning with all new enrollees who would have had an effective date October 1, 2003. Public and enrollee notices about the waiting list were issued during the month of September 2003 prior to the impact of the waiting list. On August 23, 2004, ALL Kids reopened enrollment and discontinued use of the waiting list.

If during the year funds are not available at sufficient levels for coverage of all children to income levels described in Section 4.1.3 and funding is projected to be depleted before the end of the fiscal year, it is the State’s intent to place eligible children on a waiting list until adequate funding becomes available to resume enrollment. Alabama will provide public notice through press releases, written communication with stakeholders and stakeholder groups, presentations, and written communication from the program to all applicant families whose child(ren) is/are placed on the waiting list.

When a waiting list is implemented, the program has and will continue to receive new applications. These applications will be screened for Medicaid eligibility and then reviewed for ALL Kids eligibility. If a child appears, from the application form, to be eligible for Medicaid, the form will be sent to the Medicaid Agency. If a child appears not to be eligible for Medicaid or ALL Kids but eligible for the Alabama Child Caring Foundation, the form will be sent to that program. Each family whose child is placed on the waiting list will be notified, by letter, of this placement. The notification letter will also contain information stating that the parent may wish to contact Medicaid and/or the Alabama Child Caring Foundation if his situation changes and he believes that his child may be eligible for one of these programs. The letter will also notify the parent that any child on the waiting list is eligible for the Alabama Child Caring Foundation. The letter will further encourage the parent to request that ALL Kids send a copy of his child’s application to the Alabama Child Caring Foundation. If the child remains on the waiting list for longer than three (3) months, the family will be periodically notified via letter that the child’s name is still on the waiting list.

If the State is using a waiting list, children will be enrolled on ALL Kids from the waiting list on a first on–first off basis as funding permits. When attrition has lowered program enrollment to a level at which there are sufficient state funds to re-open enrollment, children will be removed from the waiting list ( on a first on first off basis) and enrolled in ALL Kids. Children who are removed from the waiting list whose application information is greater than 90 days old will be asked to complete a form updating changes in

Model Application Template for the State Children’s Health Insurance Program

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October 1, 2009 25 Approval Date: November 19, 2010 information on their family size, income, and other points of eligibility. Upon receipt of the form, ALL Kids enrollment staff will evaluate the child’s eligibility for ALL Kids. Then, either the child will be enrolled in ALL Kids or, based on the information on the form, the information will be sent to the Medicaid Agency or the Alabama Child Caring Foundation and the family will be notified that the child has been referred to another health insurance program.

Children who have current enrollment in ALL Kids will be allowed to continue to renew their enrollment as long as they continue to meet all points of eligibility and have their renewal forms and premium balances paid in full prior to the termination dates.

4.4. Describe the procedures that assure that:

4.4.1. Through the screening procedures used at intake and follow-up eligibility determination, including any periodic redetermination, that only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including a state health benefits plan) are furnished child health assistance under the state child health plan. (Sections 2102(b)(3)(A) and 2110(b)(2)(B)) (42 CFR 457.310(b) (42CFR 457.350(a)(1)) 457.80(c)(3)) The State of Alabama assures that through enrollment screening processes, children whose applications are considered to be eligible for medical assistance under the State Medicaid plan will be referred for assistance under the appropriate plan. Additionally, ALL Kids eligibility staff query the Medicaid eligibility system to ensure applicants are not currently on any Medicaid program. All applications request the parent/guardian to provide the names and addresses of their employers. Eligibility staff screen all applications to ensure applicant children are not currently covered under group health insurance, have not voluntarily terminated group coverage within the last 90 days, and are not eligible for a state health benefits plan. If necessary, staff contact the State Employees’ Insurance Board for clarification of eligibility for a state health benefits plan. In an effort to further minimize crowd-out, the ALL Kids enrollment unit receives a daily “error report” which indicates children who have current BCBS health insurance or have terminated a BCBS policy within the last 90 days. In addition, quality assurance reviews are conducted on a sample of ALL Kids enrollees. Redetermination is completed every 12 months.

4.4.2. The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX. (Section 2102)(b)(3)(B)) (42CFR 457.350(a)(2)) When a child is screened by an ALL Kids enrollment worker as potentially eligible for Medicaid, the family’s application is sent to the Medicaid Agency. Because a joint application is used, no additional form is required to be completed. Medicaid eligibility staff have access to selected fields from the ALL Kids eligibility and enrollment data system in order to assist in processing applications referred from the ALL Kids enrollment unit. Applications are mailed,

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October 1, 2009 26 Approval Date: November 19, 2010 at least weekly, directly to Medicaid Area supervisors for distribution to county Medicaid eligibility staff. Parents are notified by the ALL Kids enrollment unit regarding this referral and given information regarding expected timelines for Medicaid eligibility determination. Applications from families in 25 counties, on which all applicants appear to qualify for Medicaid, are given to the two Medicaid eligibility workers located within the CHIP eligibility unit.

CHIP and the Alabama Medicaid Agency central office are physically located two city blocks apart. If necessary, applications and renewals, forms can be easily transferred from one agency to the other (possibly on a daily basis) so that children can be enrolled in the appropriate insurance program on an expedited basis. Currently, applications not handled by Medicaid eligibility staff located in the ALL Kids enrollment unit, are mailed from the ALL Kids Office to the Medicaid Agency area supervisors for distribution to eligibility workers. Computer systems development is ongoing in order to facilitate electronic transfer of all referred applications.

4.4.3. The State is taking steps to assist in the enrollment in SCHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4)) When a Medicaid enrollment worker determines that a child is ineligible for Medicaid due to income and potentially eligible for ALL Kids, the worker sends the application to the ALL Kids enrollment unit. No further eligibility determination is required. ALL Kids eligibility staff enter income and family size information as determined by the Medicaid eligibility worker and award coverage based on the application receipt date at the Medicaid office or the child’s last date of Medicaid coverage. ALL Kids staff work very closely with the Medicaid central office and Medicaid enrollment workers to ensure that the policies and procedures of both agencies reflect the agencies’ desires for a seamless referral system between the two.

4.4.4. The insurance provided under the state child health plan does not substitute for coverage under group health plans. Check the appropriate box. (Section 2102)(b)(3)(C)) (42CFR 457.805) (42 CFR 457.810(a)-(c))

4.4.4.1.  Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution.

4.4.4.2.  Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable.

4.4.4.3. X Coverage provided to children in families above 250% FPL: describe how substitution is monitored and identify specific strategies in place to prevent substitution.

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October 1, 2009 27 Approval Date: November 19, 2010 The State of Alabama assures that insurance provided under ALL Kids will not substitute for coverage under group health plans. Alabama implements several measures to minimize the effects of crowd-out in the CHIP program.

The joint application requires that the applicant state whether or not s/he has current health insurance and whether s/he has terminated that insurance within the past 90 days and the reason for this termination.

The ALL Kids program has a waiting period policy to deter crowd-out. Children, whose private coverage is voluntarily dropped, have a 3-month waiting period before they can enroll in ALL Kids. The CHIP Data unit monitors the percentage of enrollees who are subject to the three-month waiting period due to voluntary termination of other coverage through both internal data systems. The data unit also utilizes ongoing enrollee surveys to quantify the incidence of crowd-out. There are 4 exceptions to the waiting period policy which pertain to minimizing crowd-out: (1) children whose previous private coverage is through an individual policy; (2) children whose previous private coverage is through COBRA; (3) children whose previous private coverage is through the Alabama Child Caring Foundation; (4) children whose previous private coverage lifetime benefits limits have been met.

The ALL Kids program also requires a premium contribution for all children with the exception of Native Americans. This family contribution is a disincentive for families to drop group employer coverage for the ALL Kids program. Additionally, since the ALL Kids package was designed to be similar to the standard benefit levels offered through most employers, there is no incentive to drop employer-based dependent coverage in favor of ALL Kids based on benefit levels alone.

In addition, as a final review, Blue Cross Blue Shield reviews all applicants (sent to it) for enrollment in another Blue Cross Blue Shield plan or coverage terminated within the past 90 days. Since Blue Cross Blue Shield currently provides 85% of the private health insurance coverage in the State, ALL Kids should have a high success rate in identifying children with private health care coverage. Approximately 5% of applicants are denied ALL Kids coverage due to having other health insurance currently or in the past three months.

Because enrollment in ALL Kids PLUS is limited to enrollment in the basic ALL Kids Program, all statements above which apply to the basic program also apply to ALL Kids PLUS.

4.4.4.4.  If the state provides coverage under a premium assistance program, describe:

The minimum period without coverage under a group health plan, including any allowable exceptions to the waiting period.

The minimum employer contribution.

Model Application Template for the State Children’s Health Insurance Program

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October 1, 2009 28 Approval Date: November 19, 2010 The cost-effectiveness determination.

4.4.5. Child health assistance is provided to targeted low-income children in the state who are American Indian and Alaska Native. (Section 2102)(b)(3)(D)) (42 CFR 457.125(a)) The State of Alabama assures the provision of child health assistance to targeted low-income children in the State who are American Indians (as defined in section 4(c) of the Indian Health Care Improvement Act, 25 U.S.C. 1603(c)). As Stated in section 4.1, the ALL Kids program will provide Statewide coverage. No ALL Kids enrollee identified as being an American Indian will be charged a premium or co-pay. This policy extends to all children who identify themselves as an American Indian children whether they are a member of a federally recognized tribe or one of the eight state-only recognized tribes. Representatives from the Poarch Band of Creek Indians (the only federally recognized Tribe in Alabama) have assisted in the development of ALL Kids PLUS. Tribal children will have access to PLUS services.

CHIP staff meet and coordinate regularly with the Alabama Commission on Indian Affairs to ensure that Native American Children are identified and enrolled in ALL Kids. Additionally, a Native American was hired under a one-year contract to consult with ALL Kids staff and develop a comprehensive strategy to outreach to Native American children. Section 5. Outreach (Section 2102(c))

Describe the procedures used by the state to accomplish:

Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)) (42CFR 457.90) Phase I - Medicaid Expansion (no longer in existence) This portion of the outreach section, as it pertains to Phase I of Alabama’s Title XXI program, consists solely of efforts that were targeted toward Medicaid eligibles who were born after September 30, 1983 and who are under 19 years of age. There were four primary avenues through which outreach was conducted. These avenues were (1) the use of existing outreach approaches, (2) an initiative to improve communication with and services for the state’s rapidly expanding Hispanic population, (3) an increase in the number of Medicaid eligibility workers, and (4) coordination with the State Medical Association and physicians to educate physicians and their potentially eligible patients. Detailed information regarding these efforts is available from CHIP upon request.

Phase II - ALL Kids Outreach for ALL Kids is conducted through coordinated Statewide and regional efforts and in each county through partnerships, contracts, and regional CHIP coordinators. These efforts consist of a three-pronged approach: (1) Statewide media campaigns and initiatives; (2) outreach conducted by multi-county regional workers and consultants; and, (3) outreach conducted through existing programs and agencies. The purposes of all of these activities is to build networks and coalitions of persons who can inform individuals about the availability of

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October 1, 2009 29 Approval Date: November 19, 2010 ALL Kids and what it has to offer, and assist individuals in completing application forms. Outreach is conducted by a variety of individuals and in a variety of settings. Each feature of the three-pronged outreach approach is described below:

• Statewide media campaigns and initiatives - The media campaigns focus on informing individuals about the availability of ALL Kids and what they have to offer as well as providing information regarding where applications or other information may be obtained. Additionally, ALL Kids staff attend a wide variety of association meetings and conferences to inform memberships of the availability of children’s health insurance. The staff have developed specialized outreach materials (from videos to informational brochures and flyers to specific handouts) for specific groups to meet their needs.

Staff have exhibited at booths and presentations to the Medical Association of the State of Alabama, Alabama Chapter of the American Academy of Pediatrics, Family Practice Physicians, Dentists, Social Workers, Department of Human Resources staff, Mental Health staff, Family Law Judges, Hospitals, Hospital auxiliaries, WIC staff, Public Health Staff, etc.

• Outreach conducted by multi-county regional workers and consultants – since the Spring of 2002, ALL Kids consultants have been and/are employed throughout the state, to disseminate information about the program to develop coalitions and networks of local residents to assist individuals in completing and submitting applications. These regional coordinators, their supervisory directors, and consultants are many times based in the county health departments but also utilize numerous off-site locales and alternative working hours.

• Outreach conducted through existing programs and agencies - Information about CHIP, applications, and application assistance are available through existing child-related programs such as the Child Care Management Agencies and their targeted child day care centers, Food Stamps, Maternal and Child Health Block Grant Program clinics, WIC clinics, community health centers, Indian Health Services, school nurse programs, school counselor programs, Early Intervention programs, other social service agencies, etc. These programs and agencies have successful histories of serving the target population and the CHIP program utilizes their contact with this population to broaden outreach efforts. Dissemination of CHIP information to these entities has been facilitated since representatives of these agencies and programs served on the CHIP Advisory Council and continue to be in contact with CHIP as stakeholders.

Phase III - ALL Kids PLUS Outreach for this special population is conducted primarily by the ALL Kids PLUS authorizing agencies. Outreach includes educating primary and specialty care physicians regarding ALL Kids PLUS, identifying and contacting children who may need PLUS services through reviews of agency rolls and possible reviews of the pediatric health histories (part of the application process), contact with community health centers, etc. Information about ALL Kids PLUS is incorporated into all publications and presentations.

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October 1, 2009 30 Approval Date: November 19, 2010

In an effort to continually improve the ALL Kids PLUS, CHIP staff continue to meet with the ALL Kids PLUS participating agencies to identify and resolve any problematic areas and to recruit additional participating agencies. PLUS agencies assist the CHIP staff in developing contracts, performance standards, and procedures for ongoing monitoring and oversight of the ALL Kids PLUS program.

NOTE: The application form and other materials have been translated into Spanish. Additionally, the ALL Kids enrollment unit employs a Spanish-speaking staff member and a Hispanic consultant has been hired to develop a Hispanic outreach plan.

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October 1, 2009 31 Approval Date: November 19, 2010 Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

∼

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 7.

6.1. The state elects to provide the following forms of coverage to children: (Check all that apply.) (42CFR 457.410(a))

6.1.1. X Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420) 6.1.1.1. ∼ FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) 6.1.1.2. ∼ State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.1.3. X HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.) The benefit package offered by the health maintenance organization with the largest insured commercial, non-Medicaid enrollment of covered lives was selected after several well attended public meetings where the benefits of the three benchmark plans were compared with the assistance of the insurers/administrators for the three plans. The benefit plan was altered slightly to make it more appropriate for children’s needs. An updated description of the ALL Kids basic benefits package, effective October 1, 2003, and be found in Attachment A.

In addition to the ALL Kids basic benefits package, additional benefits may be available for enrollees who have special needs. These additional benefits are known as ALL Kids PLUS benefits and are only available as prescribed by ALL Kids PLUS authorizing agencies. These decisions regarding what benefits are provided, the requirements for their receipt, and the provision of the benefits is under the auspices of the PLUS authorizing state agencies. These state agencies are those with which CHIP has a contract for the provision of ALL Kids PLUS services, those agencies that ordinarily serve children with special health care conditions and needs, and which provide the matching funds for federal CHIP funding. A description of the ALL Kids PLUS benefits package can be found in Attachment B.

6.1.2. ∼ Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430) Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Please attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431. See instructions

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October 1, 2009 32 Approval Date: November 19, 2010 6.1.3. ∼ Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) [Only applicable to New York; Florida; Pennsylvania] Please attach a description of the benefits package, administration, date of enactment. If existing comprehensive state-based coverage is modified, please provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of 8/5/97 or one of the benchmark plans. Describe the fiscal year 1996 state expenditures for existing comprehensive state-based coverage.

6.1.4. ∼ Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) 6.1.4.1.  Coverage the same as Medicaid State plan 6.1.4.2.  Comprehensive coverage for children under a Medicaid Section 1115 demonstration project 6.1.4.3.  Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population 6.1.4.4. X Coverage that includes benchmark coverage PLUS additional coverage In the second amendment to the Alabama CHIP State Plan, ALL Kids PLUS was established which provided additional benefits for children with special health care conditions/needs. Attachment D contains a detailed description of the ALL Kids PLUS component of CHIP. 6.1.4.5.  Coverage that is the same as defined by existing comprehensive state-based coverage 6.1.4.6.  Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7.  Other (Describe)

6.2.

The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490) A description of the scope, amount and duration of services covered under ALL Kids and ALL Kids PLUS, as well as any exclusions and limitations can be found in Attachments A and B, respectively. 6.2.1. X Inpatient services (Section 2110(a)(1)) 6.2.2. X Outpatient services (Section 2110(a)(2)) 6.2.3. X Physician services (Section 2110(a)(3))

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October 1, 2009 33 Approval Date: November 19, 2010 6.2.4. X Surgical services (Section 2110(a)(4)) 6.2.5. X Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) 6.2.6. X Prescription drugs (Section 2110(a)(6)) 6.2.7. ∼ Over-the-counter medications (Section 2110(a)(7)) 6.2.8. X Laboratory and radiological services (Section 2110(a)(8)) 6.2.9. X Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9)) 6.2.10.X Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10)) 6.2.11. X Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11) 6.2.12. X Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12)) 6.2.13. X Disposable medical supplies (Section 2110(a)(13)) 6.2.14. X Home and community-based health care services (See instructions) (Section 2110(a)(14)) 6.2.15. X Nursing care services (See instructions) (Section 2110(a)(15)) 6.2.16. ∼ Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16) 6.2.17. X Dental services (Section 2110(a)(17)) 6.2.18. X Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) 6.2.19. X Outpatient substance abuse treatment services (Section 2110(a)(19)) 6.2.20. X Case management services (Section 2110(a)(20)) 6.2.21. X Care coordination services (Section 2110(a)(21)) 6.2.22 X Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22)) 6.2.23. X Hospice care (Section 2110(a)(23)) 6.2.24. X Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24)) 6.2.25. ∼ Premiums for private health care insurance coverage (Section 2110(a)(25))

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October 1, 2009 34 Approval Date: November 19, 2010 6.2.26. X Medical transportation (Section 2110(a)(26)) 6.2.27. X Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27)) 6.2.28. X Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28))

Transplantation Services

Emergency and Urgent Care Services

Skilled Nursing Services

Vision Services

6.2.-D The State will provide dental coverage to children through one of the following. Dental services provided to children eligible for dental-only supplemental services must receive the same dental services as provided to otherwise eligible CHIP children (Section 2103(a)(5)):

6.2.1.-D ~ X State Specific Dental Benefit Package. The State assures dental services represented by the following categories of common dental terminology (CDT) codes are included in the dental benefits: 1. Diagnostic (i.e., clinical exams, x-rays) (CDT codes: D0100-D0999) (must follow periodicity schedule) 2. Preventive (i.e., dental prophylaxis, topical fluoride treatments, sealants) (CDT codes: D1000-D1999) (must follow periodicity schedule) 3. Restorative (i.e., fillings, crowns) (CDT codes: D2000-D2999) 4. Endodontic (i.e., root canals) (CDT codes: D3000-D3999) 5. Periodontic (treatment of gum disease) (CDT codes: D4000-D4999) 6. Prosthodontic (dentures) (CDT codes: D5000-D5899, D5900-D5999, and D6200-D6999) 7. Oral and Maxillofacial Surgery (i.e., extractions of teeth and other oral surgical procedures) (CDT codes: D7000-D7999) 8. Orthodontics (i.e., braces) (CDT codes: D8000-D8999) 9. Emergency Dental Services

ALL Kids utilizes the BCBS of Alabama preferred Dental Network. Reimbursement for services delivered to ALL Kids' enrollees is paid based on the preferred dental network fee schedule. All network dentists agree to accept this as payment in full, with the exception of enrollee co-pays (no copays on preventive or diagnostic services).

When costs are expected to exceed $1500 for a calendar year, ALL Kids utilizes a prior authorization process to ensure medically necessary services are provided. Costs associated with diagnostic and preventive services are excluded from this $1500 threshold. The amount is calculated by totaling the amount paid in dental claims minus the amount paid for preventive and diagnostic dental services.

If an enrollee is in need of dental services beyond $1500 in a calendar year, providers are

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October 1, 2009 35 Approval Date: November 19, 2010 instructed to submit a predetermination request to BCBS. BCBS reviews all provider requests to determine dental necessity of services and ALL Kids provides final approval to pay for services exceeding $1500. Providers regularly utilize this process and payment by exception requests are routinely approved for dental services. Dentally necessary services are provided in a timely manner regardless of the time of year. There is no unnecessary carry-over of services that need immediate attention.

If a family would like to appeal the BCBS/ALL Kids decision regarding the application of “medically necessary,” there is an appeals process which is consistent with the requirements of 42 CFR 457.1160 (b) and in compliance with state laws, the Security Act of 1974 (ERISA) and all other applicable regulations of the Department of Labor Procedures. See attachment E for the Blue Cross and Blue Shield of Alabama Appeals Process.

6.2.1.2-D ~ Periodicity Schedule. The State has adopted the following periodicity schedule:  State-developed Medicaid-specific X American Academy of Pediatric Dentistry  Other Nationally recognized periodicity schedule  Other (description attached)

6.2.2-D ~ Benchmark coverage; (Section 2103(c)(5), 42 CFR 457.410, and 42 CFR 457.420)

6.2.2.1.-D ~  FEHBP-equivalent coverage; (Section 2103(c)(5)(C)(i)) (If checked, attach copy of the dental supplemental plan benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, please also attach a description of the services and applicable CDT codes)

6.2.2.2-D ~  State employee coverage; (Section 2103(c)(5)(C)(ii)) (If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, please also attach a description of the services and applicable CDT codes)

6.2.2.3.-D ~  HMO with largest insured commercial enrollment (Section 2103(c)(5)(C)(iii)) (If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, please also attach a description of the services and applicable CDT codes)

6.3 The state assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42CFR 457.480)

6.3.1. X The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR

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October 1, 2009 36 Approval Date: November 19, 2010 6.3.2. ∼ The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.4.2. of the template). Pre- existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe: Previously 8.6

6.4 Additional Purchase Options. If the state wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the state must address the following: (Section 2105(c)(2) and(3)) (42 CFR 457.1005 and 457.1010)

6.4.1. ∼ Cost Effective Coverage. Payment may be made to a state in excess of the 10% limitation on use of funds for payments for: 1) other child health assistance for targeted low-income children; 2) expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); 3) expenditures for outreach activities as provided in section 2102(c)(1) under the plan; and 4) other reasonable costs incurred by the state to administer the plan, if it demonstrates the following (42CFR 457.1005(a)):

6.4.1.1. Coverage provided to targeted low-income children through such expenditures must meet the coverage requirements above; Describe the coverage provided by the alternative delivery system. The state may cross reference section 6.2.1 - 6.2.28. (Section 2105(c)(2)(B)(i)) (42CFR 457.1005(b)) 6.4.1.2. The cost of such coverage must not be greater, on an average per child basis, than the cost of coverage that would otherwise be provided for the coverage described above.; Describe the cost of such coverage on an average per child basis. (Section 2105(c)(2)(B)(ii)) (42CFR 457.1005(b))

6.4.1.3. The coverage must be provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under section 1886(c)(5)(F) or 1923 of the Social Security Act. Describe the community based delivery system. (Section 2105(c)(2)(B)(iii)) (42CFR 457.1005(a))

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October 1, 2009 37 Approval Date: November 19, 2010 6.4.2. ∼ Purchase of Family Coverage. Describe the plan to purchase family coverage. Payment may be made to a state for the purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low-income children, if it demonstrates the following: (Section 2105(c)(3)) (42CFR 457.1010)

6.4.2.1. Purchase of family coverage is cost-effective relative to the amounts that the state would have paid to obtain comparable coverage only of the targeted low-income children involved; and (Describe the associated costs for purchasing the family coverage relative to the coverage for the low income children.) (Section 2105(c)(3)(A)) (42CFR 457.1010(a)) 6.4.2.2. The state assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42CFR 457.1010(b)) 6.4.2.3. The state assures that the coverage for the family otherwise meets title XXI requirements. (42CFR 457.1010(c))

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October 1, 2009 38 Approval Date: November 19, 2010 Section 7. Quality and Appropriateness of Care

∼ Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 8.

7.1. Describe the methods (including external and internal monitoring) used to assure the quality and appropriateness of care, particularly with respect to well-baby care, well- child care, and immunizations provided under the plan. (2102(a)(7)(A)) (42CFR 457.495(a))

The State utilizes the expertise within the University of Alabama at Birmingham (UAB) School of Public Health in the implementation of the assessment of the ALL Kids program. Quality and appropriateness of care is assessed through the use of surveys such as a new enrollee survey, a continuous enrollee survey, and a disenrollee survey. Both process measures as well as outcome measures are considered when assessing the quality and appropriateness of care. CHIP also reviews claims data for quality assessment. Among the items used in tracking are the use of several claims data indicators such as whether or not children truly have a "medical home"; how well they are adhering to the recommended scheduled well-child exams; whether or not they are appropriately immunized; whether or not non-trauma based emergency room use is going down; how referrals are being made and if specialty care and related services are being received; and, patterns of prescription drug use. The State is also considering using other databases that can provide general indicators of child health and well-being such as the State’s immunization registry, adolescent pregnancy rates and health care utilization patterns identifiable off birth certificates, and the results of child death review efforts. Alabama monitors customer/patient/provider satisfaction through the use of surveys and informal communications with families, advocacy groups, and providers.

In addition to these monitoring strategies, the State assures access to care through monitoring of the provider network and benefit package design. Program staff are actively involved in identifying new providers for the ALL Kids network and have been particularly involved in the addition of pediatric dentists, primary care nurse practitioners, community mental health centers and emergency transportation providers. Geographic distribution of providers is monitored and is crucial when decisions regarding vendor choice are made.

The ALL Kids benefits package requires preauthorization only for hospitalization services. Therefore, access to all primary care providers and specialists is open to all enrollees without referral. Claims data are monitored by program staff to ensure quality and appropriateness of care. In addition, the State employs a masters level social worker to assist families who are experiencing difficulties accessing necessary services due to benefit structure or provider geographic availability. This staff member works closely with case managers at the vendor to identify areas in need of attention and provides the State with recommendations for benefit plan adjustment and/or provider network issues.

The ALL Kids PLUS program coordinates the evaluation of quality and appropriateness of care with the ALL Kids PLUS authorizing agencies and CSHCC/N advocacy groups through

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October 1, 2009 39 Approval Date: November 19, 2010 collaboration with stakeholders. It is also anticipated that an evaluation of ALL Kids PLUS may become part of the UAB evaluation in the future.

Will the state utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.) 7.1.1. ∼ Quality standards 7.1.2. X Performance measurement The State ensures quality through contracted performance measures. These measures have been adapted in conjunction with the standards recommended by the AAP. 7.1.3. X Information strategies Vendors are required to provide key health indicators information. 7.1.4. X Quality improvement strategies The performance guarantees and provider recoupment policy were included in the RFP and are included in the contract with the health plan. 7.2. Describe the methods used, including monitoring, to assure: (2102(a)(7)(B)) (42CFR 457.495)

7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a)) Access is monitored through a number of methods including the following:

Periodic review of the number and types of providers by county

Quarterly review of claims data

Quarterly review of new enrollee, continuous enrollee, and disenrollee survey data

Feedback from families via telephone, e-mail, and postal service mail

Feedback from providers

Further, the state uses claims data to monitor well-baby care as is described in 7.1.

7.2.2 Access to covered services, including emergency services as defined in 42 CFR 457.10. (Section 2102(a)(7)) 42CFR 457.495(b)) Access is monitored through a number of methods including the following:

Quarterly review of claims data

Quarterly review of new enrollee, continuous enrollee, and disenrollee survey data

Feedback from families via telephone, e-mail, and postal service mail

Feedback from providers

Feedback from the CHIP Social Work Consultant

Further, the state uses claims data to monitor emergency room use as is described in 7.1.

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate

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October 1, 2009 40 Approval Date: November 19, 2010 number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42CFR 457.495(c)) Access is monitored through a number of methods including the following:

Periodic review of the number and types of providers by county

Quarterly review of claims data

Quarterly review of new enrollee, continuous enrollee, and disenrollee survey data

Feedback from families via telephone, e-mail, and post service mail

Feedback from providers

Feedback from CSHCC/N advocates and ALL Kids PLUS providers

The ALL Kids PLUS network includes State agencies that serve children with special health care needs/conditions and that contract with CHIP to provide state matching funds for ALL Kids enrollees who use PLUS services. Currently, Children Rehabilitation Services is the only active PLUS program. The PLUS agency provides ALL Kids children with an individual case manager who will monitor access to specialists and treatment.

In general, the Medicaid standards will be used to establish qualifications for ALL Kids PLUS case management staff. All case management staff will meet specific qualifications, including education, training and appropriate credentialing which will be established by the participating agencies.

In most circumstances, the agencies’ delivery systems are discrete and clear which program provides services for specific conditions. However, where there is potential for overlap in responsibilities, the determination of which agency will provide case management will be done based on the needs of the child with input from the family and by determining what is in the best interest of the child. The agencies using the case management process, will coordinate with each other, the child, the family, and the care providers in determining if a change in case management is needed.

7.2.4 Decisions related to the prior authorization of health services are completed in accordance with state law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR 457.495(d)) The health plan vendor has policies in place to assure that prior authorization of health services are completed in accordance with state law or regulations promulgated by the Department of Labor. CHIP staff receive feedback from providers and enrollee families if time periods are exceeded. All prior authorization of health services is in accordance with state laws.

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October 1, 2009 41 Approval Date: November 19, 2010 Section 8. Cost Sharing and Payment (Section 2103(e))

∼ Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 9.

8.1. Is cost-sharing imposed on any of the children covered under the plan? (42CFR 457.505)

8.1.1. X YES 8.1.2. ∼NO, skip to question 8.8.

8.2. Describe the amount of cost-sharing, any sliding scale based on income, the group or groups of enrollees that may be subject to the charge and the service for which the charge is imposed or time period for the charge, as appropriate. (Section 2103(e)(1)(A)) (42CFR 457.505(a), 457.510(b) &(c), 457.515(a)&(c)) There will not be any cost sharing of any type for families who are Native Americans or Alaskan Natives. For all other families cost sharing will be as follows in 8.2.1. and 8.2.3.:

8.2.1. Premiums: There are three (3) categories of enrollees: No Fee (Native Americans and Alaskan Natives). Low-Fee (children with family incomes from the base through 150% FPL), and Fee (children with family incomes from 151% FPL through 300% FPL). There is no cost sharing for children in the NO Fee group. There is a $50 premium per child, per year for children in the Low-Fee group. There is a $100 premium per child, per year for children in the Fee group. Premiums can be paid in one payment or in periodic payments (weekly, monthly, quarterly…) throughout the year. A family’s total premium payments do not exceed three times the individual premium rate (i.e. $150 or $300 depending upon the income level of the family). Enrollment data systems do not allow for a family to be billed in excess of these amounts.

8.2.2. Deductibles: None 8.2.3. Coinsurance or copayments: There are no copayments for preventive services. The only permitted copayments are:

Service Low Fee Group Co-pays (for Children with Incomes < 150% FPL) Fee Group Co-pays (for Children with Incomes >150% FPL)

Dental $3/visit $5/visit

Doctor’s office visits $3/visit $5/visit

ER Services $5/facility charge $15/facility charge

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October 1, 2009 42 Approval Date: November 19, 2010 Inpatient Services (Hospital) $5/confinement $10/confinement

Non-Emergency ER Services $10/visit $20/visit

Allergy Testing $5/lab visit $10/lab visit

Allergy Treatment $3/visit $5/visit

Ambulance $5/occurrence $10/occurrence

Mental and Nervous (Inpatient) $5/confinement $10/confinement

Outpatient Surgical Facility $5/visit $10/visit

Substance Abuse (Inpatient) $5/confinement $10/confinement

X-ray (Outpatient Facility) $3/total x-rays in 1 visit $5/total x-rays in 1 visit

In addition, a new three (3) tiered pharmacy benefit became effective October 1, 2003 for children in both the low fee and fee groups. Prescription drugs are now divided into three groups: generic, preferred brands, non-preferred brands. The designations “preferred” and “non-preferred” are assigned by the third party administrator (which is, at this time, Blue Cross Blue Shield of Alabama). When there is more than one drug in a certain pharmacological category and the drugs within the same category are determined to be equally effective, then the lowest cost drug in the category is named the “preferred” drug and the others are named “non-preferred.” The co-payment schedule is as follows:

Generic Brands Preferred Brands Non-Preferred Brands Low-Fee Group Co-Pays $1.00 $3.00 $5.00 Fee Group Co-pays $2.00 $5.00 $10.00

Copayments are described in Attachment A, the Benefits Booklet. There will be no cost sharing for ALL Kids Plus services.

8.2.4. Other:

8.3. Describe how the public will be notified, including the public schedule, of this cost- sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)((1)(B)) (42CFR 457.505(b)) All beneficiaries are notified of the cost sharing changes through letters mailed directly to the residence addresses on file in CHIP. In addition all stakeholders, including provider organizations/associations and state agencies, were also notified by letter. Further, a meeting of stakeholders was convened, prior to the cost-sharing changes, to discuss these changes.

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October 1, 2009 43 Approval Date: November 19, 2010 Premiums and co-pays are now listed in the Benefit Booklet revised 10/1/03 (Attachment A). Regional workers and administrative staff who answer phone inquiries are trained to discuss with families the premiums and co-payments required, and the $500 annual limit.

8.4. The state assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e))

8.4.1. X Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530) 8.4.2. X No cost-sharing applies to well-baby and well-child care, including age-appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520) 8.4.3 X No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42CFR 457.515(f))

8.5. Describe how the state will ensure that the annual aggregate cost-sharing for a family does not exceed 5 percent of such family’s income for the length of the child’s eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the state for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e))

Alabama ensures that the annual aggregate cost-sharing for a family does not exceed five percent (5%) of a family’s income as is required by Section 2103(3)(B) of Title XXI. In addition, cost sharing both premiums and co-payments, for children in families with incomes less than 150% FPL, are in compliance with CHIP regulations.

There is minimal cost sharing for families, other than Native Americans and Alaskan Natives who have no cost sharing. No family is charged for more than three (3) premiums even if the family has more than three children.

To protect families against excessive medical expenses and comply with the statutory limit of no more than five percent of family income being expended on cost sharing expenses, ALL Kids has an annual $500 limit on out of pocket expenses per family. For a single parent family with three children at 150 percent of poverty the statutory maximum would be about $1,654 based on 2009 FPL. Because of the low premium and low copayment structure very few families, if any, are likely to exceed the $500 limit on out of pocket expenses and would certainly not approach the 5 percent of income limit. Families are informed in all literature and outreach workers are trained to educate families about the $500 limit on out of pocket expenses. Families will be encouraged to keep receipts for all copayments and premiums in a “shoe box” method so that once the $500 maximum is reached they will have the necessary documentation to stop cost-sharing. If a family reaches this $500 limit and notifies the ALL Kids program of this, new insurance cards will be issued, to the family, which state that the child(ren) are not subject to any co-pays.

Model Application Template for the State Children’s Health Insurance Program

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October 1, 2009 44 Approval Date: November 19, 2010 8.6 Describe the procedures the state will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42CFR 457.535) If a child is identified on an application as an American Indian, the enrollment worker automatically places the child in the no-fee category if the child becomes enrolled. Therefore the insurance vendor sends an insurance card, to the family, which indicates that the child is not subject to any co-pays.

8.7 Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c)) At ten months into the enrollment period, the family is sent renewal materials which include a statement regarding any outstanding premium payment due along with the date current coverage terminates. Premium payments may be received at anytime throughout the enrollment period. However, if premiums are not paid in full by the end of the enrollment period, the child will not be eligible for renewal. An exception to this is made for families who have filed for bankruptcy during the enrollment year. At the time of renewal, if a family requests that its premium balance be forgiven, forgiveness will be granted if the family submits proof of bankruptcy status. Premiums will be removed 24 months after an enrollee’s coverage end date unless the child turned 19 while on the program in which case the premium is removed 12 months after the enrollee’s coverage end date. The state does not participate in collection action or impose benefit limitations if enrollees do not pay copayments/coinsurance.

8.7.1 Please provide an assurance that the following disenrollment protections are being applied: X State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a)) At one month, four months, seven months, and 10 months, families are notified of any outstanding premium payments. They are notified that premiums must be paid in full in order to renew at the end of the enrollment period.

X The disenrollment process affords the enrollee an opportunity to show that the enrollee’s family income has declined prior to disenrollment for non-payment of cost-sharing charges. (42CFR 457.570(b)) The amount of family income written on the renewal form is reviewed by enrollment workers at the time of renewal. If it is known to ALL Kids that a family is experiencing financial difficulty, the ALL Kids Social Work Consultant and/or ALL Kids Regional staff may assist

Model Application Template for the State Children’s Health Insurance Program

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October 1, 2009 45 Approval Date: November 19, 2010 the family in locating assistance from premium payment. Non-payment of premiums is forgiven if the family provides proof of bankruptcy status during the enrollment period.

X In the instance mentioned above, that the state will facilitate enrolling the child in Medicaid or adjust the child’s cost-sharing category as appropriate. (42CFR 457.570(b)) At the time of renewal, if the family’s income has dropped but is still above the Medicaid eligibility level, if the decision is made to forgive the unpaid premium(s), the child is renewed and placed in the appropriate ALL Kids category. If a family’s income has dropped below the ALL Kids eligibility level, the application is automatically sent to Medicaid.

X The state provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42CFR 457.570(c)) This type of grievance is handled in the same impartial manner in which other grievances are handled as described in Attachment D.

8.8 The state assures that it has made the following findings with respect to the payment aspects of its plan: (Section 2103(e))

8.8.1. X No Federal funds will be used toward state matching requirements. (Section 2105(c)(4)) (42CFR 457.220) 8.8.2. X No cost-sharing (including premiums, deductibles, copays, coinsurance and all other types) will be used toward state matching requirements. (Section 2105(c)(5) (42CFR 457.224) (Previously 8.4.5) 8.8.3. X No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under the this title. (Section 2105(c)(6)(A)) (42CFR 457.626(a)(1)) 8.8.4. X Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)) (42CFR 457.622(b)(5)) 8.8.5. X No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. (Section 2105)(c)(7)(B)) (42CFR 457.475) 8.8.6. X No funds provided under this title will be used to pay for any abortion or to assist in the purchase, in whole or in part, for coverage that includes abortion (except as described above). (Section 2105)(c)(7)(A)) (42CFR 457.475)

Model Application Template for the State Children’s Health Insurance Program

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October 1, 2009 47 Approval Date: November 19, 2010 Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107)

9.1. Describe strategic objectives for increasing the extent of creditable health coverage among targeted low-income children and other low-income children: (Section 2107(a)(2)) (42CFR 457.710(b))

1. The number of low-income (<200% FPL), uninsured children in AL will be reduced each year.

2. Given available funding, the number of low income (between the Medicaid eligibility upper income levels and 200% FPL), children enrolled in ALL Kids will be maintained at at least 50,000 (current enrollment) at any given time.

3. The number of low-income children (incomes in the Medicaid income eligibility ranges) enrolled in SOBRA Medicaid will be maintained at at least 300,000.

4. Enrollment in ALL Kids will result in more children having a medical home.

5. Enrollment in ALL Kids will result in a higher usage of preventive care.

6. Specialty services beyond the basic ALL Kids coverage package will be available for ALL Kids enrolled children with special health care needs.

9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c)) 1. Performance Goals for Objective 1: a. The number of low-income uninsured children in AL will be reduced by 1% each year until the number of low-income uninsured children is no larger than 10% of the children in the state. b. A tracking system will be established by April 2004, which will track applicants referred among ALL Kids, SOBRA Medicaid, and the Alabama Child Caring Foundation.

2. Performance Goals for Objective 2 a. The percentage of families who do not renew their children’s ALL Kids coverage due to a financial barrier (owing past premiums) will not be more than 3% annually. b. A higher percentage of families with ALL Kids enrolled child(ren), report that financial barriers to accessing care have been reduced since enrollment in ALL Kids in comparison to the time before enrollment in ALL Kids. c. Plans which target outreach activities toward specific populations: (adolescents, Native Americans, and faith-based organizations) will be developed by October, 2002.

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October 1, 2009 48 Approval Date: November 19, 2010 d. Plans which target outreach activities toward specific populations: (adolescents, Native Americans, and faith-based organizations) will be implemented each year beginning with FY 2003. e. Plans which target outreach activities toward Hispanics, birth-to-five care providers, and Native Americans will be developed by January 1, 2004. f. Plans which target outreach activities toward Hispanics, birth-to-five care providers, and Native Americans will be implemented each year beginning with FY 2005. g. Plans which target outreach activities toward specific populations (other than adolescents, faith-based organizations, Hispanics, birth-to-five care providers, and Native Americans) will be developed and implemented as data or other information indicate. h. Language and culture will not be barriers to enrollment or renewal as evidenced by the availability of telephone assistance in the customers’ preferred languages, brochures and forms in both English and Spanish, and the availability of Spanish speaking, culturally competent customer service staff. i. There will be an incremental reduction from year to year, in the percentage of children canceling ALL Kids coverage due to nonparticipation in the renewal process.

3. Performance Goal for Objective 3: There will be maintenance of effort or an increase, on the part of CHIP, to decrease the number of uninsured low-income (Medicaid eligible) children as evidenced by at least the following:

i. Continued use of a joint application form. ii. Continued use of a joint renewal form iii. Continued referral, without any barriers, of applications and renewals between ALL Kids and SOBRA Medicaid iv. Continued outreach efforts by CHIP staff for network building with community groups, professionals (individually and in groups), child care providers, schools, etc. v. Continued evaluation and monitoring of the application transfer/referral process between ALL Kids and Medicaid. vi. Continued computer enhancements to improve the communication with other agencies and current and potential ALL Kids enrollees.

4. Performance Goals for Objective 4: a. A higher percentage of families report that their ALL Kids enrolled child(ren) have a usual source of care since enrollment in ALL Kids than before enrollment in ALL Kids. b. A lower percentage of families report that their ALL Kids enrolled child(ren) have used a hospital emergency room since enrollment in ALL Kids than before enrollment in ALL Kids.

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October 1, 2009 49 Approval Date: November 19, 2010

5. Performance Goals for Objective 5 a. A higher percentage of families report that their ALL Kids enrolled child(ren) have had a well child check-up in the past year since enrollment in ALL Kids than before enrollment in ALL Kids. b. A higher percentage of families report that their ALL Kids enrolled child(ren) have had a dental visit in the past year since enrollment in ALL Kids than before enrollment in ALL Kids. c. A higher percentage of families report that their ALL Kids enrolled child(ren) have had a vision screening in the past year since enrollment in ALL Kids than before enrollment in ALL Kids.

6. Performance Goal for Objective 6: a. Contracts with state agencies which serve children with special health care needs will be maintained for the purpose of providing specialty services beyond the basic ALL Kids coverage package for these children. b. Exploration of the feasibility of establishing contracts with other state agencies that serve children with special health care needs. c. Continued monitoring of access to specialty care for children with special health care needs.

9.3. Describe how performance under the plan will be measured through objective, independently verifiable means and compared against performance goals in order to determine the state’s performance, taking into account suggested performance indicators as specified below or other indicators the state develops: (Section 2107(a)(4)(A),(B)) (42CFR 457.710(d))

Assurance of an Objective Means for Measuring Performance To ensure an objective evaluation which can be independently verified, the evaluation will be based upon data bases which contain quantifiable information. These databases will, to the extent possible, contain numeric data. The ADPH will develop and/or direct the development of needed databases which do not currently exist. Since evaluation of some performance measures does not lend itself to numeric summation, measurement of these aspects of the plan will be based on review of a completed work plan which requires conclusive documentation. All data and documentation will be auditable.

At periodic intervals, a formal comparison of program performance to the goals and measures set forth in this document or its subsequent amendments will be conducted. The CHIP staff directly responsible for the implementation of the program will conduct information comparisons of performance to these goals and measures on an ongoing basis. In this way, the program will be continuously monitored and activities may be adjusted so that the program may achieve its objectives.

Model Application Template for the State Children’s Health Insurance Program

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October 1, 2009 50 Approval Date: November 19, 2010 Measure of Performance: MEASURE ROUGH DEFINITION OF MEASURE

Reducing the Number of Uninsured Number of Uninsured CPS and/or NSAF and state data survey Tracking System Documentation that a tracking system exists and is used for 100% of the applications that are referred among ALL Kids, Medicaid, and Alabama Child Caring Foundation Related to SCHIP Enrollment Percentage of families not renewing due to owing past premiums Renewal database – comparison of number of non- renewals who owed premiums to the number who were due to renew. Percentage of families reporting a reduction in financial barriers to accessing health care New enrollee survey database – comparison of percentage of reports indicating a reduction in financial barriers to obtaining health care post-ALL Kids to pre-ALL Kids Development of plans to target outreach to adolescents, faith-based organizations Documentation of development of these plans on file Implementation of plans to target outreach to adolescents, faith-based organizations Documentation of implementation of these plans on file Development of plans to target outreach to Hispanics, Native Americans, and birth-to-five providers Documentation of development of these plans on file

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October 1, 2009 51 Approval Date: November 19, 2010 Implementation of plans to target outreach to Hispanics Native Americans, and birth-to-five providers Documentation of implementation of these plans on file Development and implementation of plans to target outreach to other groups Documentation of development and implementation of these plans on file Elimination of language and culture barriers Spanish and English brochures and applications forms on file Employment of bi-lingual customer service staff ALL Kids Customer service telephone operators are aware of and know how to use a telephone translating service. Reduction in percentage of children canceling ALL Kids due to nonparticipation in the renewal process Enrollment Data Management system – Comparison of number of enrollees who did not participate in the renewal process to those due to renew. Related to increasing Medicaid Enrollment Maintenance of effort with regard to: Use of a joint application form A joint SOBRA Medicaid and ALL Kids application form is in use Use of a joint renewal form A joint SOBRA Medicaid and ALL Kids renewal form is in use

Model Application Template for the State Children’s Health Insurance Program

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October 1, 2009 52 Approval Date: November 19, 2010 Seamless referral between ALL Kids and SOBRA Medicaid Seamless referral policy in place Continued outreach effort Outreach/Marketing files reflect outreach conducted by central office staff, regional staff, and federal program office. Evaluation of application transfer and referral process Evaluation on files of meeting minutes Continued computer enhancements Computer enhancements will be in place. Related to increasing access to care Reported usual source of care New Enrollees Survey Reported ER use New Enrollees Survey Related to use of preventive care

Reported use of well-child check-up New Enrollees Survey Reported dental visit New Enrollees Survey Reported vision screening New Enrollees Survey Other

Specialty service availability Contract(s) on file Exploration of feasibility for establishing contracts with other CSHCN state agencies Documentation on file (central office files and/or regional coordinator files) Monitoring access to care for CSHCN New Enrollees Survey

Model Application Template for the State Children’s Health Insurance Program

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October 1, 2009 53 Approval Date: November 19, 2010 Check the applicable suggested performance measurements listed below that the state plans to use: (Section 2107(a)(4)) 9.3.1. X The increase in the percentage of Medicaid-eligible children enrolled in Medicaid. 9.3.2. X The reduction in the percentage of uninsured children. 9.3.3. X The increase in the percentage of children with a usual source of care. 9.3.4. ∼ The extent to which outcome measures show progress on one or more of the health problems identified by the state. 9.3.5. ∼ HEDIS Measurement Set relevant to children and adolescents younger than 19. 9.3.6. ∼ Other child appropriate measurement set. List or describe the set used. 9.3.7. ∼ If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as: 9.3.7.1. ∼ Immunizations 9.3.7.2. X Well child care 9.3.7.3. ∼ Adolescent well visits 9.3.7.4. X Satisfaction with care 9.3.7.5. ∼ Mental health 9.3.7.6. ∼ Dental care 9.3.7.7. ∼ Other, please list: Please see 7.1 and 7.2 9.3.8. ∼ Performance measures for special targeted populations.

9.4. X The state assures it will collect all data, maintain records and furnish reports to the Secretary at the times and in the standardized format that the Secretary requires. (Section 2107(b)(1)) (42CFR 457.720) Alabama assures it will collect all data, maintain records and furnish reports to the Secretary at the times and in the standardized format that the Secretary requires.

9.5. X The state assures it will comply with the annual assessment and evaluation required under Section 10. Briefly describe the state’s plan for these annual assessments and reports. (Section 2107(b)(2)) (42CFR 457.750) Alabama assures it will comply with the annual assessment and evaluation required under Section 10. On an annual basis, the Alabama will review its operations, progress made in reducing the number of uncovered low-income children, progress made in meeting the goals and objectives stated in 9.1 and 9.2 of this document, and its compliance with applicable Federal laws and regulations. Section 9.3 states how Alabama will measure the goals and

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October 1, 2009 54 Approval Date: November 19, 2010 objectives in sections 9.1 and 9.2. Examples of data sources are: Census data, private foundation garnered data, data gathered via special surveys, utilization data from claims reports, enrollee family feedback from surveys, etc. The assessment will occur during the three months after the end of the fiscal year and a report of this assessment will be submitted to the Secretary by January 1 following the end of the fiscal year.

9.6. X The state assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit. (Section 2107(b)(3)) (42CFR 457.720) Alabama assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit.

9.7. X The state assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed. (42CFR 457.710(e)) Alabama assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed.

9.8. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.135)

9.8.1. X Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2. X Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment) 9.8.3. X Section 1903(w) (relating to limitations on provider donations and taxes) 9.8.4. X Section 1132 (relating to periods within which claims must be filed)

9.9.Describe the process used by the state to accomplish involvement of the public in the design and implementation of the plan and the method for insuring ongoing public involvement. (Section 2107(c)) (42CFR 457.120(a) and (b)) Efforts were made to make the process of developing the design and implementation of the Children’s Health Insurance Program inclusive. News coverage about the advocacy of the Children’s Health Insurance Program was provided regularly starting at the time that the issue came before the Alabama Legislature.

Formalized CHIP development groups were the CHIP Commission and the CHIP Task Force Work Groups. The CHIP Commission met three times, October 7, November 12 and December 17, 1998. The CHIP Task Force Work Groups met twelve times beginning August 6, 1998, and split into subcommittees to develop proposals in the following areas: (1) benefits, (2)

Model Application Template for the State Children’s Health Insurance Program

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October 1, 2009 55 Approval Date: November 19, 2010 eligibility, outreach and enrollment, and (3) funding. These subcommittee meetings were open to interested individuals and groups. At least three news conferences were held by the State Health Officer and/or the Medicaid Commissioner.

Public awareness was promoted through means such as television programs. Interested organizations such as Alabama ARISE, the Alabama Developmental Disabilities Planning Council, and Voices for Alabama’s Children were provided information for their membership about CHIP. Media coverage was provided and CHIP information has been made available on the Internet at: http://www.adph.org/allkids (formerly: http://www.alapubhealth.org) since October 2, 1998. During the first six and one-half month period of October 4 through April 21, 1998, 1,247 hits were made on this site specifically requesting CHIP information. This website includes a description of the program, a calendar of scheduled events, and an opportunity for interested persons to express their opinions about the program’s development. Order forms are available at every presentation. These forms enable participants to fax orders to the ALL Kids office and receive printed materials at no charge. The largest number of requests for information (312) came during the month of January. Newspaper editorials have praised the value of this program for our State’s children.

The CHIP Task Force Work Groups were comprised of employees of the Alabama Medicaid Agency, Public Health Department employees, and other interested parties including representatives of the Alabama Primary Care Association, Alabama ARISE, the Alabama Developmental Disabilities Planning Council, Voices for Alabama’s Children, the Alabama Child Caring Foundation, Alabama Dental Association, Alabama Hospital Association, Alabama Psychological Association, American Academy of Pediatrics-Alabama Chapter, Blue Cross Blue Shield, Children First, Children’s Health System, Children’s Hospital of Alabama, Family Voices, Health Maintenance Organization Association, Legislative Fiscal Office, Legislative Reference Service, Medical Association of the State of Alabama, University of Alabama at Birmingham, University of South Alabama, University of South Alabama Children’s and Women’s Hospital, United Health Care, as well as other State agencies including the Department of Education, the Department of Human Resources, the Department of Mental Health/Mental Retardation, State Employees’ Insurance Board, State Insurance Department, and the Department of Rehabilitation Services. These entities are now referred to as stakeholders and they continue to be involved as program changes are developed.

The Alabama program will continue to inform the general public about CHIP through the news media, to announce planning meetings, and to invite additional groups with an interest in being involved or informed as they become identified. There was extensive public involvement in the preparation of a comprehensive 133-page report which was released to the Alabama Legislature on January 12, 1998. In relation to the Governor’s Task Force on Children’s Health Insurance, periodic reports on the progress of recommendations contained the report are made.

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October 1, 2009 56 Approval Date: November 19, 2010 9.9.1 Describe the process used by the state to ensure interaction with Indian Tribes and organizations in the state on the development and implementation of the procedures required in 42 CFR 457.125. (Section 2107(c)) (42CFR 457.120(c)) A meeting was held with representatives of the 2,176 member Poarch Band of Creek Indians, the only federally recognized Native American group in Alabama. Six other tribes are recognized by the State. The CHIP Program was explained and discussion centered on ways to coordinate CHIP and Indian Health Service-funded care, the role of traditional Native American healing, outreach methods for children and some demographics of the Poarch Band. Several presentations have been made to the Alabama Commission on Indian Affairs and CHIP staff meet and coordinate regularly with staff of the Commission. Other forms of outreach have included numerous presentations to the tribes, presence at Native American festivals throughout the state and the employment of a Native American consultant whose specific task was to develop a regionally-based outreach plan to the Native American population in Alabama.

9.9.2 For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), please describe how and when prior public notice was provided as required in 457.65(b) through (d). Alabama has no state law applicable to public notice of either cost sharing changes or waiting list implementations in CHIP.

Public Notice of Cost Sharing Changes: Specific public notice was given via a meeting of CHIP stakeholders in August 2003 and letters to enrollees’ families informing them of the changes in cost sharing. This meeting and the mailings followed much publicity in the state regarding the state’s financial situation and the possible impact on CHIP if a statewide referendum to raise taxes on (September 9, 2003) did not pass.

Public Notice of the Waiting List: ALL Kids initiated a waiting list beginning with all new enrollees who would have had an effective date October 1, 2003. Once the decision had been made to establish a waiting list, a press statement was released and letters were sent to stakeholders and other interested parties informing them of the institution of a waiting list and stressing the importance of returning renewal forms on time. Additionally, a letter to this effect was sent to every enrollee family along with a new insurance card(s). All of these notices were issued during the month of September 2003 prior to the impact of the waiting list.

On August 23, 2004, ALL Kids reopened enrollment and discontinued use of the waiting list.

If the State determines that it is again necessary to implement a waiting list, it will provide prior, appropriate public notice.

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October 1, 2009 57 Approval Date: November 19, 2010 There are no public notice state laws regarding enrollment caps and waiting lists in SCHIP.

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October 1, 2009 58 Approval Date: November 19, 2010 9.10. Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42CFR 457.140  Planned use of funds, including -- - Projected amount to be spent on health services; - Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and - Assumptions on which the budget is based, including cost per child and expected enrollment.  Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees. CHIP Budget Plan FY2010

Enhanced FMAP rate 77.61 Federal Fiscal Year Costs Non-Federal plan expenditures Benefit Costs

Insurance payments

Managed care

Per member/per month $125 @ 711,807 member months of eligibles (end of FY 03 60,000 current enrollment)*

Fee for Service $ 172,241,610 Total Benefit Costs $ 172,241,610 (Offsetting beneficiary cost sharing payments) $ (4,346,339) Net Benefit Costs $ 167,895,271

Administration Costs

Personnel 5,010,689 General administration 2,676,420 Contractors/Brokers (e.g., enrollment contractors) 0 Claims Processing 0 Outreach/marketing costs 1,625,425 Other 687,466 Total Administration Costs 10,000,000 10% Administrative Cost Ceiling 18,655,030 Federal Share (multiplied by enh-FMAP rate) 138,064,520 State Share 39,830,751 TOTAL PROGRAM COSTS 177,895,271 State funding comes from three sources: State General Fund appropriations, Tobacco Settlement funds, and a private grant. A Robert Wood Johnson Foundation (RWJF) grant was awarded to Alabama to increase enrollment and retention of eligible children in Alabama’s health insurance programs, known as ALL Kids and SOBRA Medicaid (the Alabama Medicaid program for pregnant women and children). The grant is for $994,883 and the award dates are February 15, 2009 - February 14, 2013.

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October 1, 2009 59 Approval Date: November 19, 2010 Based on actuarial analysis the State does not anticipate any notable budgetary impact for FY2010 resulting from transitioning to PPS due to the relatively small percent of program claims expenditures attributable to FQHCs and RHCs. However, the State expects PPS expenditures to be higher than what was projected for fee for service expenditures to FQHCs and RHCs based on this analysis. For FY 2010, fee for service expenditures to FQHCs and RHCs are estimated to be between $402,000 - $431,000 with approximately 2,613- 2,750 medical visits and 719-757 dental visits. Replacing the cost of each visit with PPS rates, total projected expenditures become $459,000 - $483,000, resulting in approximately $52,000 – $56,000 more dollars.

It is estimated 55,000 members will utilize dental services during FY2010.

Section 10. Annual Reports and Evaluations (Section 2108)

10.1. Annual Reports. The state assures that it will assess the operation of the state plan under this Title in each fiscal year, including: (Section 2108(a)(1),(2)) (42CFR 457.750) 10.1.1. X The progress made in reducing the number of uncovered low- income children and report to the Secretary by January 1 following the end of the fiscal year on the result of the assessment, and

10.2. X The state assures it will comply with future reporting requirements as they are developed. (42CFR 457.710(e))

10.3. X The state assures that it will comply with all applicable Federal laws and regulations, including but not limited to Federal grant requirements and Federal reporting requirements.

Section 10.3-D X Specify that the State agrees to submit yearly the approved dental benefit package and to submit quarterly the required information on dental providers in the State to the Health Resources and Services Administration for posting on the Insure Kids Now! Website.

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October 1, 2009 60 Approval Date: November 19, 2010 *

Section 11. Program Integrity (Section 2101(a))

 Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue to Section 12.

11.1 X The state assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Section 2101(a)) (42CFR 457.940(b))

11.2. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.935(b)) The items below were moved from section 9.8. (Previously items 9.8.6. - 9.8.9) 11.2.1. X 42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents) 11.2.2. X Section 1124 (relating to disclosure of ownership and related information) 11.2.3. X Section 1126 (relating to disclosure of information about certain convicted individuals) 11.2.4. X Section 1128A (relating to civil monetary penalties) 11.2.5. X Section 1128B (relating to criminal penalties for certain additional charges) 11.2.6. X Section 1128E (relating to the National health care fraud and abuse data collection program)

* While the effective date for sections 1-10 of this plan is October 1, 2002, the effective date for this section is August 24, 2001

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

October 1, 2009 61 Approval Date: November 19, 2010 *

Section 12. Applicant and enrollee protections (Sections 2101(a))  Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan.

Eligibility and Enrollment Matters

12.1 Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120. Alabama’s appeals process meets the requirements of the Program Specific Review as outlined in CFR.457.1120 – 457.1180. The ALL Kids appeals and grievance process can be found in Attachment D. The individuals involved in the Information review (first level) are not involved in the Administrative Review (second level) thus impartiality in the appeals process is provided. The individuals who conduct the Administrative Review are not involved in the Information Review process not in the original determination process.

Health Services Matters

12.2 Please describe the review process for health services matters that complies with 42 CFR 457.1120. The State assures that the State laws or regulations are consistent with the intent of 42 CFR 457,1130(b). This grievance process for health service matters is provided by the insurance vendor and is in compliance with state laws, the Employee Retirement Income Security Act of 1974 (ERISA), and all other applicable regulations of the Department of Labor Procedures. The Blue Cross Blue Shield of Alabama appeals process can be found in Attachment E.

Premium Assistance Programs

12.3 If providing coverage through a group health plan that does not meet the requirements of 42 CFR 457.1120, please describe how the state will assure that applicants and enrollees have the option to obtain health benefits coverage other than through the group health plan at initial enrollment and at each redetermination of eligibility.

* While the effective date for sections 1-10 of this plan is October 1, 2002, the effective date for this section is August 24, 2001

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

October 1, 2009 62 Approval Date: November 19, 2010 ATTACHMENT C

ENROLLMENT UNIT

There have been two phases of the CHIP Program:

Phase 1: Medicaid Expansion – CHIP dollars were used to expand Medicaid services to children ages 14 through 18. CHIP money was used for this from February 1998 through the end of fiscal year 2002. The State Medicaid Agency determines the eligibility for this component using outstationed eligibility staff who are located throughout the state. While not responsible for the day-to-day administration of this portion of the CHIP program, ADPH works closely with Medicaid to ensure continued success.

Phase 2: ALL Kids – This part of the CHIP program provides insurance coverage to individuals meeting the following criteria:

a) Legal residents of the State of Alabama b) Under 19 years of age c) Family income above Medicaid income limits up to and including 200 % of the Federal Poverty Level (FPL). d) Not eligible for Medicaid e) Not covered under private group health insurance f) Not eligible for a state or public employee insurance coverage g) Not currently in a public institution h) U. S. citizen or eligible immigrant

From the beginning of the program in October 1998 until June 2001, the Alabama Department of Public Health (ADPH) contracted with the State Employees’ Insurance Board (SEIB) to determine eligibility for the ALL Kids portion of CHIP. In March 2001, through mutual agreement, the decision was made to transfer the staff and this function to the ADPH. This was accomplished in two phases. In June 2001 the transfer of personnel and eligibility determination functions took place and in September 2001 all remaining electronic transaction responsibilities and accounting responsibilities were transferred.

The enrollment unit is divided into three (3) functional sections: 1. Distribution – staff receive, open mail, and enter general applicant information into the enrollment database. 2. Application/Renewal Processing – staff review applications, enter remaining information, (check to see if premiums have been paid for renewals), verify applicant is not already enrolled in Medicaid, screen for Medicaid eligibility, and approve enrollment into ALL Kids as appropriate. If information is missing or needs clarification, staff will contact applicant by phone or in writing to obtain or clarify information. Appropriate letters are prepared informing applicant of enrollment or referral of the application.

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

October 1, 2009 63 Approval Date: November 19, 2010 3. Customer Service – staff respond to telephone inquiries about potential applicants, questions about eligibility, and general questions about benefits.

The following describes current procedures used to evaluate eligibility for ALL Kids:

Applications in self-addressed, stamped envelopes, for ALL Kids coverage are received through the postal service into a centralized enrollment unit. Applications are widely available from a variety of places in the community including county health departments, doctor’s offices and pharmacies, through the toll free number or by downloading from the Department’s website.

In the current ADPH system, employees enter all information found on the application into an internal Application Tracking and Eligibility Determination System. Applicants are groups by family unit and assigned a unique person identifier (this is different from SSN - we require SSN for applicants, but not parents). Family size and income are calculated by the automated system and Health Insurance Assistants ensure that these calculations are correct and approve the child for enrollment or refer them to the appropriate partner agency. If the child is ALL Kids eligible, the system transmits data of all approved applications to Blue Cross Blue Shield of Alabama for verification and enrollment in the health plan. Prior to enrollment, BCBS verifies that the applicant is not already enrolled in any other BCBS health insurance plan and therefore ineligible for ALL Kids coverage. Approximately 85% of the insured lives in Alabama have health insurance through BCBS. Therefore, this final check on eligibility is an efficient way to monitor and prevent crowd-out.

The Medicaid Electronic Data system is also accessed prior to award of coverage in order to determine if the applicant is currently enrolled in Medicaid. If this inquiry reveals that a child is currently on Medicaid the family is be notified that their child(ren) are not eligible for ALL Kids.

Notification is made to the applicant after eligibility is determined and those determined ineligible are referred to the appropriate health insurance program. Applications which appear to be eligible for Medicaid or ACCF are mailed at least weekly to these programs.

ALL Kids provides twelve months of continuous coverage for all enrolled children. At the end of this twelve-month period, participants must complete an annual renewal in order to remain enrolled in the program.

As of September 30, 2002 there were 52,495 participants in the ALL Kids program.

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

October 1, 2009 64 Approval Date: November 19, 2010 ATTACHMENT D

GRIEVANCE POLICY General Information

Applicants and enrollees of the ALL Kids Children’s Health Insurance Program (CHIP) have a right to discuss and question how eligibility for enrollment was determined. In particular they have the right to request review of program decisions concerning:

• Denial of eligibility • Failure to make a timely determination of eligibility • Suspension or termination of enrollment, including disenrollment for failure to pay premiums.

The ALL Kids Review Process has three levels of review--Information Review, Administrative Review and Formal Review. Requests for an Administrative Review and Formal Appeal must be submitted in writing. All correspondence with the applicant /enrollee concerning Administrative Review or Formal Review will be in writing.

ALL Kids Plus Services Requests for review of decisions made regarding eligibility for the ALL Kids Plus services must first be made to the ALL Kids Plus participating agency’s appropriate appeals process. This is necessary since eligibility for ALL Kids Plus is dependent on the participating agency’s eligibility criteria for services. Once the appeals process through the ALL Kids Plus participating agency has been exhausted, an appeal request may be made to the Children’s Health Insurance Program as described in ADPH ALL Kids Review Process.

Information Review In many cases problems can be handled informally through the Information Review Process without the need for a Administrative or Formal Review. CHIP staff is committed to using the Information Review process to provide a speedy and fair resolution when possible and appropriate.

Parents/designated representatives can initiate an Information Review via contact (telephone, e- mail or letter) with the Enrollment Unit supervisory staff, CHIP administrative staff, the CHIP social work consultant, CHIP regional staff, or interested agencies. Once the problem has been received, the appropriate staff will review the situation and initiate immediate action to resolve the problem and communicate the decision or resolution. If additional information is needed, the enrollee/applicant will be given the opportunity to provide clarification or submit additional information. Decisions made in the Information Review are usually provided within two working days. Notification to the applicant/enrollee will be communicated in the manner in which the request was made. Summation of the inquiry, review and resolution will be maintained on file and noted with the appropriate applicant/enrollee information.

If the problem remains unresolved in the eyes of the applicant/enrollee, they will be provided detailed information regarding their right to a Administrative Review, right to continued

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

October 1, 2009 65 Approval Date: November 19, 2010 enrollment during the review process and provided copies of all forms and the procedures necessary to move forward through the review process. Appropriate notation will be kept in the applicant’s/enrollee’s electronic file noting the initial complaint, any information gathered during the Information Review, the decision reached through Information Review, the date of such decision and the applicant/enrollees intent to go forward with the Administrative Review Process.

Administrative Review In order to be considered, an Administrative Review Request Form must be received within ten (10) days of the final decision from the Information Review. The CHIP social work consultant will assist in gathering information that may clarify the request. All information on file from the Information Review and any information gathered by the CHIP Social Work consultant will be circulated to a three person Administrative Review Committee whose members were not involved in the Information Review process nor in the original determination process.

The applicant/enrollee will be notified in advance of the date and time that the Administrative Review Committee will be hearing information regarding their situation. They have the right to speak in person or have a representative of their choosing present during the review. They may also submit additional information and review program records and guidelines pertaining to the matter under grievance.

The Committee’s decision and the Program Director’s review of the decision must be completed within thirty-days (30) of receiving the Administrative Review Request Form. Applicant/enrollees will be notified in writing of the Administrative Review Committee’s decision within three working days of the decision. Additionally this notification will include the applicant/enrollee’s rights to continued review and the policy regarding a request for Formal Review by the State Health Officer.

If the grievance remains unresolved in the applicant/enrollee’s eyes, the applicant/enrollee may file a request for a Formal Review by the State Health Officer.

Formal Review In order to be considered by the State Health Officer, a Request for Formal Review must be submitted to the CHIP office within ten (10) days of the final decision of the Administrative Review Committee. This request must be submitted on the Formal Review Request Form.

The applicant/enrollee will be notified in advance of the date and time that the State Health Officer will be hearing information regarding their case. Applicants/enrollees may appear in person or have a representative of their choosing to present information the State Health Officer. They may also submit additional information and review program records and guidelines pertaining to the matter under grievance.

Generally a decision will be issued within thirty-days (30) following receipt of the Request for Formal Review. Applicants/enrollees will be notified of the decision of the State Health Officer within three (3) working days of the decision.

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

October 1, 2009 66 Approval Date: November 19, 2010 The decision made by the State Health Officer is the final step in the administrative proceedings and will exhaust all administrative remedies.

Expedited Review If the enrollment or eligibility matter under review would worsen health conditions of the applicant/enrollee or jeopardize lives, an expedited CHIP review may be provided. An Expedited Review will be made within seventy-two (72) hours by quickly obtaining and reviewing information so as not to cause unnecessary harm to the applicant/enrollee.

Right for Continued Benefits During Appeals Process When the eligibility decision under review concerns renewal or re-determination of coverage, and the enrollee files a Request for Administrative Review, CHIP staff will ensure that coverage for that enrollee is continued until the review process is completed. The enrollee will be notified in writing of this continuation of coverage and their responsibility regarding any health services costs incurred if the resulting review decision supports termination of coverage. The enrollee will be issued a temporary health plan identification card with a coverage end date equal to the maximum length of time allowed for both the Administrative and Formal Review processes.

ALABAMA TITLE XXI PROGRAM FACT SHEET

Name of Plan:

ALL Kids

Date Plan Submitted:

November 3, 1997 Date Plan Approved:

January 30, 1998 Date Plan Effective:

February 1, 1998

Date Amendment #1 Submitted: May 21, 1998 Date Amendment #1 Approved: August 18, 1998 Date Amendment #1 Effective: October 1, 1998

Date Amendment #2 Submitted: July 1, 1999 Date Amendment #2 Approved: September 28, 1999 Date Amendment #2 Effective: October 1, 1999

Date Amendment #3 Submitted: September 27, 2001 Date Amendment #3 Approved: December 21, 2001 Date Amendment #3 Effective: June 1, 2001

Date Amendment #4 Submitted: December 18, 2002 Date Amendment #4 Approved: March 3, 2003

Date Amendment #5 Submitted: October 30, 2003 Date Amendment #5 Approved: January 16, 2004 Date Amendment #5 Effective: October 1, 2003

Date Amendment #6 Submitted: November 23, 2004 Date Amendment #6 Approved: February 18, 2005 Date Amendment #6 Effective: August 23, 2004

Date Amendment #7 Submitted: August 12, 2009 Date Amendment #7 Approved: October 21, 2009 Date Amendment #7 Effective: October 1, 2009

Date Amendment #8 Submitted: October 27, 2009 Date Amendment #8 Approved: December 3, 2009 Date Amendment #8 Effective: October 22, 2009

Date Amendment #9 Submitted: September 22, 2010 Date Amendment #9 Approved: November 19, 2010 Date Amendment #9 Effective: October 1, 2009

Date Amendment #10 Submitted: December 10, 2010

Date Amendment #10 Approved: January 20, 2011 Date Amendment #10 Effective: January 1, 2011

Date Amendment #11 Submitted: June 8, 2011 Date Amendment #11 Approved: June 15, 2011 Date Amendment #11 Effective: April 15, 2011

Background

• Implementation of Phase I of Alabama's CHIP plan began on February 1, 1998, with a Medicaid expansion of coverage for targeted low-income children under age 19, whose family income is below 100 percent of the Federal Poverty Level (FPL). This component of the CHIP program was phased out at the end of fiscal year 2002.

Amendments

• Alabama's first amendment was submitted on May 21, 1998. This amendment created a separate child health program known as Phase II, ALL Kids, for children under age 19 in families with incomes up to 200 percent of the FPL, and who are not eligible for Medicaid.

• Alabama's second amendment was submitted on July 1, 1999. This amendment created Phase III of Alabama’s CHIP program, known as ALL Kids Plus. ALL Kids Plus amended Alabama's separate child health program and provides an enhanced health benefits coverage package for children with special health care needs/conditions who are enrolled in ALL Kids. It was projected that 9 percent of the children enrolled in ALL Kids also would receive at least one service under ALL Kids Plus.

• Alabama’s third amendment was submitted on September 27, 2001. This amendment allows self-declaration of age on the CHIP application, incorporates some of the Medicaid income disregards, and makes cost sharing premium amounts equal between those who choose to pay in one lump sum and those who choose to pay in monthly installments.

• Alabama’s fourth amendment was submitted December 18, 2002. This amendment updates and amends the CHIP State plan to indicate the State’s compliance with the final CHIP regulation.

• Alabama’s fifth amendment was submitted October 30, 2003. This amendment institutes a waiting list, increases annual premiums from $50 to $100 per child for families with income above 150 percent of the FPL, imposes new annual premiums of $50 per child for families with income from 100 through 150 percent of the FPL, imposes copayments on nonpreventive services for enrollees with family income below 150 percent of the FPL, and raises copayments for enrollees with family income above 150 percent of the FPL. In addition, the amendment enhances certain

services in the benefit plan, including an increase in covered days for inpatient substance abuse facilities, and updates source of State funds to indicate that the State is receiving an approvable grant from the Robert Wood Johnson Foundation.

• Alabama submitted its sixth amendment November 23, 2004, to reopen enrollment in the ALL Kids program. This amendment also provides Alabama with general authority under the state plan to implement an enrollment cap in the future when funds are projected to be depleted before the end of the fiscal year.

• The State submitted its seventh amendment August 12, 2009. This amendment permits Alabama to expand the income eligibility level for children from its current income level up to 300 percent of the Federal poverty level (FPL). Additionally, this SPA will allow Alabama to apply cost-sharing requirements to children in this new expansion group. Premium amounts for this group will be $100 per year per child up to a family maximum of $300 per year. This SPA will also allow Alabama to apply copayments to health care services for children in families with incomes above 200 percent of the FPL, not to exceed $15 except the copayment for non-emergency use of the emergency room which will be $20. Additionally, this SPA modifies Alabama’s notification procedures for its premium grace period to come into compliance with the new requirements of section 504 of the CHIPRA. This amendment has an effective date of October 1, 2009.

• Alabama submitted its eighth amendment on October 27, 2009. This amendment includes a private foundation grant as an additional source of State funding. State General Fund appropriations, Tobacco Settlement funds, and a private grant. A Robert Wood Johnson Foundation (RWJF) grant was awarded to Alabama to increase enrollment and retention of eligible children in Alabama’s health insurance programs, known as ALL Kids and SOBRA Medicaid (the Alabama Medicaid program for pregnant women and children). The grant is for $994,883 and the award dates are February 15, 2009 - February 14, 2013. Amendment eight has an effective date of October 22, 2009.

• The State’s ninth CHIP amendment was submitted on September 22, 2010. This amendment has a retroactive effective date of October 1, 2009, for the establishment of a prospective payment system for federally qualified health centers and rural health clinics. This amendment also establishes that Alabama’s Title XXI dental benefits are compliant with Section 501 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA).

• The State’s tenth CHIP amendment was submitted on December 10, 2010 and was approved on January 20, 2011. This amendment has a retroactive effective date of January 1, 2011, to extend CHIP eligibility to children of employees of public agencies who are otherwise eligible under the State plan. The State will provide this coverage in accordance with the maintenance of effort (MOE) exception to the

exclusion of employees of a public agency of a State, in accordance with section 10203 of the Affordable Care Act of 2010.

• Alabama’s eleventh CHIP amendment was submitted on June 8, 2011, and approved on June 15, 2011. This amendment provides temporary adjustments to the State’s enrollment and redetermination policies, and cost sharing requirements for families impacted by disaster events. Through this SPA, the State can provide families with additional time to complete the renewal process, and has the flexibility to waive outstanding premium balances for families living and or working in FEMA or Governor declared disaster counties. This amendment, as it applies to the April 2011 tornadoes that devastated the northern half of Alabama, has a retroactive effective date of April 15, 2011, and a duration of 6 months. In the event of a future natural disaster, this SPA provides Alabama with the authority to implement the aforementioned temporary policy adjustments by notifying CMS of its intent, the effective date and duration of the provision, and a list of the FEMA or Governor declared disaster areas that are applicable. Although the State must provide notice to CMS, this is less administratively burdensome than repeating the SPA process during times of disaster recovery.

Children Covered Under Program

• The State reported that 137,545 children were ever enrolled in CHIP in Federal fiscal year 2010.

Administration

• The Alabama Department of Public Health (ADPH) administers ALL Kids and ALL Kids Plus.

Health Care Delivery System

• Services are provided through self-insured plans that are reimbursed on a fee-for- service basis. Currently, the only ALL Kids vendor for the above services is Blue Cross Blue Shield of Alabama, which provides services statewide.

• The exception to the fee-for-service payment system is the method of reimbursement to federally qualified health centers (FQHCs) and rural health clinics (RHCs) based on a prospective payment system (PPS). ALL Kids has elected to adopt the Medicaid PPS Rates effective October 1, 2009.

• ALL Kids Plus services are authorized through the Alabama Department of Mental Health and Mental Retardation, the Alabama Department of Rehabilitation Services, and the University of Alabama at Birmingham Sparks Center. Services may be provided through public, private, non-profit, individuals and organizations that have contracts with one of the authorizing agencies.

Benefit Package

• Initially, the State used the benefit package of the HMO with the State’s largest non- Medicaid enrollment as the benchmark for ALL Kids, but the State has made several benefit additions and enhancements to the package. Children enrolled in ALL Kids Plus receive additional services that are developmentally or physically necessary.

Cost Sharing

• There are three (3) categories of enrollees: No Fee (Native Americans and Alaskan Natives).; Low-Fee (children with family incomes from the base through 150% FPL); and Fee (children with family incomes from 151% FPL through 300% FPL). There is no cost sharing for children in the No Fee group. There is a $50 premium per child, per year for children in the Low-Fee group. There is a $100 premium per child, per year for children in the Fee group. Premiums can be paid in one payment or in periodic payments (weekly, monthly, or quarterly) throughout the year. A family’s total premium payments cannot exceed three times the individual premium rate (i.e. $150 or $300 depending upon the income level of the family). Enrollment data systems do not allow for a family to be billed in excess of these amounts.

• ALL Kids enrollees are required to pay copayments for nonpreventive services. Copayment amounts depend on family income.

Service Family Income < or = 150% of FPL Family Income > 150% of FPL Dental $3 per visit $5 per visit Doctor office $3 per visit $5 per visit ER services $5 facility charge $15 facility charge Inpatient services $5 per confinement $10 per confinement Non-emergency ER $10 per visit $20 per visit Allergy testing $5 per lab visit $10 per lab visit Allergy treatment $3 per visit $5 per visit Ambulance $5 per occurrence $10 per occurrence Mental and nervous inpatient $5 per confinement $10 per confinement Outpatient surgical facility $5 per visit $10 per visit Substance abuse inpatient $5 per confinement $10 per confinement X-ray $3 per visit $5 per visit Generic prescriptions $1 $2 Preferred prescriptions $3 $5 Non-preferred prescriptions $5 $10

State Action to Avoid Crowd-Out

• Alabama has a 3-month waiting period for enrollment in ALL Kids for families that currently have, or have voluntarily dropped, health insurance coverage. The application includes a question asking if the child currently is insured or if insurance coverage has been terminated in the last 3 months.

• In addition to self-declaration of insurance status, all enrollments are matched against the BCBS system to determine if the child is currently insured or if coverage has been dropped within the last three months.

Coordination Between CHIP and Medicaid

• A common application form is used for both title XXI and title XIX eligibility. When an ALL Kids outreach worker identifies a child potentially eligible for Medicaid, the completed application will be sent to Medicaid. Medicaid will process the application and contact the family for any additional verification or documentation.

Outreach Activities

• Outreach is conducted through statewide efforts and local partnerships. These efforts consist of a statewide media campaign, outreach conducted by trained workers, and outreach conducted through existing programs and agencies.

Financial Information

Total FFY 2011 CHIP Allotment -- $135,448,405 FFY 2011 Enhanced Federal Matching Rate – 77.98 Date last updated: CMS, CMSO, FCHPG, DSCHI: June 16, 2011

_____________________________________________________________________________ Table of Contents State/Territory Name: Alabama State Plan Amendment (SPA) #: AL-14-0014 This file contains the following documents in the order listed: 1) Approval Letter 2) Approved SPA Pages 3) SPA Summary Form The complete title XXI state plan for Alabama 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: XXI state plans and amendments: http://medicaid.gov/chip/state-program-information/chipstate- program-information.html

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

7500 Security Boulevard, Mail Stop: S2-01-16 q < M Ss Baltimore, Maryland 21244-1850

CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

MAR 1 4 2014

Cathy Caldwell, Director

Bureau of Children’s Health Insurance P.O. Box 303017

Montgomery, AL 36130-3017

Dear Ms. Caldwell:

Tam pleased to inform you that the Centers for Medicare & Medicaid Service has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) numbered AL-14-0014 submitted on February 11, 2014, related to Modified Adjusted Gross Income (MAGI) Eligibility with an effective date of January 1, 2014.

The SPA number AL-14-0014 converts the state’s existing income eligibility standards to MAGIT-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 XXI project officer is Ms. LaVern Baty. She is available to answer questions concerning this amendment. Ms. Baty’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services

7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Telephone: (410) 786-5480

Facsimile: (410) 786-5882

E-mail: Lavern.Baty@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to

Ms. Baty and Ms. Jackie Glaze, Associate Regional Administrator, Centers for Medicare & Medicaid Services, Region IV, Division of Medicaid and Children’s Health Operations. Ms. Glaze’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations Atlanta Federal Center, 4" Floor

61 Forsyth Street, SW, Suite 4T20

Atlanta, GA 30303-8909

Page 2 — Ms. Cathy Caldwell

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.

Sincerel

Eliot Fishman Director

Enclosure

ce: Jackie Glaze, ARA, CMS Region IV

Cems. CHIP Eligibility

OMB Control Number: 0938-1148 xpiration 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)

+ ile 19 107 141 “xX

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# AL-14-0014 Approval Date: MAR L 4 2014

Effective Date: January 1, 2014 Page 1 of 1

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility AL.0760.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Alabama State Funds: $ Federal Funds: $ 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. AL-14-0014 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. Page 1 of 2 Children's Health Insurance Program Eligibility: Summary Page 09/14/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01...

Submitted By: Viki Brant Last Revision Date: Feb 19, 2014 Submit Date: Feb 11, 2014 Character Count:128 out of 2000   To establish the income eligibility for the Medicaid Expansion Program for children as required by 42 CFR 457.320(a)(2) and (3). Signature of State Agency Official FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: Summary Page 09/14/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01...

_____________________________________________________________________________ Table of Contents State/Territory Name: Alabama State Plan Amendment (SPA) #: AL-14-0016 This file contains the following documents in the order listed: 1) Approval Letter 2) Approved SPA Pages 3) SPA Summary Form The complete title XXI state plan for Alabama 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: XXI state plans and amendments: http://medicaid.gov/chip/state-program-information/chipstate- program-information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services (CMs 7500 Security Boulevard, Mail Stop: S2-26-12 Cc M Ss

Baltimore, Maryland 21244-1850 CE an NE MEDICAID SERVICES

CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

APR 2 1 2014

Cathy Caldwell

Director

Bureau of Children’s Health Insurance P.O. Box 303017

Montgomery, AL 36130-3017

Dear Ms. Caldwell:

I am pleased to inform you that the Centers for Medicare & Medicaid Services (CMS) has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number AL-14-0016, submitted on February 14, 2014 and related to Modified Adjusted Gross Income (MAGI) Eligibility, with an effective date of January 1, 2014.

In SPA number AL-14-0016, page CS15 provides assurance that the state will apply methodologies based on MAGI for all separate CHIP covered groups. Page CS7 indicates that, using the approved MAGI conversion plan income thresholds, the state will cover targeted low- income children. Page CS10 allows the state to cover children who have access to public employee coverage and updates the supporting documentation. A copy of the approved CS15 is attached and should be incorporated within a separate subsection under Section 4.3 of the state’s approved CHIP state plan. A copy of the approved CS7 is attached and supersedes the current Geographic Area, Age and Income Sections 4.1.1, 4.1.2 and 4.1.3 of the current CHIP state plan. A copy of the approved CS10 and its supporting documentation is attached; the CS10 supersedes the current information on dependents of public employees in section 4.4.1 of the current CHIP state plan, and the supporting documentation should supersede the current documentation in an Appendix to the current CHIP state plan.

Your title XXI project officer is Ms. LaVern Baty. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Baty’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services 7500 Security Boulevard

Mail Stop S2-01-16

Baltimore, MD 21244-1850

Telephone: (410) 786-5480

Facsimile: (410) 786-5943

E-mail: Lavern.Baty@cms.hhs.gov

Page 2 — Ms. Cathy Caldwell

Official communications regarding program matters should be sent simultaneously to Ms. Baty and to Ms. Jackie Glaze, Associate Regional Administrator (ARA), in our Atlanta Regional Office. Ms. Glaze’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations Atlanta Federal Center, 4" Floor

61 Forsyth Street, SW, Suite 4T20

Atlanta, GA 30303-8909

If you have additional questions, please contact Ms. Barbara K. Richards, Acting Director, Division of State Coverage Programs at (410) 786-5920. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs.

Sincerel Eliot Fishman Director Enclosures cc:

Jackie Glaze, ARA, CMS Region IV, Atlanta

CcCms CHIP Eligibility

SC EENOS Prd anor AN A oRB Ee QACT ERIE

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

2102(b)(1)(B)(v) of the SSA and 42 CFR 457.310, 315 and 320

ial Targeted Low-Income Children - Uninsured children under age 19 whose household income is within standards established by the state.

The CHIP Agency operates this covered group in accordance with the following provisions: Age

Must be under age 19.

Income Standards

Income standards are applied statewide.

Are there any exceptions, e.g. populations in a county which may qualify under either a statewide income No standard or a county income standard?

Statewide Income Standards

Begin with lowest age range first.

Please note that the lower bound for CHIP eligibility should be the highest standard used for Medicaid poverty- level children for the same age group or groups entered here.

From Age To Age Above (% FPL) Up to & including (% FPL)

+ jlo 19 141 312 x

Age ranges may overlap. If there is an overlap, provide an explanation. Include the age ranges for each income standard that has overlapping ages and the reason for having different income standards.

Special Program for Children with Disabilities

Does the state have a special program for children with disabilities?

PRA Disclosure Statement

APR 2 i 2014 Effective Date: January 1, 2014

SPA# AL-14-0016 Approval Date: Page 1 of 2

Cems CHIP Eligibility

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.

'V.20130709

APR 2 1 2014

SPA# AL-14-0016 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

Cems CHIP Eligibility

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

Sec. 2110(b)(2)(B) and (b)(6) of the SSA

im Children Who Have Access to Public Employee Coverage - Otherwise eligible targeted low-income children who have access to public employee coverage on the basis of a family member's employment. The CHIP Agency operates this covered group in accordance with the following provisions: Select one of the following conditions as described in Section 2110(b)(6) of the Social Security Act: (@ Maintenance of agency contribution as provided in 2110(b)(6)(B) of the SSA. C Hardship criteria as provided in section 2110(b)(6)(C) of the Social Security Act. Coverage under this option is extended to children whose household income is: Select one of the options for the income standard when compared to Targeted Low Income Children (@ The same as the standards for Targeted Low-Income Children C. Lower than the income standards for Targeted Low-Income Children

Indicate whether coverage under this option is extended to all children who have access to public employee coverage, or only certain children:

@ All children who have access to public employee coverage

C Certain children who have access to public employee coverage:

[i] Attach methodology the state has used to calculate maintenance of agency contribution.

Aun attachment is submitted.

The state provides assurance that the state will, on an annual basis, recalculate expenditures for each participating public agency to determine if the maintenance effort condition continues to be met.

Children who are eligible for public employee health benefits coverage who are not described above are excluded from eligibility under the plan.

Children considered to have access to public employee coverage, and therefore not excluded from CHIP through this option, otherwise meet the definition of targeted low-income child provided at 42 CFR 457.310.

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# AL-14-0016 Approval Date: APR 2 i 2014

V.20131007

Effective Date: January 1, 2014 Page | of 1

Maintenance of Agency Contribution for Alabama State Employees Insurance Board

Table 1 - Monthly

Employee Employee 1997 State and Dependent and Dependent Agency Expenditure FY Costs Premium Expenditures CPI-U (Medici Increased by CPI 1997 $355.33 $164.00 $191.33 $191.33 1998 $383.11 $164.00 $219.11 3.22% $197.49 1999 $422.33 $164.00 $258.33 3.49% $204.38 2000 $469.55 $164.00 $305.55 4.06% $212.68 2001 $517.04 $164.00 $353.04 4.61% $222.49 2002 $554.40 $164.00 $390.40 4.71% $232.96 2003 $632.52 $164.00 $468.52 4.02% $242.33 2004 $670.51 $164.00 $506.51 4.40% $252.99 2005 $705.23 $164.00 $541.23 4.22% $263.67 2006 $724.43 $164.00 $560.43 4.01% $274.24 2007 $804.11 $180.00 $624.11 4.42% $286.36 2008 $854.71 $180.00 $674.71 3.71% $296.99 2009 $922.83 $180.00 $742.83 3.17% $306.40 2010 $984.23 $205.00 $779.23 3.42% $316.88 2011 $996.10 $205.00 $791.10 3.04% $326.51 2012 $1,007.26 $205.00 $802.26 3.68% $338.53

Table 2 - Annual

Annual Annual Employee Employee 1997 State and Dependent and Dependent Agency Expenditure FY Costs Premiums Expenditures CPI-U (Medici Increased by CPI

1997 $4,263.96 $1,968.00 $2,295.96 $2,295.96 1998 $4,597.32 $1,968.00 $2,629.32 3.22% $2,369.89 1999 $5,067.96 $1,968.00 $3,099.96 3.49% $2,452.60 2000 $5,634.60 $1,968.00 $3,666.60 4.06% $2,552.17 2001 $6,204.48 $1,968.00 $4,236.48 4.61% $2,669.83 2002 $6,652.80 $1,968.00 $4,684.80 4.71% $2,795.58 2003 $7,590.24 $1,968.00 $5,622.24 4.02% $2,907.96 2004 $8,046.12 $1,968.00 $6,078.12 4.40% $3,035.91 2005 $8,462.76 $1,968.00 $6,494.76 4.22% $3,164.03 ) 2006 $8,693.16 $1,968.00 $6,725.16 4.01% $3,290.90 2007 $9,649.32 $2,160.00 $7,489.32 4.42% $3,436.36 2008 $10,256.52 $2,160.00 $8,096.52 3.71% $3,563.85 2009 $11,073.96 $2,160.00 $8,913.96 3.17% $3,676.83 2010 $11,810.76 $2,460.00 $9,350.76 3.42% $3,802.57 2011 $11,953.20 $2,460.00 $9,493.20 3.04% $3,918.17 2012 $12,087.12 $2,460.00 $9,627.12 3.68% $4,062.36

APR 2 1 204

SPA# AL-14-0016 Approval Date: Effective Date: January 1, 2014

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Cems. CHIP Eligibility

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

2102(b)(1)(B)(v) of the SSA and 42 CFR 457.315

w The CHIP Agency will apply Modified Adjusted Gross Income methodologies for all separate CHIP covered groups, as described below, and consistent with 42 CFR 457.315 and 435.603(b) through (i).

In the case of determining ongoing eligibility for enrollees determined eligible for CHIP on or before December 31, 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 the state covers pregnant women, in 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: C The pregnant woman is counted just as herself. C The pregnant woman is counted just as herself, plus one. @ 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: @ Current monthly household income and family size. C Projected annual household income for the remaining months of the current calendar year and family size. In determining current monthly or projected annual household income, the state will use reasonable methods to: [7] Include a prorated portion of the reasonably predictable increase in future income and/or family size.

[7] Account for a reasonably predictable decrease in future income and/or family size.

Except as provided at 42 CFR 457.315 and 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.

Household income includes actually available cash support, exceeding nominal amounts, provided

by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. No

The CHIP Agency certifies that it has submitted and received approval for the conversion for all separate CHIP covered group income standards to MAGI-equivalent standards.

An attachment is submitted.

PRA Disclosure Statement

SPA# AL-14-0016 Approval Date: APR 2 1 2014

Effective Date: January 1, 2014 Page 1 of 2

cms. CHIP Eligibility

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.

APR 2 1 2014

SPA# AL-14-0016 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility AL.0774.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Alabama State Funds: $ Federal Funds: $ 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. AL-14-0016 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 2102(b)(1)(B)(v) of the SSA and 42 CFR 457.310, 315 and 320, Sec. 2110(b)(2)(B) and (b) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Page 1 of 2 Children's Health Insurance Program Eligibility: Summary Page 09/14/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01...

Submitted By: Viki Brant Last Revision Date: Feb 21, 2014 Submit Date: Feb 14, 2014 Character Count:132 out of 2000   Eligibility - Targeted Low-Income Children and Children Who Have Access to Public Employee Coverage; MAGI-Based Income Methodologies Signature of State Agency Official FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: Summary Page 09/14/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01...

_____________________________________________________________________________ Table of Contents State/Territory Name: Alabama State Plan Amendments (SPA) #: AL-19-0017-RIM and AL-19-0018-RIM This file contains the following documents in the order listed: 1) Approval Letter 2) Approved SPA Template 3) State Plan Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop 32-01-1ó Baltirnore, MD 21244-"1850 curs ctNl¡R:l foß MfDrc Rt & Mf,Dtc tD sERvtcfs CENÍFß TON MEDICAID & CHIP SFßVICES Children and Adults Health Prosrams Grouo SEP | 7 Zltg Ms. Teela Sanders Acting Director, Children's Health Insurance Program 201 Monroe Street Montgomery, AL36104 Dear Ms. Sanders Your title XXI Children's Health Insurance Program (CHIP) state plan amendments (SPA) AL- 19-0017-RIM and AL-19-0018-RIM have been approved. These SPAs have an effective date of July 1 ,2019. SPA number AL-19-0017-RIM permits Alabama to implement a health services initiative (HSI) to provide prenatal monitoring, case management and care coordination services to low-income, high-risk pregnant women and their infants in Montgomery, Macon, and Russell counties in order to improve pregnancy outcomes and infant health. Patients will receive services during pregnancy and for up to one year post delivery. Section 2105(aXlXDXii) of the Social Security Act (the Act) and 42 CFR 9457.10 authorize use of title XXI administrative funding for expenditures for HSIs under the plan for improving the health of children, including targeted low-income children and other low-income children. Consistent with section 2105(c)(6)(B) of the Act and 42 CFR 9457.626, title XXI funds used to support an HSI cannot supplant Medicaid or other sources of federal funding. The state shall ensure that the remaining title XXI funding, within the state's l0 percent administrative limit, is sufficient to continue the proper administration of the CHIP program. If such funds become less than sufficient, the state agrees to redirect title XXI funds from the support of this HSI to the administration of the CHIP program. The state shall report annually to CMS the expenditures funded by the HSI for each federal fiscal year. SPA number AL-19-0018-RIM permits Alabama to expand coverage for unborn children residing in Montgomery, Macon, and Russell counties with family incomes up to, and including 312 percent of the federal poverty level (FPL) whose pregnant mothers are not otherwise eligible for Medicaid. Coverage will include pregnancy-related services including prenatal care for children from conception to birth. A copy of the approved CS9 is attached and is incorporated in section 4.1.9 of the current Alabama CHIP state plan. Your title XXI project officer is Ms. Cassie Lagorio. She is available to answer questions concerning this amendment and other CHlP-related issues. Ms. Lagorio's contact information is as follows:

Page2 - Ms. Teela Sanders Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services, Mail Stop S2-01-16 7500 Security Boulevard Baltimore, MD 21244-1 850 Telephone: (410) 786-4554 E-mail: Cassandra.Lagoño@cms.hhs.gov Offrcial communications regarding program matters should be sent simultaneously to Ms. Lagorio and to Ms. Shantrina Roberts, Deputy Director, Division of Medicaid Field Operations South. Ms. Robertsos address is: Centers for Medicare & Medicaid Services Division of Medicaid Field Operations South 6l Forsyth Street, SV/, Suite 4T20 Atlanta, GA 30303-8909 V/e look forward to continuing to work with you and your staff. Sincerely, Director cc: Ms. Shantina Roberts, Deputy Director, Division of Medicaid Field Operations South /signed Anne Marie Costello/

Page 1 of 1 CHIP Eligibility State Name: Alabama OMB Control Number: 0938‐1148 Transmittal Number: AL - 19 - 0001 Separate Child Health Insurance Program Eligibility - Coverage From Conception to Birth CS9 42 CFR 457.10 Coverage From Conception to Birth - Coverage from conception to birth when the mother is not eligible for Medicaid. ■ The CHIP Agency operates this covered group in accordance with the following provisions: ✔ Age Standard From conception through birth. Does the state have an additional age definition or other age-related conditions? No Income Standards Income standards are applied statewide. No Select a method of geographic variation: Standard varies by county or city. Standard varies in some other geographic way. In each row of the table, you may enter one county if the county has an income standard that is unique to that county. If multiple counties share the same income standard, enter all the counties first, then enter the income standard that applies to those counties. Add Counties From zero up to (% FPL) Remove Add Montgomery, Macon, and Russell Counties 312 Remove Do you have any cities within your state which have their own separate income standards? No Exempted from requirement of providing or applying for a Social Security Number. ■ Exempted from requirement of verifying citizenship status. ■ 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. V.20181119 SPA number: AL-19-0018-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

Effective Date: July 1, 2019 1 Approval Date:

TEMPLATE FOR CHILD HEALTH PACWLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT CHILDREN’S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory: Alabama (Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR 457.40(b)) Scott Harris, State Health Officer, Alabama Department of Public Health (Signature of Governor, or designee, of State/Territory, Date Signed)

submits the following Child Health Plan for the Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following State officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: Teela Sanders

Position/Title: CHIP Director Name: Jeffrey Wright

Position/Title: Director, ADPH

Financial Services

Name:

Position/Title:

*Disclosure.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 (CMS-10398 #34). The time required to complete this information collection is estimated to average 80 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 any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

Effective Date: July 1, 2019 2 Approval Date:

Introduction:Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 105-33amended the Social Security Act (the Act) by adding a new title XXI, the Children’s Health Insurance Program (CHIP). In February 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) renewed the program. The Patient Protection and Affordable Care Act of 2010 further modified the program.

This template outlines the information that must be included in the state plans and the state plan amendments (SPAs). Itreflects the regulatoryrequirements at 42 CFR Part 457as well as the previously approved SPA templates that accompanied guidance issued to States through State Health Official (SHO) letters. Where applicable, we indicate the SHO number and the date it was issued for your reference. The CHIP SPA template includes the following changes: • Combined the instruction document with the CHIP SPA template to have a single document. Any modifications to previous instructions are for clarification only and do not reflect new policy guidance. • Incorporated the previously issued guidance and templates (see the Key following the template for information on the newly added templates), including: • Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002) • Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009) • Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009) • Dental and supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009) • Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010) • Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010) • Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010) • Moved sections 2.2 and 2.3 into section 5 to eliminate redundancies between sections 2 and 5. • Removed crowd-out language that had been added by the August 17 letter that later was repealed. The Centers for Medicare & Medicaid Services (CMS) is developing regulations to implement the CHIPRA requirements. When final regulations are published in the Federal Register, this template will be modified to reflect those rules and States will be required to submit SPAs illustrating compliance with the new regulations. States are not required to resubmit their State plans based on the updated template. However, States must use the updated template when submitting a State Plan Amendment.

Federal Requirementsfor Submission and Review of a Proposed SPA. (42 CFR Part 457 Subpart A) In order to be eligible for payment under this statute, each State must submit a Title XXI plan for approval by the Secretary that details how the State intends to use the funds and fulfill other requirements under the law and regulations at 42 CFR Part 457. ASPA is approved in 90 days unless the Secretary notifies the State in writing that the plan is disapproved or that specified additional information is needed. Unlike Medicaid SPAs, there is only one 90 day review period, or clock for CHIP SPAs,that may be stopped by a request for additional information and restarted after a complete

SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

Effective Date: July 1, 2019 3 Approval Date:

response is received. More information on the SPA review process is found at 42 CFR 457 Subpart A.

When submitting a State plan amendment, states should redline the changes that are being made to the existing State plan and provide a “clean” copy including changes that are being made to the existing state plan.

The template includes the following sections: 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements- This section should describe how the State has designed their program. It also is the place in the template that a State updates to insert a short description and the proposed effective date of the SPA, and the proposed implementation date(s) if different from the effective date. (Section 2101);(42 CFR 457.70) 2. General Background and Description of StateApproach to Child Health Coverage and Coordination- This section should provide general information related to the special characteristics of each state’s program. The information should include the extent and manner to which children in the State currently have creditable health coverage, current State efforts to provide or obtain creditable health coverage for uninsured children and how the plan is designed to be coordinated with current health insurance, public health efforts, or other enrollment initiatives. This information provides a health insurance baseline in terms of the status of the children in a given State and the State programs currently in place. (Section 2103); (42 CFR 457.410(A)) 3. Methods of Delivery and Utilization Controls- This section requires a description that must include both proposed methods of delivery and proposed utilization control systems. This section should fully describe the delivery system of the Title XXI program including the proposed contracting standards, the proposed delivery systems and the plans for enrolling providers. (Section 2103); (42 CFR 457.410(A)) 4. Eligibility Standards and Methodology- The plan must include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. This section includes a list of potential eligibility standards the State can check off and provide a short description of how those standards will be applied. All eligibility standards must be consistent with the provisions of Title XXI and may not discriminate on the basis of diagnosis. In addition, if the standards vary within the state, the State should describe how they will be applied and under what circumstances they will be applied. In addition, this section provides information on income eligibility for Medicaid expansion programs (which are exempt from Section 4 of the State plan template) if applicable.(Section 2102(b)); (42 CFR 457.305 and 457.320) 5. Outreach- This section is designed for the State to fully explain its outreach activities. Outreach is defined in law as outreach to families of children likely to be eligible for child health assistance under the plan or under other public or private health coverage programs. The purpose is to inform these families of the availability of, and to assist them in enrolling their children in, such a program. (Section 2102(c)(1)); (42CFR 457.90) 6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of

SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

Effective Date: July 1, 2019 4 Approval Date:

health insurance coverage in a State plan, the child health assistance provided must consist of any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage; benchmark-equivalent coverage; existing comprehensive state-based coverage; and/or Secretary- approved coverage). In this section States identify the scope of coverage and benefits offered under the plan including the categories under which that coverage is offered. The amount, scope, and duration of each offered service should be fully explained, as well as any corresponding limitations or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for State’s use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The section lists some of the methods which states may consider using. In addition to methods, there are a variety of tools available for State adaptation and use with this program. The section lists some of these tools. States also have the option to choose who will conduct these activities. As an alternative to using staff of the State agency administering the program, states have the option to contract out with other organizations for this quality of care function. (Section 2107); (42 CFR 457.495) 8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost-sharing requirements provide protection for lower income children, ban cost sharing for preventive services, address the limitations on premiums and cost-sharing and address the treatment of pre- existing medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E) 9. Strategic Objectives and Performance Goals and Plan Administration- The section addresses the strategic objectives, the performance goals, and the performance measures the State has established for providing child health assistance to targeted low income children under the plan for maximizing health benefits coverage for other low income children and children generally in the state. (Section 2107); (42 CFR 457.710) 10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess the operation of the Children’s Health Insurance Program plan and submit to the Secretary an annual report which includes the progress made in reducing the number of uninsured low income children. The report is due by January 1, following the end of the Federal fiscal year and should cover that Federal Fiscal Year. In this section, states are asked to assure that they will comply with these requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750) 11. Program Integrity- In this section, the State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Sections 2101(a) and 2107(e); (42 CFR 457, subpart I) 12. Applicant and Enrollee Protections- This section addresses the review process for eligibility and enrollment matters, health services matters (i.e., grievances), and for states that use premium assistance a description of how it will assure that applicants and enrollees are given the opportunity at initial enrollment and at each redetermination of eligibility to obtain health

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benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)

Program Options. As mentioned above, the law allows States to expand coverage for children through a separate child health insurance program, through a Medicaid expansion program, or through a combination of these programs. These options are described further below: • Option to Create a Separate Program- States may elect to establish a separate child health program that are in compliance with title XXI and applicable rules. These states must establish enrollment systems that are coordinated with Medicaid and other sources of health coverage for children and also must screen children during the application process to determine if they are eligible for Medicaid and, if they are, enroll these children promptly in Medicaid. • Option to Expand Medicaid- States may elect to expand coverage through Medicaid. This option for states would be available for children who do not qualify for Medicaid under State rules in effect as of March 31, 1997. Under this option, current Medicaid rules would apply.

Medicaid Expansion- CHIP SPA Requirements In order to expedite the SPA process, states choosing to expand coverage only through an expansion of Medicaid eligibility would be required to complete sections: • 1 (General Description) • 2 (General Background) They will also be required to complete the appropriate program sections, including: • 4 (Eligibility Standards and Methodology) • 5 (Outreach) • 9 (Strategic Objectives and Performance Goals and Plan Administration including the budget) • 10 (Annual Reports and Evaluations).

Medicaid Expansion- Medicaid SPA Requirements States expanding through Medicaid-only will also be required to submit a Medicaid State Plan Amendment to modify their Title XIX State plans. These states may complete the first check-off and indicate that the description of the requirements for these sections are incorporated by reference through their State Medicaid plans for sections: • 3 (Methods of Delivery and Utilization Controls) • 4 (Eligibility Standards and Methodology) • 6 (Coverage Requirements for Children’s Health Insurance) • 7 (Quality and Appropriateness of Care) • 8 (Cost Sharing and Payment) • 11 (Program Integrity) • 12 (Applicant and Enrollee Protections)

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• Combination of Options-CHIP allows states to elect to use a combination of the Medicaid program and a separate child health program to increase health coverage for children. For example, a State may cover optional targeted-low income children in families with incomes of up to 133 percent of poverty through Medicaid and a targeted group of children above that level through a separate child health program. For the children the State chooses to cover under an expansion of Medicaid, the description provided under “Option to Expand Medicaid” would apply. Similarly, for children the State chooses to cover under a separate program, the provisions outlined above in “Option to Create a Separate Program” would apply. States wishing to use a combination of approaches will be required to complete the Title XXI State plan and the necessary State plan amendment under Title XIX.

ProposedState plan amendments should be submitted electronically and one signed hard copy to the Centers for Medicare & Medicaid Services at the following address: Name of Project Officer Centers for Medicare & Medicaid Services 7500 Security Blvd Baltimore, Maryland 21244 Attn: Children and Adults Health Programs Group Center for Medicaid and CHIP Services Mail Stop - S2-01-16

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Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements

1.1. The state will use funds provided under Title XXI primarily for (Check appropriate box) (Section 2101)(a)(1)); (42 CFR 457.70):

Guidance: Check below if child health assistance shall be provided primarily through the development of a separate program that meets the requirements of Section 2101, which details coverage requirements and the other applicable requirements of Title XXI.

1.1.1. * Obtaining coverage that meets the requirements for a separate child health program (Sections 2101(a)(1) and 2103); OR

Guidance: Check below if child health assistance shall be provided primarily through providing expanded eligibility under the State’s Medicaid program (Title XIX). Note that if this is selected the State must also submit a corresponding Medicaid SPA to CMS for review and approval. 1.1.2. Providing expanded benefits under the State’s Medicaid plan (Title XIX) (Section 2101(a)(2)); OR

Guidance: Check below if child health assistance shall be provided through a combination of both 1.1.1. and 1.1.2. (Coverage that meets the requirements of Title XXI, in conjunction with an expansion in the State’s Medicaid program). Note that if this is selected the state must also submit a corresponding Medicaid state plan amendment to CMS for review and approval. 1.1.3.

A combination of both of the above. (Section 2101(a)(2))

* Until October 1, 2002, Alabama’s CHIP was a combination program. With the mandated gradual increase of Medicaid coverage at higher income levels for children born after September 30, 1983, the Medicaid expansion portion of CHIP was subsumed, on October 1, 2002, by the Alabama Medicaid SOBRA Program for Pregnant Women and Children.

1.1-DS

The State will provide dental-only supplemental coverage. Only States operating a separate CHIP program are eligible for this option. States choosing this option must also complete sections 4.1-DS, 4.2-DS, 6.2-DS, 8.2-DS, and 9.10 of this SPA template. (Section 2110(b)(5))

1.2.

Check to provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

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Alabama has not and will not claim expenditures for child health assistance prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS.

1.3.

Check to provide an assurance that the State complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

Assurances are on file with DHHS. The Alabama Department of Public Health continues to assure that compliance with all applicable civil rights requirements.L

Guidance: The effective date as specified below is defined as the date on which the State begins to incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date is defined as the date the State begins to provide services; or, the date on which the State puts into practice the new policy described in the State plan or amendment. For example, in a State that has increased eligibility, this is the date on which the State begins to provide coverage to enrollees (and not the date the State begins outreach or accepting applications).

1.4. Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA(42 CFR 457.65). A SPA may only have one effective date, but provisions within the SPA may have different implementation dates that must be after the effective date.

Original Plan Effective Date:February 1, 1998 Amendment 1 – Establishment of ALL Kids

Effective Date: February 1, 1998 Implementation Date: October 1, 1998 Amendment 2 – Establishment of ALL Kids PLUS

Effective/Implementation Date: October 1, 1999 Amendment 3 – Disregards

Effective/Implementation Date: June 1, 2001 Amendment 4 - Compliance

Effective/Implementation Date: August 24, 2001 Amendment 5 – Waiting List, Cost Sharing, Benefit Changes Effective/Implementation Date: October 1, 2003 Amendment 6 – Discontinuance of the Waiting List and other Clean-Up changes

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Effective/Implementation Date: November 23, 2004 Amendment 7 – Raise the upper income eligibility limit to 300% of FPL and

other minor changes Effective/Implementation Date: October 1, 2009 Amendment 8 – Include a private foundation grant as an additional source of state funding

Effective/Implementation Date: October 27, 2009 Amendment 9 – Establishment of a Prospective Payment System for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)

Effective/Implementation Date: October 1, 2009; Addendum on Dental Benefits Under Title XXI: Effective/Implementation Date: October 1, 1998 Amendment 10 – Eligibility for children of employees of a public agency (state employees and public education employees) Effective/Implementation Date: January 1, 2011 Amendment 11 – Provisions for Implementing Temporary Adjustments to

Enrollment Determination and/or Redetermination Policies and Cost Sharing Requirements for Applicants/Renewals living in and/or working in FEMA or Governor declared disaster areas at the time of a disaster event. In the event of a disaster, the State will notify CMS of the intent to provide temporary adjustments to its enrollment and/or redetermination policies, the effective dates of such adjustments and the counties/areas impacted by the disaster. Effective/Implementation Date: April 15, 2011 Amendment 12 – Increase premiums, increase co-pays and revise the methodology for determining annual aggregate cost-sharing Effective/Implementation Date: May 1, 2012 Amendment 13 – Establishment of copayments for therapy services (physical, occupational, and speech), vision services and chiropractic services; and cleanup changes

Effective/Implementation Date: August 1, 2013 Amendment 14 – Alignment of ALL Kids fee groups with provisions of the Affordable Care Act (ACA) and other editorial changes to comply with previously approved ACA SPAs.

Effective/Implementation Date: January 1, 2014 Amendment 15 - AL-16-0015-MEXP – CHIP Medicaid expansion to cover Medicaid enrollees ages 14 years to 19 years with incomes above 18% FPL through 141% FPL.

Effective Date: October 1, 2015

Implementation Date: January 1, 2016 Amendment 16 – AL-18-0016-PAR - Attestation and documentation of Mental

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Health Parity and Addiction Equity.

Submission Date: July 10, 2018

Proposed Effective Date: October 1, 2017*

Implementation Date: October 1, 2017*

*Note: Benefits were adjusted in October 2010 to be compliant with mental health parity; this amendment did not require any benefit changes Amendment 17 – AL-19-0017-RIM

- Reducing Infant Mortality (RIM) Health Service Initiative

Submission Date: July 17, 2019

Proposed Effective Date: July 1, 2019

Implementation Date: July 1, 2019 Amendment 18 – AL-19-0018-RIM

CS9 Eligibility – Coverage From Conception to Birth

Submission Date: July 17, 2019 Proposed Effective Date: July 1, 2019 Implementation Date: July 1, 2019

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Transmittal Number SPA Group PDF # Description Superseded Plan Section(s) AL-14-0016

Effective/Implementati on Date: January 1, 2014 MAGI Eligibility & Methods CS7

CS10

CS15 Eligibility – Targeted Low Income Children

Children With Access to Public Employee Coverage

MAGI-Based Income Methodologies Supersedes the current sections Geographic Area 4.1.1; Age 4.1.2; and Income 4.1.3 Section 4.4.1: Supersedes only the information on dependents of public employees in this section; supporting documentation should be incorporated as an appendix to the current state plan

Incorporate within a separate subsection under section 4.3

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CS9 Coverage from Conception to Birth

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Transmittal Number SPA Group PDF # Description Superseded Plan Section(s) (Original: AL-14-0014 Effective/Implementatio n Date: January 1, 2014)

AL-16-0015-MEXP

Effective/Implementati on Date: October 1, 2015 XXI Medicaid Expansio n CS3 Eligibility for Medicaid Expansion Program

CHIP Medicaid expansion to cover Medicaid enrollees ages 14 years to 19 years with incomes above 18% FPL through 141% FPL Supersedes the current Medicaid expansion section 4.0 AL-14-0015

Effective/Implementati on Date: January 1, 2014 Establish 2101(f) Group CS14 Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards Incorporate within a separate subsection under section 4.1 AL-14-0018

Effective/Implementati on Date: January 1, 2014 Eligibility Process CS24 Single, Streamlined Application Screen and Enroll Process Renewals Supersedes the current sections 4.3 and 4.4 AL-14-0017

Effective/Implementati on Date: January 1, 2014 Non- Financial Eligibility CS17

CS18

CS19

CS20

CS21

CS27 Non-Financial Eligibility – Residency

Non-Financial – Citizenship

Non-Financial – Social Security Number

Substitution of Coverage

Non-Payment of Premiums

Continuous Eligibility Supersedes the current section 4.1.5

Supersedes the current sections 4.1.0; 4.1.1-LR; 4.1.1- LR

Supersedes the current section 4.1.9.1

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Transmittal Number SPA Group PDF # Description Superseded Plan Section(s)

Supersedes the current section 4.4.4

Supersedes the current section 8.7

Supersedes the current section 4.1.8

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1.4- TC Tribal Consultation(Section 2107(e)(1)(C))Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved. TN No: Approval Date Effective Date: October 1, 2015 In accordance with approved policies, on January 10, 2019, a certified letter explaining the changes proposed in AL-19-0017-RIM and AL-19-0018-RIM was mailed to the Tribal Chairman of the one federally recognized Native American tribe in Alabama, the Poarch Band of Creek Indians. The letter included the purpose for the proposed changes and a description of the changes. In the letter, the Tribal Chairman was also reminded that she had the opportunity to respond to the proposed changes within 30 days and was given contact information for any such response. The certified letter was signed by the CHIP Director. TN No: Approval Date Effective Date: February 10, 2019

Section 2. General Background and Description of Approach to Children’s Health Insurance Coverage and Coordination

Guidance: The demographic information requested in 2.1. can be used for State planning and will be used strictly for informational purposes. THESE NUMBERS WILL NOT BE USED AS A BASIS FOR THE ALLOTMENT.

Factors that the State may consider in the provision of this information are age breakouts, income brackets, definitions of insurability, and geographic location, as well as race and ethnicity. The State should describe its information sources and the assumptions it uses for the development of its description. • Population • Number of uninsured • Race demographics • Age Demographics • Info per region/Geographic information

2.1. Describe the extent to which, and manner in which, children in the State (including targeted low-income children and other groups of children specified) identified , by income level and other relevant factors, such as race, ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, distinguish between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report

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requirements). (Section 2102(a)(1)); (42 CFR 457.80(a))

Prior to CHIP, the only two programs offering health insurance to low-income children were Medicaid and the Alabama Child Caring Foundation (ACCF). Medicaid served children at the minimum income levels required by federal law. This meant that Medicaid coverage was available to children at three different levels of income and age: - Those under the age of six (6) years with incomes up to 133% FPL; - Those children six (6) through 14 years of age who were born after September 30, 1983 with incomes up to 100%FPL; and, - Those remaining children through the age of 18 years (middle and older teens) with incomes at the TANF assistance level (below approximately 13% FPL). The ACCF served children (birth through 18 years) with incomes from the Medicaid levels up to 200% FPL.

From February 2, 1998 through September 30, 2002, Phase I of CHIP, a Medicaid expansion was in existence. On October 1, 2002, Phase I of Alabama’s CHIP was subsumed by the Alabama SOBRA Medicaid Program. Beginning October 1, 2015, however, children in this category (ages 14 to 19 with incomes between 13% FPL and 141% FPL) will again be enrolled in a CHIP Medicaid expansion.

Originally, CHIP used a baseline number of uninsured children derived from the Current Population Survey (CPS). This baseline including the following chart was derived from a study by Winterbottom et.al. based on a three year merged Current Population Survey, or CPS, (1990-92), which showed over 200,000 children, in Alabama, under 18 years to be uninsured.

Employer Medicaid Other Coverage Uninsured Percent 59.3 17.2 5.1 18.4 Number 652,300 189,200 110,000 202,400

However, due to concerns about the CPS regarding potential problems with subjects’ abilities to recall information, Alabama changed its baseline estimate to reflect data from the 1997 round of the Urban Institute’s National Survey of America’s Families (NSAF). The NSAF indicated that there were 173,012 uninsured children in Alabama. Of these, 91,209 were < 100% Federal Poverty Level (FPL), 49,579 were above 100 up to 200% FPL and 32,223 were >200% FPL.

In its first 4 years of implementation (October 1, 1998 – September 30, 2002), Phase II, ALL Kids, enrolled over 80,000 children. It is estimated that 52,000 children have current enrollment in ALL Kids at the end of FY 2002.

ALL Kids PLUS, added as a third amendment to the CHIP State Plan (October, 1999), serves

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as a mechanism by which children with special health care needs/conditions (CSHCN/C), who are enrolled in ALL Kids, may receive health and health related services which are beyond the scope of the basic ALL Kids package. ALL Kids PLUS was designed so that it serves as a funding source for CHIP state match and as a funding mechanism for state agencies who serve CSHCN/C with state funds. State agencies participating in ALL Kids PLUS supply the state match, provide the service, and receive full reimbursement. It was originally estimated that approximately 9% of these enrollees would also receive at least one service under ALL Kids PLUS. However because the basic benefit package is so comprehensive, a much lower percentage of children are receiving PLUS services. It is expected that this percentage will increase as more state agencies contract with CHIP to become ALL Kids PLUS providers. With the advent of ALL Kids, the ACCF has changed its income eligibility criteria to serve children who are not eligible for Medicaid or ALL Kids and who have incomes up to 235% FPL. Because, the ACCF has no enrollment restriction regarding immigrants, this program has seen a dramatic increase in its Hispanic enrollment.

Guidance: Section 2.2allows states to request to use the funds available under the 10 percent limit on administrative expenditures in order to fund services not otherwise allowable. The health services initiatives must meet the requirements of 42 CFR 457.10.

2.2. Health Services Initiatives-Describe if the State will use the health services initiative option as allowed at42 CFR 457.10. If so, describe what services or programs the State is proposing to cover with administrative funds, including the cost of each program, and how it is currently funded (if applicable), also update the budget accordingly. (Section 2105(a)(1)(D)(ii)); (42 CFR 457.10)

As permitted under section 2105(a)(1)(D)(ii) of the Social Security Act and federal regulations at 42 CFR 457.10, the State of Alabama is implementing a health services initiative (HSI) that will use CHIP funds, within the federal administrative expenditures cap allowed for states, to support the Reducing Infant Mortality (RIM) Health Services Initiative. The aim of this initiative is to reduce the infant mortality rate in selected counties within Alabama through the provision of a variety of evidence-based case management services for pregnant women and children. These case management services will target health, social, and behavioral health related high-risk factors which have been shown to impact pregnancy outcomes and infant health. Case Management services will connect patients, with high-risk factors, to appropriate services and case managers will follow-up to ensure that risk factors are being addressed satisfactorily. It is anticipated that the case manager will make a total of 6 face to face visits. Three visits would occur during the prenatal care, and three visits would be provided post delivery.

The care coordination services provided postpartum including services to the infant include:

i. Make home visit within one month following delivery to complete the following: 1. Encourage patient to keep postpartum appointment including providing appointment

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reminders to help ensure completion of the postpartum appointment. 2. Encourage patient to choose a reliable birth control method. If the patient has chosen sterilization as her method, follow-up with the patient to ensure the procedure is completed. 3. Ensure patient is established with a PMP for the infant. 4. Ensure infant has enrolled in WIC, if eligible. 5. Educate the patient on the importance of immunizations for the infant. ii. Assist in scheduling appointments with infant’s PMP up to the first year to ensure that well baby checkups are made and immunizations are up to date. Follow up after the appointments to verify that appointments were kept. Well Baby checkups are scheduled at: a. 1 month b. 2 months c. 4 months d. 6 months e. 9 months f. 12 months iii. Promote the child’s overall physical, cognitive, and emotional development through educating parents/caregivers about developmental milestones according to the child’s age and developmental abilities. iv. Complete an ASQ-3 (Ages and Stages Questionnaire, Third Edition, a developmental screening tool) as appropriate at face to face appointments. v. Educate the parents about the importance of reading to the infant to promote cognitive development. vi. Make referrals for the child, as appropriate, such as Early Intervention, Children’s Rehabilitation Services, etc. vii. Prior to the child’s first birthday, ensure he/she is established with a dentist. viii. Screen the mother for post-partum depression at each face to face visit and make referrals and follow up (as needed)

With the exception of providing necessary prenatal monitoring by a nurse in the home or health department setting, no HSI funds will be spent on direct care.

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The high-risk factors that HSI will address include the following: ACEs Score of >4

Depression1

Diabetes Mellitus Current multiple births Substance Abuse2

Maternal age3 Hypertension

Interpersonal safety Transportation needs Housing Instability

Food Insecurity

Utility needs Abuse4

Enrollment in CHIP unborn coverage Prior poor pregnancy outcome5

To be eligible for the HSI, pregnant women and/or their infants in selected counties must have at least one of the high-risk factors cited above and have an income no greater than the upper CHIP limit (currently 312% FPL). HSI services will be offered whether or not the patient has health insurance coverage and regardless of the type of insurance. Case management services for individuals enrolled in Medicaid will be time-limited until the implementation of the case management services provided in the Alabama Coordinated Health Network (ACHN) scheduled to begin October 1, 2019. Individuals with other insurance that are provided case management services will not be provided case management services using HSI funds.

Patients will be enrolled in the HSI initiative during pregnancy, during the post-partum period, or by referral. Once enrolled, HSI services will continue, as appropriate, for one-year post delivery with the exceptions noted in the paragraph above.

The HSI will be coordinated by the Alabama Department of Public Health and delivered through designated county health departments. Depending upon the needs of those participating in the initiative, services may be provided by public health nurses, public health social workers, community health workers, etc.

The proposed counties for initial implementation of the HSI include Montgomery, Macon and Russell counties. Services supported through this HSI will not supplant other federal, state or local funds allocated for similar services.

Outreach activities for the RIM HSI include providing education and information to pertinent providers, hospitals and programs serving the target population residing in the counties in which the expansion is implemented.

1 Depression noted at anytime during the pregnancy or postpartum period (90 days postpartum) 2 History of use or current substance use 3 <21 or >35 4 Emotional, physical, or sexual 5 Fetal Death – Stillbirth after 20 weeks; Infant death -first year of life; Preterm birth - <37 weeks gestation; Low Birthweight - <2500 grams; Very Low Birthweight - <1500 grams; Other serious chronic conditions (ex: heart disease, renal disease, chronic medical illnesses, etc.); and, Maternal Death (death of a woman while pregnant or within 42 days of termination of pregnancy from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes).

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In monitoring/evaluating the progress and success of this program, the total number of women and children served will be captured and reported to ALL Kids on an agreed upon schedule but no less than a quarterly basis. Tracking and reporting of visits and birth outcomes (birth weight, mortality within the first year of life and maternal health indices) will also be included in reports to ALL Kids.

The cost of the HSI is budgeted to be $753,625 for FY 2019 (July –Sept).

Case Management Costs: Initially, within the proposed three county area, approximately 500 women/families could be served in FY 2019. The number of case management hours per person/family is estimated to be 10 hours/quarter at an average cost of $135/hour. This hourly rate would account for salary cost of those providing/coordinating services. Additionally, it is estimated that staff will travel 25 miles per home visit and there will be two home visits/patient/quarter at the state mileage reimbursement rate of $0.545/mile.

Annual 1st Quarter Case Management: Enrollees X case management hours $2,700,000 $675,000

X $135.00/hour Travel: # enrollees X miles/round trip X 2 trips/quarter X mileage $ 54,500 $ 13,625 reimbursement rate

Start Up/Outreach Costs: As the HSI is being developed, costs are being allocated for personnel support to include up to two FTEs (one full-time project manager and other ancillary support staff as needed). Additionally, costs are included for the development of materials to promote and educate health care providers and community organizations throughout the implementation counties about the initiative and to garner support and participation of agencies/providers. Education and awareness materials to outreach to women will also be prepared. Expenses to conduct (as well as attend) meetings, conferences and/or trainings to share information about the program and generate participation are also included as part of the startup and implementation costs.

Annual 1st Quarter Personnel Costs (Salary, Fringe, Indirect costs) $200,000 $50,000

Educational/training materials $ 10,000 $10,000

(providers/organizations and participants) Costs for meetings (transportation/meeting fees) $ 5,000 $ 5,000

Grand Total: $2,969,500 $753,625

(Personnel, Materials, Meeting costs, Case Management)

2.3-TC Tribal Consultation Requirements-(Sections 1902(a)(73) and 2107(e)(1)(C));

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(ARRA #2, CHIPRA #3, issued May 28, 2009)Section 1902(a)(73) of the Social Security Act (the Act) requires a State in which one or more Indian Health Programs or Urban Indian Organizations furnish health care services to establish a process for the State Medicaid agency to seek advice on a regular, ongoing basis from designees of Indian health programs, whether operated by the Indian Health Service (IHS), Tribes or Tribal organizations under the Indian Self-Determination and Education Assistance Act (ISDEAA), or Urban Indian Organizations under the Indian Health Care Improvement Act (IHCIA). Section 2107(e)(1)(C) of the Act was also amended to apply these requirements to the Children’s Health Insurance Program (CHIP). Consultation is required concerning Medicaid and CHIP matters having a direct impact on Indian health programs and Urban Indian organizations.

Describe the process the State uses to seek advice on a regular, ongoing basis from federally-recognized tribes, Indian Health Programs and Urban Indian Organizations on matters related to Medicaid and CHIP programs and for consultation on State Plan Amendments, waiver proposals, waiver extensions, waiver amendments, waiver renewals and proposals for demonstration projects prior to submission to CMS. Include information about the frequency, inclusiveness and process for seeking such advice.

ALL Kids provides a certified letter to the federally recognized tribe in the state when

considering amendments to the State Plan or other program changes requiring CMS

approval. The tribe is given 30 days to respond. In the event of an emergency, ALL

Kids will submit a faxed letter to the tribe and give 10 days for response.

Section 3. Methods of Delivery and Utilization Controls

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan, and continue on to Section 4. Guidance: In Section 3.1., discussion may include, but is not limited to: contracts with managed health care plans (including fully and partially capitated plans); contracts with indemnity health insurance plans; and other arrangements for health care delivery. The State should describe any variations based upon geography, as well as the State methods for establishing and defining the delivery systems.

Should the State choose to cover unborn children under the Title XXI State plan, the State must describe how services are paid. For example, some states make a global payment for all unborn children while other states pay for services on fee-for-services basis. The State’s payment mechanism and delivery mechanism should be briefly described here.

Section 2103(f)(3) of the Act, as amended by section 403 of CHIPRA, requires separate or combination CHIP programs that operate a managed care delivery system to apply several provisions of section 1932 of the Act in the same manner as these

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provisions apply under title XIX of the Act. Specific provisions include: section 1932(a)(4), Process for Enrollment and Termination and Change of Enrollment; section 1932(a)(5), Provision of Information; section 1932(b), Beneficiary Protections; section 1932(c), Quality Assurance Standards; section 1932(d), Protections Against Fraud and Abuse; and section 1932(e), Sanctions for Noncompliance. If the State CHIP program operates a managed care delivery system, provide an assurance that the State CHIP managed care contract(s) complies with the relevant sections of section 1932 of the Act. States must submit the managed care contract(s) to the CMS Regional Office servicing them for review and approval.

In addition, states may use up to 10 percent of actual or estimated Federal expenditures for targeted low-income children to fund other forms of child health assistance, including contracts with providers for a limited range of direct services; other health services initiatives to improve children’s health; outreach expenditures; and administrative costs (See 2105(c)(2)(A)). Describe which, if any, of these methods will be used.

Examples of the above may include, but are not limited to: direct contracting with school-based health services; direct contracting to provide enabling services; contracts with health centers receiving funds under section 330 of the Public Health Service Act; contracts with hospitals such as those that receive disproportionate share payment adjustments under section 1886(d)(5)(F) or 1923 of the Act; contracts with other hospitals; and contracts with public health clinics receiving Title V funding. If applicable, address how the new arrangements under Title XXI will work with existing service delivery methods, such as regional networks for chronic illness and disability; neonatal care units, or early-intervention programs for at-risk infants, in the delivery and utilization of services. (42CFR 457.490(a))

3.1. Delivery StandardsDescribe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42CFR 457.490(a))

Phase I - Medicaid Expansion From February 2, 1998 through September 30, 2002, Phase I of CHIP, a Medicaid expansion was in existence. On October 1, 2002, Phase I of Alabama’s CHIP was subsumed by the Alabama SOBRA Medicaid Program. As of October 1, 2015, CHIP will again expand Medicaid by covering Medicaid enrollees ages 14 years to 19 years with incomes above 13% FPL through 141% FPL.

ALL Kids:

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Program Operation–Administration From inception of the program in 1998 through May, 2001, ALL Kids contracted with the State Employee’s Insurance Board (SEIB) to serve as its enrollment and premium billing/receiving office. As enrollment grew, ALL Kids staff increased, and the need for data management grew, the ADPH CHIP unit and SEIB jointly decided to move the enrollment and premium billing/receiving functions to the CHIP unit. The Alabama Department of Public Health (Department) now manages all enrollment aspects of the ALL Kids program and utilizes other contractors to administer certain aspects of the ALL Kids program including, but not limited to, the following:

1. Providing all eligible persons involved in ALL Kids an individual policy or certificate that states the insurance protection provided, the method and place of filing claims, and to whom benefits are payable. The policy or certificate indicates that coverage was obtained through CHIP; 2. Maintenance of a claims database for the purpose of program management. 3. Management of evaluation surveillance procedures. 4. Consultation for actuarial services 5. Consultation for development of data systems 6. Consultation for development of specialized outreach plans

Program Operation-Benefits and Services The ALL Kids program is a self-funded, discounted fee-for-service*, PPO, delivery system. In order to assure delivery of the insurance product(s), the Department utilizes a private health care delivery organization(s) to provide benefits and services. Both indemnity plan(s) and or managed care plans(s) are acceptable and have been used. The selected vendor(s) is required to perform, including but not limited to, the following:

1. Furnishing coverage information and ID cards; 2. Member service responses to claims inquiries; 3. Claims certification, investigation, adjudication, and internal appeals process; 4. Processing and distribution of benefit payments to providers; 5. Appropriate and accurate fee administration; 6. Strict financial accounting and reconciliation; 7. Effective management of networks (if applicable); 8. Demonstrated capability to serve Alabama membership; 9. Effective medical, pharmacy and dental management including medical review of claims decisions; 10. Production of claims, contract, and other legal forms as required; 11. Establishment and maintenance of appropriate banking arrangements; 12. Continuous and accurate electronic transmission of all data; 13. Production of reports that capture claim and utilization experience and trends; 14. Other special services as may be requested from time to time 15. Have a network of physicians, dentists, pharmacies, and other providers capable of meeting

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the demands of the ALL Kids Program. 16. Facilitation of a medical home for each enrollee.

*The exception to the fee-for-service payment system is the method of reimbursement to federally qualified health centers (FQHCs) and rural health clinics (RHCs) based on a prospective payment system (PPS). This is in compliance with section 503 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA). In accordance with this provision of CHIPRA, ALL Kids has elected to adopt the Medicaid PPS Rates effective October 1, 2009. This method of payment will be implemented August 25, 2010 for all qualifying services rendered on or after October 1, 2009.

In the past, ALL Kids has used three (3) insurance venders, Blue Cross Blue Shield of Alabama (statewide), Prime Health (in 10 southwestern counties from 10/98-9/00) and United Healthcare (14 counties from 10/01-7/02) for the above services. However, due to low enrollment in Prime Health and United Healthcare (which was due to patient choice), each of those programs elected, with the mutual consent of the ALL Kids program, to discontinue serving as an ALL Kids vendor. Currently, the only ALL Kids vendor for the above services is Blue Cross Blue Shield of Alabama. This vendor provides services statewide.

CHIP makes health care coverage available to all individuals eligible for ALL Kids on a “guaranteed issue” basis with no exclusions of coverage for pre-existing conditions, and on a “guaranteed renewable” basis for those eligible.

ALL Kids PLUS Program Operation-Administration For this addition to the program, the Alabama Department of Public Health has partnered (and seeks to partner) with other governmental agencies (which serve special needs children) to provide the state match, provide or provide for covered ALL Kids PLUS services, to authorize case by case reimbursement for ALL Kids PLUS services, to notify ALL Kids PLUS families of their approval for services, and select one case manager per child so as to minimize duplication and gaps in services. PLUS services became available through CRS as of October 1, 2000. An ALL Kids PLUS contract was signed with the Department of Mental Health and Mental Retardation effective October 1, 2002.

Several state agencies, other provider entities, and advocates within the state have met to develop the concept and plan of operation for ALL Kids PLUS.

At the present time, the list of ALL Kids PLUS authorizing agencies is restricted to those governmental agencies supplying the state match money. If other state or appropriated matching funds become available, this restriction may be modified or eliminated. A child must be enrolled in ALL Kids to qualify for PLUS services. When a child is identified with a special condition or need that a participating agency serves, he/she is referred to that agency based on that special condition/need. This agency will, based on the availability of funds, assign a case manager to the

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child, authorize needed services within the agency, and make referrals to other authorizing agencies for additional services if needed. All agencies authorizing PLUS services for a child notify the child’s case manager and referral site (if different) for approval of services. Each child will only have one ALL Kids PLUS case manager. The decision as to which agency will provide the case management will be determined by the agencies involved in the child’s care and will be based on what makes the best practice sense and is in the best interest of the child.

Authorizing agencies bill the insurance vendor(s) for any authorized PLUS services that the agencies have provided directly or indirectly. The Alabama Department of Public Health reimburses the insurance vendor(s) in the same manner that reimbursement for the basic ALL Kids program is handled. At this time, the participating PLUS agencies do not utilize a central integrated data system. However, their day-to-day practice involves coordination through the case manager with other agencies to avoid duplication. Each agency submits all claims/data to the insurance vendor (BCBS) for adjudication and reimbursement. While a child may have claims submitted by more than one agency, only one agency may be reimbursed for case management services.

Check here if the State child health program delivers services using a managed care delivery model. The State provides an assurance that its managed care contract(s) complies with the relevant provisions of section 1932 of the Act, including section 1932(a)(4), Process for Enrollment and Termination and Change of Enrollment; section 1932(a)(5), Provision of Information; section 1932(b), Beneficiary Protections; section 1932(c), Quality Assurance Standards; section 1932(d), Protections Against Fraud and Abuse; and section 1932(e), Sanctions for Noncompliance. The State also assures that it will submit the contract(s) to the CMS Regional Office for review and approval. (Section 2103(f)(3))

Guidance: In Section 3.2., note that utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package.

Examples of utilization control systems include, but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after- hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost-effective and efficient manner. (42CFR 457.490(b))

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package described in

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the approved State plan. (Section 2102)(a)(4) (42CFR 457.490(b))

Utilization control mechanisms are in place for the ALL Kids program to ensure that children use only health care that is appropriate, medically necessary, and/or approved by the State or the participating health plan. In addition, policies are in place to assure that necessary care is delivered in a cost-effective and efficient manner according to the vendors’ medical necessity definition. The current Blue Cross Blue Shield policies are available upon request.

Before being approved for participation in the ALL Kids program, health plan vendors must develop and have in place utilization review policies and procedures, demand management, and disease state management mechanisms. Provider networks approved for the ALL Kids program are accepted based on evidence of the vendors’ provider credentialing policies, provider accessibility, cost- effectiveness, and efficiency.

Each ALL Kids PLUS authorizing state agency has a utilization review mechanism particular to that agency. Services approved for ALL Kids PLUS are those which are developmentally necessary and/or physically necessary. Reviewing the appropriate use of services is part of the case manager’s duties.

The Alabama Medicaid Agency applies the same utilization controls to the CHIP Medicaid expansion enrollees as it does to the entire Medicaid child book of business. Section 4. Eligibility Standards and Methodology

Guidance: States electing to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan or combination plan should check the appropriate box and provide the ages and income level for each eligibility group. If the State is electing to take up the option to expand Medicaid eligibility as allowed under section 214 of CHIPRA regarding lawfully residing, complete section 4.1-LR as well as update the budget to reflect the additional costs if the state will claim title XXI match for these children until and if the time comes that the children are eligible for Medicaid.

4.0.

Medicaid Expansion

4.0.1. Ages of each eligibility group and the income standard for that group:

4.1.

Separate Program Check all standards that will apply to the State plan. (42CFR 457.305(a) and 457.320(a))

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4.1.0 Describe how the State meets the citizenship verification requirements. Include whether or not State has opted to use SSA verification option.

4.1.1 Geographic area served by the Plan if less than Statewide:

4.1.2 Ages of each eligibility group, including unborn children and pregnantwomen (if applicable) and the income standard for that group:

4.1.2.1-PC Age: through birth (SHO #02-004, issued November 12, 2002)

4.1.3 Income of each separate eligibility group (if applicable):

4.1.3.1-PC 0% of the FPL (and not eligible for Medicaid) through % of the FPL (SHO #02-004, issued November 12, 2002) 4.1.4 Resources of each separate eligibility group (including any standards relating to spend downs and disposition of resources):

4.1.5 Residency (so long as residency requirement is not based on length oftime in state):

4.1.6 Disability Status (so long as any standard relating to disability status does not restrict eligibility):

Children will be eligible for ALL Kids regardless of disability. ALL Kids PLUS is available to children with special conditions/needs who are enrolled in ALL Kids. ALL Kids PLUS enrollment is restricted to services authorized and financed by PLUS participating agencies. However, if access to additional matching funds becomes available and/or the health needs of CSHCC/N change, authorized services will be revised to reflect these changes.

4.1.7 Access to or coverage under other health coverage:

A child is not eligible for ALL Kids if s/he has any other health insurance coverage or is eligible for Medicaid.

4.1.8 Duration of eligibility, not to exceed 12 months:

4.1.9 Other Standards- Identify and describe other standards for or affecting eligibility,includingthose standards in 42 CFR 457.310 and 457.320 that are notaddressed above. For instance:

Comprehensive health coverage will be provided from conception to birth for those with family incomes up to and including 312% FPL, whose mothers do not have

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comprehensive coverage, and reside in select counties in Alabama (initially Montgomery, Macon and Russell). Full coverage will be provided to this population from the date of enrollment through delivery. The date of enrollment may be as early as the first day of maternity-related service provision even if the application is completed a few days after the service is received. In other cases coverage will begin on the date the application is received by the CHIP office. For example, if a woman gives birth on June 26, benefits covered in the bundled package would end on August 31. Only bundled services will be covered after delivery; coverage for other benefits will cease upon delivery. Coverage for bundled obstetrical benefits begins upon enrollment and will continue until the last day of the month in which the 60 day postpartum period has elapsed after the end of a pregnancy. Obstetric coverage for current ALL Kids members includes all prenatal care through 90 days postpartum and is billed as a bundled payment. Social Security numbers for the babies will not be required unless and until the child is born and applies for renewal.

Guidance: States may only require the SSN of the child who is applying for coverage. If SSNs are required and the State covers unborn children, indicate that the unborn children are exempt from providing a SSN. Other standards include, but are not limited to presumptive eligibility and deemed newborns.

4.1.9.1

States should specify whether Social Security Numbers (SSN) are required.

Guidance: States should describe theircontinuous eligibility process and populations that can be continuously eligible.

4.1.9.2

Continuous eligibility

4.1-PW

Pregnant Women Option (section 2112)- The State includes eligibility for one or more populations of targeted low-income pregnant women under the plan. Describe the population of pregnant women that the State proposes to cover in this section. Include all eligibility criteria, such as those described in the above categories (for instance, income and resources) that will be applied to this population. Use the same reference number system for those criteria (for example, 4.1.1-P for a geographic restriction). Please remember to update sections 8.1.1-PW, 8.1.2-PW, and 9.10 when electing this option.

Guidance: States have the option to cover groups of “lawfully residing” children and/or pregnant women. States may elect to cover (1)“lawfully residing” children described at section 2107(e)(1)(J) of the Act; (2) “lawfully residing” pregnant women described at section 2107(e)(1)(J) of the Act; or (3) both. A state electing to cover children and/or pregnant women who are considered lawfully residing in the U.S. must offer coverage to all

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such individuals who meet the definition of lawfully residing, and may not cover a subgroup or only certain groups. In addition, states may not cover these new groups only in CHIP, but must also extend the coverage option to Medicaid. States will need to update their budget to reflect the additional costs for coverage of these children. If a State has been covering these children with State only funds, it is helpful to indicate that so CMS understands the basis for the enrollment estimates and the projected cost of providing coverage. Please remember to update section 9.10 when electing this option.

4.1- LR

Lawfully Residing Option(Sections 2107(e)(1)(J) and 1903(v)(4)(A); (CHIPRA # 17, SHO # 10-006 issued July 1, 2010) Check if the State is electing the option under section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) regarding lawfully residing to provide coverage to the following otherwise eligible pregnant women and children as specified below who are lawfully residing in the United States including the following: A child or pregnant woman shall be considered lawfully present if he or she is: (1) A qualified alien as defined in section 431 of PRWORA (8 U.S.C. §1641); (2) An alien in nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission; (3) An alien who has been paroled into the United States pursuant to section 212(d)(5) of the Immigration and Nationality Act (INA) (8 U.S.C. §1182(d)(5)) for less than 1 year, except for an alien paroled for prosecution, for deferred inspection or pending removal proceedings; (4) An alien who belongs to one of the following classes: (i) Aliens currently in temporary resident status pursuant to section 210 or 245A of the INA (8 U.S.C. §§1160 or 1255a, respectively); (ii) Aliens currently under Temporary Protected Status (TPS) pursuant to section 244 of the INA (8 U.S.C. §1254a), and pending applicants for TPS who have been granted employment authorization; (iii) Aliens who have been granted employment authorization under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24); (iv) Family Unity beneficiaries pursuant to section 301 of Pub. L. 101- 649, as amended; (v) Aliens currently under Deferred Enforced Departure (DED) pursuant to a decision made by the President; (vi) Aliens currently in deferred action status; or (vii) Aliens whose visa petition has been approved and who have a pending application for adjustment of status; (5) A pending applicant for asylum under section 208(a) of the INA (8 U.S.C. § 1158) or for withholding of removal under section 241(b)(3)

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of the INA (8U.S.C. § 1231) or under the Convention Against Torture who has been granted employment authorization, and such an applicant under the age of 14 whohas had an application pending for at least180 days; (6) An alien who has been granted withholding of removal under the Convention Against Torture; (7) A child who has a pending application for Special Immigrant Juvenile status as described in section 101(a)(27)(J) of the INA (8 U.S.C. §1101(a)(27)(J)); (8) An alien who is lawfully present in the Commonwealth of the NorthernMariana Islands under 48 U.S.C. § 1806(e); or (9) An alien who is lawfully present in American Samoa under theimmigration laws of American Samoa.

Elected for pregnant women. Elected for children under age

4.1.1-LR

The State provides assurance that for an individual whom it enrolls in Medicaid under the CHIPRA Lawfully Residing option, it has verified, at the time of the individual’s initial eligibility determination and at the time of the eligibility redetermination, that the individual continues to be lawfully residing in the United States. The State must first attempt to verify this status using information provided at the time of initial application. If the State cannot do so from the information readily available, it must require the individual to provide documentation or further evidence to verify satisfactory immigration status in the same manner as it would for anyone else claiming satisfactory immigration status under section 1137(d) of the Act.

4.1-DS

Supplemental Dental(Section 2103(c)(5)-A child who is eligible to enroll in dental- only supplemental coverage, effective January 1, 2009. Eligibility is limited to only targeted low-income children who are otherwise eligible for CHIP but for the fact that they are enrolled in a group health plan or health insurance offered through an employer. The State’s CHIP plan income eligibility level is at least the highest income eligibility standard under its approved State child health plan (or under a waiver) as of January 1, 2009. All who meet the eligibility standards and apply for dental-only supplemental coverage shall be provided benefits. States choosing this option must report these children separately in SEDS. Please update sections 1.1-DS, 4.2-DS, and 9.10 when electing this option.

4.2. AssurancesThe State assures by checking the box below that it has made the following findings with respect to the eligibility standards in its plan:(Section 2102(b)(1)(B) and 42 CFR 457.320(b))

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4.2.1. These standards do not discriminate on the basis of diagnosis.

4.2.2. Within a defined group of covered targeted low-income children, these

standards do not cover children of higher income families without covering

children with a lower family income. This applies to pregnant women included

in the State plan as well as targeted low-income children.

4.2.3. These standards do not deny eligibility based on a child having a pre-existing

medical condition. This applies to pregnant women as well as targeted low-

income children.

4.2-DS Supplemental Dental -Please update sections 1.1-DS, 4.1-DS, and 9.10 when electing this option. For dental-only supplemental coverage, the State assures that it has made the following findings with standards in its plan: (Section 2102(b)(1)(B) and 42 CFR 457.320(b))

4.2.1-DS These standards do not discriminate on the basis of diagnosis.

4.2.2-DS Within a defined group of covered targeted low-income children, these

standards do not cover children of higher income families without covering

children with a lower family income.

4.2.3-DS These standards do not deny eligibility based on a child having a pre-

existing medical condition.

4.3. Methodology. Describe the methods of establishing and continuing eligibility and enrollment. The description should address the procedures for applying the eligibility standards, the organization and infrastructure responsible for making and reviewing eligibility determinations, and the process for enrollment of individuals receiving covered services, and whether the State uses the same application form for Medicaid and/or other public benefit programs. (Section 2102)(b)(2)) (42CFR 457.350)

Superseded by ACA SPA Guidance: The box below should be checked as related to children and pregnant women.Please note: A State providing dental-only supplemental coverage may not have a waiting list or limit eligibility in any way.

4.3.1. Limitation on EnrollmentDescribe the processes, if any, that a State will use for instituting enrollment caps, establishing waiting lists, and deciding which children will be given priority for enrollment. If this section does not apply to your state, check the box below. (Section 2102(b)(2)) (42CFR 457.305(b))

There are no public notice state laws regarding enrollment caps and waiting lists in CHIP. Due to insufficient state funds, ALL Kids initiated a waiting list beginning with all new enrollees who would have had an effective date October 1, 2003. Public and enrollee notices about the waiting list were issued during the month of September 2003 prior to the impact of the waiting list. On August 23, 2004, ALL Kids reopened enrollment and discontinued use of the waiting list.

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If during the year funds are not available at sufficient levels for coverage of children and funding is projected to be depleted before the end of the fiscal year, it is the State’s intent to place eligible children on a waiting list until adequate funding becomes available to resume enrollment. Alabama will provide public notice through press releases, written communication with stakeholders and stakeholder groups, presentations, and written communication from the program to all applicant families whose child(ren) is/are placed on the waiting list.

When a waiting list is implemented, the program has and will continue to receive new applications. These applications will be screened for Medicaid eligibility and then reviewed for ALL Kids eligibility. If a child is eligible for Medicaid, the child will be enrolled in Medicaid. Each family whose child is placed on the ALL Kids waiting list will be notified, by letter, of this placement. The notification letter will also contain information stating that the parent may wish to contact Medicaid if his situation changes and he believes that his child may be eligible for Medicaid. If the child remains on the waiting list for longer than three (3) months, the family will be periodically notified via letter that the child’s name is still on the waiting list.

If the State is using a waiting list, children will be enrolled on ALL Kids from the waiting list on a first on–first off basis as funding permits. When attrition has lowered program enrollment to a level at which there are sufficient state funds to re-open enrollment, children will be removed from the waiting list ( on a first on first off basis) and enrolled in ALL Kids. Children who are removed from the waiting list whose application information is greater than 90 days old will be asked to complete a form updating changes in information on their family size, income, and other points of eligibility. Upon receipt of the form, ALL Kids enrollment staff will evaluate the child’s eligibility for ALL Kids. Then, if eligible, either the child will be enrolled in ALL Kids or Medicaid and the family will be notified.

Children who have current enrollment in ALL Kids will be allowed to continue to renew their enrollment as long as they continue to meet all points of eligibility and have their renewal forms submitted and premium balances paid in full within 90 days after the date of termination. Check here if this section does not apply to your State.

Guidance: Note that for purposes of presumptive eligibility, States do not need to verify the

citizenship status of the child. States electing this option should indicate so in the

State plan.(42 CFR 457.355)

4.3.2. Check if the State elects to provide presumptive eligibility for children that meets the requirements of section 1920A of the Act. (Section 2107(e)(1)(L)); (42 CFR 457.355)

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Guidance: Describe how the State intends to implement the Express Lane option. Include information on the identified Express Lane agency or agencies, and whether the State will be using the Express Lane eligibility option for the initial eligibility determinations, redeterminations, or both.

4.3.3-EL Express Lane Eligibility Check here if the state elects the option to rely on a finding from an Express Lane agency when determining whether a child satisfies one or more components of CHIP eligibility. The state agrees to comply with the requirements of sections 2107(e)(1)(E) and 1902(e)(13) of the Act for this option. Please update sections 4.4-EL, 5.2-EL, 9.10, and 12.1 when electing this option. This authority may not apply to eligibility determinations made before February 4, 2009, or after September 30, 2013. (Section 2107(e)(1)(E))

4.3.3.1-ELAlso indicate whether the Express Lane option is applied to (1) initial eligibility determination, (2) redetermination, or (3) both.

4.3.3.2-ELList the public agencies approved by the State asExpress Lane agencies.

4.3.3.3-ELList the components/components of CHIP eligibility that are determined under the Express Lane. In this section, specify any differences in budget unit, deeming, income exclusions, income disregards, or other methodology between CHIP eligibility determinations for such children and the determination under the Express Lane option.

4.3.3.3-ELList the component/components of CHIP eligibility that are determined under the Express Lane.

4.3.3.4-ELDescribe the option used to satisfy the screen and enrollment requirements before a child may be enrolled under title XXI.

Guidance: States should describe the process they use to screen and enroll children required under section 2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and 457.80(c). Describe the screening threshold set as a percentage of the Federal poverty level (FPL) that exceeds the highest Medicaid income threshold applicable to a child by a minimum of 30 percentage points. (NOTE: The State may set this threshold higher than 30 percentage points to account for any differences between the income calculation methodologies used by an Express Lane agency and those used by the State for its Medicaid program. The State may set one screening threshold for all children, based on the highest Medicaid income threshold, or it may set more than one screening threshold, based on its existing, age-related Medicaid eligibility thresholds.) Include the screening threshold(s) expressed as a percentage of the FPL, and provide an explanation of how this was calculated. Describe whether the

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State is temporarily enrolling children in CHIP, based on the income finding from an Express Lane agency, pending the completion of the screen and enroll process.

In this section, states should describe their eligibility screening process in a way that addresses the five assurances specified below. The State should consider including important definitions, the relationship with affected Federal, State and local agencies, and other applicable criteria that will describe the State’s ability to make assurances. (Sections 2102(b)(3)(A) and 2110(b)(2)(B)), (42 CFR 457.310(b)(2), 42CFR 457.350(a)(1) and 457.80(c)(3))

4.4. Eligibility screening and coordination with other health coverage programs States must describe how they will assure that:

4.4.1. only targeted low-income children who are ineligible for Medicaid or notcovered under a group health plan or health insurance (including access to a State health benefits plan) are furnished child health assistance under the plan.(Sections 2102(b)(3)(A), 2110(b)(2)(B)) (42 CFR 457.310(b), 42CFR 457.350(a)(1) and 42 CFR 457.80(c)(3)) Confirm that the State does not apply a waiting period for pregnant women.

The State of Alabama assures that through enrollment screening processes, children whose applications are considered to be eligible for medical assistance under the State Medicaid plan will be referred for assistance under the appropriate plan. Additionally, ALL Kids eligibility staff query the Medicaid eligibility system to ensure applicants are not currently on any Medicaid program. All applications request the parent/guardian to provide the names and addresses of their employers. Eligibility staff screen all applications to ensure applicant children are not currently covered under group health insurance and have not voluntarily terminated group coverage within the last three months. In an effort to further minimize crowd-out, ALL Kids receives a daily “error report” which indicates children who have current BCBS health insurance or have terminated a BCBS policy within the last three months. In addition, quality assurance reviews are conducted on a sample of ALL Kids enrollees. Redetermination is completed every 12 months.

4.4.2. children found through the screening process to be potentially eligible formedical assistance under the State Medicaid plan are enrolled for assistance under such plan; (Section 2102(b)(3)(B)) (42CFR 457.350(a)(2)).

When a child’s application is reviewed by ALL Kids and determined to be eligible for Medicaid, ALL Kids enrolls the child in Medicaid. Because a joint application is used, no additional form is required to be completed. Parents are notified by ALL regarding this determination

4.4.3. children found through the screening process to be ineligible for Medicaid are

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enrolled in CHIP.(Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4))

ALL Kids and Medicaid have a joint eligibility and enrollment system. When a Medicaid enrollment worker determines that a child is ineligible for Medicaid and eligible for ALL Kids, the worker enrolls the child in ALL Kids. Coverage is based on the application receipt date at the Medicaid office or the child’s last date of Medicaid or ALL Kids coverage. ALL Kids staff work very closely with the Medicaid central office and Medicaid enrollment workers to ensure that the policies and procedures of both agencies reflect the agencies’ desires for seamless transitions between the two agencies.

4.4.4. the insurance provided under the State child health plan does not substitute for coverage under group health plans. (Section 2102(b)(3)(C)) (42CFR, 457.805)

This section is superseded by ACA SPA 4.4.4.1. (formerly 4.4.4.4) If the State provides coverage under a premiumassistance program, describe: 1) the minimum period without coverage under a group health plan. This should include any allowable exceptions to the waiting period; 2) the expected minimum level of contribution employers will make; and 3) how cost-effectiveness is determined. (42CFR 457.810(a)-(c))

4.4.5. Child health assistance is provided to targeted low-income children in the Statewho are American Indian and Alaska Native. (Section2102(b)(3)(D)) (42CFR 457.125(a))

The State of Alabama assures the provision of child health assistance to targeted low-income children in the State who are American Indians (as defined in section 4(c) of the Indian Health Care Improvement Act, 25 U.S.C. 1603(c)). As Stated in section 4.1, the ALL Kids program will provide Statewide coverage. No ALL Kids enrollee identified as being an American Indian will be charged a premium or co-pay. This policy extends to all children who identify themselves as an American Indian children whether they are a member of a federally recognized tribe or one of the eight state-only recognized tribes. Representatives from the Poarch Band of Creek Indians (the only federally recognized Tribe in Alabama) have assisted in the development of ALL Kids PLUS. Tribal children will have access to PLUS services.

CHIP staff meet and coordinate regularly with the Alabama Commission on Indian Affairs to ensure that Native American Children are identified and enrolled in ALL Kids. Additionally, a Native American was hired under a one-year contract to consult with ALL Kids staff and develop a comprehensive strategy to outreach to Native American children. Guidance:

When the State is using an income finding from an Express Lane agency, the State must still comply with screen and enroll requirements before enrolling children in CHIP. The State may either continue its current screen and enroll process, or elect one of two new options to fulfill these requirements.

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4.4-EL The State should designate the option it will be using to carry out screen and enroll

requirements:

The State will continue to use the screen and enroll procedures required under section 2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and 42 CFR 457.80(c). Describe this process.

The State is establishing a screening threshold set as a percentage of the Federal poverty level (FPL) that exceeds the highest Medicaid income threshold applicable to a child by a minimum of 30 percentage points. (NOTE: The State may set this threshold higher than 30 percentage points to account for any differences between the income calculation methodologies used by the Express Lane agency and those used by the State for its Medicaid program. The State may set one screening threshold for all children, based on the highest Medicaid income threshold, or it may set more than one screening threshold, based on its existing, age-related Medicaid eligibility thresholds.) Include the screening threshold(s) expressed as a percentage of the FPL, and provide an explanation of how this was calculated.

The State is temporarily enrolling children in CHIP, based on the income finding from the Express Lane agency, pending the completion of the screen and enroll process.

Section 5. Outreach and Coordination

5.1. (formerly 2.2)Describe the current State efforts to provide or obtain creditable health coverage for uninsured children by addressing sections 5.1.1 and 5.1.2.(Section 2102)(a)(2) (42CFR 457.80(b))

Guidance: The information below may include whether the state elects express lane eligibility a description of the State’s outreach efforts through Medicaid and state-only programs.

5.1.1. (formerly 2.2.1.) The steps the State is currently taking to identify and enroll all uninsured children who are eligible to participate in public health insurance programs (i.e., Medicaid and state-only child health insurance):

In Alabama, thanks to outreach efforts of a variety of public and private agencies and organizations, there is a high awareness level of children’s health insurance programs and their eligibility requirements. Over one-fourth of children under the age of 19 in Alabama are covered by Medicaid or ALL Kids. The programs are reaching children who might not otherwise have access to the health care they need.

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Prior to CHIP, the Medicaid Program was the only public health insurance program for children in Alabama. Health services are provided in Alabama to uninsured and Medicaid enrolled children by private physicians, the 67 Alabama Department of Public Health (ADPH) county health departments, 16 primary care centers (including Federally Qualified Health Centers), two children’s hospitals (The Children’s Hospital of Alabama and Women’s and Children’s Hospital at the University of South Alabama) school health nurses, and one Indian Health Service Clinic. In addition to the two children’s hospitals, Alabama Department of Rehabilitation Services, Children’s Rehabilitation Services (CRS) provides specialty care to uninsured and Medicaid enrolled children with special health care needs. As lead agency for Alabama’s Early Intervention System, this agency coordinates services for infants and toddlers eligible for IDEA (Individuals with Disabilities Education Act), part C. This section describes the current efforts made by the ADPH to provide health care services, and to identify and enroll uncovered children in the Medicaid and ALL Kids programs. This section also describes the efforts made by CRS, the Alabama Medicaid Agency, the Alabama Department of Human Resources, and the Alabama Department of Mental Health and Mental Retardation to identify and enroll all uncovered children who are eligible to participate in the Medicaid and ALL Kids programs.

Alabama Department of Public Health As the CHIP lead agency, the ADPH is actively involved in all aspects of identification and enrollment of children who are eligible to participate in public health insurance programs and health insurance programs that involve public-private partnerships. Activities include the creation, publication, and distribution of marketing materials, management of the ALL Kids enrollment process, and targeted outreach activities for specific populations such as faith-based organizations, etc. The Alabama Department of Public Health provides some direct as well as support patient care for uninsured and Medicaid enrolled children and adolescents. Direct services for this population include: preventive child health services (well-child check-ups), prenatal services, Women Infants and Children Supplemental Nutrition [WIC] program services, preventive health education, immunizations, and Family Planning program services. Support services include case management services, the provision of information and referral via toll-free telephone lines, and laboratory services. These services are funded through federal Title V Maternal and Child Health Block Grant funds, federal Title X Family Planning program funds, federal WIC Program funds, Medicaid program reimbursements, federal immunization funds, state legislative appropriations, some local government appropriations, and a small amount of patient fee revenue. A variety of the above direct and support services are provided within ADPH county health departments. In fiscal year 2001, 34,664 children (birth through age 18 years) received health services in local county health departments. (This number excludes single service patients [STD-only, Immunization-only, WIC-only].) The Alabama Department of Public Health is the state’s Title V agency. Additionally, there are approximately 512 school health nurses, R.N.s and L.P.N.s, (working under the auspices of the ADPH, private hospitals, the Alabama State Department of Education, and/or local education agencies) in the state who provide a variety of health screening services, primary care and

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emergency services, Medicaid/ALL Kids enrollment facilitation, etc.

Income assessments are performed on all patients enrolled in ADPH clinics. The income assessments are reviewed for possible Medicaid eligibility. Beginning in FY 1991, Medicaid eligibility workers were out-stationed in health departments and other health care facilities to accept applications and complete Medicaid eligibility determinations at the time of health visits. A streamlined, four-page expanded Medicaid eligibility form, which was implemented in FY 1991, has been revised into a joint application with CHIP and the Alabama Child Caring Foundation (ACCF) and is available at county health departments. Out-stationed Medicaid eligibility personnel currently assist patients in completing the forms and data is put into an automated Medicaid system on-site. Final determination for Medicaid can then be made immediately. If the children appear to be ALL Kids or ACCF eligible the application is forwarded to the appropriate program.

New applications, as well as annual reviews of established patients, are assessed by ADPH intake staff and/or care coordinators for possible referral for medical assistance through Medicaid, ACCF, or SSI. When appropriate, staff assist families in completing the application forms, making appointments, and gathering medical information. Out-stationed Medicaid eligibility workers are based in many ADPH clinics, hospitals, and primary care centers across the state. Additionally, two Medicaid outstationed workers and a clerk are now located in the CHIP office who process many ALL Kids referrals. A third worker will be added in FY 2003.

Cross training sessions with staff at many levels has improved interagency communication at the community level.

In order to provide additional outreach, the ADPH operates two toll-free telephone lines for use by the general public. The toll-free telephone lines (established prior to the implementation of CHIP and continued to the present) are known as Healthy Beginnings and Info Connection. Two integral parts of the information provided to callers, via these telephone lines, are information on Medicaid, ALL Kids, and ACCF eligibility and referrals to health providers who accept Medicaid-eligible children and Medicaid-eligible pregnant women. Referral services provided by the Healthy Beginnings and Info Connection staff members are expanded through consultation supplied by a host of additional professionals located within the ADPH. The toll-free number for Healthy Beginnings is 1-800-654-1385. The Info Connection number is 1-800-545-1098. Both lines are operational 24 hours a day, seven (7) days a week; office hours are from 8:30 A.M. to 4:30 P.M. each week day. The Healthy Beginnings and Info Connection lines are publicized statewide through newspapers, television, posters, and pamphlets. Presentations regarding the lines are conducted statewide to various organizations and agencies. The numbers are also published in Alabama South Central Bell telephone books. Additionally, with the implementation of CHIP, the CHIP unit maintains two toll-free telephone lines (888-373-5437 for enrollment and eligibility issues and 877-774-9521 for administrative issues). Finally, in addition to the above efforts, ALL Kids, Medicaid, and the Alabama Child Caring Foundation have developed a joint application and renewal form for

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use by all three programs. This enables families to be screened for eligibility for all three programs and facilitates referrals and timely enrollment in the appropriate program.

Alabama Department of Economic and Community Affairs (ADECA) ADECA notifies the ALL Kids regional staff when a plant or large business plans to close in the near future. ALL Kids regional staff present ALL Kids information and materials at employee meetings prior to the plant/business closing. In order to prevent gaps in health insurance coverage for the children of the employees of the plant/business, an ALL Kids policy was developed which provides for beginning ALL Kids coverage (for eligible children) the day after employer sponsored coverage ends if an application is received by the ALL Kids enrollment unit within 30 days after the plant/business closing.

Alabama Department of Rehabilitation Services Children’s Rehabilitation Service Children’s Rehabilitation Service (CRS) also has coordination agreements with the Alabama Medicaid Agency. (These contracts existed prior to CHIP and have continued to be in effect.) The Alabama Medicaid Agency contracted with CRS for the provision of specialty medical services, specialized therapy (such as physical, occupational, speech, etc) services, and case management services to children with special health care needs. With the implementation of ALL Kids, CRS clinics were added as preferred providers under the ALL Kids basic benefits package and the ALL Kids PLUS package.

New applications, as well as annual reviews of established patients, are assessed by CRS intake staff and/or care coordinators for possible referral for medical assistance through Medicaid, ALL Kids, ACCF, or SSI. When appropriate, staff assist families in completing the application forms, making appointments, and gathering medical information. Joint Medicaid/ALL Kids/ACCF eligibility forms are available in all CRS offices and clinics. As in the ADPH, cross training sessions with staff at many levels has improved interagency communication at the community level. Medicaid and ALL Kids information and outreach brochures and posters are available in every CRS office throughout the state.

Additionally, like the ADPH, CRS operates toll-free telephone lines for use by the general public. One line is operated at the state level in Montgomery and additional lines are located in each CRS district office. An integral part of the information provided to callers, via these telephone lines, is Medicaid, ALL Kids, and ACCF eligibility and referral information. CRS and Early Intervention (EI) have both completed database matches with ALL Kids files to identify children known to both programs. CHIP staff have participated in many staff trainings throughout the state to assist CRS and EI staff in outreach for ALL Kids, Medicaid, and ACCF.

Division of Early Intervention As the lead agency for Alabama’s early intervention system for infants and toddlers with

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developmental disabilities and their families, this unit provides a toll free Child Find telephone number for use by the general public and primary referral sources. Additional efforts for coordination are described in the PLUS sections of this document.

Medicaid Agency The Alabama Medicaid Agency has 135 eligibility workers in over 170 locations to enroll children eligible for SOBRA Medicaid whose the family’s income is at or below 100 percent of FPL (for children born after September 30, 1983) or 133 percent of the FPL (for children through age five). With the implementation of CHIP, 23 workers were added throughout the state. In March, 2002, two eligibility workers and a clerk were housed in the ALL Kids central office to review applications referred from the ALL Kids eligibility workers. In addition to the CHIP office, these workers are located in places children are likely to go to receive health care - - county health departments, Federally Qualified Health Centers and hospitals. Because workers are in the community, they can and do establish working relationships with public and private providers, social service agencies and others. For example, supervisors provide in- service training and education on Medicaid, ALL Kids, and ACCF eligibility to physicians, Head Start workers, day care centers, Human Resources staff and others. The Alabama Medicaid Agency also has 10 district offices located throughout the state that process applications for the elderly and the disabled population. The 80 eligibility workers and 20 supervisors advise applicants about other programs and refer the applicants to the proper office when they do not qualify for a disabled program. They also advise about programs for which other family members may be eligible. These district offices work closely with providers to keep them informed of all programs available through the Medicaid Agency.

Applications for Medicaid, ALL Kids, and ACCF are easily available to anyone who needs one. Applications are available not only from Medicaid workers but also at physicians’ offices, county offices of the Department of Human Resources and hospitals. All sources of the joint application (i.e., ADPH, CRS, etc.) allow a “mail-in” application process thereby allowing Medicaid to complete a phone interview instead of a face-to-face interview. Medicaid has a toll- free number for anyone to call to ask questions about Medicaid eligibility and find out where and how to apply. The number is 1-800-362-1504. Medicaid’s Web site contains information on Medicaid eligibility and is used by advocates to assist people who want to apply for Medicaid.

Through its Medical Care Advisory Committee and its Physicians Task Force, Medicaid receives guidance on ways to reach potential Medicaid eligibles. Medicaid staff regularly brief these groups, who represent both providers and consumers, on all facets of the Medicaid program, including eligibility. Both groups are kept informed of upcoming changes in the Medicaid program and encouraged to provide comments and suggestions. With welfare reform and the separation of Medicaid eligibility from eligibility for public assistance, the Alabama Medicaid Agency and the Department of Human Resources have developed new cooperative arrangements to assure that children in the state’s lowest income

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families have access to Medicaid. Applications may be completed through the mail with a telephone interview, thus eliminating the need for a face-to-face contact. Currently DHR workers assess their clients to determine whether they might be eligible for any Medicaid, ALL Kids, or ACCF program. Workers help to complete forms, gather information and make appointments as necessary. However, the enrollment function for this Medicaid program will be transferred from DHR to the Medicaid Agency within the coming year.

Outreach occurs after the birth of an infant to a Medicaid recipient. Following the birth of each newborn whose mother is a Medicaid recipient, the Alabama Medicaid Agency sends the infant's parent or guardian a pamphlet on the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program as well as a pamphlet on immunizations. When children are enrolled in the SSI Program, they are automatically enrolled in the Medicaid Program. Additionally, a brochure is sent to parents/guardians of all new SSI eligible children encouraging them to participate in the EPSDT program. In addition to these efforts, social workers within the ADPH conduct patient recruitment as a part of their case management activities. These recruitment efforts are conducted through community presentations and professional relationships with other State and local agencies which serve mothers and children.

The Alabama Department of Human Resources and the Alabama Department of Mental Health and Mental Retardation also provide case management services for Medicaid children known to their agencies, in order to facilitate their enrollment in health services particularly mental health services through the Rehabilitation Option.

Through CHIP Phase I, the Alabama Medicaid Agency, working with the Alabama Department of Public Health, took several major steps to identify and enroll all uncovered children who were eligible to participate in this public health insurance program. New eligibility workers were hired and they, plus existing eligibility workers, were trained in CHIP eligibility criteria as well as other Medicaid eligibility criteria. These eligibility workers are outstationed in health departments, hospitals, community health centers, CHIP office, etc.

In order to streamline the CHIP/Medicaid enrollment process, the Alabama Medicaid Agency initiated continuous eligibility for all Medicaid children under the age of 19 years, on April 1, 1998. Continuous eligibility means that Medicaid enrolled children maintain their Medicaid coverage continuously for one year from enrollment or re-determination.

Additionally, numerous presentations, regarding CHIP, have been made by knowledgeable professionals who are members of the broad based CHIP Workgroup and CHIP staff. These presentations include addresses to education professionals, rural health groups, child care management agencies, parents of children with special health care needs, Indian Health Service staff, the general public, etc. Some specific activities include:

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Notice to all Medicaid providers News releases and camera-ready materials for newspapers Articles published in newsletters of health care provider associations–Medical Association of the State of Alabama, Alabama Hospital Association, Alabama Dental Association, and others Television commercials Radio spots Brochures have been distributed to date for outstationed Medicaid workers, public health workers, county human resources workers, Early Intervention Coordinating Councils, Mental Health Centers, family services centers, primary health care centers, hospitals, advocacy and professional organization, and in the school system, principles and guidance counselors. Brochures distributed at state meetings of Alabama Conference of Social Work, Medical Association, American Academy of Pediatrics-Alabama Chapter, Alabama Dental Association, Family Practice doctors, and others Satellite conferences to provide information about the basic ALL Kids Program and instruction in completing the application. Distribution of applications and brochures to all public school systems, local health departments, welfare offices, hospitals, community health centers, physician and dentist offices, pharmacies, WIC clinics, and family law attorneys, etc. Public forums for parents and advocates of CSHCC/N (Children with Special Health Care Conditions/Needs)

With specific regard to the Conception to Birth expansion and the RIM HSI, the ADPH will provide information to pertinent providers, hospitals and programs serving the target population residing in the counties in which the expansion is implemented.

In addition to the above, the state has engaged in the following particular activities to promote ALL Kids PLUS. Originally, it was anticipated that ALL Kids PLUS would involve four state programs, Children’s Rehabilitation Service, Early Intervention, Mental Health/Mental Retardation, and Civitan International Research Center Sparks Clinics. After conducting database matches, reviews of Pediatric Health History information, claims data, through mutual agreement, Sparks determined that their services were being adequately reimbursed through the ALL Kids basic benefit package. Therefore, attention was focused on the remaining three agencies. Since that time, CHIP has entered into discussions with the Alabama Institute for the Deaf and Blind with regard to becoming an ALL Kids PLUS provider. CRS has had an active contract for the provision of PLUS services since October, 2000 and has served as a valuable partner in establishing protocols for the identification of ALL Kids enrollees in need of PLUS services and the identification of current clients in need of insurance coverage.

Initially it was anticipated that children would be identified for the PLUS program through an in-depth analysis of the Pediatric Health History and chart reviews. Practical experience has

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shown that this was not the most productive method of identification. Database matches were necessary as a first action to even identify ALL Kids enrollees who were being served by CRS. After this baseline was established, claims reviews were shown to be a more valuable mechanism in identifying children eligible for PLUS services than were chart reviews. This claims review revealed that a much smaller percentage of ALL Kids enrollees, than originally projected, were in need of services beyond those available in the basic benefits package. Program staff continually monitor feedback from providers and families regarding the need for additional services. This type of feedback and analysis has influenced the approaches that have been used with the other potential ALL Kids PLUS agencies. Through the activities of the regional ALL Kids staff, central office social work consultant, and customer service staff, ALL

Kids enrollees in need of these specialized services provided by ALL Kids PLUS agencies have been identified and referred as appropriate.

In August of 1999, the ADPH broadcasted a nationwide satellite conference to educate the provider community and other concerned individuals regarding ALL Kids PLUS. In addition, CHIP staff provided training on the PLUS program to CRS staff at regional meetings.

Alabama Department of Human Resources (DHR) The DHR has continued to partner with the ADPH to communicate ALL Kids information to their county staffs. They have provided initial and continuing updates to county DHR staff as well as provided periodic shipments of applications, posters, etc. The DHR has also assisted with outreach efforts through its childcare management agencies and facilitated communication with licensed child day-care homes and centers.

Guidance: The State may address the coordination between the public-private outreach and the public health programs that is occurring statewide. This section will provide a historic record of the steps the State is taking to identify and enroll all uninsured children from the time the State’s plan was initially approved. States do not have to rewrite his section but may instead update this section as appropriate.

5.1.2. (formerly 2.2.2.) The steps the State is currently taking to identify and enroll all uninsured children who are eligible to participate in health insurance programs that involve a public-private partnership:

There is only one health insurance program for children in Alabama that resembles a public- private partnership. This program is known as the Alabama Child Caring Foundation (ACCF) and is a part of Blue Cross Blue Shield. The Alabama Child Caring Foundation provides limited ambulatory health insurance to low income, non-Medicaid/non-ALL Kids, uninsured children under the age of 19 years who remain full-time students through grade 12. The

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program is funded through private donations and matching funds from Blue Cross Blue Shield. Outreach for this program is conducted through articles in Blue Cross Blue Shield publications and public service announcements in local newspapers, via television, and radio stations. The University of Alabama and Auburn University coaches’ television shows expressly advertise the Foundation. Case finding is conducted by school administrators, school nurses, day care operators, and others. Additionally referrals to the Foundation are received from the ALL Kids program, local offices of the ADPH, the Alabama Medicaid Agency, the Alabama Department of Human Resources, the Alabama Department of Industrial Relations Dislocated Workers program, individual health care providers, civic organizations, churches, Sunday School classes, other religious organizations, and from Foundation participants.

Guidance: The State should describe below how it’s Title XXI program will closely coordinate the enrollment with Medicaid because under Title XXI, children identified as Medicaid-eligible are required to be enrolled in Medicaid. Specific information related to Medicaid screen and enroll procedures is requested in Section 4.4. (42CFR 457.80(c))

5.2. (formerly 2.3)Describe how CHIP coordinates with other public and private health insurance programs, other sources of health benefits coverage for children, other relevant child health programs, (such as title V), that provide health care services for low-income children to increase the number of children with creditable health coverage.(Section 2102(a)(3),2102(b)(3)(E)and 2102(c)(2))(42CFR 457.80(c)).This item requires a brief overview of how Title XXI efforts – particularly new enrollment outreach efforts – will be coordinated with and improve upon existing State efforts.

The State of Alabama assures coordination with other public and private programs providing creditable coverage for low-income children. The SOBRA Medicaid program, ALL Kids, and the Alabama Child Caring Foundation have developed and use joint application and renewal forms.

All applications received by the ALL Kids enrollment unit are screened for Medicaid eligibility. When a child is identified by an ALL Kids enrollment worker as potentially eligible for Medicaid, the family’s application is sent to a Medicaid enrollment worker. Medicaid then processes it. As stated previously, two Medicaid enrollment workers and one clerical worker are physically located within the ALL Kids enrollment unit. This process also works in the reverse (applications are sent from Medicaid to ALL Kids).

When a child is identified by an ALL Kids enrollment worker as not potentially eligible for the Medicaid or ALL Kids but potentially eligible for the Alabama Child Caring Foundation (ACCF), the family’s application is sent to ACCF which then processes it and the opposite is also true.

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Because it is recognized that the eligibility and enrollment systems of these three programs are not as seamless as needed, ALL Kids employs a full time MSW staff person. This staff person has responsibility to assist families in overcoming obstacles related to eligibility, enrollment, claims, and referral for specialty services as needed. Additional responsibilities include development and maintenance of the ALL Kids policy manual.

In addition, the State coordinates with the ALL Kids PLUS authorizing agencies. See the previous section for a broader description of the collaboration.

5.2-EL The State should include a description of its election of the Express Lane eligibility option to provide a simplified eligibility determination process and expedited enrollment of eligible children into Medicaid or CHIP.

Guidance: Outreach strategies may include, but are not limited to, community outreach workers, outstationed eligibility workers, translation and transportation services, assistance with enrollment forms, case management and other targeting activities to inform families of low-income children of the availability of the health insurance program under the plan or other private or public health coverage.

The description should include information on how the State will inform the target of the availability of the programs, including American Indians and Alaska Natives, and assist them in enrolling in the appropriate program.

5.3. StrategiesDescribe the procedures used by the State to accomplish outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program.(Section 2102(c)(1)) (42CFR 457.90)

Phase I - Medicaid Expansion This portion of the outreach section, as it pertains to Phase I of Alabama’s Title XXI program, consists solely of efforts that were targeted toward Medicaid eligibles who were born after September 30, 1983 and who are under 19 years of age. There were four primary avenues through which outreach was conducted. These avenues were (1) the use of existing outreach approaches, (2) an initiative to improve communication with and services for the state’s rapidly expanding Hispanic population, (3) an increase in the number of Medicaid eligibility workers, and (4) coordination with the State Medical Association and physicians to educate physicians and their potentially eligible patients. Detailed information regarding these efforts is available from CHIP upon request.

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Phase II - ALL Kids Outreach for ALL Kids is conducted through coordinated Statewide and regional efforts and in each county through partnerships, contracts, and regional CHIP coordinators. These efforts consist of a three-pronged approach: (1) Statewide media campaigns and initiatives; (2) outreach conducted by multi-county regional workers and consultants; and, (3) outreach conducted through existing programs and agencies. The purposes of all of these activities is to build networks and coalitions of persons who can inform individuals about the availability of ALL Kids and what it has to offer, and assist individuals in completing application forms. Outreach is conducted by a variety of individuals and in a variety of settings. Each feature of the three-pronged outreach approach is described below:

• Statewide media campaigns and initiatives - The media campaigns focus on informing individuals about the availability of ALL Kids and what they have to offer as well as providing information regarding where applications or other information may be obtained. Additionally, ALL Kids staff attend a wide variety of association meetings and conferences to inform memberships of the availability of children’s health insurance. The staff have developed specialized outreach materials (from videos to informational brochures and flyers to specific handouts) for specific groups to meet their needs.

Staff have exhibited at booths and presentations to the Medical Association of the State of Alabama, Alabama Chapter of the American Academy of Pediatrics, Family Practice Physicians, Dentists, Social Workers, Department of Human Resources staff, Mental Health staff, Family Law Judges, Hospitals, Hospital auxiliaries, WIC staff, Public Health Staff, etc.

• Outreach conducted by multi-county regional workers and consultants – since the Spring of 2002, ALL Kids consultants have been and/are employed throughout the state, to disseminate information about the program to develop coalitions and networks of local residents to assist individuals in completing and submitting applications. These regional coordinators, their supervisory directors, and consultants are many times based in the county health departments but also utilize numerous off-site locales and alternative working hours.

• Outreach conducted through existing programs and agencies - Information about CHIP, applications, and application assistance are available through existing child-related programs such as the Child Care Management Agencies and their targeted child day care centers, Food Stamps, Maternal and Child Health Block Grant Program clinics, WIC clinics, community health centers, Indian Health Services, school nurse programs, school counselor programs, Early Intervention programs, other social service agencies, etc. These programs and agencies have successful histories of serving the target population and the CHIP program utilizes their contact with this population to broaden outreach efforts. Dissemination of CHIP information to these entities has been facilitated since representatives of these agencies and programs served on the CHIP Advisory Council and

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continue to be in contact with CHIP as stakeholders. • With specific regard to the Conception to Birth expansion and the RIM HSI, the ADPH will provide information to pertinent providers, hospitals and programs serving the target population residing in the counties in which the expansion is implemented.

Phase III - ALL Kids PLUS Outreach for this special population is conducted primarily by the ALL Kids PLUS authorizing agencies. Outreach includes educating primary and specialty care physicians regarding ALL Kids PLUS, identifying and contacting children who may need PLUS services through reviews of agency rolls and possible reviews of the pediatric health histories (part of the application process), contact with community health centers, etc. Information about ALL Kids PLUS is incorporated into all publications and presentations.

In an effort to continually improve the ALL Kids PLUS, CHIP staff continue to meet with the ALL Kids PLUS participating agencies to identify and resolve any problematic areas and to recruit additional participating agencies. PLUS agencies assist the CHIP staff in developing contracts, performance standards, and procedures for ongoing monitoring and oversight of the ALL Kids PLUS program.

NOTE: The application form and other materials have been translated into Spanish. Additionally, the ALL Kids enrollment unit employs a Spanish-speaking staff member and a Hispanic consultant has been hired to develop a Hispanic outreach plan.

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Section 6. Coverage Requirements for Children’s Health Insurance

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan and proceed to Section 7 since children covered under a Medicaid expansion program will receive all Medicaid covered services including EPSDT.

6.1. The State elects to provide the following forms of coverage to children: (Check all that apply.) (Section 2103(c)); (42CFR 457.410(a))

Guidance: Benchmark coverage is substantially equal to the benefits coverage in a benchmark benefit package (FEHBP-equivalent coverage, State employee coverage, and/or the HMO coverage plan that has the largest insured commercial, non-Medicaid enrollment in the state). If box below is checked, either 6.1.1.1., 6.1.1.2., or 6.1.1.3. must also be checked. (Section 2103(a)(1))

6.1.1.

Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420)

Guidance: Check box below if the benchmark benefit package to be offered by the State is the standard Blue Cross/Blue Shield preferred provider option service benefit plan, as described in and offered under Section 8903(1) of Title 5, United States Code. (Section 2103(b)(1) (42 CFR 457.420(b))

6.1.1.1.

FEHBP-equivalent coverage; (Section 2103(b)(1) (42 CFR 457.420(a)) (If checked, attach copy of the plan.)

Guidance: Checkbox below if the benchmark benefit package to be offered by the State is State employee coverage, meaning a coverage plan that is offered and generally available to State employees in the state. (Section 2103(b)(2))

6.1.1.2.

State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.)

Guidance: Check box below if the benchmark benefit package to be offered by the State is offered by a health maintenance organization (as defined in Section 2791(b)(3) of the Public Health Services Act) and has the largest insured commercial, non-Medicaid enrollment of covered lives of such coverage plans offered by an HMO in the state. (Section 2103(b)(3) (42 CFR 457.420(c)))

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6.1.1.3.

HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.)

The benefit package offered by the health maintenance organization with the largest insured commercial, non-Medicaid enrollment of covered lives was selected after several well attended public meetings where the benefits of the three benchmark plans were compared with the assistance of the insurers/administrators for the three plans. The benefit plan was altered slightly to make it more appropriate for children’s needs.

In addition to the ALL Kids basic benefits package, additional benefits may be available for enrollees who have special needs. These additional benefits are known as ALL Kids PLUS benefits and are only available as prescribed by ALL Kids PLUS authorizing agencies. These decisions regarding what benefits are provided, the requirements for their receipt, and the provision of the benefits is under the auspices of the PLUS authorizing state agencies. These state agencies are those with which CHIP has a contract for the provision of ALL Kids PLUS services, those agencies that ordinarily serve children with special health care conditions and needs, and which provide the matching funds for federal CHIP funding

The ALL Kids benefits plan is described in the ALL Kids Summary Plan Description (SPD), which is available upon request.The benefit package for enrollees in the CHIP Medicaid expansion will be identical to other children enrolled in comprehensive Medicaid categories.

Guidance: States choosing Benchmark-equivalent coverage must check the box below and ensure that the coverage meets the following requirements:  the coverage includes benefits for items and services within each of the categories of basic services described in 42 CFR 457.430: • dental services • inpatient and outpatient hospital services, • physicians’ services, • surgical and medical services, • laboratory and x-ray services, • well-baby and well-child care, including age-appropriate immunizations, and • emergency services;  the coverage has an aggregate actuarial value that is at least actuarially equivalent to one of the benchmark benefit packages (FEHBP-equivalent coverage, State employee coverage, or coverage offered through an HMO coverage plan that has the largest insured commercial enrollment in the state); and  the coverage has an actuarial value that is equal to at least 75 percent of the actuarial value of the additional categories in such package, if offered, as

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described in 42 CFR 457.430: • coverage of prescription drugs, • mental health services, • vision services and • hearing services.

If 6.1.2. is checked, a signed actuarial memorandum must be attached. The actuary who prepares the opinion must select and specify the standardized set and population to be used under paragraphs (b)(3) and (b)(4) of 42 CFR 457.431. The State must provide sufficient detail to explain the basis of the methodologies used to estimate the actuarial value or, if requested by CMS, to replicate the State results.

The actuarial report must be prepared by an individual who is a member of the American Academy of Actuaries. This report must be prepared in accordance with the principles and standards of the American Academy of Actuaries. In preparing the report, the actuary must use generally accepted actuarial principles and methodologies, use a standardized set of utilization and price factors, use a standardized population that is representative of privately insured children of the age of children who are expected to be covered under the State child health plan, apply the same principles and factors in comparing the value of different coverage (or categories of services), without taking into account any differences in coverage based on the method of delivery or means of cost control or utilization used, and take into account the ability of a State to reduce benefits by taking into account the increase in actuarial value of benefits coverage offered under the State child health plan that results from the limitations on cost sharing under such coverage. (Section 2103(a)(2))

6.1.2.

Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430) Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431.

Guidance: A State approved under the provision below, may modify its program from time to time so long as it continues to provide coverage at least equal to the lower of the actuarial value of the coverage under the program as of August 5, 1997, or one of the benchmark programs. If “existing comprehensive state- based coverage” is modified, an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of August 5, 1997, or one of the benchmark plans must be attached. Also, the fiscal year 1996 State expenditures for “existing comprehensive state-based coverage” must be described in the space provided for all states. (Section 2103(a)(3))

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6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) This option is only applicable to New York, Florida, and Pennsylvania.Attach a description of the benefits package, administration, and date of enactment. If existing comprehensive State-based coverage is modified, provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of August 5, 1997 or one of the benchmark plans. Describe the fiscal year 1996 State expenditures for existing comprehensive state-based coverage.

Guidance: Secretary-approved coverage refers to any other health benefits coverage deemed appropriate and acceptable by the Secretary upon application by a state. (Section 2103(a)(4)) (42 CFR 457.250)

6.1.4.

Secretary-approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) Guidance: Section 1905(r) of the Act defines EPSDT to require coverage of (1) any medically necessary screening, and diagnostic services, including vision, hearing, and dental screening and diagnostic services, consistent with a periodicity schedule based on current and reasonable medical practice standards or the health needs of an individualchild to determine if a suspected condition or illness exists; and (2) all services listed in section 1905(a) of the Act that are necessary to correct or ameliorate any defects and mental and physical illnesses or conditions discovered by the screening services, whether or not those services are covered under the Medicaid state plan. Section 1902(a)(43) of the Act requires that the State (1) provide and arrange for all necessary services, including supportive services, such as transportation, needed to receive medical care included within the scope of the EPSDT benefit and (2) inform eligible beneficiaries about the services available under the EPSDT benefit.

If the coverage provided does not meet all of the statutory requirements for EPSDT contained in sections 1902(a)(43) and 1905(r) of the Act, do not check this box.

6.1.4.1.

Coverageof all benefits that are provided to childrenthat is the same as the benefits provided under the Medicaid State plan,including Early Periodic Screening, Diagnostic, and Treatment (EPSDT).

6.1.4.2.

Comprehensive coverage for children under a Medicaid Section 1115 demonstration waiver.

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6.1.4.3.

Coverage that the State has extended to the entire Medicaid population.

Guidance: Check below if the coverage offered includes benchmark coverage, as specified in §457.420, plus additional coverage. Under this option, the State must clearly demonstrate that the coverage it provides includes the same coverage as the benchmark package, and also describes the services that are being added to the benchmark package.

6.1.4.4.

Coverage that includes benchmark coverage plus additional coverage. In the second amendment to the Alabama CHIP State Plan, ALL Kids PLUS was established which provided additional benefits for children with special health care conditions/needs. Attachment A contains a detailed description of the ALL Kids PLUS component of CHIP.

6.1.4.5.

Coverage that is the same as defined by existing comprehensive state- based coverageapplicable only in New York, Pennsylvania or Florida.(under 42 CFR 457.440)

Guidance: Check below if the State is purchasing coverage through a group health plan, and intends to demonstrate that the group health plan is substantially equivalent to or greater than coverage under one of the benchmark plans specified in 457.420, through the use of a benefit-by- benefit comparison of the coverage. Provide a sample of the comparison format that will be used. Under this option, if coverage for any benefit does not meet or exceed the coverage for that benefit under the benchmark, the State must provide an actuarial analysis as described in457.431 to determine actuarial equivalence.

6.1.4.6.

Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Provide a sample of how the comparison will be done).

Guidance: Check below if the State elects to provide a source of coverage that is not described above. Describe the coverage that will be offered, including any benefit limitations or exclusions.

6.1.4.7.

Other. (Describe)

Comprehensive health coverage will be provided from conception to birth for those with family incomes up to and including 312% FPL, whose mothers do not have comprehensive coverage, and reside in select counties in Alabama (beginning in Montgomery, Macon and Russell). Coverage begins upon enrollment and extends only through delivery with the exception of bundled obstetrical benefits. Coverage for bundled obstetrical benefits begins upon enrollment and will continue until the last day of the month in which the 60 day postpartum period has elapsed after the end of a

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pregnancy. For example, if a woman gives birth on June 26, benefits covered in the bundled package would end on August 31. The first day without coverage would be September 1. The date of enrollment may be as early as the first day of maternity- related service provision even if the application is completed a few days after the service is received. In other cases coverage will begin on the date the application is received by the CHIP office. The definition of comprehensive coverage includes coverage for obstetrical benefits. If a pregnant woman has other coverage but the other coverage does not include obstetrical benefits, then the other coverage would be considered non- comprehensive, regardless of any other benefits it insures. In this circumstance, the pregnant woman would meet the criterion for not having comprehensive coverage.

Guidance: All forms of coverage that the State elects to provide to children in its plan must be checked. The State should also describe the scope, amount and duration of services covered under its plan, as well as any exclusions or limitations. States that choose to cover unborn children under the State plan should include a separate section 6.2 that specifies benefits for the unborn child population. (Section 2110(a)) (42CFR, 457.490)

If the state elects to cover the new option of targeted low income pregnant women, but chooses to provide a different benefit package for these pregnant women under the CHIP plan, the state must include a separate section 6.2 describing the benefit package for pregnant women. (Section 2112)

6.2. The State elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490) A description of the scope, amount and duration of services covered under ALL Kids and ALL Kids PLUS, as well as any exclusions and limitations can be found in the ALL Kids Summary Plan Description (SPD) which is available upon request. Health insurance benefits provided to conception to birth enrollees will be identical to the health insurance benefits provided to any pregnant ALL Kids enrollee. The date of enrollment may be as early as the first day of maternity-related service provision even if the application is completed a few days after the service is received. In other cases coverage will begin on the date the application is received by the CHIP office. Comprehensive coverage will end upon the end of the pregnancy. Prenatal care, labor and delivery and postpartum care are paid using a bundled payment which extends into the postpartum period. In geographic areas in Alabama where CHIP unborn coverage is available, coverage for bundled obstetrical benefits begins upon enrollment and will continue until the last day of the month in which the 60 day postpartum period has elapsed after the end of a pregnancy. For example, if a woman gives birth on June 26, benefits covered in the bundled package would end on August 31. The first day without coverage would be September 1.

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6.2.1.

Inpatient services (Section 2110(a)(1))

6.2.2.

Outpatient services (Section 2110(a)(2))

6.2.3.

Physician services (Section 2110(a)(3))

6.2.4.

Surgical services (Section 2110(a)(4))

6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5))

6.2.6.

Prescription drugs (Section 2110(a)(6))

6.2.7.

Over-the-counter medications (Section 2110(a)(7))

6.2.8.

Laboratory and radiological services (Section 2110(a)(8))

6.2.9.

Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9))

6.2.10.

Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10))

6.2.11.

Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11)

6.2.12.

Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12))

6.2.13.

Disposable medical supplies (Section 2110(a)(13))

Guidance: Home and community based services may include supportive services such as home health nursing services, home health aide services, personal care, assistance with activities of daily living, chore services, day care services, respite care services, training for family members, and minor modifications to the home.

6.2.14.

Home and community-based health care services (Section 2110(a)(14))

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Guidance: Nursing services may include nurse practitioner services, nurse midwife services, advanced practice nurse services, private duty nursing care, pediatric nurse services, and respiratory care services in a home, school or other setting.

6.2.15.

Nursing care services (Section 2110(a)(15))

6.2.16.

Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16)

6.2.17.

Dental services (Section 2110(a)(17)) States updating their dental benefits must complete 6.2-DC (CHIPRA # 7, SHO # #09-012 issued October 7, 2009)

6.2.18.

Vision screenings and services (Section 2110(a)(24))

6.2.19.

Hearing screenings and services (Section 2110(a)(24))

6.2.20.

Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18))

6.2.21.

Outpatient substance abuse treatment services (Section 2110(a)(19))

6.2.22.

Case management services (Section 2110(a)(20))

6.2.23.

Care coordination services (Section 2110(a)(21))

6.2.24.

Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22))

6.2.25.

Hospice care (Section 2110(a)(23))

Guidance: See guidance for Section 6.1.4.1 for guidance on the statutory requirements for EPSDT under sections 1905(r) and 1902(a)(43) of the Act. If the benefit being provided does not meet the EPSDT statutory requirements, do not check the box below.

6.2.26.

EPSDT consistent with requirements of sections 1905(r) and 1902(a)(43) of the Act

Guidance: Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic or rehabilitative service may be provided, whether in a facility, home, school, or other setting, if recognized by State law and only if the service is: 1) prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as prescribed by State law;

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2) performed under the general supervision or at the direction of a physician; or 3) furnished by a health care facility that is operated by a State or local government or is licensed under State law and operating within the scope of the license.

6.2.27.

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (Section 2110(a)(24))

6.2.28.

Premiums for private health care insurance coverage (Section 2110(a)(25))

6.2.29.

Medical transportation (Section 2110(a)(26))

Guidance: Enabling services, such as transportation, translation, and outreach services, may be offered only if designed to increase the accessibility of primary and preventive health care services for eligible low-income individuals.

6.2.30.

Enabling services (such as transportation, translation, and outreach services) (Section 2110(a)(27))

6.2.31.

Any other health care services or items specified by the Secretary and not included under this Section (Section 2110(a)(28)) Transplantation Services Emergency and Urgent Care Services Skilled Nursing Services Vision Services 6.2-DC Dental Coverage(CHIPRA # 7, SHO # #09-012 issued October 7, 2009) The State will provide dental coverage to children through one of the following. Please update Sections 9.10 and 10.3-DC when electing this option. Dental services provided to children eligible for dental-only supplemental services must receive the same dental services as provided to otherwise eligible CHIP children (Section 2103(a)(5)):

6.2.1-DC

State Specific Dental Benefit Package. The State assures dental services represented by the following categories of common dental terminology (CDT6) codes are included in the dental benefits: 1. Diagnostic (i.e., clinical exams, x-rays) (CDT codes: D0100-D0999) (must follow periodicity schedule) 2. Preventive (i.e., dental prophylaxis, topical fluoride treatments, sealants) (CDT codes: D1000-D1999) (must follow periodicity schedule) 3. Restorative (i.e., fillings, crowns) (CDT codes: D2000-D2999) 4. Endodontic (i.e., root canals) (CDT codes: D3000-D3999) 5. Periodontic (treatment of gum disease) (CDT codes: D4000-D4999)

Current Dental Terminology,© 2010 American Dental Association. All rights reserved.

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6. Prosthodontic (dentures) (CDT codes: D5000-D5899, D5900-D5999, and D6200-D6999) 7. Oral and Maxillofacial Surgery (i.e., extractions of teeth and other oral surgical procedures) (CDT codes: D7000-D7999) 8. Orthodontics (i.e., braces) (CDT codes: D8000-D8999) 9. Emergency Dental Services

ALL Kids utilizes the BCBS of Alabama preferred Dental Network. Reimbursement for services delivered to ALL Kids' enrollees is paid based on the preferred dental network fee schedule. All network dentists agree to accept this as payment in full, with the exception of enrollee co-pays (no copayments on preventive or diagnostic services).

When costs are expected to exceed $1500 for a calendar year, ALL Kids utilizes a prior authorization process to ensure medically necessary services are provided. Costs associated with diagnostic and preventive services are excluded from this $1500 threshold. The amount is calculated by totaling the amount paid in dental claims minus the amount paid for preventive and diagnostic dental services.

If an enrollee is in need of dental services beyond $1500 in a calendar year, providers are instructed to submit a predetermination request to BCBS. BCBS reviews all provider requests to determine dental necessity of services and ALL Kids provides final approval to pay for services exceeding $1500. Providers are familiar with this process and dentally necessary services are provided in a timely manner regardless of the time of year. There is no unnecessary carry-over of services that need immediate attention.

If a family would like to appeal the BCBS/ALL Kids decision regarding the application of “medically necessary,” there is an appeals process which is consistent with the requirements of 42 CFR 457.1160 (b) and in compliance with state laws, the Security Act of 1974 (ERISA) and all other applicable regulations of the Department of Labor Procedures. 6.2.1.1-DC Periodicity Schedule. The State has adopted the following periodicity schedule: State-developed Medicaid-specific American Academy of Pediatric Dentistry Other Nationally recognized periodicity schedule Other (description attached)

6.2.2-DC

Benchmark coverage; (Section 2103(c)(5), 42 CFR 457.410, and 42 CFR 457.420)

6.2.2.1-DC FEHBP-equivalent coverage; (Section 2103(c)(5)(C)(i)) (If checked, attach copy of the dental supplemental plan benefits description and the applicable CDT7 codes. If the State chooses to provide supplemental

Current Dental Terminology, © 2010 American Dental Association. All rights reserved.

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services, also attach a description of the services and applicable CDT codes)

6.2.2.2-DC State employee coverage; (Section 2103(c)(5)(C)(ii)) (If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes)

6.2.2.3-DC HMO with largest insured commercial enrollment (Section 2103(c)(5)(C)(iii)) (If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes)

6.2-DS

Supplemental Dental Coverage- The State will provide dental coverage to children eligible for dental-only supplemental services. Children eligible for this option must receive the same dental services as provided to otherwise eligible CHIP children (Section 2110(b)(5)(C)(ii)). Please update Sections 1.1-DS, 4.1-DS, 4.2-DS, and 9.10 when electing this option.

Guidance: Under Title XXI, pre-existing condition exclusions are not allowed, with the only exception being in relation to another law in existence (HIPAA/ERISA). Indicate that the plan adheres to this requirement by checking the applicable description.

In the event that the State provides benefits through a group health plan or group health coverage, or provides family coverage through a group health plan under a waiver (see Section 6.4.2.), pre-existing condition limits are allowed to the extent permitted by HIPAA/ERISA. If the State is contracting with a group health plan or provides benefits through group health coverage, describe briefly any limitations on pre-existing conditions. (Formerly 8.6.)

6.2- MHPAEASection 2103(c)(6)(A) of the Social Security Act requires that, to the extent that it provides both medical/surgical benefits and mental health or substance use disorder benefits, a State child health plan ensures that financial requirements and treatment limitations applicable to mental health and substance use disorder benefits comply with the mental health parity requirements of section 2705(a) of the Public Health Service Act in the same manner that such requirements apply to a group health plan.If the state child health plan provides for delivery of services through a managed care arrangement, this requirement applies to both the state and managed care plans. These requirements are also applicable to any additional benefits provided voluntarily to the child health plan population by managed care entities and will be considered as part of CMS’s contract review process at 42 CFR 457.1201(l).

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6.2.1- MHPAEA Before completing a parity analysis, the State must determine whether each covered benefit is a medical/surgical, mental health, or substance use disorder benefit based on a standard that is consistent with state and federal law and generally recognized independent standards of medical practice. (42 CFR 457.496(f)(1)(i))

6.2.1.1- MHPAEA Please choose the standard(s) the state uses to determine whether a covered benefit is a medical/surgical benefit, mental health benefit, or substance use disorder benefit. The most current version of the standard elected must be used. If different standards are used for different benefit types, please specify the benefit type(s) to which each standard is applied. If “Other” is selected, please provide a description of that standard.

International Classification of Disease (ICD) Diagnostic and Statistical Manual of Mental Disorders (DSM) State guidelines (Describe: ) Other (Describe: ) 6.2.1.2- MHPAEA Does the State provide mental health and/or substance use disorder benefits?

Yes No Guidance: If the State does not provideany mental health or substance use disorder benefits, the mental health parity requirements do not apply ((42 CFR 457.496(f)(1)). Continue on to Section 6.3.

6.2.2- MHPAEA Section 2103(c)(6)(B) of the Social Security Act (the Act)provides that to the extent a State child health plan includes coverage of early and periodic screening, diagnostic, and treatment services (EPSDT) defined in section 1905(r) of the Act and provided in accordance with section 1902(a)(43) of the Act, the plan shall be deemed to satisfy the parity requirements of section 2103(c)(6)(A) of the Act.

6.2.2.1- MHPAEA Does the State child health plan provide coverage of EPSDT? The State must provide for coverage of EPSDT benefits, consistent with Medicaid statutory requirements, as indicated in section 6.2.26 of the State child health plan in order to answer “yes.”

Yes No

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Guidance: If the State child health plan does not provide EPSDT consistent with Medicaid statutory requirements at sections 1902(a)(43) and 1905(r) of the Act, please go to Section 6.2.3- MHPAEA to complete the required parity analysis of the State child health plan.

If the state does provide EPSDT benefits consistent with Medicaid requirements, please continue this section to demonstrate compliance with the statutory requirements of section 2103(c)(6)(B) of the Act and the mental health parity regulations of 42 CFR 457.496(b) related to deemed compliance.Please provide supporting documentation, such as contract language, provider manuals, and/or member handbooks describing the state’s provision of EPSDT.

6.2.2.2- MHPAEA EPSDT benefits are provided to the following:

All children covered under the State child health plan. A subset of children covered under the State child health plan. Please describe the different populations (if applicable) covered under the State child health plan that are providedEPSDT benefits consistent with Medicaid statutory requirements.

Guidance: If only a subset of children are provided EPSDT benefits under the State child health plan, 42 CFR 457.496(b)(3) limits deemed compliance to those children only and Section 6.2.3- MHPAEA must becompleted as well as the required parity analysis for the other children.

6.2.2.3- MHPAEA To be deemed compliant with the MHPAEA parity requirements, States must provide EPSDT in accordance with sections 1902(a)(43) and 1905(r) of the Act (42 CFR 457.496(b)). The State assures each of the following for children eligible for EPSDT under the separate State child health plan:

All screening services, including screenings for mental health and substance use disorder conditions, are provided at intervals that align with a periodicity schedule that meets reasonable standards of medical or dental practice as well as when medically necessary to determine the existence of suspected illness or conditions. (Section 1905(r))

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All diagnostic services described in 1905(a) of the Act are provided as needed to diagnose suspected conditions or illnesses discovered through screening services, whether or not those services are covered under the Medicaid state plan. (Section 1905(r))

All items and services described in section 1905(a) of the Act are provided when needed to correct or ameliorate a defect or any physical or mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the Medicaid State plan. (Section 1905(r)(5))

Treatment limitations applied to services provided under the EPSDT benefit are not limited based on a monetary cap or budgetary constraints and may be exceeded as medically necessary to correct or ameliorate a medical or physical condition or illness. (Section 1905(r)(5))

Non-quantitative treatment limitations, such as definitions of medical necessity or criteria for medical necessity, are applied in an individualized manner that does not preclude coverage of any items or services necessary to correct or ameliorate any medical or physical condition or illness. (Section 1905(r)(5))

EPSDT benefits are not excluded on the basis of any condition, disorder, or diagnosis. (Section 1905(r)(5))

The provision of all requested EPSDT screening services, as well as any corrective treatments needed based on those screening services, are provided or arranged for as necessary. (Section 1902(a)(43))

All families with children eligible for the EPSDT benefit under the separate State child health plan are provided information and informed about the full range of services available to them. (Section 1902(a)(43)(A)) Guidance: For states seeking deemed compliance for their entire State child health plan population, please continue to Section 6.3. If not all of the covered populations are offered EPSDT,the State must conduct a parity analysis of the benefit packages provided to those populations. Please continue to 6.2.3-

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MHPAEA.

Mental Health Parity Analysis Requirements for States Not Providing EPSDT to All Covered Populations

Guidance: The State must complete a parity analysis for each population under the State child health plan that is not providedthe EPSDT benefit consistent with the requirements 42 CFR 457.496(b). If the State provides benefits or limitations that vary within the child or pregnant woman populations, states should perform a parity analysis for each of the benefit packages. For example, if different financial requirements are applied according to a beneficiary’s income, a separate parity analysis is needed for the benefit package provided at each income level.

Please ensure that changes made to benefitlimitations under the State child health plan as a result of the parity analysis are also made in Section 6.2.

6.2.3- MHPAEAIn order to conduct the parity analysis, the State must place all medical/surgical and mental health and substance use disorder benefits covered under the State child health plan into one of four classifications: Inpatient, outpatient, emergency care, and prescription drugs. (42 CFR 457.496(d)(2)(ii);42 CFR 457.496(d)(3)(ii)(B))

6.2.3.1 MHPAEA Please describe below the standard(s) used to place covered benefits into one of the four classifications.

Benefit Classification Standards Used Inpatient Inpatient benefits are applied per the benefit plan to a registered inpatient bed patient in a hospital. Outpatient Outpatient benefits are applied per the benefit plan to a patient who is not a registered inpatient bed patient of a hospital. Pharmacy Pharmacy benefits are applied per the benefit plan and evidence based clinical criteria for use of medication, regardless of behavioral health or medical diagnosis. Emergency Services covered in connection with a medical condition that occur suddenly and without warning with symptoms which are so acute and severe as to require immediate medical attention.

6.2.3.1.1 MHPAEAThe State assures that:

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The State has classified all benefits covered under the State plan into one of the four classifications. The same reasonable standards are used for determining the classification for a mental health or substance use disorder benefit as are used for determining the classification of medical/surgical benefits. 6.2.3.1.2- MHPAEA Does the State use sub-classifications to distinguish between office visits and other outpatient services?

Yes No

6.2.3.1.2.1- MHPAEA If the State uses sub-classifications to distinguish between outpatient office visits and other outpatient services, the State assures the following:

The sub-classifications are only used to distinguish office visits from other outpatient items and services, and are not used to distinguish between similar services on other bases (ex: generalist vs. specialist visits). Guidance: For purposes of this section, any reference to “classification(s)” includes sub-classification(s) in states using sub- classifications to distinguish between outpatient office visits from other outpatient services.

6.2.3.2 MHPAEA The State assures that:

Mental health/ substance use disorder benefits are provided in all classifications in which medical/surgical benefits are provided under the State child health plan. Guidance:States are not required to cover mental health or substance use disorder benefits (42 CFR 457.496(f)(2)). However if a state does provide any mental health or substance use disorder benefits, those mental health or substance use disorder benefits must be provided in all the same classifications in which medical/surgical benefits are covered under the State child health plan (42 CFR 457.496(d)(2)(ii).

Annual and Aggregate Lifetime Dollar Limits

6.2.4- MHPAEA A State that provides both medical/surgical benefits and mental health and/or

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substance use disorder benefits must comply with parity requirements related to annual and aggregate lifetime dollar limits for benefits covered under the State child health plan. (42 CFR 457.496(c))

6.2.4.1- MHPAEA Please indicate whether the State applies an aggregate lifetime dollar limit and/or an annual dollar limit on any mental health or substance abuse disorder benefits covered under the State child health plan.

Aggregate lifetime dollar limit is applied Aggregate annual dollar limit is applied No dollar limit is applied Guidance: A monetary coverage limit that applies toall CHIP services provided under the State child health plan is not subject to parity requirements.

If there are no aggregate lifetime or annual dollar limits on any mental health or substance use disorder benefits, please go to section 6.2.5- MHPAEA.

6.2.4.2- MHPAEA Are there any medical/surgical benefits covered under the State child health plan that have either an aggregate lifetime dollar limit or an annual dollar limit? If yes, please specify what type of limits apply.

Yes (Type(s) of limit:) No Guidance: If no aggregate lifetime dollar limit is applied to medical/surgical benefits, the State may not impose an aggregate lifetime dollar limit on any mental health or substance use disorder benefits. If no aggregate annual dollar limit is applied to medical/surgical benefits, the State may not impose an aggregate annual dollar limit on any mental health or substance use disorder benefits.(42 CFR 457.496(c)(1))

6.2.4.3 – MHPAEA. States applying an aggregate lifetime or annual dollar limit on medical/surgical benefits and mental health or substance use disorder benefits must determine whether the portion of the medical/surgical benefits to which the limit applies is less than one- third, at least one-third but less than two-thirds, or at least two-thirds of all medical/surgical benefits covered under the State plan (42 CFR 457.496(c)).The portion of medical/surgical benefits subject to the limit is based on the dollar amount expected to be paid for all medical/surgical benefits under the State plan for the State plan year or portion of the plan year after a change in benefits that affects the applicability of the aggregate lifetime or annual dollar limits. (42 CFR 457.496(c)(3))

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The State assures that it has developed a reasonable methodology to calculate the portion of covered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit, as applicable. Guidance: Please include the state’s methodology to calculate the portion of covered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit and the results as anattachment to the State child health plan.

6.2.4.3.1- MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to a lifetime dollar limit:

Less than 1/3 At least 1/3 and less than 2/3 At least 2/3

6.2.4.3.2- MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to an annual dollar limit:

Less than 1/3 At least 1/3 and less than 2/3 At least 2/3 Guidance: If an aggregate lifetime limit is applied to less than one-third of all medical/surgical benefits, the State may not impose an aggregate lifetime limit on any mental health or substance use disorder benefits. If an annual dollar limit is applied to less than one-third of all medical surgical benefits, the State may not impose an annual dollar limit on any mental health or substance use disorder benefits (42 CFR 457.496(c)(1)).Skip to section 6.2.5-MHPAEA.

If the State applies an aggregate lifetime or annual dollar limit to at least one-third of all medical/surgical benefits,please continue below to provide the assurances related to the determination of the portion of total costs for medical/surgical benefits that are subject to either anannual or lifetime

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limit.

6.2.4.3.2.1- MHPAEA If the State applies an aggregate lifetime or annual dollar limit to at least1/3 and less than 2/3 of all medical/surgical benefits, the State assures the following (42 CFR 457.496(c)(4)(i)(B)); (42 CFR 457.496(c)(4)(ii)):

The State applies an aggregate lifetime or annual dollar limit on mental health or substance use disorder benefits that is no more restrictive than an average limit calculated for medical/surgical benefits. Guidance: The state’s methodology for calculating the average limit for medical/surgical benefits must be consistent with42 CFR 457.496(c)(4)(i)(B) and 42 CFR 457.496(c)(4)(ii). Please include the state’s methodology and results as an attachment to the State child health plan.

6.2.4.3.2.2- MHPAEA If at least 2/3 of all medical/surgical benefits are subject to an annual or lifetime limit, the State assures either of the following (42 CFR 457.496(c)(2)(i)); (42 CFR 457.496(c)(2)(ii)):

The aggregate lifetime or annual dollar limit is applied to both medical/surgical benefits and mental health and substance use disorder benefits in a manner that does not distinguish between medical/surgical benefits and mental health and substance use disorder benefits; or The aggregate lifetime or annual dollar limit placed on mental health and substance use disorder benefits is no more restrictive than the aggregate lifetime or annual dollar limit on medical/surgical benefits. Quantitative Treatment Limitations

6.2.5- MHPAEADoes the State apply quantitative treatment limitations (QTLs) on any mental health or substance use disorder benefits in any classification of benefits? If yes, specify the classification(s) of benefits in which the State applies one or more QTLs on any mental health or substance use disorder benefits.

Yes (Specify: )

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No Guidance: If the state does not apply any type of QTLs on any mental health or substance use disorder benefits in any classification, the state meets parity requirements for QTLs and should continue to Section 6.2.6 - MHPAEA. If the state does apply QTLsto any mental health or substance use disorder benefits, the state must conduct a parity analysis. Please continue.

6.2.5.1- MHPAEA Does the State apply any type of QTL on any medical/surgical benefits?

Yes No Guidance:If the State does not apply QTLs on any medical/surgical benefits, the State may not impose quantitative treatment limitations on mental health or substance use disorder benefits, please go to Section 6.2.6- MHPAEA related to non-quantitative treatment limitations.

6.2.5.2- MHPAEAWithin each classification of benefits in which the State applies a type of QTL on any mental health or substance use disorder benefits, theState must determine the portion of medical and surgical benefits in the classification which are subject to the limitation. More specifically, the State must determine the ratio of (a) the dollar amount of all payments expected to be paid under the State plan for medical and surgical benefits within a classification which are subject to the type of quantitative treatment limitation for the plan year (or portion of the plan year after a mid-year change affecting the applicability of a type of quantitative treatment limitation to any medical/surgical benefits in the class) to (b) the dollar amount expected to be paid for all medical and surgical benefits within the classification for the plan year. For purposes of this paragraph, all payments expected to be paid under the State plan includes payments expected to be made directly by the State and payments which are expected to be made by MCEs contracting with the State. (42 CFR 457.496(d)(3)(i)(C))

The State assures it has applied a reasonable methodology to determine the dollar amounts used in the ratio described above for each classification within which the State applies QTLs to mental health or substance use disorder benefits. (42 CFR 457.496(d)(3)(i)(E)) Guidance: Please include the state’s methodology and resultsas anattachment to the State child health plan.

6.2.5.3- MHPAEAFor each type of QTL applied to any mental health or substance use disorder benefits within a given classification,does the Stateapply the same type of QTL to “substantially all”(defined as at least two-thirds) of the medical/surgical benefits within the

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same classification? (42 CFR 457.496(d)(3)(i)(A))

Yes No Guidance: If the State does not apply a type of QTL to substantially all medical/surgical benefits in a given classification of benefits,the State may not impose that type of QTL on mental health or substance use disorder benefits in that classification. (42 CFR 457.496(d)(3)(i)(A))

6.2.5.3.1- MHPAEAFor each type of QTL applied to mental health or substance use disorder benefits, the State must determine the predominant level of that type which is applied to medical/surgical benefits in the classification. The “predominant level” of a type of QTL in a classification is the level (or least restrictive of a combination of levels) that applies to more than one-half of the medical/surgical benefits in that classification, as described in 42 CFR 457.496(d)(3)(i)(B).The portion of medical/surgical benefits in a classification to which a given level of a QTL type is applied is based on the dollar amount of payments expected to be paid for medical/surgical benefits subject to that level as compared to all medical/surgical benefits in the classification, as described in 42 CFR 457.496(d)(3)(i)(C). For each type of quantitative treatment limitation applied to mental health or substance use disorder benefits, the State assures:

The same reasonable methodology applied in determining the dollar amounts used to determine whether substantially all medical/surgical benefits within a classification are subject to a type of quantitative treatment limitation also is applied in determining the dollar amounts used to determine the predominant level of a type of quantitative treatment limitation applied to medical/surgical benefits within a classification. (42 CFR 457.496(d)(3)(i)(E)) The level of each type of quantitative treatment limitation applied by the State to mental health or substance use disorder benefits in any classification is no more restrictive than the predominant level of that type which is applied by the State to medical/surgical benefits within the same classification. (42 CFR 457.496(d)(2)(i)) Guidance: If there is no single level of a type of QTL that exceeds the one- half threshold, the State may combine levels within a type of QTL such that the combined levels are applied to at least half of all medical/surgical benefits within a classification; the predominant level is the least restrictive level of the levels combined to meet the one-half threshold. (42

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CFR 457.496(d)(3)(i)(B)(2))

Non-Quantitative Treatment Limitations

6.2.6- MHPAEAThe State may utilize non-quantitative treatment limitations (NQTLs) for mental health or substance use disorder benefits, but the State must ensure that those NQTLs comply with all the mental health parity requirements. (42 CFR 457.496(d)(4));(42 CFR 457.496(d)(5)) 6.2.6.1 – MHPAEA If the State imposes any NQTLs, complete this subsection. If the State does not impose NQTLs, please go to Section 6.2.7-MHPAEA.

The State assures that the processes, strategies, evidentiary standards or other factors used in the application of any NQTL to mental health or substance use disorder benefits are no more stringent than the processes, strategies, evidentiary standards or other factors used in the application of NQTLs to medical/surgical benefits within the same classification. Guidance: Examples of NQTLs include medical management standards to limit or exclude benefits based on medical necessity, restrictions based on geographic location, provider specialty, or other criteria to limit the scope or duration of benefits and provider network design (ex: preferred providers vs. participating providers). Additional examples of possible NQTLs are provided in 42 CFR 457.496(d)(4)(ii). States will need to provide a summary of its NQTL analysis, as well as supporting documentation as requested.

6.2.6.2 – MHPAEAThe State or MCE contracting with the State must comply with parity if they provide coverage of medical or surgical benefits furnished by out-of-network providers.

6.2.6.2.1- MHPAEA Does the State or MCE contracting with the State provide

coverage of medical or surgicalbenefits provided by out-of-network providers?

Yes No Guidance: The State can answer no if the State or MCE only provides out of network services in specific circumstances, such as emergency care, or when the network is unable to provide a necessary service covered under the contract.

6.2.6.2.2- MHPAEA If yes, the State must provide access to out-of-network providers for mental health or substance use disorder benefits. Please assure the following:

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The State attests that when determining access to out-of-network providers within a benefit classification, the processes, strategies, evidentiary standards, or other factors used to determine access to those providers for mental health/ substance use disorder benefits are comparable to and applied no more stringently than the processes, strategies, evidentiary standards or other factors used to determine access for out- of-network providers for medical/surgical benefits. Availability of Plan Information 6.2.7- MHPAEA The State must provide beneficiaries, potential enrollees, and providers with information related to medical necessity criteria and denials of payment or reimbursement for mental health or substance use disorder services (42 CFR 457.496(e)) in addition to existing notice requirements at 42 CFR 457.1180.

6.2.7.1- MHPAEA Medical necessity criteria determinations must be made available to any current or potential enrollee or contracting provider, upon request. The state attests that the following entities provide this information:

State Managed Care entities Both Other Blue Cross Blue Shield of Alabama; New Directions (Behavioral Health Benefits Manager for BCBS); Prime Therapeutics (Pharmacy Benefits Manager for BCBS)

Guidance: If other is selected, please specify the entity.

6.2.7.2- MHPAEA Reason for any denial for reimbursement or payment for

mental health or substance use disorder benefits must be made available to the

enrollee by the health plan or the State. The state attests that the following

entities provide denial information:

State Managed Care entities Both

Other

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Blue Cross Blue Shield of Alabama; New Directions (Behavioral Health Benefits Manager for BCBS); Prime Therapeutics (Pharmacy Benefits Manager for BCBS)

Guidance: If other is selected, please specify the entity. 6.3. The State assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42CFR 457.480)

6.3.1.

The State shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR 6.3.2.

The State contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.6.2. (formerly 6.4.2) of the template). Pre- existing medical conditions are permitted to the extent allowed by HIPAA/ERISA.(Formerly 8.6.) (Section 2103(f))Describe:

Guidance: States may request two additional purchase options in Title XXI: cost effective coverage through a community-based health delivery system and for the purchase of family coverage. (Section 2105(c)(2) and (3)) (42 CFR 457.1005 and 457.1010)

6.4. Additional Purchase Options-If the State wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the State must address the following: (Section 2105(c)(2) and (3)) (42 CFR 457.1005 and 457.1010)

6.4.1.

Cost Effective Coverage- Payment may be made to a State in excess of the 10 percent limitation on use of funds for payments for: 1) other child health assistance for targeted low-income children; 2) expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); 3) expenditures for outreach activities as provided in Section 2102(c)(1) under the plan; and 4) other reasonable costs incurred by the State to administer the plan, if it demonstrates the following (42CFR 457.1005(a)):

6.4.1.1. Coverage provided to targeted low-income children through such expenditures must meet the coverage requirements above; Describe the coverage provided by the alternative delivery system. The State may cross reference Section 6.2.1 - 6.2.28. (Section 2105(c)(2)(B)(i)) (42CFR 457.1005(b))

6.4.1.2. The cost of such coverage must not be greater, on an average per child basis, than the cost of coverage that would otherwise be provided for

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the coverage described above; Describe the cost of such coverage on an average per child basis. (Section 2105(c)(2)(B)(ii)) (42CFR 457.1005(b))

Guidance: Check below if the State is requesting to provide cost-effective coverage through a community-based health delivery system. This allows the State to waive the 10 percent limitation on expenditures not used for Medicaid or health insurance assistance if coverage provided to targeted low-income children through such expenditures meets the requirements of Section 2103; the cost of such coverage is not greater, on an average per child basis, than the cost of coverage that would otherwise be provided under Section 2103; and such coverage is provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under Section 330 of the Public Health Services Act or with hospitals such as those that receive disproportionate share payment adjustments under Section 1886(c)(5)(F) or 1923.

If the cost-effective alternative waiver is requested, the State must demonstrate that payments in excess of the 10 percent limitation will be used for other child health assistance for targeted low-income children; expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); expenditures for outreach activities as provided in Section 2102(c)(1) under the plan; and other reasonable costs incurred by the State to administer the plan. (42CFR, 457.1005(a))

6.4.1.3. The coverage must be provided through the use of a community based health delivery system, such as through contracts with health centers receiving funds under Section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under Section 1886(c)(5)(F) or 1923 of the Social Security Act. Describe the community-based delivery system. (Section 2105(c)(2)(B)(iii)) (42CFR 457.1005(a))

Guidance: Check 6.4.2.if the State is requesting to purchase family coverage. Any State requesting to purchase such coverage will need to include information that establishes to the Secretary’s satisfaction that: 1) when compared to the amount of money that would have been paid to cover only the children involved with a comparable package, the purchase of family coverage is cost effective; and 2) the purchase of family coverage is not a substitution for coverage already being provided to the child. (Section 2105(c)(3)) (42CFR

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457.1010)

6.4.2.

Purchase of Family Coverage- Describe the plan to purchase family coverage. Payment may be made to a State for the purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low-income children, if it demonstrates the following: (Section 2105(c)(3)) (42CFR 457.1010)

6.4.2.1. Purchase of family coverage is cost-effective. The State’s cost of purchasing family coverage, including administrative expenditures, that includes coverage for the targeted low-income children involved or the family involved (as applicable) under premium assistance programs must not be greater than the cost of obtaining coverage under the State plan for all eligible targeted low-income children or families involved; and (2) The State may base its demonstration of cost effectiveness on an assessment of the cost of coverage, including administrative costs, for children or families under premium assistance programs to the cost of other CHIP coverage for these children or families, done on a case- by-case basis, or on the cost of premium assisted coverage in the aggregate.

6.4.2.2. The State assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42CFR 457.1010(b))

6.4.2.3. The State assures that the coverage for the family otherwise meets title XXI requirements. (42CFR 457.1010(c))

6.4.3-PA: Additional State Options for Providing Premium Assistance (CHIPRA # 13, SHO # 10-002issued February, 2, 2010)A State may elect to offer a premium assistance subsidy for qualified employer-sponsored coverage, as defined in Section 2105(c)(10)(B), to all targeted low-income children who are eligible for child health assistance under the plan and have access to such coverage. No subsidy shall be provided to a targeted low-income child (or the child’s parent) unless the child voluntarily elects to receive such a subsidy. (Section 2105(c)(10)(A)).Please remember to update section 9.10 when electing this option. Does the State provide this option to targeted low-income children?

Yes

No

6.4.3.1-PA Qualified Employer-Sponsored Coverage and Premium Assistance Subsidy

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6.4.3.1.1-PAProvide an assurance that the qualified employer- sponsoredinsurance meets the definition of qualified employer-sponsored coverage as defined in Section 2105(c)(10)(B), and that the premium assistance subsidy meets the definition of premium assistance subsidy as defined in 2105(c)(10)(C).

6.4.3.1.2-PADescribe whether the State is providing the premium assistance subsidy as reimbursement to an employee or for out-of-pocket expenditures or directly to the employee’s employer.

6.4.3.2-PA: Supplemental Coverage for Benefits and Cost Sharing Protections Provided under the Child Health Plan.

6.4.3.2.1-PA If the State is providing premium assistance for qualified employer-sponsored coverage, as defined in Section 2105(c)(10)(E)(i), provide an assurance that the State is providing for each targeted low-income child enrolled in such coverage, supplemental coverage consisting of all items or services that are not covered or are only partially covered, under the qualified employer-sponsored coverage consistent with 2103(a) and cost sharing protections consistent with Section 2103(e).

6.4.3.2.2-PADescribe whether these benefits are being provided through the employer or by the State providing wraparound benefits.

6.4.3.2.3-PA If the State is providing premium assistance for benchmark or benchmark-equivalent coverage, the State ensures that such group health plans or health insurance coverage offered through an employer will be certified by an actuary as coverage that is equivalent to a benchmark benefit package described in Section 2103(b) or benchmark equivalent coverage that meets the requirements of Section 2103(a)(2).

6.4.3.3-PA: Application of Waiting Period Imposed Under State Plan:States are required to apply the same waiting period to premium assistance as is applied to direct coverage for children under their CHIP State plan, as specified in Section 2105(c)(10)(F).

6.4.3.3.1-PAProvide an assurance that the waiting period for children in premium assistance is the same as for those children in direct coverage (if State has a waiting period in place for children in direct CHIP coverage).

6.4.3.4-PA: Opt-Out and Outreach, Education, and Enrollment Assistance

6.4.3.4.1-PADescribe the State’s process for ensuring parents are permitted to

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disenroll their child from qualified employer-sponsored coverage and to enroll in CHIP effective on the first day of any month for which the child is eligible for such assistance and in a manner that ensures continuity of coverage for the child (Section 2105(c)(10)(G)).

6.4.3.4.2-PADescribe the State’s outreach, education, and enrollment efforts related to premium assistance programs, as required under Section 2102(c)(3). How does the State inform families of the availability of premium assistance, and assist them in obtaining such subsidies? What are the specific significant resources the State intends to apply to educate employers about the availability of premium assistance subsidies under the State child health plan? (Section 2102(c))

6.4.3.5-PA Purchasing Pool-A State may establish an employer-family premium assistance purchasing pool and may provide a premium assistance subsidy for enrollment in coverage made available through this pool (Section 2105(c)(10)(I)). Does the State provide this option?

Yes

No

6.6.3.5.1-PADescribe the plan to establish an employer-family premium assistance purchasing pool.

6.6.3.5.2-PAProvide an assurance that employers who are eligible to participate: 1) have less than 250 employees; 2) have at least one employee who is a pregnant woman eligible for CHIP or a member of a family that has at least one child eligible under the State’s CHIP plan.

6.6.3.5.3-PAProvide an assurance that the State will not claim for any administrative expenditures attributable to the establishment or operation of such a pool except to the extent such payment would otherwise be permitted under this title.

6.4.3.6-PA Notice of Availability of Premium Assistance-Describe the procedures that assure that if a State provides premium assistance subsidies under this Section, it must: 1) provide as part of the application and enrollment process, information describing the availability of premium assistance and how to elect to obtain a subsidy; and 2) establish other procedures to ensure that parents are fully informed of the choices for child health assistance or through the receipt of premium assistance subsidies (Section 2105(c)(10)(K)).

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6.4.3.6.1-PAProvide an assurance that the State includes information about premium assistance on the CHIP application or enrollment form.

Section 7. Quality and Appropriateness of Care

Guidance: Methods for Evaluating and Monitoring Quality- Methods to assure quality include the application of performance measures, quality standards consumer information strategies, and other quality improvement strategies.

Performance measurement strategies could include using measurements for external reporting either to the State or to consumers and for internal quality improvement purposes. They could be based on existing measurement sets that have undergone rigorous evaluation for their appropriateness (e.g., HEDIS). They may include the use of standardized member satisfaction surveys (e.g., CAHPS) to assess members’ experience of care along key dimensions such as access, satisfaction, and system performance.

Quality standards are often used to assure the presence of structural and process measures that promote quality and could include such approaches as: the use of external and periodic review of health plans by groups such as the National Committee for Quality Assurance; the establishment of standards related to consumer protection and quality such as those developed by the National Association of Insurance Commissioners; and the formation of an advisory group to the State or plan to facilitate consumer and community participation in the plan.

Information strategies could include: the disclosure of information to beneficiaries about their benefits under the plan and their rights and responsibilities; the provision of comparative information to consumers on the performance of available health plans and providers; and consumer education strategies on how to access and effectively use health insurance coverage to maximize quality of care.

Quality improvement strategies should include the establishment of quantified quality improvement goals for the plan or the State and provider education. Other strategies include specific purchasing specifications, ongoing contract monitoring mechanisms, focus groups, etc.

Where States use managed care organizations to deliver CHIP care, recent legal changes require the State to use managed care quality standards and quality strategies similar to those used in Medicaid managed care.

Tools for Evaluating and Monitoring Quality- Tools and types of information available include, HEDIS (Health Employer Data Information Set) measures, CAHPS (Consumer Assessments of Health Plans Study) measures, vital statistics data, and

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State health registries (e.g., immunization registries).

Quality monitoring may be done by external quality review organizations, or, if the State wishes, internally by a State board or agency independent of the State CHIP Agency. Establishing grievance measures is also an important aspect of monitoring.

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan, and continue on to Section 8.

Guidance: The State must specify the qualifications of entities that will provide coverage and the conditions of participation. States should also define the quality standard they are using, for example, NCQA Standards or other professional standards. Any description of the information strategies used should be linked to Section 9. (Section 2102(a)(7)(A)) (42CFR 457.495)

7.1. Describe the methods (including external and internal monitoring) used to assure the quality and appropriateness of care, particularly with respect to well-baby care, well- child care, and immunizations provided under the plan. (Section 2102(a)(7)(A)) (42CFR 457.495(a)) Will the State utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.) The State utilizes the expertise within the University of Alabama at Birmingham (UAB) School of Public Health in the implementation of the assessment of the ALL Kids program. Quality and appropriateness of care is assessed through the use of surveys such as a new enrollee survey, a continuous enrollee survey, and a disenrollee survey. Both process measures as well as outcome measures are considered when assessing the quality and appropriateness of care. CHIP also reviews claims data for quality assessment. Among the items used in tracking are the use of several claims data indicators such as whether or not children truly have a "medical home"; how well they are adhering to the recommended scheduled well-child exams; whether or not they are appropriately immunized; whether or not non-trauma based emergency room use is going down; how referrals are being made and if specialty care and related services are being received; and, patterns of prescription drug use. The State is also considering using other databases that can provide general indicators of child health and well-being such as the State’s immunization registry, adolescent pregnancy rates and health care utilization patterns identifiable off birth certificates, and the results of child death review efforts. Alabama monitors customer/patient/provider satisfaction through the use of surveys and informal communications with families, advocacy groups, and providers.

In addition to these monitoring strategies, the State assures access to care through monitoring of the provider network and benefit package design. Program staff are actively involved in identifying new providers for the ALL Kids network and have been particularly involved in the addition of pediatric dentists, primary care nurse practitioners, community mental health centers and emergency transportation providers. Geographic distribution of providers is

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monitored and is crucial when decisions regarding vendor choice are made.

The ALL Kids benefits package requires preauthorization only for hospitalization services. Therefore, access to all primary care providers and specialists is open to all enrollees without referral. Claims data are monitored by program staff to ensure quality and appropriateness of care. In addition, the State employs a masters level social worker to assist families who are experiencing difficulties accessing necessary services due to benefit structure or provider geographic availability. This staff member works closely with case managers at the vendor to identify areas in need of attention and provides the State with recommendations for benefit plan adjustment and/or provider network issues.

The ALL Kids PLUS program coordinates the evaluation of quality and appropriateness of care with the ALL Kids PLUS authorizing agencies and CSHCC/N advocacy groups through collaboration with stakeholders. It is also anticipated that an evaluation of ALL Kids PLUS may become part of the UAB evaluation in the future.

7.1.1.

Quality standards

.

Performance measurement

7.1.2 (a) CHIPRA Quality Core Set

7.1.2 (b) Other The State ensures quality through contracted performance measures. These measures have been adapted in conjunction with the standards recommended by the AAP.

7.1.3.

Information strategies Vendors are required to provide key health indicators information.

7.1.4.

Quality improvement strategies

The performance guarantees and provider recoupment policy were included in the RFP and are included in the contract with the health plan.

Guidance: Provide a brief description of methods to be used to assure access to covered services, including a description of how the State will assure the quality and appropriateness of the care provided. The State should consider whether there are sufficient providers of care for the newly enrolled populations and whether there is reasonable access to care. (Section 2102(a)(7)(B))

7.2. Describe the methods used, including monitoring, to assure: (Section 2102(a)(7)(B)) (42CFR 457.495)

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7.2.1. Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a)) Access is monitored through a number of methods including the following:

Periodic review of the number and types of providers by county

Quarterly review of claims data

Quarterly review of new enrollee, continuous enrollee, and disenrollee survey data

Feedback from families via telephone, e-mail, and postal service mail

Feedback from providers

Further, the state uses claims data to monitor well-baby care as is described in 7.1.

7.2.2. Access to covered services, including emergency services as defined in 42 CFR 457.10. (Section 2102(a)(7)) 42CFR 457.495(b)) Access is monitored through a number of methods including the following:

Quarterly review of claims data

Quarterly review of new enrollee, continuous enrollee, and disenrollee survey data

Feedback from families via telephone, e-mail, and postal service mail

Feedback from providers

Feedback from the CHIP Social Work Consultant

Further, the state uses claims data to monitor emergency room use as is described in 7.1.

7.2.3. Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42CFR 457.495(c)) Access is monitored through a number of methods including the following:

Periodic review of the number and types of providers by county

Quarterly review of claims data

Quarterly review of new enrollee, continuous enrollee, and disenrollee survey data

Feedback from families via telephone, e-mail, and post service mail

Feedback from providers

Feedback from CSHCC/N advocates and ALL Kids PLUS providers

The ALL Kids PLUS network includes State agencies that serve children with special health care needs/conditions and that contract with CHIP to provide state matching funds for ALL Kids enrollees who use PLUS services. Currently, Children Rehabilitation Services is the only active PLUS program. The PLUS agency provides ALL Kids children with an individual case manager who will monitor access to specialists and treatment.

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In general, the Medicaid standards will be used to establish qualifications for ALL Kids PLUS case management staff. All case management staff will meet specific qualifications, including education, training and appropriate credentialing which will be established by the participating agencies.

In most circumstances, the agencies’ delivery systems are discrete and clear which program provides services for specific conditions. However, where there is potential for overlap in responsibilities, the determination of which agency will provide case management will be done based on the needs of the child with input from the family and by determining what is in the best interest of the child. The agencies using the case management process, will coordinate with each other, the child, the family, and the care providers in determining if a change in case management is needed.

7.2.4. Decisions related to the prior authorization of health services are completed in accordance with State law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR 457.495(d)) Exigent medical circumstances may require more rapid response according to the medical needs of the patient. The health plan vendor has policies in place to assure that prior authorization of health services are completed in accordance with state law or regulations promulgated by the Department of Labor. CHIP staff receive feedback from providers and enrollee families if time periods are exceeded. All prior authorization of health services is in accordance with state laws. Children enrolled in a Medicaid expansion are subject to the same prior authorization policies to which children enrolled in Medicaid’s other full service children’s programs are subject.

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Section 8. Cost-Sharing and Payment

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan, and continue on to Section 9.

8.1. Is cost-sharing imposed on any of the children covered under the plan? (42CFR 457.505)Indicate if this also applies for pregnant women. (CHIPRA #2, SHO # 09- 006, issued May 11, 2009)

8.1.1.

Yes 8.1.2.

No, skip to question 8.8.

8.1.1-PW

Yes 8.1.2-PW

No, skip to question 8.8.

Guidance: It is important to note that for families below 150 percent of poverty, the same limitations on cost sharing that are under the Medicaid program apply. (These cost- sharing limitations have been set forth in Section 1916 of the Social Security Act, as implemented by regulations at 42 CFR 447.50- 447.59). For families with incomes of 150 percent of poverty and above, cost sharing for all children in the family cannot exceed 5 percent of a family's income per year. Include a statement that no cost sharing will be charged for pregnancy-related services.(CHIPRA #2, SHO # 09-006, issued May 11, 2009) (Section 2103(e)(1)(A)) (42CFR 457.505(a), 457.510(b) and (c), 457.515(a) and (c))

8.2. Describe the amount of cost-sharing, any sliding scale based on income, the group or groups of enrollees that may be subject to the charge by age and income (if applicable) and the service for which the charge is imposed or time period for the charge, as appropriate.(Section 2103(e)(1)(A)) (42CFR 457.505(a), 457.510(b) and (c), 457.515(a) and (c)) There will not be any cost sharing of any type for families who are Native Americans or Alaskan Natives. There will also not be any cost sharing of any type for families whose children are enrolled in a CHIP Medicaid expansion. For all other families cost sharing will be as follows in 8.2.1. and 8.2.3.:

8.2.1.

Premiums:

There are three (3) categories of enrollees: No Fee (Native Americans and Alaskan Natives). Low-Fee (children with family incomes from the base (above 141% FPL) up to and including 156% FPL), and Fee (children with family incomes greater than 156% FPL up to and including 312% FPL). There is no cost sharing for children in the No Fee group. There is a $52 premium per child, per year for children in the Low-Fee group. There is a $104 premium per child, per year for children in the Fee group. Premiums can be paid in one payment or in

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periodic payments (weekly, monthly, quarterly…) throughout the year. A family’s total premium payments are limited to three times the individual premium rate (i.e. $156 or $312 depending upon the income level of the family). Enrollment data systems do not allow for a family to be billed in excess of these amounts. Outstanding premium balances may be waived at the State’s discretion for applicants/enrollees living or working in FEMA or Governor declared disaster areas.

Premiums will not be charged to those enrolled in the Conception to Birth expansion.

8.2.2.

Deductibles:

None 8.2.3.

Coinsurance or copayments:

There are no copayments for preventive services. The only permitted copayments are: Service Low Fee Group Copayments (for Children with Incomes up to and including 156% FPL) Fee Group Copayments (for Children with Incomes >156% FPL up to and including 312%)

Dental $5/visit $20.00/visit

Doctor’s office visits $3/visit $13.00/visit

Behavioral Health office visits $3/visit $13.00/visit

ER Services $6/facility charge $60.00/facility charge

Inpatient Services (Hospital) $200/confinement $200/confinement

Non-Emergency ER Services $6/visit $60.00/visit

Allergy Testing $6/lab visit $17.00/lab visit

Allergy Treatment $3/visit $12/visit

Ambulance $6/occurrence $100/occurrence

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Mental and Nervous (Inpatient) $200/confinement $200/confinement

Outpatient Surgical Facility $6/visit $100/visit

Substance Abuse (Inpatient) $200/confinement $200/confinement

X-ray (Outpatient Facility) $6/total x-rays in 1 visit $65/total x-rays in 1 visit

Therapies (Physical, Occupational, Speech) $3/visit $13/visit

Routine Eye Exam $3/visit $13/visit

Eye Glasses $3/frames and/or lenses $13/ frames and/or lenses

Chiropractic visits $2/visit $5/visit

In addition, a Generic Plus pharmacy benefit became effective October 1, 2012 for children in both the low fee and fee groups. Prescription drugs are divided into two groups: generic and preferred brands. The designation “preferred” is assigned by the third party administrator. The copayment schedule is as follows:

Low Fee Group Copayments (for Children with Incomes up to and including 156% FPL) Fee Group Copayments (for Children with Incomes >156% FPL up to and including 312%) Generic $1.00 $5.00 Preferred Brands $5.00 $25.00

For those enrolled in the Conception to Birth expansion, copayments will be assessed for the services and pharmacy as indicated in the above tables. Copayment amounts will be based on family income as noted below:

0% FPL up to and including 146% FPL - No copayment requirements From >147% FPL up to and including 156% FPL - assigned to the Low Fee copayment structure From >156% FPL up to and including 312% FPL – assigned to the Fee Group copayment structure 8.2.4.

Other:

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8.2-DS

Supplemental Dental(CHIPRA # 7, SHO # #09-012 issued October 7, 2009)For children enrolled in the dental-only supplemental coverage, describe the amount of cost-sharing, specifying any sliding scale based on income. Also describe how the State will track that the cost sharing does not exceed 5 percent of gross family income. The 5 percent of income calculation shall include all cost-sharing for health insurance and dental insurance. (Section 2103(e)(1)(A)) (42 CFR 457.505(a), 457.510(b), and (c), 457.515(a) and (c), and 457.560(a)) Please update Sections 1.1-DS, 4.1-DS, 4.2- DS, 6.2-DS, and 9.10 when electing this option.

8.2.1-DS

Premiums:

8.2.2-DS

Deductibles:

8.2.3-DS

Coinsurance or copayments:

8.2.4-DS

Other:

8.3. Describe how the public will be notified, including the public schedule, of this cost sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)(1)(A)) (42CFR 457.505(b)) All enrollees are provided with coverage and cost-sharing information at initial enrollment through mailed documents. Additionally, this information is available online. All enrollees are notified of cost-sharing changes through letters mailed directly to the residence addresses on file with CHIP. In addition all stakeholders, including provider organizations/associations and state agencies, are notified by letter or other appropriate means of communication (i.e. email, fax notifications, and/or meetings) when changes are made to cost-sharing requirements. CHIP staff and customer service representatives are trained to discuss cost-sharing requirements with families, including premiums, copayments, and the annual out of pocket expenses limit.

Guidance: The State should be able to demonstrate upon request its rationale and justification regarding these assurances. This section also addresses limitations on payments for certain expenditures and requirements for maintenance of effort.

8.4. The State assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e))

8.4.1.

Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530) 8.4.2.

No cost-sharing applies to well-baby and well-child care, including age- appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520) 8.4.3

No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42CFR 457.515(f))

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8.4.1- MHPAEA There is no separate accumulation of cumulative financial requirements, as defined in 42 CFR 457.496(a), for mental health and substance abuse disorder benefits compared to medical/surgical benefits. (42 CFR 457.496(d)(3)(iii))

8.4.2- MHPAEA If applicable, any different levels of financial requirements that are applied to different tiers of prescription drugs are determined based on reasonable factors, regardless of whether a drug is generally prescribed for medical/surgical benefits or mental health/substance use disorder benefits. (42 CFR 457.496(d)(3)(ii)(A))

8.4.3- MHPAEA Cost sharing applied to benefits provided under the State child health plan will remain capped at five percent of the beneficiary’s income as required by 42 CFR 457.560 (42 CFR 457.496(d)(3)(i)(D)).

8.4.4- MHPAEA Does the State apply financial requirements to any mental health or substance use disorder benefits? If yes, specify the classification(s) of benefits in which the State applies financial requirements on any mental health or substance use disorder benefits.

Yes (Specify: inpatient, outpatient, prescription drugs, emergency room) Inpatient, outpatient, prescription drugs and emergency room No Guidance:For the purposes of parity, financial requirements include deductibles, copayments, coinsurance, and out of pocket maximums; premiums are excluded from the definition. If the state does not apply financial requirements on any mental health or substance use disorder benefits, the state meets parity requirements for financial requirements. If the state does apply financial requirements to mental health or substance use disorder benefits, the state must conduct a parity analysis. Please continue below.

Please ensure that changes made to financial requirements under the State child health plan as a result of the parity analysis are also made in Section 8.2.

8.4.5- MHPAEA Does the State apply any type of financial requirements on any medical/surgical benefits?

Yes No Guidance: If the State does not apply financial requirements on any medical/surgical benefits, the State may not impose financial requirements on

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mental health or substance use disorder benefits.

8.4.6- MHPAEA Within each classification of benefits in which the State applies a type of financial requirement on any mental health or substance use disorder benefits, theState must determine the portion of medical and surgical benefits in the class which are subject to the limitation.

The State assures it has applied a reasonable methodology to determine the dollar amounts used in the ratio described above (Section 6.2.5.2-MHPAEA) for each classification or within which the State applies financial requirements to mental health or substance use disorder benefits. (42 CFR 457.496(d)(3)(i)(E)) Guidance: Please include the state’s methodology and results of the parity analysis as anattachment to the State child health plan.

8.4.7- MHPAEAFor each type of financial requirement applied to any mental health or substance use disorder benefits within a given classification,does the Stateapply the same type of financial requirement to at least two-thirds (“substantially all”) of all the medical/surgical benefits within the same classification? (42 CFR 457.496(d)(3)(i)(A))

Yes No Guidance: If the State does not apply a type of financial requirement to substantially all medical/surgical benefits in a given classification of benefits,the State may not impose financial requirements on mental health or substance use disorder benefits in that classification. (42 CFR 457.496(d)(3)(i)(A))

8.4.8- MHPAEAFor each type of financial requirement applied to substantially all medical/surgical benefits in a classification, the State must determine the predominant level (as defined in 42 CFR 457.496(d)(3)(i)(B)) of that type which is applied to medical/surgical benefits in the classification. For each type of financial requirement applied to substantially all medical/surgical benefits in a classification, the State assures:

The same reasonable methodology applied in determining the dollar amounts used in determining whether substantially all medical/surgical benefits within a classification are subject to a type of financial requirement also is applied in determining the dollar amounts used to determine the predominant level of a type of financial requirement applied to medical/surgical benefits within a classification. (42 CFR 457.496(d)(3)(i)(E))

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The level of each type of financial requirement applied by the State to mental health or substance use disorder benefits in any classification is no more restrictive than the predominant level of that type which is applied by the State to medical/surgical benefits within the same classification. (42 CFR 457.496(d)(2)(i)) Guidance: If there is no single level of a type of financial requirement that exceeds the one-half threshold, the State may combine levels within a type of financial requirement such that the combined levels are applied to at least half of all medical/surgical benefits within a classification; the predominant level is the least restrictive level of the levels combined to meet the one-half threshold. (42 CFR 457.496(d)(3)(i)(B)(2))

8.5. Describe how the State will ensure that the annual aggregate cost-sharing for a family does not exceed 5 percent of such family’s income for the length of the child’s eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the State for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e))

Alabama ensures that the annual aggregate cost-sharing for a family does not exceed five percent (5%) of a family’s income as is required by Section 2103(3)(B) of Title XXI. In addition, cost sharing, both premiums and copayments are in compliance with CHIP regulations.

There is minimal cost sharing for families, other than Native Americans and Alaskan Natives who have no cost sharing. No family is charged for more than three (3) premiums even if the family has more than three children.

To protect families against excessive medical expenses and comply with the statutory limit of no more than five percent of family income being expended on cost sharing expenses, families will be notified in writing, at initial enrollment and renewal, of the annual out of pocket maximum. Families are informed of this policy through educational literature. Also, CHIP staff and partners are trained to educate families about the limit on out of pocket expenses. Families are encouraged to keep receipts for all copayments and premiums so that once the out of pocket maximum is reached they will have the necessary documentation to stop cost-sharing. If a family reaches this limit and notifies the ALL Kids program, ALL Kids will review the case and if the limit has been reached new insurance cards will be issued stating that the child(ren) are not subject to further co-pays for the coverage period.

8.6. Describe the procedures the State will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42CFR 457.535) If a child is identified on an application as an American Indian, the enrollment worker

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automatically places the child in the no-fee category if the child becomes enrolled. Therefore the insurance vendor sends an insurance card, to the family, which indicates that the child is not subject to any co-pays.

8.7. Provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c))

Superseded by ACA SPA Guidance: Section 8.7.1is based on Section 2101(a) of the Act provides that the purpose of title XXI is to provide funds to States to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner that is coordinated with other sources of health benefits coverage for children.

8.7.1. Provide an assurance that the following disenrollment protections are being applied:

Guidance: Provide a description belowof the State’s premium grace period process and how the State notifies families of their rights and responsibilities with respect to payment of premiums. (Section 2103(e)(3)(C))

8.7.1.1.

State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or similar fees prior to disenrollment.(42CFR 457.570(a))

ALL Kids has an annual premium for those in cost sharing categories. Upon enrollment, families are notified, by letter, that premiums are due. Enrollees have the entire 12-month coverage period to pay premium balances and receipt of benefits is not contingent upon payment of premiums. Current enrollees are not terminated for non-payment of premium during the 12-month coverage period. At one month, four months, seven months, and 10 months, families are notified of outstanding premium balances. They are notified, every notice for past-due premiums and cost-sharing, that, in most circumstances, premiums must be paid in full for ALL Kids coverage to be renewed. If a renewal application is received within 90 days past the coverage end date (and the premium is paid no later than 90 days past the coverage end date), enrollees may renew with no lapse in coverage.

8.7.1.2.

The disenrollment process affords the enrollee an opportunity to show that the enrollee’s family income has declined prior to disenrollment for non-payment of cost-sharing charges. (42CFR 457.570(b))

The amount of family income written on the renewal form is reviewed by enrollment workers at the time of renewal. If it is known to ALL Kids that a family is experiencing financial difficulty, the ALL Kids Social Work Consultant and/or ALL Kids Regional staff may assist

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the family in locating assistance for premium payment. Non-payment of premiums is forgiven if the family provides proof of bankruptcy status during the enrollment period or if the family has been affected by disaster events (living or working in FEMA or Governor declared disaster areas at the time of a disaster event).

8.7.1.3.

In the instance mentioned above, that the State will facilitate enrolling the child in Medicaid or adjust the child’s cost-sharing category as appropriate. (42CFR 457.570(b)) At the time of renewal, if the family’s income has dropped but is still above the Medicaid eligibility level, if the decision is made to forgive the unpaid premium(s), the child is renewed and placed in the appropriate ALL Kids category. If a family’s income has dropped below the ALL Kids eligibility, the child’s application is reviewed for Medicaid eligibility and, if the child meets all eligibility requirements, s/he is enrolled in Medicaid.

8.7.1.4

The State provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42CFR 457.570(c))

This type of grievance is handled in the same impartial manner in which other grievances are handled as described in Attachment A.

8.8. The State assures that it has made the following findings with respect to the payment aspects of its plan: (Section 2103(e))

8.8.1.

No Federal funds will be used toward State matching requirements. (Section 2105(c)(4)) (42CFR 457.220) 8.8.2.

No cost-sharing (including premiums, deductibles, copayments, coinsurance and all other types) will be used toward State matching requirements. (Section 2105(c)(5) (42CFR 457.224) (Previously 8.4.5) 8.8.3.

No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under the this title. (Section 2105(c)(6)(A)) (42CFR 457.626(a)(1)) 8.8.4.

Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)) (42CFR 457.622(b)(5)) 8.8.5.

No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. (Section 2105)(c)(7)(B)) (42CFR 457.475) 8.8.6.

No funds provided under this title will be used to pay for any abortion or to assist in the purchase, in whole or in part, for coverage that includes abortion (except as described above). (Section 2105)(c)(7)(A)) (42CFR 457.475)

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Section 9. Strategic Objectives and Performance Goals and Plan Administration

Guidance: States should consider aligning its strategic objectives with those discussed in Section II of the CHIP Annual Report.

9.1. Describe strategic objectives for increasing the extent of creditable health coverage among targeted low-income children and other low-income children: (Section 2107(a)(2)) (42CFR 457.710(b))

1. The number of low-income (<200% FPL), uninsured children in AL will be reduced each year.

2. Given available funding, the number of low income (between the Medicaid eligibility upper income levels and 200% FPL), children enrolled in ALL Kids will be maintained at at least 50,000 (current enrollment) at any given time.

3. The number of low-income children (incomes in the Medicaid income eligibility ranges) enrolled in SOBRA Medicaid will be maintained at at least 300,000.

4. Enrollment in ALL Kids will result in more children having a medical home.

5. Enrollment in ALL Kids will result in a higher usage of preventive care.

6. Specialty services beyond the basic ALL Kids coverage package will be available for ALL Kids enrolled children with special health care needs.

Guidance: Goals should be measurable, quantifiable and convey a target the State is working towards.

9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c)) 1. Performance Goals for Objective 1: a. The number of low-income uninsured children in AL will be reduced by 1% each year until the number of low-income uninsured children is no larger than 10% of the children in the state. b. A tracking system will be established by April 2004, which will track applicants referred among ALL Kids, SOBRA Medicaid, and the Alabama Child Caring Foundation.

2. Performance Goals for Objective 2

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a. The percentage of families who do not renew their children’s ALL Kids coverage due to a financial barrier (owing past premiums) will not be more than 3% annually. b. A higher percentage of families with ALL Kids enrolled child(ren), report that financial barriers to accessing care have been reduced since enrollment in ALL Kids in comparison to the time before enrollment in ALL Kids. c. Plans which target outreach activities toward specific populations: (adolescents, Native Americans, and faith-based organizations) will be developed by October, 2002. d. Plans which target outreach activities toward specific populations: (adolescents, Native Americans, and faith-based organizations) will be implemented each year beginning with FY 2003. e. Plans which target outreach activities toward Hispanics, birth-to-five care providers, and Native Americans will be developed by January 1, 2004. f. Plans which target outreach activities toward Hispanics, birth-to-five care providers, and Native Americans will be implemented each year beginning with FY 2005. g. Plans which target outreach activities toward specific populations (other than adolescents, faith-based organizations, Hispanics, birth-to-five care providers, and Native Americans) will be developed and implemented as data or other information indicate. h. Language and culture will not be barriers to enrollment or renewal as evidenced by the availability of telephone assistance in the customers’ preferred languages, brochures and forms in both English and Spanish, and the availability of Spanish speaking, culturally competent customer service staff. i. There will be an incremental reduction from year to year, in the percentage of children canceling ALL Kids coverage due to nonparticipation in the renewal process.

3. Performance Goal for Objective 3: There will be maintenance of effort or an increase, on the part of CHIP, to decrease the number of uninsured low-income (Medicaid eligible) children as evidenced by at least the following:

i. Continued use of a joint application form. ii. Continued use of a joint renewal form iii. Continued referral, without any barriers, of applications and renewals between ALL Kids and SOBRA Medicaid iv. Continued outreach efforts by CHIP staff for network building with community groups, professionals (individually and in groups), child care providers, schools, etc.

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v. Continued evaluation and monitoring of the application transfer/referral process between ALL Kids and Medicaid. vi. Continued computer enhancements to improve the communication with other agencies and current and potential ALL Kids enrollees.

4. Performance Goals for Objective 4: a. A higher percentage of families report that their ALL Kids enrolled child(ren) have a usual source of care since enrollment in ALL Kids than before enrollment in ALL Kids. b. A lower percentage of families report that their ALL Kids enrolled child(ren) have used a hospital emergency room since enrollment in ALL Kids than before enrollment in ALL Kids.

5. Performance Goals for Objective 5 a. A higher percentage of families report that their ALL Kids enrolled child(ren) have had a well child check-up in the past year since enrollment in ALL Kids than before enrollment in ALL Kids. b. A higher percentage of families report that their ALL Kids enrolled child(ren) have had a dental visit in the past year since enrollment in ALL Kids than before enrollment in ALL Kids. c. A higher percentage of families report that their ALL Kids enrolled child(ren) have had a vision screening in the past year since enrollment in ALL Kids than before enrollment in ALL Kids.

6. Performance Goal for Objective 6: a. Contracts with state agencies which serve children with special health care needs will be maintained for the purpose of providing specialty services beyond the basic ALL Kids coverage package for these children. b. Exploration of the feasibility of establishing contracts with other state agencies that serve children with special health care needs. c. Continued monitoring of access to specialty care for children with special health care needs.

Guidance: The State should include data sources to be used to assess each performance goal. In addition, check all appropriate measures from 9.3.1 to 9.3.8 that the State will be utilizing to measure performance, even if doing so duplicates what the State has already discussed in Section 9.

It is acceptable for the State to include performance measures for population subgroups chosen by the State for special emphasis, such as racial or ethnic minorities, particular high-risk or hard to reach populations, children with special needs, etc.

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HEDIS (Health Employer Data and Information Set) 2008 contains performance measures relevant to children and adolescents younger than 19. In addition, HEDIS 3.0 contains measures for the general population, for which breakouts by children’s age bands (e.g., ages < 1, 1-9, 10-19) are required. Full definitions, explanations of data sources, and other important guidance on the use of HEDIS measures can be found in the HEDIS 2008 manual published by the National Committee on Quality Assurance. So that State HEDIS results are consistent and comparable with national and regional data, states should check the HEDIS 2008 manual for detailed definitions of each measure, including definitions of the numerator and denominator to be used. For states that do not plan to offer managed care plans, HEDIS measures may also be able to be adapted to organizations of care other than managed care.

9.3. Describe how performance under the plan will be measured through objective, independently verifiable means and compared against performance goals in order to determine the State’s performance, taking into account suggested performance indicators as specified below or other indicators the State develops: (Section 2107(a)(4)(A),(B)) (42CFR 457.710(d)) Assurance of an Objective Means for Measuring Performance To ensure an objective evaluation which can be independently verified, the evaluation will be based upon data bases which contain quantifiable information. These databases will, to the extent possible, contain numeric data. The ADPH will develop and/or direct the development of needed databases which do not currently exist. Since evaluation of some performance measures does not lend itself to numeric summation, measurement of these aspects of the plan will be based on review of a completed work plan which requires conclusive documentation. All data and documentation will be auditable. At periodic intervals, a formal comparison of program performance to the goals and measures set forth in this document or its subsequent amendments will be conducted. The CHIP staff directly responsible for the implementation of the program will conduct information comparisons of performance to these goals and measures on an ongoing basis. In this way, the program will be continuously monitored and activities may be adjusted so that the program may achieve its objectives.

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Measure of Performance: MEASURE ROUGH DEFINITION OF MEASURE

Reducing the Number of Uninsured Number of Uninsured CPS and/or NSAF and state data survey Tracking System Documentation that a tracking system exists and is used for 100% of the applications that are referred among ALL Kids, Medicaid, and Alabama Child Caring Foundation Related to SCHIP Enrollment Percentage of families not renewing due to owing past premiums Renewal database – comparison of number of non- renewals who owed premiums to the number who were due to renew. Percentage of families reporting a reduction in financial barriers to accessing health care New enrollee survey database – comparison of percentage of reports indicating a reduction in financial barriers to obtaining health care post-ALL Kids to pre-ALL Kids Development of plans to target outreach to adolescents, faith-based organizations Documentation of development of these plans on file Implementation of plans to target outreach to adolescents, faith-based organizations Documentation of implementation of these plans on file Development of plans to target outreach to Hispanics, Native Americans, and birth-to-five providers Documentation of development of these plans on file

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Implementation of plans to target outreach to Hispanics Native Americans, and birth-to-five providers Documentation of implementation of these plans on file Development and implementation of plans to target outreach to other groups Documentation of development and implementation of these plans on file Elimination of language and culture barriers Spanish and English brochures and applications forms on file Employment of bi-lingual customer service staff ALL Kids Customer service telephone operators are aware of and know how to use a telephone translating service. Reduction in percentage of children canceling ALL Kids due to nonparticipation in the renewal process Enrollment Data Management system – Comparison of number of enrollees who did not participate in the renewal process to those due to renew. Related to increasing Medicaid Enrollment Maintenance of effort with regard to: Use of a joint application form A joint SOBRA Medicaid and ALL Kids application form is in use Use of a joint renewal form A joint SOBRA Medicaid and ALL Kids renewal form is in use

Seamless referral between ALL Kids and SOBRA Medicaid Seamless referral policy in place

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Continued outreach effort Outreach/Marketing files reflect outreach conducted by central office staff, regional staff, and federal program office. Evaluation of application transfer and referral process Evaluation on files of meeting minutes Continued computer enhancements Computer enhancements will be in place. Related to increasing access to care Reported usual source of care New Enrollees Survey Reported ER use New Enrollees Survey Related to use of preventive care

Reported use of well-child check-up New Enrollees Survey Reported dental visit New Enrollees Survey Reported vision screening New Enrollees Survey Other

Specialty service availability Contract(s) on file Exploration of feasibility for establishing contracts with other CSHCN state agencies Documentation on file (central office files and/or regional coordinator files) Monitoring access to care for CSHCN New Enrollees Survey

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Check the applicable suggested performance measurements listed below that the State plans to use: (Section 2107(a)(4)) 9.3.1.

The increase in the percentage of Medicaid-eligible children enrolled in Medicaid. 9.3.2.

The reduction in the percentage of uninsured children. 9.3.3.

The increase in the percentage of children with a usual source of care. 9.3.4.

The extent to which outcome measures show progress on one or more of the health problems identified by the state. 9.3.5.

HEDIS Measurement Set relevant to children and adolescents younger than 19. 9.3.6.

Other child appropriate measurement set. List or describe the set used.

9.3.7.

If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as: 9.3.7.1.

Immunizations 9.3.7.2.

Well childcare 9.3.7.3.

Adolescent well visits 9.3.7.4.

Satisfaction with care 9.3.7.5.

Mental health 9.3.7.6.

Dental care 9.3.7.7.

Other, list:

9.3.8.

Performance measures for special targeted populations.

9.4. The State assures it will collect all data, maintain records and furnish reports to the Secretary at the times and in the standardized format that the Secretary requires. (Section 2107(b)(1)) (42CFR 457.720)Alabama assures it will collect all data, maintain records and furnish reports to the Secretary at the times and in the standardized format that the Secretary requires.

Guidance: The State should include an assurance of compliance with the annual reporting requirements, including an assessment of reducing the number of low-income uninsured children. The State should also discuss any annual activities to be undertaken that relate to assessment and evaluation of the program.

9.5.

The State assures it will comply with the annual assessment and evaluation required under Section 10. Briefly describe the State’s plan for these annual assessments and reports. (Section 2107(b)(2)) (42CFR 457.750)

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Alabama assures it will comply with the annual assessment and evaluation required under Section 10. On an annual basis, the Alabama will review its operations, progress made in reducing the number of uncovered low-income children, progress made in meeting the goals and objectives stated in 9.1 and 9.2 of this document, and its compliance with applicable Federal laws and regulations. Section 9.3 states how Alabama will measure the goals and objectives in sections 9.1 and 9.2. Examples of data sources are: Census data, private foundation garnered data, data gathered via special surveys, utilization data from claims reports, enrollee family feedback from surveys, etc. The assessment will occur during the three months after the end of the fiscal year and a report of this assessment will be submitted to the Secretary by January 1 following the end of the fiscal year.

9.6. The State assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review or audit.(Section 2107(b)(3)) (42CFR 457.720) Alabama assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit.

Guidance: The State should verify that they will participate in the collection and evaluation of data as new measures are developed or existing measures are revised as deemed necessary by CMS, the states, advocates, and other interested parties.

9.7.

The State assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed. (42CFR 457.710(e)) Alabama assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed

9.8. The State assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a State under Title XIX: (Section 2107(e)) (42CFR 457.135)

9.8.1.

Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2.

Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment) 9.8.3.

Section 1903(w) (relating to limitations on provider donations and taxes) 9.8.4.

Section 1132 (relating to periods within which claims must be filed)

Guidance: Section 9.9 can include discussion of community-based providers and consumer representatives in the design and implementation of the plan and the method for ensuring ongoing public involvement. Issues to address include a listing of public meetings or announcements made to the public concerning the development of the children's health

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insurance program or public forums used to discuss changes to the State plan.

9.9. Describe the process used by the State to accomplish involvement of the public in the design and implementation of the plan and the method for ensuring ongoing public involvement. (Section 2107(c)) (42CFR 457.120(a) and (b))

Efforts were made to make the process of developing the design and implementation of the Children’s Health Insurance Program inclusive. News coverage about the advocacy of the Children’s Health Insurance Program was provided regularly starting at the time that the issue came before the Alabama Legislature.

Formalized CHIP development groups were the CHIP Commission and the CHIP Task Force Work Groups. The CHIP Commission met three times, October 7, November 12 and December 17, 1998. The CHIP Task Force Work Groups met twelve times beginning August 6, 1998, and split into subcommittees to develop proposals in the following areas: (1) benefits, (2) eligibility, outreach and enrollment, and (3) funding. These subcommittee meetings were open to interested individuals and groups. At least three news conferences were held by the State Health Officer and/or the Medicaid Commissioner.

Public awareness was promoted through means such as television programs. Interested organizations such as Alabama ARISE, the Alabama Developmental Disabilities Planning Council, and Voices for Alabama’s Children were provided information for their membership about CHIP. Media coverage was provided and CHIP information has been made available on the Internet at: http://www.adph.org/allkids (formerly: http://www.alapubhealth.org) since October 2, 1998. During the first six and one-half month period of October 4 through April 21, 1998, 1,247 hits were made on this site specifically requesting CHIP information. This website includes a description of the program, a calendar of scheduled events, and an opportunity for interested persons to express their opinions about the program’s development. Order forms are available at every presentation. These forms enable participants to fax orders to the ALL Kids office and receive printed materials at no charge. The largest number of requests for information (312) came during the month of January. Newspaper editorials have praised the value of this program for our State’s children.

The CHIP Task Force Work Groups were comprised of employees of the Alabama Medicaid Agency, Public Health Department employees, and other interested parties including representatives of the Alabama Primary Care Association, Alabama ARISE, the Alabama Developmental Disabilities Planning Council, Voices for Alabama’s Children, the Alabama Child Caring Foundation, Alabama Dental Association, Alabama Hospital Association, Alabama Psychological Association, American Academy of Pediatrics-Alabama Chapter, Blue Cross Blue Shield, Children First, Children’s Health System, Children’s Hospital of Alabama, Family Voices, Health Maintenance Organization Association, Legislative Fiscal Office, Legislative Reference

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Service, Medical Association of the State of Alabama, University of Alabama at Birmingham, University of South Alabama, University of South Alabama Children’s and Women’s Hospital, United Health Care, as well as other State agencies including the Department of Education, the Department of Human Resources, the Department of Mental Health/Mental Retardation, State Employees’ Insurance Board, State Insurance Department, and the Department of Rehabilitation Services. These entities are now referred to as stakeholders and they continue to be involved as program changes are developed.

The Alabama program will continue to inform the general public about CHIP through the news media, to announce planning meetings, and to invite additional groups with an interest in being involved or informed as they become identified. There was extensive public involvement in the preparation of a comprehensive 133-page report which was released to the Alabama Legislature on January 12, 1998. In relation to the Governor’s Task Force on Children’s Health Insurance, periodic reports on the progress of recommendations contained the report are made. 9.9.1. Describe the process used by the State to ensure interaction with Indian Tribes and organizations in the State on the development and implementation of the procedures required in 42 CFR 457.125. States should provide notice and consultation with Tribes on proposed pregnant women expansions.(Section 2107(c)) (42CFR 457.120(c)) A meeting was held with representatives of the 2,176 member Poarch Band of Creek Indians, the only federally recognized Native American group in Alabama. Six other tribes are recognized by the State. The CHIP Program was explained and discussion centered on ways to coordinate CHIP and Indian Health Service-funded care, the role of traditional Native American healing, outreach methods for children and some demographics of the Poarch Band. Several presentations have been made to the Alabama Commission on Indian Affairs and CHIP staff meet and coordinate regularly with staff of the Commission. Other forms of outreach have included numerous presentations to the tribes, presence at Native American festivals throughout the state and the employment of a Native American consultant whose specific task was to develop a regionally- based outreach plan to the Native American population in Alabama.

9.9.2. For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), describe how and when prior public notice was provided as required in 42 CFR457.65(b) through (d).

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Alabama has no state law applicable to public notice of either cost sharing changes or waiting list implementations in CHIP.

Public Notice of Cost Sharing Changes: Specific public notice was given via a meeting of CHIP stakeholders in August 2003 and letters to enrollees’ families informing them of the changes in cost sharing. This meeting and the mailings followed much publicity in the state regarding the state’s financial situation and the possible impact on CHIP if a statewide referendum to raise taxes on (September 9, 2003) did not pass.

Public Notice of the Waiting List: ALL Kids initiated a waiting list beginning with all new enrollees who would have had an effective date October 1, 2003. Once the decision had been made to establish a waiting list, a press statement was released and letters were sent to stakeholders and other interested parties informing them of the institution of a waiting list and stressing the importance of returning renewal forms on time. Additionally, a letter to this effect was sent to every enrollee family along with a new insurance card(s). All of these notices were issued during the month of September 2003 prior to the impact of the waiting list.

On August 23, 2004, ALL Kids reopened enrollment and discontinued use of the waiting list.

If the State determines that it is again necessary to implement a waiting list, it will provide prior, appropriate public notice.

There are no public notice state laws regarding enrollment caps and waiting lists in SCHIP. 9.9.3. Describe the State’s interaction, consultation, and coordination with any Indian tribes and organizations in the State regarding implementation of the Express Lane eligibility option.

9.10. Provide a 1-year projected budget. A suggested financial form for the budget is below. The budget must describe: (Section 2107(d)) (42CFR 457.140)

• Planned use of funds, including: • Projected amount to be spent on health services; • Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and • Assumptions on which the budget is based, including cost per child and expected enrollment. • Projected expenditures for the separate child health plan, including but not

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limited to expenditures for targeted low income children, the optional coverage of the unborn, lawfully residingeligibles, dental services, etc. • All cost sharing, benefit, payment, eligibility need to be reflected in the budget.

• Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees. • Include a separate budget line to indicate the cost of providing coverage to pregnant women. • States must include a separate budget line item to indicate the cost of providing coverage to premium assistance children. • Include a separate budget line to indicate the cost of providing dental-only supplemental coverage. • Include a separate budget line to indicate the cost of implementing Express Lane Eligibility. • Provide a 1-year projected budget for all targeted low-income children covered under the state plan using the attached form. Additionally, provide the following: - Total 1-year cost of adding prenatal coverage - Estimate of unborn children covered in year 1

CHIP Budget STATE: AL FFY Budget Federal Fiscal Year 2019 State’s enhanced FMAP rate 100%

Benefit Costs

Insurance payments 229,609,117 Managed care

per member/per month rate 220 Fee for Service

Total Benefit Costs 229,609,117 (Offsetting beneficiary cost sharing payments) -6,500,000

Cost of Proposed SPA Changes – Benefit 3,300,000 Net Benefit Costs 226,409,117

Administration Costs

Personnel 5348138 General administration 2485677 Contractors/Brokers

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STATE: AL FFY Budget Claims Processing

Outreach/marketing costs 174000 Health Services Initiatives $753,625 Other 1,283,553 Total Administration Costs 10,044,993 10% Administrative Cap 25,156,569

Cost of Proposed SPA Changes 4,053,625

Federal Share 236,454,110 State Share 0 Total Costs of Approved CHIP Plan 236,454,110

NOTE: Include the costs associated with the current SPA. Costs associated with the two changes contained within SPAs AL-19- 0017-RIM And AL-19-0018-RIM total $4,053,625. The entire cost would be paid for through Federal funds in FY 2019. For the expansion of benefits to provide coverage from conception to birth in select counties (AL-19-0018-RIM), costs are estimated to be $3,300,000 and are reflected within the line item “benefits.” The other budget item addressed in these SPAs includes costs for implementing a health service initiative (HSI) (AL-19-0017-RIM). HSI costs are projected to be $753,625 for the remaining of FY2019.

The Source of State Share Funds: No state funds will be used.

Section 10. Annual Reports and Evaluations

Guidance: The National Academy for State Health Policy (NASHP), CMS and the states developed framework for the annual report that states have the option to use to complete the required evaluation report. The framework recognizes the diversity in State approaches to implementing CHIP and provides consistency across states in the structure, content, and format of the evaluation report. Use of the framework and submission of this information will allow comparisons to be made between states and on a nationwide basis. The framework for the annual report can be obtained from NASHP’s website at http://www.nashp.org. Per the title XXI statute at Section 2108(a), states must submit reports by January 1st to be compliant with requirements.

10.1. Annual Reports. The State assures that it will assess the operation of the State plan

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under this Title in each fiscal year, including: (Section 2108(a)(1),(2)) (42CFR 457.750)

10.1.1.

The progress made in reducing the number of uninsured low-income children and report to the Secretary by January 1 following the end of the fiscal year on the result of the assessment, and

10.2.

The State assures it will comply with future reporting requirements as they are developed. (42CFR 457.710(e))

10.3.

The State assures that it will comply with all applicable Federal laws and regulations, including but not limited to Federal grant requirements and Federal reporting requirements.

10.3-DC

The State agrees to submit yearly the approved dental benefit package and to submit quarterly current and accurate information on enrolled dental providers in the State to the Health Resources and Services Administration for posting on the Insure Kids Now! Website. Please update Sections 6.2-DC and 9.10 when electing this option.

Section 11. Program Integrity (Section 2101(a))

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan, and continue to Section 12.

11.1.

The State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Section 2101(a)) (42CFR 457.940(b))

11.2. The State assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a State under Title XIX: (Section 2107(e)) (42CFR 457.935(b))(The items below were moved from section 9.8. Previously 9.8.6. - 9.8.9.)

11.2.1.

42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents) 11.2.2.

Section 1124 (relating to disclosure of ownership and related information) 11.2.3.

Section 1126 (relating to disclosure of information about certain convicted individuals) 11.2.4.

Section 1128A (relating to civil monetary penalties) 11.2.5.

Section 1128B (relating to criminal penalties for certain additional charges) 11.2.6.

Section 1128E (relating to the National health care fraud and abuse data collection program)

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Section 12. Applicant and Enrollee Protections(Sections 2101(a))

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan.

12.1. Eligibility and Enrollment Matters- Describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120. Describe any special processes and procedures that are unique to the applicant’s rights when the State is using the Express Lane option when determining eligibility. Alabama’s appeals process meets the requirements of the Program Specific Review as outlined in CFR.457.1120 – 457.1180. The ALL Kids appeals and grievance process can be found in Attachment A. The individuals involved in the Information review (first level) are not involved in the Administrative Review (second level) thus impartiality in the appeals process is provided. The individuals who conduct the Administrative Review are not involved in the Information Review process not in the original determination process. The review process for children enrolled in a CHIP Medicaid expansion is the same as the review process for children enrolled in other Medicaid full service children’s programs Guidance: “Health services matters” refers to grievances relating to the provision of health care.

12.2. Health Services Matters- Describe the review process for health services matters that complies with 42 CFR 457.1120.

The State assures that the State laws or regulations are consistent with the intent of 42 CFR 457,1130(b). This grievance process for health service matters is provided by the insurance vendor and is in compliance with state laws, the Employee Retirement Income Security Act of 1974 (ERISA), and all other applicable regulations of the Department of Labor Procedures. A copy of the Blue Cross Blue Shield of Alabama appeals process can be found in the ALL Kids Summary Plan Description (SPD) which is available upon request. The grievance process for children enrolled in a CHIP Medicaid expansion is the same as the review process for children enrolled in other Medicaid full service children’s programs.

12.3. Premium Assistance Programs-If providing coverage through a group health plan that does not meet the requirements of 42 CFR 457.1120, describe how the State will assure that applicants and enrollees have the option to obtain health benefits coverage other than through the group health plan at initial enrollment and at each redetermination of eligibility.

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ATTACHMENT A

GRIEVANCE POLICY General Information

Applicants and enrollees of the ALL Kids Children’s Health Insurance Program (CHIP) have a right to discuss and question how eligibility for enrollment was determined. In particular they have the right to request review of program decisions concerning:

• Denial of eligibility • Failure to make a timely determination of eligibility • Suspension or termination of enrollment, including disenrollment for failure to pay premiums.

The ALL Kids Review Process has three levels of review--Information Review, Administrative Review and Formal Review. Requests for an Administrative Review and Formal Appeal must be submitted in writing. All correspondence with the applicant /enrollee concerning Administrative Review or Formal Review will be in writing.

ALL Kids Plus Services Requests for review of decisions made regarding eligibility for the ALL Kids Plus services must first be made to the ALL Kids Plus participating agency’s appropriate appeals process. This is necessary since eligibility for ALL Kids Plus is dependent on the participating agency’s eligibility criteria for services. Once the appeals process through the ALL Kids Plus participating agency has been exhausted, an appeal request may be made to the Children’s Health Insurance Program as described in ADPH ALL Kids Review Process.

Information Review In many cases problems can be handled informally through the Information Review Process without the need for a Administrative or Formal Review. CHIP staff is committed to using the Information Review process to provide a speedy and fair resolution when possible and appropriate.

Parents/designated representatives can initiate an Information Review via contact (telephone, e-mail or letter) with the Enrollment Unit supervisory staff, CHIP administrative staff, the CHIP social work consultant, CHIP regional staff, or interested agencies. Once the problem has been received, the appropriate staff will review the situation and initiate immediate action to resolve the problem and

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communicate the decision or resolution. If additional information is needed, the enrollee/applicant will be given the opportunity to provide clarification or submit additional information. Decisions made in the Information Review are usually provided within two working days. Notification to the applicant/enrollee will be communicated in the manner in which the request was made. Summation of the inquiry, review and resolution will be maintained on file and noted with the appropriate applicant/enrollee information.

If the problem remains unresolved in the eyes of the applicant/enrollee, they will be provided detailed information regarding their right to a Administrative Review, right to continued enrollment during the review process and provided copies of all forms and the procedures necessary to move forward through the review process. Appropriate notation will be kept in the applicant’s/enrollee’s electronic file noting the initial complaint, any information gathered during the Information Review, the decision reached through Information Review, the date of such decision and the applicant/enrollees intent to go forward with the Administrative Review Process.

Administrative Review In order to be considered, an Administrative Review Request Form must be received within ten (10) days of the final decision from the Information Review. The CHIP social work consultant will assist in gathering information that may clarify the request. All information on file from the Information Review and any information gathered by the CHIP Social Work consultant will be circulated to a three person Administrative Review Committee whose members were not involved in the Information Review process nor in the original determination process.

The applicant/enrollee will be notified in advance of the date and time that the Administrative Review Committee will be hearing information regarding their situation. They have the right to speak in person or have a representative of their choosing present during the review. They may also submit additional information and review program records and guidelines pertaining to the matter under grievance.

The Committee’s decision and the Program Director’s review of the decision must be completed within thirty-days (30) of receiving the Administrative Review Request Form. Applicant/enrollees will be notified in writing of the Administrative Review Committee’s decision within three working days of the decision. Additionally this notification will include the applicant/enrollee’s rights to continued review and the policy regarding a request for Formal Review by the State Health Officer.

If the grievance remains unresolved in the applicant/enrollee’s eyes, the applicant/enrollee may file a request for a Formal Review by the State Health Officer.

SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

Effective Date: July 1, 2019 107 Approval Date:

Formal Review In order to be considered by the State Health Officer, a Request for Formal Review must be submitted to the CHIP office within ten (10) days of the final decision of the Administrative Review Committee. This request must be submitted on the Formal Review Request Form.

The applicant/enrollee will be notified in advance of the date and time that the State Health Officer will be hearing information regarding their case. Applicants/enrollees may appear in person or have a representative of their choosing to present information the State Health Officer. They may also submit additional information and review program records and guidelines pertaining to the matter under grievance.

Generally a decision will be issued within thirty-days (30) following receipt of the Request for Formal Review. Applicants/enrollees will be notified of the decision of the State Health Officer within three (3) working days of the decision.

The decision made by the State Health Officer is the final step in the administrative proceedings and will exhaust all administrative remedies.

Expedited Review If the enrollment or eligibility matter under review would worsen health conditions of the applicant/enrollee or jeopardize lives, an expedited CHIP review may be provided. An Expedited Review will be made within seventy-two (72) hours by quickly obtaining and reviewing information so as not to cause unnecessary harm to the applicant/enrollee.

Right for Continued Benefits During Appeals Process When the eligibility decision under review concerns renewal or re-determination of coverage, and the enrollee files a Request for Administrative Review, CHIP staff will ensure that coverage for that enrollee is continued until the review process is completed. The enrollee will be notified in writing of this continuation of coverage and their responsibility regarding any health services costs incurred if the resulting review decision supports termination of coverage. The enrollee will be issued a temporary health plan identification card with a coverage end date equal to the maximum length of time allowed for both the Administrative and Formal Review processes.

SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

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Key for Newly Incorporated Templates The newly incorporated templates are indicated with the following letters after the numerical section throughout the template.

• PC- Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002) • PW- Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009) • TC- Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009) • DC- Dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009) • DS- Supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009) • PA- Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010) • EL- Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010) • LR- Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010)

SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

Effective Date: July 1, 2019 109 Approval Date:

CMS Regional Offices CMSRegion al Offices States Associate Regional Administrator Regional Office Address Region 1- Boston Connecticut Massachuset ts Maine New Hampshire Rhode Island Vermont Richard R. McGreal richard.mcgreal@cms.hhs.gov John F. Kennedy Federal Bldg. Room 2275 Boston, MA 02203-0003 Region 2- New York New York Virgin Islands New Jersey Puerto Rico Michael Melendez michael.melendez@cms.hhs.gov 26 Federal Plaza Room 3811 New York, NY 10278-0063 Region 3- Philadelphia Delaware District of Columbia Maryland Pennsylvania Virginia West Virginia Ted Gallagher ted.gallagher@cms.hhs.gov The Public Ledger Building 150 South Independence Mall West Suite 216 Philadelphia, PA 19106 Region 4- Atlanta Alabama Florida Georgia Kentucky Mississippi North Carolina South Carolina Tennessee Jackie Glaze jackie.glaze@cms.hhs.gov

Atlanta Federal Center 4th Floor 61 Forsyth Street, S.W. Suite 4T20 Atlanta, GA 30303-8909 Region 5- Chicago Illinois Indiana Michigan Minnesota Ohio Wisconsin Verlon Johnson verlon.johnson@cms.hhs.gov 233 North Michigan Avenue, Suite 600 Chicago, IL 60601 Region 6- Dallas Arkansas Louisiana New Mexico Oklahoma Texas Bill Brooks bill.brooks@cms.hhs.gov 1301 Young Street, 8th Floor Dallas, TX 75202 Region 7- Kansas City Iowa Kansas Missouri Nebraska

James G. Scott james.scott1@cms.hhs.gov Richard Bulling Federal Bldg. 601 East 12 Street, Room 235 Kansas City, MO 64106-2808 Region 8- Denver Colorado Montana North Dakota South Dakota Utah Wyoming Richard Allen richard.allen@cms.hhs.gov Federal Office Building, Room 522 1961 Stout Street Denver, CO 80294-3538 Region 9- San Francisco

Arizona California Hawaii Nevada American Samoa Guam Northern Mariana Islands Gloria Nagle gloria.nagle@cms.hhs.gov 90 Seventh Street Suite 5-300 San Francisco Federal Building San Francisco, CA 94103

SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

Effective Date: July 1, 2019 110 Approval Date:

Region 10- Seattle Idaho Washington Alaska Oregon Carol Peverly carol.peverly@cms.hhs.gov 2001 Sixth Avenue MS RX-43 Seattle, WA 98121

SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

Effective Date: July 1, 2019 111 Approval Date:

GLOSSARY Adapted directly fromSec. 2110. DEFINITIONS. CHILD HEALTH ASSISTANCE- For purposes of this title, the term ‘child health assistance’ means payment for part or all of the cost of health benefits coverage for targeted low-income children that includes any of the following (and includes, in the case described in Section 2105(a)(2)(A), payment for part or all of the cost of providing any of the following), as specified under the State plan: 1. Inpatient hospital services. 2. Outpatient hospital services. 3. Physician services. 4. Surgical services. 5. Clinic services (including health center services) and other ambulatory health care services. 6. Prescription drugs and biologicals and the administration of such drugs and biologicals, only if such drugs and biologicals are not furnished for the purpose of causing, or assisting in causing, the death, suicide, euthanasia, or mercy killing of a person. 7. Over-the-counter medications. 8. Laboratory and radiological services. 9. Prenatal care and prepregnancy family planning services and supplies. 10. Inpatient mental health services, other than services described in paragraph (18) but including services furnished in a State-operated mental hospital and including residential or other 24-hour therapeutically planned structured services. 11. Outpatient mental health services, other than services described in paragraph (19) but including services furnished in a State-operated mental hospital and including community-based services. 12. Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices). 13. Disposable medical supplies. 14. Home and community-based health care services and related supportive services (such as home health nursing services, home health aide services, personal care, assistance with activities of daily living, chore services, day care services, respite care services, training for family members, and minor modifications to the home). 15. Nursing care services (such as nurse practitioner services, nurse midwife services, advanced practice nurse services, private duty nursing care, pediatric nurse services, and respiratory care services) in a home, school, or other setting. 16. Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. 17. Dental services. 18. Inpatient substance abuse treatment services and residential substance abuse treatment services. 19. Outpatient substance abuse treatment services. 20. Case management services. 21. Care coordination services. 22. Physical therapy, occupational therapy, and services for individuals with speech, hearing, and

SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

Effective Date: July 1, 2019 112 Approval Date:

language disorders. 23. Hospice care. 24. Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services (whether in a facility, home, school, or other setting) if recognized by State law and only if the service is-- a. prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as defined by State law, b. performed under the general supervision or at the direction of a physician, or c. furnished by a health care facility that is operated by a State or local government or is licensed under State law and operating within the scope of the license. 25. Premiums for private health care insurance coverage. 26. Medical transportation. 27. Enabling services (such as transportation, translation, and outreach services) only if designed to increase the accessibility of primary and preventive health care services for eligible low-income individuals. 28. Any other health care services or items specified by the Secretary and not excluded under this section.

TARGETED LOW-INCOME CHILD DEFINED- For purposes of this title-- 1. IN GENERAL- Subject to paragraph (2), the term ‘targeted low-income child’ means a child-- a. who has been determined eligible by the State for child health assistance under the State plan; b. (i) who is a low-income child, or (ii) is a child whose family income (as determined under the State child health plan) exceeds the Medicaid applicable income level (as defined in paragraph (4)), but does not exceed 50 percentage points above the Medicaid applicable income level; and c. who is not found to be eligible for medical assistance under title XIX or covered under a group health plan or under health insurance coverage (as such terms are defined in Section 2791 of the Public Health Service Act). 2. CHILDREN EXCLUDED- Such term does not include-- a. a child who is a resident of a public institution or a patient in an institution for mental diseases; or b. a child who is a member of a family that is eligible for health benefits coverage under a State health benefits plan on the basis of a family member's employment with a public agency in the State. 3. SPECIAL RULE- A child shall not be considered to be described in paragraph (1)(C) notwithstanding that the child is covered under a health insurance coverage program that has been in operation since before July 1, 1997, and that is offered by a State which receives no Federal funds for the program's operation. 4. MEDICAID APPLICABLE INCOME LEVEL- The term ‘Medicaid applicable income level’ means, with respect to a child, the effective income level (expressed as a percent of the poverty line)

SPA number: AL-19-0017-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

Effective Date: July 1, 2019 113 Approval Date:

that has been specified under the State plan under title XIX (including under a waiver authorized by the Secretary or under Section 1902(r)(2)), as of June 1, 1997, for the child to be eligible for medical assistance under Section 1902(l)(2) for the age of such child. 5. TARGETED LOW-INCOME PREGNANT WOMAN.—The term ‘targeted low-income pregnant woman’ means an individual— (A) during pregnancy and through the end of the month in which the 60-day period (beginning on the last day of her pregnancy) ends; (B) whose family income exceeds 185 percent (or, if higher, the percent applied under subsection (b)(1)(A)) of the poverty line applicable to a family of the size involved, but does not exceed the income eligibility level established under the State child health plan under this title for a targeted low-income child; and(C) who satisfies the requirements of paragraphs (1)(A), (1)(C), (2), and (3) of Section 2110(b) in the same manner as a child applying for child health assistance would have to satisfy such requirements.

ADDITIONAL DEFINITIONS- For purposes of this title: 1. CHILD- The term ‘child’ means an individual under 19 years of age. 2. CREDITABLE HEALTH COVERAGE- The term ‘creditable health coverage’ has the meaning given the term ‘creditable coverage’ under Section 2701(c) of the Public Health Service Act (42 U.S.C. 300gg(c)) and includes coverage that meets the requirements of section 2103 provided to a targeted low-income child under this title or under a waiver approved under section 2105(c)(2)(B) (relating to a direct service waiver). 3. GROUP HEALTH PLAN; HEALTH INSURANCE COVERAGE; ETC- The terms ‘group health plan’, ‘group health insurance coverage’, and ‘health insurance coverage’ have the meanings given such terms in Section 2191 of the Public Health Service Act. 4. LOW-INCOME CHILD - The term ‘low-income child’ means a child whose family income is at or below 200 percent of the poverty line for a family of the size involved. 5. POVERTY LINE DEFINED- The term ‘poverty line’ has the meaning given such term in section 673(2) of the Community Services Block Grant Act (42 U.S.C. 9902(2)), including any revision required by such section. 6. PREEXISTING CONDITION EXCLUSION- The term ‘preexisting condition exclusion’ has the meaning given such term in section 2701(b)(1)(A) of the Public Health Service Act (42 U.S.C. 300gg(b)(1)(A)). 7. STATE CHILD HEALTH PLAN; PLAN- Unless the context otherwise requires, the terms ‘State child health plan’ and ‘plan’ mean a State child health plan approved under Section 2106. 8. UNINSURED CHILD- The term ‘uninsured child’ means a child that does not have creditable health coverage.

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Alabama AL-19-0018-RIM

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop 32-01-1ó Baltirnore, MD 21244-"1850 curs ctNl¡R:l foß MfDrc Rt & Mf,Dtc tD sERvtcfs CENÍFß TON MEDICAID & CHIP SFßVICES Children and Adults Health Prosrams Grouo SEP | 7 Zltg Ms. Teela Sanders Acting Director, Children's Health Insurance Program 201 Monroe Street Montgomery, AL36104 Dear Ms. Sanders Your title XXI Children's Health Insurance Program (CHIP) state plan amendments (SPA) AL- 19-0017-RIM and AL-19-0018-RIM have been approved. These SPAs have an effective date of July 1 ,2019. SPA number AL-19-0017-RIM permits Alabama to implement a health services initiative (HSI) to provide prenatal monitoring, case management and care coordination services to low-income, high-risk pregnant women and their infants in Montgomery, Macon, and Russell counties in order to improve pregnancy outcomes and infant health. Patients will receive services during pregnancy and for up to one year post delivery. Section 2105(aXlXDXii) of the Social Security Act (the Act) and 42 CFR 9457.10 authorize use of title XXI administrative funding for expenditures for HSIs under the plan for improving the health of children, including targeted low-income children and other low-income children. Consistent with section 2105(c)(6)(B) of the Act and 42 CFR 9457.626, title XXI funds used to support an HSI cannot supplant Medicaid or other sources of federal funding. The state shall ensure that the remaining title XXI funding, within the state's l0 percent administrative limit, is sufficient to continue the proper administration of the CHIP program. If such funds become less than sufficient, the state agrees to redirect title XXI funds from the support of this HSI to the administration of the CHIP program. The state shall report annually to CMS the expenditures funded by the HSI for each federal fiscal year. SPA number AL-19-0018-RIM permits Alabama to expand coverage for unborn children residing in Montgomery, Macon, and Russell counties with family incomes up to, and including 312 percent of the federal poverty level (FPL) whose pregnant mothers are not otherwise eligible for Medicaid. Coverage will include pregnancy-related services including prenatal care for children from conception to birth. A copy of the approved CS9 is attached and is incorporated in section 4.1.9 of the current Alabama CHIP state plan. Your title XXI project officer is Ms. Cassie Lagorio. She is available to answer questions concerning this amendment and other CHlP-related issues. Ms. Lagorio's contact information is as follows:

Page2 - Ms. Teela Sanders Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services, Mail Stop S2-01-16 7500 Security Boulevard Baltimore, MD 21244-1 850 Telephone: (410) 786-4554 E-mail: Cassandra.Lagoño@cms.hhs.gov Offrcial communications regarding program matters should be sent simultaneously to Ms. Lagorio and to Ms. Shantrina Roberts, Deputy Director, Division of Medicaid Field Operations South. Ms. Robertsos address is: Centers for Medicare & Medicaid Services Division of Medicaid Field Operations South 6l Forsyth Street, SV/, Suite 4T20 Atlanta, GA 30303-8909 V/e look forward to continuing to work with you and your staff. Sincerely, Director cc: Ms. Shantina Roberts, Deputy Director, Division of Medicaid Field Operations South /Signed by Anne Marie Costello/

Page 1 of 1 CHIP Eligibility State Name: Alabama OMB Control Number: 0938‐1148 Transmittal Number: AL - 19 - 0001 Separate Child Health Insurance Program Eligibility - Coverage From Conception to Birth CS9 42 CFR 457.10 Coverage From Conception to Birth - Coverage from conception to birth when the mother is not eligible for Medicaid. ■ The CHIP Agency operates this covered group in accordance with the following provisions: ✔ Age Standard From conception through birth. Does the state have an additional age definition or other age-related conditions? No Income Standards Income standards are applied statewide. No Select a method of geographic variation: Standard varies by county or city. Standard varies in some other geographic way. In each row of the table, you may enter one county if the county has an income standard that is unique to that county. If multiple counties share the same income standard, enter all the counties first, then enter the income standard that applies to those counties. Add Counties From zero up to (% FPL) Remove Add Montgomery, Macon, and Russell Counties 312 Remove Do you have any cities within your state which have their own separate income standards? No Exempted from requirement of providing or applying for a Social Security Number. ■ Exempted from requirement of verifying citizenship status. ■ 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. V.20181119 SPA number: AL-19-0018-RIM Approval Date: September 17, 2019 Effective Date: July 1, 2019

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Alabama AL-20-0019

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Children and Adults Health Programs Group

Scott Harris, MD, MPH State Health Officer Alabama Department of Public Health Post Office Box 303017 Montgomery, AL 36130-3017

Dear Dr. Harris:

Your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) AL- 20-0019-CEN, submitted on February 26, 2020, with additional information submitted on June 24, 2021, has been approved. This amendment has an effective date of July 1, 2020.

Through this SPA, Alabama amends its previously approved CS15 SPA to account for reasonably predictable increases and decreases in income for individuals with income that is likely to fluctuate. The methodology used to account for and verify reasonably predictable changes in income is identical to the methodology used in the state’s Medicaid program, as approved under Medicaid SPA AL-20-0012 on May 28, 2021. A copy of the approved CS15 state plan page is attached and should be incorporated into the state’s approved CHIP state plan. This page supersedes the previous CS15 that was approved on April 21, 2014.

Your title XXI project officer is Jack Mirabella. They are available to answer questions concerning this amendment and other CHIP-related issues. Their contact information is as follows: Centers for Medicare & Medicaid Services

Center for Medicaid and CHIP Services

7500 Security Boulevard, Mail Stop: S2-01-16

Baltimore, MD 21244-1850

Telephone: (410) 786-2424

E-mail: jack.mirabella@cms.hhs.gov

If you have any questions, please contact Meg Barry, Director, Division of State Coverage Programs, at (410) 786-1536. We look forward to continuing to work with you and your staff.

Sincerely,

Amy Lutzky

Deputy Director /Signed by Amy Lutzky/

Page 1 of 2 CHIP Eligibility State Name: Alabama OMB Control Number: 0938‐1148 Transmittal Number: AL - 20 - 0019 Separate Child Health Insurance Program MAGI-Based Income Methodologies CS15 2102(b)(1)(B)(v) of the SSA and 42 CFR 457.315 The CHIP Agency will apply Modified Adjusted Gross Income methodologies for all separate CHIP covered groups, as described below, and consistent with 42 CFR 457.315 and 435.603(b) through (i). ✔ In the case of determining ongoing eligibility for enrollees determined eligible for CHIP on or before December 31, 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 the state covers pregnant women, in 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: The pregnant woman is counted just as herself. The pregnant woman is counted just as herself, plus one. 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: Current monthly household income and family size. Projected annual household income for the remaining months of the current calendar year and family size. In determining current monthly or projected annual household income, the state will use reasonable methods to: Include a prorated portion of the 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 457.315 and 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. Household income includes actually available cash support, exceeding nominal amounts, provided by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. No The CHIP Agency certifies that it has submitted and received approval for the conversion for all separate CHIP covered group income standards to MAGI-equivalent standards. ✔ An attachment is submitted.

Page 2 of 2 CHIP 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 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. V.20160722

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Alabama AL-20-0021-BH

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-01-16 Baltimore, Maryland 21244-1850 Children and Adults Health Programs Group November 10, 2021 Ms. Teela Sanders Director, Children's Health Insurance Program 201 Monroe Street Montgomery, AL 36104 Dear Ms. Sanders: Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA) number AL-20-0021-BH, submitted on July 30, 2020, with additional information received on November 3, 2021 has been approved. Through this SPA, Alabama has demonstrated compliance with section 5022 of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act. This SPA has an effective date of October 1, 2019. Section 5022 of the SUPPORT Act added Section 2103(c)(5) to the Social Security Act (the Act) and requires child health and pregnancy related assistance to include coverage of services necessary to prevent, diagnose, and treat a broad range of behavioral health symptoms and disorders. Additionally, Section 2103(c)(5)(B) of the Act requires that these behavioral health services be delivered in a culturally and linguistically appropriate manner. Alabama demonstrated compliance by providing the necessary assurances and benefit descriptions that the state covers a range of behavioral health services in a culturally and linguistically appropriate manner. Your Project Officer is Joshua Bougie. He is available to answer your questions concerning this amendment and other CHIP-related matters. His contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Telephone: (410) 786-8117 E-mail: joshua.bougie@cms.hhs.gov

Page 2 — Ms. Teela Sanders

If you have additional questions, please contact Emily King, Deputy Director, Division of State Coverage Programs, at (443) 478-6811. We look forward to continuing to work with you and your staff.

Sincerely,

/Signed by Amy Lutzky/

Amy Lutzky Deputy Director

Effective Date: July 1, 2021 1 Approval Date: July 2, 2021

TEMPLATE FOR CHILD HEALTH PACWLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT CHILDREN’S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory: Alabama (Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR 457.40(b)) Scott Harris, State Health Officer, Alabama Department of Public Health (Signature of Governor, or designee, of State/Territory, Date Signed)

submits the following Child Health Plan for the Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following State officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: Teela Sanders

Position/Title: CHIP Director Name: Shaundra B. Morris

Position/Title: Director, ADPH

Financial Services

Name:

Position/Title:

*Disclosure. 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 (CMS-10398 #34). The time required to complete this information collection is estimated to average 80 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 any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Effective Date: July 1, 2021 2 Approval Date: July 2, 2021

Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 105-33amended the Social Security Act (the Act) by adding a new title XXI, the Children’s Health Insurance Program (CHIP). In February 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) renewed the program. The Patient Protection and Affordable Care Act of 2010 further modified the program.

This template outlines the information that must be included in the state plans and the state plan amendments (SPAs). It reflects the regulatory requirements at 42 CFR Part 457as well as the previously approved SPA templates that accompanied guidance issued to States through State Health Official (SHO) letters. Where applicable, we indicate the SHO number and the date it was issued for your reference. The CHIP SPA template includes the following changes: • Combined the instruction document with the CHIP SPA template to have a single document. Any modifications to previous instructions are for clarification only and do not reflect new policy guidance. • Incorporated the previously issued guidance and templates (see the Key following the template for information on the newly added templates), including: • Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002) • Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009) • Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009) • Dental and supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009) • Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010) • Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010) • Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010) • Moved sections 2.2 and 2.3 into section 5 to eliminate redundancies between sections 2 and 5. • Removed crowd-out language that had been added by the August 17 letter that later was repealed. The Centers for Medicare & Medicaid Services (CMS) is developing regulations to implement the CHIPRA requirements. When final regulations are published in the Federal Register, this template will be modified to reflect those rules and States will be required to submit SPAs illustrating compliance with the new regulations. States are not required to resubmit their State plans based on the updated template. However, States must use the updated template when submitting a State Plan Amendment.

Federal Requirements for Submission and Review of a Proposed SPA. (42 CFR Part 457 Subpart A) In order to be eligible for payment under this statute, each State must submit a Title XXI plan for approval by the Secretary that details how the State intends to use the funds and fulfill other requirements under the law and regulations at 42 CFR Part 457. ASPA is approved in 90 days unless the Secretary notifies the State in writing that the plan is disapproved or that specified additional information is needed. Unlike Medicaid SPAs, there is only one 90-day review period, or clock for CHIP Spas, that may be stopped by a request for additional information and restarted after a complete

Effective Date: July 1, 2021 3 Approval Date: July 2, 2021

response is received. More information on the SPA review process is found at 42 CFR 457 Subpart A.

When submitting a State plan amendment, states should redline the changes that are being made to the existing State plan and provide a “clean” copy including changes that are being made to the existing state plan.

The template includes the following sections: 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements- This section should describe how the State has designed their program. It also is the place in the template that a State updates to insert a short description and the proposed effective date of the SPA, and the proposed implementation date(s) if different from the effective date. (Section 2101) ;(42 CFR 457.70) 2. General Background and Description of State Approach to Child Health Coverage and Coordination- This section should provide general information related to the special characteristics of each state’s program. The information should include the extent and manner to which children in the State currently have creditable health coverage, current State efforts to provide or obtain creditable health coverage for uninsured children and how the plan is designed to be coordinated with current health insurance, public health efforts, or other enrollment initiatives. This information provides a health insurance baseline in terms of the status of the children in a given State and the State programs currently in place. (Section 2103); (42 CFR 457.410(A)) 3. Methods of Delivery and Utilization Controls- This section requires a description that must include both proposed methods of delivery and proposed utilization control systems. This section should fully describe the delivery system of the Title XXI program including the proposed contracting standards, the proposed delivery systems and the plans for enrolling providers. (Section 2103); (42 CFR 457.410(A)) 4. Eligibility Standards and Methodology- The plan must include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. This section includes a list of potential eligibility standards the State can check off and provide a short description of how those standards will be applied. All eligibility standards must be consistent with the provisions of Title XXI and may not discriminate on the basis of diagnosis. In addition, if the standards vary within the state, the State should describe how they will be applied and under what circumstances they will be applied. In addition, this section provides information on income eligibility for Medicaid expansion programs (which are exempt from Section 4 of the State plan template) if applicable. (Section 2102(b)); (42 CFR 457.305 and 457.320) 5. Outreach- This section is designed for the State to fully explain its outreach activities. Outreach is defined in law as outreach to families of children likely to be eligible for child health assistance under the plan or under other public or private health coverage programs. The purpose is to inform these families of the availability of, and to assist them in enrolling their children in, such a program. (Section 2102(c)(1)); (42CFR 457.90) 6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of

Effective Date: July 1, 2021 4 Approval Date: July 2, 2021

health insurance coverage in a State plan, the child health assistance provided must consist of any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage; benchmark-equivalent coverage; existing comprehensive state-based coverage; and/or Secretary- approved coverage). In this section States identify the scope of coverage and benefits offered under the plan including the categories under which that coverage is offered. The amount, scope, and duration of each offered service should be fully explained, as well as any corresponding limitations or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for State’s use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The section lists some of the methods which states may consider using. In addition to methods, there are a variety of tools available for State adaptation and use with this program. The section lists some of these tools. States also have the option to choose who will conduct these activities. As an alternative to using staff of the State agency administering the program, states have the option to contract out with other organizations for this quality of care function. (Section 2107); (42 CFR 457.495) 8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost-sharing requirements provide protection for lower income children, ban cost sharing for preventive services, address the limitations on premiums and cost-sharing and address the treatment of pre- existing medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E) 9. Strategic Objectives and Performance Goals and Plan Administration- The section addresses the strategic objectives, the performance goals, and the performance measures the State has established for providing child health assistance to targeted low income children under the plan for maximizing health benefits coverage for other low income children and children generally in the state. (Section 2107); (42 CFR 457.710) 10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess the operation of the Children’s Health Insurance Program plan and submit to the Secretary an annual report which includes the progress made in reducing the number of uninsured low income children. The report is due by January 1, following the end of the Federal fiscal year and should cover that Federal Fiscal Year. In this section, states are asked to assure that they will comply with these requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750) 11. Program Integrity- In this section, the State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Sections 2101(a) and 2107(e); (42 CFR 457, subpart I) 12. Applicant and Enrollee Protections- This section addresses the review process for eligibility and enrollment matters, health services matters (i.e., grievances), and for states that use premium assistance a description of how it will assure that applicants and enrollees are given the opportunity at initial enrollment and at each redetermination of eligibility to obtain health

Effective Date: July 1, 2021 5 Approval Date: July 2, 2021

benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)

Program Options. As mentioned above, the law allows States to expand coverage for children through a separate child health insurance program, through a Medicaid expansion program, or through a combination of these programs. These options are described further below: • Option to Create a Separate Program- States may elect to establish a separate child health program that are in compliance with title XXI and applicable rules. These states must establish enrollment systems that are coordinated with Medicaid and other sources of health coverage for children and also must screen children during the application process to determine if they are eligible for Medicaid and, if they are, enroll these children promptly in Medicaid. • Option to Expand Medicaid- States may elect to expand coverage through Medicaid. This option for states would be available for children who do not qualify for Medicaid under State rules in effect as of March 31, 1997. Under this option, current Medicaid rules would apply.

Medicaid Expansion- CHIP SPA Requirements In order to expedite the SPA process, states choosing to expand coverage only through an expansion of Medicaid eligibility would be required to complete sections: • 1 (General Description) • 2 (General Background) They will also be required to complete the appropriate program sections, including: • 4 (Eligibility Standards and Methodology) • 5 (Outreach) • 9 (Strategic Objectives and Performance Goals and Plan Administration including the budget) • 10 (Annual Reports and Evaluations).

Medicaid Expansion- Medicaid SPA Requirements States expanding through Medicaid-only will also be required to submit a Medicaid State Plan Amendment to modify their Title XIX State plans. These states may complete the first check-off and indicate that the description of the requirements for these sections are incorporated by reference through their State Medicaid plans for sections: • 3 (Methods of Delivery and Utilization Controls) • 4 (Eligibility Standards and Methodology) • 6 (Coverage Requirements for Children’s Health Insurance) • 7 (Quality and Appropriateness of Care) • 8 (Cost Sharing and Payment) • 11 (Program Integrity) • 12 (Applicant and Enrollee Protections)

Effective Date: July 1, 2021 6 Approval Date: July 2, 2021

• Combination of Options-CHIP allows states to elect to use a combination of the Medicaid program and a separate child health program to increase health coverage for children. For example, a State may cover optional targeted-low income children in families with incomes of up to 133 percent of poverty through Medicaid and a targeted group of children above that level through a separate child health program. For the children the State chooses to cover under an expansion of Medicaid, the description provided under “Option to Expand Medicaid” would apply. Similarly, for children the State chooses to cover under a separate program, the provisions outlined above in “Option to Create a Separate Program” would apply. States wishing to use a combination of approaches will be required to complete the Title XXI State plan and the necessary State plan amendment under Title XIX.

Proposed State plan amendments should be submitted electronically and one signed hard copy to the Centers for Medicare & Medicaid Services at the following address: Name of Project Officer Centers for Medicare & Medicaid Services 7500 Security Blvd Baltimore, Maryland 21244 Attn: Children and Adults Health Programs Group Center for Medicaid and CHIP Services Mail Stop - S2-01-16

Effective Date: July 1, 2021 7 Approval Date: July 2, 2021

Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements

1.1. The state will use funds provided under Title XXI primarily for (Check appropriate box) (Section 2101) (a)(1)); (42 CFR 457.70):

Guidance: Check below if child health assistance shall be provided primarily through the development of a separate program that meets the requirements of Section 2101, which details coverage requirements and the other applicable requirements of Title XXI.

1.1.1. * Obtaining coverage that meets the requirements for a separate child health program (Sections 2101(a)(1) and 2103); OR

Guidance: Check below if child health assistance shall be provided primarily through providing expanded eligibility under the State’s Medicaid program (Title XIX). Note that if this is selected the State must also submit a corresponding Medicaid SPA to CMS for review and approval. 1.1.2. Providing expanded benefits under the State’s Medicaid plan (Title XIX) (Section 2101(a)(2)); OR

Guidance: Check below if child health assistance shall be provided through a combination of both 1.1.1. and 1.1.2. (Coverage that meets the requirements of Title XXI, in conjunction with an expansion in the State’s Medicaid program). Note that if this is selected the state must also submit a corresponding Medicaid state plan amendment to CMS for review and approval. 1.1.3.

A combination of both above. (Section 2101(a)(2))

* Until October 1, 2002, Alabama’s CHIP was a combination program. With the mandated gradual increase of Medicaid coverage at higher income levels for children born after September 30, 1983, the Medicaid expansion portion of CHIP was subsumed, on October 1, 2002, by the Alabama Medicaid SOBRA Program for Pregnant Women and Children.

1.1-DS

The State will provide dental-only supplemental coverage. Only States operating a separate CHIP program are eligible for this option. States choosing this option must also complete sections 4.1-DS, 4.2-DS, 6.2-DS, 8.2-DS, and 9.10 of this SPA template. (Section 2110(b)(5))

1.2.

Check to provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

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Alabama has not and will not claim expenditures for child health assistance prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS.

1.3.

Check to provide an assurance that the State complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

Assurances are on file with DHHS. The Alabama Department of Public Health continues to assure that compliance with all applicable civil rights requirements.

Guidance: The effective date as specified below is defined as the date on which the State begins to incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date is defined as the date the State begins to provide services; or, the date on which the State puts into practice the new policy described in the State plan or amendment. For example, in a State that has increased eligibility, this is the date on which the State begins to provide coverage to enrollees (and not the date the State begins outreach or accepting applications).

1.4. Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA(42 CFR 457.65). A SPA may only have one effective date, but provisions within the SPA may have different implementation dates that must be after the effective date.

Original Plan Effective Date: February 1, 1998 Amendment 1 – Establishment of ALL Kids

Effective Date: February 1, 1998 Implementation Date: October 1, 1998 Amendment 2 – Establishment of ALL Kids PLUS

Effective/Implementation Date: October 1, 1999 Amendment 3 – Disregards

Effective/Implementation Date: June 1, 2001 Amendment 4 - Compliance

Effective/Implementation Date: August 24, 2001 Amendment 5 – Waiting List, Cost Sharing, Benefit Changes Effective/Implementation Date: October 1, 2003 Amendment 6 – Discontinuance of the Waiting List and other Clean-Up changes

Effective Date: July 1, 2021 9 Approval Date: July 2, 2021

Effective/Implementation Date: November 23, 2004 Amendment 7 – Raise the upper income eligibility limit to 300% of FPL and

other minor changes Effective/Implementation Date: October 1, 2009 Amendment 8 – Include a private foundation grant as an additional source of state funding

Effective/Implementation Date: October 27, 2009 Amendment 9 – Establishment of a Prospective Payment System for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)

Effective/Implementation Date: October 1, 2009; Addendum on Dental Benefits Under Title XXI: Effective/Implementation Date: October 1, 1998 Amendment 10 – Eligibility for children of employees of a public agency (state employees and public education employees) Effective/Implementation Date: January 1, 2011 Amendment 11 – Provisions for Implementing Temporary Adjustments to

Enrollment Determination and/or Redetermination Policies and Cost Sharing Requirements for Applicants/Renewals living in and/or working in FEMA or Governor declared disaster areas at the time of a disaster event. In the event of a disaster, the State will notify CMS of the intent to provide temporary adjustments to its enrollment and/or redetermination policies, the effective dates of such adjustments and the counties/areas impacted by the disaster. Effective/Implementation Date: April 15, 2011 Amendment 12 – Increase premiums, increase co-pays and revise the methodology for determining annual aggregate cost-sharing Effective/Implementation Date: May 1, 2012 Amendment 13 – Establishment of copayments for therapy services (physical, occupational, and speech), vision services and chiropractic services; and cleanup changes

Effective/Implementation Date: August 1, 2013 Amendment 14 – Alignment of ALL Kids fee groups with provisions of the Affordable Care Act (ACA) and other editorial changes to comply with previously approved ACA SPAs.

Effective/Implementation Date: January 1, 2014 Amendment 15 - AL-16-0015-MEXP – CHIP Medicaid expansion to cover Medicaid enrollees ages 14 years to 19 years with incomes above 18% FPL through 141% FPL.

Effective Date: October 1, 2015

Implementation Date: January 1, 2016 Amendment 16 – AL-18-0016-PAR - Attestation and documentation of Mental

Effective Date: July 1, 2021 10 Approval Date: July 2, 2021

Health Parity and Addiction Equity.

Submission Date: July 10, 2018

Proposed Effective Date: October 1, 2017*

Implementation Date: October 1, 2017*

*Note: Benefits were adjusted in October 2010 to be compliant with mental health parity; this amendment did not require any benefit changes Amendment 17 – AL-19-0017-RIM

- Reducing Infant Mortality (RIM) Health Service Initiative

Submission Date: July 17, 2019

Proposed Effective Date: July 1, 2019

Implementation Date: July 1, 2019 Amendment 18 – AL-19-0018-RIM

CS9 Eligibility – Coverage From Conception to Birth

Submission Date: July 17, 2019 Proposed Effective Date: July 1, 2019 Implementation Date: July 1, 2019 Amendment 19 – AL-20-0019-CEN CS15 MAGI-Based Income Methodologies – Temporary Income Submission Date: February 26, 2020 Proposed Effective Date: July 1, 2020 Implementation Date July 1, 2020 Amendment 20 – AL-20-0020-COVI Allowing for Temporary Waiving of cost sharing requirements for enrollees who reside and/or work in a State or Federally declared disaster area. Submission Date: July 29, 2020 Implementation Date: March 1, 2020 Effective Date: March 1, 2020

Amendment 21 - AL-20-0021-BH

Documentation of AL CHIP compliance with the SUPPORT Act.

Submission Date: July 29, 2020 Implementation Date: October 24, 2018

Amendment 22 – AL-21-0022-PP Postpartum coverage Health Services Initiative for ALL Babies Submission Date: May 13, 2021 Proposed Effective Date: July 1, 2021

Implementation Date: July 1, 2021

Effective Date: July 1, 2021 11 Approval Date: July 2, 2021

Transmittal Number SPA Group PDF # Description Superseded Plan Section(s) AL-14-0016 (Original: AL-14-0016 Effective/Implementati on Date: January 1, 2014)

AL-20-0019-CEN (affects only CS15) Effective Implementation Date: July 1, 2020 MAGI Eligibility & Methods CS7

CS10

CS15 Eligibility – Targeted Low Income Children

Children With Access to Public Employee Coverage

MAGI-Based Income Methodologies Supersedes the current sections Geographic Area 4.1.1; Age 4.1.2; and Income 4.1.3 Section 4.4.1: Supersedes only the information on dependents of public employees in this section; supporting documentation should be incorporated as an appendix to the current state plan

Incorporate within a separate subsection under section 4.3

AL-19-0018-RIM Effective Date: July 1, 2019 Implementation Date: July 1, 2019

CS9 Coverage from Conception to Birth