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

Effective Date:

Approval Date: 1 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.

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

Effective Date:

Approval Date: 2 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: ________________Arkansas____________________________________ (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))

________________________________________________________________________ Roy Jeffus, Director, DMS (Signature of Governor, or designee, of State, 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: Kurt Knickrehm Position/Title: Director, Department of Human Services (DHS) Name: Roy Jeffus Position/Title: DHS Division of Medical Services (DMS) Name:

Position/Title:

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 (or minutes) 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, P.O. Box 26684, Baltimore, Maryland 21207 and to the Office of the Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.

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

Effective Date:

Approval Date: 3 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

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.

A. Background

Arkansas has aggressively pursued health care for children by covering optional benefits and categories that benefit children and developing Medicaid 1115 demonstrations. For example, Arkansas has elected to provide the full range of EPSDT services to children without requiring the EPSDT screen. Also Arkansas was one of the first states in the nation to cover the TEFRA-134 children, authorized by the Tax Equity and Fiscal Responsibility Act of 1982.

Effective 1-1-03, the State began covering TEFRA children in a TEFRA- like 1115 demonstration in which the parents pay a premium based on a sliding scale; some parents are not required to pay a premium. The TEFRA-like demonstration provides for the care of a child in its home, if he/she would qualify for Medicaid as a resident in a Title XIX institution, e.g., a nursing facility or an Intermediate Care Facility for the Mentally Retarded, etc. Parental income and resources are not counted in the child’s eligibility determination; however parental income is counted in the premium amount calculation. The eligibility income limit for this demonstration is three times the SSI limit. The TEFRA-like 1115 demonstration makes Medicaid available to a large segment of the state’s chronically ill children.

In its quest to provide health care for children, the State also opted to cover uninsured children through a Medicaid 1115 demonstration, ARKids First. This demonstration is discussed in item B, below.

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

Effective Date:

Approval Date: 4 SCHIP Phase I, a Medicaid expansion, was approved August 6, 1998 and implemented October 1, 1998. This was a small SCHIP Medicaid expansion in which the last of the eligible children aged-out of the program September 30, 2002. SCHIP Phase II is a separate SCHIP program that was approved February 16, 2001 but not implemented. Phase III supersedes Phase II. Phase III will cover some of the children in the State’s Medicaid 1115 demonstration, ARKids B, as an SCHIP Medicaid expansion and cover unborn children as a separate child health program.

B. ARKids First Background and Development

In 1997, Arkansas’ Governor, the Arkansas State legislature, the President and Congress were all addressing the issue of health care for vast numbers of uninsured children. Governor Mike Huckabee supported enabling state legislation and an appropriations bill in the 1997 legislative session that created and funded ARKids First, a Medicaid 1115 demonstration. The Arkansas Legislature passed both bills and Governor Mike Huckabee signed both bills into law by on March 10, 1997 (see Attachments A and B). Effective August 4, 2000, the 1115 demonstration was renamed ARKids B.

Ray Hanley, then Director, Division of Medical Services (DMS), formed and chaired an ARKids First work group, which was composed of individuals from the following: the Governor’s Office (the Department of Human Services liaison), Arkansas Children’s Hospital, Arkansas Department of Health, Catholic Social Services, Arkansas Advocates for Children and Families, Easter Seals, Communities in School of Arkansas, Arkansas Chapter for American Academy of Pediatrics, Electronic Data Systems (Arkansas Medicaid’s fiscal agent), and various individuals in the Department of Human Services (DHS), including Tom Dalton, then Department Director. The first meeting was held February 7, 1997, one day after President Clinton announced his FFY98 budget package which included a proposal to expand health insurance access for poor children in families that earn too much for Medicaid but not enough to afford private health insurance. Additional ARKids First meetings were held as needed. Most of the discussion and concerns involved eligibility factors and the benefit package.

The Arkansas legislation, though not as detailed, mirrors the SCHIP legislation in its purpose, i.e., to provide health insurance coverage for uninsured children under 19 whose family income is at or below 200% of the poverty level. The ARKids First program was designed as an SCHIP program, but used the Medicaid 1115 demonstration process for

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

Effective Date:

Approval Date: 5 implementation since the SCHIP legislation had not been passed at the time Arkansas’ program was under development. The ARKids First Medicaid 1115 demonstration was approved by CMS on August 19, 1997 and implemented on September 1, 1997; only days after the SCHIP legislation was signed by the President.

The State developed the ARKids First Program with the thought that it would be able to roll the ARKids First Medicaid 1115 demonstration into an SCHIP program. However, the State recognizes that as the ARKids First (now ARKids B) Medicaid demonstration and the SCHIP legislation were developing, they didn’t make completely parallel steps. Therefore, ARKids B enrollees, who do not meet the definition of an SCHIP targeted low-income child, will continue to receive their health care services through Title XIX federal funding. Children in ARKids B who meet the definition of an SCHIP targeted low-income child may receive their services through either Title XIX or Title XXI federal funding, at the discretion of the State. All of the ARKids B children will remain in the Medicaid 1115 demonstration regardless of the funding source. The children who do not meet the definition of an SCHIP targeted low-income child are the children of state employees and the children who meet the eligibility requirements for regular Medicaid.

The ARKids First application form and the promotional materials identify the program as ARKids First. (Effective August 4, 2000, ARKids First became an umbrella for ARKids A, regular children’s Medicaid, and ARKids B, the 1115 demonstration.) Applications may be made by mail, and a toll free number is available to clients. Applications in English or Spanish may be printed from the ARKids First web site at www.arkidsfirst.com.

The ARKids B benefit package and copayments are comparable to insurance offered to state employees. The State elected a copayment as the only cost sharing requirement, because it is the most equitable form of cost sharing. The State did not want to assess an enrollment fee nor monthly premiums because it wanted the family’s cost sharing responsibility to be related solely to usage. The State will keep the current copayment structure in place for ARKids B enrollees without regard to the funding source (XIX or XXI).

The application form, the benefit package, and the identification card will be the same for all ARKids B enrollees without regard to the funding source.

It is possible for Arkansas to pursue this SCHIP Medicaid expansion for

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

Effective Date:

Approval Date: 6 the ARKids B 1115 demonstration because section 2110(b)(II) of the SCHIP legislation and CMS Q&A 14(a) provide that states, which expanded Medicaid through an 1115 demonstration after June 1, 1997 may claim the enhanced match rate for such children. The ARKids B program was implemented on September 1, 1997. C. Overview of ARKids B 1115 Demonstration (Medicaid and SCHIP) The Arkansas Department of Human Services administers regular Medicaid and the ARKids B demonstration, which will be funded by Titles XIX and XXI.

The essential elements of the ARKids B program, without regard to the funding source, are as follows:

• Covers children under 19.

• Family income must be at or below 200% of the poverty level.

• There is no asset test.

• Children must have been uninsured for the preceding 6 months or insurance was lost through “no-fault” such as parent is no longer employed and health insurance was lost.

• The benefit package is the Secretary approved Medicaid 1115 demonstration benefit package granted for ARKids B. The benefit package will be the same for all ARKids B enrollees without regard to the funding source.

• Cost-sharing is required for services that are not categorized as well-health.

Notes: Generally, in this document, the 1115 demonstration is referenced as ARKids B, even though it was known as ARKids First until August 4, 2000.

The Division of Medical Services (DMS) and the Division of County Operations (DCO) are divisions of the Department of Human Services. DMS is responsible for the administration of the Medicaid and SCHIP programs except for eligibility, which is the responsibility of DCO.

The SCHIP definition of a targeted low-income child excludes children

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

Effective Date:

Approval Date: 7 of state employees and children who meet the eligibility criteria for regular Medicaid, however these children are covered in the ARKids B program. The State will not use Title XXI funding for these children. D. Overview of Unborn Child

The Arkansas Department of Human Services administers the SCHIP unborn child program.

The essential elements of the program are:

• Medical verification of the pregnancy is required.

• Applicant must have no other insurance that covers the pregnancy.

• Net income must be at or below 200% FPL.

• The resource limit is the same as the resource limit for the SOBRA pregnant women category under Medicaid.

• The benefits will be the same as the SOBRA pregnant women category under Medicaid.

1.2

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))

The State assures 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.

1.3

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)

The state assures that it 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

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

Effective Date:

Approval Date: 8 part 80, part 84, and part 91, and 28 CFR part 35.

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):

Effective date: Medicaid expansion – Phase I: 10-1-98 Separate State SCHIP – Phase II: Not Implemented Medicaid expansion (ARKids B) - Phase III: 1-1-01 Unborn Child Coverage – Phase III: 7-1-03.

Implementation date: Medicaid expansion – Phase I: 10-1-98 Separate State SCHIP – Phase II: Not Implemented Medicaid expansion (ARKids B) - Phase III: The State implemented retroactively to 1-1-01. Unborn Child Coverage – Phase III: The target implementation date is July 1, 2003.

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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 9 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)) A. Children Covered by Department of Human Services (DHS) Programs As of the October/December 2003 quarter, there were 274,062 children enrolled in regular Medicaid. The racial break out is as follows: 154,695 (56.5%) white; 90,294 (33%) black; 16,205 (6%) Hispanic; 596 (.3%) Native American; 946 (.4%) Asian; and 11,326 (4.2%) other and unknown. The poverty level breakout shows that 91.7% were below poverty while only 8.3% were above the poverty level.

There were 64,065 children enrolled in the ARKids B category as of the October/December 2003 quarter. The racial breakout is as follows: 45,818 (71.5%) white; 14,121 (22%) black; 3002 (4.7%) Hispanic; 131 (.2%) Native American; and 772 (1.2%) other and unknown. The poverty level breakout shows that 11.1% are at or below the poverty level and 88.9% are above the poverty level.

Please see Attachments C and D for the racial breakout by age for regular Medicaid categories and for ARKids B, respectively.

Attachments E and F show eligibles by age by county for regular Medicaid categories and for ARKids B, respectively, for the October-December 2003 quarter.

Attachments G and H show a breakout of expenditures by State Category of Service for regular Medicaid categories and for ARKids B, respectively for the October-December 2003 quarter. B. SCHIP

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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 10 Phase I, was implemented 10-1-98. Phase I was a Medicaid expansion, which added children under 19 born after 9-30-82 and before 10-1-83. The last child aged out of the Medicaid expansion on 9-30-02.

Phase II, a separate SCHIP, was approved 2-16-01, but was not implemented. The separate state SCHIP would have covered a portion of the ARKids B children.

Phase III, is a combination program: The Medicaid expansion is a subset of the ARKids B Medicaid 1115 demonstration (implemented retroactively to 1-1- 01); the separate child health program covers the unborn child. Phase III supersedes Phase II. C. Discussion of Creditable Health Coverage

Arkansas has located two studies relevant to this issue. Information from each study is listed below:

1. According to data from the Casey Foundation, based on their annual surveys (1992 through 1996 were combined in order to have a valid sample), Arkansas had 352,800 children (under 18) who were at or below 200% of the Poverty Level. Their data further shows that 112,700, or 32%, were uninsured children. We think the number of uninsured is high because we have been adding one year of eligible children each year to the Pregnant Women, Infants and Children category during the course of the five survey years used in their estimates.

2. According to the Southern Institute on Children and Families “Uninsured Children in the South-Second Report” dated November 1996, there are 99,752 uninsured children, under 18, in Arkansas who are at or below 200% of the Poverty Level.

The source of the estimates of uninsured children is the Current Population Survey. Uninsured means the lack of any health insurance, including Medicaid, for an entire year. The data were prepared by the Urban Institute using data specifications submitted by the Southern Institute on Children and Families for 1989 and 1993.

D. Public-Private Partnerships

The State does not have a public-private partnership. The State does not have a BC/BS Caring Program for Children.

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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 11 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):

Medicaid

The State has been extremely active in its effort to identify and enroll uncovered children who are eligible to participate in the Arkansas Medicaid Program.

The State has cooperative agreements with 35 hospitals, clinics, and organizations throughout the state to place out-stationed DHS Medicaid eligibility workers in their facilities. This has simplified the application process and has encouraged individuals and families to apply for Medicaid when otherwise they might not have done so.

DHS also has an agreement with the Federally Qualified Health Centers for 19 staff who cover their 36 sites. These FQHC staff members assist in the application process.

Medicaid outreach is also furthered by a contract between the Arkansas Department of Human Services and the Arkansas Department of Health (ADH) for ConnectCare, the Arkansas Primary Care Case Management program. ConnectCare provides outreach through statewide television and radio advertisements to inform both current eligibles and potential eligibles about the merits of primary medical coverage through Arkansas Medicaid.

DHS also has an agreement with ADH to establish Presumptive Eligibility for Pregnant Women in the SOBRA category. Arkansas was one of the first states in the nation to employ the Presumptive Eligibility process for this group. State-only Child Health Insurance

The State does not have any State-only child health insurance programs.

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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 12 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:

The State does not have a public-private partnership. The State does not have a BC/BS Caring Program for Children.

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))

Children currently covered in the 1115 demonstration, ARKids B, will be covered for health coverage funded through Title XIX or Title XXI. Targeted to Uninsured Children The ARKids B program is designed to provide health insurance coverage for uninsured children under age 19. Uninsured is defined as not having group or employer sponsored primary comprehensive health insurance within the previous 6 months, unless such insurance was lost through no-fault. An example of no-fault would be if the child(ren) had had health insurance through a parent’s employment and the parent is no longer employed. Also children who have inaccessible health insurance are considered to be uninsured. For example, a child has inaccessible health insurance if the child has an out of state, non-custodial parent with HMO insurance for his/her child(ren) but the HMO network does not contain medical providers where the child resides. Coordination With Medicaid On August 4, 2000 Arkansas began using the ARKids First name as an umbrella for the 1115 demonstration and certain Medicaid categories. ARKids First is divided into ARKids A, regular Medicaid, and ARKids B, the 1115 demonstration (to be funded by Titles XIX and XXI). The application form is an ARKids First umbrella application, which asks applicants to check one of three blocks to show their application preference - either ARKids program, ARKids A only, or ARKids B only. The application form contains a chart, which shows the services and cost sharing requirements in each program. The same chart is used for reapplications. Parents are not required to receive regular Medicaid for their children, if they prefer to receive ARKids B. Children in ARKids B, who are eligible for regular Medicaid, will not be funded by Title XXI.

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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 13

The following is paraphrased from Arkansas Medical Services Policy Manual Policy Directive Number MS 00-8 dated August 4, 2000:

A. If the applicant selects “ARKids A”, “either”, or makes no selection, then eligibility will be pursued for ARKids A (regular Medicaid); if the applicant is not eligible for ARKids A, the applicant’s eligibility will be determined for ARKids B (the 1115 demonstration).

B. If the applicant selects “ARKids A only” and the children are eligible for ARKids A, then the children will be certified as ARKids A.

However if the applicant selects “ARKids A only” and the children are not eligible for ARKids A but they are eligible for ARKids B, the caseworker will take the following steps:

1. Attempt to contact the applicant immediately by phone. Inform the applicant that the children are not eligible for ARKids A but are eligible for ARKids B and ask if he or she would like to receive ARKids B. 2. If the caseworker cannot reach the applicant by phone, a form letter will be mailed giving the applicant 15 days to respond if he/she wants to receive ARKids B for the children. 3. Dispose of the application upon receipt of the information from the applicant or after 15 days from the date the form letter was sent, whichever occurs earlier. 4. If the applicant declines ARKids B coverage or doesn’t respond within the 15 day notice period, the application will be denied.

C. If the applicant selects “ARKids B only,” the worker will determine eligibility for ARKids A and ARKids B. If the children are eligible for ARKids A, which would provide more coverage, the caseworker will take the following steps:

1. Attempt to call the applicant immediately. Inform the applicant that the children are eligible for ARKids A and that it provides more coverage than ARKids B. Ask the applicant to again specify which coverage he or she prefers the children to receive. If the applicant states that he or she does want ARKids A then the application will be certified for ARKids A. If the applicant refuses ARKids A, a notice will be sent stating that the children have been approved for ARKids B but are eligible for ARKids A. The notice will also inform the applicant that if he or she changes his or her mind within 30 days and would prefer to receive ARKids A, to contact the worker who can approve the children in ARKids A without a new application. 2. If the applicant cannot be reached by phone, a form letter will be sent

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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 14 giving the applicant 15 days to respond if he or she wants ARKids A for the children. 3. The worker will dispose of the application upon receipt of the information from the applicant or after 15 days from the date the form was sent, whichever occurs earlier. 4. If the applicant does not respond, the children will be certified as ARKids B.

Note: ARKids B will be funded by Titles XIX and XXI. Title XXI will only be used for those ARKids B children who meet the SCHIP definition of a targeted low-income child. Coordination with Children’s Medical Services The Department of Human Services operates a Children’s Medical Services Program which provides care coordination and/or specialized medical care and rehabilitation for children with special health care needs whose families are partially or wholly unable to provide for such services and who meet the agency’s criteria. Children’s Medical Services are funded by federal (Title V) and state funds. The Children’s Medical Services staff coordinate closely with Medicaid/SCHIP, especially with regard to the TEFRA-like Medicaid 1115 demonstration, to ensure that the children they serve receive the widest range of services to which they are entitled. Please reference Section 1.1.3.A., for more information regarding the TEFRA-like demonstration. Coordination with Maternal and Child Health The Title V Maternal and Child Health (MCH) programs are administered by the Arkansas Department of Health. Preventive health services are available to women, children, adolescents and families in 100 service sites in the state’s 75 counties. Preventive services provided include well child screens, immunizations, prenatal care, family planning, hearing and vision screening, newborn screening, blood lead screening and follow-up. Over 250,000 Arkansans receive some level of Title V MCH services each year. Services to children with Special Health Care Needs are coordinated with DHS.

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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 15 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))

The utilization controls will be the same as under Title XIX.

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))

The utilization controls will be the same as under Title XIX.

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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 16 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.

Geographic area served by the Plan: Statewide 4.1.2.

Age: Conception to birth (Separate Child HealthProgram) 4.1.3.

Income: At or below 200% FPL. 4.1.4.

Resources (including any standards relating to spend downs and disposition of resources): The resource test for the separate child health program is the same as applied to the comparable group in the Medicaid State Plan. 4.1.5.

Residency (so long as residency requirement is not based on length of time in state): Enrollees must be current Arkansas residents with the intent to remain in the State. 4.1.6.

Disability Status (so long as any standard relating to disability status does not restrict eligibility): Not applicable. 4.1.7.

Access to or coverage under other health coverage: SCHIP enrollees cannot be eligible for Medicaid. SCHIP enrollees cannot have access to a state health benefits program; enrollees in the separate child health program (unborn child) may not have health insurance that covers pregnancy related services. 4.1.8.

Duration of eligibility: The duration of eligibility is conception to birth. 4.1.9.

Other standards (identify and describe): There is no SSN requirement for the separate child health program to cover unborn children.

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.

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. 4.2.3.

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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 17 4.3. Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2)) (42CFR 457.350)

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.

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. (Section 2102)(b)(3)(A)) (42CFR 457.350(a)(1) and 457.80(c)(3))

At eligibility determination and redetermination, applications are reviewed for coverage under a group health plan or health insurance coverage that covers pregnancy related services, for access to a state health benefits plan and for Medicaid eligibility prior to enrollment in the State’s separate child health program.

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))

Screening procedures identify any applicant or enrollee who would be potentially eligible for Medicaid services based on the eligibility of his or her mother under one of the poverty level groups described in section 1902 (1) of the Act, section 1931 of the Act, or a Medicaid demonstration project approved under section 1115 of the Act.

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))

Any applicant or enrollee who is found ineligible for Medicaid services (based on the eligibility of his or her mother) is automatically reviewed for SCHIP Medicaid expansion or separate child health plan eligibility.

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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 18 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.

Coverage for the unborn child covers only those who do not qualify for Medicaid although the income and resource limit is the same as the SOBRA pregnant women’s Medicaid category; the difference is that the unborn child coverage does not require the pregnant woman to meet Medicaid citizenship requirements. The state child health program requires that the pregnant woman has no health insurance coverage for the pregnancy. Also, the unborn child benefit package is limited to services related to the pregnancy, or which if not treated could complicate the pregnancy; and the eligibility period is limited. Due to the above factors, the State does not think there will be substitution of coverage.

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

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.

The cost-effectiveness determination.

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

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Approval Date: 19 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))

American Indian and Alaska Native children are eligible for Arkansas’ SCHIP separate child health program on the same basis as any other children in the State, regardless of whether they may be eligible for or served by Indian Health Services-funded care.

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

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Approval Date: 20 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)

Arkansas developed a comprehensive outreach strategy for ARKids B*. The strategy applies equally to the title XIX and the SCHIP components of ARKids B. Outreach for the separate child health insurance program is through the ConnectCare contract with ADH and through the ADH pregnant women’s program, including presumptive eligibility. Media Campaign

In addition to the regular Medicaid outreach, Arkansas developed outreach geared specifically to the ARKids B Program. Governor Mike Huckabee held a gala press conference on September 11, 1997, to launch the ARKids B* Program. This has been followed by an extensive media campaign, including television, radio, print, and distribution of brochures in such places as McDonald’s food sacks. A key factor in the success of this campaign to date has been the active role Governor Huckabee has taken by appearing in television and radio public service announcements, as well as in the printed materials and on the ARKids B website: www.ARKidsfirst.com.

The media campaign has been modified to incorporate the changes in the use of the ARKids First name; ARKids First is now composed of ARKids A (Medicaid) and ARKids B, the 1115 demonstration. The SCHIP eligibles will be part of the ARKids B component. Coordination With Public and Private Entities

The outreach effort has been further advanced by working in cooperation with a broad range of public and private entities. These include Arkansas Children’s Hospital (they co-sponsored an ARKids First (ARKids B) newspaper insert with DHS), Arkansas Advocates for Children and Families, and several public schools, day care centers, hospitals, clinics, churches, and community centers. Arkansas Department of Human Services (DHS) county offices have widely distributed ARKids First application forms to these organizations. Arkansas Advocates for Children and Families has been particularly

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Approval Date: 21 instrumental in providing outreach by successfully writing a foundation grant proposal to conduct targeted outreach efforts in key parts of the state.

A supply of ARKids First applications was given to the Arkansas Department of Health (ADH) for distribution in their WIC clinics and to give to pregnant women for whom they are establishing presumptive eligibility in the Pregnant Women, Infants and Children category of Medicaid (SOBRA). ADH will be a primary intake point for the separate child health insurance program. Contracts A. Contract with Arkansas Advocates for Children and Families

The State has a contract with Arkansas Advocates for Children and Families, the State’s leading child advocacy agency, to provide a targeted outreach campaign for ARKids First (ARKids A and both the Title XIX and SCHIP components of ARKids B). This organization has an established statewide network of local community resources such as local Health Community Coalitions, volunteers, schools, and other organizations, which are in daily contact with the targeted population, to perform outreach. This contract targets working families and families who are less likely to have been exposed to the direct media campaign, and more likely to face barriers to health care access (e.g., employment restrictions, inadequate or no transportation, language and /or communication barriers). Examples of how the outreach system functions include the following:

• Training sessions with local coalitions made up of community health care centers, private health care providers, school district personnel, local businesses and Chambers of Commerce, and faith-based organizations.

• Setting up information tables/booths at school, city or county health fairs and other special events.

• Gathering information for local coalition members and program recipients about ways to eliminate real or perceived barriers to access.

B. Contract with the Arkansas Department of Health

The State also has a contract with the Arkansas Department of Health (ADH) to provide information to recipients/applicants through a media campaign and a 24 hour toll-free telephone Help Line Service. The Help Line Service responds to questions received from Medicaid and ARKids First (ARKids A

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Approval Date: 22 and ARKids B) applicants/recipients and providers by telephone concerning eligibility, access, enrollment, rights and responsibilities and other issues. The ADH media campaign publicizes the telephone Help Line, promotes appropriate usage of the medical care system, and uses the most cost- effective strategies, as determined by ADH with DHS approval. The campaign may include television and radio advertising, direct mail, print media, telemarketing and other viable methods that target children.

Website

The ARKids First website address is www.arkidsfirst.com. The site has six subject links: 1) eligibility, 2) questions, 3) apply, (this includes an application in English or Spanish which can be printed from the website), 4) benefits, 5) more information, and 6) other services.

The Arkansas Medicaid website is located at www.medicaid.state.ar.us. This site contains a link to the ARKids First site. 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.

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

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.

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

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Approval Date: 23

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 Conception through birth: the State covers the same services that it covers in the Medicaid state plan for SOBRA pregnant women. 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. Coverage that includes benchmark coverage plus additional coverage 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)

For the unborn child, the State covers pregnancy related services and services that if not treated could complicate the pregnancy, i.e., the State covers the same services that it covers for the SOBRA pregnant women category in the Medicaid State Plan. Exception: Sterilization procedures are not covered for the SCHIP unborn child group. The services checked below are generally

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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 24 covered for Medicaid categorically needy eligibles and are potentially covered for the SCHIP unborn child group, depending on the need of the recipient. Arkansas Medicaid program rules apply; examples include benefit limits, extension of benefit limit procedures, prior authorization requirements, age limits, etc.

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 prepregnancy 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)) 6.2.14.

Home and community-based health care services (See instructions) (Section 2110(a)(14)) 6.2.15.

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.

Dental services (Section 2110(a)(17)) 6.2.18.

Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) 6.2.19.

Outpatient substance abuse treatment services (Section 2110(a)(19)) 6.2.20.

Case management services (Section 2110(a)(20)) 6.2.21.

Care coordination services (Section 2110(a)(21)) 6.2.22.

Physical therapy, occupational therapy, and services for

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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 25 individuals with speech, hearing, and language disorders (Section 2110(a)(22)) 6.2.23.

Hospice care (Section 2110(a)(23)) 6.2.24.

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)) 6.2.26.

Medical transportation (Section 2110(a)(26)) 6.2.27.

Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27)) 6.2.28.

Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28))

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 6.4.2. of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe: Previously 8.6

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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 26 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))

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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 27 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))

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

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Approval Date: 28 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))

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.

Performance measurement 7.1.3.

Information strategies 7.1.4.

Quality improvement strategies

7.2. Describe the methods used, including monitoring, to assure: (2102(a)(7)(B)) (42CFR 457.495)

The methods used to assure quality and appropriateness of care, are the same as under Title XIX.

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))

The methods used to monitor and assure access to care, including well- care, are the same as under Title XIX.

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))

The methods used to monitor and assure access to care, including emergency services, are the same as under Title XIX.

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))

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

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Approval Date: 29 The methods used 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”, are the same as under Title XIX.

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))

Decisions related to the prior authorization of health services are in accordance with Title XIX.

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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 30 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.

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))

8.2.1. Premiums:

8.2.2. Deductibles: 8.2.3. Coinsurance or copayments: 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))

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))

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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 31 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))

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)

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))

8.7.1 Please provide an assurance that the following disenrollment protections are being applied:

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))

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))

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))

The state provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42CFR 457.570(c))

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, 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.

No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance

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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 32 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)

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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 33 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))

I. The infrastructure of the Arkansas Department of Human Services, Division of Medical Services and Division of County Operations, will be able to accommodate all critical facets of Arkansas' Title XXI program. II. Low-income children who were previously without health insurance coverage will have health insurance coverage through Arkansas’ Title XXI Program. Previously uninsured children who may be potentially eligible for Arkansas’ Title XXI Program will be identified through ongoing outreach activities. III. Children enrolled in Arkansas’ Title XXI Program will have access to health care. IV. Arkansas’ Title XXI Program will improve the health status of children enrolled in the program as well as improve the overall health care system accessed through the program.

9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c))

Performance Goal for Objective I:

Effective upon implementation of the SCHIP state plan, the State will have in place: 1) data systems modifications with regard to screening for Medicaid, SCHIP eligibility determination, enrollment, participant information, health service utilization, billing, provider information, etc.; 2) personnel to implement SCHIP (i.e., eligibility workers, administrative staff, and support staff; and 3) existing and new cases will be coded to the system to identify the case as either Title XIX or Title XXI.

Performance Goal for Objective II:

Mechanisms to conduct outreach have been developed and implemented, and are ongoing. The outreach does not specifically reference SCHIP since the SCHIP Medicaid expansion program is part of ARKids B and the separate child health insurance program to cover unborn children will be linked to the Medicaid SOBRA pregnant women category. However, the outreach is specifically geared toward families whose family income is at or below 200%

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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 34 of the federal poverty level. This, of course, includes the SCHIP population. Please reference section 5, above.

Performance Goal for Objective III:

As children are enrolled in the SCHIP component of ARKids B, their parents will be asked to select a primary care physician (PCP) of their choice. As pregnant women are enrolled in the state health insurance program for coverage of their unborn child, they will be asked to select a PCP. The Division of Medical Services’ Primary Care Case Management Program, ConnectCare, offers over 1800 physicians statewide, who have caseload availability of approximately 1,000,000 patients. Access availability is five to one. ConnectCare will apply equally to the Title XIX and Title XXI children.

Performance Goal for Objective IV:

Upon implementation of the SCHIP state plan, the health status of the children in the SCHIP Medicaid expansion and in the separate state child health insurance program will be improved through increased access to the health care system and through having a health care home. Also the ConnectCare program provides information that promotes preventive health 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))

Measurement of Performance Goal for Objective I:

The State will monitor the data system to ensure that current cases were converted and new cases are assigned to the Title XXI and Title XIX components, as appropriate. Statistical and financial reports will be generated which will reflect cases and expenditures in each component of ARKids B and for the SCHIP unborn child group. The State will also monitor timeliness and quality of case processing.

Measurement of Performance Goal for Objective II:

Weekly, monthly and quarterly management reports will be used to measure enrollment in ARKids B (Titles XIX and XXI) and in the separate state child health insurance program.

Measurement of Performance Goal for Objective III:

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

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Approval Date: 35

Arkansas Medicaid’s Primary Care Case Management Program, Connect Care, has in place an extensive quality evaluation plan (QEP) operated through the Arkansas Foundation for Medical Care, Inc. (AFMC), the state certified Quality Improvement Organization (QIO). The purpose of the QEP is to improve the quality of services to Medicaid and Title XXI recipients within the ConnectCare program resulting in an overall improvement of the recipient’s health status. Arkansas will also measure performance through claims data and individual PCP performance measurements.

Measurement of Performance Goal for Objective V:

AFMC measures health status, including immunizations and well child visits, based on both claims data and Arkansas Department of Health statistics (Titles XIX and XXI). Arkansas will also measure performance in the Medicaid expansion through an ARKids B recipient satisfaction survey.

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, please list: 9.3.8.

Performance measures for special targeted populations.

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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 36 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)

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)

The State has an approved Section 1915(b) waiver for Primary Care Case Management (PCCM). The State is responsible for assessment and evaluation under the PCCM waiver and intends to use the same contract for the SCHIP Medicaid expansion and the separate state child health insurance program. The contractor evaluates data including number of office visits, continuity of care, and hospitalizations, etc.

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 of audit. (Section 2107(b)(3)) (42CFR 457.720)

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))

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)

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))

The ARKids B work group and the Arkansas Advocates for Children and Families agency agreed that Arkansas should pursue funding appropriate

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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 37 ARKids B children through Title XXI. The separate state child health insurance program to cover unborn children is supported by the Arkansas Advocates for Children and Families, the Arkansas Department of Health and the Arkansas Center for Health Improvement.

Changes in Medicaid expansion and the separate state child health insurance program will be promulgated as required by the State’s Administrative Procedures Act (APA). The APA requires that the agency publish a notice, regarding proposed rules, in a newspaper with statewide circulation. As a part of the APA process, DMS also notifies “interested persons” and appropriate Medicaid providers of proposed rules to solicit comments and input. The APA process requires the review of new and revised rules by the Administrative Rules and Regulations Subcommittee of the Arkansas Legislative Council.

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))

There is no American Indian Nation, Tribe or reservation in Arkansas. However, we were able to locate a private-not-for-profit organization in Little Rock called the American Indian Center of Arkansas. They have agreed to cooperate with us in providing information to targeted low- income children who are Indians. We will provide them with ARKids First applications and pamphlets.

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).

Amendments relating to eligibility or benefits, including cost sharing and enrollment procedures will be promulgated according to the State’s Administrative Procedures Act. The Act requires a public notice in a statewide newspaper with a 30-day comment period.

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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 38 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.

The source of the non-Federal share is State General Revenue.

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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 39

SCHIP Budget Plan Template

State Fiscal Year 2005 (July 1, 2004 – June 30, 2005)

Fiscal Year Costs Enhanced FMAP rate 82.31% 1 Benefit Costs

Insurance payments

Managed care

per member/per month rate @ # of eligibles $ 17,496.00 Fee for Service $ 3,259,854.72 Total Benefit Costs $ 3,277,350.72 2 (Offsetting beneficiary cost sharing payments)

Net Benefit Costs

Administration Costs

Outreach $ 49,100.00 Reporting $ 49,100.00 Quality Assurance $ 25,000.00 Assessment $ 28,300.00 Eligibility $ 176,235.08 Other

Total Administration Costs $ 327,735.08 10% Administrative Cost Ceiling $ 360,508.58

Federal Share (multiplied by SCHIP-FMAP rate) $ 2,967,556.42 State Share $ 637,529.38 TOTAL PROGRAM COSTS $ 3,605,085.802

See Attachments I and J for supporting documentation.

1This is a weighted percentage (i.e., July-September 2004 are at 82.27% and October 2004 through June 2005 are at 82.32%).

2These program estimates are only for the coverage of unborn children.

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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 40 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.

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.

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.

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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 41 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 items 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)

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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 42 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

Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120.

The review process for eligibility and enrollment matters is the same as the Medicaid Fair Hearing process.

12.2. Health Services Matters

Please describe the review process for health services matters that comply with 42 CFR 457.1120.

The review process for health service matters is the same as the Medicaid Fair Hearing process.

12.3. Premium Assistance Programs

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.

N/A

ARKANSAS TITLE XXI PROGRAM FACT SHEET

Name of Plan:

ARKids B

Date Plan Submitted:

May 6, 1998 Date Plan Approved:

August 6, 1998 Date Plan Effective:

October 1, 1998

Date Amendment #1 Submitted: December 4, 1998 Date Amendment #1 Approved: February 16, 2001 Date Amendment #1 Effective:

January 1, 2001 (not implemented)

Date Amendment #2 Submitted: July 10, 2002 Date Amendment #2 Withdrawn: April 15, 2004

Date Amendment #3 Submitted: April 2, 2004 Date Amendment #3 Approved: June 30, 2004 Date Amendment #3 Effective:

July 1, 2003

Background

• On May 6, 1998, Arkansas submitted a Title XXI plan to expand Medicaid eligibility to children born after September 30, 1982, and prior to October 1, 1983, whose family income is at or below 100 percent of the Federal Poverty Level (FPL).

• Arkansas also has a Medicaid section 1115 demonstration, called ARKids B, which was implemented on September 1, 1997, to cover uninsured children through age 18 with family income up to 200 percent of the FPL who do not qualify under the State Medicaid plan. The State may claim title XXI funds for children enrolled in the ARKids B demonstration who are not eligible for the mandatory Medicaid group. As of September 30, 2002, this is the only population of children in the State’s SCHIP Medicaid expansion program.

• The State submitted its first amendment to the SCHIP state plan on December 4, 1998, to establish a separate child health program as a new component of ARKids B. This amendment was never implemented and the State’s third amendment revises the state plan to remove this component.

• The State submitted its second amendment on July 2, 2002, to move children from the ARKids B demonstration to the State’s approved, but not implemented, separate child health program. This amendment was withdrawn April 15, 2004. Page 1 of 3

• The State submitted its third amendment on April 2, 2004, to add coverage for unborn children with family incomes up to and including 200 percent of the FPL who are not otherwise eligible for Medicaid. Coverage is under a separate child health program and will include prenatal care and associated health services for children from conception through birth. This amendment also removes the State’s separate child health program that was approved with the second amendment (but not implemented) and updates the State plan to indicate compliance with the final SCHIP regulations.

Children Covered Under Program

• The State reported that 1,912 children were ever enrolled in the program during Federal fiscal year 2002.

Administration

• The Division of Medical Services, the single State agency, administers the program.

Health Care Delivery System

• The delivery system is the same for Medicaid and SCHIP. This system is a primary care case management program called ConnectCare.

Benefit Package

• Children in the SCHIP Medicaid expansion program receive the ARKids B Medicaid section 1115 demonstration benefit package.

• The Medicaid benefit package is provided to unborn children.

Cost Sharing

• Children enrolled in the SCHIP Medicaid expansion program pay the ARKids B Medicaid section 1115 demonstration cost sharing: copayments are required for prescription drugs ($5), office visits other than well-child visits ($10), durable medical equipment (20 percent of the Medicaid-allowed amount) and the first inpatient day (20 percent of the Medicaid per diem cost).

• There is no cost sharing for unborn children.

Outreach Activities

• The State has a contract with Arkansas Advocates for Children and Families to conduct a targeted outreach campaign. This organization provides information, training, and materials to grassroots organizations that are in daily contact with the targeted population.

Page 2 of 3

Page 3 of 3 • The State also has a contract with the Arkansas Department of Health to provide information to applicants and recipients through a media campaign and a 24-hour toll-free telephone Help Line Service. The Help Line Service responds to questions received from applicants, recipients, and providers, concerning eligibility, access, enrollment, rights and responsibilities and other issues.

Financial Information

Total FFY 2004 SCHIP Allotment -- $35,073,372 FFY 2004 Enhanced Federal Matching Rate -- 82.27%

Date Last Updated: June 30, 2004

_____________________________________________________________________________

Table of Contents

State/Territory Name: Arkansas

State Plan Amendment (SPA) #: AR-13-0021

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages

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

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

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

Children and Adults Health Programs Group

JAN 0.6 2014 Dr. Andy Allison Medicaid Director Department of Health and Human Services P.O. Box 1437 (Slot S401) 700 Main Street Little Rock, AR 72203

Dear Dr. Allison:

Iam pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number AR-13-0021, submitted on September 23, 2013, and related to Modified Adjusted Gross Income (MAGI) Eligibility has been approved with an effective date of January 1, 2014. ;

SPA number AR-13-0021 converts the state’s existing income eligibility standards to MAGI- equivalent standards, by age group, for children covered in its title XX1I-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. Victoria Collins. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Collins’ contact information is as follows:

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

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-2167

Facsimile: (410) 786-5943

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

Official communications regarding program matters should be sent simultaneously to Ms. Collins and to Mr. Bill Brooks, Associate Regional Administrator (ARA) in our Dallas Regional Office. Mr. Brooks’ address is:

Page 2 — Dr. Andy Allison

Centers for Medicare & Medicaid Services Office of the Regional Administrator

1301 Young Street, Suite 714

Dallas, TX 75202

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.

Eliot Fishman Director

Enclosures ce: Mr. Bill Brooks, CMS Region VI, Dallas

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility AR.0352.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Arkansas State Funds: $ 11286633.00 Federal Funds: $ 28834886.00 Submitted By: Glenda Higgs 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. AR-13-0021 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: Please attach a revised CHIP budget. Document Subject of Amendment Please provide a brief summary of SPA changes. Character Count:0 out of 2000 Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/07/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

Last Revision Date: Jan 2, 2014 Submit Date: Sep 23, 2013 FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/07/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

CHIP Eligibility

EL TRE NERS MTEC CORNER

OMB Control Number: 0938-1148

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)

19 107 142

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.

JAN 0 6 2014

SPA# AR-13-0021 Approval Date: Effective Date: January 1, 2014

Page | of |

_____________________________________________________________________________

Table of Contents

State/Territory Name: Arkansas

State Plan Amendment (SPA) #: AR-13-0022

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages

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

DEPARTMENT OF HEALTH & HUMAN SERVICES aa ——— ;

Centers for Medicare & Medicaid Services oe RA Sy, 7500 Security Boulevard, Mail Stop: S2-01 -16 (CENTERS FOR MEDICARE & MEDICAID SERVICES Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

DEC 1 9 2013

Andrew Allison, Ph.D.

Director, Division of Medical Services Arkansas Department of Human Services P.O. Box 1437, Slot S-401

700 Main Street

Little Rock, AR 72203

Dear Dr. Allison:

I am pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number AR-13-0022, submitted on September 23, 2013, and related to Modified Adjusted Gross Income (MAGI) Eligibility has been approved with an effective date of January 1, 2014.

MAGI Eligibility & Methods:

SPA number AR-13-0022 provides assurance on page CS15 that the state will apply methodologies based on MAGI for all separate CHIP covered groups; and, using the approved MAGI conversion plan income thresholds, the state indicates on page CS9 that it will cover children from conception to birth when the mother is not eligible for Medicaid. 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 CS9 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.

Your Title XX] project officer is Ms. Victoria Collins. She is available to answer questions concerning this amendment. Ms. Collins’s contact information is as follows:

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

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

Telephone: (410) 786-2176

Facsimile: (410) 786-5882

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

Page 2 ~ Dr. Andrew Allison

Official communications regarding program matters should be sent simultaneously to Ms. Collins and Mr. Bill Brooks, Associate Regional Administrator, Division of Medicaid and Children’s Health Operations, in our Dallas Regional Office. Mr. Brooks’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations 1301 Young Street, Room 714

Dallas, TX 75202

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

Sincerely,

ot Fishman Director

Enclosures ce: Bill Brooks, ARA, CMS Region VI, Dallas

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility AR.0342.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Arkansas State Funds: $ Federal Funds: $ Submitted By: Glenda Higgs Last Revision Date: Dec 17, 2013 Submit Date: Sep 23, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. AR-13-0022 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 Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:71 out of 2000 CHIP State Plan is being amended to add MAGI-Based Income Methodologies Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/02/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/02/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

“CMS 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

wl 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.

Tf 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. 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: {[] Include a prorated portion of the reasonably predictable increase in future income and/or family size. (J 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. °

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.

PRA Disclosure Statement

DEC 1 9 2013

SPA# AR-13-0022 Approval Date: Effective Date: January 1, 2014 Page 1 of 2

coms 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.20130917

SPA# AR-13-0022 Approval Date: DEC j 9 2013 Effective Date: January 1, 2014

Page 2 of 2

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

42 CFR 457.10

[m) 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. |Yes

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

Statewide Income Standard

The statewide income standard is: From zero up to |209 | % FPL

[=] 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.

SPA# AR-13-0022 Approval Date:, DEC i 9 2013 Effective Date: January 1, 2014

Page | of 1

_____________________________________________________________________________

Table of Contents

State/Territory Name: Arkansas

State Plan Amendment (SPA) #: AR-13-0040

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages

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

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

‘CMS 7500 Security Boulevard, Mail Stop: 52-01-16 \

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

Children and Adults Health Programs Group

FEB 0 4 2014 Andrew Allison, Ph.D.

Director, Division of Medical Services Arkansas Department of Human Services P.O. Box 1437, Slot S-401

700 Main Street

Little Rock, AR 72203

Dear Dr. Allison:

I am pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number AR-13-0040 submitted on December 16, 2013, and related to Modified Adjusted Gross Income (MAGI) Eligibility has been approved with an effective date of January 1, 2014.

Establish 2101(f) Group:

SPA number AR-13-0040 describes the state’s plan to provide coverage in its separate CHIP, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is attached, and should be incorporated within a separate subsection under Section 4.1 of Arkansas’ approved CHIP state plan.

Your Title XXI project officer is Ms. Victoria Collins. She is available to answer questions concerning this amendment. Ms. Collins’ contact information is as follows:

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

7500 Security Boulevard, Mail Stop $2-01-16 Baltimore, MD 21244-1850

Telephone: (410) 786-2176

Facsimile: (410) 786-5882

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

Official communications regarding program matters should be sent simultaneously to Ms. Collins and Mr. Bill Brooks, Associate Regional Administrator, Division of Medicaid and Children’s Health Operations, in our Dallas Regional Office. Mr. Brooks’ address is:

Page 2 — Dr. Andrew Allison

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations 1301 Young Street, Room 714

Dallas, TX 75202

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

Sincerely,

Eliot Fishman Director

Enclosures ce: Bill Brooks, ARA, CMS Region VI, Dallas

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility AR.0605.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Arkansas State Funds: $ Federal Funds: $ Submitted By: Glenda Higgs Last Revision Date: Dec 16, 2013 Submit Date: Dec 16, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. AR-13-0040 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Section 2101(f) of the ACA & 42 CFR 457.310(d) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:118 out of 2000 To allow separate CHIP coverage for children found ineligible for Medicaid due to the elimination of income disregards Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/07/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/07/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

CHIP Eligibility

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

EE

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

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

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

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected

® from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage in a separate CHIP (expected to be no later than April 1, 2016 ).

Describe the methodology used by the state to identify and enroll children in a separate CHIP who are subject to the protection afforded by Section 2101(f) of the Affordable Care Act:

co The state has demonstrated and CMS has agreed that all children qualifying for section 2101(f) protection will qualify for the ~ state’s existing separate CHIP.

@ ihe state will enroll all children in a separate CHIP who lose Medicaid eligibility because of an increase in family income at their ~ first renewal applying MAGI methods.

The state will enroll children in a separate CHIP whose family income falls above the converted MAGI Medicaid FPL but at or below the following percentage of FPL. The state has demonstrated and CMS has agreed that all or almost all the children who c would have maintained Medicaid eligibility if former disregards were applied will be within this income range and therefore covered in the separate CHIP.

(% FPL

The state will enroll children in a separate CHIP who are found to be ineligible for Medicaid based on MAGI but whose family income has not increased since the child’s last determination of Medicaid eligibility or who would have remained eligible for

© Medicaid (based on the 2013 Medicaid income standard) if the value of their 2013 disregards had been applied to the family income as determined by MAGI methodology.

© Other.

Describe the benefits provided to this population:

© This population will be provided the same benefits as are provided to children in the state’s Medicaid program. @ This population will be provided the same benefits as are provided to children in the state's separate CHIP.

© Other (consistent with Section 2103 of the SSA and 42 CFR 457 Subpart D).

Describe premiums and cost sharing required of this population:

© Cost sharing is the same as for children in the Medicaid program.

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CHIP Eligibility

@ Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP.

CONbo premiums, copayments, deductibles, coinsurance or other cost sharing is required.

© Other premiums and/or cost-sharing requirements (consistent with Section 2103(e) of the SSA and 42 CFR 457 Subpart E).

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.

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Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: Arkansas

State Plan Amendment (SPA) #: AR-14-0042

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages

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

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

7500 Security Boulevard, Mail Stop: S2-26-12 Baltimore, Maryland 21244-1850 ATER EOR MEOLCaID & Cate sawn

CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

APR 2 1 2014

Dr. Andy Allison

Medicaid Director

Department of Health and Human Services P.O. Box 1437 (Slot S401)

700 Main Street

Little Rock, AR 72203

Dear Dr. Allison:

Iam 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 AR-14-0042, related to Modified Adjusted Gross Income (MAGI) Eligibility, Non-Financial Eligibility Group, submitted on March 21, 2014. This SPA has an effective date of January 1, 2014.

The SPA number AR-14-0042 is approved to clarify the state’s non-financial eligibility policies on residency. Copies of the approved state plan pages are attached and these approved pages supersede section 4.1.5 of Arkansas’ current state plan.

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

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

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-2176

Facsimile: (410) 786-5943

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

Official communications regarding program matters should be sent simultaneously to Ms. Collins and to Mr. Bill Brooks, Associate Regional Administrator (ARA) in our Dallas Regional Office. Mr. Brooks’ address is:

Page 2 — Dr. Andy Allison

Mr. Bill Brooks

Centers for Medicare and Medicaid Services Office of the Regional Administrator

1301 Young St. Suite 714

Dallas, TX 75202

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.

Eliot Fishman Director

Enclosures

ce: Mr. Bill Brooks, ARA, CMS Region VI, Dallas

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility AR.0819.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Arkansas State Funds: $ Federal Funds: $ Submitted By: Glenda Higgs Last Revision Date: Apr 11, 2014 Submit Date: Mar 21, 2014 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. AR-14-0042 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 Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:77 out of 2000 Separate Child Health Insurance Program Non-Financial Eligibility - Residency Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/04/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/04/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

CHIP Eligibility

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

42 CFR 457.320

Residency

The CHIP Agency provides CHIP to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions.

A child is considered to be a resident of the state under the following conditions:

wl A non-institutionalized child, if capable of indicating intent and who is emancipated or married, if the child is living in the state and:

1. Intends to reside in the state, including without a fixed address, or

2. Has entered the state with a job commitment or seeking employment, whether or not currently employed. [Hf A non-institutionalized child not described above and a child who is not a ward of the state:

1. Residing in the state, with or without a fixed address, or

2. The state of residency of the parent or caretaker, in accordance with 42 CFR.435.403(h)(1), with whom the individual resides.

ry An institutionalized child, who is not a ward of the state, if the state is the state of residence of the child's custodial parent or caretaker at the time of placement, or

[fl A child who is a ward of the state regardless of where the child lives, or

A child physically located in the state when there is a dispute with one or more states as to the child's actual state of Cy residence.

If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions: [A non-institutionalized pregnant woman who is living in the state and: 1. Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state, or 2. Entered with a job commitment or seeking employment, whether or not currently employed.

ial An institutionalized pregnant woman placed in an out-of-state-institution, as defined in 42 CFR 435.1010, including foster care homes, by an agency of the state, or

mw An institutionalized pregnant woman residing in an in-state-institution, as defined in 42 CFR 435.1010, whether or not the individual established residency in the state prior to entering the institution, or

TT A pregnant woman physically located in the state when there is a dispute with one or more states as to the pregnant woman's actual state of residence.

The state has in place related to the residency of children and pregnant women (if covered by the state):

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Cems. CHIP Eligibility

One or more interstate agreement(s). io

A policy related to individuals in the state only for educational purposes. |Yes

Provide a description of the policy:

An individual age 18-22 and a full-time student in an Arkansas school is not a resident of Arkansas if: a) Neither parent lives in Arkansas, b) The student is claimed as a tax dependent by someone in a state other than Arkansas, and ic) The student is applying on his or her own behalf.

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, Mary land 21244-1850.

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_____________________________________________________________________________ Table of Contents State/Territory Name: Arkansas State Plan Amendments (SPA) #: AR-16-0002-CHIP This file contains the following documents in the order listed: 1) Approval Letter 2) Final Approved State Plan

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop $2-01-16 < M Ss Baltimore, MD 21244-1850

CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES Children and Adults Health Programs Group

Dawn Stehle DEC 08 2016

Director, Division of Medical Services Arkansas Department of Human Services P.O. Box 1437, Slot S-401

700 Main Street

Little Rock, AR 72203

Dear Ms. Stehle:

Tam writing 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) AR-16-0002-CHIP health services initiative (HSI), submitted on August 19, 2016, with an effective date of January 1, 2017. This SPA permits Arkansas to implement the Health & Well- Being Program for Maltreated Children HSI.

This HS] targets the population of children identified by the Arkansas Department of Human Services at high risk for maltreatment. The goals of this HSI are to prevent the removal of children from the home, prevent a recurrence of maltreatment and improve the overall health and. well-being of young children and their families. The state will implement the SafeCare evidence-based home visitation program that has been shown to reduce child maltreatment among families with a history of maltreatment or with risk factors for maltreatment. The SafeCare program provides parent training in three focused areas: (1) parent-child/infant interactions, (2) infant and child health and (3) home safety for children. In addition, the state will provide services that educate families about the relationship of household management/hygiene and children’s health, including preventing children’s exposure to lead in the home and surrounding environment.

This SPA provides funding through the HSI option at section 2105(a)(1)(D)(ii) of the Social Security Act and 42 CFR §457.10 to use available title XXI administrative funding to pay for activities that protect public health, protect the health of individuals, improve or promote a state’s capacity to deliver public health services, or strengthen the human and material resources necessary to accomplish public health goals relating to improving the health of children, including targeted low-income children and other low-income children.

The state has ensured that the remaining title XX] funding, within the state’s 10 percent 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 its HSIs 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. .

/Anne Marie Costello/

1 TEMPLATE FOR CHILD HEALTH PLAN 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: _________________ARKANSAS______________________________ (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)) ___________Dawn Stehle, Director, DMS_________________ (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: Cindy Gillespie Position/Title: Director, Department of Human Services (DHS) Name: Dawn Stehle Position/Title: Director, DHS Division of Medical Services (DMS) 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 0938-0707. 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.

2 Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 105-33 amended 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 457 as 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: o 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. o 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) o Moved sections 2.2 and 2.3 into section 5 to eliminate redundancies between sections 2 and 5. o 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. A SPA 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 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

3 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 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,

4 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 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: o Option to Create a Separate Program- States may elect to establish a separate child health

5 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. o 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: 1. (Eligibility Standards and Methodology) 2. (Outreach) 3. (Strategic Objectives and Performance Goals and Plan Administration including the budget) 4. (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: 1. (Methods of Delivery and Utilization Controls) 2. (Eligibility Standards and Methodology) 3. (Coverage Requirements for Children’s Health Insurance) 4. (Quality and Appropriateness of Care) 5. (Cost Sharing and Payment) 6. (Program Integrity) 7. (Applicant and Enrollee Protections)

o 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.

6

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

7

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

A. Background

Arkansas aggressively pursued health care for children by covering optional benefits and categories that benefit children. For example, Arkansas elected to provide the full range of EPSDT services to children without requiring the EPSDT screen. Also Arkansas was one of the first states in the nation to cover the TEFRA-134 children authorized by the Tax Equity and Fiscal Responsibility Act of 1982.

Effective 1-1-03, the State began covering TEFRA children in a TEFRA-like 1115(a) demonstration waiver in which the parents pay a premium based on a sliding scale; some parents are not required to pay a premium. The TEFRA-like demonstration waiver provides for the care of a child in his/her home, if he/she qualifies for Medicaid as a resident in a Title XIX institution, e.g., a nursing facility or an Intermediate Care

8 Facility for the Mentally Retarded, etc. Parental income and resources are not counted in the child’s eligibility determination. Before eligibility determination for the TEFRA-like demonstration waiver, the child must first be determined if he/she would meet Title XIX Medicaid eligibility. Parental income is counted in the premium amount calculation. The eligibility income limit for this demonstration waiver is three times the SSI limit. The TEFRA-like demonstration waiver makes Medicaid available to a large segment of the state’s chronically ill children.

In its quest to provide health care for children, the State also opted to cover uninsured children through a Medicaid 1115(a) demonstration waiver, ARKids First. This demonstration is discussed in item B, below.

CHIP Phase I, a Medicaid expansion, was approved August 6, 1998 and implemented October 1, 1998. This was a small CHIP Medicaid expansion in which the last of the eligible children aged-out of the program September 30, 2002. CHIP Phase II is a separate CHIP program that was approved February 16, 2001 but not implemented. Phase III superseded Phase II. Phase III covered some of the children in the State’s 1115(a) demonstration waiver, ARKids-B, as an CHIP Medicaid expansion and the Unborn Child program as a separate child health program.

In 2013, on recommendation from CMS, the State made the decision to transition the ARKids-B program from an 1115(a) demonstration waiver CHIP Medicaid expansion program to a separate child health program through the CHIP state plan. The Unborn Child program has been in the CHIP state plan since 1-1-04 as a separate child health program, and the State continues to serve this population.

B. ARKids First Background and Development

In 1997, Arkansas’ Governor, the Arkansas State legislature, the President and Congress were all addressing the issue of health care for vast numbers of uninsured children. Governor Mike Huckabee supported enabling state legislation and an appropriations bill in the 1997 legislative session that created and funded ARKids First, an 1115(a) demonstration waiver. The Arkansas Legislature passed both bills and Governor Mike Huckabee signed both bills into law on March 10, 1997 Effective August 4, 2000, the 1115(a) demonstration waiver was renamed ARKids-B.

Ray Hanley, then Director, Division of Medical Services (DMS), formed and chaired an ARKids First work group, composed of individuals from the Governor’s Office (the Department of Human Services liaison), Arkansas Children’s Hospital, Arkansas Department of Health, Catholic Social Services, Arkansas Advocates for Children and Families, Easter Seals, Communities in School of Arkansas, Arkansas Chapter for American Academy of Pediatrics, Electronic Data Systems (Arkansas Medicaid’s then fiscal agent), and various individuals in the Department of Human Services (DHS),

9 including Tom Dalton, then Department Director. The first meeting was held February 7, 1997, one day after President Clinton announced his FFY ‘98 budget package that included a proposal to expand health insurance access for poor children in families that earn too much for Medicaid but not enough to afford private health insurance. Additional ARKids First meetings were held as needed. Most of the discussion and concerns involved eligibility factors and the benefit package.

The Arkansas legislation, though not as detailed, mirrors the CHIP legislation in its purpose, i.e., to provide health insurance coverage for uninsured children under age 19 whose family income is at or below 200% of the poverty level. The ARKids First program was designed as a CHIP program, but used the 1115(a) demonstration waiver process for implementation, since the CHIP legislation had not been passed at the time Arkansas’ program was under development. The ARKids First 1115(a) demonstration waiver was approved by CMS on August 19, 1997 and implemented on September 1, 1997; only days after the CHIP legislation was signed by the President.

Arkansas developed the ARKids First Program with the thought that it would be able to roll the ARKids First 1115 demonstration waiver into a CHIP program. However, the State recognized that as the ARKids First demonstration waiver and the CHIP legislation were developing, they didn’t make completely parallel steps. Therefore, ARKids First enrollees, who did not meet the definition of a CHIP targeted low-income child, would continue to receive their health care services through Title XIX federal funding. Children in ARKids First who met the definition of a CHIP targeted low- income child would be able to receive their services through either Title XIX or Title XXI federal funding, at the discretion of the State. All of the ARKids First children would remain in the 1115(a) demonstration waiver regardless of the funding source. The children who did not meet the definition of a CHIP targeted low-income child were the children of state employees and the children who met the eligibility requirements for regular Title XIX Medicaid. In 2002, CMS instructed the State that parents or guardians of children who met eligibility for Title XIX Medicaid did not have the choice to have their children receive services through either Title XIX Medicaid or the Title XXI CHIP ARKids First 1115(a) demonstration waiver. Children found eligible for Title XIX Medicaid must receive services through the Title XIX Medicaid program. Effective August 4, 2000, the ARKids First program was separated into ARKids-A (regular children’s Title XIX Medicaid program) and ARKids-B (1115(a) demonstration waiver Title XXI CHIP program), and ARKids First became an umbrella for these two programs.

The application form and the promotional materials for ARKids-A and ARKids-B identify the two programs as ARKids First. Applications may be made at the local DHS County Office, by mail, or through the internet, and a toll free number is available to clients. Applications in English or Spanish may be printed from the ARKids First website at www.arkidsfirst.com. Applications in other languages are available upon request.

10

C. ARKids-B Title XXI CHIP Separate Child Health Program

In November 2013, CMS recommended the State transition the ARKids-B 1115(a) demonstration waiver Title XXI CHIP Medicaid expansion program to a Title XXI CHIP separate child health program through the CHIP state plan and advised that if this was done, orthodontia services would have to be added to the ARKids-B program’s benefit package of services. As the current ARKids-B 1115(a) demonstration waiver’s renewal was due to end December 31, 2013, the State requested and CMS approved an extension of the ARKids-B demonstration waiver to allow the State time to prepare, submit, and have approved an amendment to the CHIP state plan.

Effective 1/1/14 ARKids-B beneficiaries ages 6 through 18 in families with incomes from 100% FPL up to 142% FPL were moved to Title XIX Medicaid ARKids-A (MAGI CHIP SPA Group 2/CS2 PDF page) but continue to be funded through title XXI CHIP.

Children ages 0 through age 18 in families with a household income above 142% FPL up to and including 211% FPL are eligible for ARKids-B. There is no asset test. The State maintains qualifying criteria for ARKids-B that includes income criteria based on modified adjusted gross income methodologies as defined at 42 CFR §435.603. As allowed under 42 CFR §457.805, all ARKids-B enrollees must not have had employer- sponsored or group health insurance within 90 days prior to program enrollment. The State maintains, at minimum, the required exemptions to the period of uninsurance as specified at 42 CFR §457.805. There is no presumptive eligibility. Retroactive eligibility may be determined up to three months prior to the date of application. ARKids-B offers a less comprehensive benefit package than the State’s traditional Title XIX Medicaid program (ARKids-A) and requires co-payments.

The State elected a copayment as the only cost sharing requirement, because it is the most equitable form of cost sharing. The State did not want to assess an enrollment fee nor monthly premiums because it wanted the family’s cost sharing responsibility to be related solely to usage. Cost sharing is required for services that are not categorized as well-health. The State will keep the current copayment structure in place for ARKids-B enrollees.

The benefit package includes inpatient and outpatient hospital services, physician surgical and medical services, laboratory and x-ray services, well-baby care, including age-appropriate immunizations. Enrollees in the ARKids-B are not eligible for the full range of Medicaid State Plan services. The ARKids-B schedule of benefits is outlined in the table in section 6.2. ARKids-B Program).

ARKids-B utilizes the same provider system as ARKids-A (regular children’s Title XIX Medicaid) and operates under a primary care case management model. ARKids-B beneficiaries select or align with a primary care physician responsible for furnishing

11 primary and preventive services and making medically necessary referrals. Enrollees are entitled to change their primary care physician selection at any time, without limitation. As part of the enrollment materials, enrollees are provided with information concerning their disenrollment rights.

The Division of Medical Services (DMS) and the Division of County Operations (DCO) are divisions of the Department of Human Services. DMS is responsible for the administration of the Medicaid and CHIP programs except for eligibility, which is the responsibility of DCO.

D. Overview of Unborn Child Title XXI CHIP Separate Child Health Program

The Arkansas Department of Human Services administers the CHIP Unborn Child program.

The essential elements of the program are:

 Medical verification of the pregnancy is required.

 Applicant must have no other insurance that covers the pregnancy.

 Statewide income standard is from zero up to 209% FPL

 There is no resource test for the Unborn Child program.

 The benefits (with the exception of sterilization or any other family planning services) will be the same as the SIXTH OMNIBUS BUDGET RECONCILIATION ACT (SOBRA) pregnant women category under Title XIX Medicaid and include only obstetrical services and treatment for conditions that may complicate or endanger the pregnancy. Benefits include:  Prenatal services  Delivery  Postpartum services (Postpartum coverage is through the end of the month in which the 60th day from the date of delivery falls. When one or more physicians in a group see the Unborn Child program beneficiary and at least two months of antepartum care were provided culminating in delivery or the beneficiary was continuously CHIP eligible for two or more months before delivery and on the delivery date, the global method of billing CHIP for postpartum services provided is used. When less than two months of antepartum care was provided to the Unborn Child program beneficiary or the beneficiary was not CHIP eligible for at least the last two months of the pregnancy, the antepartum/obstetrical care without delivery

12 and the delivery and postpartum care can be billed to CHIP using the itemized billing method.)  Services that are determined by the physician as medically necessary as, if not provided, could complicate or endanger the eligible Unborn Child program’s beneficiary’s pregnancy.

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))

The State assures 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.

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)

The state assures that it 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.

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.

13 Original Plan

Effective Date: Medicaid Expansion (ARKids First Program) – Phase I: 10-1-98

Implementation Date: Medicaid Expansion (ARKids First Program) – Phase I: 10-1-98

SPA # 1, Purpose of SPA: Separate State CHIP – Phase II

Effective Date: Not Implemented

Implementation Date: Not Implemented

SPA # 2, Purpose of SPA: Medicaid Expansion (ARKids-B Program) – Phase III

Effective Date: 1-1-01

Implementation Date: Implemented retroactively to 1-1-01

SPA # 3, Purpose of SPA: Separate State CHIP (Unborn Child Program) – Phase III

Effective Date: 7-1-04

Implementation Date: 7-1-04

SPA # 4, Purpose of SPA: To make technical changes to align Arkansas’ CHIP state plan with current practice in the State---To delete the references to the ARKids-B opt-out provision & to clarify that Primary Care Case Management (PCCM) is now included in the HIFA ARHealthNetworks 1115(a) demonstration waiver.

Effective Date: 5-5-11 Implementation Date: 5-1-11

SPA # 5, Purpose of SPA: Add Poison Control & Drug Information Center Health Services Initiative

Effective Date: 7-1-11 Implementation Date: 7-1-11

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Superseding Pages of MAGI CHIP State Plan Material Transmittal Number & Effective/Implementation Date SPA Group PDF Number Description Superseded Plan Section(s) AR-13-0039 Effective/Implementation Date: 10/1/13 MAGI-based eligibility processing CS24 An alternative single, streamlined application, screening & enrollment process, renewals Supersedes the current sections 4.3 & 4.4 AR-14-0015 CS9 & CS13 Effective/Implementation Date: 1/1/14

CS7 & CS13 Effective/Implementation Date: 8/1/15 MAGI Eligibility CS13

CS15

CS7

CS9 The state elects to cover as a deemed newborn, a child born to a mother who is covered as a targeted low-income child under the state’s separate CHIP on the date of the newborn’s birth

Assurance that state will apply MAGI based income methodologies for all separate CHIP covered groups

Coverage of targeted low-income children

Coverage of children from conception to birth when mother is not eligible for Medicaid Supersedes the current section 4.1.3

Supersedes the current section 4.1.3

Supersedes the current sections 4.1.1; 4.1.2 & 4.1.3

Supersedes the current sections 4.1.1; 4.1.2 & 4.1.3 AR-14-0003 Effective/Implementation Date: 1/1/14 MAGI eligibility for children covered under title XXI funded Medicaid C3 Converts state’s existing income eligibility standards to MAGI-equivalent standards, by age group Section 4.0 of the current CHIP state plan

15 Superseding Pages of MAGI CHIP State Plan Material Transmittal Number & Effective/Implementation Date SPA Group PDF Number Description Superseded Plan Section(s) AR-13-0040 Effective/Implementation Date: 1/1/14 Establish 2101(f) groups CS14 Eligibility – Children ineligible for Medicaid as a result of the elimination of income disregards Incorporate within a separate subsection under section 4.1 AR-14-0042 Effective/Implementation Date: 1-1-14 MAGI eligibility

CS17

CS18

CS19

CS20

CS21

CS23 Non-financial eligibility policies on:

Residency

Citizenship

Social security number

Substitution of coverage

Non-payment of premiums

Other eligibility standards

Section 4.1.5

Sections 4.1.0; 4.1-LR & 4.1.1- LR

Section 4.1.9.1

Section 4.4.4

Section 8.7

Section 4.1.9

SPA # 6, Purpose of SPA: Separate State CHIP (ARKids-B Program)

Effective Date: 8-1-15

Implementation Date: 8-1-15

SPA # 7. Purpose of SPA: Add Intensive Home & Community-Based Family & Child/Youth Support Health Services Initiative

Effective Date: 11-1-16

Implementation Date: 11-1-16

16 SPA # 8, Purpose of SPA: Add Health & Well-Being Program for Maltreated Children Health Services Initiative

Effective Date: 1-1-17

Implementation: 1-1-17

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.

Not applicable, as there are no Indian Health Programs or Urban Indian Organizations in the State of Arkansas

TN No: Approval Date Effective Date _____

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

A. Children Covered by Department of Human Services (DHS) Programs

17 As of the January - March, 2014 quarter, there were 307,568 children enrolled in regular Title XIX Medicaid (ARKids-A). The racial break out is as follows: 165,507 (53.81%) White; 76,006 (24.71%) Black or African American; 38,727 (12.59%) Hispanic or Latino (No Race Information Available); 6,253 (2.03%) Hispanic or Latino and One or More Races; 1,000 (.33%) American Indian or Alaska Native; 2,127 (.69%) Asian; 2,061 (.67%) Native Hawaiian or Other Pacific Islander; 5,215 (1.70%) More than One Race (Hispanic or Latino Not Indicated) 10,657 (3.46%) Unknown; and 15 (.00487) No Entry.

There were 71,506 children enrolled in the Title XXI CHIP ARKids-B category as of the January – March, 2014 quarter. The racial breakout is as follows: 44,559 (62.31%) White; 13,428 (18.77%) Black or African American; 7,947 (11.11%) Hispanic or Latino (No Race Information Available; 1,041 (1.45%) Hispanic or Latino and One or More Races; 196 (.27%) American Indian or Alaska Native; 715 (.99%) Asian; 358 (.50%) Native Hawaiian or Other Pacific Islander; 928 (1.29%) More than One Race (Hispanic or Latino Not Indicated; 2,333 (3.26%) Unknown and 1(.00135%) No Entry.

B. CHIP

Phase I, was implemented 10-1-98. Phase I was a Medicaid expansion, which added children under age 19 born after 9-30-82 and before 10-1-83. The last child aged out of the Medicaid expansion on 9-30-02.

Phase II, a separate CHIP, was approved 2-16-01, but was not implemented. The separate state CHIP would have covered a portion of the ARKids-B children.

Phase III, was a combination program: The Medicaid expansion was a subset of the Title XXI CHIP ARKids-B 1115(a) demonstration waiver (implemented retroactively to 1-1-01). The separate child health program covered the Unborn Child program (implemented 7-1-04). Phase III supersedes Phase II.

In November 2013, CMS recommended the State transition the Title XXI CHIP ARKids-B 1115(a) demonstration waiver Medicaid expansion program to a separate child health program through the CHIP state plan. As the current ARKids-B 1115(a) demonstration waiver’s renewal period was due to end December 31, 2013, the State requested and CMS approved a 6-month extension (January 1 – June 30, 2014), a one-month (July 1 -31, 2014) extension, a 5-month (August 1 – December 31, 2014) extension, and a 5-month (January 1 – May 31, 2015) extension of the ARKids-B 1115(a) demonstration waiver to allow the State time to prepare and submit an amendment to the CHIP state plan, make necessary systems changes, put into place an inter-agency agreement with the Arkansas Department of Health (ADH) for the ADH to continue to provide vaccines to providers of ARKids-B beneficiaries, since these beneficiaries would no longer be eligible for the VFC program once ARKids-B is transitioned to the CHIP state plan as a separate child health program, and to accomplish other needed actions to accomplish this transition. Because the State’s currently approved CHIP state plan had been entered on an older template version, before the CHIP SPA #6 was completed, the State’s currently approved CHIP state plan was transitioned to the latest version

18 of the CHIP state plan template, and the CHIP SPA #6 was prepared on the latest template version.

C. Continued Need for CHIP Coverage Within the State of Arkansas

In a report release March 13, 2014, it is indicated Arkansas children are more likely to receive vaccinations, dental care, mental health and other health services than they were just a few years ago, although the State continues to lag behind most of the nation in many areas of children’s well- being, and State’s youth still need better access to medical care and consistent health education. These findings were published in the fourth edition of “Natural Wonders: The State of Children’s Health in Arkansas” that was published by Natural Wonders Partnership Council, a group that includes the Arkansas Department of Human Services, the Arkansas Department of Health, the Arkansas Department of Education, Arkansas Children’s Hospital, Arkansas Advocates for Children & Families, Arkansas State Dental Health Association, Arkansas Chapter of the American Academy of Pediatrics, the University of Arkansas for Medical Sciences College of Medicine Department of Pediatrics, the University of Arkansas for Medical Sciences Fay W. Boozman College of Public Health, the University of Arkansas at Little Rock, University of Arkansas at Little Rock Institute of Economic Advancement, the University of Arkansas Clinton School of Public Service, Arkansas Blue Cross and Blue Shield, Arkansas Center for Health Improvement, Arkansas Kids Count, the Arkansas Association of Educational Administrators, Arkansas Children’s Trust Fund, Arkansas Hunger Relief Alliance, Arkansas Minority Health Commission, and other state agencies and organizations.

The report provides an update on efforts to address the biggest risks faced by the State’s children and offers strategies for improving children’s health based on data collection and analysis drawing on reports by other organizations, as well as focus groups conducted by Children’s Hospital and a survey of 1,000 households in 2012, the report lists 10 priorities for improving children’s health. The report identified nine areas of emphasis for addressing the health needs of Arkansas children: 1.) Prenatal Care, Infant Mortality and Teen Pregnancy; 2.) Immunizations; 3.) Oral Health; 4.) Injury Prevention; 5.) Tobacco Use Prevention; 6.) Obesity Prevention; 7.) Mental Health Services; 8.) Health Services Needs and Expansions; 9.) Capacity Building.

The Arkansas System of Care is now reaching more families than ever. Family support partners help families set wrap-around goals for at-risk children, local care coordinating councils strengthen community-based servicers, and local youth-and family-focused activities help support families struggling with behavioral health problems. The federal Patient Protection and Affordable Care Act of 2010 and the “Private Options” 1115 demonstration waiver, the State’s program to use federal Medicaid money to subsidize private insurance for people earning up to 138% of the FPL are expected to extend insurance coverage to 500,000 previously uninsured Arkansans. As their parents secure coverage, as many as 40% of the State’s remaining uninsured children are expected to receive coverage as well. A 2013 law ensures that new home-visiting programs are evidence- based and establishes an evaluation plan to track and measure outcomes for child and family well- being and school readiness. Arkansas has already received more than $7 million annually to expand evidence-based home-visiting program and to improve training of home visitors across the State. An additional 1,000 families are being served today as a result of this effort.

19

The 2014 update provides a new dataset, allowing analysis to compare progress made in these areas since the first report was issued. Conducted in late 2012, the survey questioned 1,000 households about needs, challenges and assets related to children’s health. The Natural Wonders update also drew on the results of eight focus groups in Batesville, Forrest City, Gurdon, Lavaca, Little Rock, Jonesboro, and Springdale. Additional data was drawn from existing sources ranging from the U. S. Census Bureau to the Annie E. Casey Foundation Kids Count to neighborhood focused research by local organizations. The report emphasizes opportunities for improvement in several areas where children still face risks to their health and well-being.

Addressing access to health-care services, the report noted that more than 3000 children are enrolled in the ARKids First programs (Title XIX Medicaid ARKids-A and Title XXI CHIP ARKids-B), but Arkansas children on Medicaid/CHIP are less likely than those in other states to receive recommended medical checkups.

According to the report, vaccination compliance among Arkansas children increased from 57% in 2007 to 72% in 2011. However, the report also noted that more than 4,300 Arkansas children didn’t receive vaccinations in 2012 – 2013, blamed in part because parents can claim a “philosophical” objection to having their children vaccinated.

Twenty seven percent of Arkansas children ages 6 – 9 years of age now have dental sealants compared to 15% in 2009, and three new mobile dental clinics managed and staff by Arkansas Children’s Hospital have resulted in more than 2,000 previously underserved Arkansas children receiving dental care annually.

Arkansas’ childhood obesity rates are still high, with about 38% of children registering overweight or obesity weight levels. That percentage is about 6 points higher than the national average of 32%. Arkansas ranks 44th in the nation for obese children.

The State’s youth smoking rate dropped from 36% in 2000 to 24% in 2010. In 2013, two state laws passed that will help reduce children’s access and exposure to e-cigarettes.

The Arkansas Trauma System was formalized in 2009 so injured patients could be routed more efficiently to the best facility for care.

With support from Arkansas Children’s Hospital and the Blue & You Foundation, hundreds of classrooms in the State now have free access to online health education curriculum through Health Teacher and GoNoodle. Arkansas is the only state in the nation with this kind of initiative.

And while teenage births reported in 2011 for Arkansas dropped slightly by about 2.9% since 2009, falling from 15.5% of all births in 2002 to 12.6 % of all births in 2011, The State is the fourth highest nationwide in babies born to 15 – 19 year old mothers. In addition, the State’s infant mortality rate is high and deaths attributed to Sudden Infant Death Syndrome are almost twice the national average. The report suggests renewed emphasis on strategies to reduce these statistics and relieve other

20 risks children in Arkansas face.

The report noted that a study by Feeding America, a national network of food banks, found that 28% of Arkansas children in 2011 lived in households that are considered food insecure, meaning household members reported that a lack of money limited what they ate. Arkansas ranks first nationwide in food insecurity, despite Arkansas food banks providing more than 34 million pounds of food to families in 2013. The report notes that Arkansas’ child food insecurity rate is 27.8%. Children’s Hospital’s financial counselors, who normally help parents find assistance to pay medical bills, began helping eligible families apply for food stamps. The hospital also began participating in the U. S. Agriculture Department’s summer food service program, offering children free lunches from the cafeteria. The hospital gave out 1,728 meals under the program and plans to expand the program within the next few months to provide meals year-round.

A law was passed in 2009 that prohibits 16 and 17 year olds from driving between 11:00 p.m. and 4:00 a.m. or with more than one unrelated passenger younger than 21 unless the driver who is 21 years of age or older is also in the car. Also drivers younger than 18 years of age are prohibited from using a cellphone while driving. A 2012 study by the Arkansas Center for Health Improvement found that traffic deaths in crashes in Arkansas involving teen drivers dropped 59% from 25 deaths per 10,000 drivers in 2008 to 10 deaths per 10,000 drivers in 2010. However, the State’s motor vehicle accidents are still the leading cause of death in unintentional injuries for residents between the ages of 1 – 44 years of age.

D. Public-Private Partnerships

The State does not have a public-private partnership. The State does not have a BC/BS Caring Program for Children.

Guidance: Section 2.2 allows 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 at 42 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)

Poison Control & Drug Information Center Health Services Initiative

Arkansas uses the health services initiative (HSI) option allowed at 42 CFR 457.10 to support the Arkansas Poison and Drug Information Center (APDIC). The University of Arkansas for Medical Sciences (UAMS) College of Pharmacy operates the APDIC as a service to individuals and healthcare professionals of the State. The APDIC mission is to provide timely, useful clinical advice in potential poison exposures while enhancing a statewide system of population-based surveillance, vital records

21 and statistics, with an ongoing plan to monitor, test and implement processes to reach unprecedented levels of performance. The APDIC provides emergency telephone treatment advice, referral assistance, and information to manage exposure to poisonous and hazardous substances and provides emergent drug information to healthcare providers statewide. APDIC operates 24 hours a day, seven days a week at no charge to the public with full information and treatment capabilities. Presently all the Specialists in Poison Information (SPIs) are Certified Specialists in Poison Information (CSPIs), and the center employs three toxicologists (2 pharmacists and 1 physician) to manage cases. The services are provided via a toll-free telephone number to all communities throughout Arkansas, including underserved, low income, and indigent populations. Services are available by use of an interpreter in over 150 languages and telecommunication devices are used for the deaf and hearing impaired.

APDIC public education programs on poisoning response and prevention direct attention and resources to at-risk children, adolescents and adults living in poverty, including minority and immigrant communities. The public education specifically targets the federally designated delta region of Arkansas. The APDIC works closely with schools, healthcare organizations, parenting groups, and childcare providers throughout Arkansas to promote poison awareness. The toxicologists in the center have worked closely with the Arkansas Department of Health on emerging drugs of abuse and were instrumental in helping move the synthetic marijuana substances, “Bath Salts”, and phenazepam to scheduled status in Arkansas. The APDIC public education program provided education programs to over 30,000 children, parents and caregivers throughout Arkansas. Additionally, over 150,000 educational brochures, telephone stickers and magnets are distributed throughout Arkansas each year. Materials have been developed in English and Spanish.

Approximately 23,000 exposure cases from Arkansas are received annually by APDIC. From SFY12 children represented 63.4% of all poisoning exposure cases received by APDIC. An estimated 34.8% of total cases relate to poisoning exposures of children in families whose annual household incomes are no more than 200% FPL. APDIC calculated the number of children below 200% by tracking the total number of calls; the ages of the persons involved and then estimated the number of children below 200% based on The Kids Count Data Center 2010 statistics that estimates 55% of Arkansas’ children are living in households with incomes no greater than 200% FPL. In addition to calls regarding exposures, the APDIC receives over 11,500 calls each year from Arkansans requesting poison or drug information. These calls are considered preventive.

APDIC intervention resulted in over 88% of the exposure calls originating at home (in children less than six years of age) being handled in the home, so the children did not have to use an emergency department or need a 911 call and response. Each call to the APDIC significantly reduces costs in other medical spending. A recent study in the Journal of Medical Toxicology showed a median of 36 dollars in unnecessary healthcare charges were prevented for each dollar spent supporting a poison center.

The APDIC public toll-free number is listed in the emergency section of all Arkansas telephone directories. The number is also included in numerous community directories throughout Arkansas. The APDIC serves every county of the State on at least a monthly basis.

22 Without the CHIP funding, the Arkansas Poison and Drug Information Center would not have the operating funds to continue to provide 24 hour services to the citizens of Arkansas. The funds provided for the APDIC from the Health Services Initiative will only provide funding for costs that are directly related to the provision of services by the APDIC.

The APDIC will provide actual expenditures on children for each quarter of the SFY for reimbursement. Exposures in children have ranged from 62-68% of total case annually during 2004-2011.

The only provider that currently qualifies under the APDIC methodology is the University of Arkansas for Medical Sciences (UAMS), a State Operated public provider. UAMS receives and retains the entire Medicaid payments under APDIC. However, a specific agreed upon quarterly IGT dollar amount is received from UAMS and by signed agreement (one single quarterly agreement) is associated with the total of all Medicaid amounts paid to UAMS. The agreement specifies that the IGT $ amount cannot exceed the quarterly total Medicaid amount paid to UAMS after the IGT is received multiplied by the quarterly State Match % rate.

The State assures that the APDIC will not supplant or match CHIP Federal funds with other Federal funds, nor allow other Federal funds to supplant or match CHIP Federal funds.

Intensive Home &Community-Based Family & Child/Youth Support Health Services Initiative

Arkansas uses the health services initiative (HSI) option allowed at 42 CFR 457.10 to provide intensive home and community-based family and child/youth support services to children/youth who are involved in the Arkansas child welfare system and have serious mental health challenges. Children/youth in the State’s child welfare system would include any child/youth with an open protective services case, to include those in the legal custody of the Arkansas Department of Human Services (DHS) as well as those with “in-home cases”. Families involved that have “in-home cases” are those that have a true finding of child/youth maltreatment, but the children/youth are still in the legal and physical custody of their parents/caregivers while the DHS provides services and supports to address the issues that brought the family to the attention of the DHS as well as otherwise strengthen the family unit. The State will consider using access to children through the HSI program to enroll eligible but unenrolled children in Medicaid or CHIP where possible and appropriate.

The State assures that the Intensive Home and Community-Based Family and Child/Youth Support Health Services Initiative will target only children/youth under the age of 19.

Children/youth must meet criteria in all five (5) of the following categories to be considered having “serious mental health challenges”:

1. A child under the age of 18 or a youth between the ages of 18 and 19 who receives behavioral health services prior to the 18th birthday and who meets the following requirements: A. Functional Impairment in two of the following five capacities (compared with expected development level):

23 a. Functional self-care: Impairment in self-care is manifested by a person’s consistent inability to take care of personal grooming, hygiene, clothes and meeting of nutritional needs; b. Functioning in the community: Impairment in community function is manifested by a consistent lack of age appropriate behavioral controls, decision-making, judgement and value systems which result in potential involvement or involvement in the juvenile justice system; c. Functioning in social relationships, d. Functioning in the family, e. Functioning at school/work; 2. The child/youth must have one of the following: A. Has demonstrated a danger to self or others within the last 6 months; B. Has engaged in serious or repeated acts of destruction to property within the last 6 months; C. The individual is self-destructive such as at risk for suicide, runaway, promiscuity or at risk for causing serious injury to others; 3. The child/youth has a psychiatric disorder that has been diagnosed by a licensed mental health professional. The following disorders are exclude unless co-occurring with another psychiatric disorder: A. Autism Spectrum Disorder, B. Substance Use Disorder, C. Intellectual Disability Disorder; 4. The child/youth is currently involved with two or more child-serving divisions or agencies including mental health services; 5. The child/youth meets criteria for at least two of the following six: A. Is currently at risk for out-of-home placement in a residential facility for severe behavioral or psychiatric issues; B. Is currently an inpatient in an acute care psychiatric hospital or has experienced two or more acute care psychiatric hospitalization within the last 12 months; C. Recent (within last six months) or pending discharge from a residential facility for severe behavioral or psychiatric issues; D. A history of one or more suicide attempts within the past 12 months; E. History of significant trauma; F. Behavior has resulted in significant involvement with the Juvenile Court in the last 12 months.

The goal of the project is to provide needed behavioral support to children/youth and to foster families and relative caregivers to allow children/youth to move out of a psychiatric or behavioral residential treatment facility and return to community settings. The behavior management will be the focus of the program and will be provided to the family who receives the child/youth into a home setting. The children/youth could be in the custody of the Arkansas Department of Human Services (DHS) and be placed in foster homes or children/youth who can return to biological families. In both instances, the children/youth and families will be provided with behavioral assistance. The goal of the project is also to reduce the number of children/youth in the custody of the state who are living in psychiatric residential

24 treatment facilities by helping move them to family homes. Families will be provided the support needed to safely manage the behavioral health issues of the child/youth after discharge from a psychiatric residential treatment facility through an array of services to prepare for and manage the transition and integration the child/youth back into the home/community setting and manage behavioral issues. The proposed services are in addition to the services available in the Medicaid benefit package under the Rehabilitation option. Community-based behavioral health services that are available do not include the intensive behavioral support outlined in this HSI.

The psychiatric or behavioral residential treatment facility can begin work with the child/youth in preparation for the transition and integration of the child/youth back into the home/community setting. At the time the child/youth is ready to be discharged and the child’s/youth’s caregiver has been identified, the psychiatric residential treatment facility will work with the caregiver prior to the actual discharge. The first 90 days is the period of transition when a child/youth leaves a psychiatric or behavioral residential treatment facility and moves to a family home, community and educational setting. The child/youth has been in a highly structured environment with constant supervision and set schedule. The change to a new setting and, in most cases, new family causes much stress and adjustment for both the child/youth and family. The most intensive level of behavioral structuring and intervention is needed during this time. Providers may ask for extension of services if the child/youth or family needs continued support to maintain the child/youth in the community setting. If a child/youth is asked to be removed out of a particular foster home, the HSI services will follow the child/youth to his/her subsequent placement. Services provided through the HSI can also be used to prevent re-admissions to a psychiatric residential treatment facility or ensure the support is available to prevent initial admission.

This HSI is expected to benefit a total of 110 children/youth. At any given time, approximately 65% of the children/youth in the Arkansas foster care system are IV-E eligible and, as such, receive foster care IV-E Medicaid (“category 92”). Any child/youth who is SSI eligible is receiving Medicaid in “category 45” SSI Medicaid including IV-E eligible children/youth. If the SSI Medicaid ends, the agency places the child/youth in another Medicaid category for which the child/youth is eligible. The majority of the remaining (approximately) 35% children/youth at any given point in time in Arkansas foster care system are enrolled in Medicaid based on a different category (e.g., “category 91”). There is a small population of children/youth in foster care who do not receive Medicaid. Children/youth who would not be open in Medicaid include those who are:

1. Not citizens, 2. Incarcerated/lock-up, 3. Placed out-of-state, 4. Have too much income (extremely rare), 5. Have just entered foster care and the agency has not yet completed Medicaid determination (extremely rare).

The State has chosen five coverage regions that would include both urban and rural areas. The areas include the northeast corner of the state as well as the southeast corner. The northeast corner of the state and the counties below this corner of the state are part of the delta regions of Arkansas that

25 borders Mississippi. The counties contain some of the highest poverty rates in Arkansas. The remaining areas cover the state in between these two corners and contain both rural and urban areas.

Services Definitions:

Child/Youth and Family Support Services is a specific outcome oriented intervention provided individually with the child/youth and/or his/her caregiver(s) that provides the necessary support to attain the goals of family and community integration. The interventions will be guided by the particular behaviors displayed by the youth/child. All interventions will be trauma informed. The ranges of interventions are individualized to the child/youth/caregiver and become part of a behavioral plan developed in conjunction to the wrap-around process. The wrap-around service coordinator will identify non-traditional services and supports needed and can work with the family caregiver and community resources to access those needed. The wrap-around plan involves all staff that work with the child/youth either directly or through the child welfare family service worker. Most likely, the child welfare family service worker will provide information to court personnel. Services will be individualized based on level of experience and knowledge of the caregiver. Some caregivers will have been trained as therapeutic foster care parents so would not need additional parenting curricula training, but would need individualized support and coaching. For caregivers that have not been trained, the Nurturing Parenting Program will be utilized. Services involve applying positive behavioral interventions and supports within the community to foster behaviors that are rehabilitative and restorative in nature. The intervention should result in sustainably positive behavioral changes that improve functioning, enhance the quality of life and strengthen skills in a variety of life domains.

Services for Principal Caregivers are designed to increase a child’s/youth’s positive behaviors and encourage compliance with parents/guardians at home; working with teachers/schools to modify classroom environment to increase positive behaviors in the classroom; and increase a child’s/youth’s social skills, including understanding of feelings, conflict management, academic engagement, and cooperation with teachers and other school staff. This service is intended to increase parental skill development in managing their child’s/youth’s symptoms of their illness and training the parents/guardians in effective interventions and techniques for working with the schools.

Services for Child/Youth may take the form of mental health Behavioral Aids to assist in integration into home and community environment. Behavioral Aids work directly with the child/youth to intervene with negative behaviors and support the development of the positive behaviors that would allow the child/youth to function in a community setting. The Arkansas Medicaid program under the rehabilitation option allows service provision by mental health paraprofessionals. Under that program, each mental health paraprofessional, including Behavioral Aids, must receive 40 hours of initial training and be certified by the behavioral health agency provider. All paraprofessionals providing services under this HSI will be certified mental health paraprofessionals. The Behavioral Aid is provided to the child/youth in their home, community and school setting as needed to help the child/youth internalize the skills learned through therapy services and prevent behaviors such as aggression toward others, self-injury and property damage. The number of Behavioral Aids needed by the child/youth through the school day and then in the home would depend on the level of need of the child/youth and Labor law. If the child’s/youth’s need necessitates a Behavioral Aid throughout the school day and also in the home, the

26 child/youth could have two Behavioral Aids based on what is allowed in Labor law regarding hours worked, overtime, etc.

The services included in the Intensive Home and Community-Based Family and Child/Youth Support Health Services Initiative will be done in conjunction with a state general revenue funded program of care coordination. The care coordination model used is the Wrap-Around Process which means that the child/youth and family take the lead in setting goals and deciding how to meet them. Each child/youth/family is assigned to a Wrap-Around Specialist who helps the family communicate their strengths and needs and build up and access community resources. This program:

 Helps parents/caregivers and child/youth to communicate their family’s strengths and needs;  Supports parents/caregivers to realistically plan for challenges they may experience when the child/youth comes home after residential treatment and by working with residential provider to develop a transition plan;  Helps parents/caregivers understand and interact with mental health, educational, health, child welfare, and other systems;  Provides access to non-traditional services and supports including mentoring, tutoring, individual and family therapy, supportive recreational and enrichment activities, camps, parenting support, crisis support, and other needed services or supports identified by the child/youth and their families.

The Intensive Home and Community-Based Family and Child/Youth Support Health Services Initiative will be managed by the care coordinator leading the Wrap-Around Process. The family and support services will be provided by para-professional staff members employed by an Arkansas Medicaid certified behavioral health agency and supervised by a master’s level clinician. Reimbursement for the Intensive Home and Community-Based Family and Child/Youth Support Health Services Initiative will be an inclusive daily rate that can be higher during the first 90 days out of the congregate care setting and a lower rate the second 90 days and then tapered off.

Examples of the above defined services would include risk management and safety planning for child/youth leaving congregate care setting and reintegrating into a family home setting; support to caregiver to understand and manage behaviors; development of behavioral management plan; caregiver coaching to address behaviors associated with community reintegration and trauma; accompanying child/youth on community outings to observe behaviors, identify behavioral triggers, intervene and use results to train caregivers.

These services are in addition to the services available in the Medicaid benefit package under the Rehabilitation option. Community-based behavioral health services that are available do not include the intensive behavioral support outlined in this HSI.

The State assures that the Intensive Home and Community-Based Family and Child/Youth Support Health Services Initiative will not supplant or match CHIP federal funds with other federal funds, nor allow other federal funds to supplant or match CHIP federal funds.

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Health & Well-Being Program for Maltreated Children Health Services Initiative

Arkansas uses the health services initiative (HSI) option allowed at 42 CFR 457.10 to provide health & well-being services to improve the health and safety of maltreated children under the age of eight whose families do not qualify or are not already enrolled in an evidence-based home visiting program and whose families are involved in a protective services case (court and non-court involved) due to a true report or a differential response case involving:

 Neglect o Environmental Neglect* o Inadequate Supervision* o Medical Neglect  Failure to Thrive  Garrett’s Law **  Medical Neglect  Munchausen Syndrome by proxy  Assessing the presence of and to prevent children’s exposure to lead in the home and surrounding environment.

*Two of the allegations that will be eligible for referral to this program are environmental neglect and inadequate supervision, both of which fall under the general category of neglect. In many of the environmental neglect cases involving infants and toddlers, the environment of the home poses a threat to the health and safety of those infants and toddlers who are still crawling on the floor, often playing on the floor, and/or are not adequately supervised because environmental neglect cases typically involve home situations that include, but are not limited to, animal feces on the floor, exposed wires, broken windows, holes in the floor, severe roach/flea/bed bug/rodent infestations, rotted food within easy access and general lack of cleanliness due to the parents not knowing how to properly clean/manage the home and/or not having the resources to purchase certain cleaning materials, pay for exterminator services, repairs, etc. Another example of supporting parents in the daily management of the household would include ensuring parents know how to properly and regularly bathe their children, launder their clothes and meal plan on a budget to provide adequate nutrition to their children even with limited financial resources.

**An individualized assessment of the family’s needs and strengths is conducted on all referrals to the agency, including Garrett’s Law reports. Given that Garrett’s Law reports involve substance-exposed infants, referrals for substance abuse assessment and treatment are included in the family’s case plan the vast majority of the time. Referral/coordination with mental/behavioral health treatment is also included as needed based on the family’s individualized assessment. The evidence-based Family Advocacy Support Tool (FAST) is the assessment instrument utilized for in-home cases. Arkansas recognizes that HSIs' monies can only be used for children, not parents. The HSI funds used in the Health & Well-Being Program for Maltreated Children HSI program will be dedicated to services for the children in these cases while other funding streams will cover and other agency staff will be responsible for general case plan services. It is important to remember that referral to the Health & Well-Being for

28 Maltreated Children HSI program is just one possible service (assuming eligibility criteria are met) within a family’s case. While there will be dedicated Health & Well-Being for Maltreated Children HSI program staff, there will still be a primary DCFS caseworker assigned to the family to manage the overall case plan, speak to the family’s progress in court, etc.

This population includes a segment of one of the greatest risk populations identified in the Arkansas Department of Human Services, Division of Children & Family Services’ 2016 Child & Family Services Plan (CFSP) 2015 – 2019/Annual Progress & Services Report (APSR). The Health & Well-Being for Maltreated Children HSI program improves Arkansas’ capacity to deliver public health and child welfare services to the children described above and their families. There will be additional child health services (i.e., delivery of public health information and child welfare services related to the health needs of children served) provided to families referred to the Health & Well-Being for Maltreated Children HSI program in addition to participation in the evidence-based Safe-Care home visiting program curriculum used in the HSI.

If a family meets the criteria for the HSI, the family will receive all of the services proposed in the HSI. All families involved with the Division of Children & Family Services (DCFS) do receive an initial family assessment (the evidence-based Family Advocacy Support Tool (FAST) for families with in-home protective services cases). The Family Service Worker (FSW) will be responsible for completing the FAST for each family, not the HSI caseworker. Families referred to the HSI may receive additional services outside of the HSI based on the results of the FAST, but those additional services will also be provided by the family’s primary FSW, not the HSI caseworker.

The State assures that the Health & Well-Being for Maltreated Children HSI program will target only children/youth under the age of 19, the majority being low income. The State estimates that 98% of the children served in this program would fall under the CHIP eligibility threshold.

The goals for the Health & Well-Being for Maltreated Children Health Services Initiative program are:

 To prevent the removal of children from the home and re-occurrence of child maltreatment;  To improve the overall health and well-being of young children and their families;  To assist parents in managing the health needs of their young children.;  To coach parents of young children in positive parenting techniques that encourage healthy physical, cognitive, social and emotional development of their children;  To assess the presence of and to prevent children’s exposure to lead in the home and surrounding environment.  To provide support to parents in the daily management of their households in order to improve the health, safety and overall functioning of the home to ensure the health of young children living in the home.;

There will be additional child health services (i.e., delivery of public health information and child welfare services related to the health needs of children served) provided to families referred to this HSI in addition to participation in the evidence-based SafeCare home visiting program curriculum. In an effort to further enhance this evidence-based home visiting program and other health-related activities

29 described above, program staff will also provide more generalized “home-making” services to the families’ homes that will support parents in the daily management of their households to improve the health and safety of their young children and complement the information and activities already provided through other evidence-based home visiting program activities that address similar topics. These services are designed to improve the health, safety and overall functioning of the home and include activities such as teaching parents how to properly clean the home to maintain proper hygiene for their young children’s safety, how to develop a meal plan on a budget to ensure adequate health and nutrition for their young children. This will not impact the model delivery of the evidence-based practice. This will simple be an addition to the SafeCare home visiting program curriculum.

The program will assist parents in managing the health needs of their young children by helping parents keep various medical appointments for their young children, providing transportation to their children’s appointments as needed and making necessary referrals to specialized health services. Program staff will provide educational material regarding family planning, immunizations and other public health- related materials to promote the health and safety of young children. To stay within HSI guidelines, transportation to children’s medical appointments is the only transportation included in the Health & Well-Being for Maltreated Children HSI program. There will be other transportation services that need to be provided, e.g., transportation to other case plan services, court, etc.), but those transportation services will be provided under a different funding stream and by staff other than Health & Well-Being for Maltreated Children HSI program.

The program will also include the implementation of an evidence-based home-visiting program provided by a Family Service Worker with support from HSI program staff. This program focuses on infant and child health, parent-child/infant interactions and home safety for young children and has been demonstrated in the literature to support positive parenting linked with lessened child maltreatment.

SafeCare Evidence-Based Home Visiting Program

The SafeCare evidence-based home visiting program is designed to remediate parenting behaviors that can lead to child neglect and abuse. The program was developed to offer a more easily disseminated and streamlined program to parents at risk for child abuse and neglect. This program has also shown success in reducing recidivism in child protective services (CPS) reports. The SafeCare evidence-based home visiting program provides parent training in three focused areas: (1) parent-child/infant interactions, (2) infant and child health and (3) home safety for young children. The program emphasizes learning a social context and uses behavioral principles for parent training across the three areas. The State will contract with the national SafeCare program to provide training and follow-up coaching support to staff in Arkansas to ensure model fidelity. Contracts with the national SafeCare program have already been made to confirm that this would be a possibility.

SafeCare Evidence-Based Home Visiting Program Components

30 The SafeCare evidence-based home visiting program includes one-on-one home visits between home visitors and families. All SafeCare evidence-based home visiting program activities include baseline assessments and observation of parental knowledge and skills, parent training to enhance the health and safety of their young children and follow-up assessments to monitor change which permits the evaluation of the effectiveness of the program with our populations. Each training activity typically involves one assessment session and five training sessions. Home visitors use a seven-step approach to address target behaviors related to promoting the health of their young children: (1) describe the desired target parent behaviors, (2) explain the rationale for each behavior, (3) model each behavior, (4) ask the parent to practice the behavior, (5) provide positive feedback, (6) provide constructive feedback and (7) review the parent’s performance, have the parent practice and set goals for the week. The training is designed to promote generalization skills across time, behaviors and settings as they relate to improving the health of their young children. The program will be evaluated using the tools provided by the national SafeCare model. If the HSI program isn’t proven to be effective, changes will be made accordingly, as long as the delivery of the program maintains model fidelity.

SafeCare Evidence-Based Home Visiting Program Target Population

The SafeCare evidence-based home visiting program is designed to improve the health and safety of young children for families with a history of child maltreatment or risk factors for child maltreatment, including young parents; parents with multiple children; parents with history of depression or other mental health problems, substance abuse or intellectual disabilities; parents being reunified with their children; parents recently released from prison and parents with a history of domestic violence or intimate partner violence. The program also serves parents of children with developmental or physical disabilities or mental health, emotional or behavioral issues. The SafeCare evidence-based home visiting program is intended to complement the more specialized intervention services these families might be receiving from other agencies that improve the health and safety of their young children. The SafeCare evidence-based home visiting program is available to parents with children ages birth to age eight and has been used with culturally diverse populations.

SafeCare Evidence-Based Home Visiting Program Intensity & Length

The SafeCare evidence-based home visiting program home visitors conduct weekly or bi-weekly home visits for approximately 60 to 90 minutes each. The SafeCare evidence-based home visiting program visitation is typically delivered between 18 and 22 weeks, depending on parents’ progress and whether other services are integrated into SafeCare evidence-based home visiting program delivery. The SafeCare program is designed to be delivered within 18 weeks; however some families may need additional support/tutorials that may extend the program up to 22 weeks. Home visitors work with parents until they meet a set of skill-based criteria established for each of the three program areas. While a family case with DCFS that is managed by the DCFS Family Service Worker (FSW) may be open longer than 18 – 22 weeks, the actual HSI program provided by the HSI specific case worker will only be delivered for 18 – 22 weeks.

Assessing for the Presence & Prevention of Lead Exposure in the Home and Surrounding Environment

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The health & well-being program for maltreated children health services initiative also includes the assessment for the presence and prevention of lead exposure in the home and surrounding environment When lead exposure is found in the home, work is done with the parent in the following areas:

Creating barriers between living/play areas & lead sources. Until the environmental clean-up is completed, parents are provided instruction in cleaning and isolating all sources of lead, such as closing and locking doors to keep children away from chipping or peeling paint on walls, applying temporary barriers such as contact paper or duct tape, covering holes in walls or blocking children’s access to other sources of lead.

Regularly wash children’s hands & toys. Instructing parents that hands and toys can become contaminated from household dust or exterior soil. Both are known lead sources.

Regularly wet-mop floors & wet-wipe window components. Instructing parents that because household dust is a major source of lead, they should wet-mop floors and wet-wipe horizontal surfaces every 2 – 3 weeks. Windowsills and wells can contain high levels of leaded dust. Parents are instructed that windowsills and wells should be kept clean; if feasible, windows should be shut to prevent abrasion of painted surfaces or opened from the top sash, and shoes should be taken off when entering the house to prevent bringing lead-contaminated soil in from the outside.

Prevent children from playing in bare soil; if possible, provide them with sandboxes. Parents are instructed, if possible, to plant grass on areas of bare soil or cover the soil with grass seed, mulch or wood chips, and until the bare soil is covered, move play areas away from bare soil and away from the sides of the house. If there is a sandbox, parents are instructed to cover the box when not in use to prevent cats from using it as a litter box. This will help protect children from exposure to animal waste.

The State assures that the Health Well-Being Program for Maltreated Children HSI will not supplant or match CHIP federal funds with other federal funds, nor allow other federal funds to supplant or match CHIP federal funds.

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

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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.

Not applicable, as there are no Indian Health Programs or Urban Indian Organizations in the State of Arkansas.

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 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

33 (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 Standards 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) 42 CFR 457.490(a))

The delivery standards will be the same as under Title XIX Medicaid.

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))

34 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))

The utilization controls will be the same as under Title XIX.

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. [X] Medicaid Expansion

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

See page CS3.

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

See page CS14 for children who lose Medicaid/CHIP due to the elimination of income disregards.

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:

See page CS9.

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

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

See page CS9.

35

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)

See page CS9.

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 of time in state):

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

Not applicable.

4.1.7 Access to or coverage under other health coverage:

CHIP enrollees cannot be eligible for Title XIX Medicaid. CHIP enrollees cannot have access to a state health benefits program. Enrollees in the Title XXI CHIP Unborn Child separate child health program may not have health insurance that covers pregnancy related services. If a parent or guardian voluntarily terminates within 90-days preceding application for a child for the Title XXI CHIP ARKids-B separate child program an insurance in which the child is covered for a reason other than those allowed conditions or exemptions specifically stated in eligibility criteria, the child will be ineligible for the ARKids-B separate child health program. See also page CS20 – Substitution of Coverage.

4.1.8 Duration of eligibility, not to exceed 12 months:

Continuous eligibility does not apply to the Unborn Child CHIP separate child program.

4.1.9 Other Standards- Identify and describe other standards for or affecting eligibility, including those standards in 457.310 and 457.320 that are not addressed above. For instance:

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

36 newborns.

4.1.9.1

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

See page CS19

Guidance: States should describe their continuous 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 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;

37 (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) of the INA (8 U.S.C. § 1231) or under the Convention Against Torture who has been granted employment authorization, and such an applicant under the age of 14 who has 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 Northern Mariana Islands under 48 U.S.C. § 1806(e); or (9) An alien who is lawfully present in American Samoa under the immigration laws of American Samoa.

[ ] Elected for pregnant women. [ ] Elected for children under age __19___.

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

38 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. Assurances The 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))

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

39 public benefit programs. (Section 2102)(b)(2)) (42CFR, 457.350)

See page CS15 for Modified Adjusted Gross Income (MAGI)-based income methodologies.

See page CS24 for eligibility processing.

Retroactive coverage for the Title XXI CHIP separate child health programs ARKids-B and Unborn Child: The effective first day of coverage for the ARKids-B and Unborn Child programs is the first day of the month of application unless retroactive coverage is approved. The State is required to provide retroactive eligibility for up to three full months prior to the date of application to applicants who:

1. Received medical services in the retroactive period, and 2. Were eligible in the month the medical services were received.

Retroactive eligibility will be provided to applicants who were otherwise eligible in the month services were received regardless of whether they were ineligible at other times during retroactive period. Retroactive eligibility is separate and apart from current eligibility, i.e., applicants not eligible for the current period may be eligible for the retroactive period. Retroactive eligibility is the same for the Title XXI CHIP ARKids-B and Unborn Child programs. Coverage for ARKids-B will end on the last day of the month that eligibility ceases, unless continued eligibility is determined at the time of reevaluation. Women in the Unborn Child program will receive coverage during pregnancy and the 60 day postpartum period. Postpartum coverage is through the end of the month in which the 60th day from the date of delivery falls. When one or more physicians in a group see the Unborn Child program beneficiary and at least two months of antepartum care were provided culminating in delivery or the beneficiary was continuously CHIP eligible for two or more months before delivery and on the delivery date, the global method of billing CHIP for postpartum services provided is used. When less than two months of antepartum care was provided to the Unborn Child program beneficiary or the beneficiary was not CHIP eligible for at least the last two months of the pregnancy, the antepartum/obstetrical care without delivery and the delivery and postpartum care can be billed to CHIP using the itemized billing method.

The methods of establishing eligibility and continuing enrollment are the same as under Title XIX.

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 Enrollment Describe 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))

Check here if this section does not apply to your State.

40

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)

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

4.3.3.2-EL List the public agencies approved by the State as Express Lane agencies.

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

4.3.3.4-EL Describe 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

41 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 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

See page CS24 for eligibility processing.

States must describe how they will assure that:

4.4.1. only targeted low-income children who are ineligible for Medicaid or not covered 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), 42 CFR 457.350(a)(1) and 42 CFR 457.80(c)(3)) Confirm that the State does not apply a waiting period for pregnant women applicants

At eligibility determination and redetermination, an applicant for/beneficiary of the Title XXI CHIP ARKids-B separate child health program is reviewed to determine that the applicant/beneficiary is not Title XIX Medicaid eligibility and that the parent or guardian did not voluntarily terminate an insurance policy in which the child was covered within 90-days preceding application for the child for ARKids-B, for a reason other than those allowed conditions or exemptions specifically stated in eligibility criteria,. At eligibility determination and redetermination, an applicant for/beneficiary of the Title XXI CHIP Unborn Child separate child health program is reviewed to determine that the applicant/beneficiary is not Title XIX Medicaid eligible and is not under an insurance policy that covers pregnancy related services prior to enrollment in the State’s Unborn Child program. The Unborn Child separate child health program does not assess a waiting period for applicants. See also page CS10 – Children Who Have Access to Public Employee Coverage.

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

Screening procedures identify any applicant or enrollee of the Title XXI CHIP ARKids-B or Unborn Child separate child health programs who would be potentially eligible for Title XIX Medicaid services. An application can be completed and submitted electronically. An application can also be completed in writing on an approved DHS application form and submitted to the Agency via mail, fax, e-mail, telephone or in person to a designated DHS Agency. An application can be submitted by the individual, the individual’s spouse, or Authorized Representative, emancipated minor, or if the applicant is a minor who is not living with a parent, a caretaker acting responsibly for the minor. Although an application will be accepted and processed with only the minimal information listed below, the applicant is to complete as much information as possible in order to avoid delays in determining eligibility and processing the application. An application must include at a minimum the following information:

1. Applicant’s name, 2. Applicant’s address (or other means of contacting the applicant if homeless), and 3. Applicant’s signature (written, telephonic, or electronic).

An application submitted to DHS for processing must be monitored and tracked to ensure that the application is disposed of in a timely manner. The system is designed to monitor and track the application process from beginning to end. Therefore, each application received by the Agency must be entered into the system upon receipt to begin the process and to assign an application ID. The is referred to as registering the application. Applications submitted online will automatically be registered by the system. Applications submitted to DHS via mail, phone, fax, e-mail or in person must be entered into the system and registered by the Agency staff. Medicaid/CHIP applications must be disposed of within 45 days from the date of application unless a disability determination is required. Applications requiring a disability determination must be disposed of within 90 days from the date of application. Eligibility for all Medicaid/CHIP categories is determined in accordance with general eligibility requirements and financial eligibility. Non-financial criteria are determined depending on the category of coverage. Eligibility factors are verified in accordance with Medical Services eligibility policy requirements. Generally speaking, the system determines Medicaid/CHIP eligibility according to a rules based engine utilizing the data entered into the system by the individual, agency staff, or a combination of both. Specific eligibility determination process steps are as follows:

1. Once enough information has been entered, the system will screen the applicant’s eligibility for Medicaid/CHIP and if the individual appears eligible, will verify the applicant’s data through various data matches. 2. If the applicant’s data and data sources are “reasonably compatible” and

43 eligibility exists, the system will approve the application, update all information regarding the case, and send a notification of approval to the individual. 3. If eligibility does not exist based on the information entered on the application, the system will deny the application and send a notice to the individual. 4. If additional information is required to process the application due to reasonable compatibility issues or missing data, the system will send a notification to the individual requesting the needed information. 5. An interview with the applicant is not required. The applicant will be contacted only if necessary to obtain necessary information. 6. When all requested information is supplied by the applicant, the caseworker will enter the information into the system which will then determine eligibility. 7. If the application is denied, the system will send a notification of denial.

Applications must be disposed of by one of the following actions:

Approval: When all eligibility requirements are determined to be met, the application will be approved, and the individual enrolled in the appropriate Medicaid/CHIP coverage group. An approval notice is sent to the applicant advising that he or she has been approved for coverage with the effective date of coverage.

Denial: An application will be denied in the following situations:

1. The applicant is determined to be ineligible due to an eligibility requirement not being met; 2. Eligibility cannot be established due to failure of the applicant to provide information necessary to determine eligibility; or 3. The applicant withdraws the application.

When an application is denied, a denial notice is sent advising the applicant of the denial, reason for denial, and the applicant’s right to appeal the denial.

Each individual approved for Medicaid/CHIP by DHS will be enrolled in the appropriate eligibility coverage group. The system will make this determination based on the information entered to the system. Upon enrollment, a Medicaid or ARKids ID card is issued to the eligible individual if the person does not already have an existing care.

4.4.3. children found through the screening process to be ineligible for Medicaid are enrolled in CHIP; (Sections 2102(a)(1) and (2) and 2102(c)(2)) 42CFR 431.636(b)(4))

Any applicant or enrollee who is found ineligible for Medicaid services is automatically reviewed for CHIP separate child health program eligibility.

44 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)

See page CS20 for substitution of coverage

4.4.4.1. (formerly 4.4.4.4) If the State provides coverage under a premium assistance 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 State who are American Indian and Alaska Native. (Section 2102(b)(3)(D)) (42 CFR 457.125(a))

American Indian and Alaska Native children are eligible for Arkansas’ CHIP separate child health program on the same basis as any other children in the State, regardless of whether they may be eligible for or served by Indian Health Services-funded care.

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.

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.

45

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):

Medicaid/CHIP

The State has been extremely active in its effort to identify and enroll uncovered children who are eligible to participate in the Arkansas Medicaid/CHIP Program.

The State has cooperative agreements with 35 hospitals, clinics, and organizations throughout the state to place out-stationed DHS Medicaid/CHIP eligibility workers in their facilities. This has simplified the application process and has encouraged individuals and families to apply for Medicaid/CHIP when otherwise they might not have done so.

DHS also has an agreement with the Federally Qualified Health Centers for 19 staff who cover their 36 sites. These FQHC staff members assist in the application process. Medicaid/CHIP outreach is also furthered by a contract between the Arkansas Department of Human Services and the Arkansas Department of Health (ADH) for ConnectCare, the Arkansas Primary Care Case Management program. ConnectCare provides outreach through statewide television and radio advertisements to inform both current eligibles and potential eligibles about the merits of primary medical coverage through Arkansas Medicaid/CHIP.

State-only Child Health Insurance

The State does not have any State-only child health insurance programs.

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

46 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:

The State does not have a public-private partnership. The State does not have a BC/BS Caring Program for Children.

Guidance: The State should describe below how its 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.

Children formerly covered in the 1115 demonstration ARKids B will be covered for health coverage funded through Title XXI CHIP as a separate child health program.

Targeted to Uninsured Children

The ARKids-B program is designed to provide health insurance coverage for uninsured children under age 19. Uninsured is defined as not having group or employer sponsored primary comprehensive health insurance within the previous 90 days prior to program enrollment unless such insurance was lost through no-fault. An example of no-fault would be if the child had had health insurance through a parent’s employment, and the parent is no longer employed. Also children who have inaccessible health insurance are considered to be uninsured. For example, a child has inaccessible health insurance if the child has an out of state, non-custodial parent with HMO insurance for his/her child, but the HMO network does not contain medical providers where the child resides.

Coordination With Medicaid

The ARKids First name is used as an umbrella for ARKids-A (Title XIX Medicaid) and ARKids-B (Title XXI CHIP).. Based on the family’s countable income and household size, eligibility will be determined in the appropriate ARKids First category; ARKids-A or ARKids-B.

The application form contains a chart, which shows the services and cost sharing requirements in

47 each program.

Title XXI CHIP ARKids-B uses the same provider network and the same fiscal agent to process claims that Title XIX Medicaid ARKids-A uses.

NOTE: ARKids-B will be funded by Title XXI.

Coordination with Children’s Medical Services

The Department of Human Services operates a Children’s Medical Services Program which provides care coordination and/or specialized medical care and rehabilitation for children with special health care needs whose families are partially or wholly unable to provide for such services, and who meet the agency’s criteria. Children’s Medical Services are funded by federal (Title V) and state funds. The Children’s Medical Services staff coordinates closely with Medicaid/CHIP, especially with regard to the TEFRA-like Medicaid 1115 demonstration waiver, to ensure that the children they serve receive the widest range of services to which they are entitled. Please reference Section 1.1.3. (Sub-Section A) for more information and history regarding the TEFRA- like demonstration.

Coordination with Maternal and Child Health

The Title V Maternal and Child Health (MCH) programs are administered by the Arkansas Department of Health. Preventive health services are available to women, children, adolescents and families in 100 service sites in the state’s 75 counties. Preventive services provided include well-child screens, immunizations, prenatal care, family planning, hearing and vision screening, newborn screening, blood lead screening, and follow-up. Over 250,000 Arkansans receive some level of Title V MCH services each year. Services to children with Special Health Care Needs are coordinated with DHS.

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, out stationed 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.

48 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. Strategies 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)

Arkansas developed a comprehensive outreach strategy for ARKids-B. The strategy applies equally to the Title XXI CHIP ARKids-B and the Unborn Child separate child health programs. Outreach for the ARKids-B and Unborn Child programs is through the ConnectCare contract with ADH and through the ADH pregnant women’s program. Outreach and education for ARKids First (Title XIX Medicaid ARKids-A and Title XXI CHIP ARKids-B) is also through a contract.

Media Campaign

In addition to the regular Title XIX Medicaid ARKids-A outreach, Arkansas developed outreach geared specifically to the Title XXI CHIP ARKids-B Program. Governor Mike Huckabee held a gala press conference on September 11, 1997, to launch the ARKids-B Program. This has been followed by an extensive media campaign, including television, radio, print, and distribution of brochures in such places as McDonald’s food sacks. A key factor in the success of this campaign was the active role Governor Huckabee took by appearing in television and radio public service announcements, as well as in the printed materials and on the ARKids-B website: www.ARKidsfirst.com.

The media campaign has been modified to incorporate the changes in the use of the ARKids First name; ARKids First is now composed of ARKids-A (Title XIX Medicaid) and ARKids-B, (Title XXI CHIP)..

Coordination With Public and Private Entities

The outreach effort has been further advanced by working in cooperation with a broad range of public and private entities. These include Arkansas Children’s Hospital (they co-sponsor an ARKids First (ARKids-A (Title XIX Medicaid) and ARKids–B (Title XXI CHIP) newspaper insert with DHS), Arkansas Advocates for Children and Families, and several public schools, day care centers, hospitals, clinics, churches, and community centers. Arkansas Department of Human Services (DHS) county offices widely distribute ARKids First application forms to these organizations. Arkansas Advocates for Children and Families has been particularly instrumental in providing outreach by targeting outreach efforts in key parts of the state.

A supply of applications for ARKids First (ARKids-A (Title XIX Medicaid), ARKids-B (Title XXI CHIP) and the Unborn Child (Title XXI CHIP) separate child health programs) are provided to the Arkansas Department of Health (ADH) for distribution in their WIC clinics. ADH is a primary intake

49 point for the separate child health insurance programs.

Contracts

A. Contract Funded through the Arkansas Department of Human Services to Provide Education and Outreach

Arkansas Department of Human Services spends approximately $125,000 each state fiscal year on outreach and education for ARKids First (Title XIX Medicaid ARKids-A and Title XXI CHIP ARKids-B). The primary goal of the outreach and education is to prompt families already participating in the ARKids program to utilize prevention services, such as well child checkups. There is a print media campaign that promotes using ARKids for well-child, dental and eye check- ups. Materials are purchased (such as refrigerator magnets with a list of every needed well-child checkup for the first four years of a child’s life) that are distributed during at least a dozen large scale family consignment sales across the state. In addition, Radio Disney Summer Safety Roadshow events are held at each of five summer feeding sites across the state and radio advertising is conducted.

B. Contract with the Arkansas Department of Health

The State has a contract with the Arkansas Department of Health (ADH) to provide information to recipients/applicants through a media campaign and a 24 hour toll-free telephone Help Line Service. The Help Line Service responds to questions received from ARKids First (ARKids–A (Title XIX Medicaid) and ARKids–B (Title XXI CHIP)) applicants/recipients and providers by telephone concerning eligibility, access, enrollment, rights and responsibilities and other issues. The ADH media campaign publicizes the telephone Help Line, promotes appropriate usage of the medical care system, and uses the most cost-effective strategies, as determined by ADH with DHS approval. The campaign may include television and radio advertising, direct mail, print media, telemarketing and other viable methods that target children.

Website

The ARKids First website address is http://www.arkidsfirst.com. The site has six subject links: 1) eligibility, 2) questions, 3) apply, (this includes an application in English or Spanish which can be printed from the website), 4) benefits, 5) more information, and 6) other services.

The Arkansas Medicaid website is located at https://www.medicaid.state.ar.us. This site contains a link to the ARKids First site.

Section 6. Coverage Requirements for Children’s Health Insurance – ARKids-B Program

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.

50

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.[X] 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: Check box 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)))

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.)

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,

51  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 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

52 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))

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.[X] Secretary-approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) .) See ATTACHMENT A for a copy of Arkansas State and Public School Employees benchmark benefits description.

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 waiver

6.1.4.3. Coverage that either includes the full EPSDT benefit or that the State has extended to the entire Medicaid population

Guidance: Check below if the coverage offered includes benchmark coverage, as specified in 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.[X] Coverage that includes benchmark coverage plus additional coverage.) Vision services (eye exam – one routine eye exam [refraction] every 12 months and eyeglasses – one pair every 12 months) and dental services (routine dental care & orthodontia) make up the additional benefit coverage to the Arkansas State and Public School Employees benchmark benefits. (See ATTACHMENT A for a copy of Arkansas State and Public School Employees benchmark benefits description).

53

6.1.4.5. Coverage that is the same as defined by existing comprehensive state-based coverage applicable only New York, Pennsylvania, or Florida (under 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 to coverage under one of the benchmark plans specified in 457.420, through 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 in 457.431 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)

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)

ARKids-B Program

The Title XXI CHIP ARKids-B program’s benefit package includes inpatient and outpatient hospital services, physician, surgical and medical services, laboratory and x-ray services, well baby care, including age-appropriate immunizations. Enrollees in ARKids-B are not eligible for the full range of Medicaid State

54 Plan services. The chart below provides a description of the coverage and the amount, duration, and scope of services covered in certain services included in the ARKids-B benefit package, as well as any exclusions or limitations. The services checked below in the pre-print are included in the ARKids-B benefit package.

Ambulance (Emergency Only) Ambulatory Surgical Center Audiological Services (only Tympanometry, CPT procedure code 92567, when the diagnosis is within the ICD-9-CM range of 381.0 through 382.9) Certified Nurse Midwife Chiropractor Dental Care (routine dental care & orthodontia) Durable Medical Equipment (DME) (Limited to $500 per State Fiscal Year (SFY) July 1 – June 30) Emergency Dept. Services (Emergent, non-emergent, assessment) Family Planning Federally Qualified Health Center (FQHC) Home Health (10 visits per SFY (July 1 – June 30)) Hospital, Inpatient Hospital, Outpatient Inpatient Psychiatric Hospital & Psychiatric Residential Treatment Facility Immunizations (All per protocol) Laboratory & X-Ray Medical Supplies (Limited to $125/month unless benefit extension is approved) Mental & Behavioral Health, Outpatient Nurse Practitioner Physician Podiatry Prenatal Care Prescription Drugs Preventive Health Screenings (All per protocol) Rural Health Clinic Speech Therapy Evaluation – Four 30 minute units/SFY (July 1 – June 30) unless benefit extension is approved Therapy – Four 15 minute units/day unless benefit extension is approved Physical Therapy Evaluation – Four 30 minute units/SFY (July 1 – June 30) unless benefit extension is approved Therapy – Four 15 minute units/day unless benefit extension is approved Occupational Therapy Evaluation – Four 30 minute units/SFY (July 1 – June 30) unless benefit extension is approved Therapy – Four 15 minute units/day unless benefit extension is approved Substance Abuse Treatment Services (SATS), outpatient Vision

55 (Eye exam – One routine eye exam (refraction) every 12 months Eyeglasses) – One pair every 12 months

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))

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.[X] 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))

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.

56

6.2.14.

Home and community-based health care services (Section 2110(a)(14))

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.[X] 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.[X] 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.

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.

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.

Hospice care (Section 2110(a)(23))

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; 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.

6.2.24.[X] Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (Section 2110(a)(24))

The Title XXI CHIP ARKids-B benefit package includes vision services that include one eye exam (refraction) and one pair of eyeglasses every 12 months

57 6.2.25.

Premiums for private health care insurance coverage (Section 2110(a)(25))

6.2.26.[X] 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.

6.2.27.

Enabling services (such as transportation, translation, and outreach services (Section 2110(a)(27))

6.2.28.

Any other health care services or items specified by the Secretary and not included under this Section (Section 2110(a)(28))

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[X] State Specific Dental Benefit Package. The State assures dental services represented by the following categories of common dental terminology (CDT1) 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

6.2.1.1-DC 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

Current Dental Terminology, © 2010 American Dental Association. All rights reserved.

58 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 CDT2 codes. If the State chooses to provide supplemental 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.)

6.3. The State assures that, with respect to pre-existing medical conditions, one of the following two

Current Dental Terminology, © 2010 American Dental Association. All rights reserved.

59 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)) (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 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

60 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 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

61 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 # 10-002 issued 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

6.4.3.1.1-PA Provide an assurance that the qualified employer- sponsored insurance 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-PA Describe 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

62 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-PA Describe 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-PA Provide 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-PA Describe the State’s process for ensuring parents are permitted to disenroll their child from qualified employer-sponsored coverage and to enroll in CHIP

63 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-PA Describe 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-PA Describe the plan to establish an employer-family premium assistance purchasing pool.

6.6.3.5.2-PA Provide 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-PA Provide 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

64 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)).

6.4.3.6.1-PA Provide an assurance that the State includes information about premium assistance on the CHIP application or enrollment form.

Section 6. Coverage Requirements for Children’s Health Insurance – Title XXI CHIP Unborn Child Program

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: Check box 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.)

65

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)))

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.)

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 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

66 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))

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)

6.1.4.1. [] Coverage the same as Medicaid state plan

67 6.1.4.2.

Comprehensive coverage for children under a Medicaid Section 1115 demonstration waiver

6.1.4.3.

Coverage that either includes the full EPSDT benefit or that the State has extended to the entire Medicaid population

Guidance: Check below if the coverage offered includes benchmark coverage, a . 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

6.1.4.5.

Coverage that is the same as defined by existing comprehensive state-based coverage applicable only New York, Pennsylvania, or Florida (under 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 to coverage under one of the benchmark plans specified in 457.420, through 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 in 457.431 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.[X] Other (Describe)

Conception through birth: For the Title XXI CHIP Unborn Child program, the State covers the same services that it covers in the Medicaid state plan for SIXTH OMNIBUS BUDGET RECONCILIATION ACT (SOBRA) pregnant women with the

68 exception of sterilization or other family planning services. Services include prenatal services, delivery, 60 day postpartum services and services for conditions that are determined by a physician as needed, as if not provided, could complicate and/or endanger the pregnancy. Postpartum coverage is through the end of the month in which the 60th day from the date of delivery falls. When one or more physicians in a group see the Unborn Child program beneficiary and at least two months of antepartum care were provided culminating in delivery or the beneficiary was continuously CHIP eligible for two or more months before delivery and on the delivery date, the global method of billing CHIP for postpartum services provided is used. When less than two months of antepartum care was provided to the Unborn Child program beneficiary or the beneficiary was not CHIP eligible for at least the last two months of the pregnancy, the antepartum/obstetrical care without delivery and the delivery and postpartum care can be billed to CHIP using the itemized billing method.

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)

Title XXI CHIP Unborn Child Program

For the Unborn Child program, the State covers pregnancy related services and services that are determined as medically needed by a physician as, if not provided, could complicate or endanger the pregnancy. In the Unborn Child program the State covers the same services that it covers for the SIXTH OMNIBUS BUDGET RECONCILIATION ACT (SOBRA) pregnant women category in the Title XIX Medicaid state plan with the exception of sterilization or any other family planning services. The services checked below are covered as a result of the eligible Unborn Child program’s beneficiary’s pregnancy. Other services not checked below could potentially be covered for the CHIP Unborn Child group, depending on the need of the recipient and is determined by a physician as medically needed, as if not provided, could complicate and/or endanger the pregnancy. Arkansas CHIP program rules apply; examples include benefit limits, extension of benefit limit procedures, prior authorization requirements, age limits, etc.

6.2.1.[X] Inpatient services (Section 2110(a)(1))

69

6.2.2.[X] Outpatient services (Section 2110(a)(2))

6.2.3.[X] Physician services (Section 2110(a)(3))

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.

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))

Guidance: Nursing services may include nurse practitioner services, nurse midwife services, advanced practice nurse services, private duty nursing care,

70 pediatric nurse services, and respiratory care services in a home, school or other setting.

6.2.15.[X] 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.

Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18))

6.2.19.[ ] Outpatient substance abuse treatment services (Section 2110(a)(19))

6.2.20.

Case management services (Section 2110(a)(20))

6.2.21.

Care coordination services (Section 2110(a)(21))

6.2.22.

Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22))

6.2.23.

Hospice care (Section 2110(a)(23))

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; 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.

6.2.24.[] Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (Section 2110(a)(24))

6.2.25.

Premiums for private health care insurance coverage (Section 2110(a)(25))

6.2.26.

Medical transportation (Section 2110(a)(26))

Guidance: Enabling services, such as transportation, translation, and outreach

71 services, may be offered only if designed to increase the accessibility of primary and preventive health care services for eligible low-income individuals.

6.2.27.

Enabling services (such as transportation, translation, and outreach services) (Section 2110(a)(27))

6.2.28.

Any other health care services or items specified by the Secretary and not included under this Section (Section 2110(a)(28))

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)): Not applicable for Title XXI CHIP Unborn Child program, as there is no dental coverage included in this program.

6.2.1-DC State Specific Dental Benefit Package. The State assures dental services represented by the following categories of common dental terminology (CDT3) codes are included in the dental benefits: 10. Diagnostic (i.e., clinical exams, x-rays) (CDT codes: D0100- D0999) (must follow periodicity schedule) 11. Preventive (i.e., dental prophylaxis, topical fluoride treatments, sealants) (CDT codes: D1000-D1999) (must follow periodicity schedule) 12. Restorative (i.e., fillings, crowns) (CDT codes: D2000-D2999) 13. Endodontic (i.e., root canals) (CDT codes: D3000-D3999) 14. Periodontic (treatment of gum disease) (CDT codes: D4000- D4999) 15. Prosthodontic (dentures) (CDT codes: D5000-D5899, D5900- D5999, and D6200-D6999) 16. Oral and Maxillofacial Surgery (i.e., extractions of teeth and other oral surgical procedures) (CDT codes: D7000-D7999) 17. Orthodontics (i.e., braces) (CDT codes: D8000-D8999) 18. Emergency Dental Services

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)

Current Dental Terminology, © 2010 American Dental Association. All rights reserved.

72

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 CDT4 codes. If the State chooses to provide supplemental 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.)

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

Current Dental Terminology, © 2010 American Dental Association. All rights reserved.

73

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)) (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 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

74 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 457.1010)

75 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 # 10-002 issued 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

76 6.4.3.1-PA Qualified Employer-Sponsored Coverage and Premium Assistance Subsidy

6.4.3.1.1-PA Provide an assurance that the qualified employer-sponsored insurance 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-PA Describe 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-PA Describe 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

77 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-PA Provide 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-PA Describe the State’s process for ensuring parents are permitted to 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-PA Describe 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

78 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-PA Describe the plan to establish an employer- family premium assistance purchasing pool.

6.6.3.5.2-PA Provide 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-PA Provide 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)).

6.4.3.6.1-PA Provide 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.

79

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 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.

80 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.)

7.1.1.

Quality standards

7.1.2.[X] Performance measurement

7.1.2 (a)[X] CHIPRA Quality Core Set

7.1.2 (b)[X] Other

7.1.3.[X] Information strategies

7.1.4.[X] Quality improvement strategies

Access to Services – Arkansas Foundation for Medical Care (AFMC), DHS DMS contract agent for provider relations, encourages provider participation and compliance in the primary care case management program and other programs through site visits and regular correspondence to primary care physicians, select specialty physicians, and hospitals. Additionally, AFMC provider relations provides submissions to professional journals, participates in professional and specialty organizations, and sponsors conferences. Each quarter more than 750 primary care physicians are visited and pertinent information is shared related to program performance, policy, and updates on planned activities and initiatives.

AFMC regularly distributes articles of interest directly to the provider community via newsletter, blast faxes, conference calls and virtual meetings as well as publications in established journals. Furthermore, provider representatives are actively engaged in trade associations, such as the Arkansas Medical Society, the Arkansas Academy of Family Practice, and the Arkansas Hospital Association. These relationships afford additional opportunities for strengthening the provider network via collaboration, presentations, and exhibits at conferences and other healthcare related events throughout the state annually to offer a more dedicated venue for detailed discussion, collaboration and relationship advancement with the provider community and related stakeholders.

81 Information to Beneficiaries Regarding Covered Services, Preventive Health, and Facilitate Access to Primary Care Physicians and Specialists – Arkansas Foundation for Medical Care (AFMC), DHS DMS contract agent for beneficiary relations improves the quality and effectiveness of medical care by establishing and maintaining positive relationships with beneficiaries in Medicaid and CHIP related matters. This is accomplished through direct contact with beneficiaries and the creation, printing, and distribution of promotional, interventional, and informational materials. AFMC also operates a toll free complaint line that is available to the Medicaid or CHIP beneficiaries Monday – Friday.

There are a minimum of four beneficiary communications per year. Materials are available in Spanish and English and other languages upon request, e.g., beneficiaries are mailed a postcard with the number of the Beneficiary Grievance Line.

AFMC beneficiary relations also maintains a website that contains tools for beneficiaries as well as professionals. Educational materials can be downloaded and printed or ordered at the website by either beneficiaries or health care professionals. Currently the website has approximately 10 pages of educational brochures available, e.g. Acute MI Indictors, Adolescent Immunization (Spanish and English), Adolescent Immunization Poster (Spanish and English), All Terrain Vehicle Safety (Spanish and English), Antibiotic Resistance Activity Sheet. Informational blogs are also available at the AFMC website. New B/P Guideline and Eat Like a Diabetic are the newest blogs posted. Other current informational blogs are: Adult Immunization, Adverse Drug Events, Breast Cancer Prevention, Cardiac Disparities, Colorectal Cancer.

Additionally, DHS DMS partners with the Arkansas Department of Health (ADH) to provide beneficiary outreach in the form of a newsletter with pertinent Medicaid or CHIP related messages. ADH provides a call center to facilitate the selection of a primary care physician and assistance in locating a dental provider.

Quality Improvement Strategies – DHS DMS contracts with a Quality Improvement Organization (QIO) to serve as a quality improvement contract agent. The QIO identifies potential projects through research of current challenges, national initiatives and HEDIS measures that will improve the quality of care for Arkansas beneficiaries. Data analysis is performed to determine the target population, clinical measures, and strategies for success. Project topics and research are presented to DHS DMS for approval.

Upon approval by DHS DMS, development of the project is begun including more intensive research utilizing evidence-based guidelines and criteria, journal research, and data analysis.

Strategies for success, resources, educational tools, and materials are developed for academic detailing. Materials are reviewed by the QIO contract agent’s communication department to ensure that the literacy level is appropriate for the target audience. The project plan including all resources, educational tools and materials, and strategies for success is submitted to DHS for approval prior to dissemination of the project to the provider community. Academic detailing is provided to the relevant provider population to increase the quality of service provided to Medicaid

82 and CHIP beneficiaries.

Performance Metrics – Arkansas Foundation for Medical Care (AFMC) beneficiary relations also assesses beneficiaries’ needs and satisfaction through standardized surveys or focus groups. AFMC develops and conducts surveys and provides data analysis and reports. AFMC statisticians and analysts conduct consumer satisfaction surveys for beneficiaries participating in Primary Care Case Management (PCCM), Children’s Health Insurance Program, Tax Equity and Fiscal Responsibility Act (TEFRA). These populations are surveyed using Consumer Assessment of Healthcare Providers and Systems (CAHPS®) modified CAHPS®, Experience of Care and Health Outcomes (ECHO®), Pregnancy Risk Assessment Monitoring System (PRAMS)-Like, SF-36. And custom designed surveys.

AFMC manages all aspects of sample design, population sampling, survey design, data collection, and analysis. AFMC also sends survey results to the National CAHPS® Benchmarking Database (NCBD). This process provided a means for comparison to other participating states’ health care programs and set appropriate benchmarks CAHPS® surveys are designed to assess consumer satisfaction with various aspects of the healthcare delivery system including, but not limited to, the plan structure, providers, customer service, and overall healthcare and wellness.

In addition to CAHPS®, DHS DMS monitors performance of both the Medicaid and CHIP state plans through use of the HEDIS data set. Each year, DHS DMS data analytics contract agents publish a HEDIS report with many of the available metrics. Additionally, AFMC data analytics contract agent assists DHS DMS in compiling the date required for the submission through CARTS and CHIPRA core metrics such as annual well-child visits, annual dental visits, and immunization data.

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)

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))

Enrollees participating in the Title XXI CHIP ARKids-B separate child health program must enroll with a ConnectCare primary care physician (PCP) or Patient Centered Medical Home (PCMH) who is responsible for managing the health care of the enrollees. This would include the provision of primary care services and health education to the enrollees; making referrals for medically necessary specialty physicians’ services and for hospital care and other medically necessary services; monitoring and coordinating the

83 immunization status of childhood and adolescent immunizations of enrollees under the age of 21 in his/her PCP caseload; coordinating and monitoring enrollees’ prescribed medical and rehabilitative services with the providers of those services, hospital care, and other services; as well as assisting in locating medical services for the enrollees; and the monitoring and maintenance of the Child Health Services/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) screening periodicity of any enrollees under the age of 21, regardless of who screens those enrollees. This would also include the coordination and monitoring of any subsequent referrals, treatment, or testing for the enrollees. This monitoring and assurance in accessing care are consistent with those methods used for Title XIX enrollees.

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))

The role of the Provider Representative includes the ongoing visitation with health care providers, facilities, and emergency rooms to ensure these providers continued acceptance of Title XIX and Title XXI eligible beneficiaries and their adherence to policies of covered health care services. Statistical analysis is used as a means of identifying, among other things, problem(s) associated with access to covered services. When any access problems are identified, the Provider Representative conducts follow-up with providers to identify solutions and correction of the identified problem(s).

Enrollees participating in the Title XXI CHIP ARKids-B and Unborn Child separate child health programs must enroll with a ConnectCare primary care physician (PCP) or Patient Centered Medical Home (PCMH). ConnectCare and Patient Centered Medical Home enrollees must have the same access as private pay and insured persons to emergency and non-emergency medical services.

ConnectCare PCPs must have hours of operation that are reasonable and adequate to serve all of his/her patients; make available 24/7 telephone access to a live voice (an employee of the primary care physician or an answering service) or to an answering machine that will immediately page an on-call professional who will provide information and instructions for treating emergency and non-emergency conditions, make appropriate referrals for non-emergency services, and provide information regarding accessing other services and handling medical problems during hours the PCP’s office is closed; respond to after-hours calls regarding non-emergencies within 30-minutes; make after-hours telephone numbers as widely available as possible to his/her patients; and regularly check answering machines to ensure the machine functions correctly and instructions are up-to- date when answering machines with recorded instructions are employed for after-hours callers.

Patient Centered Medical Homes (PCMH) must make available 24/7 access to care; provide telephone access to a live voice (e.g., an employee of the primary care physician or an answering service) or to an answering machine that immediately pages an on-call

84 medical profession 24/7 who will provide information and instructions for treating emergency and non-emergency conditions, make appropriate referrals for non-emergency services, and provide information regarding accessing other services and handling medical problems during hours the PCP’s office is closed; respond to after-hours calls regarding non-emergencies within 30-minutes (calls must be treated as an emergency if made under circumstances where a prudent layperson with an average knowledge of health care would reasonably believe that treatment is immediately necessary to prevent death or serious health impairment); make after-hours telephone number known, at a minimum, by providing the 24-hour emergency number to all beneficiaries, posting the 24-hour emergency number on all public entries to each site, and including the 24-hour emergency phone number on answering machine greetings; and regularly check answering machines to ensure the machine functions correctly and instructions are up-to-date when answering machines with recorded instructions are employed for after-hours callers. Documentation by written report of the completion of these activities must be provided by the Patient Centered Medical Home (PCMH) via provider portal.

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))

Enrollees participating in the Title XXI CHIP ARKids-B and Unborn Child separate child health programs must enroll with a ConnectCare primary care physician (PCP) or Patient Centered Medical Home (PCMH) who is responsible for managing the health care of the enrollees. This would include the provision of primary care services and health education to the enrollees; making referrals for medically necessary specialty physicians’ services and for hospital care and other medically necessary services; monitoring and coordinating the immunization status of childhood and adolescent immunizations of enrollees under the age of 21 in his/her PCP caseload; coordinating and monitoring enrollees’ prescribed medical and rehabilitative services with the providers of those services, hospital care, and other services; as well as assisting in locating medical services for the enrollees in-network and out-of-network when in-network providers are not adequate for the enrollees’ medical condition; and the monitoring and maintenance of the Child Health Services/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) screening periodicity of any enrollees under the age of 21, regardless of who screens those enrollees. This would also include the coordination and monitoring of any subsequent referrals, treatment, or testing for the enrollees. ConnectCare and Patient Centered Medical Home enrollees must have the same access as private pay and insured persons to emergency and non-emergency medical services. This monitoring and assurance in accessing care are consistent with those methods used for Title XIX enrollees.

ConnectCare PCPs must have hours of operation that are reasonable and adequate to serve all of his/her patients; make available 24/7 telephone access to a live voice (an

85 employee of the primary care physician or an answering service) or to an answering machine that will immediately page an on-call professional who will provide information and instructions for treating emergency and non-emergency conditions, make appropriate referrals for non-emergency services, and provide information regarding accessing other services and handling medical problems during hours the PCP’s office is closed; respond to after-hours calls regarding non-emergencies within 30-minutes; make after-hours telephone numbers as widely available as possible to his/her patients; and regularly check answering machines to ensure the machine functions correctly and instructions are up-to- date when answering machines with recorded instructions are employed for after-hours callers.

Patient Centered Medical Homes (PCMH) must identify the top 10% of high-priority beneficiaries using DMS patient panel data that ranks beneficiaries by risk or the practice’s patient-centered assessment to determine which beneficiaries on this list are high-priority; identify and reduce medical neighborhood barriers to coordinated care at the practice level; make available 24/7 access to care; provide telephone access to a live voice (e.g., an employee of the primary care physician or an answering service) or to an answering machine that immediately pages an on-call medical profession 24/7 who will provide information and instructions for treating emergency and non-emergency conditions, make appropriate referrals for non-emergency services, and provide information regarding accessing other services and handling medical problems during hours the PCP’s office is closed; respond to after-hours calls regarding non-emergencies within 30-minutes (calls must be treated as an emergency if made under circumstances where a prudent layperson with an average knowledge of health care would reasonably believe that treatment is immediately necessary to prevent death or serious health impairment); make after-hours telephone number known, at a minimum, by providing the 24-hour emergency number to all beneficiaries, posting the 24-hour emergency number on all public entries to each site, and including the 24-hour emergency phone number on answering machine greetings; regularly check answering machines to ensure the machine functions correctly and instructions are up-to-date when answering machines with recorded instructions are employed for after-hours callers; establish processes that result in contact with beneficiaries who have not received preventive care; complete a short survey related to beneficiaries’ ability to receive timely care, appointments, and information form specialists, including Behavioral Health (BH) specialists.

The role of the Provider Representative includes the ongoing visitation with health care providers, facilities, and emergency rooms to ensure these providers continued acceptance of Title XIX and Title XXI eligible beneficiaries and their adherence to policies of covered health care services. Statistical analysis is used as a means of identifying, among other things, problem(s) associated with access to covered services. When any access problems are identified, the Provider Representative conducts follow-up with providers to identify solutions and correction of the identified problem(s).

86 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 Arkansas DHS Division of Medical Services employs and contracts with quality improvement organizations who exercise a stringent review of prior authorizations (PAs) completed for covered health care services for Title XIX and Title XXI enrollees to ensure PAs have been completed in accordance with State law, in accordance with the medical needs of the patient, and within the specified number of days after the receipt of a request for services.

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. [X] Yes for the Title XXI CHIP ARKids-B separate child health program

NOTE: There is no cost-sharing imposed on beneficiaries of the Title XXI CHIP Unborn Child separate child health program

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))

87 CHIP Title XXI CHIP ARKids-B Program

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))

8.2.1.

Premiums:

8.2.2.

Deductibles:

8.2.3. [X] Coinsurance or copayments:

Co-payments and co-insurance apply for all services with the exception of immunizations, preventive health screenings, family planning, and prenatal care. The Title XXI CHIP ARKids-B schedule of co-payments and co-insurance is outlined in the following table. The annual cumulative cost-sharing maximum cannot exceed 5% of the ARKids-B beneficiary’s family’s income.

Benefits/Limits Co-Pay/Co-Insurance Ambulance (Emergency Only) $10 per trip Ambulatory Surgical Center $10 per visit Audiological Services (only Tympanometry, CPT procedure code 92567, when the diagnosis is within the ICD-9-CM range of 381.0 through 382.9)

None Certified Nurse Midwife $10 per visit Chiropractor $10 per visit Dental Care (routine dental care & orthodontia) $10 per visit Durable Medical Equipment (DME) (Limited to $500 per State Fiscal Year (SFY) July 1 – June 30)

10% of Medicaid allowed per DME item Emergency Dept. Services (Emergent, non- emergent, assessment)

$10 per visit Family Planning None Federally Qualified Health Center (FQHC) $10 per visit Home Health (10 visits per SFY (July 1 – June 30)) $10 per visit Hospital, Inpatient 10% of first inpatient day Hospital, Outpatient $10 per visit Inpatient Psychiatric Hospital & Psychiatric Residential Treatment Facility

10% of first inpatient day Immunizations (All per protocol) None Laboratory & X-Ray $10 per visit Medical Supplies (Limited to $125/month unless benefit extension is approved

None Mental & Behavioral Health, Outpatient $10 per visit Nurse Practitioner $10 per visit

88 Physician $10 per visit Podiatry $10 per visit Prenatal Care None Prescription Drugs $5 per prescription (Must use generic, if available) Preventive Health Screenings (All per protocol) None Rural Health Clinic $10 per visit Speech Therapy Evaluation – Four 30 minute units/SFY (July 1 – June 30) unless benefit extension is approved Therapy – Four 15 minute units/day unless benefit extension is approved

$10 per visit Physical Therapy Evaluation – Four 30 minute units/SFY (July 1 – June 30) unless benefit extension is approved Therapy – Four 15 minute units/day unless benefit extension is approved

$10 per visit Occupational Therapy Evaluation – Four 30 minute units/SFY (July 1 – June 30) unless benefit extension is approved Therapy – Four 15 minute units/day unless benefit extension is approved

$10 per visit Substance Abuse Treatment Services (SATS), outpatient

$10 per visit Vision (Eye exam, Eyeglasses)

$10 per visit No co-pay for eyeglasses

8.2.4.

Other:

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:

89

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))

The State has developed and distributed to Division of County Operations (DCO) County Offices, physicians’ offices, hospitals, and other public businesses throughout the state ARKids First (includes ARKids-A (Title XIX Medicaid program) and ARKids-B (Title XXI CHIP state plan separate child health program)) pamphlets that include information pertaining to cost sharing, the cumulative 5% cap based on the ARKids-B beneficiary’s families’ income, and families of eligible ARKids-B beneficiaries are not responsible for tracking their out-of-pocket expenses for the purpose of the 5% cap. There is also an ARKids First website that includes this same information. The Arkansas Department of Human Services spends approximately $125,000 per state fiscal year via contract on outreach and education for ARKids First which includes information pertaining to cost sharing, the cumulative 5% cap based on the ARKids-B beneficiary’s families’ income, and families of eligible ARKids-B beneficiaries are not responsible for tracking their out-of-pocket expenses for the purpose of the 5% cap are not responsible for tracking their out-of-pocket expenses for the purpose of the 5% cap. 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. [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))

To protect families against excessive medical expenses and comply with the statutory limit of no more than 5% of family income being expended on cost sharing expenses, the state keeps the co- pays the families are required to pay minimal. Because of the low co-payment, very few families are likely to exceed the limit and would not approach the 5% limit.

90 The annual 5% cap is calculated when the ARKids-B beneficiary is approved. The MMIS generates a notice to the ARKids-B beneficiary’s family notifying the family of their specific cumulative cap for cost sharing based on the family’s income. If a family’s income decreases during the year, the 5% cap is recalculated, and a new notice is sent to the family. The 5% cap is not recalculated if the family’s income increases. All beneficiaries’ specific 5% limits are recalculated each year in June, and the recalculated limit is effective July 1.

Arkansas’ Medicaid MMIS system tracks the ARKids-B beneficiaries’ families’ progress toward the 5% cap. Families are not responsible for tracking their out-of-pocket expenses for the purpose of the 5% cap. Providers (who are responsible for the collection of co-pays from Medicaid and CHIP beneficiaries) indicate the services rendered to the ARKids-B beneficiary on the claim form submitted. The MMIS automatically calculates the co-pay that would apply for the services rendered and checks the accrual amount against the ARKids-B beneficiary’s family’s income (via ARKids Family Income/File). When cost sharing reaches, in the aggregate, 5% of the ARKids-B beneficiary’s family’s total income, co-payments are no longer assessed against the ARKids-B beneficiary’s family until the next SFY.

Families are notified when their cost sharing maximum is met. There will be a statement on the notice (received by both the ARKids-B beneficiary’s family and the provider) that the cost-sharing maximum has been met and that Medicaid is paying the full Medicaid allowed rate for the service.

Sometimes an ARKids-B beneficiary’s family will exceed the 5% cap due to a lag in processing previous claims. Providers are required to refund to the ARKids-B beneficiary’s family the cost sharing amount that exceeded the 5% cap that the provider collected from the family if, at the time a claim is submitted and processed, the system determines that the family’s cumulative cost- sharing maximum has been met. This may happen even though the family was required to provide cost-sharing on the date of service if the provider waited a period of time to submit the claim for payment. For example, a family had not yet met its cost-sharing maximum on the date of service, and therefore the provider collected the required cost share amount. The provider submitted the claim two months later, and in the interim, the family met its cost sharing maximum through receiving and paying for other services. In this case, even though the family was required to pay a co-payment on the date of service, that amount is not in the system until the claim is processed. On the date the claim was adjudicated, the family had met its obligation for cost sharing, and the provider must refund to the family the amount the family paid that exceeds the 5% cap that the provider collected from the family for cost sharing.

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)

The MMIS checks the race of enrollees. Any enrollee who is of the American Indian race (based on the definition in the Indian Health Care Improvement Act of 1976) or are children of the Alaska Native race are excluded from cost sharing.

91 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))

Collecting co-payments from beneficiaries is providers’ responsibility. Providers may not deny services to CHIP eligible beneficiaries because of the beneficiaries’ inability to pay cost-sharing. However, beneficiaries’ inability to pay cost-sharing does not eliminate beneficiaries’ liability for the cost-sharing charge.

Guidance: Section 8.7.1 is 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 below of 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))

The State does not charge premiums to Title XXI CHIP ARKids-B enrollees.

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))

The State does not dis-enroll Title XXI CHIP ARKids-B beneficiaries due to non-payment of a co-payment.

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))

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))

8.7.1.4

The State provides the enrollee with an opportunity for an

92 impartial review to address disenrollment from the program. (42CFR 457.570(c))

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)

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))

I. Increase the number of children in Arkansas who are enrolled in CHIP. II. Increase access to care for children enrolled in CHIP. III. Improve the healthcare of children enrolled in CHIP through the use of preventative care.

Guidance: Goals should be measurable, quantifiable and convey a target the State is working towards.

93 9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c))

Performance Goal for Objective I:

The total number of children enrolled in CHIP will increase each year by one half percent or be adjusted up or down based on historical data. Performance Goal for Objective II:

The total number of children receiving preventive dental services, including orthodontia, will increase each year by one half percent or be adjusted up or down based on historical data.

Performance Goal for Objective III:

The total number of children under 15 months of life; children ages 3 through 6 years; and adolescents ages 12 through 18 years receiving well-child visits will increase each year by one half percent or be adjusted up or down based on historical data.

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.

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))

94 (42CFR 457.710(d))

Measurement of Performance Goal for Objective I:

The baseline for measuring this goal will be based on the beneficiary enrollment data for ARKids-B for FFY 2014. Thereafter, beneficiary enrollment data for ARKids-B for the current FFY will be used.

Measurement of Performance Goal for Objective II:

The baseline for measuring this goal will be based on preventive dental services claims data for FFY 2014. Thereafter, preventive dental services claims data for the current FFY will be used.

Measurement of Performance Goal for Objective III:

The baseline for measuring this goal will be based on well-child visits HEDIS measures claims data for FFY 2014. Thereafter, well-child visits HEDIS measures claims data for the current FFY will be used.

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. [X] 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. [X]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 childcare 9.3.7.3. [X] 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.

95

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)

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)

The State uses a Primary Care Case Management (PCCM) and Patient Centered Medical Home (PCMH) systems. The State is responsible for assessment and evaluation under the PCCM and PCMH systems and intends to use the same contract for the Title XXI CHIP ARKids-B and Unborn Child separate state child health programs. The contractor evaluates data including number of office visits, continuity of care, and hospitalizations, etc.

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)

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))

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

96 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 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))

The ARKids-B work group and the Arkansas Advocates for Children and Families agency agree that Arkansas should continue funding eligible children through the Title XXI ARKids-B CHIP separate state child health program and to cover unborn children in the Unborn Child CHIP separate child health program. This is supported by the Arkansas Advocates for Children and Families, the Arkansas Department of Health, and the Arkansas Center for Health Improvement.

Changes in the Title XXI CHIP ARKids-B and Unborn Child CHIP separate child health programs will be promulgated as required by the State’s Administrative Procedures Act (APA). The APA also requires that the agency publish a notice, regarding proposed rules, in a newspaper with statewide circulation. As a part of the APA process, DMS also notifies “interested persons” and appropriate Medicaid/CHIP providers of proposed rules to solicit comments and input. A public hearing will be conducted during the required APA 30-day comment period to obtain public comment. The APA process requires the review of new and revised rules by the Administrative Public Health and Rules and Regulations Subcommittees of the Arkansas Legislative Council.

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))

Not applicable, as there are no American Indian Nations, Tribes, reservations or organizations in the State of Arkansas.

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 CFR 457.65(b) through (d).

Amendments relating to eligibility or benefits, including cost sharing and enrollment procedures will be promulgated according to the State’s Administrative Procedures Act. The Act requires a public notice in a statewide newspaper with a 30-day comment period.

A public hearing will be conducted during the required APA 30-day comment period to obtain public comment/input.

9.9.3. Describe the State’s interaction, consultation, and coordination with any Indian

97 tribes and organizations in the State regarding implementation of the Express Lane eligibility option.

Not applicable, as there are no American Indian Nations, Tribes, reservations or organizations in the State of in the State of Arkansas.

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)

Poison Control & Drug Information Center Health Services Initiative

Please See ATTACHMENT B for State’s projected one-year CHIP budget for poison control and drug information center health services initiative.

 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 limited to expenditures for targeted low income children, the optional coverage of the unborn, lawfully residing eligibles, 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

Please See ATTACHMENT B for State’s projected one-year CHIP budget for poison control and drug information center health services initiative.

98

CHIP Budget STATE: FFY Budget Federal Fiscal Year

State’s enhanced FMAP rate

Benefit Costs

Insurance payments

Managed care

per member/per month rate

Fee for Service

Total Benefit Costs

(Offsetting beneficiary cost sharing payments)

Net Benefit Costs

Cost of Proposed SPA Changes – Benefit

Administration Costs

Personnel

General administration

Contractors/Brokers

Claims Processing

Outreach/marketing costs

Health Services Initiatives

Other

Total Administration Costs

10% Administrative Cap

Cost of Proposed SPA Changes

Federal Share

State Share

Total Costs of Approved CHIP Plan

NOTE: Include the costs associated with the current SPA.

The Source of State Share Funds:

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)

Intensive Home & Community-Based Family & Child/Youth Support Health Services Initiative

99

Please See ATTACHMENT C for State’s projected one-year CHIP budget for intensive home and community-based family and child/youth support health services initiative.

 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 limited to expenditures for targeted low income children, the optional coverage of the unborn, lawfully residing eligibles, 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

Please See ATTACHMENT C for State’s projected one-year CHIP budget for intensive home and community-based family and child/youth support health services initiative.

CHIP Budget STATE: FFY Budget Federal Fiscal Year

State’s enhanced FMAP rate

Benefit Costs

Insurance payments

Managed care

per member/per month rate

100 Fee for Service

Total Benefit Costs

(Offsetting beneficiary cost sharing payments)

Net Benefit Costs

Cost of Proposed SPA Changes – Benefit

Administration Costs

Personnel

General administration

Contractors/Brokers

Claims Processing

Outreach/marketing costs

Health Services Initiatives

Other

Total Administration Costs

10% Administrative Cap

Cost of Proposed SPA Changes

Federal Share

State Share

Total Costs of Approved CHIP Plan

NOTE: Include the costs associated with the current SPA.

The Source of State Share Funds:

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)

Health & Well-Being Program for Maltreated Children Health Services Initiative

Please See ATTACHMENT D for State’s projected one-year budget for health & well-being program for maltreated children health services initiative.

 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.

101  Projected expenditures for the separate child health plan, including but not limited to expenditures for targeted low income children, the optional coverage of the unborn, lawfully residing eligibles, 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

Please See ATTACHMENT D for State’s projected one-year budget for health & well-being program for maltreated children health services initiative.

CHIP Budget STATE: FFY Budget Federal Fiscal Year

State’s enhanced FMAP rate

Benefit Costs

Insurance payments

Managed care

per member/per month rate

Fee for Service

Total Benefit Costs

(Offsetting beneficiary cost sharing payments)

Net Benefit Costs

Cost of Proposed SPA Changes – Benefit

Administration Costs

Personnel

General administration

Contractors/Brokers

102 Claims Processing

Outreach/marketing costs

Health Services Initiatives

Other

Total Administration Costs

10% Administrative Cap

Cost of Proposed SPA Changes

Federal Share

State Share

Total Costs of Approved CHIP Plan

NOTE: Include the costs associated with the current SPA.

The Source of State Share Funds:

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)

Lawfully Residing Alien Children and Pregnant Women Option

Please See ATTACHMENT E for State’s projected one-year budget for lawfully residing alien children and pregnant women option.

 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 limited to expenditures for targeted low income children, the optional coverage of the unborn, lawfully residing eligibles, 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

103 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

Please See ATTACHMENT E for State’s projected one-year budget for lawfully residing alien children and pregnant women option.

CHIP Budget STATE: FFY Budget Federal Fiscal Year

State’s enhanced FMAP rate

Benefit Costs

Insurance payments

Managed care

per member/per month rate

Fee for Service

Total Benefit Costs

(Offsetting beneficiary cost sharing payments)

Net Benefit Costs

Cost of Proposed SPA Changes – Benefit

Administration Costs

Personnel

General administration

Contractors/Brokers

Claims Processing

Outreach/marketing costs

Health Services Initiatives

Other

Total Administration Costs

10% Administrative Cap

Cost of Proposed SPA Changes

Federal Share

104 State Share

Total Costs of Approved CHIP Plan

NOTE: Include the costs associated with the current SPA.

The Source of State Share Funds:

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 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.

105

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)

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 comply 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.

The review process for CHIP eligibility and enrollment matters is the same as the Medicaid Fair Hearing process.

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 comply with 42 CFR 457.1120.

The review process for CHIP health service matters is the same as the Medicaid Fair Hearing process.

12.3. Premium Assistance Programs- If providing coverage through a group health plan that

106 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.

N/A

107 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)

108

CMS Regional Offices CMS Regional 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 Region 10- Seattle Idaho Washington Alaska Oregon Carol Peverly carol.peverly@cms.hhs.gov 2001 Sixth Avenue MS RX-43 Seattle, WA 98121

109 GLOSSARY Adapted directly from Sec. 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 pregnancy 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 language disorders. 23. Hospice care.

110 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) 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

111 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: Arkansas State Plan Amendments (SPA) #: AR-19-0010 This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, MailStop 52-01-16 Baltimore, MD 21244-1850 Children and Adults Health Prosrams Group rvts CTÑTÉRS FO¡ MEDICARE & MTDICAID SERVICES CENT¡tr fOR À,IED¡CAID & CHIP SERV|CES Dawn Stehle Medicaid Director Department of Human Services 112 V/est 8th Street, Slot 5401 Little Rock, AR 72201-4608 JUL t I Zotg Dear Ms. Stehle: I am pleased to inform you that your title XXI Children's Health Insurance Program (CHIP) state plan amendment (SPA), AR-19-0010, has been approved. AR-l9-0010 demonstrates compliance with the CHIP managed care regulations at 42 CFR 457, Subpart L for utilization of a managed care delivery system. This SPA has an effective date of July I , 2018 for the Healthy Smiles dental managed care program. The effective date for the Provider-Led Arkansas Shared Savings Entity (PASSE) program is March 1,2019, when the state began to enroll CHIP eligible children into PASSE. Sections 2101(a),2103(Ð(3), 2107(b), and2107(e) of the Social Security Act, as implemented through regulations at 42 CFR 457 Subpart L, describe the application of managed care requirements to CHIP. Arkansas has provided the necessary assurances indicating that the state complies with the managed care requirements in the delivery of CHIP services and benefits covered under the state's separate child health plan. This SPA approval does not substitute for CMS review of any contracts between the state and managed care entities that serve the state's CHIP populations. All managed care contracts for CHIP populations in effect as of the state fiscal year beginning on or after July 1,2018 must comply with the CHIP managed care regulations and be submitted for CMS review. Your title XXI project officer is Ms. Jasmine Aplin. She is available to answer questions concerning this amendment and other CHlP-related issues. Her contact information is as follows: 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: (4 I 0) 7 86-8102 E-mail : .lasmine.AplinlÒcms. hhs. sov

Page 2 - Ms. Dawn Stehle Official communications regarding program matters should be sent simultaneously to Ms. Aplin and Mr. Bill Brooks, Director, Division of Medicaid Field Operations South. Mr. Brooks' address is: Centers for Medicare & Medicaid Services Division of Medicaid Field Operations South 1301 Young St. Suite 714 Dallas, TX 75202 If you have additional questions, please contact Ms. Amy Lutzky, Director, Division of State Coverage Programs at ( 410) 786-0721. We look forward to continuing to work with you and your staff. Sincerely, Director cc: Mr. Bill Brooks, Director, Division of Medicaid Field Operations South /signed Anne Marie Costello/

1 \TEMPLATE FOR CHILD HEALTH PLAN 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: __ARKANSAS____________________________________________________ (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))___Janet Mann, Director, DMS_______________________________________________ (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: Cindy Gillespie Position/Title: Director, Department of Human Services (DHS) Name: Janet Mann

Position/Title: Director, DHS Division of Medical Services (DMS) Name: ____________ Position/Title: ______________ *Disclosure. In accordance with 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. Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 1005-33 amended 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, as amended by the Health Care and Education Reconciliation Act of 2010, further modified the program. The HEALTHY KIDS Act and The Bipartisan Budget Act of 2018 together resulted in an extension of funding for CHIP through federal fiscal year 2027.

2

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 457 as 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. • Added new provisions related to delivery methods, including managed care, to section 3 (81 FR 27498, issued May 6, 2016) States are not required to resubmit existing State plans using this current updated template. However, States must use this updated template when submitting a new 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. A SPA 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 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.

3 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 the State to specify its proposed method of delivery. If the State proposes to use managed care, the State must describe and attest to certain requirements of a managed care delivery system, including contracting standards; enrollee enrollment processes; enrollee notification and grievance processes; and plans for enrolling providers, among others. (Section 2103); (42 CFR Part 457. Subpart L) 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)); (42 CFR 457.90) 6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of 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

4 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 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:

5 • 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)

• 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

6 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.

Where the state’s assurance is requested in this document for compliance with a requirement of 42 CFR 457 et seq., the state shall place a check mark to affirm that it will comply no later than the applicable compliance date.

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

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

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

A. Background

Arkansas aggressively pursued health care for children by covering optional benefits and categories that benefit children. For example, Arkansas elected to provide the full range of EPSDT services to children without requiring the EPSDT screen. Also Arkansas was one of the first states in the nation to cover the TEFRA-134 children authorized by the Tax Equity and Fiscal Responsibility Act of 1982.

Effective 1-1-03, the State began covering TEFRA children in a TEFRA-like 1115(a) demonstration waiver in which the parents pay a premium based on a sliding scale; some parents are not required to pay a premium. The TEFRA-like demonstration waiver provides for the care of a child in his/her home, if he/she qualifies for Medicaid as a resident in a Title XIX institution, e.g., a nursing facility or an Intermediate Care Facility for the Mentally Retarded, etc. Parental income and resources are not counted in the child’s eligibility determination. Before eligibility determination for the TEFRA-like demonstration waiver, the child must first be determined if he/she would meet Title XIX Medicaid eligibility. Parental income is counted in the premium amount calculation. The eligibility income limit for this demonstration waiver is three times the SSI limit. The TEFRA-like demonstration waiver makes Medicaid available to a large segment of the state’s chronically ill children.

In its quest to provide health care for children, the State also opted to cover uninsured children through a Medicaid 1115(a) demonstration waiver, AR Kids First. This demonstration is discussed in item B, below.

CHIP Phase I, a Medicaid expansion, was approved August 6, 1998 and implemented October 1, 1998. This was a small CHIP Medicaid expansion in which the last of the eligible children aged-out of the program September 30, 2002. CHIP Phase II is a separate CHIP program that was approved February 16, 2001 but not implemented. Phase III superseded Phase II. Phase III covered some of the children in the State’s 1115(a) demonstration waiver, ARKids-B, as an CHIP Medicaid expansion and the Unborn Child program as a separate child health program.

In 2013, on recommendation from CMS, the State made the decision to transition the ARKids-B program from an 1115(a)-demonstration waiver CHIP Medicaid expansion program to a separate child health program through the CHIP state plan. The Unborn

8 Child program has been in the CHIP state plan since 1-1-04 as a separate child health program, and the State continues to serve this population.

B. ARKids First Background and Development

In 1997, Arkansas’ Governor, the Arkansas State legislature, the President and Congress were all addressing the issue of health care for vast numbers of uninsured children. Governor Mike Huckabee supported enabling state legislation and an appropriations bill in the 1997 legislative session that created and funded ARKids First, an 1115(a)- demonstration waiver. The Arkansas Legislature passed both bills and Governor Mike Huckabee signed both bills into law on March 10, 1997 Effective August 4, 2000, the 1115(a)-demonstration waiver was renamed ARKids-B.

Ray Hanley, then Director, Division of Medical Services (DMS), formed and chaired an ARKids First work group, composed of individuals from the Governor’s Office (the Department of Human Services liaison), Arkansas Children’s Hospital, Arkansas Department of Health, Catholic Social Services, Arkansas Advocates for Children and Families, Easter Seals, Communities in School of Arkansas, Arkansas Chapter for American Academy of Pediatrics, Electronic Data Systems (Arkansas Medicaid’s then fiscal agent), and various individuals in the Department of Human Services (DHS), including Tom Dalton, then Department Director. The first meeting was held February 7, 1997, one day after President Clinton announced his FFY ‘98 budget package that included a proposal to expand health insurance access for poor children in families that earn too much for Medicaid but not enough to afford private health insurance. Additional ARKids First meetings were held as needed. Most of the discussion and concerns involved eligibility factors and the benefit package.

The Arkansas legislation, though not as detailed, mirrors the CHIP legislation in its purpose, i.e., to provide health insurance coverage for uninsured children under age 19 whose family income is at or below 200% of the poverty level. The ARKids First program was designed as a CHIP program, but used the 1115(a) demonstration waiver process for implementation, since the CHIP legislation had not been passed at the time Arkansas’ program was under development. The ARKids First 1115(a) demonstration waiver was approved by CMS on August 19, 1997 and implemented on September 1, 1997; only days after the CHIP legislation was signed by the President.

Arkansas developed the ARKids First Program with the thought that it would be able to roll the ARKids First 1115 demonstration waiver into a CHIP program. However, the State recognized that as the ARKids First demonstration waiver and the CHIP legislation were developing, they didn’t make completely parallel steps. Therefore, ARKids First enrollees, who did not meet the definition of a CHIP targeted low-income child, would continue to receive their health care services through Title XIX federal funding. Children in ARKids

9 First who met the definition of a CHIP targeted low-income child would be able to receive their services through either Title XIX or Title XXI federal funding, at the discretion of the State. All of the ARKids First children would remain in the 1115(a) demonstration waiver regardless of the funding source. The children who did not meet the definition of a CHIP targeted low-income child were the children of state employees and the children who met the eligibility requirements for regular Title XIX Medicaid. In 2002, CMS instructed the State that parents or guardians of children who met eligibility for Title XIX Medicaid did not have the choice to have their children receive services through either Title XIX Medicaid or the Title XXI CHIP ARKids First 1115(a) demonstration waiver. Children found eligible for Title XIX Medicaid must receive services through the Title XIX Medicaid program. Effective August 4, 2000, the ARKids First program was separated into ARKids-A (regular children’s Title XIX Medicaid program) and ARKids-B (1115(a) demonstration waiver Title XXI CHIP program), and ARKids First became an umbrella for these two programs.

The application form and the promotional materials for ARKids-A and ARKids-B identify the two programs as ARKids First. Applications may be made at the local DHS County Office, by mail, or through the internet, and a toll free number is available to clients. Applications in English or Spanish may be printed from the ARKids First website at www.arkidsfirst.com. Applications in other languages are available upon request.

C. ARKids-B Title XXI CHIP Separate Child Health Program

In November 2013, CMS recommended the State transition the ARKids-B 1115(a) demonstration waiver Title XXI CHIP Medicaid expansion program to a Title XXI CHIP separate child health program through the CHIP state plan and advised that if this was done, orthodontia services would have to be added to the ARKids-B program’s benefit package of services. As the current ARKids-B 1115(a) demonstration waiver’s renewal was due to end December 31, 2013, the State requested and CMS approved an extension of the ARKids-B demonstration waiver to allow the State time to prepare, submit, and have approved an amendment to the CHIP state plan.

Effective 1/1/14 ARKids-B beneficiaries ages 6 through 18 in families with incomes from 100% FPL up to 142% FPL were moved to Title XIX Medicaid ARKids-A (MAGI CHIP SPA Group 2/CS2 PDF page) but continue to be funded through title XXI CHIP.

Children ages 0 through age 18 in families with a household income above 142% FPL up to and including 211% FPL are eligible for ARKids-B. There is no asset test. The State maintains qualifying criteria for ARKids-B that includes income criteria based on modified adjusted gross income methodologies as defined at 42 CFR §435.603. As allowed under

10 42 CFR §457.805, all ARKids-B enrollees must not have had employer-sponsored or group health insurance within 90 days prior to program enrollment. The State maintains, at minimum, the required exemptions to the period of uninsurance as specified at 42 CFR §457.805. There is no presumptive eligibility. Retroactive eligibility may be determined up to three months prior to the date of application. ARKids-B offers a less comprehensive benefit package than the State’s traditional Title XIX Medicaid program (ARKids-A) and requires co-payments.

The State elected a copayment as the only cost sharing requirement, because it is the most equitable form of cost sharing. The State did not want to assess an enrollment fee nor monthly premiums because it wanted the family’s cost sharing responsibility to be related solely to usage. Cost sharing is required for services that are not categorized as well-health. The State will keep the current copayment structure in place for ARKids-B enrollees.

The benefit package includes inpatient and outpatient hospital services, physician surgical and medical services, laboratory and x-ray services, well-baby care, including age- appropriate immunizations. Enrollees in the ARKids-B are not eligible for the full range of Medicaid State Plan services. The ARKids-B schedule of benefits is outlined in the table in section 6.2. ARKids-B Program).

ARKids-B utilizes the same provider system as ARKids-A (regular children’s Title XIX Medicaid) and operates under a primary care case management model. ARKids-B beneficiaries select or align with a primary care physician responsible for furnishing primary and preventive services and making medically necessary referrals. Enrollees are entitled to change their primary care physician selection at any time, without limitation. As part of the enrollment materials, enrollees are provided with information concerning their disenrollment rights.

The Division of Medical Services (DMS) and the Division of County Operations (DCO) are divisions of the Department of Human Services. DMS is responsible for the administration of the Medicaid and CHIP programs except for eligibility, which is the responsibility of DCO.

D. Overview of Unborn Child Title XXI CHIP Separate Child Health Program

The Arkansas Department of Human Services administers the CHIP Unborn Child program.

The essential elements of the program are:

11  Medical verification of the pregnancy is required.

 Applicant must have no other insurance that covers the pregnancy.

 Statewide income standard is from zero up to 209% FPL  There is no resource test for the Unborn Child program.

 The benefits (with the exception of sterilization or any other family planning services) will be the same as the SIXTH OMNIBUS BUDGET RECONCILIATION ACT (SOBRA) pregnant women category under Title XIX Medicaid and include only obstetrical services and treatment for conditions that may complicate or endanger the pregnancy. Benefits include: • Prenatal services • Delivery  Postpartum services (Postpartum coverage is through the end of the month in which the 60th day from the date of delivery falls. When one or more physicians in a group see the Unborn Child program beneficiary and at least two months of antepartum care were provided culminating in delivery or the beneficiary was continuously CHIP eligible for two or more months before delivery and on the delivery date, the global method of billing CHIP for postpartum services provided is used. When less than two months of antepartum care was provided to the Unborn Child program beneficiary or the beneficiary was not CHIP eligible for at least the last two months of the pregnancy, the antepartum/obstetrical care without delivery and the delivery and postpartum care can be billed to CHIP using the itemized billing method.)  Services that are determined by the physician as medically necessary as, if not provided, could complicate or endanger the eligible Unborn Child program’s beneficiary’s pregnancy.

E. Healthy Smiles Dental Managed Care Program

The Arkansas Department of Human Services transitioned the Medicaid dental program to a prepaid ambulatory health plan (PAHP) on January 1, 2018. Two vendors were selected to provide state-wide dental benefits:

a. Delta Dental b. Managed Care of North America (MCNA)

In early December 2017, all Arkansas Medicaid and CHIP beneficiaries who are eligible for dental benefits were randomly and evenly assigned to one of the two dental managed care plans. Each plan sent a welcome packet to each member and the members were able to access plan providers starting January 1, 2018, for covered dental services. Both dental vendors will provide the same dental services that were covered under the Medicaid and CHIP

12 fee-for-service program.

F. Provider Led Arkansas Shared Savings Entity (PASSE)-MCO Model of care for client with high behavioral health or developmental disabilities service needs.

Effective February 1, 2018, Arkansas included the ARKids-B Title XXI CHIP program beneficiaries as part of its overall 1915(b) waiver implementing a Provider-Led Arkansas Shared Savings Entity (PASSE) Program. As of May 6, 2019, approximately 2,598 children who participate in ARKids-B were also enrolled in a PASSE. More ARKids-B eligible children will be mandatorily enrolled in a PASSE if they are determined to be a Tier 2 or Tier 3 on the Arkansas Independent Assessment (ARIA) for behavioral health or developmental disabilities services.

The PASSE program is an innovative approach to organizing and managing the delivery of services for Medicaid beneficiaries with high behavioral health and developmental disability service needs. It was created by Act 775 of the 2017 Arkansas Regular Session, which was signed into law by Arkansas Governor, Asa Hutchinson, on March 31, 2017. Under this unique model of organized care, Arkansas provider-led and owned organizations, known Provider-Led Arkansas Shared Savings Entities (PASSEs), are responsible for integrating the physical health services, behavioral health services, and specialized developmental disability services for approximately 30,000 individuals who have intensive levels of treatment or care needs due to mental illness, substance abuse, or intellectual and developmental disability. These vulnerable Arkansans will benefit from the provision and continuity of all medically necessary services in a well-organized system of coordinated care.

The PASSE program was implemented in two phases. The first phase was a Primary Care Case Management (PCCM) model approved by CMS under 1915(b) authority. In Phase I, which began on February 1, 2018, the PASSEs provided care coordination to each member attributed to the PASSE, but medical services were still provided on a fee for service basis. The purpose of this phase was to allow the PASSEs time to build their infrastructure and become more familiar with the population they would be serving and their unique needs. During Phase I, members were “attributed” to a PASSE based on their previous provider relationships. In Phase I, there were four PASSEs licensed and providing care coordination.

For Phase II, which began on March 1, 2019, the began providing all services to members under a “full-risk” Medicaid Managed Care (MCO) model. In this phase, the PASSEs continue to provide care coordination to enrolled beneficiaries. Additionally, PASSEs are now responsible for development of each member’s person-centered service plan (PCSP), as well as for the delivery of services. Only three PASSE’s signed the Provider Agreement and moved into Phase II. Under Phase II, members are no longer attributed to a PASSE but are auto-assigned through a “round-robin” approach that assures equal distribution among the three PASSEs.

13

Each PASSE signs a PASSE Provider Agreement (PA) that is renewed annually and will be held accountable for the requirements laid out in the PA during that year. Medicaid pays the PASSE an actuarially sound per member per month (PMPM) that must be used to cover all needed services for each of its members.

DHS has created a new Office of Innovation and Delivery System Reform (IDSR) which will provide monitoring and oversight of the services provided to PASSE members. The IDSR includes Beneficiary Support, which will provide guidance to beneficiaries on the PASSE system.

The State will be using the following system to deliver services: MCO: Risk-comprehensive contracts are fully-capitated and require that the contractor be an MCO or HIO. Comprehensive means that the contractor is at risk for inpatient hospital services and any other mandatory State plan service in section 1905(a), or any three or more mandatory services in that section. References to MCOs generally apply to these risk- comprehensive entities.

14

1.1-DS

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: Medicaid Expansion (ARKids First Program) – Phase I: 10-1-98

Implementation Date: Medicaid Expansion (ARKids First Program) – Phase I: 10-1-98

SPA #1, Purpose of SPA: Separate State CHIP – Phase II Proposed effective date: Not Implemented

Proposed implementation date: Not Implemented

SPA # 2, Purpose of SPA: Medicaid Expansion (ARKids-B Program) – Phase III

Effective Date: 1-1-01

Implementation Date: Implemented retroactively to 1-1-01

SPA # 3, Purpose of SPA: Separate State CHIP (Unborn Child Program) – Phase III

Effective Date: 7-1-04

Implementation Date: 7-1-04

SPA # 4, Purpose of SPA: To make technical changes to align Arkansas’ CHIP state plan with current practice in the State---To delete the references to the ARKids-B opt-out provision & to clarify that Primary Care Case Management (PCCM) is now included in the HIFA ARHealthNetworks 1115(a) demonstration waiver.

Effective Date: 5-5-11

Implementation Date: 5-1-11

SPA # 5, Purpose of SPA: Add Poison Control & Drug Information Center Health Services

15 Initiative

Effective Date: 7-1-11

Implementation Date: 7-1-11 Superseding Pages of MAGI CHIP State Plan Material Transmittal Number & Effective/Implementation Date SPA Group PDF Number Description Superseded Plan Section(s) AR-13-0039 Effective/Implementation Date: 10/1/13 Eligibility Processing CS24 Single, streamlined application, screening & enrollment process, renewals Supersedes the current sections 4.3 & 4.4 AR-14-0015 Effective/Implementation Date: 8/1/15 MAGI Eligibility & Methods CS13

CS7

CS10 Deemed newborn

Coverage of targeted low-income children

Coverage for children who have access to public employee coverage Section 4.3

Sections 4.1.1; 4.1.2 & 4.1.3

Section 4.1.7 AR-13-0021 Effective/Implementation Date: 1/1/14 XXI Medicaid Expansion CS3 Eligibility for Medicaid expansion program Section 4.0 AR-13-0040 Effective/Implementation Date: 1/1/14 Establish 2101(f) groups CS14 Children ineligible for Medicaid as a result of the elimination of income disregards Incorporate within a separate subsection under section 4.1 AR-14-0042 Effective/Implementation Date: 1/1/14 Non- Financial Eligibility CS17 Residency Section 4.1.5

Superseding Pages of MAGI CHIP State Plan Material Transmittal Number & Effective/Implementation Date SPA Group PDF Number Description Superseded Plan Section(s) AR-14-0016 Non-Financial CS18 Citizenship Sections 4.1.0;

16 Effective/Implementation Date: 8/1/15 Eligibility

CS19

CS20

CS27

Social security number

Substitution of coverage

Continuous eligibility 4.1-LR & 4.1.1- LR

Section 4.1.9.1

Section 4.4.4

Sections 4.1.8 & 4.1.9.2 AR-13-0022 Effective/Implementation Date: 1/1/14 MAGI Eligibility & Methods CS9

CS15 Conception to Birth

MAGI-based income methodology Sections 4.1.1; 4.1.2 & 4.1.3

Incorporated within a separate subsection under Section 4.3 AR-17-0006 Effective/Implementation Date: 1/1/18 Non-Financial Eligibility CS18 Citizenship Supersedes previously approved CS18 AR-18-0003 Effective/Implementation Date: 1/1/18 Eligibility Processing CS24 Change Arkansas to an Assessment State Supersedes previously approved CS24

SPA # 6, Purpose of SPA: Separate State CHIP (ARKids-B Program)

Effective Date: 8-1-15

Implementation Date: 8-1-15

SPA # 7. Purpose of SPA: Add Intensive Home & Community-Based Family & Child/Youth Support Health Services Initiative

Effective Date: 11-1-16

Implementation Date: 11-1-16

SPA # 8, Purpose of SPA: Add Health & Well-Being Program for Maltreated Children Health

17 Services Initiative

Effective Date: 1-1-17

Implementation: 1-1-17

SPA #10, Purpose of SPA: Provide information regarding the implementation of two new organized care models. The first is “Healthy Smiles,” the Arkansas Dental Managed Care program authorized under 1915(b). The second is called the Provider-Led Arkansas Shared Savings Entities (PASSE) program. PASSE is authorized under a concurrent 1915(b)/1915(c) Waiver and 1915(i) State Plan Amendment. This amendment changes the service delivery system for dental services and for the beneficiaries going into the PASSE from fee-for-service to managed care.

Effective Date, Healthy Smiles: 7-1-18

Implementation, Health Smiles: 7-1-18

Effective Date, PASSE: 37-1-19

Implementation, PASSE: 73-1-19

18 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 (Eligibility Standards and Methodology).

Guidance: In Section 3.1, describe all delivery methods the State will use to provide services to enrollees, including: (1) contracts with managed care organizations (MCO), prepaid inpatient health plans (PIHP), prepaid ambulatory health plans (PAHP), primary care case management entities (PCCM entities), and primary care case managers (PCCM); (2) contracts with indemnity health insurance plans; (3) fee-for-service (FFS) paid by the State to health care providers; and (4) any other arrangements for health care delivery. The State should describe any variations based upon geography and by population (including the conception to birth population). States must submit the managed care contract(s) to CMS’ Regional Office for review.

3.1. Delivery Systems (Section 2102(a)(4)) (42 CFR 457.490; Part 457, Subpart L)

3.1.1 Choice of Delivery System 3.1.1.1 Does the State use a managed care delivery system for its CHIP populations? Managed care entities include MCOs, PIHPs, PAHPs, PCCM entities and PCCMs as defined in 42 CFR 457.10. Please check the box and answer the questions below that apply to your State. No, the State does not use a managed care delivery system for any CHIP populations. Yes, the State uses a managed care delivery system for all CHIP populations.

All children enrolled in CHIP will be enrolled in Healthy Smiles. Yes, the State uses a managed care delivery system; however, only some of the CHIP population is included in the managed care delivery system and some of the CHIP population is included in a fee- for-service system. If the State uses a managed care delivery system for only some of its CHIP populations and a fee-for-service system for some of its CHIP populations, please describe which populations are, and which are not, included in the State’s managed care delivery system for CHIP. States will be asked to specify which managed care entities are used by the State in its managed

19 care delivery system below in Section 3.1.2.

Children in the ARKids-B Title XXI CHIP Separate Child Health Program will receive all medically necessary services, except for those listed in 3.1.1.2, through a PASSE if they have been identified through the independent assessment as in need of behavioral health services or services for individuals with developmental or intellectual disabilities at a Tier II or Tier III level of need. For individuals served by the Division of Behavioral Health: • Tier II: Rehabilitative Level Services—At this level of need, services are provided in a counseling services setting, but the level of need requires a broader array of services to address functional deficits. • Tier III: Intensive Level Services—Eligibility for this level of need will be identified by additional criteria, which could lead to placement in residential settings for more intensive delivery of services. For individuals served by the Division of Developmental Disabilities Services: • Tier II: Institutional Level of Care—The individual scored high enough in certain areas to be eligible for paid services and supports. • Tier III: Institutional Level of Care—The individual scored high enough in certain areas to be eligible for the most intensive level of services, including 24 hours a day/7 days a week paid services and supports. Guidance: 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

20 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. (42 CFR 457.490(b)) If the State does not use a managed care delivery system for any or some of its CHIP populations, describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of: • 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); 42 CFR 457.490(a)) • The utilization control 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); 42 CFR 457.490(b))

Guidance: Only States that use a managed care delivery system for all or some CHIP populations need to answer the remaining questions under Section 3 (starting with 3.1.1.2). If the State uses a managed care delivery system for only some of its CHIP population, the State’s responses to the following questions will only apply to those populations. 3.1.1.2 Do any of your CHIP populations that receive services through a managed care delivery system receive any services outside of a managed care delivery system? No Yes

If yes, please describe which services are carved out of your managed care delivery system and how the State provides these services to an enrollee, such as through fee-for-service. Examples of carved out services may include transportation and dental, among others. For children who are not enrolled in the PASSE, they will only receive dental services through the Healthy Smiles Dental Managed Care program. All other services will still be provided in the fee-for-service system.

21 For children who are enrolled in the PASSE, the following services are carved-out of the model: • Nonemergency Medical Transportation • Dental Benefits • School-based services provided by school employees • Services provided to residents of a human development center, a skilled nursing facility, or an assisted living facility • They are enrolled in ARChoices, Independent Choices, the 1915(c) Autism Waiver, or any successor to these programs. 3.1.2 Use of a Managed Care Delivery System for All or Some of the State’s CHIP Populations 3.1.2.1 Check each of the types of entities below that the State will contract with under its managed care delivery system, and select and/or explain the method(s) of payment that the State will use: Managed care organization (MCO) (42 CFR 457.10) Capitation payment

Describe population served:

Those individuals who receive behavioral health and developmental disabilities services who are determined to meet the Tier II or Tier III level of need, unless they are residing in a Human Development Center, a skilled nursing facility, or an assisted living facility or they are enrolled in ARChoices, Independent Choices, the 1915(c) Autism Waiver, or a successor to one of these programs.

Prepaid inpatient health plan (PIHP) (42 CFR 457.10) Capitation payment Other (please explain)

Describe population served:

Guidance: If the State uses prepaid ambulatory health plan(s) (PAHP) to exclusively provide non-emergency medical transportation (a NEMT PAHP), the State should not check the following box for that plan. Instead, complete section 3.1.3 for the NEMT PAHP.

22 Prepaid ambulatory health plan (PAHP) (42 CFR 457.10) Capitation payment Other (please explain)

Describe population served: All children who are enrolled in CHIP will be mandatorily enrolled in the Healthy Smiles PAHP.

Primary care case manager (PCCM) (individual practitioners) (42 CFR 457.10) Case management fee Other (please explain)

Primary care case management entity (PCCM Entity) (42 CFR 457.10) Case management fee Shared savings, incentive payments, and/or other financial rewards for improved quality outcomes (see 42 CFR 457.1240(f)) Other (please explain)

If PCCM entity is selected, please indicate which of the following function(s) the entity will provide (as described in 42 CFR 457.10), in addition to PCCM services: Provision of intensive telephonic case management Provision of face-to-face case management Operation of a nurse triage advice line Development of enrollee care plans Execution of contracts with fee-for-service (FFS) providers in the FFS program Oversight responsibilities for the activities of FFS providers in the FFS program Provision of payments to FFS providers on behalf of the State Provision of enrollee outreach and education activities Operation of a customer service call center Review of provider claims, utilization and/or practice patterns to conduct provider profiling and/or practice improvement Implementation of quality improvement activities including administering enrollee satisfaction surveys or collecting data necessary for performance measurement of providers Coordination with behavioral health systems/providers Other (please describe)

23 3.1.2.2

The State assures that if its contract with an MCO, PAHP, or PIHP allows the entity to use a physician incentive plan, the contract stipulates that the entity must comply with the requirements set forth in 42 CFR 422.208 and 422.210. (42 CFR 457.1201(h), cross-referencing to 42 CFR 438.3(i)) 3.1.3 Nonemergency Medical Transportation PAHPs Guidance: Only complete Section 3.1.3 if the State uses a PAHP to exclusively provide non- emergency medical transportation (a NEMT PAHP). If a NEMT PAHP is the only managed care entity for CHIP in the State, please continue to Section 4 after checking the assurance below. If the State uses a PAHP that does not exclusively provide NEMT and/or uses other managed care entities beyond a NEMT PAHP, the State will need to complete the remaining sections within Section 3.

The State assures that it complies with all requirements applicable to NEMT PAHPs, and through its contracts with such entities, requires NEMT PAHPs to comply with all applicable requirements, including the following (from 42 CFR 457.1206(b)): • All contract provisions in 42 CFR 457.1201 except those set forth in 42 CFR 457.1201(h) (related to physician incentive plans) and 42 CFR 457.1201(l) (related to mental health parity). • The information requirements in 42 CFR 457.1207 (see Section 3.5 below for more details). • The provision against provider discrimination in 42 CFR 457.1208. • The State responsibility provisions in 42 CFR 457.1212 (about disenrollment), 42 CFR 457.1214 (about conflict of interest safeguards), and 42 CFR 438.62(a), as cross-referenced in 42 CFR 457.1216 (about continued services to enrollees). • The provisions on enrollee rights and protections in 42 CFR 457.1220, 457.1222, 457.1224, and 457.1226. • The PAHP standards in 42 CFR 438.206(b)(1), as cross-referenced by 42 CFR 457.1230(a) (about availability of services), 42 CFR 457.1230(d) (about coverage and authorization of services), and 42 CFR 457.1233(a), (b) and (d) (about structure and operation standards). • An enrollee's right to a State review under subpart K of 42 CFR 457. • Prohibitions against affiliations with individuals debarred or excluded by Federal agencies in 42 CFR 438.610, as cross referenced by 42 CFR 457.1285. • Requirements relating to contracts involving Indians, Indian Health Care Providers, and Indian managed care entities in 42 CFR 457.1209.

3.2. General Managed Care Contract Provisions

24

3.2.1

The State assures that it provides for free and open competition, to the maximum extent practical, in the bidding of all procurement contracts for coverage or other services, including external quality review organizations, in accordance with the procurement requirements of 45 CFR part 75, as applicable. (42 CFR 457.940(b); 42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(e)) 3.2.2

The State assures that it will include provisions in all managed care contracts that define a sound and complete procurement contract, as required by 45 CFR part 75, as applicable. (42 CFR 457.940(c)) 3.2.3

The State assures that each MCO, PIHP, PAHP, PCCM, and PCCM entity complies with any applicable Federal and State laws that pertain to enrollee rights, and ensures that its employees and contract providers observe and protect those rights (42 CFR 457.1220, cross-referencing to 42 CFR 438.100). These Federal and State laws include: Title VI of the Civil Rights Act of 1964 (45 CFR part 80), Age Discrimination Act of 1975 (45 CFR part 91), Rehabilitation Act of 1973, Title IX of the Education Amendments of 1972, Titles II and III of the Americans with Disabilities Act, and section 1557 of the Patient Protection and Affordable Care Act. 3.2.4

The State assures that it operates a Web site that provides the MCO, PIHP, PAHP, and PCCM entity contracts. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(3)) 3.3 Rate Development Standards and Medical Loss Ratio 3.3.1 The State assures that its payment rates are: Based on public or private payment rates for comparable services for comparable populations; and Consistent with actuarially sound principles as defined in 42 CFR 457.10. (42 CFR 457.1203(a))

Guidance: States that checked both boxes under 3.3.1 above do not need to make the next assurance. If the state is unable to check both boxes under 3.1.1 above, the state must check the next assurance. If the State is unable to meet the requirements under 42 CFR 457.1203(a), the State attests that it must establish higher rates because such rates are necessary to ensure sufficient provider participation or provider access or to enroll providers who demonstrate exceptional efficiency or quality in the provision of services. (42 CFR 457.1203(b))

25 3.3.2

The State assures that its rates are designed to reasonably achieve a medical loss ratio standard equal to at least 85 percent for the rate year and provide for reasonable administrative costs. (42 CFR 457.1203(c)) 3.3.3

The State assures that it will provide to CMS, if requested by CMS, a description of the manner in which rates were developed in accordance with the requirements of 42 CFR 457.1203(a) through (c). (42 CFR 457.1203(d)) 3.3.4

The State assures that it annually submits to CMS a summary description of the reports pertaining to the medical loss ratio received from the MCOs, PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(a)) 3.3.5 Does the State require an MCO, PIHP, or PAHP to pay remittances through the contract for not meeting the minimum MLR required by the State? (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b)(1)) No, the State does not require any MCO, PIHP, or PAHP to pay remittances. Yes, the State requires all MCOs, PIHPs, and PAHPs to pay remittances. Yes, the State requires some, but not all, MCOs, PIHPs, and PAHPs to pay remittances.

If the State requests some, but not all, MCOs, PIHPs, and PAHPs to pay remittances through the contract for not meeting the minimum MLR required by the State, please describe which types of managed care entities are and are not required to pay remittances. For example, if a state requires a medical MCO to pay a remittances but not a dental PAHP, please include this information. If the answer to the assurance above is yes for any or all managed care entities, please answer the next assurance: The State assures that it if a remittance is owed by an MCO, PIHP, or PAHP to the State, the State: • Reimburses CMS for an amount equal to the Federal share of the remittance, taking into account applicable differences in the Federal matching rate; and • Submits a separate report describing the methodology used to determine the State and Federal share of the remittance with the annual report provided to CMS that summarizes the reports received from the MCOs, PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b))

3.3.6

The State assures that each MCO, PIHP, and PAHP calculates and reports the medical loss ratio in accordance with 42 CFR 438.8. (42 CFR 457.1203(f))

26 3.4 Enrollment

The State assures that its contracts with MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities provide that the MCO, PIHP, PAHP, PCCM or PCCM entity: • Accepts individuals eligible for enrollment in the order in which they apply without restriction (unless authorized by CMS), up to the limits set under the contract (42 CFR 457.1201(d), cross-referencing to 42 CFR 438.3(d)(1)); • Will not, on the basis of health status or need for health care services, discriminate against individuals eligible to enroll (42 CFR 457.1201(d), cross-referencing to 42 CFR 438.3(d)(3)); and • Will not discriminate against individuals eligible to enroll on the basis of race, color, national origin, sex, sexual orientation, gender identity, or disability and will not use any policy or practice that has the effect of discriminating on the basis of race, color, national origin, sex, sexual orientation, gender identity or disability. (42 CFR 457.1201(d), cross-referencing to 438.3(d)(4)) 3.4.1 Enrollment Process 3.4.1.1

The State assures that it provides informational notices to potential enrollees in an MCO, PIHP, PAHP, PCCM, or PCCM entity that includes the available managed care entities, explains how to select an entity, explains the implications of making or not making an active choice of an entity, explains the length of the enrollment period as well as the disenrollment policies, and complies with the information requirements in 42 CFR 457.1207 and accessibility standards established under 42 CFR 457.340. (42 CFR 457.1210(c)) 3.4.1.2

The State assures that its enrollment system gives beneficiaries already enrolled in an MCO, PIHP, PAHP, PCCM, or PCCM entity priority to continue that enrollment if the MCO, PIHP, PAHP, PCCM, or PCCM entity does not have the capacity to accept all those seeking enrollment under the program. (42 CFR 457.1210(b)) 3.4.1.3 Does the State use a default enrollment process to assign beneficiaries to an MCO, PIHP, PAHP, PCCM, or PCCM entity? (42 CFR 457.1210(a)) Yes No

If the State uses a default enrollment process, please make the following assurances: The State assigns beneficiaries only to qualified MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities that are not subject to the intermediate sanction of having suspension of all new enrollment

27 (including default enrollment) under 42 CFR 438.702 and have capacity to enroll beneficiaries. (42 CFR 457.1210(a)(1)(i)) The State maximizes continuation of existing provider-beneficiary relationships under 42 CFR 457.1210(a)(1)(ii) or if that is not possible, distributes the beneficiaries equitably and does not arbitrarily exclude any MCO, PIHP, PAHP, PCCM or PCCM entity from being considered. (42 CFR 457.1210(a)(1)(ii), 42 CFR 457.1210(a)(1)(iii))

3.4.2 Disenrollment 3.4.2.1

The State assures that the State will notify enrollees of their right to disenroll consistent with the requirements of 42 CFR 438.56 at least annually. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f)(2)) 3.4.2.2

The State assures that the effective date of an approved disenrollment, regardless of the procedure followed to request the disenrollment, will be no later than the first day of the second month following the month in which the enrollee requests disenrollment or the MCO, PIHP, PAHP, PCCM or PCCM entity refers the request to the State. (42 CFR 457.1212, cross-referencing to 438.56(e)(1)) 3.4.2.3

If a beneficiary disenrolls from an MCO, PIHP, PAHP, PCCM, or PCCM entity, the State assures that the beneficiary is provided the option to enroll in another plan or receive benefits from an alternative delivery system. (Section 2103(f)(3) of the Social Security Act, incorporating section 1932(a)(4); 42 CFR 457.1212, cross referencing to 42 CFR 438.56; State Health Official Letter #09-008) 3.4.2.4 MCO, PIHP, PAHP, PCCM and PCCM Entity Requests for Disenrollment. The State assures that contracts with MCOs, PIHPs, PAHPs, PCCMs and PCCM entities describe the reasons for which an MCO, PIHP, PAHP, PCCM and PCCM entity may request disenrollment of an enrollee, if any. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(b)) Guidance: Reasons for disenrollment by the MCO, PIHP, PAHP, PCCM, and PCCM entity must be specified in the contract with the State. Reasons for disenrollment may not include an adverse change in the enrollee's health status, or because of the enrollee's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior

28 resulting from his or her special needs (except when his or her continued enrollment in the MCO, PIHP, PAHP, PCCM or PCCM entity seriously impairs the entity's ability to furnish services to either this particular enrollee or other enrollees). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(b)(2)) 3.4.2.5 Enrollee Requests for Disenrollment. Guidance: The State may also choose to limit disenrollment from the MCO, PIHP, PAHP, PCCM, or PCCM entity, except for either: 1) for cause, at any time; or 2) without cause during the latter of the 90 days after the beneficiary’s initial enrollment or the State sends the beneficiary notice of that enrollment, at least once every 12 months, upon reenrollment if the temporary loss of CHIP eligibility caused the beneficiary to miss the annual disenrollment opportunity, or when the State imposes the intermediate sanction specified in 42 CFR 438.702(a)(4). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)) Does the State limit disenrollment from an MCO, PIHP, PAHP, PCCM and PCCM entity by an enrollee? (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)) Yes No

If the State limits disenrollment by the enrollee from an MCO, PIHP, PAHP, PCCM and PCCM entity, please make the following assurances (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)): The State assures that enrollees and their representatives are given written notice of disenrollment rights at least 60 days before the start of each enrollment period. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(f)(1)) The State assures that beneficiary requests to disenroll for cause will be permitted at any time by the MCO, PIHP, PAHP, PCCM or PCCM entity. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(1) and (d)(2)) The State assures that beneficiary requests for disenrollment without cause will be permitted by the MCO, PIHP, PAHP, PCCM or PCCM entity at the following times: • During the 90 days following the date of the beneficiary's initial enrollment into the MCO, PIHP, PAHP, PCCM, or PCCM entity, or during the 90 days following the date the State sends the beneficiary notice of that enrollment, whichever is later; • At least once every 12 months thereafter;

29 • If the State plan provides for automatic reenrollment for an individual who loses CHIP eligibility for a period of 2 months or less and the temporary loss of CHIP eligibility has caused the beneficiary to miss the annual disenrollment opportunity; and • When the State imposes the intermediate sanction on the MCO, PIHP, PAHP, PCCM or PCCM entity specified in 42 CFR 438.702(a)(4). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(2)) 3.4.2.6

The State assures that the State ensures timely access to a State review for any enrollee dissatisfied with a State agency determination that there is not good cause for disenrollment. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(f)(2)) 3.5 Information Requirements for Enrollees and Potential Enrollees 3.5.1

The State assures that it provides, or ensures its contracted MCOs, PAHPs, PIHPs, PCCMs and PCCM entities provide, all enrollment notices, informational materials, and instructional materials related to enrollees and potential enrollees in accordance with the terms of 42 CFR 457.1207, cross-referencing to 42 CFR 438.10. 3.5.2

The State assures that all required information provided to enrollees and potential enrollees are in a manner and format that may be easily understood and is readily accessible by such enrollees and potential enrollees. (42 CFR 457.1207, cross- referencing to 42 CFR 438.10(c)(1)) 3.5.3

The State assures that it operates a Web site that provides the content specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)-(i) either directly or by linking to individual MCO, PIHP, PAHP and PCCM entity Web sites. 3.5.4

The State assures that it has developed and requires each MCO, PIHP, PAHP and PCCM entity to use: • Definitions for the terms specified under 42 CFR 438.10(c)(4)(i), and • Model enrollee handbooks, and model enrollee notices. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(4))

3.5.5

If the State, MCOs, PIHPs, PAHPs, PCCMs or PCCM entities provide the information required under 42 CFR 457.1207 electronically, check this box to confirm that the State assures that it meets the requirements under 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(6) for providing the material in an accessible manner. Including that: • The format is readily accessible; • The information is placed in a location on the State, MCO's, PIHP's, PAHP's,

30 or PCCM's, or PCCM entity's Web site that is prominent and readily accessible; • The information is provided in an electronic form which can be electronically retained and printed; • The information is consistent with the content and language requirements in 42 CFR 438.10; and • The enrollee is informed that the information is available in paper form without charge upon request and is provided the information upon request within 5 business days. 3.5.6

The State assures that it meets the language and format requirements set forth in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(d), including but not limited to: • Establishing a methodology that identifies the prevalent non-English languages spoken by enrollees and potential enrollees throughout the State, and in each MCO, PIHP, PAHP, or PCCM entity service area; • Making oral interpretation available in all languages and written translation available in each prevalent non-English language; • Requiring each MCO, PIHP, PAHP, and PCCM entity to make its written materials that are critical to obtaining services available in the prevalent non- English languages in its particular service area; • Making interpretation services available to each potential enrollee and requiring each MCO, PIHP, PAHP, and PCCM entity to make those services available free of charge to each enrollee; and • Notifying potential enrollees, and requiring each MCO, PIHP, PAHP, and PCCM entity to notify its enrollees: o That oral interpretation is available for any language and written translation is available in prevalent languages; o That auxiliary aids and services are available upon request and at no cost for enrollees with disabilities; and o How to access the services in 42 CFR 457.1207, cross-referencing 42 CFR 438.10(d)(5)(i) and (ii).

3.5.7

The State assures that the State or its contracted representative provides the information specified in 42 CFR 457.1207, cross-referencing to 438.10(e)(2), and includes the information either in paper or electronic format, to all potential enrollees at the time the potential enrollee becomes eligible to enroll in a voluntary managed care program or is first required to enroll in a mandatory managed care program and within a timeframe that enables the potential enrollee to use the information to choose among the available MCOs, PIHPs, PAHPs, PCCMs and PCCM entities: • Information about the potential enrollee's right to disenroll consistent with the

31 requirements of 42 CFR 438.56 and which explains clearly the process for exercising this disenrollment right, as well as the alternatives available to the potential enrollee based on their specific circumstance; • The basic features of managed care; • Which populations are excluded from enrollment in managed care, subject to mandatory enrollment, or free to enroll voluntarily in the program; • The service area covered by each MCO, PIHP, PAHP, PCCM, or PCCM entity; • Covered benefits including: o Which benefits are provided by the MCO, PIHP, or PAHP; and which, if any, benefits are provided directly by the State; and o For a counseling or referral service that the MCO, PIHP, or PAHP does not cover because of moral or religious objections, where and how to obtain the service; • The provider directory and formulary information required in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h) and (i); • Any cost-sharing for the enrollee that will be imposed by the MCO, PIHP, PAHP, PCCM, or PCCM entity consistent with those set forth in the State plan; • The requirements for each MCO, PIHP or PAHP to provide adequate access to covered services, including the network adequacy standards established in 42 CFR 457.1218, cross-referencing 42 CFR 438.68; • The MCO, PIHP, PAHP, PCCM and PCCM entity's responsibilities for coordination of enrollee care; and • To the extent available, quality and performance indicators for each MCO, PIHP, PAHP and PCCM entity, including enrollee satisfaction. 3.5.8

The State assures that it will provide the information specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f) to all enrollees of MCOs, PIHPs, PAHPs and PCCM entities, including that the State must notify all enrollees of their right to disenroll consistent with the requirements of 42 CFR 438.56 at least annually. 3.5.9

The State assures that each MCO, PIHP, PAHP and PCCM entity will provide the information specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f) to all enrollees of MCOs, PIHPs, PAHPs and PCCM entities, including that: • The MCO, PIHP, PAHP and, when appropriate, the PCCM entity, must make a good faith effort to give written notice of termination of a contracted provider within the timeframe specified in 42 CFR 438.10(f), and • The MCO, PIHP, PAHP and, when appropriate, the PCCM entity must make available, upon request, any physician incentive plans in place as set forth in 42 CFR 438.3(i).

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3.5.10