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State/Territory Name: Arkansas State Plan Amendment (SPA) #: 21-0001 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Pages

Records / Submission Packages - View All AR - Submission Package - AR2023MS0001O - (AR-23-0001) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group Division of Program Operations 601 E. 12th St. Room 355 Kansas City, MO 64106 Center for Medicaid & CHIP Services May 03, 2023 Janet Mann Director of Department of Human Services DHS Division of Medical Services 112 West 8th Street Slot S401 LIttle Rock, AR 72201-4608 Re: Approval of State Plan Amendment AR-23-0001 Dear Janet Mann, On March 08, 2023, the Centers for Medicare and Medicaid Services (CMS) received Arkansas State Plan Amendment (SPA) AR-23-0001, in which the state proposed to adopt the changes to the eligibility rules for the Former Foster Care Children eligibility group, as enacted by the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, Pub. L. No. 115-217, section 1002. We approve Arkansas State Plan Amendment (SPA) AR-23-0001 with an effective date(s) of January 01, 2023. If you have any questions regarding this amendment, please contact Lee Herko at Lee.Herko@cms.hhs.gov Sincerely, James G. Scott Director, Division of Program Operations Center for Medicaid & CHIP Services CMS Cf US JOR MEDICARE &MEDICAJO SIIMCES

Records / Submission Packages - View All AR - Submission Package - AR2023MS0001O - (AR-23-0001) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | AR2023MS0001O | AR-23-0001 CMS-10434 OMB 0938-1188 Package Header Package ID AR2023MS0001O Submission Type Official Approval Date 05/03/2023 Superseded SPA ID N/A SPA ID AR-23-0001 Initial Submission Date 3/8/2023 Effective Date N/A State Information State/Territory Name: Arkansas Medicaid Agency Name: DHS Division of Medical Services Submission Component State Plan Amendment Medicaid CHIP 0 0 0

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | AR2023MS0001O | AR-23-0001 Package Header Package ID AR2023MS0001O Submission Type Official Approval Date 05/03/2023 Superseded SPA ID N/A SPA ID AR-23-0001 Initial Submission Date 3/8/2023 Effective Date N/A SPA ID and Effective Date SPA ID AR-23-0001 Reviewable Unit Proposed Effective Date Superseded SPA ID Mandatory Eligibility Groups 1/1/2023 AR-22-0027 Former Foster Care Children 1/1/2023 AR-13-15-MM1 Page Number of the Superseded Plan Section or Attachment (If Applicable):

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | AR2023MS0001O | AR-23-0001 Package Header Package ID AR2023MS0001O Submission Type Official Approval Date 05/03/2023 Superseded SPA ID N/A SPA ID AR-23-0001 Initial Submission Date 3/8/2023 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives Section 1002(a) of the SUPPORT Act modifies these eligibility requirements for the former foster care children group in two ways. First, section 1002(a)(1)(A) of the SUPPORT Act eliminates the requirement that an individual not be eligible for another mandatory eligibility group (other than the adult group) to be eligible for the former foster care children group. As a result, a person may be enrolled in the former foster care children group even if the individual meets the eligibility requirements for a separate mandatory group described in section 1902(a)(10)(A)(i) of the Act, so long as the individual is not actually enrolled in such group. Second, section 1002(a)(1)(B) and (C) of the SUPPORT Act expanded eligibility for the former foster care children group by requiring that states cover individuals who aged out of foster care in a state other than the state in which they are currently seeking Medicaid coverage. Specifically, sections 1002(a)(1)(B) and (C) of the SUPPORT Act amend sections 1902(a)(10)(A)(i) (IX)(cc) and (dd) of the Act, respectively, to replace each reference to “the State” with a reference to “a State.” (Emphasis added). This means that all states must cover in the former foster care children group individuals who aged out of foster care in another state, as long as they otherwise meet the eligibility requirements for this group. The Arkansas Medicaid State Plan is being updated to reflect these changes. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2023 $42107 Second 2024 $56143 Federal Statute / Regulation Citation Statute: 1902(a)(10)(A)(i)(IX); Section 1002(a)(2) of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (Pub. L. No. 115-271) Regulation: 42 CFR 435.150 Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | AR2023MS0001O | AR-23-0001 Package Header Package ID AR2023MS0001O Submission Type Official Approval Date 05/03/2023 Superseded SPA ID N/A SPA ID AR-23-0001 Initial Submission Date 3/8/2023 Effective Date N/A Governor's Office Review PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 7/18/2023 5:00 PM EDT No comment Comments received No response within 45 days Other 0 0 0 0

Records / Submission Packages - View All AR - Submission Package - AR2023MS0001O - (AR-23-0001) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | AR2023MS0001O | AR-23-0001 CMS-10434 OMB 0938-1188 Package Header Package ID AR2023MS0001O Submission Type Official Approval Date 05/03/2023 Superseded SPA ID AR-22-0027 User-Entered SPA ID AR-23-0001 Initial Submission Date 3/8/2023 Effective Date 1/1/2023 Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Infants and Children under Age 19 CONVERTED Parents and Other Caretaker Relatives CONVERTED Pregnant Women APPROVED Deemed Newborns NEW Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care NEW Former Foster Care Children APPROVED Transitional Medical Assistance NEW Extended Medicaid due to Spousal Support Collections NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  SSI Beneficiaries NEW Closed Eligibility Groups NEW Individuals Deemed To Be Receiving SSI NEW

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Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Working Individuals under 1619(b) NEW Qualified Medicare Beneficiaries NEW Qualified Disabled and Working Individuals NEW Specified Low Income Medicare Beneficiaries NEW Qualifying Individuals NEW

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Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | AR2023MS0001O | AR-23-0001 Package Header Package ID AR2023MS0001O Submission Type Official Approval Date 05/03/2023 Superseded SPA ID AR-22-0027 User-Entered SPA ID AR-23-0001 Initial Submission Date 3/8/2023 Effective Date 1/1/2023 B. The state elects the Adult Group, described at 42 CFR 435.119. Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Adult Group CONVERTED C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 7/18/2023 5:02 PM EDT Yes No

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Records / Submission Packages - View All AR - Submission Package - AR2023MS0001O - (AR-23-0001) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Former Foster Care Children MEDICAID | Medicaid State Plan | Eligibility | AR2023MS0001O | AR-23-0001 Individuals under the age of 26, who were in foster care and on Medicaid when they turned age 18 or aged out of foster care. CMS-10434 OMB 0938-1188 Package Header Package ID AR2023MS0001O Submission Type Official Approval Date 05/03/2023 Superseded SPA ID AR-13-15-MM1 User-Entered SPA ID AR-23-0001 Initial Submission Date 3/8/2023 Effective Date 1/1/2023 The state covers the mandatory former foster care children group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are under age 26 2. Were in foster care upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21). 3. Are described under either Section B. or C. B. Individuals Covered For individuals who turn 18 before January 1, 2023: 1. The state covers individuals who: a. Upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21) were: i. In foster care under the responsibility of the state or a Tribe within the state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program); and ii. Enrolled in Medicaid under the state's Medicaid state plan or 1115 demonstration; and b. Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. 2. In addition to B.1., the state elects to cover individuals who were in foster care under the responsibility of the state or a Tribe within the state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program) when they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act, and meet the following criteria: C. Individuals Covered For individuals who turn 18 on or after January 1, 2023: 1. The state covers individuals who: a. Upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21) were: i. In foster care under the responsibility of any state or a Tribe within any state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program); and ii. Enrolled in Medicaid under a state's Medicaid state plan or 1115 demonstration; and b. Are not enrolled in mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. a. They were enrolled in Medicaid under the state's Medicaid state plan or 1115 demonstration at any time during the foster care period in which they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. b. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project when they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. c. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project at any time during the foster care period in which they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. □ □ □

2. In addition to C.1., the state elects to cover individuals who were in foster care under the responsibility of any state or a Tribe within any state (including children who were cared for through a grant to a state under the unaccompanied refugee minor program) when they turned 18 or a higher age at which that state's or Tribe's foster care assistance ends under title IV-E of the Act, and meet the following criteria: a. They were enrolled in Medicaid under a state's Medicaid state plan or 1115 demonstration at any time during the foster care period in which they turned 18 or a higher age at which a state's or Tribe's foster care assistance ends. b. They were placed by a state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project when they turned 18 or a higher age at which a state's or Tribe's foster care assistance ends. c. They were placed by a state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project at any time during the foster care period in which they turned 18 or a higher age at which a state's or Tribe's foster care assistance ends. □ ~ □

Former Foster Care Children MEDICAID | Medicaid State Plan | Eligibility | AR2023MS0001O | AR-23-0001 Package Header Package ID AR2023MS0001O Submission Type Official Approval Date 05/03/2023 Superseded SPA ID AR-13-15-MM1 User-Entered SPA ID AR-23-0001 Initial Submission Date 3/8/2023 Effective Date 1/1/2023 D. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 7/18/2023 5:03 PM EDT

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services MAY 0 6 2011 Thomas Betlach, Director Region IX Division of Medicaid & Children's Health Operations 90 Seventh Street, Suite 5-300 (5W) San Francisco, CA 94103-6706 Arizona Health Care Cost Containment System 801 East Jefferson Street Phoenix, AZ 85034 Dear Mr. Betlach: Enclosed is an approved copy of Arizona's State Plan Amendment (SPA) Number 10-001, which was submitted to my office on January 11, 2010 to implement nominal cost sharing under Section 1916 for all State Plan Medicaid populations not otherwise exempt and to implement Section 1916(a) alternative cost sharing for Transitional Medical Assistance (TMA) parents/caretaker relatives with family income exceeding 100% FPL. The effective date of this SPA is October 1, 2010 as requested. Enclosed are the following approved State Plan pages to be incorporated within your approved State Plan: • Section 4.18, pages 54-56 • Attachment 4.18-A, pages 1-3 • Attachment 4.18-F, pages 1, 1(a), 2, 3, 3(a), and 4-8 If you have any questions, please contact Cheryl Young at (415) 744-3598 or by email at cheryl. young @cms.hhs.gov. Enclosure cc: Jessica Schubel, CMCS HeeYoung Ansell, DMCHO Sincerely, . ~1{_~ Gloria Nagle, Ph.D., MPA Associate Regional Administrator Division of Medicaid & Children's Health Operations

Revision: HCFA-AT-91-4(BPD) AUGUST 1991 54 OMBNo.: 0938- Statefferritory: _____ ___,_AI==iz=o~na,__ ____________ _ Citation 4.18 Recipient Cost Sharing and Similar Charges 42 CFR 447.51 through 44 7.5 8 1916(a) and (b) ofthe Act TN No.10-001 Supersedes TN No. 03-009 (a) Unless a waiver under 42 CFR 431.55(g) applies, deductibles, coinsurance rates, and copayments do not exceed the maximum allowable charges under 42 CFR 447.54. (b) Except as specified in items 4.18(b)(4), (5), and ( 6) below, with respect to individuals covered as categorically needy or as qualified Medicare beneficiaries (as defmed in section 1905(p )(1) of the Act) under the plan: ( 1) No enrollment fee, premium, or similar charge is imposed under the plan. (2) No deductible, coinsurance, copayment, or similar charge is imposed under the plan for the following: (i) Services to individuals under age 18, or under-- [X] Age 19 [ ] Age 20 [ ] Age 21 Reasonable categories of individuals who are age 18 or older, but under age 21, to whom charges apply are listed below, if applicable. (ii) Services to pregnant women related to the pregnancy or any other medical condition that may complicate the pregnancy. Approval Date __ M_A Y_0_6_1D_H_ Effective DateOctober 1, 2010

Revision: HCFA-PM-91-4 AUGUST 1991 (BPD) 55 OMB No.: 0938- State!ferritory: _____ ---=.Ar~iz,o"-"na=--------------- Citation 42 CFR 447.51 through 447.58 4.18(b)(2) 42 CFR 438.108 42 CFR 447.60 1916 of the Act, P.L. 99-272, (Section 9505) TN No. 10-001 Supersedes TN No. 03-009 (Continued) (iii) All services furnished to pregnant women. women. [X] Not applicable. Charges apply for services to pregnant women unrelated to the pregnancy. (iv) Services furnished to any individual who is an inpatient in a hospital, long-term care facility, or other medical institution, if the individual is required, as a condition of receiving services in the institution to spend for medical care costs all but a minimal amount of his or her income required for personal needs. (v) Emergency services if the services meet the requirements in 42 CFR 447.53(b)(4). (vi) Family planning services and supplies furnished to individuals of childbearing age. (vii) Services furnished by a managed care organization, health insuring organization, prepaid inpatient health plan, or prepaid ambulatory health plan in which the individual is enrolled, unless they meet the requirements of 42 CFR 447.60. [ X ] Managed care enrollees are charged deductibles, coinsurance rates, and copayments in an amount equal to the State Plan service cost -sharing. [ )Managed care enrollees are not charged deductibles, coinsurance rates, and copayments. (viii) Services furnished to an individual receiving hospice care, as defmed in section 1905(o) of the Act. Approval Date MAY 0 6 2011 Effective Date October 1, 2010

Revision: HCFA-PM-91-4 AUGUST 1991 (BPD) 56 OMB No.: 0938- State/Territory: _____ ___..:....Ar,_=iz=o=na=--------------- Citation 42 CFR 447.51 through 447.48 4.18(b) (Continued) TN No. 10-001 Supersedes TNNo. 92-25 (3) Unless a waiver under 42 CFR 431.55(g) applies, nominal deductible, coinsurance, copayment, or similar charges are imposed for services that are not excluded from such charges under item (b )(2) above. [ ] Not applicable. No such charges are imposed. (i) For any services, no more than one type of charge is imposed (ii) Charges apply to services furnished to the following age groups: [ ] 18 or older [X] 19 or older [ ] 20 or older [ ] 21 or older [ ] Charges apply to services furnished to the following reasonable categories of individuals listed below who are 18 years of age or older but under age 21. MAY06Z011 Approval Date _____ _ Effective Date October l, 2010

Revision: HCFA-PM-85-14 (BERC) SEPTEMBER 1985 ATTACHMENT 4.18-A Page 1 OMB : 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Arizona A. The following charges are imposed under section 1916 of the Social Security Act and 42 CFR 447.50-.60 with the exceptions specified at Section 1916(a)(2) and (j) of the Act and 42 CFR 447.53(b): Group of Individuals All other individuals covered under the State Plan with the exception of those covered under the TMAgroup under Att. 4.18-F TN No. 10-001 Supersedes TNNo. 93-10 Type of Charge Item/Service Ded. Coins. Copay Method of Determining Family Income Prescription drugs N/A N/A $2.30/ Same drug Outpatient visit, excluding N/A N/A $3 .40/visit Same emergency room visit if coded as non-emergent surgical procedures or evaluation and management services If not imposed above, any N/A N/A $2.30/visit Same services rendered during a visit coded as physical, occupational, or speech therapy services Approval Date MAY 0 6 Z011 Effective Date October 1, 2010

Revision: HCFA-PM-85-14 (BERC) SEPTEMBER 1985 ATTACHMENT 4.18-A Page2 OMB: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: B. The method used to collect cost sharing charges for categorically needy individuals: X Providers are responsible for collecting the cost sharing charges from individuals. The agency reimburses providers the full Medicaid rate for services and collects the cost sharing charges from individuals. C. The basis for determining whether an individual is unable to pay the charge, and the means by which such an individual is identified to providers, is described below: By state administrative rule, all providers are required to accept the individual's self-declaration of the inability to pay the charge. TN No. 10-001 Supersedes TNNo. N/A Approval Date MAY 0 6 1011 Effective Date October 1, 2010

Revision: HCFA-PM-85-14 (BERC) SEPTEMBER 1985 ATTACHMENT 4.18-A Page3 OMB: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Arizona D. The procedures for implementing and enforcing the exclusions from cost sharing contained in 42 CFR 447.53(b) are described below: Providers are able to access and track copayment information from the verification systems used by AHCCCS providers (excluding IVR) such as EVS, the web, and HIPAA transactions 270 and 271. The verification system will identify the member's eligibility category where a specific copay level is assigned by population. It will also identify whether the member is subject to a mandatory or nominal copayment and specify the copayment amount by service level. This system also identifies services which are exempt from copayments. Prior to implementation, AHCCCS provided information all providers and contractors which described the copayment requirements by eligibility category, including descriptions of exempt services and populations. This communication is posted on the website along with the rule, which sets forth the copayment requirements and prohibitions. Contracted health plans receive daily and monthly rosters from AHCCCS that identify each member's cost sharing designation (nominal, mandatory or exempt). In addition, AHCCCS sends the health plans a reference extract table which is used to identify the copay amounts for specific services by the member's cost sharing category. Interim Plan: October 1, 2010-April 30, 2011: To ensure that American Indians are exempted from cost sharing, fee for service users, who represent the vast majority of American Indian (AI) AHCCCS recipients, will be exempted from cost sharing. Because some AI's choose to receive services through MCO's, the AHCCCS Client Advocate Office will work with managed care enrollees to exempt AI's served under managed care. Final Plan: Effective no later than May 1, 2011:, As a result of an analysis of FFS claims and encounters, AHCCCS will identify all active and previous users of Indian Health Service Facilities, Tribally-Operated 638 Health Programs and Urban Indian Health Programs (liT/Us) for which AHCCCS has provided reimbursement. All users identified though this analysis will be flagged and exempted from all cost sharing, and this information will be communicated to MCOs' and providers. The AHCCCS Client Advocate office will also work closely with the identified population to ensure that cost sharing is not applied to any American Indian who has ever utilized an 1/T/U or received a service through referral by Contract Health Services. E. Cumulative maximums on charges: X State policy does not provide for cumulative maximums. Cumulative maximums have been established as described below: TN No. 10-001 Supersedes TNNo. N/A MJ\ '{ 0 6 2011 Approval Date _ _ _____ _ Effective Date October 1, 2010

Revision: June 2010 OMB Approved # Attachment 4.18-F Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Arizona Alternative Premiums and Cost Sharing Charges The following alternative premiums and cost sharing charges are imposed under section 1916A of the Social Security Act and 42 CFR 447.50 and 447.62- 447.82. A State may select one or more options for cost-sharing (including copayments, coinsurance, and deductibles) and premiums. A. For groups of individuals with family income at or below 100 percent of the FPL: 1. Cost Sharing a. Amount of Cost Sharing 1. _ / No cost sharing is imposed. 11. _» Nominal cost sharing is imposed under section 1916 ofthe Act (see Attachment 4.18-A and/or 4.18-C). 2. Premiums a. Amount of Premiums No premiums may be imposed for individuals with family income at or below 100 percent of the FPL. B. For groups of individuals with family income above 100 percent but at or below 150 percent of the FPL: 1. Cost Sharing a. Amount of Cost Sharing 1. _/ No cost sharing is imposed. 11. I Nominal cost sharing is imposed under section 1916 ofthe Act (see Attachment 4.18-A and/or 4.18-C). 111. _» Alternative cost sharing is imposed under section 1916A ofthe Act as follows (specify the amounts by group and services (see below): TN No. 10-001 Supersedes TNNo. N/A Approval Date _M_A_~_0_6_2_0_ 11_ Effective Date October 1, 2010

Revision: June 2010 OMB Approved # Attachment 4.18-F Page 1(a) STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Arizona Group of Item/Service Type of Charge *Method of Individuals Deductible Coinsurance Copayment Determining Family Income if different than for eligibility (including mthly or qtrly period) Individuals who receive Transitional Medical Assistance under§ 1925 of the Social Security Act above 100% FPL and at or below 150% FPL Prescription Drugs Outpatient visit, excluding emergency room visit if coded as evaluation and management services If not imposed above, any services rendered during a visit coded as physical, occupational, or speech therapy services If not imposed above, any services rendered during a visit coded as non-emergent surgical procedures when provided in a physician's office, an ASC or any other outpatient setting, excluding an emergency room TN No. 10-001 Supersedes TNNo. N/A N/A N/A $2.30/drug Same N/A N/A $4.00/ outpatient Same visit N/A N/A $3. 00/visit Same N/A N/A $3.00 Same Approval Dat~AY 0 6 2011 Effective Date October 1, 2010

Revision: June 2010 OMB Approved # Attachment 4.18-F Page2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Arizona b. Limitations: • The total aggregate amount of cost sharing and premiums imposed for all individuals in the family under sections 1916 and 1916A of the Act may not exceed 5 percent of the family income of the family involved, as applied on a_ monthly or K._ quarterly basis as specified by the State. • Cost sharing with respect to any item or service may not exceed 10 percent of the cost of the specific item or service. • Cost sharing may not be imposed for the services, items, and populations specified at section 1916A(b)(3)(B) of the Act and 42 CFR 447.70(a). • Additional limitations specified by the State: c. Enforcement _]SJ Providers are permitted to require the payment of any cost sharing as a condition for the provision of care, items, or services. TN No. 10-001 Supersedes TNNo. N/A MAY 0 6 2011 Approval Date ______ _ Effective Date October 1, 2010

Revision: June 2010 OMB Approved # Attachment 4.18-F Page 3 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Arizona Regardless of whether the State elects the above option to permit providers to enforce the collection of cost sharing payments, providers are permitted to reduce or waive cost sharing on a case-by-case basis. However, the State's payments to providers must be reduced by the amount of the beneficiary cost-sharing obligations, regardless of whether the provider collects the full cost sharing amount. 2. Premiums a. Amount of Premiums No premiums may be imposed for individuals with family income above 100 percent of the FPL but at or below 150 percent. C. For groups of individuals with family income above 150 percent of the FPL: 1. Cost Sharing a. Amount of Cost Sharing 1. _/ No cost sharing is imposed. 11. I Nominal cost sharing is imposed under section 1916 ofthe Act (see Attachment 4.18-A and/or 4.18-C). 111. _]Y Alternative cost sharing is imposed under section 1916A ofthe Act as follows (specify amounts by groups and services (see below)): TN No. 10-001 Supersedes TNNo. N/A Approval Date __ M_A_Y_0_ 6_Z_O_ll_ Effective Date October 1, 2010 OMB Approved #

Revision: June 2010 Attachment 4.18-F Page 3(a) STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Arizona Group of Item/Service Type of Charge *Method of Individuals Deductible Coinsurance Copayment Determining Family Income if different than for eligibility (including mthly or qtrly period) Individuals who receive Transitional Medical Assistance under § 1925 of the Social Security Act above 150% FPL Prescription Drugs Outpatient visit, excluding emergency room visit if coded as evaluation and management services If not imposed above, any services rendered during a visit coded as physical, occupational, or speech therapy services If not imposed above, any services rendered during a visit coded as non-emergent surgical procedures when provided in a physician's office, an ASC or any other outpatient setting, excluding an emergency room TN No. 10-001 Supersedes TNNo. N/A NIA N/A $2.30/drug Same NIA N/A $4.00/outpatient Same visit NIA N/A $3.00/visit Same NIA NIA $3.00/visit Sap1e Approval Date _ M_A_Y_O _6_2_0_11_ Effective Date October 1, 2010

Revision: June 2010 OMB Approved # Attachment 4.18-F Page4 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Arizona b. Limitations: • The to~al aggregate amount of cost sharing and premiums imposed for all individuals in the family under sections 1916 and 1916A of the Act may not exceed 5 percent of the family income of the family involved, as applied on a_ monthly or X quarterly basis as specified by the State. • Cost sharing with respect to any item or service may not exceed 20 percent of the cost of the specific item or service. • Cost sharing may not be imposed for the services, items, and populations specified at section 1916A(b)(3)(B) of the Act and 42 CFR 447.70(a). • Additional limitations specified by the State: N/A c. Enforcement _]Y Providers are permitted to require the payment of any cost sharing as a condition for the provision of care, items, or services. Regardless of whether the State elects the above option, providers are permitted to reduce or waive cost sharing on a case-by-case basis. However, a State's payments to providers must be reduced by the amount ofthe beneficiary cost-sharing obligations, regardless of whether the provider collects the full cost sharing amount. 2. Premiums a. Amount ofPremiums 1. _]Y No premiums are imposed. n. I Premiums are imposed under section 1916A ofthe Act as follows (specify the premium amount by group and income level. TN No. 10-001 Supersedes TNNo. N/A Approval Date __ M_A_Y_0_6_2_0 1_1_ Effective Date October 1, 2010

Revision: June 2010 OMB Approved # Attachment 4.18-F Page 5 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Arizona b. Limitation: • The total aggregate amount of cost sharing and premiums imposed for all individuals in the family under sections 1916 and 1916A ofthe Act may not exceed 5 percent ofthe family income of the family involved, as applied on a_ monthly or _ quarterly basis as specified by the State. • Premiums may not be imposed for the populations specified at section 1916A(b)(3)(A) of the Act and 42 CFR 447.66(a). • Additional limitations specified by the State: c. Enforcement 1. _/ Prepayment is required for the following groups of applicants when they apply for Medicaid: TN No. 10-001 Supersedes TNNo. N/A MAY 0 6 Z011 Approval Date ______ _ Effective Date October 1, 2010

Revision: June 2010 OMB Approved # Attachment 4.18-F Page 6 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Arizona 11. _/ Prepayment is required for the following groups of beneficiaries as a condition for receiving Medicaid services for the premium period: NIA 111. _/Eligibility is terminated for failure to pay after a grace period of_ days after the premium due date (at least 60 days) for the following groups of Medicaid beneficiaries: NIA 1v. _/ Payment will be waived by the State on a case-by-case basis if payment would create an undue hardship for the individual. D. Period of determining 5 percent aggregate family limit for premiums and cost sharing: Specify the period for which the 5 percent maximum will be applied. _]S) Quarterly _I Monthly TN No. 10-001 Supersedes TNNo. N/A Approval Date _ M_A_Y_0_6_2_01_1_ Effective Date October 1, 2010

Revision: June 2010 OMB Approved # Attachment 4.18-F Page 7 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Statefferritory: Arizona E. Method for tracking beneficiaries' liability for premiums and cost-sharing: 1. Describe the methodology used by the State to identify beneficiaries who are subject to premiums or to cost sharing for specific items or services. Alternative cost sharing is only applied to persons determined eligible for Transitional Medical Assistance under section 1925 through the State's normal eligibility redetermination process, which includes reviews initiated by eligible persons who report an increase in income. Interim Plan: October 1, 2010- April 30, 2011 :To ensure that American Indians are exempted from cost sharing, fee for service users, who represent the vast majority of American Indian (AI) AHCCCS recipients, will be exempted from cost sharing. Because some AI's choose to receive services through MCO's, the AHCCCS Client Advocate Office will work with managed care enrollees to exempt AI's served under managed care. Final Plan: Effective no later than May 1, 2011 :As a result of an analysis of FFS claims and encounters, AHCCCS will identify all active and previous users of Indian Health Service Facilities, Tribally-Operated 638 Health Programs and Urban Indian Health Programs (Iff/Us) for which AHCCCS has provided reimbursement. All users identified though this analysis will be flagged and exempted from all cost sharing, and this information will be communicated to MCOs' and providers. The AHCCCS Client Advocate office will also work closely with the identified population to ensure that cost sharing is not applied to any American Indian who has ever utilized an 1/T/U or received a service through referral by Contract Health Services. 2. Describe how the State identifies for providers, ideally through the use of automated systems, whether cost sharing for a specific item or service may be imposed on an individual beneficiary and whether the provider may require the beneficiary, as a condition for receiving the item or service, to pay the cost sharing charge. Contracted health plans will be informed of the services subject to copayments and their corresponding dollar amounts. Health plans will make this information available to their network of providers through the 834- the Benefit Enrollment Maintenance Transaction, a HIP AA required format used as the roster to contracted health plans. Additionally, all providers will be able to access information from the verification systems used by AHCCCS providers (except IVR) such as EVS, the web, and HIPAA transactions 270 and 271. Information regarding whether the member is subject to a mandatory or nominal copayment, when copayments can not be charged and what a member's specific copayment level is by service type. 3. Describe the State's processes (that do not rely on beneficiaries) used for tracking beneficiaries' incurred premiums and cost sharing under sections 1916 and 1916A of the Act if families are at risk of reaching their total aggregate limit for premiums and cost sharing, how the State informs beneficiaries and providers when a beneficiary's family has incurred premiums and cost sharing up to its 5 percent aggregate limit, and how the State assures that the family is no longer subject to further premiums and cost sharing for the remainder of the monthly or quarterly cap period. The State will use available Health Plan adjudicated encounters to identify beneficiaries reaching the 5% aggregate copayment amount in a quarter by using the lowest possible family income and calculating the applicable copayment amounts for reported services during the quarter. If it is determined that a beneficiary has reached the 5% cap, the State will identify this status in the verification systems described above to inform providers that the member is not be subject to further cost sharing. TN No. 10-001 Supersedes TNNo. N/A Approval Date MAY 0 6 201 1 Effective Date October 1, 201 0

Revision: June 2010 OMB Approved # Attachment 4.18-F Page 8 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURlTY ACT State/Territory: Arizona 4. Describe the process through which beneficiaries may request that the State reassess the family's aggregate limit for premiums and cost sharing when the family's income has changed or if a family member's Medicaid enrollment is being terminated due to nonpayment of a premium. Members are informed of applicable cost sharing requirements through the member handbook, the public website, and special copay notices provided to members prior to implementation. Members are advised they can request a reassessment of the family's aggregate limit if they believe the family's income has changed. F. Public Notice Requirements: Explain how the State meets the following public notice requirements at 42 CFR 447.76. 1. The requirement at 42 CFR 447.76(a) and (b) for making available certain information about the State's premiums and cost sharing policies and procedures to the general public, applicants, beneficiaries, and providers: AHCCCS posted the cost sharing State Plan Amendment on the public website. Additionally, AHCCCS filed the Notice of Proposed rule making and fmal rule making with the Secretary of State, made this information available on the public website, and conducted a public hearing at the Agency. A matrix of all public comments as well as the Administration's responses to each of the comments were posted to the website. Furthermore, the rulemaking process allowed for public participation at the Governor's Regulatory Review Council prior to the adoption of the rule. Member handbooks were updated to include updated information about cost sharing. Additionally, members subject to the mandatory copayments received advanced notice of the mandatory copayment requirements. AHCCCS updated the member application to describe cost sharing requirements as well as exemptions from cost sharing. 2. The requirement at 42 CFR 447.76(c) to provide the public with advance notice and the opportunity to comment prior to submitting a State plan amendment (SPA) to establish or substantially modify alternative premiums and/or cost sharing under section 1916A ofthe Act: Notice of the proposed rule and the opportunity to provide written or oral comments on the rule were published in the State Administrative Register. Following publication of the proposed rule, the agency allowed a 30 day period for submission of public comments and conducted a public hearing where oral public comments were solicited at the close of the comment period. In addition, a public hearing was conducted by a separate executive branch agency, the Governor's Regulatory Review Council, at which public comment was solicited prior to fmalization of the administrative rule. All of this information was published on both the AHCCCS and Secretary of State's websites. TN No. 10-001 Supersedes TNNo. N/A Approval Date MAY 0 6 1011 Effective Date October 1, 2010

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: Centers for Medicare and Medicaid Services TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 1. TRANSMITTAL NUMBER: 10-001 FORM APPROVED OMB NO 0938-0193 2. STATE Arizona 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE J~:~ly l' ~()H) October 1, 2010 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN r8J AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: ~~¥ ~Q : $23~.729"' $~3§ , §22 (Gtt:leF)- ($397,248) Section 1916A of the Social Security Act ~~¥ ~ ~: $92a,Q92 • $329,937 (Gtt:leF) ($Qaa,aQQ) Section 1916 of the Social Security Act FFY 11: ($683,000) FFY 12: ($670, 700) 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Attachment 4.18-F, pages 1, 1(a), 2, 3, 3(a), 4-8 Same Attachment 4.18-A, pages 1-3 Attachment 4.18-A, page 1 Section 4.18 pages 54-56 Section 4.18 page 54-56 10. SUBJECT OF AMENDMENT: Implements alternative cost sharing for certain populations as authorized under the Deficit Reduction Act(§ 1916A of the Social Security Act) and nominal cost sharing under § 1916 of the Social Security Act for all other individuals covered under the State Plan not otherwise exempted. 11. GOVERNOR'S REVIEW (Check One): r8J GOVERNOR'S OFFICE REPORTED NO COMMENT 0 OTHER, AS SPECIFIED: 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: ~ Monica Coury 801 E. Jefferson, MD#4200 13. TYPED NAME: Phoenix, Arizona 85034 Monica Coury 14. TITLE: Assistant Director 15. DATE SUBMITTED: January 11 , 2010 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROV'HIY O 6 2Dl1 January 11, 2010 PLAN APPROVED- ONE COPY ATIACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. ~~OFREGJW~/~IAL: October l, 20 11 21. TYPED NAME: 22. 'fiTLE: Associate Regional A.~...~... · ·-or Gloria Nagle Division ofMedicaid & Children's Health Op€:rations , 23. REMARKS: Boxes 4, 7, 8, 9 and 10 changes made by AZ on 9/28/10 per CMS request Box 4 changes the effective date. Box 7 updates the Fiscal Impact amounts. Boxes 8 and 9 adds pages 54-56 of Section 4.18. Block 9: Deletes "Same" since only Attachment 4.18-A page 1 is being superseded. Box 10: Adds language to indicate to whom nominal cost sharing applies. FORM HCFA-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Region IX Division of Medicaid & Children's Health Operations 90 Seventh Street, Suite 5·300 (5W) San Francisco, CA 94103-6706 AUG 1 1 2010 Tom Betlach, Director Arizona Health Care Cost Containment System 80 I East Jefferson Street Phoenix, AZ 85034 Dear Mr. Betlach: Enclosed is an approved copy of Arizona State Plan Amendment (SPA) No. 10-006, which eliminates certain optional services and imposes limitations on other optional services for adults age 21 and older. Specifically, this SPA eliminates podiatrist's services; preventive dental services; and well and physical exams. This SPA also limits prosthetics coverage and organ transplantation. Dental services also are limited to treatments of oral disease prior to transplantation and to extractions prior to treatment of certain cancers. This SPA is effective October 1,2010. If you have any questions, please contact Cheryl Young by phone at (415) 744-3598 or by email at Cheryl.Young@cms.hhs.gov. Sincerely, ~7!eP Gloria Nagle, Ph.D., MPA Associate Regional Administrator Division of Medicaid & Children's Health Operations cc: Michele Bowser, CMS Center for Medicaid and State Operations (two copies) HeeYoung Ansell, CMS DMCHO

Revision: HCFA-PM-93-5 (MB) ATTACHMENT 3.1-A May 1993 Page 2 OMB No.: Staterrerritory: ARIZONA AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDEDTO THE CATEGORICALLY NEEDY 4.a. Nursing facility services (other than services in an institution for mental diseases) for indIviduals 21 years of age or older. Provided: No limitations x With limitations* 4.b. Early and periodic screening, diagnostic and treatment services for individuals under 21 years of age, and treatment of conditions found.* 4.c. Family planning services and supplies for individuals of child-bearing age. Provided: No limitations x With limitations* 5.a. Physicians' services whether furnished in the office, the patient's home, a hospital, a nursing facility or elsewhere. Provided: No limitations x With limitations** b. Medical and surgical services furnished by a dentist (in accordance with section 1905(a)(5)(B) of the Act). Provided: No limitations With limitations* 6. Medical care and any other ~pe of remedial care recognized under State law, furnished by licensed practitIOners within the scope of their practice as defined by State law. a. Podiatrists' services. Provided: No limitations With limitations* X Not providea * Description provided in Limitations section of this Attachment. **Sole limitation is authorization by appropriate entity as defined in the Limitations section of this Attachment. TN No. 10-006 AUC Supersedes Approval Date Effective Date October 1,2010 TN No. 99-04

Attachment 3.1-A Limitations PageS Department of Education will also be allowed to provide behavioral health services in the public school system. Personal Care Services. Personal care services include assistance to eligible members in meeting essential personal physical needs, e.g., skin care, oral hygiene, toileting, ambulation, use of assistive device, feeding, training in activities of daily living. These services are covered in accordance with the requirements in 42 CFR § 440.167. Providers of personal care services will be the same providers as those described under nursing services, e.g., state-licensed registered nurses or licensed practical nurses or LEA certified school-based health attendants. In addition, school-based health attendants, who are specially trained and certified by the LEA in general care, such as first aid and CPR and the specific needs of the students they assist, will be allowed to provide certain delegated tasks under the supervision of the licensed nurses. Audiological Services. Audiology services include testing and evaluating hearing­ impaired children that mayor may not be improved by medication or surgical treatment. These services are covered in accordance with the requirements in the AHCCCS Medical Policy Manual (AMPM) Chapter 700. Annual audiological assessments will be provided as Arizona Administrative Code, R9-22-213, requires for students with disabilities and are separate from the screenings offered to the general student population. Providers of audiological services must be registered with AHCCCS, meet the licensing requirements of 42 CFR § 440.110 (c)(3), and be licensed as an Audiologist through the Arizona Department of Health Services (ADHS). 4.c. Family planning services and supplies for individuals of child-bearing age. Family planning services include: 1. contraceptive counseling, medication, supplies and associated medical and laboratory exams; 11. sterilizations; and, 111. natural family planning education or referral. Family planning services do not include abortion or abortion counseling. 5 b. Medical and surgical services furnished by a dentist (in accordance with section 1905(a)(5)(B) of the Act). The following dental services are not covered under this benefit and are not considered physician services: dental cleanings, routine dental examinations, dental restorations including crowns and fillings, extractions, pulpotomies, root canals, and the construction or delivery of complete or partial dentures. TN No. 10-006 AUG 1 1 2010 Supersedes Approval Date: Effective Date: October 1, 2010 TN No. 04-011

Attachment 3.l-A Limitations Page 6 Serv~ces covered by a dentist must be related to the treatment of a medical condition such as acute pain, infection, or fracture ofthe jaw and include examination of the oral cavity, required radiographs, complex oral surgical procedures such as treatment of maxillofacial fractures, administration of an appropriate level of anesthesia and the prescription of pain medication and antibiotics. 6. Medical care and any other types of remedial care recognized under State law, furnished by licensed practitioners within the scope of their practice as defined by State law. 6b. Optometrists' services. Optometrists' services when they are provided by a licensed optometrist. See section 12d for limitations on eyeglasses and contact lenses. 6d. Other practitioners' services. Other practitioners' services provided by: 1. Respiratory Therapists 11. Certified Nurse Practitioners 111. Certified Registered Nurse Anesthetists IV. Non-physician First Surgical Assistants and Physician Assistants v. Licensed midwives within the limitations provided in the AHCCCS policy and Procedures who practice within their scope in state statute and within national ACOG guidelines. VI. Licensed affiliated practice dental hygienists practicing within the scope of Arizona's state practice act. TN No. 10-006 AUG 1 1 2010 . Supersedes Approval Date: EffectIve Date: October 1, 2010 TN No. 09-004

Attachment 3.1-A Limitations Page 8 Behavioral health services provided in a clinic include individual, group and/or family . counseling/therapy, psychotropic medications, psychotropic medication adjustment and monitoring, emergency/crisis services, behavior management, psychosocial rehabilitation, screening, evaluation and diagnosis, case management services, laboratory and radiology services. The duration, scope and frequency of each therapeutic modality shall be part of a treatment plan. Screening services are limited to no more than one service during each six-month period of continuous behavioral health enrollment. 10. Dental services. Dental services are limited to (1) the elimination of oral infections and the treatment of oral disease, which includes dental cleanings, treatment of periodontal disease, medically necessary extractions and the provision of simple restorations as a medically necessary pre­ requisite to organ transplantation, and (2) prophylactic extraction of teeth in preparation for radiation treatment of cancer of the jaw, neck or head. 11. Physical therapy and related services. Physical therapies and related services as described in 11 b and 11 c for persons 21 years of age and older when a rehabilitation plan demonstrating rehabilitation potential is documented. The duration, scope and frequency of each therapeutic modality must be prescribed by the rehabilitation plan. Assessment, evaluation, and treatment services are included as part of this benefit. Out-patient physical therapy is limited to 15 visits per contract year. A "visit" is defined as all physical therapy services received on the same day. Therapies and related services for persons under the age of 21 are covered whether or not there is a demonstrated potential for rehabilitation. Providers meet the applicable requirements at 42 CFR 440.110. llb. Occupational therapy. Outpatient occupational therapy is not covered for persons 21 years of age or older unless the person is enrolled in ALTCS. Providers meet the applicable requirements at 42 CFR 440.110. Hc. Services for individuals with speech, hearing, and language disorders (provided by or under the supervision of a speech pathologist or audiologist). Outpatient speech therapy is not covered for persons 21 years of age or older unless the person is enrolled in ALTCS. Assessment, evaluation, and treatment services are included as part ofthis benefit. Providers meet the applicable requirements at 42 CFR 440.110. TN No. 10-006 AUG 1 2010 Supersedes Approval Date: Effective Date: October 1, 2010 TN No. 09-004

Attachment 3.1-A Limitations Page 9 12. Prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed by a . physician skilled in diseases of the eye or by an optometrist. 12a. Prescribed drugs. Prescription drugs for covered transplantation services shall be provided in accordance with AHCCCS transplantation policies. Over-the-counter or non-prescription medications are not covered unless an appropriate, alternative over-the-counter medication is available and less costly than a prescription medication. 12c. Prosthetic devices. Prosthetic devices are limited to devices prescribed by a physician or other licensed practitioner to artificially replace missing, deformed or malfunctioning portions of the body and which are medically necessary to the rehabilitation of the member. Covered prosthetic devices for members age 21 and older do not include hearing aids, cochlear implants, bone anchored hearing aids, insulin pumps, percussive vests, microprocessors for controlled joints for the lower limbs in addition to microprocessor­ controlled joints for the lower limbs, penile implants, and vacuum devices. Orthotic devices, which are defined as devices that are prescribed by a physician or other licensed practitioner of the healing arts to support a weak or deformed portion of the body, are not covered. 12d. Eyeglasses. Eye examinations for prescriptive lenses and the provision of prescriptive lenses under EPSDT services. Adult services are limited to eyeglasses and contact lenses as the sole prosthetic device after a cataract extraction. 13. Other diagnostic, screening, preventive, and rehabilitative services, i.e., other than those provided elsewhere in the plan. 13b. Screening services. Coverage is available for evidence-based medically necessary screening services for children based on guidelines from the American Academy of Pediatrics and CDC/ACIP for immunizations. Coverage is available for evidence-based medically necessary screening services for adults as described in the AHCCCS Medical Policy Manual (www.azallcccs.gov/shared/MedicaIPolicyManual/MedicaIPolicyManual.aspx?ID=policyma nuals) which are based, in part, on guidelines from the U.S. Preventive Services Task Force. TN No. 10-006 Al 'G ", 1 'WI 1,"j .' , I I' i U Supersedes Approval Date: Effective Date: October 1, 2010 L" , TN No. 09-004

Attachment 3.I-A Limitations Page 9(a) 13c. Preventive services. Coverage is available for evidence-based medically necessary preventive services for children based on guidelines from the American Academy of Pediatrics and CDC/ACIP for immunizations. Coverage is available for evidence-based medically necessary preventive services for adults as described in the AHCCCS Medical Policy Manual (http://ahcccsnew/shared/MedicaIPolicyManual/MedicaIPolicyManual.aspx?ID=policymanu als) which are based, in part, on guidelines from the u.s. Preventive Services Task Force. Preventive services not covered are: well exams meaning physical examinations in absence of any known disease or symptom or any specific medical complaint by the patient precipitating the examination. PAP smears, mammograms and colonoscopies are covered services. 13d. Rehabilitative services. Rehabilitation services include physical therapy, occupational therapy, speech and hearing services provided by licensed professionals in order to reduce physical disability and/or restore functional level. Services shall be provided on an inpatient or outpatient basis within the limitations outlined under section II. Rehabilitative services provided by a behavioral health and/or substance abuse rehabilitation agency. TN No. 10-006 AUG ?()1() Supersedes Approval Date: '-_"'_' Effective Date: October I, 2010 TN No. N/A

Revision: HCFA-PM-87-4 ATTACHMENT 3.I-E March 1987 Page I State/Territory: Arizona Standards for the Coverage of Organ Transplant Services Medically necessary transplant services are available to AHCCCS members as described in the AHCCCS Medical Policy Manual, meeting nationally recognized criteria for non-experimental, non-investigational organ or tissue transplants. Covered transplant services do not include the following: • Pancreas only transplants • Pancreas after kidney transplants • Lung transplants • Allogeneic umelated hemopoietic cell transplants • Heart transplants for non-ischemic cardiomyopathy • Liver transplants for diagnosis of Hepatitis C • Transplants ofthe intestines All AHCCCS members are eligible to receive the medically necessary transplants and related services described in the AHCCCS Medical Policy Manual with the following exceptions: • Title XIX SaBRA Family Planning Program members; and • Federal Emergency Services Program (FESP) members. AHCCCS members must meet specific prior authorization medical criteria to receive transplant services as specified in the AHCCCS Medical Policy Manual, or in a supplemental part of the AHCCCS Medical Policy Manual. The Manual and all supplements and updates to the Manual are available to the public on the agency's web site: http://ahcccsnew/shared/MedicaIPolicyManual/MedicaIPolicyManual.aspx?ID=policymanuals. TN No. 10-006 AUG 1 2010 Supersedes Approval Date _ Effective Date October 1, 2010 TN No. 01-012

Attachment 4.l9-A Page 6a STATE OF ARIZONA METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES INPATIENT HOSPITAL CARE 1) Transplants: AHCCCS shall negotiate contracts with hospitals qualified to perform covered organ and hematopoietic cell transplantation services. Reimbursement is based on a fixed price per type of transplant, by component, which may include stop-loss provisions. Component reimbursement is based on provider cost reports. At no time will payment for the entire case exceed a hospital's billed charges. Cornea transplants and bone graft transplantation are excluded from the component methodology and are reimbursed based on the tiered per diem rates. 2) Specialty Services: AHCCCS may negotiate contracts for specialized hospital services, including but not limited to: subacute, neonatalogy, neurology, cardiology and bum care. Rates are determined based on provider cost information and at no time will contracted rates exceed billed charges. III. RATE-SETTING METHODOLOGY The final payment for each tier is the sum of two separate components: operating and capital. This section describes each component and how it is calculated. Five ofthe seven tiers are statewide. The NICU tier is peer grouped for NICU Level II versus NICU Level III, as certified by the Arizona Perinatal Trust. The Routine tier is peer grouped for rehabilitation hospital versus general acute care hospital. A. Base Operating Component The operating component of the rate represents the weighted average operating cost per day for treating AHCCCS patients in that tier across all acute care hospitals in Arizona with two exceptions: Exception 1: For the Routine tier, the component represents the weighted average operating cost per day by peer group. The peer groups for the Routine tier are rehabilitation hospitals, and general acute care hospitals. TN No. 10-006 f~' UG 1 1 'ln1il Supersedes Approval Date Effective Date: October 1, 2010 TN No. 07-007

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE AND MEDICAID SERVICES OMS NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF I. TRANSMITTAL NUMBER: STATE PLAN MATERIAL 10-006 2. STATE Arizona FOR: Centers for Medicare and Medicaid Services TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE October I, 20 I0 5. TYPE OF PLAN MATERIAL (Check One): D NEW STATE PLAN D AMENDMENT TO BE CONSIDERED AS NEW PLAN ~ AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT Se orate Transmittal or each amendment 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT:' Section 1905(a) ofthe Social Security Act 42 CFR Part 440 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Attachment 3.I-A, page 2 Attachment 3.I-A Limitations, pages 5, 6, 8, 9, 9(a) Attachment 3.I-E, page I Attachment 4.19-A, page 6(a) J7II 10. SUBJECT OF AMENDMENT: FFY 2011: ($18,441,900) IN FFY 2012: ($18,650,200) //'t 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (IfApplicable): Same Implements reductions and limitations in optional services to the adult benefit package. II. GOVERNOR'S REVIEW (Check One): ~ GOVERNOR'S OFFICE REPORTED NO COMMENT D OTHER, AS SPECIFIED: D COMMENTS OF GOVERNOR'S OFFICE ENCLOSED D NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: /~4 ",/ OJ Monica Coury f--13-'--~-;-:-~-~~=~=N=·:~=:~=:~=··~=~:=--.·------------------1 ~~~e~'i~~~~~~~~~~~gi;oo MonicaCou 14. TITLE: Assistant Director 15. DATE SUBMITTED: Ma 21,2010 FORM HCFA-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Region IX Division ofMedicaid & Children's Health Operations 90 Seventh Street, Suite 5-300 (5W) San Francisco, CA 94103-6706 SEP 2 4 2010 Tom Betlach, Director Arizona Health Care Cost Containment System 801 East Jefferson Street Phoen~ AZ 85034 Dear Mr. Betlach: Enclosed is an approved copy of Arizona State Plan Amendment (SPA) No. 10-008, which prohibits the estate recovery of Medicare cost sharing benefits for dual eligible beneficiaries age 55 and over in compliance with Section 115 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). This SPA is effective July 1,2010. Arizona submitted documentation to CMS in order to demonstrate its compliance with this provision effective January I, 2010. Based on a review ofthis documentation, it appears that Arizona has made a good-faith effort to comply with the estate recovery provision fur dates ofservice on or after January 1,2010. If you have any questions, please contact Cheryl Young by phone at (415) 744-3598 or by email at Cheryl.Young@cms.hhs.gov. Sincerely, ~?t* Gloria Nagle, Ph.D., MPA Associate Regional Administrator Division of Medicaid & Children's Health Operations cc: Michele Bowser, CMS Center for Medicaid and State Operations (two copies) HeeYoung Ansell, CMS DMCHO

53a Revision: HCFA-PM-95-3 (MB) May 1995 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Statefferritory: ARIZONA b) Adjustments or Recoveries The State complies with the requirements ofsection 1917(b) ofthe Act and regulations at 42 CFR 433.36(hHi). Adjustments or recoveries for Medicaid claims correctly paid are as follows: (l) For permanently institutionalized individuals; adjustments or .recoveries are made from the individual's estate or upon sale ofthe property subject to a lien imposed because of medical assistance paid on behalf ofthe individual for services provided in a nursing facility, ICFIMR, or other medical institution. Adjustments or recoveries are made for all other medical assistance paid on behalf ofthe individual. (2) __ The State determines "permanent institutional status" of individuals under the age of 55 other than those with respect to whom it imposes liens on real property under §1917(a) (I) (B) (even if it does not impose those liens). (3) For any individual who received medical assistance at age 55 or older, adjustments or recoveries ofpayments are made from the individual's estate for nursing facility services, home and community-based services, and related hospital and prescription drug services . .lL. In addition to adjustment or recovery of payments for services listed above, payments are adjusted or recovered for other services under the State plan as below: All services provided to ALTCS members based on the total amount ofreimbursement paid by AHCCCS for Medicaid covered services. The reimbursements include, but are not limited to, capitation payments, reinsurance, any FFS payments, Medicare Part A and B, and Medicare premiums, deductibles, coinsurance and copayments or any other forms of cost sharing; for individuals age 55 and over, except for Medicare cost sharing identified at 4.17(b )(3XContinued). TN No. Supersedes Approval Date SEP 2 4 2010 Effective Date July I, 2010 TN No. 04-005

Page 53a-1 Revision: HCFA-PM-95-3 (MB) May 1995 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Staterrerritory: ARIZONA 4.17 (b) (3) Adjustments or Recoveries (Continued) Limitations on Estate Recovery - Medicare Cost Sharing: (i) Medical assistance for Medicare cost sharing is protected from estate recovery for the following categories ofdual eligibles: QMB, SLMB, QI, QDWI, QMB+, SLMB+. This protection extends to medical assistance for four Medicare cost sharing benefits: (part A and B premiums, deductibles, coinsurance, co­ payments) with dates of service on or after January 1,2010. The date of service for deductibles, coinsurance, and co-payments is the date the request for payment is received by the State Medicaid Agency. The date ofservice for premiums is the date the State Medicaid Agency paid the premium. (ii) In addition to being a qualified dual eligible the individual must also be age 55 or over. The above protection from estate recovery for Medicare cost sharing benefits (premiums, deductibles, coinsurance, co-payments) applies to approved mandatory (i.e., nursing facility, home and community-based services, and related prescription drugs and hospital services) as well as optional Medicaid services identified in the State plan, which are applicable to the categories ofduals referenced above. TN No. 10-008 Supersedes Approval Date SEP 2 4 2010 Ef'fect;ve Date July 1. 2010 TN No. NA

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE AND MEDICAID SERVICES OMS NO 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: Centers for Medieare and Medicaid StSrvices i TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): l. TRANSMIITAL NUMBER: 10-008 2. STATE Arizoga 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE July I, ~01O o NEW STATE PLAN o AMENDMENT TO BE CONSIDERED AS NEW PLAN 181 AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal[or each amendment) 6. FEDERAL STATUTEIREGULATION CITATION: 7. FEDERAL BUDGET IMPACT:' Section 1917(bXl)(BXii) of the Social Security Act (42 U.S.C. FFY 2010 $ 23,000 1396p(bXIXBXii» FFY 2011 $128,000 8. PAGE NUMBER OF THE PLAN SECTION OR AITACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR AITACHMENT (IfApplicable): Section 4.17, pp. 538, 53a-l Section4.17, pp.53a 10. SUBJECT OF AMENDMENT: Adds estate recovery protections resulting from Section 1 15 of MIPPA, which requires states to exempt Medicare cost-sharing benefits paid under the Medicare Savings Programs from estate recovery effective 111110. 11. GOVERNOR'S REVIEW (Check One): 181 GOVERNOR'S OFFICE REPORTED NO COMMENT o OTHER, AS SPECIFIED: o COMMENTS OF GOVERNOR'S OFFICE ENCLOSED P o NO RE LY RECEIVED WITHIN 45 DAYS OF SUBMITI'AL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN Monica Coury 801 E. Jefferson, MD#4200 t---:-:~"';;::;::,=:::::::::~==::"-----------------1 Phoenix, Arizona 85034 s FORM HCFA-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Tom Betlach, Director Arizona Health Care Cost Containment System 801 East Jefferson Street Phoenix, AZ 85034 Dear Mr. Betlach: Region IX Division ofMedicaid & Children's Health Operations 90 Seventh Street, Suite 5-300 (5W) San Francisco, CA 94103-6706 MAR 0 5 2012 ... . .. Enclosed is an approved copy of Arizona State Plan Amendment (SPA) No. 10-009. This SPA was submitted in response to a companion letter issued for SPA 09-004 issued on April 15, 2010. This SPA clarifies the service descriptions and provider qualifications for behavioral health services provided under the rehabilitation services component of the State Plan. The effective date of this SPA is July 1, 2010 as requested. Enclosed are the following approved State Plan pages to be incorporated within your approved State Plan: • Attachment 3.1-A Limitations, pages 9(a)- 9(j) If you have any questions, please contact Cheryl Young by phone at (415) 744-3598 or by email at Cheryl.Young@cms.hhs.gov. Sincerely, ~?(~ Gloria Nagle, Ph.D., M.P.A. Associate Regional Administrator Division of Medicaid & Children's Health Operations cc: Jessica Schubel, CMCS HeeYoung Ansell, CMS DMCHO

13c. Preventive services. Attachment 3.1-A Limitations Page 9(a) Coverage is available for evidence-based medically necessary preventive services for children based on guidelines from the American Academy of Pediatrics and CDC/ ACIP for immunizations. ' Coverage is available for evidence-based medically necessary preventive services for adults as described in the AHCCCS Medical Policy Manual (http://www.azahcccs.gov/shared!MedicalPolicyManual/MedicalPolicyManual.aspx) which are based, in part, on guidelines from the U.S. Preventive'Serviees T~sk Force. Preventive services not covered are: well exams meaning physical examinations in absence of any known disease or symptom or any specific medical complaint by the patient precipitating the examination. PAP smears, mammograms and colonoscopies are covered services. 13d. Rehabilitative services. Rehabilitative Services- Services to teach independent living, social and communication skills to persons or their families to promote the maximum reduction of behavioral health symptoms and/or restoration of an individual to his/her best age appropriate functional level for the purpose of maximizing the person's ability to live independently and function in the community. Services may be provided to a person, a group of persons or their families with the person( s) present. Rehabilitative services must be provided by individuals who are qualified behavioral health professionals, behavioral health technicians or behavioral health paraprofessionals as described in the following pages of Attachment 3.1-A Limitations, pages 9(b)-9G). TNNo.: 10-009 Supersedes TNNo.: 10-006 Approval Date: MAR 0 5 2012 Effective Date: July 1, 2010

Attachment 3.1-A Limitations Page 9(b) Screening/Evaluation/ Assessment: Screening is an initial assessment to determine the need for behavioral health services. Assessment/evaluation is the assessment of a member's medical, psychological, psychiatric or social condition to determine if a behavioral health disorder exists and if so, to establish a treatment plan for all medically necessary services. This includes emergency/crisis evaluation and assessment. Providers: Licensed practitioners of the healing arts and Behavioral Health Technicians (BHTs). Crisis assessment/evaluation includes Behavioral Health Paraprofessionals (BHPPs). (See Staff Qualifications Section) Limitations: BHT' s are limited to providing this service under an Ari~ona D'epartment of Health Services Office of Behavioral Health Licensure (ADHS/OBHL) licensed agency. BHPP's conducting crisis evaluations/assessments are limited to providing this service under an ADHS/OBHL licensed agency. As an additional limitation, these services can only be provided in the following settings: office, home, urgent care facility, inpatient hospital, outpatient hospital, emergency room, inpatient psychiatric facility, community mental health center, rural health clinic, outpatient clinic, including Federally Qualified Health Centers (FQHCs), rural substance abuse transitional agency, homeless shelter, medical day program, therapeutic day program, Level 2 behavioral health group home, and Level 3 behavioral health group home. Individual, Group and/or Family Therapy and Counseling: Therapy and counseling services that address the therapeutic goals outlined in the service plan. Services may be provided to an individual, a group of persons, a family or multiple families. Family counseling may not include the member but must be for the direct benefit of the member. Providers: Licensed practitioners of the healing arts and BHTs. (See Staff Qualifications Section) Limitations: BHT's are limited to providing this service under an ADHS/DBHS licensed agency. As an additional limitation, these services cannot be billed in combination with services in an institutional setting, residential treatment center, or Level 2/3 group home. TN No.: 10-009 Supersedes TNNo.: N/A MAR 0 5 2012 . Approval Date: ______ Effective Date: July 1, 2010

Attachment 3.1-A Limitations Page 9(c) Living Skills Training: These services are provided for the restoration, enhancement, maintenance, and assistance in obtaining age appropriate independent living, social, and communication skills to members and/or their families in order to maximize the member's ability to live and participate in the community and to function independently. Examples of areas that may be addressed include self care, household management, social decorum, same-and opposite sex friendships, avoidance of exploitation, budgeting, recreation, development of social support networks and use of community resources. Services may be provided to a person, a group of persons or their families with the member present. Providers: Licensed practitioners of the healing arts, BHT's, BHPP's, Home and Community Based Service (HCBS) Habilitation Providers (See Staff Qualifications 'Section) Limitations: BHT's and BHPP's are limited to providing this service under an ADHS/OBHL licensed agency or a State Certified Community Service Agency. As an additional limitation, these services can not be billed in combination with services in an institutional setting, residential treatment center, or Level2/3 group home. Health Promotion: Education and training provided to a group of persons and/or their families related to the enrolled member's treatment plan on health related topics such as the nature of illness, relapse and symptom management, medication management, stress management, safe sex practices, HIV education and healthy lifestyles. Providers: Licensed practitioners of the healing arts, BHT's, BHPP's (See Staff Qualifications Section) Limitations: BHT's and BHPP's are limited to providing this service under an ADHS/OBHL licensed agency or a State Certified Community Service Agency. As an additional limitation, these services can not be billed in combination with services in an institutional setting, residential treatment center, or Level 2/3 group home. Supported Employment Services: These services are designed to assist a person or group of persons with a medical/behavioral health condition that enables a member to function in the workplace. These services include supporting the member's ability to manage mental health related symptoms, facilitate recovery from mental illness; assist with personal, community and social competencies, and to aid members to establish and navigate environmental supports. Providers: Licensed practitioners of the healing arts, BHT's, BHPP's (See Staff Qualifications Section) Limitations: BHT's and BHPP's are limited to providing this service under an ADHS/OBHL licensed agency or a State Certified Community Service Agency. As an additional limitation, these services can not be billed in combination with services in an institutional setting, residential treatment center, or Level2/3 group home. TN No.: 10-009 Supersedes TNNo.: N/A MAR 0 5 '2012 Approval Date: ______ Effective Date: July 1, 2010

Attachment 3.1-A Limitations Page 9(d) Family Support/Home Care Training: These services include face to face interactions with a member's family and are directed toward restoration, enhancement, or maintenance of the family functioning to increase their ability to effectively interact and care for the member in the home and community when relevant to the member's treatment plan. May involve support activities such as assisting the family to adjust to the member's disability, developing skills to effectively interact and/or manage the member, understanding the causes and treatment of behavioral health issues, understanding and effectively utilizing the system, or planning long term care for the member. Providers: Licensed practitioners of the healing arts, BHT's, BHPP's, Habilitation providers. (See Staff Qualifications Section) · · ., · <· • Limitations: BHT's and BHPP's are limited to providing this service under an ADHS/OBHL licensed agency or a State Certified Community Service Agency As an additional limitation, these services can not be billed in combination with services in an institutional setting, residential treatment center, or Level2/3 group home. Home Care Training to Home Care Client (HCTC): These services are provided by behavioral health therapeutic home providers and are designed to maximize the member's ability to live and participate in the community and to function independently, including assistance in the self- administration of medication and any ancillary services (such as living skills and health promotion) indicated by the member's treatment plan as appropriate. Providers: Behavioral health therapeutic home providers that are contracted with licensed behavioral health providers. Contractors are required to ensure that behavioral health therapeutic home providers have successfully completed pre-service training in the type of care and services required by the members being placed into the home. Behavioral health therapeutic home providers must have access to crisis intervention and emergency consultation services. A clinical supervisor must be assigned to oversee the care provided in the home. Limitations: HCTC services can only be provided for no more than three adults in an Adult Therapeutic Foster Home licensed by ADHS/OBHL or home licensed by federally recognized Indian tribes that attest to CMS via AHCCCS that they meet equivalent requirements. HCTC services can only be provided for no more than three children in a Professional Foster Home licensed by ADES or home licensed by federally recognized Indian tribes that attest to CMS via AHCCCS that they meet equivalent requirements. HCTC providers are reimbursed through their contractual agreement with the licensed behavioral health provider. These services do not include reimbursement for the cost of room and board. Services such as living skills, health promotion and home care training family services that are provided at this setting and billed as a component ofHCTC, cannot be billed for separately. (As an additional limitation, these services can only be billed in the behavioral health therapeutic home). TN No.: 10-009 Supersedes TNNo.: N/A MAR 0 5 2011 Approval Date: Effective Date: July 1, 2010

Attachment 3 .1-A Limitations Page 9(e) Peer Support Services: Services provided by persons who have been consumers of the behavioral health system and who are at least 18 years old. Peer support may involve assistance with more effectively utilizing the service delivery system such as assisting with developing plans of care, accessing supports, partnering with professionals, overcoming service barriers or assisting the member to understand and cope with the member's disability, behavior coaching, role modeling and rnentoring. Providers: BHTs and BHPP's (See Staff Qualifications Section) .. , . ,. Limitations: BHT's and BHPP's are limited to providing this service under an ADHS/OBHL licensed agency or a State Certified Community Service Agency. As an additional limitation, these services can not be billed in combination with services in an institutional setting, residential treatment center, or Level 2/3 group horne. TN No.: 10-009 Supersedes TNNo.: N/A MAR 0 5 2011 Approval Date: ______ Effective Date: July 1, 2010

Licensed Behavior Analyst Licensed Clinical Social Worker (LCSW) Licensed Marriage/Family Therapist (LMFT) Licensed Professional Counselor (LPC) Licensed Independent Substance Abuse Counselor (LISA C) Behavioral Health Professional (BHP) TN No.: 10-009 Supersedes TNNo.: N/A Attachment 3.1-A Limitations Page 9(t) Staff/Provider Qualifications Graduate degree, master's degree or doctoral degree from an accredited college or university or institution of higher learning accredited by a recognized accrediting agency. Minimum of225 classroom hours of specific graduate level instruction that meet nationally recognized standards for behavior analysts as determined oy the board. Master degree or higher in social work from a regionally accredited college or university in a program accredited by the Council on Social Work Education or an equivalent foreign degree as determined by the Foreign Equivalency Determination Service of the Council on Social Work Education. Master degree or higher in a behavioral health science from a regionally accredited college or university whose program is accredited by the Commission on Accreditation for Marriage and Family Education or determined by the marriage and family credentialing committee to be substantially equivalent to a program accredited by the Commission on Accreditation for and Education. Master degree or higher in counseling or related field from a regionally accredited college or university in a program that consists of 48 hours semester credit hours or a program accredited by CACREP or CORE in a program that consists of a minimum of 48 semester credit hours. Master or higher from a regionally accredited college or university in a behavioral health service with a minimum of 24 semester credit hours of counseling related coursework as determined by the substance abuse credentialing committee. A licensed psychologist, a registered nurse with at least one year of full time behavioral health work experience, or a behavioral health medical practitioner, licensed social worker, counselor, marriage and family therapist, behavior analyst or substance counselor licensed according to A.R.S, title 32, Chapter 33, an individual who is licensed or certified to practice social work, counseling or marriage and family therapy by a MAR 0 5 2012 Licensed by the Az Board of Behavioral Health Examiners .. , . •· Licensed by the Az. Board of Behavioral Health Examiners Licensed by the Az. Board of Behavioral Health Examiners Licensed by the Az. Board of Behavioral Health Examiners Licensed by the Az. Board of Behavioral Health Examiners L'~'"''"'"'u by the respective professional discipline board. Approval Date: _____ _ Effective Date: July 1, 2010 A.R.S 32- 2091.14 R4-6-401 R4-6-601 R4-6-501 R4-6-703 R9-20-101

Registered Nurse (RN) Licensed (LPN) Nurse Nurse Practitioner (NP) Physician Assistant (PA) Psychologist Physician (MD, DO) Psychiatrist (MD,DO) 1N No.: 10-009 Supersedes 1NNo.: N/A in another state and has documentation of submission of an application for Az certification per A.R.S , Title 32, Chapter 22 is licensed within one of submittal of Satisfactory completion of basic curriculum in an approved registered nursing program and holds a or from that nrn,or<lm Satisfactory completion of basic curriculum in an approved practical or professional nursing program and hold a diploma, certificate or from that nrnm'<>m Graduate from a physician's assistant educational program approved by the board and licensed the board. Doctoral degree from an institution ofhigher education in clinical or counseling psychology, school or educational psychology or any other subject area in applied psychology from an educational institution that has been accredited by a regional accrediting agency at the time of Graduate from an approved school of medicine or receive a medical education that the board deems to be of equivalent quality, successful completion of an approved 12 month hospital internship, residency or clinical fellowship Licensed physician who has completed three years of graduate training in psychiatry in a program approved by the American Medical Association or the American Osteopathic Association Attachment 3.1-A Limitations Page 9(g) Licensed by the Az. Board of Nursing the Az. Board of Nursing Certified by the Az. Board ofNursing Licensed by the Az. Regulatory Board of Assistants. Licensed by the Az. Board of Psychologists Examiners Licensed by the Az. Medical Board Licensed by the Az. Board of Medical Examiners. A.R.S 32-1632 A.R.S 32-1637 A.R.S. 3-1601 A.R.S. 32- 2521 A.R.S. 32- 2071 A.R.S 32-1422 Title 36-501 MAR 0 5 2012 Approval Date: __ n_____ Effective Date: July 1, 2010

Behavioral Health Medical Practitioner (BHMP) Behavioral Health Out Patient Clinic Behavioral Health Technician (BHT) TNNo.: 10-009 Supersedes TNNo.: N/A An individual physician, physician assistant or nurse practitioner licensed by authorized by law to use the prescribe medication and devices, as defined in A.R.S. § 32-1901, with at least one year of full time behavioral health work Licensed to provide services such as vv•.u'"""'"~'>' medication services, court ordered evaluation . and treatment and opioid treatment. Master's degree or bachelor's degree related to behavioral health; is a registered nurse, is a physician assistant who is not working as a medical practitioner, has a bachelor's degree and at least one year of full time behavioral health work experience; has as associate's degree and at least two years of full time behavioral health work experience; has a high school diploma or high school equivalency diploma and a combination of education in a field related to behavioral health and full time behavioral health work experience totaling at least two years; is licensed a practical nurse, according to A.R.S Title 32, Chapter 15, with at least three years of full time behavioral health work experience; or has a high school diploma or high school equivalency diploma at least four years of full time behavioral health work experience. Attachment 3 .1-A Limitations Page 9(h) Licensed by the A.R.S 32-1901 respective professional board. Licensed by ADHS/ R9-20-301 O{fice of Behavioral Health Licensure (services provided by staff who are not independent billers are billed by the agency . HCPCS codes. BHT's working full R9-20-204 time receive at least four hours of clinical supervision by a BHP in a calendar month. Clinical supervision includes reviewing/ discussing client behavioral health issues, services and records; recognizing and meeting the needs of clients who are seriously mentally ill or individuals with co- occurring disorders; reviewing/ discussing other topics that enhance the skills and knowledge of staff members; providing a client with an assessment or treatment plan, determining whether an assessment or treatment plan is complete and accurate and meets the client's treatment needs. Approval Date: MAR 0 5 2011 Effective Date: July 1, 2010

Behavioral Health Paraprofessional (BHPP) Community Service Agency (CSA) HCBS Certified Habilitation Provider Associate's degree, a high school diploma or a high school equivalency diploma, must be at least 21 years old and has the skills and knowledge necessary to provide behavioral health services that the agency is authorized to provide and meet the needs of client populations served by the agency. The skills and knowledge of the BHPP are verified by a clinical director, BHP or BHT with a combination of at least 6 years of education in a field related to behavioral health and full time behavioral health work experience; and either visual observation of the BHPP interacting with another individual such as role playing or; verbal interaction with the BHPP such as interviewing, discussion or question and answer or; a written examination. CSA's must be State Certified by ADHS/DBHS and be registered with AHCCCS. Staff provider qualifications include BHP's, BHT's and or BHPP's with a Department of Public Safety Fingerprint Clearance Card, current First Aid training, current CPR training and must meet qualifications per ADHS/DBHS MI5.2. Certified by the Department of Economic Security and registered with AHCCCS administration. The Habilitation Provider must receive an orientation to the unique characteristics and specific needs of the eligible person under their care. Habilitation Providers must be informed regarding whom to contact in emergency, significant events or other incidents involving the eligible person. Habilitation Providers nrCIVU1P. habilitation Attachment 3.1-A Limitations Page 9(i) ""''"lr'Y"' full time receive at least four hours of clinical supervision by a BHP or BHT in a calendar month. Clinical supervision includes reviewing/discussing client behavioral health issues, services and records; recognizing and meeting the needs of clients who are seriously mentally ill or individuals with co- occurring disor~ers; rexiewing/discussing other topics that enhance the skills and knowledge of staff members. CSA's are re-certified every year by ADHS/DBHS. The behavioral health provider treatment team, as part of the service planning process, must periodically review services provided by Habilitation Providers. The behavioral health provider is responsible for the timely review and resolution of any known issues or complaints involving the member and a Habilitation Provider. ADHS/DBH S policy MI 5.2 Certified by DES/DDD. TN No.: 10-009 Supersedes TNNo.: N/A Approval Date: MAR 0 5 2012 Effective Date: July 1, 2010

services Demonstration Waiver; however, Habilitation Providers are also authorized to provide rehabilitation services as described in specific settings above. Attachment 3 .1-A Limitations Page 90) .,, TN No.: 10-009 Supersedes TNNo.: N/A Approval Date: MAR 0 5 2011 Effective Date: July 1, 2010

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES FORM APPROVED OMB 8-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF I. TRANSMITTAL NUMBER: 2. STATE Arizona STATE PLAN MATERIAL I0-009 FOR: Centers for Medicare and Medicaid Services TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 0 NEW STATE PLAN 6. FEDERAL STATUTE/REGULATION CITATION: Section I905(a)(13) ofthe Social Security Act 42 CFR Part 440.I30( d) 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: A..ttachm.eat 3 .1 A, page 9(A), page 9(b) Attachment 3.I-A Limitations, pages 9(a-j) I 0. SUBJECT OF AMENDMENT: 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE July I, 20IO 7. FEDERAL BUDGET IMPACT:' FFY 2011: NJA FFY 2011: $0 .. , FFY 2012: $0 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Same Describes behavioral health services provided under rehabilitative services. II. GOVERNOR'S REVIEW (Check One): I8J GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL I2. SIGNATURE OF STATE AGENCY OFFICIAL: FORM HCFA-I79 (07-92) 0 OTHER, AS SPECIFIED: I6. RETURN TO:

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Thomas Betlach, Director Region IX Division of Medicaid & Children's Health Operations 90 Seventh Street, Suite 5-300 (5W) San Francisco, CA 94103-6706 JUL 1 4 201 1 Arizona Health Care Cost Containment System 801 East Jefferson Street Phoenix, AZ 85034 Dear Mr. Betlach: Enclosed is an approved copy of Arizona's State Plan Amendment (SPA) Number 11-005, which was submitted to my office on April 21, 2011. This SPA restores medically necessary transplant services to Arizona Health Care Cost Containment System (AHCCCS) members meeting nationally-recognized criteria for certain non-experimental, non-investigational organ and tissue transplants that previously had been eliminated effective October 1, 2010. The effective date of this SPA is April 1, 2011 as requested. Enclosed is the following approved State Plan page to be incorporated within your approved State Plan: • Attachment 3.1-E, page 1 • Attachment 4.19-B, page 3-3a If you have any questions, please contact Cheryl Young at (415) 744-3598 or by email at cheryl.young@cms.hhs.gov. Enclosure cc: Jessica Schubel, CMCS HeeYoung Ansell, DMCHO Sincerely, J~~h=f' Associate Regional Administrator Division of Medicaid & Children's Health Operations

Revision: HCF A-PM-87-4 March 1987 State/Territory: Arizona AITACHMENT 3.1-E Page 1 Standards for the Coverage of Organ Transplant Services Medically necessary transplant services are available to AHCCCS members as described in the AHCCCS Medical Policy Manual, meeting nationally recognized criteria for non- experimental, non-investigational organ or tissue transplants. All medically necessary, non experimental transplants are covered for EPSDT members. For persons age 21 and older, AHCCCS coverage of transplants is limited to the following: • Heart • Liver • Kidney • Simultaneous Pancreas/Kidney • Autologous and Allogenic related and unrelated Hematopoietic Cell • Cornea • Bone • Lung • Pancreas after Kidney AHCCCS does not cover the following transplants for persons age 21 years and older: • Pancreas only transplants • Partial pancreas transplants, including islet cell transplants • Intestine transplants (Visceral) • Any other transplant not listed in the covered transplants above. All AHCCCS members are eligible to receive the medically necessary transplants and related services described in the AHCCCS Medical Policy Manual with the following exceptions: • Title XIX SOBRA Family Planning Program members; and • Federal Emergency Services Program (FESP) members. AHCCCS has established specific prior authorization medical criteria for coverage of transplant and related services as specified in the AHCCCS Medical Policy Manual. The Manual, including all supplements and updates to the Manual are available to the public on the agency's web site: http://www.azahcccs.gov/shared/MedicalPolicyManual!MedicalPolicyManual.aspx?ID=p olicymanuals TN No. 11-005 Supersedes TN No. 10-006 Approval Date JUL 1 4 2011 Effective Date April 1, 2011

State: ARIZONA Attachment 4.19-B Page3 METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES OTHER TYPES OF CARE • Organ Transplantation AHCCCS shall negotiate contracts with hospitals qualified to perform covered organ and hematopoietic cell transplantation services. Reimbursement is based on a fixed price per type of transplant, by component, which may include stop-loss provisions. Component reimbursement is based on provider cost reports. At no time will payment for the entire case exceed a hospital's billed charges. The follow-up time period lasts until the transplant team releases the member, not to exceed 60 days post-transplant. • Specialty Services AHCCCS may negotiate contracts for specialized hospital services, including but not limited to: subacute, neonatalogy, neurology, cardiology and burn care. Rates are determined based on provider cost information and at no time will contracted rates exceed billed charges TN No. 11-005 Supersedes TN No. 04-008 Approval Date ___ J_UL_ 1_4 _2_01_1 _ _ Effective Date April 1, 2011

State: ARIZONA Attachment 4.19-B Page 3a METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES OTHERTYPESOFCARE • Federally Qualified Health Centers (FQHCs) AHCCCS will utilize the following payment methodology from January 1, 2001, forward. 1) AHCCCS will establish a baseline Prospective Payment System effective January 1, 2001. The calculation will conform to section 1902(a)(15)(c) of the Social Security Act. AHCCCS will use the center/clinic's fiscal year that ends during calendar year 1999 and 2000 for the base rate calculations. Each FQHCIRHC may elect to have rates adjusted by either the BIPA 2000 methodology, or the Alternative Payment Methodology. If the FQHCIRHC elects the BIPA methodology, the Medicare Economic Index (MEl) at the beginning of each federal fiscal year (October 1st) will be used to update rates on a prospective basis. If the FQHCIRHC elects the Alternative Payment Methodology, the Physician Service Index (PSD subcomponent of the Medical Care component of the Consumer Price Index at the beginning of each federal fiscal year (October 1st) will be used to update rates on a prospective basis. Under either methodology, the baseline rates for 1999 and 2000 will be calculated based on the provider's cost data for the center/clinic's fiscal year that end during calendar year 1999 or 2000. Costs included in the base rate calculation will include all Medicaid covered services provided by the center/clinic. The calculated 1999 and 2000 base rates will be averaged by calculating a simple average ofthe costs per encounter for 1999 and 2000. The calculation is as follows: Total Medicaid costs 1999 +Total Medicaid costs 2000 = Average Cost Per Visit Total visits 1999 +Total visits 2000 These base rates will then be indexed forward utilizing the MEl from the midpoint of the cost report period being utilized, to the midpoint of the initial rate period (January 1, 2001 through September 30, 2001). Annually thereafter, the MEl for those FQHCs/RHCs selecting the BIPA methodology, or the PSI for those FQHCs/RHCs selecting the Alternative Payment Methodology, will be applied to the inflated based rates at the beginning of the federal fiscal year (October 1st). AHCCCS and the FQHCs/RHCs have agreed to supplement payments to the FQHCs/RHCs payments once the PPS baseline is established, if necessary. 2) For a center/clinic that becomes a FQHC or RHC after FY 2000, AHCCCS will calculate the initial rate using data from an established FQHC or RHC in the same or adjacent area with a similar caseload. Absent an existing FQHC or RHC with a similar caseload, the center/clinic rate will be based on projected costs subject to tests of reasonableness. Costs would be subjected to reasonable cost definitions as outlined in Section 1833(a)(3) of the Act. If a center/clinic has inadequate cost data for one of the base periods, that TNNo. 11-005 Supersedes TNNo.N/A Approval Date ___ J_U_L_1_4_20_11 __ Effective Date April I, 2011

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES FORM APPROVED OMB NO 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF I. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL II-005 Arizona FOR: Centers for Medicare and Medicaid Services 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURJTY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE CENTERS FOR MEDICARE AND MEDICAID SERVICES April I, 20II DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN ~AMENDMENT COMPLETE BLOCKS 6 THRU IO IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: Social Security Act Section I903(i)(l) FFY 11 : $1 ,370,700 447 CFR Subgart F FFY 12: $2,692,000 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) : Attachment 3 .I-E, page I Same Attachment 4.I9B gages 3 and 3(a) I 0. SUBJECT OF AMENDMENT: Restores transplants previously covered by AHCCCS prior to October 1, 2010. 11 . GOVERNOR'S REVIEW (Check One): ~ GOVERNOR'S OFFICE REPORTED NO COMMENT 0 OTHER, AS SPECIFIED: 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: I6. RETURN TO: ~ Monica Coury 80 I E. Jefferson, MD#4200 I3. TYPED NAME: Phoenix, Arizona 85034 Monica Coury 14. TITLE: Assistant Director 15. DATE SUBMITTED: April21 , 2011 FOR REGIONAL OFFICE USE ONLY I7. DATE RECENED: 18.DATEAPPROJO~: l 4: lOll April21, 2011 PLAN APPROVED- ONE COPY AU ACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIG1, ~~Jr_~NA~FICIAL: April I, 2011 / .... AI 21. TYPED NAME: Gloria Nagle 22. ~: Associate Regional A · tor, Division of Medicaid & Children's Health Operations 23. REMARKS: Box 8: Addition of Attachment ·4.19-B pages made by State on 5/26/11 via email. Box 6: Addition of relevant Federal Statute/Regulation citations added by CMS on 6/27/11 with permission from State. FORM HCFA-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Thomas J. Betlach, Director Region IX Division of Medicaid & Children's Health Operations 90 Seventh Street, Suite 5-300 {SW) San Francisco, CA 94103-6706 SEP 2 2 2011 Arizona Health Care Cost Containment System 801 East Jefferson Street Phoenix, AZ 85034 Dear Mr. Betlach: Enclosed is an approved copy of Arizona State Plan Amendment (SPA) No. 11-013. This SPA allows Arizona to document compliance with the Affordable Care Act (ACA) Section 2301. ACA Section 2301 requires States that recognize freestanding birth centers to provide coverage and separate payments for freestanding birth center facility services and services rendered by certain professionals proyiding services in freestanding birth centers. The effective date of this SPA is March 23,2010 as requested. Enclosed is the following approved State Plan page to be incorporated within your approved State Plan: • Attachment 3.1-A page 11 • Attachment 4.19-B, page 5a If you have any questions, please have your staff contact Cheryl Young at (415) 744-3598 or at Cheryl.Young@cms.hhs.gov. cc: Jessica Schubel Hee Young Ansell Sincerely, ~J{cy? Gloria Nagle, Ph.D., MP A Associate Regional Administrator Division of Medicaid & Children's Health Operations

ATTACHMENT 3.1-A Page 11 State/Territory ARIZONA AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY Freestanding Birth Center Services 27. (i) Licensed or Otherwise State-Approved Freestanding Birth Centers Provided: ...J No limitations 0 With limitations 0 None licensed or approved Please describe any limitations: .. ~~. : .. ,., 27. (ii) Licensed or Otherwise State-Recognized covered professionals providing services in the Freestanding Birth Center Provided: ...J No limitations 0 With limitations (please describe below) 0 Not Applicable (there are no licensed or State approved Freestanding Birth Centers) Please describe any limitations: Please check all that apply: D (a) Practitioners furnishing mandatory services described in another benefit category and otherwise covered under the State plan (i.e., physicians and certified nurse midwives). 0 (b) Other licensed practitioners furnishing prenatal, labor and delivery, or postpartum care in a freestanding birth center within the scope of practice under State law whose services are otherwise covered under 42 CFR 440.60 (e.g., lay midwives, certified professional midwives (CPMs), and any other type of licensed midwife).* 0 (c) Other health care professionals licensed or otherwise recognized by the State to provide these birth attendant services (e.g., doulas, lactation consultant, etc.).* *For (b) and (c) above, please list and identify below each type of professional who will be providing birth center services: TN No. 11-013 Supersedes TNNo._NA_ SEP 2 2 Z011 Approval Date ________ _ Effective Date March 23,2010

State: ARIZONA METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES OTHERTYPESOFCARE Attachment 4.19-B Page Sa • Care and Services in Religious Non-Medical Health Care Institutions (RNHCI) Inpatient care and services are considered to be furnished by a RNHCI in its capacity as a hospital. Payment for such inpatient services may be no more than the Medicare cost reimbursement under the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982. Extended care services are services furnished by a RNHCI in its capacity as a skilled nursing facility. Payment for such extended care services shall be made in accordance with the AHCCCS fee-for-service payment rates specified in Attachment 4.19-D of the State Plan. When AHCCCS reimburses for the following public and private provider services, payment is the lesser of the provider's charge or the capped fee amount established by AHCCCS. The Arizona Medicaid Fee Schedule was last updated as of April1, 2011 and made effective for services rendered on or after that date. The current Arizona Medicaid Fee Schedule is located at http:/ /azahcccs.gov/ commercial/ProviderBilling/rates/rates.aspx. For both private and public providers, AHCCCS reimburses the following services as described in Attachment 3.1-A Limitations, using this methodology: • Clinic Services, including Freestanding Ambulatory Surgery Centers and Freestanding Dialysis Centers • Freestanding Birth Centers • Rural Health Clinic Services • Migrant Health Center, Community Health Center and Homeless Health Center Services • Home Health Services, including Durable Medical Equipment, Supplies and Prosthetic Devices • Behavioral Health Services • Family Planning Services • Physician Services • Nurse-Midwife services • Pediatric and Family Nurse Practitioner Services 1NNo. 11-013 Supersedes 1N No. 09-004 SEP 2 2 2011 Approval Date _______ _ Effective Date March 23,2010

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED FOR MEDICARE AND MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: Centers for Medicare and Medicaid Services TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 1. TRANSMITTAL NUMBER: 11-013 Arizona 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE March 23,2010 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN ACA, Section 2301 ··{!.,! .•. 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Attachment 3.1-A, page 11 Attachment 4.19-B, page 5a 10. SUBJECT OF AMENDMENT: 93 Amends State Plan to provide documentation of compliance with the Affordable Care Act, Section 2301, which ensures Medicaid coverage and separate payments for freestanding birth center facility services and services rendered by certain professionals providing services in freestanding birth centers, to the extent the State licenses or otherwise recognizes these providers under State law. 11. GOVERNOR'S REVIEW (Check One): [8] GOVERNOR'S OFFICE REPORTED NO COMMENT 0 OTHER, AS SPECIFIED: 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: FORM HCFA-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Tom Betlach, Director Region IX Division ofMedicaid & Children's Health Operations 90 Seventh Street, Suite 5-300 (5W) San Francisco, CA 94103-6706 ocr1 2 2011 Arizona Health Care Cost Containment System 801 East Jefferson Street Phoenix, AZ 85034 Dear Mr. Betlach: Enclosed is an approved copy of Arizona State Plan Amendment (SPA) No. 11-014. This SPA restores the hospice benefit for acute care program members ages 21 and older. The effective date of this SPA is July 20, 2011 as requested. Enclosed is the following approved State Plan page to be incorporated within your approved State Plan: • Attachment 3.1-A page 7 • Attachment 3.1-A Limitations page 10 If you have any questions, please contact Cheryl Young by phone at (415) 744-3598 or by email at Cheryl. Young @cms.hhs.gov. Sincerely, ~11-w / Gloria Nagle, Ph.D., M.P.A. Associate Regional Administrator Division of Medicaid & Children's Health Operations cc: Jessica Schubel, CMCS HeeYoung Ansell, CMS DMCHO

Revision: HCFA-PM-86-20 (BERC) SEPTEMBER 1986 ATTACHMENT 3.1-A Page7 OMB No.: 0938-0193 State/Territory: ARIZONA AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY 15. a. Intermediate care facility services (other than such services in an institution for mental diseases) for persons determined, in accordance with section 1902( a)(31 )(A) of the Act, to be in need of such care. _x_ Provided: _ Not provided No limitations _x_ With limitations**'f' · •· b. Including such services in a public institution (or distinct part thereof) for the mentally retarded or persons with related conditions. _x_ Provided: _ Not provided No limitations _x_ With limitations* 16. Inpatient psychiatric facility services for individuals under 21 years of age. _x_ Provided: _ Not provided No limitations _x_ With limitations** 17. Nurse-midwife services. _x_ Provided: No limitations _x_ With limitations* _ Not provided 18. Hospice care (in accordance with section 1905(o) ofthe Act). _x_ Provided: Not Provided. No limitations _x_ With limitations in accordance with §2302 of the Affordable Care Act * * Description provided in Limitations section of this Attachment. **Sole limitation is authorization by appropriate entity as defined in the Limitations section of this Attachment. TN No. 11-014 Supersedes TN No. 10-002 OCT 1 2 2011 Approval Date _______ _ Effective Date July 20, 2011

Attachment 3.1-A Limitations Page 10 15b. Including such services in a public institution (or distinct part thereof) for the mentally retarded or persons with related conditions. The public institution shall meet all federally approved standards and only include the Arizona Training Program facilities, a state-owned or operated service center, a state-owned or operated community residential setting, or an existing licensed facility operated by this state or under contract with the Department ofEconomic Security on or before July 1, 1988. 17. Nurse-midwife services. Certified nurse-midwife services when provided by a certified nui,se-IIJt~wife in collaboration with a licensed physician. ' 18. Hospice care Refer to the limitation description provided on pages 2( a) and (b) ofthis subsection. 19. Case management services and Tuberculosis related services 19a. Case management services as defmed in, and to the group specified in, Supplement 1 to ATTACHMENT 3.1-A (in accordance with section 1905(a)(19) or section 1915(g) of the Act). Targeted case management services as defined in Supplement 1 to Attachment 3.1-A. 20. Extended services for pregnant women. Extended services to pregnant women include all covered services ifthey are determined to be medically necessary and related to the pregnancy. 20a. Pregnancy-related and postpartum services for a 60-day period after the pregnancy ends and any remaining days in the month in which the 60th day falls. Prenatal care shall not be provided to women eligible for the Federal Emergency Services Program 24. Any other medical care and any other type of remedial care recognized under State law, specified by the Secretary. 24a. Transportation. Emergency ambulance transportation for emergency medical situations, and non-emergency transportation for non-emergency medical situations. Emergency ambulance transportation does not require prior authorization from an appropriate entity. 24d Nursing facility services for patients under 21 years of age. TN No. 11-014 Supercedes TN No. 04-011 Approval Date __ O_C_T_ .. 1_2_2_0_11 __ Effective Date: July 20, 2011

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: Centers for Medicare and Medicaid Services TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 1. TRANSMITTAL NUMBER: 11-014 FORM APPROVED OMB NO 0938-0193 2. STATE Arizona 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE July 20, 2011 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN [gl AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMP ACT: FFY 12$0 1905(o) FFY 13l20 . ~.-~~, . . . 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Attachment 3.1-A, page 7 Attachment 3.1-A Limitations, page 10 N,LA Attachment 3.1-A, page 7 Attachment 3.1-A Limitations, page 10 10. SUBJECT OF AMENDMENT: Updates the State Plan to indicate Hospice Care is a provided service, effective July 20, 2011. 11. GOVERNOR'S REVIEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT [gl OTHER, AS SPECIFIED: 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: /~~·- &:-' Monica Coury ·,;:: ·-· :~ 801 E. Jefferson, MD#4200 13. TYPEDNAME: Phoenix, Arizona 85034 I Monica Coury 14. TITLE: Assistant Director 15. DATE SUBMITTED: July 15, 2011 FOR REGIONAL OFFICE ,USE ONLY 17. DATE RECEIVED: 18. DATE APPRO<f&. l 2 2011 July 15, 2011 PLAN APPROVED- ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20.~TURE OF RE~AL OFFICIAL: July 20, 2011 ....... _b./; 21. TYPED NAME: 22. TITLE: Associate Regional Administrator Gloria Nagle Division of Medicaid & Children's Health .Operations 23. REMARKS: Box 7: FFY12 clarification and FFY13 impact added by State on 9/30/11 per CMS request. Box 9: Pages added per CMS request made via email on 10/6/11. FORM HCFA-179 (07-92)

Table of Contents State/Territory Name: Arizona State Plan Amendment (SPA) #: 13-0010-MM This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

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

San Francisco Regional Office

90 Seventh Street, Suite 5-300 (65W)

San Francisco, CA 94103-6706

ae

(CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

Tom Betlach, Director

Arizona Health Care Cost Containment System 5 4 801 East Jefferson Street OCT 2 5 20 Phoenix, AZ 85034

Dear Mr. Betlach:

Enclosed is an approved copy of Arizona’s State Plan Amendment (SPA) 13-0010-MM, which was submitted to CMS on August 30, 2013. SPA 13-0010-MM incorporates citizen and non- citizen eligibility requirements into Arizona’s Medicaid State Plan in accordance with the

Medicaid regulations. The effective date of the SPA is January 1, 2014.

Enclosed is a copy of the new State Plan pages to be incorporated within a separate section at the back of Arizona’s approved State plan:

e S89, Pages 1-3

In addition, enclosed is a summary of State Plan pages which are superseded by SPA-13-0010- MM, which should also be incorporated into a separate section in the front of the State Plan:

e Superseding Pages of State Plan Material, 13-0010-MM

If you have any questions, please contact Rebecca Bruno at (415)744-3677, or rebecca.bruno@cms.hhs.gov.

Sincerely,

/s/ Gloria Nagle, Ph.D., MPA Associate Regional Administrator Division of Medicaid & Children’s Health Operations

cc: Wakina Scott HeeYoung Ansell

AZ.0272.R00.00 - Oct 01, 2013 Page 1 of 2

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Arizona

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.

10/01/2013 _| (am/dd/yyyy)

Federal Statute/Regulation Citation -1902(a)(46)(B); 8 U.S.C. 1611, 1612, 1613, and 1641; 1903(v)(2),(3) and (4); 42 CFR 435.4; 42 CFR 435.406; ¢

Federal Budget Impact Federal Fiscal Year Amount

First Year (2014 i Second Year (2015 | $0.00

Subject of Amendment AZ SPA Action #6: Citizenship and Immigration Status $89; affirms citizenship regulations, specifies reasonable opportunity options, and specifies policy options related to immigrant eligibility

Governor's Office Review © Governor's office reported no comment

© Comments of Governor's office received Describe:

© No reply received within 45 days of submittal

6 Other, as specified Describe: Governor's Office is aware

Signature of State Agency Official

Submitted By: Theresa Gonzales Last Revision Date: Sep 30, 2013 Submit Date: Aug 30, 2013

http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp 10/29/2013

SUPERSEDING PAGES OF

STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 13-0010 MM Arizona PAGE NUMBER OF THE PLAN SECTION OR PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT (If Applicable):

S89 Non-Financial Eligibility- Citizenship and Non-citizen Eligibility Attachment 2.6-A: Page 2, Item 3,Subparagraphs (a), (b) and (c), TN 92-1, effective January 1, 1992, approved August 25, 1992

Attachment 2.6-A: Page 3, Item 3, Subparagraphs (d) and (e), TN 02-004, effective October 1, 2002, approved September 20, 2002

cms Medicaid Eligibility

8U.

1902(a)(46)(B)

1903(v)(2),(3) and (4)

42. CFR 435.4

42 CFR 435.406

42 CFR 435.956 ,

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

S.C. 1611, 1612, 1613, and 1641

Citizenship and Non-Citizen Eligibility

The state provides Medicaid to citizens and nationals of the United States and certain non-citizens consistent with requirements of 42 CFR 435.406, including during a reasonable opportunity period pending verification of their citizenship, national status or satisfactory immigration status.

{li The state provides Medicaid eligibility to otherwise eligible individuals: [H] Who are citizens or nationals of the United States; and

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity [@ Reconciliation Act PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); and

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality or

al satisfactory immigration status consistent with requirements of 1903(x), 1137(d), 1902(ee) of the SSA and 42 CFR 435.406, and 956.

The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual.

The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the verification process.

CYes @No

The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date earlier than the date the notice is received by the individual.

@Yes ONo The date benefits are furnished is: © The date of application containing the declaration of citizenship or immigration status.

© The date the reasonable opportunity notice is sent.

@ Other date, as described: ||First day of the month of application containing the declaration of citizenship or immigration status.

Transmittal Number: AZ-13-0010-MM Approval Date: October 25, 2013 Effective Date: 1/1/2014

Arizona

S89 Page | of 3

CCMs. Medicaid Eligibility

The state provides Medicaid coverage to all Qualified Non-Citizens whose eligibility is not prohibited by section 403 of PRWORA (8 U.S.C. §1613).

@Yes ONo

The state elects the option to provide Medicaid coverage to otherwise eligible individuals under 21 and Pregnant women, lawfully residing in the United States, as provided in section 1903(v)(4) of the Act.

OYes @No

wl An individual is considered to be lawfully residing in the United States if he or she is lawfully present and otherwise meets the eligibility requirements in the state plan.

[W An individual is considered to be lawfully present in the United States if he or she: 1. Is a qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c);

2. Is a non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17));

3. Is anon-citizen who has been paroled into the United States in accordance with 8 U.S.C. 1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings;

4. Is a non-citizen who belongs to one of the following classes: [H) Granted temporary resident status in accordance with 8 U.S.C. 1160 or 1255a, respectively;

wl Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization;

[| Granted employment authorization under 8 CFR 274a.12(c); {@ Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended;

[B) Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; [&) Granted Deferred Action status;

{M] Granted an administrative stay of removal under 8 CFR 241; [] Beneficiary of approved visa petition who has a pending application for adjustment of status;

5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231, or under the Convention Against Torture who -

{@] Has been granted employment authorization; or

[Ml Is under the age of 14 and has had an application pending for at least 180 days; 6. Has been granted withholding of removal under the Convention Against Torture; 7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C. 1101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or

9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b));

Transmittal Number: AZ-13-0010-MM Approval Date: October 25, 2013 Effective Date: 1/1/2014 age Arizona S89 Re 2 0:

CCMs. Medicaid Eligibility

10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition.

( Other

The state assures that it provides limited Medicaid services for treatment of an emergency medical condition, not related to an organ transplant procedure, as defined in 1903(v)(3) of the SSA and implemented at 42 CFR 440.255, to the following individuals who meet all Medicaid eligibility requirements, except documentation of citizenship or satisfactory immigration

status and/or present an SSN:

[lM] Qualified non-citizens subject to the 5 year waiting period described in 8 U.S.C. 1613;

wi Non-qualified non-citizens, unless covered as a lawfully residing child or pregnant woman by the state under the option in accordance with 1903(v)(4) and implemented at 435.406(b). .

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Approval Date: October 25, 2013 Effective Date: 1/1/2014 Transmittal Number: AZ-13-0010-MM s89 Page 3 of 3

Arizona

Table of Contents State/Territory Name: Arizona State Plan Amendment (SPA) #: 13-0005-MM This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

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

San Francisco Regional Office

90 Seventh Street, Suite 5-300 (5W)

San Francisco, CA 94103-6706 CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

September 30, 2013

Tom Betlach, Director

Arizona Health Care Cost Containment System 801 East Jefferson Street

Phoenix, AZ 85034

Dear Mr. Betlach:

Enclosed is an approved copy of Arizona’s state plan amendment (SPA) 13-0005-MM, which was submitted to CMS on July 8, 2013. SPA 13-0005-MM incorporates the MAGI-based eligibility process requirements, including the single streamlined application, into Arizona’s Medicaid State Plan in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.

The approval of SPA 13-0005-MM includes full approval of your alternative single streamlined application — both the paper and online versions.

Enclosed is a copy of the new state plan pages and attachments to be incorporated within a separate section at the back of Arizona’s approved state plan:

$94, pages 1-2

Attachment 1 - Alternative single, streamlined paper application: Arizona Department of Economic Security/Family Assistance Administration (DES/FAA)/Arizona Health Care Cost Containment System (AHCCCS Application for Help with Health Coverage Costs, AH-001 (10/13)

e Attachment 2 - An alternative paper application for multiple human service programs, including health insurance, SNAP and TANF: Arizona Department of Economic Security/Family Assistance Administration (DES/FAA)/Arizona Health Care Cost Containment System (AHCCCS) Combined Application for Benefits, FA-001 (10/13)

e Attachment 3 - Health—e-Arizona Plus Medical Application Roadmap

e Attachment 4 - Health-e-Arizona Plus Online Flow Chart

e Attachment 5 - Key Differences between the Health—e-Arizona Plus online application and the CMS online application

e . Attachment 6 - Statement regarding Agreements Related to Coordination of Eligibility and

. Enrollment

In addition, the following current state plan pages have been superseded by SPA 13-0005-MM and reserved in the State Plan:

e Section 2, Page 10, section 2.1(a), TN # 92-4, effective date: 1/1/92, approved: 6/2/92 e Section 2, Page 11a, section 2.1(d), TN # 92-4, effective date: 1/1/92, approved: 6/2/92

Please note that the HHS Office for Civil Rights (OCR) has an open civil rights investigation in Arizona to resolve complaints filed under Title VI of the Civil Rights Act. During the course of its investigation, OCR has identified compliance concerns with Arizona's Medicaid forms and procedures for processing Medicaid applications. CMS’ review of Arizona's State Plan amendment and.proposed forms, in lieu of using the CMS Model Single Streamlined Application, was limited to an analysis of compliance

with applicable Medicaid laws and regulations. Because compliance with Federal civil rights laws is also a condition of receipt of Medicaid funding, however, HHS OCR also reviewed Arizona's forms in the context of its Title VI investigation and we sent comments to the state on behalf of OCR on August 9, 2013. HHS OCR officials met with Arizona State officials to discuss resolution measures on August 12, 2013 and CMS is happy to provide technical assistance about Medicaid issues during the course of any subsequent discussions. Both CMS and HHS OCR are committed to working together with Arizona to meet the deadlines under the Affordable Care Act to assist the State of Arizona in being ready

to launch Marketplace options in a way that ensures that both Medicaid and civil rights issues are addressed.

CMS appreciates the significant amount of work your staff dedicated to preparing this State Plan amendment. If you have any questions concerning this SPA, please contact Rebecca Bruno at 415-744- 3677, or by e-mail at Rebecca.Bruno@cms.hhs.gov.

Sincerely,

/s/ Gloria Nagle, Ph.D., MPA Associate Regional Administrator Division of Medicaid & Children’s Health Operations

ce: Wakina Scott HeeYoung Ansell

AZ.0189.R00.00 - Oct 01, 2013 Page 1 of 2

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Arizona

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.

AZ~13-0005

Proposed Effective Date 10/01/2013 |am/aa/yyyy)

Federal Statute/Regulation Citation 142 CFR 435, Subpart J and Subpart M

Federal Budget Impact Federal Fiscal Year Amount

First Year s{86550800.00 Second Year [i5 | 5 125606400.00

Subject of Amendment Arizona State Plan Amendment to include the General Eligiblity Requirements; Eligibility Process $94 information in the State Plan.

Governor's Office Review ® Governor's office reported no comment

© Comments of Governor's office received Describe:

® No reply received within 45 days of submittal @ Other, as specified

Describe: Governor's Office is aware. Signature of State Agency Official . Submitted By: Theresa Gonzales Date Submitted: Sep 30, 2013

http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp 10/01/2013

DATE RECEIVED; 7/8/2013

DATE APPROVED: 9/30/2013

PLAN APPROVED ~ ONE COPY ATTACHED

EFFECTIVE DATE OF APPROVED MATERIAL:

SIGNATURE OF REGIONAL OFFICIAL:

10/1/2013 TYPED NAME TTELE Gloria Nagle Associate Regional Administrator

Medicaid Eligibility

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

42 CFR 435, Subpart J and Subpart M

Eligibility Process

furnishing Medicaid.

Application Processing

modified adjusted gross income standard.

section 1413(b)(1)(A) of the Affordable Care Act

individuals seeking assistance only through such programs.

el

applicable modified adjusted gross income standard:

other basis, submitted to the Secretary.

Fae ace

minimizes the burden on applicants, submitted to the Secretary.

internet website described in 42 CFR 435.1200(f), by telephone, via mail, and in person.

The agency also accepts applications by other electronic means:

The state meets all the requirements of 42 CFR 435, Subpart J for processing applications, determining and verifying eligibility, and

Indicate which application the agency uses. for individuals applying for coverage who may be eligible based on the applicable

oO The single, streamlined application for all insurance affordability programs, developed by the Secretary in accordance with

An alternative single, streamlined application developed by the state in accordance with section 1413(b)(1)(B) of the Affordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary.

An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the ) agency makes readily available the single or alternative application used only for insurance affordability programs to

Indicate which application the agency uses for individuals applying for coverage who may be eligible on a basis other than the

The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and (1 approved by the Secretary, and supplemental forms to collect additional information needed to determine cligibility on such

® An application designed specifically to determine eligibility on a basis other than the applicable MAGI standard which

The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the

® Yes O No Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 Arizona $94

Page 1 of 2

Medicaid Eligibility

Indicate the other electronic means below:

Name of Method Description

An individual can fax an application to the Medicaid or Human Services Agency

The agency has procedures to take applications, assist applicants and perform initial processing of applications for the eligibility groups listed below at locations other than those used for the receipt and processing of applications for the title [V-A program, including Federally-qualified health centers and disproportionate share hospitals.

Parents and Other Caretaker Relatives Pregnant Women

Infants and Children under Age 19

Redetermination Processing

Redeterminations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 435.916:

[Once every 12 months

aw Without requiring information from the individual if able to do so based on reliable information contained in the individual's account or other more current information available to the agency

If the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional {@) information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available.

my Redeterminations of eligibility for individuals whose financial eligibility is not based on the applicable modified adjusted gross income standard are performed, consistent with 42 CFR 435.916 (check all that apply):

—X] Once every 12 months

(1 Once every 6 months

(1) Other, more often than once every 12 months Coordination of Eligibility and Enrollment

The state meets all the requirements of 42 CFR 435, Subpart M relative to coordination of eligibility and enrollment between Medicaid, CHIP, Exchanges and other insurance affordability programs. The single state agency has entered into agreements with the Exchange and with other agencies administering insurance affordability programs.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 Arizona S94 Page 2 of 2

10

Revision: HCFA-PM-91-4 (BPD) OMB No.: 0938- August 1991

State: Arizona

Reserved

TN No.: 13-0005-MM Supersedes Approval Date September 30, 2013 Effective Date October 1, 2013 TN No.: 92-4

lla

Revision: HCFA-PM-91-8 (MB) OMB No. October 1991

State/Territory: Arizona

Reserved

TN No. 13-0005-MM Supersedes Approval Date September 30, 2013 Effective Date October 1, 2013 TN No. 92-4

Attachment 1 Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

Arizona Department of Economic Security/Family Assistance Administration (DES/FAA) Arizona Health Care Cost Containment System (AHCCCS)

Application for Help with Health Coverage Costs AHCCCS Medical Assistance, Help with Medicare Costs, and Tax Credits to help pay premiums

Tear off and keep pages A through D for your records.

i i H i 9 Use this application to see if you and your family qualify for: What is this application for? « — Free or low-cost insurance from AHCCCS

« Help with your Medicare costs * Anew tax credit that can help pay your health insurance premiums

i i j 9 An application may be completed by you or anyone you choose who knows or can Who can use this application : - get the information needed to complete the application for you and your family

members. You can use this application to apply for anyone in your family, even if they already have insurance.

Your family includes:

¢ Your spouse, if married

e Your children under age 22 who live with you

¢ Your partner who lives with you (but only if you have a child together who needs health insurance)

¢ People you claim on your income tax return even if they do not live with you

e Relatives in your care who are under the age of 19 and live with you

If you want to select a representative to complete your application, complete the Authorized Representative form on page 1 of the application.

Where else can | apply? ~ You can apply faster online at: www.healthearizonaplus.gov

You can fill out this application and turn it in by mail, fax or in person to any local or any Department of Economic Security (DES)/Family Assistance Administration (FAA) office. You can find a list of local FAA offices at www.azdes.gov/faa, or you can call our 24 hour Interactive Voice Response system at

1-855-HEA-PLUS (432-7587).

What information do | need to ~ Nou may need:

; ig : ¢ Birth dates : complete this application? ¢ — Social Security numbers ¢ _ Employer and income information for everyone in your family * — Information for any current health insurance : * — Information about any job-related health insurance available to your family We ask about income and other information to make sure you and your family get Me do as e oe for so much the correct benefits. information’? We will keep all information you provide private, as required by law. What happens next? __ Send your completed, signed application to the address on page 14 or take it to

your local DES office. If you do not have all of the information available, you can still submit your application and we will help you get the rest of the information.

i 2 if you need help filling out this application, please tell us. If you need a language What if I need help 4 interpreter or accommodations for a disability, please check the kind of help you need on page 1 of the application.

Online: www.healthearizonaplus.gov

Phone: 1-855-HEA-PLUS (432-7587)

In person: Visit www.azdes.gov/faa or call 1-855-HEA-PLUS (432-7587) to find the office closest to you

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 AH-001 (10/13) Arizona Page A

Attachment 1 Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

What is AHCCCS Medical Assistance?

AHCCCS stands for Arizona Health Care Cost Containment System, and it is the State of Arizona's Medicaid program. AHCCCS can provide medical benefits and help with Medicare costs to Arizona residents who meet certain income and other eligibility standards. AHCCCS Medical Assistance covers the following medical services:

* Prescription Medication* © Medical Supplies ¢ Chemotherapy

© Doctor's Office Visits** * Medically Necessary Transportation « Emergency Medical Care

¢ Laboratory and X-ray Services * Medically Necessary Specialist Care * Rehabilitation Services

© Hospital Services ¢ Behavioral Health Care © 90 days of nursing care services _ © Dialysis © Immunizations (shots) * AHCCCS prescription coverage is limited for people who have Medicare. ** Wellness visits for people age 21 and over are not covered.

What is Medicare Savings Program?

Medicare Savings Program may pay: ¢ Medicare Part A premium * Medicare deductibles and copayments ¢ Medicare Part B premium e Automatic Extra Help for Medicare Part D prescription expenses

What if | am not eligible for AHCCCS Medical Assistance?

If you are not eligible for AHCCCS Medical Assistance, you may be eligible for federal tax credits to help with your health insurance premiums. If you are not eligible for any programs through AHCCCS, we will send your information to the federal Health Insurance Marketplace to see about health insurance tax credits.

Do | need a Social Security number? Federal law requires you give a Social Security number (SSN) for anyone who wants to get AHCCCS Medical Assistance or help with Medicare costs (42 U.S.C. § 1320b-7; 42 U.S.C. § 405(c)(2)(C), 7 U.S.C. §§ 2011-2036, and Social Security Act (SSA) of 1935 (Section 1137) as amended by P.L. 98-369). If you or anyone you are applying for does not have a Social Security number (SSN), we will refer you to the Social Security office to apply for one. Immigrants who are not legally able to get a Social Security number are not required to give one or apply for one. Any person you are applying for who is legally able to get a Social Security number but does not have one or does not apply for one will not be eligible for benefits. * Ifyou are not applying for benefits for yourself, you do not have to give us your Social Security number. ¢ We will not use your SSN as your DES or AHCCCS identification number. ¢ We will not give any Social Security numbers to the United States Citizenship and Immigration Services (USCIS).

We use your information, including Social Security number, to: ¢ Verify identity * Collect money we overpaid you in the form of benefits ¢ Verity citizenship and immigration status Computer match with state, local and federal agencies and our other programs to verify information ¢ Verify income Share with other government agencies and their contractors to assess program management and compliance « Prevent duplicate benefits We may give your information to law enforcement officials for the purpose of arresting persons fleeing to avoid

the law

If we are not able to find proof of the information you have given us through the sources available to us, then you must provide proof of the information for us to decide if you are eligible.

DES and/or AHCCCS will keep your information for at least 7 years. Do | have to give information about my citizenship and immigration status?

¢ To get the most AHCCCES Medical Assistance benefits and/or help with Medicare costs, you need to give us information about citizenship and immigration

status for each person who is applying for help.

If you choose not give us information regarding immigration status but still want AHCCCS Medical Assistance, you may only be eligible for emergency medical services.

© You do not need to give us information about citizenship and immigration status for any person who is not applying for AHCCCS Medical Assistance and/or

help with Medicare costs.

You do need to give us information on income, resources, or other information for those who have not given us citizenship or immigration status information

to complete the application process.

Under federal law, certain non-citizens such as refugees or political asylees may qualify for medical benefits. For those non-citizens, United States

Citizenship and Immigration Services (USCIS) guidelines state that use of these benefits will not affect your ability to become a Lawful Permanent Resident.

Ifyou are not applying for benefits or if you chose not to provide citizenship or immigration information, we will not try to find out this information from USCIS.

We will not report you, a family, or a household member to U.S. Immigration and Customs Enforcement (ICE) unless you inform us that you, your family or a

household member is in the U.S. illegally.

How long does it take to find out if | qualify for benefits after you receive my application?

For AHCCCS Medical Assistance and/or help with Medicare costs, we will make a decision within 20 days if you are pregnant. If you need a disability determination report, we will make a decision within 90 days. For all other applicants, we will make a decision within 45 days.

How does AHCCCS Medical Assistance work?

If you are approved for AHCCCS Medical Assistance, you will receive your health care from an AHCCCS health plan unless:

¢ You are American Indian and you choose American Indian Health Program as your health plan.

* You are just asking for help with your Medicare costs. If you are approved for one of the Medicare Savings Programs (QMB), AHCCCS may pay your Medicare premiums and Medicare coinsurance and deductibles.

« AHCCCS can only pay for your emergency services because of your status with United States Citizenship and Immigration Services (USCIS). If you are

approved for emergency services only, you may receive medical services from any provider (doctor, hospital, etc.) that has an agreement to bill AHCCCS for

covered emergency services.

How does a health plan work? The health plan works with the health care providers (doctors, hospitals, pharmacies, etc.) to provide all AHCCCS covered services. The health plan will send you a member handbook once you are enrolled. You can call the health plan if you have any questions about your benefits or services or if you need interpreter services or an accommodation because of a disability. The telephone number for your health plan’s member or customer service can be found on your AHCCCS ID card and in your Member Handbook.

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 AH-001 (10/13) Arizona Page B

Attachment 1 Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

What is a primary doctor?

After you enroll in a health plan, your health plan will give you a list of primary doctors in your area to choose from. If you do not choose a primary doctor one will be assigned to you. You have the right to change your primary doctor at any time by calling your health plan's Member Services. Your primary doctor will:

© Take care of your health care

¢ Be the first person you go to for non-emergency medical services

¢ Send you to a specialist when needed

How do | get behavioral health services? To get behavioral health services you can go through your primary doctor, or call the behavioral health telephone number on your AHCCCS ID card.

What if | have Medicare or other health insurance?

* Be sure to tell your health plan that you have Medicare or any other health insurance.

* If your doctor does not contract with your AHCCCS health plan, your doctor must call the AHCCCS health plan to coordinate care or you may be responsible for any Medicare or other health insurance co-payments or deductibles.

¢ If you are in an HMO, you should pick a primary doctor who works with both your HMO and your AHCCCS health plans.

« Ifyou have Medicare, your prescription coverage under AHCCCS is limited. If you have questions about prescriptions, call 1-800-MEDICARE (1-800-633-4227) or your AHCCCS health plan.

What is an AHCCCS ID card and what do | do with it?

Your AHCCCS ID card has your unique AHCCCS 1D number.

* Show the card when you get medical care. You may also need to show picture ID. ¢ Doctors, hospitals and pharmacists use your AHCCCS ID card to obtain faster verification of eligibility. * Keep your AHCCCS ID card with you at all times.

¢ Do not let anyone else use your AHCCCS ID card or you may be prosecuted. What does AHCCCS Medical Assistance cost? Premiums: ¢ Most people do not have to pay a monthly premium for AHCCCS Medical Assistance. * Some people with income too high to qualify for AHCCCS Medical Assistance with no monthly premium may be able to get it by paying a monthly premium.

If you have to pay a premium, the premium amounts are $10 to $35 per person for employed people with disabilities.

Aco-payment is the amount you pay a health care provider when you receive a medical service. Your co-payment amount will vary depending on which AHCCCS program you are enrolled in and the services you need. For some AHCCCS programs, the provider can deny services if the co-payments are not made. Co-payments for services are:

* $2.30 to $10.00 for prescriptions

* $0.00 to $30.00 for non-emergency use of an emergency room

* $3.40 to $5.00 for outpatient visits for evaluation and management services including doctors office visits

* $2.30 to $3.00 for physical, occupational or speech therapy

Remember to report any changes in income because this may change your co-payment amount.

The following people are never asked to pay co-payments:

* Children under age 19.

* People determined to be Seriously Mentally Ill (SMI) by the Arizona Department of Health Services.

¢ Individuals through age 20 eligible to receive services from the Children’s Rehabilitative Services (CRS) program.

¢ People who are temporarily residing in nursing homes or residential facilities such as an Assisted Living Home and only when the acute care member's medica! condition would otherwise require hospitalization. The exemption from co-payments is limited to 90 days in a contract year.

* People who receive hospice care. Co-payments are never charged for the following services for anyone:

¢ Hospitalizations ¢ Emergency services ¢ — Pregnancy related health care including id for on a fee-for-service basis Family planning services and supplies tobacco cessation for pregnant women

You have the RIGHT to:

* Be treated fairly and equally regardless of race, color, religion, national origin, sex, age, disability, or political beliefs.

* Apply for AHCCCS Medical Assistance and/or help with Medicare costs and be given a letter that tells you if you are eligible or not.

¢ Review DES and/or AHCCCS manuals that show the rules and regulations of the DES and/or AHCCCS program if you want to know the reason for our

decision.

* Talk about your case with a worker or supervisor.

¢ Have all information you give regarding your eligibility kept private according to state and federal law.

© Ask for a fair hearing if you disagree with your application being denied, your benefits ended, or your DES and/or AHCCCS services being reduced, or if a

decision is not made on your application within 45 days and the delay is due to DES or AHCCCS.

* Look at your file before a fair hearing.

* Bring an attorney or any other person to a fair hearing. You have the RESPONSIBILITY to:

* Provide DES and/or AHCCCS with the needed information to correctly determine your eligibility and authorize AHCCCS to investigate and contact any sources necessary to confirm the accuracy of the information which pertains to eligibility. Give us any information you have about an absent parent. If you have reason for not providing this information (such as adoption pending, abuse, incest, neglect, etc.) you may claim good cause. You must cooperate with the Division of Child Support Services (DCSS) to establish paternity, unless you can prove good cause. * Take necessary steps to obtain any annuities, pensions, retirement and disability benefits to which you may be entitled, including, but not limited to Social Security benefits, Railroad retirement, Veterans benefits and unemployment compensation. If you are approved for benefits, you will get a letter telling you what changes you must report. You MUST report changes timely.

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013

AH-001 (10/13) Arizona rae’

Attachment 1 Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

How to Choose an AHCCCS Health Care Plan:

You need to choose a health plan that services your county. « All AHCCCS health plans provide the same covered medical services. « Review the health plans for your county listed below. American Indians may choose American Indian Health Program or an AHCCCS Health Plan. « Before you choose a plan, check with your doctor, pharmacy or hospital, to see if they work with the plan that you want. If you want more information about the doctors, specialists or hospitals that work with a health plan that serves your county, call the number listed below for the health plan.

If you do not choose a health plan, one will be assigned to you. If you have been enrolled in an AHCCCS health plan within the past 90 days, you may be enrolled with your previous health plan.

Enter the health plan choice on this application. This health plan choice does not affect your plan selection through the federal Health Insurance Marketplace.

ENE =EEE GENE =EEEEER TE APACHE COUNTY MOHAVE COUNTY

UnitedHealthcare Community Plan. .1-800-348-4058 UnitedHealthcare Community Plan..

Health Choice Arizona............. 1-800-322-8670 Health Choice Arizona

1-800-348-4058 .-1-800-322-8670

American Indian Health Program .. 928-729-8000 American Indian Health Program. ...928-769-2900 If your zip code is 85943, you must choose from the health If your zip code is 86434, you must choose from the health plans listed under Navajo County. plans listed under Yavapai County.

COCHISE COUNTY NAVAJO COUNTY

University Family Care -.- 1-800-582-8686 | UnitedHealthcare Community Plan.. -1-800-348-4058

UnitedHealthcare Community Plan . 1-800-348-4058 Health Choice Arizona . . 1-800-322-8670

American Indian Health Program.... .- 520-295-2479 American Indian Health Program... 928-338-4911 COCONINO COUNTY | PIMA COUNTY

--1-800-348-4058 1-800-322-8670 . 1-866-560-4042 . 1-800-582-8686 - 1-800-624-3879 ---.520-295-2479

UnitedHealthcare Community Plan . Health Choice Arizona American Indian Health Program

+.» 1-800-348-4058 UnitedHealthcare Community Plan .

1-800-322-8670 Health Choice Arizona .. 928-283-2501 Care 1*Arizona....... University Family Care. If your zip code is 86336 or 86340, you must choose from Mercy Care Plan... the health plans listed under Yavapai County. American Indian H

GILA COUNTY ] If your zip code is 85645, you must choose from the health

Health Choice Arizona... «+. 1-800-322-8670 plans listed under Santa Cruz County.

University Family Care... 1-800-582-8686

American Indian Health Program -- 928-475-2371 PINAL COUNTY

| Health Choice Arizona ..

University Family Care...

... 1-800-582-8686 American Indian Health Program. 1-800-348-4058

.. 928-475-2686 If your zip code is 85242 or 85220, you must choose from

the health plans listed under Maricopa County.

.--- 1-800-322-8670 - 1-800-582-8686 «520-562-3321

GRAHAM COUNTY

University Family Care UnitedHealthcare Community Plan American Indian Health Program...

If your zip code is 85643, you must choose from the health plans listed under Cochise County. If your zip code is 85292 you must choose from the health

1 plans listed under Gila County. GREENLEE COUNTY University Family Care UnitedHealthcare Community Plan . American Indian Health Program...

. 1-800-582-8686 SANTA CRUZ COUNTY 1-800-348-4058 University Family Care. .- 928-475-2371 UnitedHealthcare Community Plan. American Indian Health Service

1-800-348-4058 YAVAPAI COUNTY 1-800-582-8686 UnitedHealthcare Community Plan. .. 928-669-2137 University Family Care................. American Indian Health Program.

- 1-800-582-8686 - 1-800-348-4058 --.520-295-2479

LA PAZ COUNTY UnitedHealthcare Community Plan . University Family Care ............

American Indian Health Program

- 1-800-348-4058 - 1-800-582-8686 -.-- 602-263-1200

MARICOPA COUNTY Health Net of Arizona. Care 1* Arizona...... Health Choice Arizona UnitedHealthcare Community Plan Mercy Care Plan..... Maricopa Health Plan. American Indian Health Program

... 1-888-788-4408 If your zip code is 85342, 85358 or 85390, you must 1-866-560-4042 choose from the health plans listed under Maricopa 1-800-322-8670 County.

1-800-348-4058 1-800-624-3879 If your zip code is 86351 you must choose from the health 1-800-582-8686 plans listed under Coconino County.

.. 602-263-1200

YUMA COUNTY UnitedHealthcare Community Plan.. University Family Care American Indian Health Program.

--.1-800-348-4058 1-800-582-8686 ..- 760-572-4100

— eure Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013

AH-001 (10/13) Arizona Page D

Attachment 1 Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

Arizona Department of Economic Security/Family Assistance Administration (DES/FAA) Arizona Health Care Cost Containment System (AHCCCS)

Application for Help with Health Coverage Costs

Contact Information: Tell us how we can contact an adult member of your family.

Name (First, Middle, Last):

Home Address: Apt. # City: State: Zip Code: Mailing Address (if different): Apt. # City: State: Zip Code: Phone Number: This number is: OHome OCell GQWork OMessage OQ Other: Other Phone Number: This number is: OQHome OCell QWork OMessage Qi Other: What is the preferred SPOKEN household language? OQEnglish OSpanish OQ Other: What is the preferred WRITTEN household language? OEnglish O Spanish OQ Other:

| would like to get information about this application by: Email: Yes QNo _ Email address: Text: QYes QONo Number to text (standard text rates apply):

If “Yes” is not marked for Email or Text, all information for this application will be sent via U.S. Mail to the mailing address provided.

| need the following help with this application (check all that apply): Q Reading/understanding this application Q Filling out this application Q American Sign Language Q Braille

Q Other: Q Language Interpreter Language:

| need the following accommodations for this application (check all that apply): QO Hearing Q Speaking Q Seeing Q Writing Q Walking

Q Other:

Authorized Representative:

This section is OPTIONAL. You may authorize someone else to represent you. AHCCCS cannot release any information about your eligibility without your written consent.

Representative's Name:

Representative’s Mailing Address:

Representative’s Phone Number:

Representative’s Other Phone Number:

What is the representative's preferred SPOKEN language? OcEnglish QO Spanish

What is the representative's preferred WRITTEN language? OQEnglish UO Spanish

My representative would like to get information about this application by:

Email: OQ Yes ONo Email address:

Text: OYes ONo Number to text (standard text rates apply): If “Yes” is not marked for Email or Text, all information for this application will be sent via U.S. Mail to the mailing address provided.

Organization (if applicable): City:

This number is: Q Home O Cell This number is: Q Home QO Cell

State: Zip Code: Q Work O Message UO Other: OQ Work QO Message QO Other: Q Other: Q Other:

By signing below |, the customer, give permission for the person listed above By signing below I, the representative, agree to act on the customer's behalf. | also as my representative to act on my behalf in the process of qualifying me for agree to: AHCCCS Medical Assistance and/or Medicare Savings Program. |, therefore: | « Provide only truthful and complete information under penalty of perjury. * — Give permission for my representative to complete and sign my . Fill in and sign needed forms. application. © Obtain and give to DES and/or AHCCCS all information needed to determine if

« Give permission for my representative to provide any documents requested, including personal information.

* Give permission to my representative to sign on my behalf to permit other people, businesses, or agencies to give personal information about me to DES and/or AHCCCS, including protected health information needed to determine if | am disabled.

. Agree to give information about my personal circumstances to my representative.

* Agree to allow my representative to assign all my rights to medical reimbursement claims to AHCCCS on my behalf.

the customer can qualify for AHCCCS Medical Assistance and/or Medicare Savings Program, such as the customer’s Social Security number, income, citizenship, residency, medical insurance, and information about the customer's spouse, minor children, and parents (if the customer is a minor child). ¢ Tell DES and/or AHCCCS right away if the customer:

o Has an increase or decrease in income;

o Hasachange in address; or

o Has achange in health insurance.

If | am determined eligible, this authorization will stay in effect until | or my representative tells you to stop it. This authorization will expire when my application for assistance is withdrawn or denied, or when my eligibility ends. However, this authorization will continue during any time while | am contesting my eligibility in an administrative hearing or court proceeding.

Signature of Applicant:

Date:

Signature of Representative:

Date:

Transmittal Number: AZ 13-0005-MM AH-001 (10/13) Arizona

Effective Date: October 1, 2013

Approval Date: September 30, 2013 Page 1

Attachment 1 Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

PERSON 1:

Tell us about each person in your family starting with you. See page A for a definition of who you must include. If you are a representative, tell us about the first person in the family applying.

Personal Information:

Name (First, Middle, Last): Gender: OMale QO Female Date of Birth: Social Security Number (optional if not applying): Marital Status: Q Never Married Q Divorced Q Widowed Q Married-name of spouse:

ls PERSON 1 attending school full ime? QYes ONo If yes, name of school:

Is PERSON 1 applying for help with health insurance costs? QO Yes OQNo _ If yes, AHCCCS health plan choice: OPTIONAL. See page D for enrollment plan choices.

Does PERSON 1 need help paying for medical bills Q Yes QNo_ If yes, what months? from the last 3 months? Check here if PERSON 1 only wants help with Medicare costs? Q Medicare claim number:

If PERSON 1 is applying, continue answering the questions below. If NOT applying, skip this page and go to the next page to tell us about PERSON 1’s income.

Citizenship/Residency: Tell us about PERSON 1's citizenship/residency. You may need to provide proof of citizenship/residency. ls PERSON 1 a U.S. citizen or U.S. national? See page B for more information. Q Yes QO No QO Choose not to answer If PERSON 1 is NOT a U.S. citizen, what is his/her immigration status?

Q Lawful Permanent Resident (LPR) Q Battered Spouse, Child or Parent Q Removal/Suspension of Deportation Q Lawful Temporary Resident Q Cuban-Haitian Entrant Q Registry Applicants Q Non-Immigrant Status Q Deferred Action Status Q Special Immigrant Juvenile Status Applicant O Asylee Q Deferred Enforced Departure Q Temporary Protection Status (TPS) Q Refugee Q Legalization under LIFE Act QO Victim of Trafficking Q Conditional Entrant granted before 1980 Q Legalization under IRCA Applicant Q Withholding of Deportation QO Other Q Order of Supervision Q Applicant for Asylum, LPR, TPS, or Q 1 do not want to provide Q Paroled into United States Withholding Deportation What immigration document does PERSON 1 have? Q Permanent Resident card Q 1-94 QO Visa Q Foreign Passport Q None O Other: Immigration Document Number: Has PERSON 1 lived in the U.S. since August 22,1996? OQ Yes No

Did PERSON 1 move to Arizona in the last 4 months? QOYes ONo

j ‘dent? Is PERSON 1 an Arizona resident? OYes ONo If yes, date moved:

Race (optional), select one or more: Ethnicity (optional): Q Asian Q Hawaiian or other Pacific Islander O White Q Hispanic/Latino Q Black or African American QO American Indian/Alaska Native Q Other: QO Non-Hispanic/Non-Latino If PERSON 1 is American Indian or Alaska Native: Is he/she enrolled in a federally recognized tribe? QYes QNo _ Ifyes, name of tribe: Has he/she ever gotten services from Indian Health Service, Q Yes ONo _ Ifno, is he/she eligible? QYes ONo

a tribal health program, or urban Indian health program, or through a referral from one of these programs?

Program Screening: These questions will help determine what programs PERSON 1 may be eligible for.

If PERSON 1 is under the age of 65, does he/she have a mental or physical disability that has kept or will OYes QONo keep him/her from working for at least 12 months?

If PERSON 1 works and is under the age of 65, does he/she have a disability that is expected to last at QYes QONo least 12 months?

Does PERSON 1 need help with activities of daily living (bathing, dressing, etc.) through personal QOYes ONo assistance, services, nursing home, or other medical facility?

Is PERSON 1 pregnant? QYes ONo

If yes: Number of babies due: Expected due date: Does PERSON 1 live with at least one child under age 19 and.is the main care taker of the child? QYes ONo Has PERSON 1 ever received Supplemental Security Income (SSI Cash)? OYes ONo

Additional Questions:

Is PERSON 1 in jail or prison? QOYes ONo Was PERSON 1 released from jail or prison within the last 4 months? OYes QO No Ifyes, release date:

Go to the next page to tell us more about PERSON 1.

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 AH-001 (10/13) Arizona Page 2

Attachment 1 Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

PERSON 1:

Tell us about PERSON 1's expected taxes, income and potential benefits. Complete this page even if PERSON 1 is not applying.

Federal Income Tax Filing: Tell us how PERSON 1 will file income taxes NEXT YEAR.

Will PERSON 1 file taxes NEXT YEAR? QYes ONo If yes, will PERSON 1 file jointly with a spouse? QYes ONo If yes, name of spouse:

Will PERSON 1 claim dependents on his/her tax return? QYes ONo lf yes, name of dependent(s):

Will PERSON 1 be claimed as a dependent on someone QYes ONo lf yes, name of tax filer: else's tax return? Relationship to tax filer:

Does PERSON 1 pay any expenses that may be Q Alimony Amount paid: How often? deducted on the federal income tax return? Q Student loan interest | Amount paid: How often? Do not include self-employment expenses. Q Other deductions Amount paid: How often? Check all that apply. Describe deductions:

Employment: Tell us about PERSON 1’s employment. You may need to provide proof of income. If self-employed, please attach the most current federal tax forms: 1040, SE, and applicable schedules such as C, C-EZ, E, F and K1. If you do not have tax forms, attach proof of business income and expenses for the last and current calendar month.

Does PERSON 1 work? QYes ONo If yes, give employment information below: Employer's Name and Gross Earnings How many hours worked

Phone Number: (before deductions): How often paid? per week?

Is PERSON 1 self-employed? QYes ONo If yes, type of work:

If yes, annual net amount:

Does PERSON 1’s income change because of contract or QYes ONo If yes, how much income does PERSON 1 expect to make seasonal employment? over the next 12 months?

Other Income: Tell us about other income PERSON 1 receives. You may need to provide proof of income.

Type of Income: Amount: How often received? Who pays the income? Social Security benefits

Retirement/pension

Unemployment

Disability/worker's compensation

Alimony

Tribal money OGaming Oi Other:

Per capita payments from natural resources, usage rights, leases or royalties

Payments from natural resources, farming, ranching, fishing, leases or royalties from Indian trust land

Money from selling things that have cultural significance

Other:

. Other:

Check here if this person does not have income Q

Potential Benefits: Tell us about PERSON 1 and his/her spouse to help determine if PERSON 1 may be eligible for additional benefits.

Has PERSON 1 or his/her spouse (living or deceased) ever worked QYes ONo_ Ifyes, employer name:

for a government agency or an employer with a pension plan? If yes, dates of employment: Is PERSON 1 or his/her spouse (living or deceased) a veteran? QYes ONo If yes, branch of service: If yes, dates of service:

Questions for People Under 19 Years Old: This section is only required if PERSON 1 is under age 19.

ts PERSON 1’s parent (living or deceased) a veteran? QO Yes ONo _Ifyes, branch of service: If yes, dates of service:

Does PERSON 1 have a parent living outside the home? QYes ONo

Is there anyone else in PERSON 1's family? If YES, go to the next page to tell us about PERSON 2. If NO, go to page 12.

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 AH-001 (10/13) Arizona Page 3

Attachment 1 Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

PERSON 2:

Tell us about the other people in your family. See page A for a definition of who you must include.

Personal Information:

Name (First, Middle, Last): Gender: OMale QO Female Date of Birth: Social Security Number (optional if not applying): Marital Status: Q Never Married Q Divorced Q Widowed Q Married-name of spouse: Relationship to Person 1: Q Spouse Q Child/Step Child Q Parent Q Other: Q Grandchild Q Niece/Nephew Q Legal Guardian

Does PERSON 2 live at the same address as Person 1? QYes ONo If no, what is PERSON 2's home address?

Is PERSON 2 attending school fulltime? OYes ONo If yes name of school:

Is PERSON 2 applying for help with health insurance costs? Q Yes No _ If yes, AHCCCS health plan choice: OPTIONAL. See page D for enrollment plan choices.

Does PERSON 2 need help paying for medical bills Q Yes QNo_ Ifyes, what months? from the last 3 months? Check here if PERSON 2 only wants help with Medicare costs? Q Medicare claim number:

If PERSON 2 is applying, continue answering the questions below. If NOT applying, skip this page and go to the next page to tell us about PERSON 1’s income.

Citizenship/Residency: Tell us about PERSON 2's citizenship/residency. You may need to provide proof of citizenship/residency.

ls PERSON 2 a U.S. citizen or U.S. national? See page B for more information. Q Yes Q No Q Choose not to answer If PERSON 2 is NOT a U.S. citizen, what is his/her immigration status?

Q Lawful Permanent Resident (LPR) Q Battered Spouse, Child or Parent Q Removal/Suspension of Deportation Q Lawful Temporary Resident Q Cuban-Haitian Entrant Q Registry Applicants Q Non-Immigrant Status Q Deferred Action Status Q Special Immigrant Juvenile Status Applicant O Asylee Q Deferred Enforced Departure Q Temporary Protection Status (TPS) QO Refugee Q Legalization under LIFE Act Q Victim of Trafficking Q Conditional Entrant granted before 1980 Q Legalization under IRCA Applicant Q Withholding of Deportation Q Other Q Order of Supervision Q Applicant for Asylum, LPR, TPS, or Q | do not want to provide Q Paroled into United States Withholding Deportation What immigration document does PERSON 2 have? Q Permanent Resident card QO 1-94 QO Visa Q Foreign Passport Q None Q Other: Immigration Document Number: Has PERSON 2 lived in the U.S. since August 22,1996? QO Yes ONo

Did PERSON 2 move to Arizona in the last 4 months? OQ Yes OQ No

i ident? Is PERSON 2 an Arizona resident? OYes ONo If yes, date moved:

Race (optional), select one or more: Ethnicity (optional): Q Asian Q Hawaiian or other Pacific Islander OQ White Q Hispanic/Latino Q Biack or African American Q American Indian/Alaska Native Q Other: Q Non-Hispanic/Non-Latino If PERSON 2.is American Indian or Alaska Native: Is he/she enrolled in a federally recognized tribe? OQ Yes UO No _ Iifyes, name of tribe: Has he/she ever gotten services from Indian Health Service, Q Yes ONo _Ifno, is he/she eligible? QO Yes ONo

a tribal health program, or urban Indian health program, or through a referral from one of these programs?

Program Screening: These questions will help determine what programs PERSON 2 may be eligible for.

if PERSON 2 is under the age of 65, does he/she have a mental or physical disability that has kept or will QOYes ONo keep him/her from working for at least 12 months?

If PERSON 2 works and is under the age of 65, does he/she have a disability that is expected to last at QYes ONo least 12 months?

Does PERSON 2 need heip with activities of daily living (bathing, dressing, etc.) through personal QYes ONo assistance, services, nursing home, or other medical facility? 2

ls PERSON 2 pregnant? QYes QONo If yes: Number of babies due: Expected due date:

Does PERSON 2 live with at least one child under age 19 and is the main care taker of the child? QYes QONo

Has PERSON 2 ever received Supplemental Security Income (SSI Cash)?? Q Yes ONo

Additional Questions:

Is PERSON 2 in jail or prison? QYes ONo Was PERSON 2 released from jail or prison within the last 4 months? QO Yes OQ No _Ifyes, release date:

Go to the next page to tell us more about PERSON 2. Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 AH-001 (10/13) Arizona Page 4

Attachment 1 Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

PERSON 2:

Tell us about PERSON 2’s expected taxes, income and potential benefits. Complete this page even if PERSON 2 is not applying.

Federal Income Tax Filing: Tell us how PERSON 2 will file income taxes NEXT YEAR.

Will PERSON 2 file taxes NEXT YEAR? QO Yes OQNo If yes, will PERSON 2 file jointly with a spouse? OYes QONo If yes, name of spouse:

Will PERSON 2 claim dependents on his/her tax return? OYes ONo If yes, name of dependent(s):

Will PERSON 2 be claimed as a dependent on someone Q Yes ONo If yes, name of tax filer:

else's tax return? Relationship to tax filer:

Does PERSON 2 pay any expenses that may be QO Alimony Amount paid: How often? deducted on the federal income tax return? Q Student loan interest Amount paid: How often? Do not include self-employment expenses. i Q Other deductions Amount paid: How often? Check all that apply. Describe deductions:

Employment: Tell us about PERSON 2’s employment. You may need to provide proof of income. If self-employed, please attach the most current federal tax forms: 1040, SE, and applicable schedules such as C, C-EZ, E, F and K1. If you do not have tax forms, attach proof of business income and expenses for the last and current calendar month.

Does PERSON 2 work? QYes ONo If yes, give employment information below:

Is PERSON 2 self-employed? QYes QONo If yes, type of work: If yes, annual net amount:

Does PERSON 2's income change because of contract or Q Yes OQ No If yes, how much income does PERSON 2 expect to make seasonal employment? over the next 12 months?

Other Income: Tell us about other income PERSON 2 receives. You may need to provide proof of income. Type of Income: Amount: How often received? ho pays the income? Social Security benefits

Retirement/pension

Unemployment

DisabilityAworker's compensation

Alimony

Tribal money QO Gaming Q Other:

Per capita payments from natural resources, usage rights, leases or royalties

Payments from natural resources, farming, ranching, fishing, leases or royalties from Indian trust land

Money from selling things that have cultural significance

Other:

Other:

Check here if this person does not have income Q

Potential Benefits: Tell us about PERSON 2 and his/her spouse to help determine if PERSON 2 may be eligible for additional benefits.

Has PERSON 2 or his/her spouse (living or deceased) ever worked QYes QNo _Ifyes, employer name: for a government agency or an employer with a pension plan? If yes, dates of employment: Is PERSON 2 or his/her spouse (living or deceased) a veteran? QYes UO No = Ifyes, branch of service:

If yes, dates of service:

Questions for People Under 19 Years Old: This section is only required if PERSON 2 is under age 19.

ls PERSON 2's parent (living or deceased) a veteran? Q Yes UONo _Ifyes, branch of service: If yes, dates of service:

Does PERSON 2 have a parent living outside the home? QYes ONo

Is there anyone else in PERSON 1's family? If YES, go to the next page to tell us about PERSON 3. If NO, go to page 12.

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 AH-001 (10/13) Arizona Page 5

Attachment 1 Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

PERSON

Tell us about the other people in your family. See page A for a definition of who you must include.

Personal information:

Name (First, Middle, Last): Gender: OMale QO Female Date of Birth: Social Security Number (optional if not applying): Marital Status: Q Never Married Q Divorced QO Widowed Q Married-name of spouse: Relationship to Person 1: Q Spouse Q Child/Step Child Q Parent Q Other: Q Grandchild QO Niece/Nephew Q Legal Guardian

Does PERSON 3 live at the same address as Person 1? Q Yes ONo If no, what is PERSON 3's home address?

Is PERSON 3 attending school fulltime? Yes ONo If yes, name of school:

ls PERSON 3 applying for help with health insurance costs? O Yes Q)No If yes, AHCCCS health pian choice: OPTIONAL. See page D for enrollment pian choices.

Does PERSON 3 need help paying for medical bills Q Yes Q No If yes, what months? from the last 3 months? Check here if PERSON 3 only wants help with Medicare costs? 0 Medicare claim number:

lf PERSON 3 is applying, continue answering the questions below. If NOT applying, skip this page and go to the next page to tell us about PERSON 1’s income.

Citizenship/Residency: Tell us about PERSON 3's citizenship/residency. You may need to provide proof of citizenship/residency. Is PERSON 3 a U.S. citizen or U.S. national? See page B for more information. Q Yes Q No Q Choose not to answer If PERSON 3 is NOT a U.S. citizen, what is his/her immigration status?

Q Lawful Permanent Resident (LPR) Q Battered Spouse, Child or Parent QO Removal/Suspension of Deportation Q Lawful Temporary Resident Q Cuban-Haitian Entrant Q Registry Applicants Q Non-Immigrant Status Q Deferred Action Status Q Special Immigrant Juvenile Status Applicant O Asylee Q Deferred Enforced Departure Q Temporary Protection Status (TPS) O Refugee Q Legalization under LIFE Act Q Victim of Trafficking Q Conditional Entrant granted before 1980 Q Legalization under IRCA Applicant Q Withholding of Deportation Q Other Q Order of Supervision Q Applicant for Asylum, LPR, TPS, or Q I do not want to provide Q Paroled into United States Withholding Deportation What immigration document does PERSON 3 have? © Permanent Resident card QO 1-94 QO Visa Q Foreign Passport Q None Q Other: Immigration Document Number: Has PERSON 3 lived in the U.S. since August 22,1996? QYes ONo

Did PERSON 3 move to Arizona in the last 4 months? OQ Yes QO No

Is PERSON 3 an Arizona resident? OYes ONo if yes, date moved:

Race (optional), select one or more: Ethnicity (optional): Q Asian Q Hawaiian or other Pacific Islander QO White Q Hispanic/Latino Q Black or African American Q American Indian/Alaska Native Q Other: Q Non-Hispanic/Non-Latino lf PERSON 3 is American Indian or Alaska Native: es \s he/she enrolled in a federally recognized tribe? QYes OQNo _ Ifyes, name of tribe: Has he/she ever gotten services from Indian Health Service, Q Yes OQ No _ If no, is he/she eligible? QYes ONo

a tribal health program, or urban Indian health program, or through a referral from one of these programs?

Program Screening: These questions will help determine what programs PERSON 3 may be eligible for.

If PERSON 3 is under the age of 65, does he/she have a mental or physical disability that has kept or will QO Yes ONo keep him/her from working for at least 12 months?

If PERSON 3 works and is under the age of 65, does he/she have a disability that is expected to last at QYes QONo least 12 months?

Does PERSON 3 need help with activities of daily living (bathing, dressing, etc.) through personal QYes ONo assistance, services, nursing home, or other medical facility?

Is PERSON 3 pregnant? QYes QONo lf yes: Number of babies due: Expected due date:

Does PERSON 3 live with at least one child under age 19 and is the main care taker of the child? QYes ONo

Has PERSON 3 ever received Supplemental Security Income (SS! Cash)? QYes QONo

Additional Questions:

Is PERSON 3 in jail or prison? QYes QNo

Was PERSON 3 released from jail or prison within the last4 months? O Yes ONo _ Iifyes, release date: Go to the next page to tell us more about PERSON 3.

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 AH-001 (10/13) Arizona Page 6

Attachment 1 Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

PERSON 3:

Tell us about PERSON 3's expected taxes, income and potential benefits. Complete this page even if PERSON 3 is not applying.

Federal income Tax Filing: Tell us how PERSON 3 will file income taxes NEXT YEAR.

Will PERSON 3 file taxes NEXT YEAR? Q Yes ONo If yes, will PERSON 3 file jointly with a spouse? QYes ONo If yes, name of spouse:

Will PERSON 8 claim dependents on his/her tax return? QO Yes. ONo lf yes, name of dependent(s):

Will PERSON 3 be claimed as a dependent on someone QYes ONo If yes, name of tax filer:

else's tax return? Relationship to tax filer:

Does PERSON 3 pay any expenses that maybe . QO Alimony Amount paid: How often? deducted on the federal income tax return? Q Student loan interest | Amount paid: How often? Do not include self-employment expenses. Q Other deductions Amount paid: How often? Check all that apply. Describe deductions:

Employment: Tell us about PERSON 3's employment. You may need to provide proof of income. If self-employed, please attach the most current federal tax forms: 1040, SE, and applicable schedules such as C, C-EZ, E, F and K1. If you do not have tax forms, attach proof of business income and expenses for the last and current calendar month.

Does PERSON 3 work? QYes ONo If yes, give employment information below:

Is PERSON 3 self-employed? QYes ONo If yes, type of work:

If yes, annual net amount:

Does PERSON 3's income change because of contract or QO Yes QNo If yes, how much income does PERSON 3 expect to make seasonal employment? over the next 12 months?

Other Income: Tell us about other income PERSON 3 receives. You may need to provide proof of income.

Type of Income: Amount: How often received? Who pays the income? Social Security benefits

Retirement/pension

Unemployment

Disability/worker's compensation

Alimony

Tribal money UO Gaming OQ Other:

Per capita payments from natural resources, usage rights, leases or royalties

Payments from natural resources, farming, ranching, fishing, leases or royalties from Indian trust land

Money from selling things that have cultural significance

Other:

Other:

Check here if this person does not have income Q

Potential Benefits: Tell us about PERSON 3 and his/her spouse to help determine if PERSON 3 may be eligible for additional benefits.

Has PERSON 3 or his/her spouse (living or deceased) ever worked QYes ONo _Ifyes, employer name: for a government agency or an employer with a pension plan? If yes, dates of employment: Is PERSON 3 or his/her spouse (living or deceased) a veteran? QYes UNo _Ifyes, branch of service:

If yes, dates of service:

Questions for People Under 19 Years Old: This section is only required if PERSON 3 is under age 19.

ls PERSON 3’s parent (living or deceased) a veteran? QYes ONo _Iifyes, branch of service: If yes, dates of service: Does PERSON 3 have a parent living outside the home? QYes ONo

Is there anyone else in PERSON 1's family? If YES, go to the next page to tell us about PERSON 4. If NO, go to page 12.

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 AH-001 (10/13) Arizona Page 7

Attachment 1 Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

PERSON 4:

Tell us about the other people in your family. See page A for a definition of who you must include.

Personal Information:

Name (First, Middle, Last): Gender: OMale QO Female Date of Birth: Social Security Number (optional if not applying): Marital Status: Q Never Married Q Divorced Q Widowed Q Married-name of spouse: Relationship to Person 1: Q Spouse Q Child/Step Child QO Parent Q Other: Q Grandchild Q Niece/Nephew Q Legal Guardian Does PERSON 4 live at the same address as Person 1? QYes ONo

If no, what is PERSON 4's home address?

is PERSON 4 attending school fulltime? OYes OQNo If yes, name of school:

ls PERSON 4 applying for help with health insurance costs? O Yes QNo If yes, AHCCCS health plan choice: OPTIONAL. See page D for enrollment plan choices.

Does PERSON 4 need help paying for medical bills Q Yes QNo _ If yes, what months? from the last 3 months? Check here if PERSON 4 only wants help with Medicare costs? Q Medicare claim number:

\f PERSON 4 is applying, continue answering the questions below. If NOT applying, skip this page and go to the next page to tell us about PERSON 1’s income.

Citizenship/Residency: Tell us about PERSON 4's citizenship/residency. You may need to provide proof of citizenship/residency.

ls PERSON 4 a U.S. citizen or U.S. national? © See page B for more information. Q Yes Q No Q Choose not to answer If PERSON 4 is NOT a U.S. citizen, what is his/her immigration status? Q Lawful Permanent Resident (LPR) Q Battered Spouse, Child or Parent Q Removal/Suspension of Deportation Q Lawful Temporary Resident Q Cuban-Haitian Entrant Q Registry Applicants Q Non-Immigrant Status Q Deferred Action Status Q Special Immigrant Juvenile Status Applicant O Asylee Q Deferred Enforced Departure Q Temporary Protection Status (TPS) O Refugee O Legalization under LIFE Act Q Victim of Trafficking Q Conditional Entrant granted before 1980 Q Legalization under IRCA Applicant Q Withholding of Deportation Q Other O Order of Supervision Q Applicant for Asylum, LPR, TPS, or QI do not want to provide Q Paroled into United States Withholding Deportation What immigration document does PERSON 4 have? QO Permanent Resident card O 1-94 O Visa Q Foreign Passport Q None Q Other: Immigration Document Number: Has PERSON 4 lived in the U.S. since August 22,1996? QO Yes ONo

Did PERSON 4 move to Arizona in the last 4 months? O Yes O No

i ident? Is PERSON 4 an Arizona resident? OYes ONo if yes, date moved:

Race (optional), select one or more: Ethnicity (optional): Q Asian Q Hawaiian or other Pacific Islander OQ White Q Hispanic/Latino Q Black or African American Q American Indian/Alaska Native QO Other: Q Non-Hispanic/Non-Latino \f PERSON 4 is American Indian or Alaska Native: Is he/she enrolled in a federally recognized tribe? QYes ONo _ Iifyes, name of tribe: Has he/she ever gotten services from Indian Health Service, QYes ONo _ Ifno,is he/she eligible? OUYes ONo

a tribal health program, or urban Indian health program, or through a referral from one of these programs?

Program Screening: These questions will help determine what programs PERSON 4 may be eligible for.

if PERSON 4 is under the age of 65, does he/she have a mental or physical disability that has kept or will QOYes ONo keep him/her from working for at least 12 months?

lf PERSON 4 works and is under the age of 65, does he/she have a disability that is expected to last at QYes ONo least 12 months?

Does PERSON 4 need help with activities of daily living (bathing, dressing, etc.) through personal QYes ONo assistance, services, nursing home, or other medical facility?

Is PERSON 4 pregnant? QYes QONo If yes: Number of babies due: Expected due date:

Does PERSON 4 live with at least one child under age 19 and is the main care taker of the child? QYes ONo

Has PERSON 4 ever received Supplemental Security Income (SSI Cash)? QYes QONo

Additional Questions:

ls PERSON 4 in jail or prison? QYes ONo Was PERSON 4 released from jail or prison in the last 4 months? QYes OQNo _ifyes, release date:

Go to the next page to tell us more about PERSON 4.

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 AH-001 (10/13) Anizona Page 8

Attachment 1 Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

PERSON 4:

Tell us about PERSON 4's expected taxes, income and potential benefits. Complete this page even if PERSON 4 is not applying.

Federal Income Tax Filing: Tell us how PERSON 4 will file income taxes NEXT YEAR.

Will PERSON 4 file taxes NEXT YEAR? QO Yes. ONo If yes, will PERSON 4 file jointly with a spouse? QYes ONo If yes, name of spouse:

Will PERSON 4 claim dependents on his/her tax return? O Yes ONo If yes, name of dependent(s):

Will PERSON 4 be claimed as a dependent on someone Q Yes QONo If yes, name of tax filer:

else's tax return? Relationship to tax filer:

Does PERSON 4 pay any expenses that may be QO Alimony Amount paid: How often? deducted on the federal income tax return? Q Student loan interest | Amount paid: How often? Do not include self-employment expenses. _ ~Q Other deductions Amount paid: How often? Check ail that apply. Describe deductions:

Employment: Tell us about PERSON 4’s employment. You may need to provide proof of income. If self-employed, please attach the most current federal tax forms: 1040, SE, and applicable schedules such as C, C-EZ, E, F and K1. If you do not have tax forms, attach proof of business income and expenses for the last and current calendar month.

Does PERSON 4 work? QYes ONo If yes, give employment information below: Employer's Name and Gross Earnings

How many hours worked

id? How often paid? per week?

Phone Number: (before deductions):

ls PERSON 4 self-employed? QYes ONo If yes, type of work: lf yes, annual net amount:

Does PERSON 4's income change because of contract or Q Yes Q No If yes, how much income does PERSON 4 expect to make seasonal employment? over the next 12 months?

Other Income: Tell us about other income PERSON 4 receives. You may need to provide proof of income.

Type of Income: Amou How often received? Who pays the income? Social Security benefits Retirement/pension Unemployment Disability/worker's compensation Alimony Tribal money OQGaming Q Other:

Per capita payments from natural resources, usage rights, leases or royalties

Payments from natural resources, farming, ranching, fishing, leases or royalties from Indian trust land

Money from selling things that have cultural significance Other: Other: Check here if this person does not have income Q

Potential Benefits: Tell us about PERSON 4 and his/her spouse to help determine if PERSON 4 may be eligible for additional benefits.

Has PERSON 4 or his/her spouse (living or deceased) ever worked QYes QNo _Ifyes, employer name: for a government agency or an employer with a pension plan? If yes, dates of employment: Is PERSON 4 or his/her spouse (living or deceased) a veteran? QYes OQ No _ifyes, branch of service:

If yes, dates of service:

Questions for People Under 19 Years Old: This section is only required if PERSON 4 is under age 19.

Is PERSON 4’s parent (living or deceased) a veteran? Q Yes OQNo _Ifyes, branch of service: If yes, dates of service:

Does PERSON 4 have a parent living outside the home? QYes QONo \s there anyone else in PERSON 1’s family? If YES, go to the next page to tell us about PERSON 5. If NO, go to page 12.

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 AH-001 (10/13) Arizona Page 9

Attachment 1 Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

PERSON 5:

If there are more than 5 people in your household, make a copy of pages 10 and 11, then tell us about the other people in your household. See page A for a definition of who you must include.

Personal Information:

Name (First, Middle, Last): Gender: OMale OQ Female Date of Birth: Social Security Number (optional if not applying): Marital Status: Q Never Married Q Divorced Q Widowed Q Married-name of spouse: Relationship to Person 1: Q Spouse Q Child/Step Child Q Parent Q Other: Q Grandchild Q Niece/Nephew Q Legal Guardian Does PERSON 5 live at the same address as Person 1? QYes ONo

If no, what is PERSON 5’s home address?

ls PERSON 5 attending school full time? QYes ONo If yes, name of school:

ls PERSON 5 applying for help with health insurance costs? Q Yes OQ No If yes, AHCCCS health plan choice: OPTIONAL. See page D for enrollment plan choices.

Does PERSON 5 need help paying for medical bills QO Yes QNo_ Ifyes, what months? from the last 3 months? Check here if PERSON 5 only wants help with Medicare costs? Q Medicare claim number:

lf PERSON 5 is applying, continue answering the questions below. If NOT applying, skip this page and go to the next page to tell us about PERSON 1’s income.

Citizenship/Residency: Tell us about PERSON 5's citizenship/residency. You may need to provide proof of citizenship/residency.

ls PERSON 5 a US. citizen or U.S. national? See page B for more information. QO Yes Q No Q Choose not to answer

If PERSON 5 is NOT a U.S. citizen, what is his/her immigration status?

Q Lawful Permanent Resident (LPR) Q Battered Spouse, Child or Parent O Removal/Suspension of Deportation Q Lawful Temporary Resident Q Cuban-Haitian Entrant Q Registry Applicants Q Non-Immigrant Status Q Deferred Action Status Q Special Immigrant Juvenile Status Applicant QO Asylee Q Deferred Enforced Departure Q Temporary Protection Status (TPS) O Refugee QO Legalization under LIFE Act Q Victim of Trafficking Q Conditional Entrant granted before 1980 Q Legalization under IRCA Applicant Q Withholding of Deportation O Other O Order of Supervision Q Applicant for Asylum, LPR, TPS, or QO I do not want to provide Q Paroled into United States Withholding Deportation What immigration document does PERSON 5 have? Q Permanent Residentcard Q1-94 Q Visa QO Foreign Passport QO None Q Other: Immigration Document Number: Has PERSON 5 lived in the U.S. since August 22,1996? OQ Yes ONo

Did PERSON 5 move to Arizona in the last 4 months? O Yes QO No

. dent? Is PERSON 5 an Arizona resident? OQ Yes ONo if yes, date moved:

Race (optional), select one or more: Ethnicity (optional): O Asian Q Hawaiian or other Pacific Islander OQ White Q Hispanic/Latino Q Black or African American Q American Indian/Alaska Native Q Other: Q Non-Hispanic/Non-Latino If PERSON 5 is American Indian or Alaska Native: Is he/she enrolled in a federally recognized tribe? QO Yes ONo _ Ifyes, name of tribe: Has he/she ever gotten services from Indian Health Service, QYes QNo_ Ifno,is he/she eligible? OYes ONo

a tribal health program, or urban Indian health program, or through a referral from one of these programs?

Program Screening: These questions will help determine what programs PERSON 5 may be eligible for.

If PERSON 5 is under the age of 65, does he/she have a mental or physical disability that has kept or will QYes QNo keep him/her from working for at least 12 months?

If PERSON 5 works and is under the age of 65, does he/she have a disability that is expected to last at QyYes ONo least 12 months?

Does PERSON 5 need help with activities of daily living (bathing, dressing, etc.) through personal QOYes OQNo assistance, services, nursing home, or other medical facility?

ls PERSON 5 pregnant? QYes ONo \f yes: Number of babies due: Expected due date:

Does PERSON 5 live with at least one child under age 19 and is the main care taker of the child? QYes ONo

Has PERSON 5 ever received Supplemental Security Income (SSI Cash)? QYes ONo

Additional Questions:

ls PERSON 5 in jail or prison? QYes QONo

Was PERSON 5 released from jail or prison in the last 4 months? QO Yes QNo _Ifyes, release date:

Go to the next page to tell us more about PERSON 5. Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 AH-001 (10/13) Arizona Page 10

Attachment 1 Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

RSON 5:

Tell us about PERSON 5's expected taxes, income and potential benefits. Complete this page even if PERSON 5 is not applying.

Federal Income Tax Filing: Tell us how PERSON 5 will file income taxes NEXT YEAR.

Will PERSON 5 file taxes NEXT YEAR? QyYes -QNo If yes, will PERSON 5 file jointly with a spouse? QYes ONo If yes, name of spouse:

Will PERSON 5 claim dependents on his/her tax return? QOYes ONo If yes, name of dependeni(s):

Will PERSON 5 be claimed as a dependent on someone QYes ONo If yes, name of tax filer:

else's tax return? Relationship to tax filer:

Does PERSON 5 pay any expenses that may be QO Alimony Amount paid: How often? deducted on the federal income tax return? Q Student loan interest = Amount paid: How often? Do not include self-employment expenses. Q Other deductions Amount paid: How often? Check all that apply. Describe deductions:

Employment: Tell us about PERSON 5’s employment. You may need to provide proof of income. If self-employed, please attach the most current federal tax forms: 1040, SE, and applicable schedules such as C, C-EZ, E, F and K1. If you do not have tax forms, attach proof of business income and expenses for the last and current calendar month.

Does PERSON 5 work? QYes QONo If yes, give employment information below: How many hours worked per week?

Employer’s Name and Gross Earnings

id? Phone Number: (before deductions): How often paid?

Is PERSON 5 self-employed? QYes QONo If yes, type of work:

If yes, annual net amount:

Does PERSON 5’s income change because of contract or Q Yes Q No If yes, how much income does PERSON 5 expect to make seasonal employment? over the next 12 months?

Other Income: Teli us about other income PERSON 5 receives. You may need to provide proof of income. Type of Income: Amount: How often received? Who pays the income? Social Security benefits

Retirement/pension

Unemployment

Disability/worker’s compensation

Alimony

Tribal money OGaming OQ Other:

Per capita payments from natural resources, usage rights, leases or royalties

Payments from natural resources, farming, ranching, fishing, leases or royalties from Indian trust land

Money from selling things that have cultural significance

Other:

Other:

Check here if this person does not have income Q

Potential Benefits: Tell us about PERSON 5 and his/her spouse to help determine if PERSON 5 may be eligible for additional benefits.

Has PERSON 5 or his/her spouse (living or deceased) ever worked QYes OQ No If yes, employer name: for a government agency or an employer with a pension plan? If yes, dates of employment: Is PERSON 5 or his/her spouse (living or deceased) a veteran? QYes UO No _sIifyes, branch of service: If yes, dates of service:

Questions for People Under 19 Years Old: This section is only required if PERSON 5 is under age 19.

ls PERSON 5's parent (living or deceased) a veteran? Q Yes No ff yes, branch of service: If yes, dates of service:

Does PERSON 5 have a parent living outside the home? QYes ONo

Go to the next page to tell us about health insurance.

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 AH-001 (10/13) Arizona Page 11

Attachment 1 Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

Health Insurance: Answer the following questions for everyone applying.

Health Insurance Coverage:

Do any applicants have health insurance other than AHCCCS or Medicare? QYes ONo If yes, give the following information:

ormatio ame o a e Provide Po b overag D Do any applicants have an injury or illness due to an accident or medical malpractice? QYes ONo_Ifyes, who? Are any applicants currently admitted to a hospital? QYes QNo_ Ifyes, who?

Health Insurance Tax Credits:

If you are not eligible for AHCCCS Medical Assistance, you may be eligible for federal tax credits to help with your health insurance premiums. If you are not eligible for any programs through AHCCCS, we will send your information to the federal Health Insurance Marketplace to see about health insurance tax credits.

Insurance from Jobs: Tell us about health insurance that may be offered through a job.

Is anyone eligible for health insurance coverage offered by an employer, or will you become QYes QNo Q!do not know eligible for coverage in the next 60 days? If YES, answer the questions below. If NO, or | DO NOT KNOW go to the next page.

Tell us about the job that offers health insurance coverage. If there are plans offered by more than one employer and you need more space, please attach additional pages. If you need help with the information, contact the employer.

Employee Name: Employee Social Security Number: Employer Name: Employer Identification Number (EIN): Employer Address: City: State: Zip Code:

Who can we contact about employment health insurance coverage at this job?

If you are in a waiting or probationary period for insurance offered by an employer, when can you enroll in coverage? Who is eligible for coverage from this job?

Does the employer offer a health plan that meets the minimum value standard*? OQYes OQONo OQ !donot know If YES: answer the questions below. If NO or | DO NOT KNOW: go to the next page.

For the lowest-cost plan that meets the minimum value standard* offered only to the employee (do not include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/she received the maximum discount for any tobacco cessation programs, and did not receive any other discounts based on wellness programs: How much will the employee have to pay in premiums for that plan? $ QI do not know How often will the employee have to pay the premium? Q Weekly O Every 2 weeks Q Twice a month Q Quarterly Q Yearly Qtdonotknow OQ Other: What changes will the employer make for the new plan year (if known)? Q Employer will not offer health coverage Q Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard". How much will the employee have to pay in premiums for that plan? $ QO | do not know How often will the employee have to pay the premium? Q Weekly O Every 2 weeks Q Twice a month O Quarterly O Yearly Qtdonotknow OQ Other: Q1do not know

Renewal of Tax Credit Coverage in Future Years:

To make it easier for the Federal Facilitated Marketplace to determine my eligibility for help paying for health coverage in future years, | agree to allow the Marketplace to use income data, including information from tax returns. The Marketplace will send me a notice, let me make changes, and | can opt out at any time.

Yes, renew my eligibility for the next: OSyears O4years O3years O2years 1 year

No, do not use information from tax returns to renew my coverage QO

“An employer-sponsored health plan meets “minimum value standard’ if the plan's share of the total allowed benefit costs covered by the plan is no less than 60% of such costs. Go to the next page to sign the application.

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 AH-001 (10/13) Arizona Page 12

Attachment 1 Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

is signed. All unrelated adults without a child in common must sign the application. Otherwise, the application must be signed by one of the following:

The applicant or the applicant's designee (we must have documentation showing this person is authorized to act on the applicant's behalf); or

¢ The applicant's spouse, if married and living within the same household; or

¢ The parent/legal guardian of a minor child.

Penalty Warning The information provided on this form may be verified by federal, state, and local officials. !f any information is inaccurate, you may be denied benefits. ¢ You must not knowingly withhold or give false information with the intent to receive or to continue receiving AHCCCS benefits to which you are not entitled. ¢ You will be required to pay back to AHCCCS any benefits you receive as a result of withholding or giving false information and you will be subject to criminal prosecution. ¢ Itis fraud for any person to knowingly withhold information with the intent to receive or continue to receive benefits to which he/she is not eligible. Any person found guilty of fraud may be subject to fines, criminal prosecution, imprisonment or other penalties as provided for by applicable State and Federal laws. Release of Information | authorize DES and/or AHCCCS to investigate and contact any sources necessary to establish eligibility and the accuracy of financial information that pertains to AHCCCS eligibility. Assignment of Rights to Other Benefits for Medical Care | understand that if | am or members of my family are approved for AHCCCS benefits, AHCCCS can collect payment from any other parties who may be responsible for paying for my/our health costs. This includes: Private or employer-sponsored health insurance (not including Medicare) ¢ Persons, such as an absent spouse or parent, who are legally responsible for providing medical support Private or employer-sponsored disability insurance Private or employer-sponsored accident insurance ¢ Insurance claims, jury awards, or legal settlements resulting from injuries

| understand that AHCCCS cannot collect more than the costs paid by AHCCCS. | also understand that | must give information about other responsible parties and take any action needed to receive medical support. This includes establishing paternity of my children, unless | can prove good cause not to do so.

| understand that AHCCCS and/or their contractors will release information to DES/Division of Child Support Services (DCSS), for a parent of a child who does not live in the home and the child has AHCCCS or private health insurance. DCSS may use this information to get a medical support order. Statement of Truth

By signing this application:

* | agree | have read and understand my rights and responsibilities, and provided Social Security numbers for each applicant that has a Social Security number.

* | agree | have read and understand the assignment or rights to other benefits for Medical Care above.

| agree to cooperate with Arizona or Federal personnel in the completion of a quality control review on my eligibility for benefits.

¢ | understand that my records will be kept confidential and will only be released for purposes authorized by federal and state law.

| swear under penalty of perjury that the statements and documents provided about myself and persons in my home, that relates to my eligibility for benefits, is true and correct to the best of my knowledge, and that | have not withheld any information. | swear under penalty of perjury that any photocopied information | have provided are the same as the original documents.

Signature of Applicant: Date: Signature of Spouse: Date: Signature of Other Adult in Household: Date: Signature of Authorized Representative: Date: Signature of Witness (if signed with mark): Date:

Release of Information to Hospitals/Hospital Agents/Organizations/Agencies:

You may give permission to DES and AHCCCS to release information about applicant eligibility. DES and AHCCCS cannot share any information about applicants without the applicant's written permission. This section is OPTIONAL.

Name of Hospital/Hospital’s Agent/Organization/Agency: Contact Person: Phone Number: Mailing Address: City: State: Zip Code:

| give permission for DES and/or AHCCCS staff to tell the hospital, hospital agent, organization, or agency listed above: ¢ That | have applied for AHCCCS Medical Assistance; ¢ The information or proof needed to see if | can get AHCCCS Medical Assistance; and ¢ — If approved for AHCCCS Medical Assistance, the effective date of my eligibility, the redetermination due date, and the category of assistance for which | was approved. If denied for AHCCCS Medical Assistance, the reason | was denied.

Signature of Applicant: Date:

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 AH-001 (10/13) Arizona Page 13

Attachment 1 Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

Voter Registration:

Tell us if any person over the age of 18 listed on this application would like to register to vote. If yes, we will mail a voter registration form. You may also access a voter registration form at www.azsos.gov/election/voterinformation.htm. If you would like help filling out the voter registration application form, we will help you. You may fill out the application form in private. Your answer to this question will not impact the programs you are eligible for.

Would any person on this application over the age of 18 like to register to vote? QO Yes OQ No QO Already registered to vote If YES is not checked, all persons over the age of 18 on this application will be considered to have decided not to register to vote at this time.

If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with:

State Election Director Secretary of State’s Office 1700 West Washington Phoenix, AZ 85007 602-542-8683

Application Checklist:

Before submitting your application, remember to:

Q Give us your contact information Qa Include information about each person in your family

Q Sign the application

Submit the Application:

Submit your completed and signed application along with any supporting documents to your local DES/FAA office.

If any additional information is needed, you will be contacted. You will be notified of our decision.

Thank you for applying!

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 AH-001 (10/13) Atizona Page 14

Attachment 2 AHCCCS DES Combined Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

Arizona Department of Economic Security/Family Assistance Administration (DES/FAA) Arizona Health Care Cost Containment System (AHCCCS)

Application for Benefits

Tear off and keep pages A through H for your records.

What is this application for?

Use this application to see if you and members of your household qualify for: « Free or low-cost insurance from AHCCCS ¢ — Help with your Medicare costs « — Nutrition Assistance « Cash Assistance/Temporary Assistance for Needy Families (TANF) e

Tuberculosis Control A new tax credit that can help pay your health insurance premiums

See page B for a description of each program. .

Who can use this application?

An application may be completed by you or anyone you choose who knows or can get the information needed to complete the application for you and your household members. You can use this application to apply for anyone in your household, even if they already have benefits, including health insurance.

Your household includes: Your spouse, if married Your children under age 22 who live with you Your partner who lives with you (but only if you have a child together who needs health insurance or Cash Assistance) People you claim on your income tax return even if they do not live with you Relatives in your care who are under the age of 19 and live with you * _ People who you live with that purchase and prepare food with you If you want to select a representative to complete your ap i

plication, com Where else can | apply? You can apply faster online at www.healthearizonaplus.gov.

You can also apply in person at any local Department of Economic Security (DES)/Family Assistance Administration (FAA) office. You can find a list of local FAA offices at www.azdes.gov/aa, or can call our 24 hour Interactive Voice Response system at 1-855-HEA-PLUS (432- 7587). What information do | need to complete this application? For everyone in your household, you may need: e Birth dates Social Security numbers Employer and income information for everyone in your househoid Resources (e.g., bank account, cash, property) Expenses Information for any current health insurance Information about any job-related health insurance available to members of your household Other information needed to complete your application Note; You can file an application with only your name, address, and the signature of a responsible household member or your authorized representative. This will hold your date of application but eligibility cannot be determined until you complete a full application and an interview, if needed.

Why do we ask for so much information?

We ask about income and other information to make sure you and members of your household get the correct benefits for your household.

We will keep all information you provide private, as required by law.

What happens next?

Send your completed, signed application to the address on page 21 or take it to your local DES office. If you do not have all of the information vailable, you can still submit your application and we will help you get the rest of the information.

What if | need help?

If you need help filling out this application, please tell us. If you need a language interpreter or accommodations for a disability, please check

the kind of help you need on page 1 of the application.

Online: www.healthearizonaplus.gov Phone: 1-855-HEA-PLUS (432-7587) In person: Visit www.azdes.gov/faa to find the office closest to you.

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 FA-001 (10/13) Arizona Page A

Attachment 2 AHCCCS DES Combined Application Do you need help with this application? Visit healthearizonaplus gov or call 1-855-HEA-PLUS (432-7587)

Program Information:

You can use this application to apply for one or more programs. Each program has a symbol. On the application, look for the symbol for the program(s) you want to apply for and answer those questions. These are the symbols you will see on this application:

a = Health Insurance Costs (AHCCCS Medical Assistance, Medicare Savings Program, Tax Credits) r") = Nutrition Assistance

$ = Cash Assistance

& = Tuberculosis Control

What is AHCCCS Medical Assistance?

# AHCCCS stands for Arizona Health Care Cost Containment System, and it is the State of Arizona’s Medicaid program. AHCCCS can provide medical benefits and help with Medicare costs to Arizona residents who meet certain income and other eligibility standards.

AHCCCS Medical Assistance covers the following medical services:

e Prescription Medication* ¢ Medical Supplies e Chemotherapy

¢ Doctor's Office Visits* « Medically Necessary Transportation « Emergency Medical Care ¢ Laboratory and X-ray Services ¢ Medically Necessary Specialist Care ¢ Rehabilitation Services

¢ Hospital Services ¢ Behavioral Health Care ¢ 90 days of nursing care ¢ Dialysis ¢ Immunizations (shots) services

* AHCCCS prescription coverage is limited for people who have Medicare. ** Wellness visits for people age 21 and over are not covered.

What is Medicare Savings Program?

* Medicare Savings Program may pay: ¢ Medicare Part A premium e Medicare deductibles and copayments ¢ Medicare Part B premium e Automatic Extra Help for Medicare Part D prescription expenses

What are Nutrition Assistance benefits?

e Nutrition Assistance benefits help low-income families or individuals buy food for a healthier diet. If you have little or no money, you may be eligible for Emergency Nutrition Assistance benefits. Be sure to answer the Emergency Nutrition Assistance benefits questions on page 2 of this application.

What is Cash Assistance?

$ Cash Assistance gives temporary cash benefits to low income families. Parents or relatives of dependent children who are in their care may be eligible. Some families may qualify for a one-time lump sum cash assistance payment. We will determine if you qualify for this payment option.

What is Tuberculosis Control?

& Tuberculosis Control gives cash support to individuals who are determined unable to work by the Department of Health Services as a result of communicable Tuberculosis.

What if | am not eligible for AHCCCS Medical Assistance?

ra If you are not eligible for AHCCCS Medical Assistance, you may be eligible for federal tax credits to help with your health insurance premiums. If you are not eligible for any programs through AHCCCS, we will send your information

to the federal Health Insurance Marketplace to see about health insurance tax credits. Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 FA-001 (10/13) Arizona Page B

Attachment 2 AHCCCS DES Combined Application Do you need help with this application? Visit www.hea

How does AHCCCS Medical Assistance work?

Wthearizonaplus gov or call 1-855-HEA-PLUS (432-7587,

> If you are approved for AHCCCS Medical Assistance, you will receive your health care from an AHCCCS

health plan unless:

« You are American Indian and you choose American Indian Health Program as your health plan.

« You are just asking for help with your Medicare costs. If you are approved for one of the Medicare Savings Programs (QMB), AHCCCS may pay your Medicare premiums and Medicare coinsurance and deductibles.

« AHCCCS can only pay for your emergency services because of your status with United States Citizenship and Immigration Services (USCIS). If you are approved for emergency services only, you may receive medical services from any provider (doctor, hospital, etc.) that has an agreement to bill AHCCCS for covered emergency services.

How much does AHCCCS Medical Assistance cost?

- Premiums: « Most people do not have to pay a monthly premium for AHCCCS Medical Assistance. e Some people with income too high to qualify for AHCCCS Medical Assistance with no monthly premium may be able to get it by paying a monthly premium. If you have to pay a premium, the premium amounts are $10 to $35 per person for employed people with disabilities.

Co-payments:

A co-payment is the amount you pay a health care provider when you receive a medical service. Your co-payment amount will vary depending on which AHCCCS program you are enrolled in and the services you need. For some AHCCCS programs, the provider can deny services if the co-payments are not made. Co-payments for services are:

¢ $2.30 to $10.00 for prescriptions

¢ $0 to $30.00 for non-emergency use of an emergency room

¢ $3.40 to $5.00 for outpatient visits for evaluation and management services including doctor's office

visits

¢ $2.30 to $3.00 for physical, occupational or speech therapy

Remember to report any changes in income because this may change your co-payment amount.

The following people are never asked to pay co-payments: ¢ Children under age 19

« People determined to be Seriously Mentally III (SMI) by the Arizona Department of Health Services

¢ Individuals through age 20 eligible to receive services from the Children’s Rehabilitative Services (CRS) program

« People who are temporarily residing in nursing homes or residential facilities such as an Assisted Living Home and only when the acute care member's medical condition would otherwise require hospitalization. The exemption from co-payments is limited to 90 days in a contract year

« People who receive hospice care

Co-payments are never charged for the following services for anyone:

¢ Hospitalizations e Emergency services e Family planning ¢ Services paid on a fee-for-service « Pregnancy related health care services basis including tobacco cessation for

pregnant women

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 FA-001 (10/13) Arizona mm

Attachment 2 AHCCCS DES Combined Application Do you need help with this application? Visit www healthearizonaplus gov or call 1-855-HEA-PLUS (432-7587

Do I need a Social Security number?

Medical Assistance, help with Medicare costs, Nutrition Assistance, Cash Assistance, and/or Tuberculosis Control (42 U.S.C. § 1320b-7; 42 U.S.C. § 405(c)(2)(C), 7 U.S.C. §§ 2011-2036, and Social Security Act (SSA) of 1935 (Section 1137) as amended by P.L. 98-369).

If you or anyone you are applying for does not have a Social Security number, we will refer you to the Social Security office to apply for one. Immigrants who are not legally able to get a Social Security number are not required to give one or apply for one. Any person you are applying for who is legally able to geta Social Security number but does not have one or does not apply for one will not be eligible for benefits.

e If you are not applying for benefits for yourself, you do not have to give us your Social Security number. However, it may reduce the total amount of Nutrition Assistance and/or Cash Assistance benefits for the person you are applying for because we will not include you in the benefit amount.

¢ We will not use your SSN as your DES or AHCCCS identification number.

¢ We will not give any Social Security numbers to the United States Citizenship and Immigration Services (USCIS).

. e $ & Federal law requires you give a Social Security number (SSN) for anyone who wants to get AHCCCS

We use your information, including Social Security number, to:

Verify identity

e Verity citizenship and immigration status

« Verify income and resources

¢ Prevent duplicate benefits

e Establish and enforce child support

¢ Computer match with state, local and federal agencies and our other programs to verify information

e Collect money we overpaid you in the form of benefits

¢ Share with other government agencies and their contractors to assess Nutrition Assistance and/or Cash Assistance program management and compliance

« We may give your information to law enforcement officials for the purpose of arresting persons fleeing to avoid the law

If we are not able to find proof of the information you have given us through the sources available to us, then you must provide proof of the information for us to decide if you are eligible.

DES and/or AHCCCS will keep your information for at least 7 years.

Do | have to give information about my citizenship and immigration status?

+ e ¢ To get the most help, you need to give us information about citizenship and immigration status for each $ person who is applying for help.

e Giving us the citizenship and immigration status for all people who are eligible for benefits allows us to include them in the Nutrition Assistance and/or Cash Assistance benefit amount. When you do not give us this information, it will not affect the eligibility of the people you are applying for who have given us verification of their citizenship or qualified non-citizen status, but it may affect the amount of the benefits for these people.

e If you choose not to give us information regarding immigration status but still want AHCCCS Medical Assistance, you may only be eligible for emergency medical services.

« You do not need to give us information about citizenship and immigration status for any person who is not applying.

e You do need to give us information on income, resources, or other information for those who have not given us citizenship or immigration status information to complete the application process.

« Under federal law, certain non-citizens such as refugees or political asylees may qualify for Medical Assistance, Nutrition Assistance, and/or Cash Assistance. For those non-citizens, United States Citizenship and Immigration Services (USCIS) guidelines state that use of these benefits will not affect your ability to become a Lawful Permanent Resident.

¢ If you are not applying for any benefits or if you chose not to provide citizenship or immigration information, we will not try to find out this information from USCIS.

¢ We will not report you, a family, or a household member to U.S. Immigration and Customs Enforcement (ICE) unless you inform us that you, your family or a household member is in the U.S. illegally.

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 FA-001 (10/13) Arizona Page D

Attachment 2 AHCCCS DES Combined Application Do you need help with this application? Visit -healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587

Will | have to do an interview?

e $ & When applying for AHCCCS Medical Assistance and/or help with Medicare costs, an interview is not needed. When applying for Nutrition Assistance, Cash Assistance, and/or Tuberculosis Control you or your representative must complete an interview in person or by phone. If you need special accommodations for an interview, please tell us on page 1 of the application so we can be ready for your interview.

it take to find out if | am eligible for benefits after you receive my application?

Ts For AHCCCS Medical Assistance and/or help with Medicare costs, we will make a decision within 45 days. ¢ If you are pregnant, we will make a decision within 20 days. « If you need a disability determination report, we will make a decision within 90 days.

e For Nutrition Assistance, we will make a decision within 30 days. « lf you are eligible for Emergency Nutrition Assistance, we will make a decision within 7 days.

$ For Cash Assistance, we will make a decision within 45 days.

« If you are a relative or legal guardian applying only for children who are not your own, we will determine if the children qualify within 20 days.

How will | know if | am eligible?

+ e & If you are approved for benefits, you will receive a letter explaining the benefits you are $ eligible for and the amount of benefits you will get. If you are denied, we will send you a letter explaining the reason for our decision.

How can | get my benefits when my application is approved?

rs If you are approved for AHCCCS Medical Assistance and/or help with Medicare costs, you will get an approval letter. You will get your AHCCCS ID card from your enrollment plan 10 to 14 business days after you get your approval letter. If you need medical services before you get your AHCCCS ID card, contact your enrollment plan.

e $ 6 If you are approved for Nutrition Assistance, Cash Assistance, and/or Tuberculosis Control:

¢ You will get an Electronic Benefit Transfer (EBT) card. This card works like a debit card. You will get a pamphlet with instructions on how to use your card.

« Your benefits are put on your EBT card after approval. It can take up to 48 hours for the benefits to be available. You can call the Customer Service number on the back of the card to check the balance of your benefits.

lf you are eligible for Emergency Nutrition Assistance, you may get an EBT card at your local DES/FAA office.

«If you qualify for Nutrition Assistance benefits, you can use the EBT card to buy approved food items. If you qualify for Cash Assistance benefits, you can use your EBT card to get cash or buy non-food items at any store where EBT cards are accepted. You may also withdraw your Cash Assistance benefits at ATMs, but there may be a fee.

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 FA-001 (10/13) Arizona =

Attachment 2 AHCCCS DES Combined Application

Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

What is expected of me?

FOSS

+s +S

es

For all programs:

e You must provide DES and/or AHCCCS with the needed information to correctly determine your eligibility and authorize DES and/or AHCCCS to investigate and contact any sources necessary to confirm the accuracy of the information for your eligibility.

e If you are approved for benefits, you will get a letter telling you what changes you must report. You MUST report your changes timely.

Program-specific expectations:

If applying for help with AHCCCS Medical Assistance, help with Medicare costs, and/or Cash Assistance, you must take necessary steps to obtain any annuities, pensions, retirement and disability benefits to which you may be entitled, including, but not limited to, Social Security benefits, Railroad retirement, Veterans benefits and unemployment compensation.

For AHCCCS Medical Assistance and/or Cash Assistance, you must give us any information you have about an absent parent. If you have reason for not providing this information (such as adoption pending, abuse, incest, neglect, etc.) you may claim good cause. You must cooperate with the Division of Child Support Services (DCSS) to establish paternity, unless you can prove good cause.

All adult household members and minor parents who are eligible for Nutrition Assistance and/or Cash Assistance benefits must be fingerprint imaged. Exceptions may apply.

What are my rights?

FOS

You have the RIGHT to: « Courteous and professional treatment.

e Be treated fairly and equally regardless of race, color, religion, national origin, sex, age, disability, or political beliefs.

e Apply for benefits and be given a letter that tells you if you are eligible or not, and/or get a letter before your benefits are reduced or stopped.

e Review DES and AHCCCS policy manuals that show the rules and regulations of AHCCCS Medical Assistance, Medicare Savings Program, Nutrition Assistance, Cash Assistance, and Tuberculosis Control if you want to know the reason for our decision.

¢ Talk about your case with a worker or supervisor.

e Have all information you give regarding your eligibility kept private according to state and federal law.

e Ask for a fair hearing if you disagree with your application being denied, your benefits ended, or are being reduced, or if a decision is not made on your application within the allowable number of days and the delay is due to DES or AHCCCS.

e Look at your file before a fair hearing.

¢ Bring an attorney or any other person to a fair hearing.

To file a discrimination complaint, contact:

USDA, Director Attention: Regional Manager

Office of Civil Rights U.S. Department of Health and Human Services Room 326-W, Whitten Building Office for Civil Rights/Region IX

1400 Independence Avenue, S.W. 50 United Nations Plaza, Room 322 Washington, D.C. 20250-9410 San Francisco, CA 94102

1-202-720-5964 (voice and TDD) 1-800-368-1019 (voice)

1-415-437-8311 (TDD)

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013

FA-001 (10/13) Arizona Page F

Attachment 2 AHCCCS DES Combined Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

What are the Rules and Penalties?

es

If you, your representative, or any household member hides information or gives false information on purpose to get or continue to get Nutrition Assistance and/or Cash Assistance benefits that you are not entitled to, that person will be subject to:

¢ Criminal Prosecution

« Fines

¢ Imprisonment

¢ Other penalties provided for by state and federal laws

If you get Nutrition Assistance and/or Cash Assistance, you must follow the rules below:

« Do not make false statements or hide information. If you are not truthful, you may have to pay back DES for benefits you receive and you may be taken to court.

¢ Do not do anything dishonest to get benefits that you are not supposed to get.

¢ Do not buy, sell, trade, exchange or otherwise transfer your or someone else’s Nutrition Assistance benefits or EBT card.

¢ Do not buy containers with deposits for the purpose of discarding the product and returning the containers to get cash refund deposits.

* Do not sell products bought with Nutrition Assistance benefits to exchange them for cash or items other than eligible food.

« Do not buy products originally bought with Nutrition Assistance benefits to exchange those products for cash or items other than eligible food.

« Do not steal Nutrition Assistance or Cash Assistance benefits.

¢ Do not use your Nutrition Assistance benefits to buy non-food items such as alcohol and tobacco.

¢ Do not alter an EBT card.

« Do not use someone else’s EBT card unless you are an authorized user approved by DES.

If you knowingly break the rules and get Nutrition Assistance and/or Cash Assistance benefits, we will disqualify you from getting benefits for:

¢ 12 months for the first violation

* 24 months for the second violation

« Permanently for the third violation

You or a household member will not be eligible to get Nutrition Assistance and/or Cash Assistance benefits if you or the household member: ¢ Is a fleeing felon or probation/parole violator. « Has been convicted of using or getting Nutrition Assistance benefits in a transaction involving the sale of firearms, ammunition or explosives. This person can never get Nutrition Assistance benefits again. ¢ Has been found guilty of using or getting Nutrition Assistance benefits in a transaction involving the sale of a controlled substance. This person is not eligible to get Nutrition Assistance benefits for 2 years for the first violation and permanently for the second violation. e Has committed and was convicted of a federal or state felony on or after August 23, 1996 for the possession, use or distribution of a controlled substance. « Has been found by a court of law to have given false identification or residence information in order to get benefits in more than one case. This person is not eligible to get benefits for 10 years. ¢ Refuses to sign and comply with the Personal Responsibility Agreement (PRA). We give you the PRA during the interview process. ¢ Is an adult recipient (18 years or older) of Cash Assistance when any of the following apply: ¢ The recipient does not return the completed Illegal Drug Use Statement. We send the Illegal Drug Use Statement by U.S. Mail after Cash Assistance has been approved. * The recipient fails to take a required drug test. ¢ The recipient fails the drug test.

You must pay DES back for any Nutrition Assistance and/or Cash Assistance benefits you received for which your household was not eligible. You can make a repayment agreement. If you do not keep your repayment agreement, we may reduce your Nutrition Assistance and/or Cash Assistance benefits, take your income tax refunds, or take other legal action, including taking the amounts from your earnings.

The following additional penalties apply to the Nutrition Assistance Program: ¢ An additional disqualification, of up to 18 months, may be ordered by a court. « Any participant or household member who makes false statements or hides information can be fined up to $250,000.00, imprisoned for up to 20 years, or both.

TrahemitPHAROKY CORSAGE MeMRATS BaaY AeoBUPiess #9 further progEculin DUEARiLEMES PLANS

FA-001 (10/13) Arizona PageG

Attachment 2 AHCCCS DES Combined Application

Do you need help with this application? Visit www healthearizonaplus gov or call 1-855-HEA-PLUS (432-7587)

How to Choose an AHCCCS Health Care Plan:

+

You need to choose a health plan that services your county.

« All AHCCCS health plans provide the same covered medical services. « Review the health plans for your county listed below. American Indians may choose American Indian Health

Program or an AHCCCS health plan.

¢ Before you choose a plan, check with your doctor, pharmacy, or hospital to see if they work with the plan that you want. If you want more information about the doctors, specialists, or hospitals that work with a health plan that serves your county, call the number listed below for the health plan.

If you do not choose a health plan, one will be assigned to you. If you have been enrolled in an AHCCCS health plan within the past 90 days, you may be enrolled with your previous health plan.

Enter the health plan choice on this application.

APACHE COUNTY UnitedHealthcare Community Plan. Health Choice Arizona American Indian Health Program.

. 1-800-348-4058 . 1-800-322-8670 .-928-729-8000

If your zip code is 85943, you must choose from the health plans listed under Navajo County.

COCHISE COUNTY

University Family Care UnitedHealthcare Community Plan. American Indian Health Program.

. 1-800-582-8686 . 1-800-348-4058 -.520-295-2479

COCONINO COUNTY UnitedHealthcare Community Plan. Health Choice Arizona .. “ American Indian Health Program.

. 1-800-348-4058 . 1-800-322-8670 --928-283-2501

If your zip code is 86336 or 86340, you must choose from the health plans listed under Yavapai County.

GILA COUNTY

Health Choice Arizona... University Family Care... American Indian Health Program

GRAHAM COUNTY

University Family Care... “ UnitedHealthcare Community Plan American Indian Health Program...

. 1-800-322-8670 . 1-800-582-8686 --928-475-2371

. 1-800-582-8686 - 1-800-348-4058 .. 928-475-2686

If your zip code is 85643, you must choose from the health plans listed under Cochise County.

GREENLEE COUNTY University Family Care UnitedHeaithcare Community Plan. American Indian Health Program...

. 1-800-582-8686 . 1-800-348-4058 ..928-475-2371

LA PAZ COUNTY UnitedHealthcare Community Plan. University Family Care ............ American Indian Health Program.

MARICOPA COUNTY Health Net of Arizona. Care 1* Arizona ..... Health Choice Arizona UnitedHealthcare Community Plan Mercy Care Plan.... Maricopa Health Plan. American Indian Health Program

. 1-800-348-4058 . 1-800-582-8686 928-669-2137

. 1-888-788-4408 . 1-866-560-4042 . 1-800-322-8670 . 1-800-348-4058 . 1-800-624-3879 .. 1-800-582-8686

--602-263-1200

q mittal FA-001 (10/3) Arizona

MOHAVE COUNTY

UnitedHealthcare Community Plan Health Choice Arizona American Indian Health Program ..

. 1-800-348-4058 1-800-322-8670 .. 928-769-2900

If your zip code is 86434, you must choose from the health plans listed under Yavapai County.

NAVAJO COUNTY UnitedHealthcare Community Plan Health Choice Arizona ..

American Indian Health Program ..

- 1-800-348-4058 -800-322-8670 -. 928-338-4911

PIMA COUNTY UnitedHealthcare Community Plan . Health Choice Arizona . Care 1" Arizona........ University Family Care.. Mercy Care Plan. American Indian

«. 1-800-348-4058 1-800-322-8670 1-866-560-4042 1-800-582-8686 1-800-624-3879 .. 520-295-2479

fe)

'f your zip code is 85645, you must choose from the health plans listed under Santa Cruz County.

PINAL COUNTY Health Choice Arizona . University Family Care.. American Indian Health

. 1-800-322-8670 1-800-582-8686 « 520-562-3321

rogram ..

If your zip code is 85242 or 85220, you must choose from the health plans listed under Maricopa County.

If your zip code is 85292 you must choose from the health plans listed under Gila County.

SANTA CRUZ COUNTY University Family Care UnitedHealthcare Community Plan American Indian Health Service ....

YAVAPAI COUNTY UnitedHealthcare Community Plan University Family Care............... American Indian Health Program ..

.. 1-800-582-8686 1-800-348-4058 .. 520-295-2479

1-800-348-4058 1-800-582-8686 .. 602-263-1200

If your zip code is 85342, 85358 or 85390, you must choose from the health plans listed under Maricopa County.

If your zip code is 86351 you must choose from the health plans listed under Coconino County.

YUMA COUNTY UnitedHealthcare Community Plan .. University Family Care.. American Indian Health Program

1-800-348-4058 1-800-582-8686 760-572-4100

Page H

Attachment 2 AHCCCS DES Combined Application Do you need help with this application? Visit www. healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

A) Contact Information: T . o $ & Tell us how we can contact an adult member of your household. Name (First, Middle, Last): Home Address: Apt. #: City: State: Zip Code: Mailing Address (if different): Apt. #: City: State: Zip Code: Do you live in a shelter? QYes ONo If ‘Yes,’ what kind of shelter? Phone Number: This number is: OHome OCell OWork OMessage Q Other: Other Phone Number: This number is: OHome OCell GOWork OMessage QO Other:

What is the preferred SPOKEN household language? OQeEnglish OSpanish UO Other:

What is the preferred WRITTEN household language? OQeEnglish OSpanish QO Other:

| would like to get information about this application by:

Email: OQYes ONo Email address:

Text: QYes ONo Number to text (standard text rates apply): If ‘Yes’ is not marked for Email or Text, all information for this application will be sent via U.S. Mail to the mailing address provided.

| need the following help with this application (check all that apply):

O Reading/understanding this application Q Filling out this application Q Other:

QO American Sign Language QO Braille QO Language Interpreter Language: | need the following accommodations for this application (check all that apply):

QO Hearing QO Speaking O Seeing Q Writing Q Walking Q Other: — =

Authorized Representative:

rs e $ & This section is OPTIONAL. You may authorize someone else to represent you in the application process. DES and/or AHCCCS cannot release any information about your eligibility without your written consent.

Representative’s Name: Is representative your legal guardian? O Yes O No Representative's Mailing Address: City: State: Zip Code: Representative’s Phone Number: This number is: QO Home O Cell GQ Work UO Message QO Other: Representative’s Other Phone Number: This number is: Home QO Cell Q Work O Message UO Other: What is the representative's preferred SPOKEN language? QEnglish OSpanish OQ Other:

What is the representative's preferred WRITTEN language? QEnglish OSpanish QO Other:

My representative would like to get information about this application by: Email: OYes ONo Email address: Text: QYes ONo Number to text (standard text rates apply):

{f ‘Yes’ is not marked for Email or Text, all information for this application will be sent via U.S. Mail to the mailing address provided.

By signing below |, the customer, give permission for the person listed above By signing below |, the representative, agree to act on the customer's behalf. | also as my representative to act on my behalf in the process of qualifying me for agree to: AHCCCS Medical Assistance, help with Medicare costs, Nutrition Assistance, « Provide only truthful and complete information under penalty of perjury. Cash Assistance, and/or Tuberculosis Control. |, therefore: . Fill in and sign needed forms. . * _ Give permission for my representative to complete and sign my * Obtain and give to DES and/or AHCCCS all information needed to determine it application. the customer can qualify for help with healthcare costs, help with Medicare . Give permission for my representative to provide any documents costs, Nutrition Assistance, Cash Assistance, and/or Tuberculosis Control, such requested, including personal information. as the customer's Social Security number, income, assets, citizenship, . Give permission to my representative to sign on my behalf to permit other residency, medical insurance, and information about the customer's spouse, people, businesses, or agencies to give personal information about me to minor children, and parents (if the customer is a minor child). DES and/or AHCCCS, including protected health information needed to « — Tell DES and/or AHCCCS right away if the customer: determine if | am disabled. o Has an increase or decrease in income; « Agree to give information about my personal circumstances to my o Has an increase or decrease in assets; representative. o Changes ownership of assets, including opening or closing financial ¢ Agree to allow my representative to assign all my rights to medical accounts; reimbursement claims to AHCCCS on my behaif. o Has achange in address; or o Has achange in health insurance or the amount of premiums paid. If | am determined eligible, this authorization will stay in effect until | or my representative tells you to stop it. This authorization will expire when my application for assistance is withdrawn or denied, or when my eligibility ends. However, this authorization will continue during any time while | am contesting my eligibility in an administrative hearing or court proceeding. . Signature of Applicant: Signature of Representative: _ Date: Date: Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013

FA-001 (10/13) Arizona Page 1

Attachment 2 AHCCCS DES Combined Application Do you need help with this application? Visit wy

lus.gov or call 1-855-HEA-PLUS (432-7587

Release of Information to Hospitals/Hospital Agents/Organizations/Agencies:

You may give permission to DES and AHCCCS to release information about applicant eligibility. AHCCCS and DES cannot share any information about applicants without the applicant's written permission. This section is OPTIONAL.

Name of Hospital/Hospital’s Agent/Organization/Agency: Contact Person: Phone Number: Mailing Address: City: State: Zip Code: | give permission for DES and/or AHCCCS staff to tell the hospital, hospital agent, organization, or agency listed above:

« That! have applied for AHCCCS Medical Assistance;

¢ The information or proof needed to see if | can get AHCCCS Medical Assistance ; and

« — If approved for AHCCCS Medical Assistance, the effective date of my eligibility, the redetermination due date, and the category of assistance for which | was approved. If denied for AHCCCS Medical Assistance, the reason | was denied.

Signature of Applicant: Date:

Access to Electronic Benef

$s

This section is OPTIONAL. If you are applying for Nutrition Assistance, Cash Assistance, and/or Tuberculosis Control You may choose a person, called an Alternate Cardholder, to get your benefits for you. If you need an Alternate Cardholder, choose a person you trust. Remember, lost or stolen benefits will not be replaced.

EBT Representative'’s Name: EBT Representative’s Date of Birth: EBT Representative’s Mailing Address: City: State:___— Zip Code: EBT Representative's Phone Number: QHome OCell QWork OQ Message QO Other: EBT Representative’s Other Phone Number: QHome OCell QWork QO Message QO Other: Signature of Applicant: Date: Someone Who Knows You Well: e & We often need to contact people or organizations that can verify information to determine your eligibility for public assistance. $ When we contact these people or organizations we tell them your name, our title and that we work for the Department of

Economic Security (DES). We are prohibited by law from telling them anything about you or about your assistance case. Please provide contact information below.

Name of someone who knows you well: Relationship to you: __ Mailing Address: City: State: Zip Code:

Daytime Phone Number:

Name of Landlord: Relationship to you:

Mailing Address: City: State: Zip Code:

Daytime Phone Number:

Emergency Nutrition Assistance: ls anyone in your household applying for Emergency Nutrition Assistance? If YES: fill out this section. If NO: go to page 3.

What is the total amount of income, before deductions, you expect to get this month? $ What is the total amount of cash on hand and money in your checking and savings account? $ What are the total monthly housing costs (rent or mortgage, taxes, homeowner/rental insurance, etc.)? $ What are the total monthly utility costs (gas, electric, phone, water, etc.) ? $ Does anyone receive Tribal Food Distribution? QYes ONo ls anyone a migrant or seasonal farm worker? QYes_ QNo Did anyone get Nutrition Assistance benefits from any other state? QyYes ONo

If ‘Yes,’ who received? When? State: Go to the next page to tell us about PERSON 1.

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 FA-001 (10/13) Arizona _

Attachment 2 AHCCCS DES Combined Application Do you need help with this application? Visit www healthearizonaplus. gov or call 1-855-HEA-PLUS (432-7587,

PERSON 1:

Tell us about each person in your household, starting with you. See page A for a definition of who you must include. If you are a representative, tell us about the first person in the household applying.

+e $ & Personal Information:

Name (First, Middle, Last): Gender: OQ Male OQ Female Date of Birth: Social Security Number (optional if not applying): Marital Status: Q Never Married Q Divorced Q Widowed QO Married-name of spouse: ls PERSON 1 attending school? OYes ONo If ‘Yes,’ is PERSON 1 attending school: QO Full Time Q Part Time Name of School: Grade Level: "Fs PERSON 1 applying for help with health Q Yes QNo If ‘Yes, AHCCCS heaith plan choice: insurance costs OPTIONAL. See page H for enrollment plan choices.

* \s PERSON 1 applying for help with Medicare costs? Q Yes OQ No if Yes,’ Medicare claim number: Does PERSON 1 need help paying for medical bills Yes QNo __ If'Yes,’ what months? from the last 3 months?

® Is PERSON 1 applying for Nutrition Assistance? Q Yes QO No $ Is PERSON 1 applying for Cash Assistance? QOYes QONo & Is PERSON 1 applying for Tuberculosis Control? QYes ONo

if PERSON 1 is applying for any benefits: continue answering the questions below. if PERSON 1 is NOT applying for any benefits: go to page 5 to tell us about PERSON 1's income.

FS ry $ & Citizenship/Residency: Tell us about PERSON 1's citizenship/residency. You may need to provide proof of citizenship/residency.

Is PERSON 1 a U.S. citizen or U.S. national? See page D for more information. QO Yes QNo QO Choose not to answer

lf PERSON 1 is NOT a U.S. citizen, what is his/her immigration status?

Q Lawtul Permanent Resident (LPR) Q Battered Spouse, Child or Parent QO Removal/Suspension of Deportation

Q Lawful Temporary Resident Q Cuban-Haitian Entrant Q Registry Applicants

Q Non-Immigrant Status Q Deferred Action Status Q Special Immigrant Juvenile Status Applicant QAsylee Q Deferred Enforced Departure Q Temporary Protection Status (TPS)

Q Refugee Q Legalization under LIFE Act Q Victim of Trafficking

Q Conditional Entrant granted before 1980 Q Legalization under IRCA Applicant 1 Withholding of Deportation

Q Other Q Order of Supervision Q Applicant for Asylum, LPR, TPS, or

Q | do not want to provide QO Paroled into United States Withholding Deportation

What immigration document does PERSON 1 have? Immigration Document Number:

Q Permanent Residentcard Q1-94 OVisa Has PERSON 1 lived in the U.S. since August 22, 1996? O Yes ONo Q Foreign Passport QNone QO Other:

Did PERSON 1 move to Arizona in the last 4 months? QOYes ONo

Is PERSON 1 an Arizona resident? OYes ONo If ‘Yes,’ date moved:

Race (optional), select one or more: Ethnicity (optional):

Q Asian Q Hawaiian or other Pacific Islander OQ White Q Hispanic/Latino

Q Black or African American Q American Indian/Alaska Native Q Other: Q Non-Hispanic/Non-Latino if PERSON 1 is American Indian or Alaska Native:

Is-he/she enrolled in a federally recognized tribe? QyYes OQNo if ‘Yes,’ name of tribe:

Has he/she ever gotten services from Indian Health Service, a tribal QYes ONo _ If‘No,’is he/she eligible? OYes ONo health program, or urban Indian health program, or through a referral from one of these programs?

@$ istheishe ving Gh a reservation? QYes No __ If ‘Yes,’ name of reservation:

eo: Tribal Census Number:

Go to the next page to tell us more about PERSON 1.

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 FA-001 (10/13) Arizona Page 3

Attachment 2 AHCCCS DES Combined Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

PERSON 1:

This section asks specific questions for each type of benefit. If PERSON 1 is not applying for any benefits, go to page 5. If PERSON 1 is applying for benefits, complete each applicable section.

+ eo $ 6 Questions for All Applicants: Answer the following questions if PERSON 1 is applying for benefits.

is PERSON 1 physically or mentally disabled? QO Yes O No

IS PERSON 1 in jail or prison? Q Yes O No

Was PERSON 1 released from jail or prison in the last 4 months? QYesQ No if ‘Yes,’ release date:

+ $ AHCCCS Medical Assistance, Help with Medicare Costs, and Cash Assistance Questions: Complete this section if PERSON 1 is applying for help AHCCCS Medical Assistance and/or help with Medicare costs, and/or Cash Assistance.

Is PERSON 1 pregnant? OYes ONo If‘Yes,’ number of babies due: If ‘Yes,’ expected due date:

lf PERSON 1 is under age 19, are both of his/her parents living in the home? QYes ONo If ‘No,’ complete the information below:

Parent's Name (First, Last): : Social Security Number: Date of Birth: Mailing Address: City: State: Zip Code: Phone Number: Reason parent is absent: O Deceased QO Out of home Parent's Name (First, Last): Social Security Number: Date of Birth: __ Mailing Address: City: State: Zip Code: Phone Number: Reason parent is absent: OQ Deceased QO Out of home + AHCCCS Medical Assistance and Help with Medicare Costs Questions: Answer these questions if PERSON 1 is applying for AHCCCS Medical Assistance and/or help with Medicare costs. If PERSON 1 is under the age of 65, does he/she have a mental or physical disability that has kept or QYes ONo will keep him/her from working for at least 12 months? If PERSON 1 works and is under the age of 65, does he/she have a disability that is expected to last QYes ONo at least 12 months? Does PERSON 1 need help with activities of daily living (bathing, dressing, etc.) through personal QYes ONo assistance, services, nursing home, or other medical facility? Does PERSON 1 live with at least one child under age 19 and is the main care taker of the child? QYes ONo Has PERSON 1 ever received Supplemental Security Income (SSI Cash)? OQYes. OQNo e $ Nutrition Assistance and Cash Assistance Questions: Answer these questions if PERSON 1 is applying for Nutrition Assistance and/or Cash Assistance. PERSON 1 may still be able to get benefits if he/she has a felony drug

conviction. See page G for more information.

Has PERSON 1 had a felony conviction for possession, use, or distribution of a QO Yes QNo © if ‘Yes,’ date of conviction:

controlled substance on or after August 23, 19967 City/state of conviction: Type of conviction: Has PERSON 1 been found to have committed a Nutrition Assistance and/or QYes ONo _ If‘Yes,’ name of state: Cash Assistance Intentional Program Violation in Arizona or any other state? Is PERSON 1 fleeing from law enforcement agencies on any charges, or is QYes UW No

PERSON 1 in violation of probation or parole according to a court?

e Nutrition Assistance Questions: Answer these questions if PERSON 1 is applying for Nutrition Assistance.

“If PERSON 1 is disabled or over age 60, does he/she have any paid or unpaid medical QYes ONo expenses, even if he/she has medical insurance (example: travel expenses to and from medical provider, doctor visits, prescriptions, lab work, etc.)?

Is PERSON 1 living in an assisted living facility or group home? QYes ONo

Go to the next page to tell us more about PERSON 1.

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 FA-001 (10/13) Arizona Page 4

Attachment 2 AHCCCS DES Combined Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

PERSON 1:

Tell us about PERSON 1's income, potential benefits and expected tax filing status. Complete this page even if PERSON 1 is not applying for any benefits.

e $ & Employment: Tell us about PERSON 1’s employment, including self-employment and rental income. You may need to provide proof of income. If self-employed, please attach the most current federal tax forms: 1040, SE, and applicable schedules such as C, C-EZ, E, F and K1. If you do not have tax forms, attach proof of business income and expenses for the last and current calendar month.

Does PERSON 1 work? QYes QONo if yes, give employment information below: Employer's Name and Gross Earnings

How many hours worked

id? How often paid? per week?

Phone Number: (before deductions):

ls PERSON 1 self-employed? QOYes ONo If ‘Yes,’ type of work: If ‘Yes,’ annual net (after deductions) amount:

If ‘Yes,’ has PERSON 1 been in this business for 12 months? OQ Yes ONo If ‘No,’ date business started:

Does PERSON 1’s income change because of contract or QYes ONo lf yes, how much income does PERSON 1 expect to seasonal employment? make over the next 12 months? Does PERSON 1 work in exchange for food or rent? QYes QNo If ‘Yes,’ where?

+ e $ & Other Income: Tell us about other income PERSON 1 receives. You may need to provide proof of income.

Type of income: Amount: How often received? Who pays the income?

Social Security benefits :

Supplemental Security Income (SSI Cash)

Retirement/pension

Unemployment

Disability/worker’s compensation

Child support OQ Courtordered O Other:

Alimony

Veterans benefits

Gifts or loans

Tribal money UO Gaming Q Other:

Per capita payments from natural resources, usage rights, leases or royalties

Payments from natural resources, farming, ranching, fishing, leases or royalties from Indian trust land

Money from selling things that have cultural significance

Other: Check here if this person does not have income =) + $ Potential Benefits: Tell us about PERSON 1 to help determine if he/she may be eligible for additional benefits. Has PERSON 1 or his/her spouse (living or deceased) ever worked QYes No If‘Yes,’ employername: __ __ for a government agency or an employer with a pension plan? lf ‘Yes, dates of employment: Has PERSON 1 or his/her spouse (living or deceased) served in the QYes ONo | if ‘Yes,’ branch of service: military? If ‘Yes,’ dates of service: If PERSON 1 is under age 19, has his/her parent {living or deceased). OYes ONo _ If ‘Yes,’ branch of service: served in the military? If ‘Yes,’ dates of service: — . Federal Income Tax Filing: Tell us how PERSON 1 will file income taxes NEXT YEAR. Will PERSON 1 file taxes NEXT YEAR? QOYes .ONo If ‘Yes,’ will PERSON 1 file jointly with a spouse? QyYes QONo If ‘Yes,’ name of spouse: Will PERSON 1 claim dependents on his/her tax return? yee Ne If Yes," name of dependent(s): me Will PERSON 1 be claimed as a dependent on someone QyYes ONo if ‘Yes,’ name oftaxfiler: else’s tax return? Relationship to tax filer: Does PERSON 1 pay any expenses that may be - ~~ OQ Alimony Amount paid: How often? __ deducted on the federal income tax return? Q Student loan interest ~ Amount paid: How often? Do not include self-employment expenses. Q Other deductions Amount paid: How often? _ Check all that apply. Describe deductions: ee Is there anyone else in PERSON 1's household? If YES, go to the next page to tell us about PERSON 2. If NO, go to page 18. Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013

FA-001 (10/13) Arizona Page5S

Attachment 2 AHCCCS DES Combined Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

Tell us about the other people in your household. See page A for a definition of who you must include.

Personal Information:

Name (First, Middle, Last): Gender: QMale O Female Date of Birth: Social Security Number (optional if not applying): Relationship to Person 1: Q Spouse Q Child/Step Child Q Parent Q Other:

Q Grandchild O Niece/Nephew Q Legal Guardian

Marital Status: QO Never Married OQ Divorced Q Widowed _Q Married-name of spouse:

Does PERSON 2 live at the same address as Person 1? Q Yes Q No

If ‘No,’ what is PERSON 2’s home address?

ls PERSON 2 attending school? OQ Yes ONo Name of school:

If ‘Yes,’ is PERSON 2 attending school: © Full Time Q Part Time Grade Level:

Is PERSON 2 applying for help with health QYes ONo _ If‘Yes,’ AHCCCS health plan choice: insurance costs? OPTIONAL. See page H for enrollment plan choices. Is PERSON 2 applying for help with Medicare QO Yes QNo If ‘Yes,’ Medicare claim number: costs? “ Does PERSON 2 need help paying for medical QYes OINo _ If‘Yes,’ what months? bills from the last 3 months? ® |s PERSON 2 applying for Nutrition Assistance? QO Yes QNo $ Is PERSON 2 applying for Cash Assistance? QYes QNo & Is PERSON 2 applying for Tuberculosis Control? Q Yes QNo

If PERSON 2 is applying for any benefits: continue answering the questions below. if PERSON 2 is NOT applying for any benefits: go to page 8 to tell us about PERSON 2's income.

+ e $ & Citizenship/Residency: Tell us about PERSON 2’s citizenship/residency. You may need to provide proof of citizenship/residency.

Is PERSON 2 a U.S. citizen or U.S. national? See page D for more information.

QYes ONo OQ Choose not to answer

If PERSON 2 is NOT a U.S. citizen, what is his/her immigration status?

Q Lawful Permanent Resident (LPR) Q Battered Spouse, Child and Parent Q Lawful Temporary Resident Q Cuban-Haitian Entrant

Q Non-Immigrant Status Q Deferred Action Status

Q Removai/Suspension of Deportation Q Registry Applicants Q Special Immigrant Juvenile Status Applicant

O Asylee

O Refugee

Q Conditional Entrant Granted before 1980 Q Other

QO! do not want to provide

What immigration document does PERSON 2 have? O Visa Q None OQ Other:

QO Permanent Resident card Q 1-94 Q Foreign Passport

Q Deferred Enforced Departure

Q Legalization under LIFE Act

Q Legalization under IRCA Applicant Q Order of Supervision

QO Paroled into United States

Immigration Document Number: Has PERSON 2 lived in the U.S. since August 22, 1996? 0 Yes No

Q Temporary Protection Status (TPS) Q Victim of Trafficking

Q Withholding of Deportation

Q Applicant for Asylum, LPR, TPS, or Withholding Deportation

Is PERSON 2 an Arizona resident? Q Yes

Q No

If ‘Yes,’ date moved:

Did PERSON 2 move to Arizona in the last 4 months?

OYes QONo

Race (optional), select one or more:

Ethnicity (optional):

QO Asian Q Hawaiian or other Pacific Islander O White Q Hispanic/Latino Q Black or African American Q American Indian/Alaska Native Q Other: Q Non-Hispanic/Non-Latino Is he/she enrolled in a federally recognized tribe? QYes (QNo if ‘Yes,’ name of tribe: Has he/she ever gotten services from Indian Health Service, atribal OlYes OQNo _ If‘No, ishe/sheeligible? OYes ONo health program, or urban indian heatth program, or through a referral from one of these programs? QyYes QNo _ If ‘Yes,’ name of reservation:

Os Is he/she living on a reservation? @s Tribal Census Number:

Go to the next page to tell us more about PERSON 2.

Transmittal Number: AZ 13-0005-MM FA-001 (10/13) Arizona

Effective Date: October 1, 2013

Approval Date: September 30, 2013 Page 6

Attachment 2 AHCCCS DES Combined Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

This section asks specific questions for each type of benefit. lf PERSON 2 is not applying for any benefits, go to page 8. If PERSON 2is applying for benefits, complete each applicable section.

+ eo $ & Questions for All Applicants: Answer the following questions if PERSON 2 is applying for benefits.

ls PERSON 2 physically or mentally disabled? QYes ONo IS PERSON 2 in jail or prison? QYes ONo Was PERSON 2 released from jail or prison in the last 4 months? QYes ONo _If ‘Yes,’ release date: *- $ AHCCCS Medical Assistance, Help with Medicare Costs, and Cash Assistance Questions: Complete this section if PERSON 2 is applying for AHCCCS Medical Assistance and/or help with Medicare costs, and/or Cash Assistance. Is PERSON 2 pregnant? QYes No _ If ‘Yes,’ number of babies due:

If ‘Yes,’ expected due date:

If PERSON 2 is under age 19, are both of his/her parents living in the home? QYes ONo If ‘No,’ complete the information below:

Parent's Name (First, Last): = Social Security Number: Date of Birth: Mailing Address: City: State: Zip Code: Phone Number: 2 Reason parent is absent: OQ Deceased Q Out of home Parent’s Name (First, Last): Social Security Number: Date of Birth: Mailing Address: City: State: Zip Code: Phone Number: Reason parent is absent: Q Deceased OQ Out of home

*- AHCCCS Medical Assistance and Help with Medicare Costs Questions: Answer these questions if PERSON 2 is applying for AHCCCS Medical Assistance and/or help with Medicare costs. If PERSON 2 is under the age of 65, does he/she have a mental or physical disability that has kept or QYes ONo will keep him/her from working for at least 12 months? If PERSON 2 works and is under the age of 65, does he/she have a disability that is expected to last QYes ONo at least 12 months? Does PERSON 2 need help with activities of daily living (bathing, dressing, etc.) through personal QYes ONo assistance, services, nursing home, or other medical facility? Does PERSON 2 live with at least one child under age 19 and is the main care taker of the child? QYes ONo

Has PERSON 2 ever received Supplemental Security Income (SSI Cash)? Q Yes ONo

e $ Nutrition Assistance and Cash Assistance Questions: Answer these questions if PERSON 2 is applying for Nutrition Assistance and/or Cash Assistance. PERSON 2 may still be able to get benefits if he/she has a felony drug conviction. See page G for more information.

Has PERSON 2 had a felony conviction for possession, use, or distribution of a QYes. OQNo_ If ‘Yes,’ date of conviction:

controlled substance on or after August 23, 1996? City/state of conviction: Type of conviction: Has PERSON 2 been found to have committed a Nutrition Assistance and/or QO Yes CO No if ‘Yes,’ name of state: Cash Assistance Intentional Program Violation in Arizona or any other state? is PERSON 2 fleeing from law enforcement agencies on any charges, or is QYes ONo

PERSON 2 in violation of probation or parole according to a court?

e Nutrition Assistance Questions: Answer these questions if PERSON 2 is applying for Nutrition Assistance.

Tf PERSON 2 is disabled or over age 60, does he/she have any paid or unpaid medical QOYes ONo expenses, even if he/she has.medical insurance (example: travel expenses to and from medical provider, doctor visits, prescriptions, lab work, etc.)? :

Is PERSON 2 living in an assisted living facility or group home? QYes ONo $ Cash Assistance Questions: Answer this question if PERSON 2 is under age 19 and applying for Cash Assistance. If PERSON 2 is under age 19 and is living with his/her parents, are his/her shots current? Q Yes OQNo

Go to the next page to tell us more about PERSON 2.

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 FA-001 (10/13) Arizona Page7

Attachment 2 AHCCCS DES Combined Application

Do you need help with this application? Visit ov or Call 1-855-HEA-PLUS (432-7587)

PERSON 2:

Tell us about PERSON 2's income, potential benefits and expected tax filing status. Complete this page even if PERSON 2 is not applying for any benefits.

Cs eo $ & Employment: Tell us about PERSON 2’s employment, including self-employment and rental income. You may need to provide proof of income. If self-employed, please attach the most current federal tax forms: 1040, SE, and applicable schedules such as C, C-EZ, E, F and K1. If you do not have tax forms, attach proof of business income and expenses for the last and current calendar month.

Does PERSON 2 work? QYes ONo If yes, give employment information below:

Employer’s Name and Gross Earnings How many hours worked Phone Number: (before deductions): per week?

How often paid?

ls PERSON 2 self-employed? QYes ONo If ‘Yes,’ type of work: If ‘Yes,’ annual net (after deductions) amount:

If ‘Yes,’ has PERSON 2 been in this business for 12 months? O Yes No If ‘No,’ date business started:

Does PERSON 2’s income change because of contract or OYes ONo If yes, how much income does PERSON 2 expect to seasonal employment? make over the next 12 months? Does PERSON 2 work in exchange for food or rent? QYes QONo If ‘Yes,’ where?

+ e $ & Other Income: Tell us about other income PERSON 2 receives. You may need to provide proof of income.

Type of Inco Amount: How often received? Who pays the income? Social Security benefits Supplemental Security Income (SSI Cash) Retirement/pension Unemployment Disability/worker's compensation Child support Court ordered QO Other: Alimony Veterans benefits Gifts or loans Tribal money OQ Gaming Q Other: Per capita payments from natural resources, usage rights, leases or royalties Payments from natural resources, farming, ranching, fishing, leases or royalties from indian trust land Money from selling things that have cultural significance Other: Check here if this person does not have income Q + $ Potential Benefits: Tell us about PERSON 2 to help determine if he/she may be eligible for additional benefits. Has PERSON 2 or his/her spouse (living or deceased) ever worked QO Yes ONo _if‘Yes,’ employer name: for a government agency or an employer with a pension plan? if Yes,’ dates of employment: _ Has PERSON 2 or his/her spouse (living or deceased) served in the QYes ONo _ If ‘Yes,’ branch of service: military? if ‘Yes,’ dates of service: If PERSON 2 is under age 19, has his/her parent (living or deceased) OQ Yes ONo _ if ‘Yes,’ branch of service: served in the military? ; if ‘Yes,’ dates of service: _ + Federal Income Tax Filing: Tell us how PERSON 2 will file income taxes NEXT YEAR. Will PERSON 2 file taxes NEXT YEAR? Q Yes . QNo If ‘Yes,’ will PERSON 2 file jointly with a spouse? QYes QONo If ‘Yes,’ name of spouse: __ Will PERSON 2 claim dependents on his/her tax return? O¥gex “No if eee name,of dependentis): — Will PERSON 2 be claimed as a dependent on someone QYes ONo If ‘Yes,’ name of tax filer: _ else's tax return? Relationship to tax filer: Does PERSON 2 pay any expenses that may be Q Alimony Amount paid: How often? deducted on the federal income tax return? i QO Student loan interest = Amount paid: How often? Do not include self-employment expenses. O Other deductions Amount paid: ss How often? Check all that apply. Describe deductions:

Is there anyone else in PERSON 1’s household? If YES, go to the next page to tell us about PERSON 3. If NO, go to page 18.

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 FA-001 (10/13) Arizona Page 8

Attachment 2 AHCCCS DES Combined Application Do you need help with this application? Visit www hea i ov or call 1-855-HEA-PLUS (432-7587

PERSON 3:

Tell us about the other people in your household. See page A for a definition of who you must include.

+o $ & Personal Information:

Name (First, Middle, Last): Gender: QO Male QO Female Date of Birth: Social Security Number (optional if not applying): Relationship to Person 1: Q Spouse Q Child/Step Child Q Parent Q Other: Q Grandchild Q Niece/Nephew Q Legal Guardian

Marital Status: _ Q Never Married O Divorced Q Widowed Q Married-name of spouse: Does PERSON 2 live at the same address as Person 1? QO Yes QNo

If ‘No,’ what is PERSON 2’s home address? Is PERSON 3 attending school? QOlYes ONo If ‘Yes,’ is PERSON 3 attending school: QO Full Time Q Part Time

Name of School: Grade Level: Is PERSON 3 applying for help with health QO Yes QNo If ‘Yes, AHCCCS health plan choice:

insurance costs? OPTIONAL. See page H for enrollment plan choices.

" |s PERSON 3 applying for help with Medicare costs? OQ Yes QNo If ‘Yes,’ Medicare claim number:

4 Does PERSON 3 need help paying for medical bills Yes No _ If‘Yes,’ what months? from the last 3 months?

@ \s PERSON 3 applying for Nutrition Assistance? O Yes QNo $ Is PERSON 3 applying for Cash Assistance? QO Yes QO No & Is PERSON 3 applying for Tuberculosis Control? QYes ONo

If PERSON 3 is applying for any benefits: continue answering the questions below. If PERSON 3 is NOT applying for any benefits: go to page 11 to tell us about PERSON 3's income.

rs e $ & Citizenship/Residency: Tell us about PERSON 3’s citizenship/residency. You may need to provide proof of

citizenship/residency. Is PERSON 3 a U.S. citizen or U.S. national? See page D for more information. QO Yes QO No QO Choose not to answer If PERSON 3 is NOT a U.S. citizen, what is his/her immigration status? Q Lawful Permanent Resident (LPR) Q Battered Spouse, Child or Parent QO Removal/Suspension of Deportation QO Lawful Temporary Resident QO Cuban-Haitian Entrant QO Registry Applicants Q Non-Immigrant Status O Deferred Action Status Q Special Immigrant Juvenile Status Applicant O Asylee QO Deferred Enforced Departure QO Temporary Protection Status (TPS) QO Refugee Q Legalization under LIFE Act Q Victim of Trafficking Q Conditional Entrant granted before 1980 Q Legalization under IRCA Applicant © Withholding of Deportation Q Other Q Order of Supervision QO Applicant for Asylum, LPR, TPS, or Q 11 do not want to provide Q Paroled into United States Withholding Deportation What immigration document does PERSON 3 have? Immigration Document Number: QO Permanent Resident card O1-94 OVisa Has PERSON 3 lived in the U.S. since August 22, 1996? QO Yes Q No O Foreign Passport Q None QO Other:

Did PERSON 3 move to Arizona in the last 4 months? QYes ONo

Is PERSON 3 an Arizona resident? OYes ONo If ‘Yes,’ date moved:

Race (optional), select one or more: Ethnicity (optional):

O Asian Q Hawaiian or other Pacific Islander © White Q Hispanic/Latino

Q Black or African American Q American Indian/Alaska Native QO Other: QO Non-Hispanic/Non-Latino If PERSON 3 is American Indian or Alaska Native:

Is he/she enrolled in a federally recognized tribe? QYes ONo If‘Yes,’ name of tribe:

Has he/she ever gotten services from Indian Health Service, a tribal Q Yes ONo _ If‘No,’is he/she eligible? OYes ONo health program, or urban Indian health program, or through a referral from one of these programs?

@$ 16 he/che living of a teeervation? QYes ONo__ If‘Yes,’ name of reservation:

@3 Tribal Census Number:

he n je fo tell us mor: out PERSON 3. Transmittal Number: AZ 1 300080? the BEARS Bate! SS SBSTS BBIH" Approval Date: September 30, 2013 FA-001 (10/13) Arizona Page9

Attachment 2 AHCCCS DES Combined Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

ERSON 3

This section asks specific questions for each type of benefit. If PERSON 3 is not applying for any benefits, go to page 11. If PERSON 3is applying for benefits, complete each applicable section.

Ts eo $ & Questions for All Applicants: Answer the following questions if PERSON 3 is applying for benefits.

ls PERSON 3 physically or mentally disabled? QYes OQNo

ls PERSON 3 in jail or prison? QYes ONo

Was PERSON 3 released from jail or prison in the last 4 months? QYes ONo _ If ‘Yes,’ release date:

> $ AHCCCS Medical Assistance, Help with Medicare Costs, and Cash Assistance Questions: Complete this section if PERSON 3 is applying for AHCCCS Medical Assistance and/or help with Medicare costs, and/or Cash Assistance.

Is PERSON 3 pregnant? z QO Yes ONo If‘Yes,’ number of babies due: If ‘Yes,’ expected due date:

\f PERSON 3 is under age 19, are both of his/her parents living in the home? QYes ONo If ‘No,’ complete the information below:

Parent's Name (First, Last): Social Security Number: Date of Birth: Mailing Address: City: State: Zip Code: Phone Number: Reason parent is absent: QO Deceased QO Out of home Parent's Name (First, Last): Social Security Number: Date of Birth: _ Mailing Address: City: State: Zip Code: Phone Number: Reason parent is absent: Q Deceased OQ Out of home Ts AHCCCS Medical Assistance and Help with Medicare Costs Questions: Answer these questions if PERSON 3 is applying for AHCCCS Medical Assistance and/or help with Medicare costs. lf PERSON 3 is under the age of 65, does he/she have a mental or physical disability that has kept or OYes ONo will keep him/her from working for at least 12 months? |f PERSON 3 works and is under the age of 65, does he/she have a disability that is expected to last QYes QONo at least 12 months? Does PERSON 3 need help with activities of daily living (bathing, dressing, etc.) through personal QYes ONo assistance, services, nursing home, or other medical facility? Does PERSON 3 live with at least one child under age 19 and is the main care taker of the child? QYes ONo Has PERSON 3 ever received Supplemental Security Income (SSI Cash)? OYes ONo e $ Nutrition Assistance and Cash Assistance Questions: Answer these questions if PERSON 3 is applying for Nutrition Assistance and/or Cash Assistance. PERSON 3 may still be able to get benefits if he/she has a felony drug conviction. See page G for more information. Has PERSON 3 had a felony conviction for possession, use, or distribution of a QYes (No _ If‘Yes,’ date of conviction: controlled substance on or after August 23, 1996? : City/state of conviction: : Type of conviction: Has PERSON 3 been found to have committed a Nutrition Assistance and/or QYes OU No _If‘Yes,’ name of state: Cash Assistance Intentional Program Violation in Arizona or any other state? Is PERSON 3 fleeing from law enforcement agencies on any charges, or is - OYes No

PERSON 3 in violation of probation or parole according to a court?

eo Nutrition Assistance Questions: Answer these questions if PERSON 3 is applying for Nutrition Assistance.

"If PERSON 3 is disabled or over age 60, does he/she have any paid or unpaid medical OYes ONo expenses, even if he/she has medical insurance (example: travel expenses to and from medical provider, doctor visits, prescriptions, lab work, etc.)?

Is PERSON 3 living in an assisted living facility or group home? QYes ONo

$ Cash Assistance Questions: Answer this question if PERSON 3 is under age 19 and applying for Cash Assistance.

If PERSON 3 is under age 19 and is living with his/her parents, are his/her shots current? QYes OQNo

Go to the next page to tell us more about PERSON 3.

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 FA-001 (10/13) Arizona Page 10

Attachment 2 AHCCCS DES Combined Application

Do you need help with this application? Visit

10Vv or call 1-855-HEA-PLUS (432-7587)

PERSON 3:

Tell us about PERSON 3's income, potential benefits and expected tax filing status. Complete this page even if PERSON 3 is not applying for any benefits.

- e $ & Employment: Tell us about PERSON 3's employment, including self-employment and rental income. You may need to provide proof of income. !f self-employed, please attach the most current federal tax forms: 1040, SE, and applicable schedules such as C, C-EZ, E, F and K1. If you do not have tax forms, attach proof of business income and expenses for the last and current calendar month.

Does PERSON 3 work? QYes QONo If yes, give employment information below: Employer’s Name and Gross Earnings How many hours worked Phone Number: (before deductions): per week?

How often paid?

ls PERSON 3 self-employed? QYes ONo If ‘Yes,’ type of work: If ‘Yes,’ annual net (after deductions) amount:

If ‘Yes,’ has PERSON 3 been in this business for 12 months? OQ Yes No If ‘No,’ date business started:

Does PERSON 3's income change because of contract or QYes ONo If yes, how much income does PERSON 3 expect to seasonal employment? make over the next 12 months? Does PERSON 3 work in exchange for food or rent? QYes ONo If ‘Yes,’ where?

+ e $ & Other Income: Tell us about other income PERSON 3 receives. You may need to provide proof of income. peo ‘e) e a fe) ‘@) o7te ece ed oO pa e Oo

Social Security benefits Supplemental Security Income (SSI Cash) Retirement/pension Unemployment Disability/worker’s compensation Child support Q Court ordered QO Other:

Alimony

Veterans benefits

Gifts or loans

Tribal money QO Gaming Q Other:

Per capita payments from natural resources, usage rights, leases or royalties

Payments from natural resources, farming, ranching, fishing, leases or royalties from Indian trust land

Money from selling things that have cultural significance

Other: Check here if this person does not have income Q + $ Potential Benefits: Tell us about PERSON 3 to help determine if he/she may be eligible for additional benefits. Has PERSON 3 or his/her spouse (living or deceased) ever worked OYes No. If ‘Yes,’ employer name: for a government agency or an employer with a pension plan? If‘Yes,’ dates of employment: Has PERSON 3 or his/her spouse (living or deceased) served in the QYes No _ if ‘Yes,’ branch of service: military? if ‘Yes,’ dates of service: If PERSON 3 is under age 19, has his/her parent (living or deceased) _QYes O1No _ If ‘Yes,’ branch of service: served in the military? If ‘Yes,’ dates of service: - Federal Income Tax Filing: Tell us how PERSON 3 will file income taxes NEXT YEAR. “Will PERSON 3 file taxes NEXT YEAR? GYes No If ‘Yes,’ will PERSON 3 file jointly with a spouse? QYes QONo If ‘Yes,’ name of spouse: Will PERSON 8 claim dependents on his/her tax return? Oives: _ SI No IEYes, name of dependent(s): Will PERSON 3 be claimed as a dependent on someone QyYes QNo If ‘Yes,’ name of tax filer: _ else's tax return? Relationship to tax filer: Does PERSON 3 pay any expenses that may be O Alimony Amount paid: How often? deducted on the federal income tax return? Q Student loan interest... Amount paid: How often? Do not include self-employment expenses. Q Other deductions Amount paid: How often? Check all that apply. Describe deductions:

ls there anyone else in PERSON 1's household? If YES, go to the next page to tell us about PERSON 4. If NO, go to page 18.

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 FA-001 (10/13) Arizona Page 11

Attachment 2 AHCCCS DES Combined Application Do you need help with this application? Visit www healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587

PERSON 4:

Tell us about the other people in your household. See page A for a definition of who you must include.

+o $ & Personal Information:

Name (First, Middle, Last): Gender: QOMale OQ Female Date of Birth: Social Security Number (optional if not applying): Relationship to Person 1: Q Spouse Q Child/Step Child Q Parent Q Other: Q Grandchild Q Niece/Nephew Legal Guardian

Marital Status: Q Never Married Q Divorced QO Widowed Q Married-name of spouse: Does PERSON 2 live at the same address as Person 1? QyYes ONo

If ‘No,’ what is PERSON 2's home address? Is PERSON 4 attending school? OYes ONo If ‘Yes,’ is PERSON 4 attending school: OQ Full Time Q Part Time

Name of School: Grade Level: "PF is PERSON 4 applying for help with health QO Yes QNo If ‘Yes, AHCCCS health plan choice:

insurance costs? OPTIONAL. See page H for enrollment plan choices.

‘4 \s PERSON 4 applying for help with Medicare costs? OQ Yes Q No If ‘Yes,’ Medicare claim number:

"F Does PERSON 4 need help paying for medical bills Yes QNo If ‘Yes,’ what months? from the last 3 months?

®@ Is PERSON 4 applying for Nutrition Assistance? QO Yes Q No $ 1s PERSON 4 applying for Cash Assistance? QYes QONo & Is PERSON 4 applying for Tuberculosis Control? QYes ONo

If PERSON 4 is applying for any benefits: continue answering the questions below. If PERSON 4 is NOT applying for any benefits: go to page 14 to tell us about PERSON 4's income.

rs e $ & Citizenship/Residency: Tell us about PERSON 4’s citizenship/residency. You may need to provide proof of

citizenship/residency. ls PERSON 4a U.S. citizen or U.S. national? See page D for more information. Q Yes ONo Q Choose not to answer If PERSON 4 is NOT a U.S. citizen, what is his/her immigration status? Q Lawful Permanent Resident (LPR) Q Battered Spouse, Child or Parent Q Removal/Suspension of Deportation Q Lawful Temporary Resident Q Cuban-Haitian Entrant Q Registry Applicants Q Non-Immigrant Status Q Deferred Action Status Q Special immigrant Juvenile Status Applicant O Asylee Q Deferred Enforced Departure Q Temporary Protection Status (TPS) QO Refugee Q Legalization under LIFE Act Q Victim of Trafficking Q Conditional Entrant granted before 1980 Q Legalization under IRCA Applicant 0 Withholding of Deportation Q Other Q Order of Supervision Q Applicant for Asylum, LPR, TPS, or QI do not want to provide Q Paroled into United States Withholding Deportation What immigration document does PERSON 4 have? Immigration Document Number: QO Permanent Resident card Q1-94 OVisa Has PERSON 4 lived in the U.S. since August 22, 1996? O Yes O No O Foreign Passport Q None OQ Other:

Did PERSON 4 move to Arizona in the last 4 months? QYes ONo

i ident? ls PERSON 4 an Arizona resident? OYes ONo If ‘Yes,’ date moved:

Race (optional), select one or more: Ethnicity (optional):

QO Asian Q Hawaiian or other Pacific Islander O White Q Hispanic/Latino

QO Black or African American Q American Indian/Alaska Native QO Other: Q Non-Hispanic/Non-Latino If PERSON 4 is American Indian or Alaska Native:

Is he/she enrolled in a federally recognized tribe? QO Yes QONo If‘Yes,’ name of tribe:

Has he/she ever gotten services from Indian Health Service, a tribal Q Yes QNo _If‘No,’is he/she eligible? OYes ONo health program, or urban Indian health program, or through a referral from one of these programs?

@3 4s he/she living on a reservation? os Tribal Census Number:

QYes ONo _'If‘Yes,’ name of reservation:

Go to the next page to tell us more about PERSON 4. Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 FA-001 (10/13) Arizona Page 12

Attachment 2 AHCCCS DES Combined Application Do you need help with this application? Visit www. healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

This section asks specific questions for each type of benefit. If PERSON 4 is not applying for any benefits, go to page 14. If PERSON 4 is applying for benefits, complete each applicable section.

Ts e $ & Questions for All Applicants: Answer the following questions if PERSON 4 is applying for benefits.

ls PERSON 4 physically or mentally disabled? QYes ONo IS PERSON 4 in jail or prison? QYes ONo Was PERSON 4 released from jail or prison in the last 4 months? Q Yes UO No _If'Yes,’ release date:

rT $ AHCCCS Medical Assistance, Help with Medicare Costs, and Cash Assistance Questions: Complete this section if PERSON 4 is applying for AHCCCS Medical Assistance and/or help with Medicare costs, and/or Cash Assistance.

Is PERSON 4 pregnant? : é i - QYes No _If‘Yes,’ number of babies due: If ‘Yes,’ expected due date:

\f PERSON 4 is under age 19, are both of his/her parents living in the home? QYes ONo If ‘No,’ complete the information below:

Parent's Name (First, Last): Social Security Number: Date of Birth: Mailing Address: City: State: Zip Code: Phone Number: Reason parent is absent: QO Deceased O Out of home Parent's Name (First, Last): Social Security Number: Date of Birth: Mailing Address: City: State: Zip Code: Phone Number: Reason parent is absent: QO Deceased ( Out of home AHCCCS Medical Assistance and Help with Medicare Costs Questions: Answer these questions if PERSON 4 is applying for AHCCCS Medical Assistance and/or help with Medicare costs. If PERSON 4 is under the age of 65, does he/she have a mental or physica! disability that has kept or QOYes QONo will keep him/her from working for at least 12 months? If PERSON 4 works and is under the age of 65, does he/she have a disability that is expected to last QYes ONo at least 12 months? Does PERSON 4 need help with activities of daily living (bathing, dressing, etc.) through personal OYes ONo assistance, services, nursing home, or other medical facility? Does PERSON 4 live with at least one child under age 19 and is the main care taker of the child? QYes ONo Has PERSON 4 ever received Supplemental Security Income (SSI Cash)? QYes ONo e $ Nutrition Assistance and Cash Assistance Questions: Answer these questions if PERSON 4 is applying for Nutrition Assistance and/or Cash Assistance. PERSON 4 may still be able to get benefits if he/she has a

felony drug conviction. See page G for more information. Has-PERSON 4 had a felony conviction for possession, use, or distribution of a QOYes (No _If‘Yes,’ date of conviction:

controlled substance on or after August 23, 19967 City/state of conviction: : : Type of conviction: Has PERSON 4 been found to have committed a Nutrition Assistance and/or QOYes OINo _ If‘Yes,’ name of state: _ Cash Assistance intentional Program Violation in Arizona or any other state? ls PERSON 4 fleeing from law enforcement agencies on any charges, or is QO Yes. QNo

PERSON 4 in violation of probation or parole according to a court?

} Nutrition Assistance Questions: Answer these questions if PERSON 4 is applying for Nutrition Assistance.

“if PERSON 4 is disabled or over age 60, does he/she have any paid or unpaid medical : OYes ONo expenses, even if he/she has medical insurance (example: travel expenses to and from medical provider, doctor visits, prescriptions, lab work, etc.}? :

Is PERSON 4 living in an assisted living facility or group home? QYes QONo

$ Cash Assistance Questions: Answer this question if PERSON 4 is under age 19 and applying for Cash Assistance. If PERSON 4 is under age 19 and is living with his/her parents, are his/her shots current? QYes ONo Go to the next page to tell us more about PERSON 4. Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 FA-001 (10/13) Arizona Page 13

Attachment 2 AHCCCS DES Combined Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

PERSON 4:

Tell us about PERSON 4’s income, potential benefits and expected tax filing status. Complete this page even if PERSON 4 is not applying for any benefits.

- e $ & Employment: Tell us about PERSON 4’s employment, including self-employment and rental income. You may need to provide proof of income. If self-employed, please attach the most current federal tax forms: 1040, SE, and applicable schedules such as C, C-EZ, E, F and K1. If you do not have tax forms, attach proof of business income and expenses for the last and current calendar month.

Does PERSON 4 work? QYes QNo if yes, give employment information below:

Employer's Name and Gross Earnings How many hours worked per week?

How often paid?

Phone Number: (before deductions):

ls PERSON 4 self-employed? QYes ONo If ‘Yes,’ type of work:

If ‘Yes,’ annual net (after deductions) amount: If ‘Yes,’ has PERSON 4 been in this business for 12 months? O Yes No If ‘No,’ date business started:

Does PERSON 4's income change because of contract or QYes ONo \f yes, how much income does PERSON 4 expect to seasonal employment? make over the next 12 months? Does PERSON 4 work in exchange for food or rent? QYes ONo If ‘Yes,’ where?

+ eo $ & Other Income: Tell us about other income PERSON 4 receives. You may need to provide proof of income. Type of Income: Amount: How often received? Who pays the income? Social Security benefits

Supplemental Security Income (SS! Cash)

Retirement/pension

Unemployment

Disability/worker’s compensation

Child support O Court ordered Q Other:

Alimony

Veterans benefits

Gifts or loans

Tribal money 1 Gaming Q Other:

Per capita payments from natural resources, usage rights, leases or royalties

Payments from natural resources, farming, ranching, fishing, leases or royalties from Indian trust land

Money from selling things that have cultural significance

Other: Check here if this person does not have income Q + $ Potential Benefits: Tell us about PERSON 4 to help determine if he/she may be eligible for additional benefits. Has PERSON 4 or his/her spouse (living or deceased) ever worked QYes ONo _ if ‘Yes,’ employer name: for a government agency or an employer with a pension plan? If ‘Yes,’ dates of employment: Has PERSON 4 or his/her spouse (living or deceased) served in the QYes UONo _ if ‘Yes,’ branch of service: military? If ‘Yes,’ dates of service: lf PERSON 4 is under age 19, has his/her parent (living or deceased) QYes No if ‘Yes,’ branch of service: served in the military? a If ‘Yes,’ dates of service: = __ - Federal Income Tax Filing: Tell us how PERSON 4 will file income taxes NEXT YEAR. “Will PERSON 4 file taxes NEXT YEAR? OYes ONo If ‘Yes,’ will PERSON 4 file jointly with a spouse? QYes ONo If ‘Yes,’ name of spouse: Will PERSON 4 claim dependents on his/her tax return? Gives 2° ER No af Ves, namie of dependent(s): Will PERSON 4 be claimed as a dependent on someone OYes ONo If ‘Yes,’ name of tax filer: else's tax return? Relationship to tax filer: Does PERSON 4 pay any expenses that may be OQ Alimony Amount paid: How often? deducted on the federal income tax return? Q Student loan interest © Amount pai How often? Do not include self-employment expenses. Q Other deductions Amount paid: How often? Check all that apply. Describe deductions: Is there anyone else in PERSON 1's household? If YES, go to the next page to tell us about PERSON 5. If NO, go to page 18. Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013

FA-001 (10/13) Arizona Page 14

Attachment 2 AHCCCS DES Combined Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

PERSON 5:

If there are more than 5 people in your household, make a copy of pages 15, 16 and 17, then tell us about the other people in your household. See page A for a definition of who you must include. Attach copied pages to this application.

+o $ & Personal Information:

Name (First, Middle, Last): Gender: OMale O Female Date of Birth: Social Security Number (optional if not applying): Relationship to Person 1: Q Spouse O Child/Step Child O Parent O Other: Q Grandchild O Niece/Nephew Q Legal Guardian Marital Status: Q Never Married Q Divorced Q Widowed QO Married-name of spouse: Does PERSON 2 live at the same address as Person 1? O Yes Q No If ‘No,’ what is PERSON 2's home address? Is PERSON 5 attending school? OQYes ONo if ‘Yes,’ is PERSON 5 attending school: O Full Time Oj Part Time Name of School: Grade Level: F Is PERSON 5 applying for help with health Q Yes QNo If ‘Yes,, AHCCCS health plan choice: _ insurance costs? OPTIONAL. See page H for enrollment pian choices.

‘ \s PERSON 5 applying for help with Medicare costs? Q Yes Q No If Yes,’ Medicare claim number:

" Does PERSON 5 need help paying for medical bills Yes ONo If ‘Yes,’ what months? from the last 3 months?

® |s PERSON 5 applying for Nutrition Assistance? QO Yes ONo $ Is PERSON 5 applying for Cash Assistance? QYes ONo & Is PERSON 5 applying for Tuberculosis Control? QYes ONo

If PERSON 5 is applying for any benefits: continue answering the questions below. If PERSON 5 is NOT applying for any benefits: go to page 17 to tell us about PERSON 5’s income.

ra e $ & Citizenship/Residency: Tell us about PERSON 5's citizenship/residency. You may need to provide proof of citizenship/residency.

Is PERSON 5 a U.S. citizen or U.S. national? See page D for more information. QO Yes QNo QO Choose not to answer

\f PERSON 5 is NOT a U.S. citizen, what is his/her immigration status?

Q Lawtul Permanent Resident (LPR) QO Battered Spouse, Child or Parent OQ Removal/Suspension of Deportation

Q Lawful Temporary Resident Q Cuban-Haitian Entrant Q Registry Applicants

Q Non-Immigrant Status Q Deferred Action Status O Special Immigrant Juvenile Status Applicant QO Asylee Q Deferred Enforced Departure Q Temporary Protection Status (TPS)

Q Refugee QO Legalization under LIFE Act O Victim of Trafficking

Q Conditional Entrant granted before 1980 Q Legalization under IRCA Applicant © Withholding of Deportation

Q Other Q Order of Supervision Q Applicant for Asylum, LPR, TPS, or

Q I do not want to provide Q Paroled into United States Withholding Deportation

What immigration document does PERSON 5 have? Immigration Document Number:

Q Permanent Resident card O1-94 OVisa Has PERSON 5 lived in the U.S. since August 22, 1996? O Yes O No Q Foreign Passport QNone_ OQ Other:

Did PERSON 5 move to Arizona in the last 4 months? QYes ONo

ls PERSON 5 an Arizona resident? OYes ONo If ‘Yes,’ date moved:

Race (optional), select one or more: Ethnicity (optional):

QO Asian Q Hawaiian or other Pacific Islander O White Q Hispanic/Latino

Q Black or African American QO American Indian/Alaska Native Q Other: QO Non-Hispanic/Non-Latino If PERSON 5 is American Indian or Alaska Native:

|s he/she enrolled in a federally recognized tribe? QYes ONo If‘Yes,’ name of tribe:

Has he/she ever gotten services from Indian Health Service, a tribal QYes QNo _ if‘No,’is he/she eligible? OYes ONo health program, or urban Indian health program, or through a referral from one of these programs?

es Is he/she living on a reservation? QO Yes QNo _ if‘Yes,’ name of reservation:

os Tribal Census Number:

Go to the next page to tell us more about PERSON 5. Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 FA-001 (10/13) Arizona Page 15

Attachment 2 AHCCCS DES Combined Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

This section asks specific questions for each type of benefit. If PERSON 5 is not applying for any benefits, go to page 17. If PERSON Sis applying for benefits, complete each applicable section.

rs e $ & Questions for All Applicants: Answer the following questions if PERSON 5 is applying for benefits.

ls PERSON 5 physically or mentally disabled? QYes ONo

IS PERSON 5 in jail or prison? QYes QONo

Was PERSON 5 released from jail or prison in the last 4 months? QYes ONo _ If ‘Yes,’ release date:

+S AHCCCS Medical Assistance, Help with Medicare Costs, and Cash Assistance Questions: Complete this section if PERSON 5 is applying for AHCCCS Medical Assistance and/or help with Medicare costs, and/or Cash Assistance.

Is PERSON 5 pregnant? Q Yes OUNo If ‘Yes,’ number of babies due: if ‘Yes,’ expected due date:

!f PERSON 5 is under age 19, are both of his/her parents living in the home? QYes ONo If ‘No,’ complete the information below:

Parent's Name (First, Last): : Social Security Number: Date of Birth: Mailing Address: City: State: Zip Code: Phone Number: : Reason parent is absent: Q Deceased UO Out of home Parent's Name (First, Last): Social Security Number: Date of Birth: Mailing Address: City: State: Zip Code: Phone Number: Reason parent is absent: Q Deceased QO Out of home rs AHCCCS Medical Assistance and Help with Medicare Costs Questions: Answer these questions if PERSON 5 is applying for AHCCCS Medical Assistance and/or help with Medicare costs. If PERSON 5 is under the age of 65, does he/she have a mental or physical disability that has kept or QYes ONo will keep him/her from working for at least 12 months? If PERSON 5 works and is under the age of 65, does he/she have a disability that is expected to last QYes ONo at least 12 months? Does PERSON 5 need help with activities of daily living (bathing, dressing, etc.) through personal QYes ONo assistance, services, nursing home, or other medical facility? Does PERSON 5 live with at least one child under age 19 and is the main care taker of the child? QYes ONo Has PERSON 5 ever received Supplemental Security Income (SSI Cash)? = QYes ONo e $ Nutrition Assistance and Cash Assistance Questions: Answer these questions if PERSON 5 is. applying for Nutrition Assistance and/or Cash Assistance. PERSON 5 may still be able to get benefits if he/she has a felony drug conviction. See page G for more information. Has PERSON 5 had a felony conviction for possession, use, or distribution of a OYes. OQ No _ If ‘Yes,’ date of conviction: controlled substance on or after August 23, 1996? City/state of conviction: _ Type of conviction: —__ Has PERSON 5 been found to have committed a Nutrition Assistance and/or QYes No _ If'Yes,’ name of state: Cash Assistance Intentional Program Violation in Arizona or any other state? Is PERSON 5 fleeing from law enforcement agencies on any charges, or is OQYes ONo

PERSON 5 in violation of probation or parole according to a court?

e Nutrition Assistance Questions: Answer these questions if PERSON 5 is applying for Nutrition Assistance.

“TfPERSON 5 is disabled or over age 60, does he/she have any paid or unpaid medical QYes ONo expenses, even if he/she has medical insurance (example: travel expenses to and from medical provider, doctor visits, prescriptions, lab work, etc.)?

Is PERSON 5 living in an assisted living facility or group home? QYes ONo $ Cash Assistance Questions: Answer this question if PERSON 5 is under age 19 and applying for Cash Assistance. lf PERSON 5 is under age 19 and is living with his/her parents, are his/her shots current? QYes ONo

Go to the next page to tell us more about PERSON 5.

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 FA-001 (10/13) Arizona Page 16

Attachment 2 AHCCCS DES Combined Application Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

Tell us about PERSON 5's income, potential benefits and expected tax filing status. Complete this page even if PERSON 5 is not applying for any benefits.

+ eo $ & Employment: Tell us about PERSON 5's employment, including self-employment and rental income. You may need to provide proof of income. If self-employed, please attach the most current federal tax forms: 1040, SE, and applicable schedules such as C, C-EZ, E, F and K1. If you do not have tax forms, attach proof of business income and expenses for the last and current calendar month.

Does PERSON 5 work? QYes QONo If yes, give employment information below: Employer’s Name and Gross Earnings

How many hours worked

id? How often paid? per week?

Phone Number: (before deductions):

Is PERSON 5 self-employed? QYes ONo If ‘Yes,’ type of work: If ‘Yes,’ annual net (after deductions) amount:

If ‘Yes,’ has PERSON 5 been in this business for 12 months? QYes OQ No If ‘No,’ date business started:

Does PERSON 5's income change because of contract or QYes ONo If yes, how much income does PERSON 5 expect to seasonal employment? make over the next 12 months? _ Does PERSON 5 work in exchange for food or rent? QYes QNo If ‘Yes,’ where?

+ e $ 6 Other Income: Tell us about other income PERSON 5 receives. You may need to provide proof of income. Type of Income: Amount: How often received? Who pays the income?

Social Security benefits Supplemental Security Income (SSI Cash) Retirement/pension Unemployment Disability/worker’s compensation Child support O Courtordered QO Other:

Alimony

Veterans benefits

Gifts or loans

Tribal money Q Gaming Q Other:

Per capita payments from natural resources, usage rights, leases or royalties

Payments from natural resources, farming, ranching, fishing, leases or royalties from Indian trust land

Money from selling things that have cultural significance

Other: Check here if this person does not have income Q + $ Potential Benefits: Tell us about PERSON 5 to help determine if he/she may be eligible for additional benefits. Has PERSON 5 or his/her spouse (living or deceased) ever worked Q Yes ONo = if ‘Yes,’ employer name: for a government agency or an employer with a pension plan? If ‘Yes,’ dates of employment: Has PERSON 5 or his/her spouse (living or deceased) served in the QYes ONo if ‘Yes,’ branch of service: military? If ‘Yes,’ dates of service: If PERSON 5 is under age 19, has his/her parent (living or deceased) (Yes INO _if ‘Yes,’ branch of servic _ _ served in the military? : : If ‘Yes,’ dates of service: _ - Federal Income Tax Filing: Tell us how PERSON 5 will file income taxes NEXT YEAR. Will PERSON 5 file taxes NEXT YEAR? QYes QNo If ‘Yes,’ will PERSON 5 file jointly with a spouse? QYes QONo If ‘Yes,’ name of spouse: Will PERSON 5 claim dependents on his/her tax return? ELYSS ala No Yee," Hame Of dependent(s): Will PERSON 5 be claimed as a dependent on someone ~QYes ONo If ‘Yes,’ name of tax filer: else’s tax return? Relationship to tax filer: Does PERSON 5 pay any expenses that may be Q Alimony Amount paid: How often? deducted on the federal income tax return? __U Student loan interest. Amount paid: How often? Do not include self-employment expenses. Q Other deductions Amount paid; How often? Check all that apply. Describe deductions: Is there anyone else in PERSON 1’s household? !f YES, attach extra pages to tell us about the other people. !f NO, go to page 18. Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013

FA-001 (10/13) Arizona Page 17

Attachment 2 AHCCCS DES Combined Application

Nutrition Assistance, Cash Assistance and Tuberculosis Control Questions:

Is anyone in your household applying for Nutrition Assistance, Cash Assistance, and/or Tuberculosis Control? If YES: answer the questions below. If NO: go to the next page.

6 5 o & Temporary Absence: Tell us about any people who are temporarily living outside of your home that are expected to

return. and La Date Le pected emporary Addre Re Date O O re e $ Resources and Expenses: Answer the following questions if anyone in your household is applying for Nutrition Assistance and/or Cash Assistance.

Do you or anyone in your household own or have their name on QO Yes -QNo © If ‘Yes,’ total value: $_ _ bank accounts (checking or savings), credit union accounts, Who owns? _ IRAs, Keoghs, or 401Ks? Name of financial institution: Do you or anyone in your household own or have their name on QYes (OINo _If‘Yes,' total value: $ stocks, bonds, money market accounts, Certificates of Deposit Who owns? (CD's), trust funds, or life insurance? Name of financial institution: Do you or anyone in your household own, rent, lease or maintain | OQ Yes No _ If ‘Yes,’ total value: a home? Who owns?

Where? Do you or anyone in your household own real property (land or QYes QNo _if'Yes,’ total value: $ buildings)? Who owns?

Where? Do you or anyone in your household own vehicles (cars, trucks, QYes ONo_If‘Yes,’ total value: $ boats, RVs, motorcycles, etc.)? How many vehicles? Do you or anyone in your household own other resources? QYes (QINo _If‘Yes,’ total value: $

Describe resources:

Who owns? Did you or anyone in your household ever apply for or get QO Yes UINo — If‘Yes,’ who? benefits from any other state? What type of benefits?

When did benefits stop? Name of state/county: _

Do you or anyone in your household pay for the care of a QYes (ONo _ If‘Yes,’ who pays? child or disabled adult in order to work, look for work, attend Amount paid for care: $ training, or attend school? How often is care paid for?

Do you or anyone in your household have transportation QYes ONo -If'Yes,’ amount: $ costs to travel to/from the person or agency that provides provider, z

after school care or adult daycare? Do you or anyone in your household pay court-ordered child QO Yes OQNo _If‘Yes,’ who pays? support? Amount paid $ How often paid?

Does your household have enough monthly income, cash and/or | Q Yes. No __ If‘No,’ how are you paying your bills? bank account balances to cover your monthly rent/mortgage, utility and child care payments?

e Food Preparation: If anyone in your household is applying for Nutrition Assistance, tell us how your household buys and prepares food. Does anyone in your household buy and prepare his/her own food separate from others QYes QONo in the household?

If ‘Yes,’ tell us about the people who buy and prepare their own food: Name (First & Las Relationship to PERSON 1:

Does this person

pay expenses? What expenses?

QOYes ONo QYes ONo QOYes ONo QYes ONo

Is anyone in your household applying for AHCCCS Medical Assistance, help with Medicare costs, and/or Cash Assistance? If YES: Go to the next page. If NO: go to page 20.

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 FA-001 (10/13) Arizona Page 18

Attachment 2 AHCCCS DES Combined Application Do you need help with this application? Visit

Health Insurance:

- $ Health Insurance Coverage: Answer the following questions if anyone in your household is applying for AHCCCS Medical Assistance, help with Medicare costs, and/or Cash Assistance. Do any applicants have health insurance other than AHCCCS or Medicare? QYes ONo

If ‘Yes,’ give the following information:

- Answer the following questions for everyone applying for AHCCCS Medical Assistance and/or help with Medicare costs. Do any applicants have an injury or illness due to an accident or medical malpractice? QYes OQ No _ If ‘Yes,’ who? Are any applicants currently admitted to a hospital? QYes ONo _ If'Yes,’ who?

Health Insurance Tax Credits:

If you are not eligible for you AHCCCS Medical Assistance, you may be eligible for federal tax credits to help with your health insurance premiums. If you are not eligible for any programs through AHCCCS, we will send your information to the federal Health Insurance Marketplace to see about health insurance tax credits.

+ Insurance from Jobs: Tell us about health insurance that may be offered through a job.

Is anyone eligible for health insurance coverage offered by an employer, or will you QYes ONo Q | do not know become eligible for coverage in the next 60 days? lf YES: answer the questions below. If NO or | DO NOT KNOW: go to the next page.

Tell us about the job that offers health insurance coverage. If there are plans offered by more than one employer and you need more space, please attach additional pages. If you need help with the information, contact the employer.

Employee Name: Employee Social Security Number: Employer Name: Employer Identification Number (EIN): Employer Address: City: State: Zip Code:

Who can we contact about employment health insurance coverage at this job?

If you are in a waiting or probationary period for insurance offered by an employer, when can you enroll in coverage? Who is eligible for coverage from this job?

Does the employer offer a health plan that meets the minimum value standard*? Q Yes Q No QI do not know if YES: answer the questions below. If NO or |DO NOT KNOW: go to the next page.

For the lowest-cost plan that meets the minimum value standard* offered only to the employee (do not include family plans): if the employer has wellness programs, provide the premium that the employee would pay if he/she received the maximum discount for any tobacco cessation programs, and did not receive any other discounts based on wellness programs: How much will the employee have to pay in premiums for that plan? $ Q | do not know How often will the employee have to pay the premium? Q Weekly OTwiceamonth OeEvery2Weeks OMonthly QO Quarterly O Yearly Qldonotknow OQ Other: What changes will the employer make for the new plan year (if known)? Q Employer will not offer health coverage Q Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard*. How much will the employee have to pay in premiums for that plan? $ Q | do not know How often will the employee have to pay the premium? QWeekly OTwiceamonth OQEvery2Weeks OMonthly QO Quarterly O Yearly Oldonotknow QO Other: _ QI do not know

+ Renewal of Tax Credit Coverage in Future Years:

To make it easier for the Federal Facilitated Marketplace to determine my eligibility for help paying for health coverage in future years, | agree to allow the Marketplace to use income data, including information from tax returns. The Marketplace will send me a notice, let me make changes, and | can opt out at any time.

Yes, renew my eligibility forthe next OS5yearss O4years O3years O2years 1 year

No, do not use information from tax returns to renew my coverage

*An employer-sponsored health plan meets “minimum value standard” if the plan's share of the total allowed benefit costs covered by the plan is no less than 60% of such costs.

Transmittal Number: AZ 13-0005-MM Go EPERRE BEATE BEG 9 OHI aPPlication. Approval Date: September 30, 2013 FA-001 (10/13) Arizona Page 19

Attachment 2 AHCCCS DES Combined Application

Do you need help with this application? Visit www. gov or Call 1-855-HEA-PLUS (432-7587) Sign the Application

ra e $ & The application is not valid until it is signed. All unrelated adults without a child in common must sign the application. Otherwise, the application must be signed by one of the following: ¢ The applicant or the applicant's designee (we must have documentation showing this person is authorized to act on the applicant's behalf); or ¢ The applicant's spouse, if married and living within the same household; or The parent/legal guardian of a minor child. Penalty Warning The information provided on this form may be verified by federal, state, and local officials. If any information is inaccurate, you may be denied benefits. ¢ You must not knowingly withhold or give false information with the intent to receive or to continue receiving DES and/or AHCCCS benefits to which you are not entitled. ¢ You will be required to pay back to DES and/or AHCCCS any benefits you receive as a result of withholding or giving false information and you will be subject to criminal prosecution. ¢ Itis fraud for any person to knowingly withhold information with the intent to receive or continue to receive benefits to which he/she is not eligible. Any person found guilty of fraud may be subject to fines, criminal prosecution, imprisonment or other penalties as provided for by applicable State and Federal laws.

Release of Information

| authorize DES and/or AHCCCS to investigate and contact any sources necessary to establish eligibility and the accuracy of financial information that pertains to AHCCCS eligibility.

Assignment of Rights to Other Benefits for Medical Care

| understand that if | am or members of my household are approved for DES and/or AHCCCS benefits, DES and/or AHCCCS can collect payment from any other parties who may be responsible for paying for my/our health costs. This includes:

« Private or employer-sponsored health insurance (not including Medicare)

« Persons, such as an absent spouse or parent, who are legally responsible for providing medical support

« Private or employer-sponsored disability insurance

« Private or employer-sponsored accident insurance

Insurance claims, jury awards, or legal settlements resulting from injuries

1 understand that DES and/or AHCCCS cannot collect more than the costs paid by DES and/or AHCCCS. | also understand that | must give information about other responsible parties and take any action needed to receive medical support. This includes establishing paternity of my children, unless | can prove good cause not to do so.

| understand that DES and/or AHCCCS and/or their contractors will release information to DES/Division of Child Support Services (DCSS), for a parent of a child who does not live in the home and the child has AHCCCS or private health insurance. DCSS may use this information to get a medical support order.

Assignment of Rights to Other Benefits for Cash Assistance

State and federal law (A.R.S. 46-407) provide that the legal rights to child support and spousal maintenance must be assigned to the State of Arizona for all persons receiving Cash Assistance. | understand:

« While receiving Cash Assistance, the State has the right to keep child support or spousal maintenance collections, including support or spousal maintenance that was owed while Cash Assistance was paid.

« When Cash Assistance stops, current support payments will be paid to me. The state may continue to collect any assigned back payments for support {assigned arrears) owed before and during the time | received Cash Assistance.

¢ Child support payments will be used to pay back the state for Cash Assistance paid to me or anyone on my application.

* The State will not keep more from my collected current support or assigned arrears than the total amount of Cash Assistance | received.

e Also the State will not keep any arrears that are more than the total amount of Cash Assistance | received.

Statement of Truth

By signing this application:

| agree | have read and understand the rules and penalties on page G. | have read and understand my rights and responsibilities, and provided Social Security numbers for each applicant that has a Social Security number.

¢ | agree | have read and understand the assignment or rights to other benefits for Medical Care above.

« | agree | have read and understand the assignment of support rights for Cash Assistance above.

¢ | agree that certain Nutrition Assistance and/or Cash Assistance household members will cooperate with the work programs, which includes looking for work and accepting training and/or a job. If anyone does not, or will not, look for work, attend training, or accept a job, my benefits may be reduced or stopped.

| agree to cooperate with Arizona or Federal personnel in the completion of a quality control review on my eligibility for benefits.

¢ In the event DES or its agents engage in child support enforcement activities involving me, | understand the Assistant Attorneys General and Deputy County Attorneys handling the cases represent DES, and not me or my children.

¢ If my child support case goes to court, | understand certain personal information contained in this application or my DES records may be released to the court and other parties to the case and becomes a public record document.

| also hereby agree to accept service of process by first class mail with regard to any paternity or child support proceeding initiated by DES and its agents.

¢ | understand that my records will be kept confidential and will only be released for purposes authorized by federal and state law.

| swear under penalty of perjury that the statements and documents provided about myself and persons in my home, that relates to my eligibility for benefits,

is true and correct to the best of my knowledge, and that | have not withheld any information. | swear under penalty of perjury that any photocopied information | have provided are the same as the original documents.

Signature of Applicant: Date: _ Signature of Spouse: Date: Signature of Other Adult in Household: Date: Signature of Authorized Representative: Date: Signature of Witness (if signed with mark): Date: Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013

FA-001 (10/13) Arizona Page 20

Attachment 2 AHCCCS DES Combined Application Do you need help with this application? Visit www.he

Voter Registration:

althearizonaplus.gov or call 1-855-HEA-PLUS (432-7587)

e $ & Tell us if any person over the age of 18 listed on this application would like to register to vote. If ‘Yes,’ we will mail a voter registration form.

You may also access a voter registration form at www.azsos.gov/election/voterinformation.htm. If you would like help filling out the voter

registration application form, we will help you. You may fill out the application form in private. Your answer to this question will not impact the programs you are eligible for.

Would any person on this application over the age of 18 like to register to vote? QO Yes OQ No O Already registered to vote

If YES is not checked, all persons over the age of 18 on this application will be considered to have decided not to register to vote at this time.

If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with:

State Election Director Secretary of State’s Office 1700 West Washington Phoenix, AZ 85007 602-542-8683

Submit the Application:

- e $ & Submit your completed and signed application along with any supporting documents to your local DES/FAA office.

If any additional information is needed, you will be contacted. You will be notified of our decision.

Thank you for applying!

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 FA-001 (10/13) Arizona Page 21

Attachment 3 HEAplus Medical Application

Online

for Medical

gram is Currently Frozen.

[Account Creation - User Agreement

[Additional Comment

|Account Creation - About You

identifying information, email, phone numbers and

[Home Address

[Malling Address

User Name and Password

Secret Questions

[Consent to Verify identity

identity Verification

[Account Summary

[Select Programs

[Notification of information Use and Privacy

|You and the Applying Household

Questions to establish whether the customer is applying for him/herself or his/her famity or houesehold or isa representative for another household

{identifying information about the primary applicant or

[Main Contact information ieanietaietenl [Contact Home Address [Contact Mailing Address [Other Contact information Email and phone numbers Persons Who Live With You who the applicant intends to include [This screen will display if there is more than one person . AllPersons Who ts Applying? ited on the applivation [Establishes which persons want benefits [This screen will display only when there are three or more All Persons Relationships individuals in the household to define relationships between, lother applicants. ‘All Persons, [Demographic Details [captures 008, SSN (optional if not applying i we Detail [Captures DOB, SSN, Citizenship, immigration Status and related Applying Persons |Demographic Details information, Collects the primary applicant's tax filing plans, status, and any Primary Applicant [Tax Household Information including fiving out of the lor whether he/she is a tax dependent (if appropriate) 5 (Collects all other persons’ tax filing plans, status, and any tote Feens x noushcntomaton san wl pe for pens oor apie bene out he lor whether each is 2 tax dependent (if appropriate) [This screen will display for any tax dependent of a filer that [Provides the option to supply information about the tax filer, All Other Persons /Additional Tax Household Information najthe dows not tive with which is necessary for eligibility for aSTC ‘AilPersons fiouschold Suramary “Applying Persons [Temporarily Away From Home ‘All Persons [Race and Ethnicity All Persons [American indian “Applying Persons Prior Medical (Prior Quarter Coverage) jo be for January 2018 [Appiving Persons [Arizona Resides

ISSN Verification Results

[This screen will display when one or more persons in the ‘has a SSN that coutd not be verified

[Allows correction of entries and retry of verification or collection of clarifying inf

Citizenship/immigration Summary

[This screen will display when one or more persons in the household has Citizenship/Immigration Status that could not] be verified

[Collects clarifying information

Transmittal Number: AZ 13-0005-MM

Arizona

Effective Date: October 1, 2013

Approval Date: September 30, 2013

1

Attachment 3 HEAplus Medical Application

Applying Femates (Medical) in the pregnancy range

Pregnancy

[This screen will display i there is one or more female i ages 9-60

[Tell Us About Parents (Absent Parent(s))

[This screen will display for if there is one or more applying children for whom one or both parents are not in the

|Caretaker Relative

[This screen will display if there is one or more children with no parents in the application, but one or more adult relative

Applying Persons incarceration ‘Applying Persons Medicare Covera ‘All Persons of Verified and Not Verified Display of as and) ‘AllPersons [Confirm income Found From Electronic Sources [Collects incidence of income for jobs not found be electronic All Persons lAdditional income information |sources, self employment and other income and determines lwhat additional pages are needed to collect income This screen will display for persons indicated to have Rental Al Persons, Rental Income Income on the Additional income information screen [This screen will display for persons indicated to have self- All Persons, Self-Employment income Income on the Additional income screen [This screen will display for persons indicated to have Income| All Persons, Income from Franchises, Corporations or LLC from Franchise, Corporation or LLC on the Additional Income Information screen This screen should ony display for persons who selected All Persons JOther income that they have Other income on the Income information screen ‘AllPersons [Expected income Changes [Collects reasonably predictable changes all Persons Mowsebold Hes to Income [This screen will display ifthe the household that attests to having no income ‘All Persons income Summary This screen will display if any applying person is not eligible ‘All Persons apart of the Tax Household lAltowed Deductions From income or Medical Assistance at this point. If everyone in the

lhouehold is eligible for Medical Assistance at this point, the system will skip this screen.

‘Applying Persons Not Already Found Eligible for Medicaid based on MAGI

lunable to Work Due to Disability

This screen will only display for persons who were not already eligible, DO NOT have EARNED income, and are greater than 18 years of age and are not already known to Ibe disabled based on data from electronic sources

Eligibility checked if potential linkage to ABD exists

Applying Persons Not Already Found Eligible tor Medicaid based on MAG!

|Working and Disabled

[This screen will only display for persons who were not already eligible, have EARNEO income, are between the ages| lof 16-65 and are not already known to be disabled based on Jdata from electronic sources

Eligibility checked if potential linkage to Medicaid Buy In {called Freedom to Work) exists

Transmittal Number: AZ 13-0005-MM

Arizona

Effective Date: October 1, 2013

Approval Date: September 30, 2013

2

Attachment 3 HEAplus Medical Application

Applying Persons Not Already Found Eligible for Medicaid based on MAGI

impairment Related Work Expenses/Blind Related Work Expenses

[This screen will only display for persons who were not lalready eligible, are verified or disabled or have

checked with applied

Medicare, and are working

Applying Persons Not Already Found Eligible for Medicaid

[This screen will only display for persons who were not

aaevee student already eligible, are verified or potentially disabled or have_|Eligibity checked with appropriate deductions applied Medicare and are > 22 and have Earned income ; This screen will only display for persons who were not ‘Applying Persons Not Already Found Eligible for Medicaid Ying sport already eligible, are verified or potentially disabled or have |Eligibility for ABD checked with deductions applied based on MAG! rene Persons) eligible or gible for Bay Wom [This sreen will display for persons who are eligible or

{Program Called Freedom to Work)

eligible for Freedom To Work.

All Persons

Etigibiity Summary and Information Verified and Not Verified

Display of summary as feedback and transition

Persons Eligible or Potentially Eligible for Medicaid

Persons Who Are Inpatient or Have Injury or lliness Due to Melpractice

La sreen will display if there are persons eligible or

[Question regarding inpatient is required by State Rule to indicate need for expedited processing, It is not necessary if bitty is real-time. Question

eligible for: pending

regarding potential source of TPL applies to any person chgible lor eligible for

Persons Eligible or Potentially Eligible for Medicaid

Other Health insurance

[This screen should only display for persons who selected

arenes Cligible or Eigible for Medicaid or « through TRICARE, VA, Peace Corps _| that they have insurance on the Insurance Information screen (previous screen) , ; ; [This i an optional question, buts important to the completion Persons Eligible or Eligible for Health Pian [isscreen wit play it appicants are potently ele lof their enrollment and avoid additional contact to ebtain their

for a Medicaid program

choice.

‘Applying Persons Potentially Eligible for APTC

Tax Fiter Other information

|This screen will display for persons who are potentially APTC eligible and 1) The tax filer who claimed the people didn’t provide an SSH

2) People who are potentially eligible for APTC but did not plan to file a tax return or were not indicated as dependents 3) People who are potentially eligible for APTC and ARE married but indicated that they do not plan to file as married fling a joint return.

Applying Persons Potentially Eligible for APTC

insurance Coverage through a Job

[This screen will display if there is one or more persons ally APTC eligible

‘Applying Persons Potentially Eligible for APTC who entered]

This screen will display for persons who are potentially APTC|

Other Heatth Coverage information on the previous Employer Health Coverage Options eligible and who entered Other Health Coverage screen (on the previous screen)

[This screen will display if there is one of more persons Applying Persons Potentially Eligible for APTC Renewal of Coverage in Future Years potentiathy eglote for APTC

Persons Eligible or Potentially Eligible for Medicaid

lOther Possible Benefits

Potential for access to pension or veterans administration

[Name an Authorized Representative

[Rights and Declarations - Signature

Etigibitity Results with Notices and/or Request for Verification

Vote

[Next steps

Next Steps as applicable to complete the eligibility and Jenrotlment process or access benefits

Transmittal Number: AZ 13-0005-MM

Arizona

Effective Date: October 1, 2013

Approval Date: September 30, 2013 3

Attachment 4 HEA Plus Online Flow Chart

HEAplus

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 Arizona 1

Attachment 4 HEA Plus Online Flow Chart

Dependent and/or Tax Filer to be added

rom Feanchise

Franchises Corporations or Employed ‘Sef Employed

sw Vested

Verified | i tzenship/ 5 {tmmiggation Verified :

Sage | Applicant between

HEAplus

{ iprandiacenc Bang

¥

less than Sindividuals {in Househ od

3.8 more Individuals ‘Applying chill for

Household whom both parents arenotin the

Hthere isone or more applying chs with no parents in the application, but ‘one o more adult rebst

household

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013

Arizona 2

Attachment 4 HEA Plus Online Flow Chart

‘One or morepersons not ligble for Medicaid based on MAG! Al applying persons are Not atready elite, no earned ligble lor Medicald income and> 18 asad on MAG! \ Conditions not met Etighle or other conditions not met Not almady elie, have earned income, age 26-65 Condigons Not YY Met Eligble or other conditions not met Fiot almady eligible, are verited ‘ cr potentialy disabled or have Eligible ot other ‘Medicare, and are working Not ateady elyitte, are veified orpowntally disabled or have Medicare

” 2

a

<

Elighle or potential etgible for + ‘Medicaid Buy n (Freedom To Work) (hon Eigibte 7 oo Eligble or potential ebpible for ‘ABD and/or Medicare Cost Sharing | Elighbitty Summ ary and Information Verified and « << i Veified es

Transmittal Number: AZ 13-0005-MM Arizona

Effective Date: October 1, 2013

Approval Date: September 30, 2013 3

Attachment 4 HEA Plus Online Flow Chart

No. eligible for Medicad, but

Llgbie or potentialy

elighle for Medicaid [Persons Who Ae inpatient orHave

| Pier erties Our to Malpractic.

a

Have insurance

r | Govern trom TRCARE, VA Penne cons

HEAplus

Am sana seminal

Not eligible or potentially digible i

Eligble or potentially eligble forMedicad

‘No onepotentialy ble tor APTC,

Potentiaty etgibie for APTC, but other

Potentiaty APTC eligibteand 1) The tax filer who claimed the people didn’t provide an SSN or

2)No plans to file taxes or to fie as married fling jointly, if

Health coverage canditions ‘not mat

Potentiaby APTC eligible ‘and haveother Heath coverage or access to coverage through 2 job

rewal of Coveragein Future Years

E Authorise a Repres

5 ‘wiedicalExgibity Results wth wast for verifications »

Next Steps, if any.

Condusion of Online

‘Account Transfer to FEM for Persons Potentially Eligible for = © APTC

Transmittal Number: AZ 13-0005-MM Arizona

Effective Date: October 1, 2013

Approval Date: September 30, 2013 4

Attachment 5 Key Differences HEA plus Key Differences Between Arizona’s Health-e-Arizona Plus Online Application and the CMS Document for the Health Insurance Marketplace Online Application

Health-e-Arizona Plus (www.healthearizonaplus.gov) will be Arizona’s integrated online application for Medicaid, CHIP, SNAP, and TANF Cash Assistance.

The Health-e-Arizona Plus online application was compared to the CMS document List of Items in the Online Application to Support Eligibility Determinations for Enrollment through the Health Insurance Marketplace and for Medicaid and the Children’s Health Insurance Program, 4/29/2013.

The following questions or data elements are collected on the CMS Health Insurance Marketplace online application, but are not on the Health-e-Arizona Plus online application:

Eligible Immigration Status

Because there is a requirement that a Medicaid applicant attest to their qualified immigration status, we cannot use the method outlined on the CMS single streamlined application. Not all legal statuses are Medicaid qualified immigration statuses. Therefore, we have listed the statuses for selection. We also provide the individual with the option to indicate they do not want to provide their immigration status. In this situation the person can only be eligible for emergency services.

Potential Disability Per the CMS document, disability related questions are asked of all applicants to ‘screen applicants for the potential for

Medicaid eligibility on a basis other than Modified Adjusted Gross Income (MAGI)’. Arizona asks potential disability questions only for those persons not otherwise confirmed to be disabled by electronic data sources and who are not already found eligible on the basis of MAGI.

Expedited Income

Per the CMS document, Section IX, describes a process ‘for tax filers whose income tax data indicates that the household income is above a certain amount so the household doesn’t need to answer questions about current/monthly income.’ Arizona will not use FTI and does not ask these questions.

American Indian/Alaska Native income questions

While income, including tribal income is collected, it is collected along with all other types of income, rather than broken out to a separate series of questions.

Discrepancies The CMS document includes 10 questions asked for an person where the electronic income data is not reasonably

compatible with the household income attestation. Arizona asks similar conditional questions when, upon reviewing the income data from electronic sources, indicates that the income data is not, or no longer, accurate. These questions and the rules associated with the answers to these questions are integral to Arizona’s verification plan and specifically Arizona’s rules for reasonable compatibility.

Special Enrollment Periods

We have not included special enrollment period questions for potential APTC eligible persons. The CMS paper Single Streamlined Application does not include these questions. Guidance also indicates that these are not required for alternative paper or online applications.

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 Arizona 1

Attachment 5 Key Differences HEA plus The following questions or data elements are collected on the Health-e-Arizona Plus online application, but are not on the CMS Health Insurance Marketplace online application:

Questions Related to All Medical Assistance Programs

Relationships

We ask for relationships of all persons in relation to other persons, not just in relationship to the primary applicant.

Immigration Status

Because there is a requirement that a Medicaid applicant attest to their qualified immigration status, we cannot use Because there is a requirement that a Medicaid applicant attest to their qualified immigration status, we cannot use the method outlined on the CMS single streamlined application. Not all legal statuses are Medicaid qualified immigration statuses. Therefore, we have listed the statuses for selection. We also provide the individual with the option to indicate they do not want to provide their immigration status. In this situation the person can only be eligible for emergency services.

Pregnancy

We ask for the expected due date in order to follow-up when no newborn has been reported by the expected due date.

Arizona resident

We ask this question to ensure that the individual considers him/herself a resident of Arizona. We also ask whether any applying person has moved to Arizona in the last month (or in the last four months if prior quarter coverage is needed).

Potential Benefits

We ask two questions to identify potential benefits for which the individual may be eligible. This includes through access to pension or veterans administration benefits

No Income

For households attesting to having ‘No Income’, we ask questions related how they are meeting their needs. Based on the answers to the questions, they may have income that is considered countable income (e.g., working odd jobs) that they had not previously entered. As indicated in our verification plan, we will perform post eligibility checks of data sources at 6 months to determine if the household is receiving income.

Questions Related to Medicaid and CHIP only

Inpatient State rule requires that we determine eligibility expedited timeframe for persons who are inpatient in a hospital

inpatient. This question is asked following eligibility determination, but before signature.

Injury or illness due to an accident or medical malpractice

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 Arizona 2

Attachment 5 Key Differences HEA plus We ask this question to identify potential sources of third party liability. This question is asked following eligibility determination, but before signature and is a federal requirement to pursue sources of third party liability

Health Plan Choice

We ask the individuals who are eligible for Medicaid or CHIP, or are eligible pending verification, to indicate their health plan choice. This is an optional question, but is important to the completion of their enrollment and avoid additional contact to obtain their choice. This question is asked following eligibility determination, but before signature.

Questions Related to CHIP Only (Note: Arizona’s CHIP program enrollment is frozen)

Chronic or Serious IlIness

If the CHIP program should reopen, we would ask if any CHIP eligible child, that has lost insurance in the last 90 days, has a chronic or serious illness. Arizona waives the 90 day bare period for an eligible child with a chronic or serious illness

Questions Related to ABD and Medicaid Buy In (i.e., Freedom to Work (FTW)) Programs

We ask the following questions only as needed for persons identified by data sources to be blind or disabled or otherwise not eligible for Medicaid or CHIP on the basis of MAGI.

Past receipt of Supplemental Security Income (SSI Cash) We ask this question to identify potential eligibility for certain ABD categories. Potential Disability

We ask if the person has a mental or physical disability that has or will keep him/her from working for at least 12 months to identify potential eligibility for the Aged, Blind, Disabled (ABD) program.

We ask if the person works and has a significant impairment to identify potential eligibility for the Freedom to Work program.

Impairment/Blind Related Work Expenses We collect eligible expenses only as applicable and needed to complete the eligibility determination Student Earned Income Exclusion

We collect student status for persons under age 22, disabled or potentially disabled, and having earned income, and otherwise over income for these programs in order to apply the student earned income exclusion.

Court-Ordered Child Support

We collect court-order child support for parents of a disabled or potentially disabled person who is otherwise over income for these programs, in order to apply the child support deduction

Transmittal Number: AZ 13-0005-MM Effective Date: October 1, 2013 Approval Date: September 30, 2013 Arizona 3

Table of Contents State/Territory Name: Arizona State Plan Amendment (SPA) #: 13-0007-MM This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages 5) Additional Attachments that are part of the state plan

nN

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

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

San Francisco Regional Office

90 Seventh Street, Suite 5-300 (5W)

San Francisco, CA 94103-6706

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

“oct 0 4 2013

Tom Betlach, Director

Arizona Health Care Cost Containment System 801 East Jefferson Street

Phoenix, AZ 85034

Dear Mr. Betlach:

Enclosed is an approved copy of Arizona’s State Plan Amendment (SPA) 13-0007-MM, which was submitted to CMS on August 30, 2013. SPA 13-0007-MM incorporates Mandatory MAGI-based eligibility groups into Arizona’s Medicaid State Plan in accordance with the Affordable Care Act. The effective date of the SPA is January 1, 2014.

Enclosed is a copy of the new State Plan pages to be incorporated within a separate section at the back of Arizona’s approved State plan:

$25, Pages 1-3

$28, Pages 1-2

$30, Page 1-5

$32, Pages 1-2

$33, Page 1

Attachment 1 - AZ MAGI Income Conversion Plan Numbers, Pages 1-2

In addition, enclosed is a summary of State Plan pages which are superseded by SPA-13-0007-MM and SPA 13-0008-MM, which should also be incorporated into a separate section in the front of the State Plan:

© 13-0007-MM and 13-0008-MM Superseding Pages of State Plan Material, Pages 1-2

If you have any questions, please contact Rebecca Bruno at (415)744-3677 or rebecca.bruno@cms.hhs.gov.

Sincerely,

/s/ Gloria Nagle, Ph.D., MPA Associate Regional Administrator Division of Medicaid & Children’s Health Operations

cc: Wakina Scott HeeYoung Ansell

AZ.0269.R00.00 - Jan 01, 2014 Page 1 of 2

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Arizona

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.

13-0007 |

Proposed Effective Date 01/01/2014 | (mm/dd/yy)

»

Federal Statute/Regulation Citation #825: 1902(a)(10)(A)(i)(1); 1931 (b) and (d); 42 CFR 435.110; #28: 1902(a)(10)(A)(@)(ID and (IV); 1902(@)(1

Federal Budget Impact Federal Fiscal Year Amount First Year [2014 $ 1263346500.00 Second Year [2015 | $2275564400.00 Subject of Amendment

SPA Action #1: MAGI-based Eligibility Groups (Mandatory)

Governor's Office Review © Governor's office reported no comment

&) Comments of Governor's office received Describe:

wi

® No reply received within 45 days of submittal @ Other, as specified

Describe:

Governor's Office is aware

Signature of State Agency Official

Submitted By: Theresa Gonzales Last Revision Date: Sep 27, 2013 Submit Date: . Aug 30, 2013

http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp 10/23/2013

DATE RECEIVED:

8/30/2013

DATE APPROVED:

October 4, 2013

PLAN APPROVED — ONE COPY ATTACHED

EFFECTIVE DATE OF APPROVED MATERIAL:

1/1/2014

SIGNATURE OF REGIONAL OFFICIAL:

TYPED NAME

Gloria Nagle

E

Associate Regional Administrator

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

13-0007-MM and 13-0008MM

STATE:

Arizona

Pages or sections of pages being superseded by $25, S28, S30, S51, S52, S53, S54, S57, and $14 and related pages or sections of pages being deleted as obsolete

State Plan Section Complete Pages Removed | Partial Pages Removed Page 1 Page 2, A.2.b Page 3 Page 2, A.2.c Page 3a Page 2a, A.3 Page 4 Page 9c, B.1 remove Page 4a “Caretaker relatives” Page 12 and “Pregnant women” Attachment 2.2-A Page 13 Page 20, B.14 Page 13a Page 25, C.4 Page 14 Page 14a Page 21 Page 23 Page 23b Supplement 1 to Attachment 2.2-A. Page 1 Page 3b Page 1, A.2.a(i) and Page lla (iii) . Page 19 Page 6 related to AFDC Page 19a recipients, pregnant _ Page 19b women, infants, and Attachment 2.6-A Page 21 children Page 7, l.a(1) and (2) Page 12, 5.e(2) and (3) Page 18, 5.e Page 25, 11.a(3) Supplement 1 to Attachment 2.6-A | Pages 1, 2, 3, 4 Supplement 2 to Attachment 2.6-A | Pages 1-5

Supplement 8a to Attachment 2.6-A

Page la, IV

Page la, V delete citations for AFDC- related groups

Supplement 12 to Attachment 2.6-A

Pages 1 - 4

Supplement 14 to Attachment 2.6-A

Page 1

Medicaid Eligibility

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

42, CFR 435.110

1902(a)(10)(A)G)@) 1931(b) and (d)

rl Parents and Other Caretaker Relatives - Parents and other caretaker relatives of dependent Children with household income at or below a standard established by the state.

The state attests that it operates this eligibility group in accordance with the following provisions: pe Pp [Mf] Individuals qualifying under this eligibility group must meet the following criteria:

a Are parents or other caretaker relatives (defined at 42 CFR 435.4), including pregnant women, of dependent children (defined at 42 CFR 435.4) under age 18. Spouses of parents and other caretaker relatives are also included.

The state elects the following options:

This eligibility group includes individuals who are parents or other caretakers of children who are 18 years old, provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training.

(] Options relating to the definition of caretaker relative (select any that apply): Options relating to the definition of dependent child (select the one that applies): The state elects to eliminate the requirement that a dependent child must be deprived of parental support or

@ care by reason of the death, physical or mental incapacity, or absence from the home or unemployment of at least one parent.

Oo The child must be deprived of parental support or care, but a less restrictive standard is used to measure unemployment of the parent (select the one that applies):

{M] Have household income at or below the standard established by the state.

rl MAGI-based income methodologies are used in calculating household income. Please refer as necessary to SLO MAGI- Based Income Methodologies, completed by the state.

[lm] Income standard used for this group

[i] Minimum income standard

The minimum income standard used for this group is the state's AFDC payment standard in effect as of May 1, 1988, * converted to MAGI-equivalent amounts by household size. The standard is described in $14 AFDC Income Standards.

The state certifies that it has submitted and received approval for its converted May 1, 1988 AFDC payment standard.

[BH] Maximum income standard

Transmittal Number: AZ-13-0007-MM Approval Date: October 4, 2013 Effective Date: January 1, 2014 $25 - Page 1 of 3

Medicaid Eligibility

The state certifies that it has submitted and received approval for its converted income standard(s) for parents and other caretaker relatives to MAGI-equivalent standards and the determination of the maximum income standard to be used for parents and other caretaker relatives under this eligibility group.

The state's maximum income standard for this eligibility group is:

® The state's effective income level for section 1931 families under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size.

O The state's effective income level for section 1931 families under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size.

The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 © demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size.

The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 © demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size.

Enter the amount of the maximum income standard:

@ A percentage of the federal poverty level: |106 %

re} The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent standard. The “ standard is described in $14 AFDC Income Standards.

The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage © increase in the Consumer Price Index for urban consumers (CPI-U) since such date, converted to a MAGI- equivalent standard. The standard is described in S14 AFDC Income Standards.

re} The state's TANF payment standard, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards.

© Other dollar amount [M] Income standard chosen: Indicate the state's income standard used for this eligibility group: © The minimum income standard @ The maximum income standard

The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage © increase in the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in $14 AFDC Income Standards.

© Another income standard in-between the minimum and maximum standards allowed

Transmittal Number: AZ-13-0007-MM Approval Date: October 4, 2013 Effective Date: January 1, 2014

$25 Page 2 of 3

Medicaid Eligibility

The amount of the income standard for this eligibility group is:

© A percentage of the federal poverty level: %

© A dollar amount [M There is no resource test for this eligibility group. [H] Presumptive Eligibility

The state covers individuals under this group when determined presumptively eligible-by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible.

OQYes @©No

PRA Disclosure Statement Accofding to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Transmittal Number: AZ-13-0007-MM Approval Date: October 4, 2013 Effective Date: January 1, 2014

$25 Page 3 of 3

Medicaid Eligibility

“" QMB Control Number 0938-1148 OMB Expirati

42, CFR 435.116 1902(a)(10)(A)(i)(IIT) and (FV) 1902(a)(10)(A)(di)(D), (IV) and (CX) 1931(b) and (d)

1920

[i] Pregnant Women - Women who are pregnant or post-partum, with household income at or below a standard established by the state. [Z] The state attests that it operates this eligibility group in accordance with the following provisions: [ii] Individuals qualifying under this eligibility group must be pregnant or post-partum, as defined in 42 CFR 435.4.

Pregnant women in the last trimester of their pregnancy without dependent children are eligible for full benefits under this group in accordance with section 1931 of the Act, if they meet the income standard for state plan Parents and Other Caretaker Relatives at 42 CFR 435.110.

@ Yes © No

a MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI-Based Income Methodologies, completed by the state.

[i] Income standard used for this group [#] Minimum income standard (Once entered and approved by CMS, the minimum income standard cannot be changed.)

The state had.an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for pregnant women, or as of July 1, 1989, had authorizing legislation to do so.

© Yes @©No The minimum income standard for this eligibility group is 133% FPL.

[fl Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for pregnant women to MAGI-equivalent standards and the determination of the maximum income standard to be used for pregnant women under this eligibility group.

The state's maximum income standard for this eligibility group is:

The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(IM) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10)

© (A)(ii)() (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)Gi)CV) (institutionalized pregnant women) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGIT-equivalent percent of FPL.

Transmittal Number: AZ-13-0007-MM Approval Date: October 4, 2013 Effective Date: January 1, 2014 $28

Page 1 of 2

Medicaid Eligibility

The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(X) (optional poverty level-related pregnant women), 1902(a)(10)

© (A)(ii)(1) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(Gi)(TV) (institutionalized pregnant women) in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

O The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

re) The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

@ 185% FPL [if Income standard chosen Indicate the state's income standard used for this eligibility group: © The minimum income standard © The maximum income standard

® Another income standard in-between the minimum and maximum standards allowed.

The amount of the income standard for this eligibility group is: }156 % FPL

[ll There is no resource test for this eligibility group. [i Benefits for individuals in this eligibility group consist of the following: @ All pregnant women eligible under this group receive full Medicaid coverage under this state plan.

ra} Pregnant women whose income exceeds the income limit specified below for full coverage of pregnant women receive only pregnancy-related services.

[i] Presumptive Eligibility

The state covers ambulatory prenatal care for individuals under this group when determined presumptively eligible by a qualified entity.

© Yes @No

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Transmittal Number: AZ-13-0007-MM Approval Date: October 4, 2013 Effective Date: January 1, 2014 $28

Page 2 of 2

Medicaid Eligibility

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

42 CFR 435.118

1902(a)(10)(A)()(IHD, (IV), (V1) and (VI) 1902(a)(10)(A)(i)(IV) and (IX) 1931(b) and (d)

a Infants and Children under Age 19 - Infants and children under age 19 with household income at or below standards established by the state based on age group. ,

The state attests that it operates this eligibility group in accordance with the following provisions: [H] Children qualifying under this eligibility group must meet the following criteria: [IM] Are under age 19 [lH] Have household income at or below the standard established by the state.

wa MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state.

[M] Income standard used for infants under age one [Minimum income standard

The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for infants under age one, or as of July 1, 1989, had authorizing legislation to do so.

© Yes ©@)No

The minimum income standard for infants under age one is 133% FPL.

[H| Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for infants under age one to MAGI-equivalent standards and the determination of the maximum income standard to be used for infants under age one.

The state's maximum income standard for this age group is:

The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(IID) (qualified children), 1902(a)(10)(A)(i)(@'V) (mandatory poverty level-related

©) infants), 1902(a)(10)(A)(ii)(X) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(TV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL.

Transmittal Number: AZ-13-0007-MM Approval Date: October 4, 2013 Effective Date: January 1, 2014 $30

Page 1 of 5

Medicaid Eligibility

The state's highest effective income level for coverage of infants under age one undef sections 1931 (low-income families), 1902(a)(10)(A)()() (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related

© infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGIT-equivalent percent of FPL.

Oo The state's effective income level for any population of infants under age one under a Medicaid 1115

demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

fe) The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

@® 185% FPL

[i] Income standard chosen The state's income standard used for infants under age one is:

© The maximum income standard

If not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)()(IE) (qualified children), 1902(a)(10)

@® (A)(DAV) (mandatory poverty level-related infants), 1902(a)(10)(A)Gi)(EX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(II1) (qualified children), 1902(a)(10)

ie (A)()QV) (mandatory poverty level-related infants), 1902(a)(10)(A)(i)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

0 Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010.

The amount of the income standard for infants under one is: |147 % FPL

[MH] Income standard for children age one through age five, inclusive

[=] Minimum income standard Transmittal Number: AZ-13-0007-MM Approval Date: October 4, 2013 Effective Date: January 1, 2014

$30 Page 2 of 5

Medicaid Eligibility

The minimum income standard used for this age group is 133% FPL. [| Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for children age one through five to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age one through five.

The state's maximum income standard for children age one through five is:

The state's highest effective income level for coverage of children age one through five under sections 1931 (low- @ income families), 1902(a)(10)(A)(i)(II1) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- ~ related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

The state's highest effective income level for coverage of children age one through five under sections 1931 (low-

O income families), 1902(a)(10)(A)(i)(II) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

O The state's effective income level for any population of children age one through five under a Medicaid 1115 “ demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

re} The state's effective income level for any population of children age one through five under a Medicaid 1115 ” demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

Enter the amount of the maximum income standard: }141 % FPL

[M] Income standard chosen The state's income standard used for children age one through five is:

@ The maximum income standard

If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(M) (qualified children),

© 1902(a)(10)(A)(@(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(ID) (qualified children),

© 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

Transmittal Number: AZ-13-0007-MM Approval Date: October 4, 2013 Effective Date: January 1, 2014 $30

Page 3 of 5

Medicaid Eligibility

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children

© age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children

© age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. 7

Another income standard in-between the minimum and maximum standards allowed, provided it is higher than “”. the effective income standard for this age group in the state plan as of March 23, 2010. [M]_ Income standard for children age six through age eighteen, inclusive [| Minimum income standard The minimum income standard used for this age group is 133% FPL.

[Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for children age six through eighteen to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age six through age eighteen.

The state's maximum income standard for children age.six through eighteen is:

The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(II1) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty

” Jevel-related children age six through eighteen) and 1902(a)(10)(A)(i)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

The state's highest effective income level for coverage of children age six through eighteen under sections 1931 O (low-income families), 1902(a)(10)(A)(i)(IM) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty

level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect

under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

re} The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 ~ demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

fe} The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 "*“ demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

© 133% FPL

[lM] Income standard chosen

The state's income standard used for children age six through eighteen is:

transmittal Number: AZ-' I Approval Date: October 4, 2013 Effective Date: January 7, 2074 $30

Page 4 of 5

Medicaid Eligibility

©@ The maximum income standard

If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)()(II) (qualified children),

© 1902(a)(10)(A)()(VM) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)CL) (qualified children), 1902(a)(10)(A)(@)(VI) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL.

re Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010.

[i] There is no resource test for this eligibility group. [Ml Presumptive Eligibility The state covers children when determined presumptively eligible by a qualified entity.

© Yes @No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number: The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data - resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Transmittal Number: AZ-13-0007-MM Approval Date: October 4, 2013 Effective Date: January 1, 2014 , $30

Page 5 of S

Medicaid Eligibility

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

i

1902(a)(10)(A)(@)(VIN) 42 CFR 435.119

The state covers the Adult Group as described at 42 CFR 435.119. @ Yes ©No [Ml Adult Group - Non-pregnant individuals age 19 through 64, not otherwise mandatorily eligible, with income at or below 133% FPL. The state attests that it operates this eligibility group in accordance with the following provisions: [Ml Individuals qualifying under this eligibility group must meet the following criteria: [lf] Have attained age 19 but not age 65. [Ml Are not pregnant.

[Hf Are not entitled to or erirolled for Part A or B Medicare benefits.

wl Are not otherwise eligible for and enrolled for mandatory coverage under the state plan in accordance with 42 CFR 435, subpart B.

Note: In 209(b) states, individuals receiving SSI or deemed to be receiving SSI who do not qualify for mandatory Medicaid eligibility due to more restrictive requirements may qualify for this eligibility group if otherwise eligible.

[Hf] Have household income at or below 133% FPL.

rr MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI-Based Income Methodologies, completed by the state.

[ll There is no resource test for this eligibility group.

Parents or other caretaker relatives living with a child under the age specified below are not covered unless the child is [il receiving benefits under Medicaid, CHIP or through the Exchange, or otherwise enrolled in minimum essential coverage, as defined in 42 CFR 435.4.

@ Under age 19, or OA higher age of children, if any, covered under 42 CFR 435.222 on March 23, 2010: {| Presumptive Eligibility

The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible.

© Yes @No

PRA Disclosure Statement

Transmittal Number: AZ-13-0007-MM Approval Date: October 4, 2013 Effective Date: January 1, 2014 $32

Page 1 of 2

Medicaid 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 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Transmittal Number: AZ-13-0007-MM Approval Date: October 4, 2013 Effective Date: January 1, 2014 $32

Page 2 of 2

Medicaid Eligibility

‘” OMB Control Number 0938-1148 OMB Expiration d

42 CFR 435.150 1902(a)(10)(A)G)(EX)

wi Former Foster Care Children - Individuals under the age of 26, not otherwise mandatorily eligible, who were on Medicaid and in foster care when they turned age 18 or aged out of foster care. °

[7] The state attests that it operates this eligibility group under the following provisions:

[i Individuals qualifying under this eligibility group must meet the following criteria: [i] Are under age 26.

i Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. ‘

Were in foster care under the responsibility of the state or Tribe and were enrolled in Medicaid under the state's state [lf plan or 1115 demonstration when they turned 18 or at the time of aging out of that state's or Tribe's foster care program.

The state elects to cover children who were in foster care and on Medicaid in any state at the time they turned 18 or aged out of the foster care system.

OyYes @No

The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR’ 435.118) eligibility groups when determined presumptively eligible.

©yYes @No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Transmittal Number: AZ-13-0007-MM Approval Date: October 4, 2013 Effective Date: January 1, 2014 $33

Page 1 of 1

Attachment 1 - AZ MAGI Income Conversion Plan Numbers

TABLE 1: Arizona MAGI income conversion Plan as submitted ‘to CMS on 6/11/13

Coverage Category | SIPP Time Sampling | Net Income Standard | Income band used | Converted Standard Results Period (yes/no) in conversion used (Alternative (Yes/No) Method states to fill out only if applicable) Parents and other caretaker relatives January, . No April, July No 100% FPL 75% - 100% FPL 106% FPL (mandatory under Section 2012 1931) Pregnant women, January, pregnancy only coverage No April, July No 150% FPL 125% - 150% FPL 156% FPL 2012 Children under age 1 January, No April, July No 140% FPL 115% - 140% FPL 147% FPL 2012 Children ages 1 to 5 January, No April, July No 133% FPL 108% - 133% FPL 141% FPL 2012 Children ages 6 to 18 January, No April, July No 100% FPL 75% - 100% 104% FPL 2012 Family planning services January, No April, July No 150% FPL 125% - 150% FPL 156% FPL 2012

Transmittal Number: AZ-13-0007-MM

Approval Date: October 4, 2013

Effective Date: January 1, 2014

1

Attachment 1 - AZ MAGI Income Conversion Plan Numbers

Coverage Category | SIPP Time Sampling | Net Income Standard | Income band used | Converted Standard Results Period (yes/no) in conversion. . used (Alternative (Yes/No) Method states to fill out only if applicable) Other Medicaid section January, 1115 demonstration (¢.g., No April, July No 100% FPL 75% - 100% FPL 105% FPL childless adults). Insert 2012 more rows if needed. Fixed dollar standards % FPL by family size Fixed dollar standards Family size Family size 1 1 1 2, $233, 2__0-19% 2__ $247 = __ $312 AFDC payment standard January, 3 $238 3 {= 1% 3 3u 5/1/1988 No April, Jaly No 5 $412 5 019% 5 $441 2012 6___$472 6__0=19% 6_$505 7 7___0-19% 7. Add-on for additional Add-on for additional Add-on for additional family members if family members if family members if relevant__$60 relevant_0— 19% relevant_$64 Fixed dollar standards % FPL by family size Fixed dollar standards Family size Family size 1 $204 1 0-22% 1__ $214 5 2 $275 2 0-22% 2___ $289 7 january, 3 $347, 3 0 - 22% 3__ $365 a dial standard No April, July | No | 4__$418 40-22% 4 $440, 2012 5 $489 5 0-22% 5__$516 6 $561 6. 0 -~ 22% 6__ $591, T____ $632 T__0-22% T__$667 Add-on for additional Add-on for additional Add-on for additional family members if family members if family members if televant__ $72 televant_0— 22% televant_$76

Transmittal Number: AZ-13-0007-MM

Approval Date: October 4, 2013

Effective Date: January 1, 2014

2

Table of Contents State/Territory Name: Arizona State Plan Amendment (SPA) #: 13-0008-MM This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services as rn San Francisco Regional Office

“wi 90 Seventh Street, Suite 5-300 (6W) ‘a San Francisco, CA 94103-6706

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATION. =~ CENTERS FOR MEDICARE & MEDICAID SERVICES

Tom Betlach, Director ‘oct 0.4 20 Arizona Health Care Cost Containment System

801 East Jefferson Street

Phoenix, AZ 85034

Dear Mr. Betlach:

Enclosed is an approved copy of Arizona’s State Plan Amendment (SPA) 13-0008-MM, which was submitted to CMS on August 30, 2013. SPA 13-0008-MM incorporates Optional MAGI-based eligibility groups into Arizona’s Medicaid State Plan in accordance with the Affordable Care Act. The effective date of the SPA is January 1, 2014.

Enclosed is a copy of the new State Plan pages to be incorporated within a separate section at the back of Arizona’s approved State plan:

S14, Pages 1-5 S50, Page 1 S51, Page 1 $52, Page 1 $53, Page 1 S54, Page 1 S55, Page 1 S57, Pages 1-2 S59, Page 1

Please note, that with the approval of AZ 13-0007-MM, the AZ MAGI Income Conversion Plan Numbers document and the 13-0007-MM and 13-0008-MM Superseding Pages of State Plan Material document, which also pertains to this SPA, have already been incorporated into the State Plan.

If you have any questions, please contact Rebecca Bruno at (415)744-3677, or Rebecca.bruno@cms.hhs.gov.

Sincerely,

/s/ Gloria Nagle, Ph.D., MPA Associate Regional Administrator Division of Medicaid & Children’s Health Operations

cc: Wakina Scott HeeYoung Ansell

AZ.0270.R00.00 - Jan 01, 2014

Page 1 of 2

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Arizona Transmittal Number:

Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered.

Proposed Effective Date : 01/01/2014 | (mm/dd/yyyy)

Federal Statute/Regulation Citation

#$50: 1902(a)(10)(A)Gi)(XX); 1902(hh); 42 CFR 435.218; #851: 1902(a)(10)(A)(ii)(1); 42 CFR 435.220; #852: Federal Budget Impact Federal Fiscal Year Amount First Year | | $0.00 | Second Year (2015 $0.00

Subject of Amendment SPA Action #1: MAGI-based Eligibility Groups (Optional)

Governor's Office Review

©) Governor's office reported no comment

© Comments of Governor's office received Describe:

© No reply received within 45 days of submittal @ Other, as specified Describe:

The Governor's Office is aware

Signature of State Agency Official

Submitted By: Theresa Gonzales Last Revision Date: Sep 27, 2013 Submit Date: Aug 30, 2013

http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp 10/23/2013

DATE RECEIVED:

8/30/2013

DATE APPROVED:

October 4, 2013

PLAN APPROVED — ONE COPY ATTACHED

EFFECTIVE DATE OF APPROVED MATERIAL:

1/1/2014

SIGNATURE OF REGIONAL OFFICIAL:

TYPED NAME

Gloria Nagle

..۩6=6hLdh

Associate Regional Administrator

Medicaid Eligibility

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

Enter the AFDC Standards below. All states must enter:

MAGI-equivalent AFDC Payment Standard in Effect As of May 1, 1988 and AFDC Payment Standard in Effect As of July 16, 1996

Entry of other standards is optional. ne

The standard is as follows:

© Statewide standard

© Standard varies by region

© Standard varies by living arrangement

© Standard varies in some other way

Additional incremental amount

Household size | Standard ($) @ Yes ONo : Increment amount $ |64 247 312 376 441 505

The dollar amounts increase automatically each year

© Yes @No

The standard is as follows:

Transmittal Number: AZ 13-0008-MM Approval Date: October 4, 2013 Effective Date: January 1, 2014

S14 Page 1 of 5

Medicaid Eligibility

© Statewide standard CO Standard varies by region

© Standard varies by living arrangement

© Standard varies in some other way

Additional incremental amount _

Household size | Standard ($) @ Yes ONo :

204

Increment amount $ |72

275

347

418

489

561

632

703

The dollar amounts increase automatically each year

© Yes @No

The standard is as follows:

© Statewide standard CO Standard varies by region © Standard varies by living arrangement

© Standard varies in some other way

Transmittal Number: AZ 13-0008-MM Approval Date: October 4, 2013 - Effective Date: January 1, 2014 $14 Page 2 of 5

Medicaid Eligibility

Household size

Standard ($)

214

289

365

440

516