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 SEP 2 9 2009 Toby Douglas Chief Deputy Director of Health Care Programs California Department of Health Care Services 1501 Capitol Avenue, MS 0002 P.O. Box 997413 Sacramento, CA 95899-7413 Dear Mr. Douglas: Enclosed is an approved copy ofCalifornia State plan amendment (SPA) No. 09-006, effective October 1,2009. This SPA implements Section 19150) authority for self-directed personal assistance services to transition Medi-Cal beneficiaries currently receiving services through the In-Home Supportive Services (IHSS) Plus Section 1115 Demonstration project which expires on September 30, 2009. This SPA adds the following pages to the State plan: • Pages 1ge and 20d to Section 3 - Services • Page 13 to Attachment 3.1 A • Page 11 to Attachment 3.1 B • Supplement 5 to Attachment 3.lA and B • Pages 26-28 to Section 4.19B If you have any questions please contact Michelle Baldi at (415) 744-3656. Sincerely, i--e("Gloria Nagle, Ph.D., M.P.A. Associate Regional Administrator Division ofMedicaid & Children's Health Operations cc: Dina Kokkos-Gonzales, California Department of Health Care Services Jeannie Smalley, California Department ofHealth Care Services Kathryn Waje, California Department of Health Care Services Christopher Thompson, Center for Medicaid and State Operations Carrie Smith, c.enter for Medicaid and State Operations

OMS Approved 0938-1024 1ge STATE/TERRITORY: CALIFORNIA Citation 3.1 (a)C I) Amount, Duration, and Scope of Services: Categorically Needy (Continued) 19150) X (xiii) Self-Directed Personal Assistance Services, as described and limited in Supplement.2- to Attachment 3.1-A. ATTACHMENT 3.I-A identifies the medical and remedial services provided to the categorically needy. SEP 292009 TN No. 09-006 Approval Date: Effective date: October I, 2009 Supersedes TN No. None

OMB Approved 0938-1024 20d STATE/TERRITORY: CALIFORNIA Citation 3.1 (a)(2) Amount, Duration, and Scope of Services: Medically Needy (Continued) 19150) X (xiii) Self-Directed Personal Assistance Services, as described and limited in Supplement _5_ to Attachment 3.1-8. ATTACHMENT 3.1-B identifies medical and remedial services provided to each covered group of the medically needy. TN No. 09-006 Approval Date: SEP 292009 Effective date: October 1, 2009 Supersedes TN No. None

OMS Approved 0938-1024 Attachment 3.1 -A Page 13 State Plan Under Title XIX ofthe Social Security Act STATE/TERRITORY: CALIFORNIA 28. l Self-Directed Personal Assistance Services, as described in Supplement _5_ to Attachment 3.1-A. X Election of Self-Directed Personal Assistance Services: By virtue of this submittal, the State elects Self-Directed Personal Assistance Services as a State Plan service delivery option. No election of Self-Directed Personal Assistance Services: By virtue ofthis submittal, the State elects not to add Self-Directed Personal Assistance Services as a State Plan service delivery option. TN No. 09-006 Approval Date:SEP 29 2009 Effective date: October I, 2009 Supersedes TN No. None

OMS Approved 0938-1024 Attachmenf3.l -B Page 11 State Plan Under Title XIX ofthe Social Security Act STATE/TERRITORY: CALIFORNIA 27. l Self-Directed Personal Assistance Services, as described in Supplement -lL to Attachment 3.1-B. l Election of Self-Directed Personal Assistance Services: By virtue of this submittal, the State elects Self-Directed Personal Assistance Services as a State Plan service delivery option. No election of Self-Directed Personal Assistance Services: By virtue ofthis submittal, the State elects not to add Self-Directed Personal Assistance Services as a State Plan service delivery option. TN No. 09-006 Approval Date: SEP 29 2009 Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement ~ to Attachment 3.1-A Page 1 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA Notwithstanding anything else in this State Plan provision, the coverage will be subject to such other requirements that are promulgated by CMS through interpretive issuance or final regulation. 1. Eligibility The State determines eligibility for Self-Directed Personal Assistance Services: A. X In the same manner as eligibility is determined for traditional State Plan personal care services, described in Item 26 ofthe Medicaid State Plan. B. __In the same manner as eligibility is determined for services provided through a 1915(c) Home and Community-Based Services Waiver. 11. Service Package The State elects to have the following included as Self-Directed Personal Assistance Services: A. .1l. State Plan Personal Care and Related Services, to be self-directed by individuals eligible under the State Plan. B. __ Services included in the following section 1915(c) Home and Community­ Based Services waiver(s) to be self directed by individuals eligible under the waiver(s). The State assures that all services in the impacted waiver(s) will continue to be provided regardless of service delivery model. Please list waiver names and services to be included. 111. Payment Methodology A. X The State will use the same payment methodology for individuals self- directing their PAS under section 1915(j) than that approved for State plan personal care services or for section 1915(c) Home and Community-Based waiver services. TN No. 09-006 Approval Date: SEP ? 9 ?n09 Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement ~ to Attachment 3.1-A Page 2 State Plan Under Title XIX of the Social Security Act STATEITERRITORY: CALIFORNIA B. __The State will use a different payment methodology for individuals self­ directing their PAS under section 19150) than that approved for State plan personal care services or for section 1915(c) Home and Community-Based waiver services. Amended Attachment 4.19-B page(s) are attached. IV. Use of Cash A. X The State elects to disburse cash prospectively to participants self- directing personal assistance services. The State assures that all Internal Revenue Service (IRS) requirements regarding payroll/tax filing functions will be followed, including when participants perform the payroll/tax filing functions themselves. Only for participants receiving the following options: • Restaurant Meal Allowance (please see Permissible Purchases, section xv.); and • Severely impaired recipients who have chosen the Cash Option. o California regulation limits the receipt of Advance Pay (Cash Option) to severely impaired recipients. o California Department of Social Services (CDSS), Manual of Policies and Procedures (MPP) 30-701(s) (1) Severely Impaired Individual means a recipient with a total assessed need...for 20 hours or more per week of service in one or more of the following areas: (A) Any personal care service listed in Section 30-757.14. (B) Preparation ofmeals. (C) Meal cleanup when preparation ofmeals and consumption offood (feeding) are required. (D) Paramedical services. B. The State elects not to disburse cash prospectively to participants self- directing personal assistance services. TN No. 09-006 Approval Date: SEP 2 9 2009 Effective date: October 1, 2009 Supersedes TN No. None

OMS Approved 0938-1024 Supplement ~ to Attachment 3.1-A Page 3 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA v. Voluntary Disenrollment The State will provide the following safeguards to ensure continuity of services and assure participant health and welfare during the period oftransition between self­ directed and traditional service delivery models. There will be no break in service for those voluntary disenrolling and transitioning to State Plan Personal Care Services, thus assuring participant health and welfare. Participants or their authorized/legal representative(s) may initiate disenrollment at any time by contacting the county social services office. If a voluntary disenrollment is received by mail, or is initiated by the participant's authorized/legal representative, the county will contact the participant to ensure the disenrollment request represents the wishes of the participant. The Case Management Information and Payrolling System (CMIPS) updates eligibility status changes immediately upon data entry. Vi. Involuntary Disenrollment A. The circumstances under which a participant may be involuntarily disenrolled from self-directing personal assistance services, and returned to the traditional service delivery model are noted below. Circumstances for involuntary disenrollment, which may be initiated by the county, include but are not limited to the following: • Participant moved out of State; • Participant no longer resides in a dwelling that meets the Federal requirement under Section 19150)(1); • Participant has lost Medi-Cal eligibility; • Participant no longer requires personal care services or assistance with Activities ofDaily Living (ADL) and/or Instrumental Activities ofDaily Living (lADL); • Participant is no longer in the population served under the State Plan option; TN No. 09-006 Approval Date: SEP 2 9 2009 _ Effective date: October 1, 2009 Supersedes TN No. None

OM8 Approved 0938-1024 Supplement _5_ to Attachment 3.I-A Page 4 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA • Participant is institutionalized; • Participant cannot comply with the 19150) program requirements. B. The State will provide the following safeguards to ensure continuity of services and assure participant health and welfare during the period of transition between self-directed and traditional service delivery models. The State will provide all appropriate safeguards available to ensure continuity of services. For example, if a participant cannot comply with the program requirements due to mental or physical inability to self-direct (e.g. the participant is no longer capable of managing their cash option funds), the county social worker/case manager would first work with the participant to assist them in proper management of their funds in order to prevent involuntary disenrollment. If the participant is still unable to properly manage their funds, and the cash option is their only link to this State Plan Option, then the county social worker/case manager would initiate disenrollment and transition the participant to the traditional service delivery model. Once this transition is initiated, CMIPS updates eligibility status changes immediately upon data entry. vii. Participant Living Arrangement Any additional restrictions on participant living arrangements, other than homes or property owned, operated, or controlled by a provider of services, not related by blood or marriage to the participant are noted below. No additional restrictions on participant living arrangements. Vlll. Geographic Limitations and Comparability A. l The State elects to provide self-directed personal assistance services on a statewide basis. B. The State elects to provide self-directed personal assistance services on a targeted geographic basis. Please describe: _ TN No. 09-006 Approval Date: SEP , 9 7009 _ Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement ~ to Attachment 3.I-A Page 5 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA C. _ The State elects to provide self-directed personal assistance services to all eligible populations. D. X The State elects to provide self-directed personal assistance services to targeted populations. Please describe: This program option is only for those participants that: • have chosen Restaurant Meal Allowance; and/or • are severely impaired and have chosen the Advanced Pay (cash option); and/or • have chosen a legally liable relative provider. E. l The State elects to provide self-directed personal assistance services to an unlimited number of participants. F. __ The State elects to provide self-directed personal assistance services to __ (insert number of) participants, at any given time. IX. Assurances A. The State assures that there are traditional services, comparable in amount, duration, and scope, to self-directed personal assistance services. B. The State assures that there are necessary safeguards in place to protect the health and welfare of individuals provided services under this State Plan Option, and to assure financial accountability for funds expended for self-directed personal assistance services. C. The State assures that an evaluation will be perfonned of participants' need for personal assistance services for individuals who meet the following requirements: 1. Are entitled to medical assistance for personal care services under the Medicaid State Plan; or 11. Are entitled to and are receiving home and community-based services under a section 1915(c) waiver; or lll. May require self-directed personal assistance services; or TN No. 09-006 Approval Date: SEP 29 2009 Effective date: October 1,2009 Supersedes TN No. None

OM8 Approved 0938-1024 Supplement _5_ to Attachment 3.I-A Page 6 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA iv. May be eligible for self-directed personal assistance services. D. The State assures that individuals are informed of all options for receiving self­ directed and/or traditional State Plan personal care services or personal assistance services provided under a section 1915(c) waiver, including information about self-direction opportunities that is sufficient to inform decision-making about the election of self-direction and provided on a timely basis to individuals or their representatives. E. The State assures that individuals will be provided with a support system meeting the following criteria: 1. Appropriately assesses and counsels individuals prior to enrollment; 11. Provides appropriate counseling, information, training, and assistance to ensure that participants are able to manage their services and budgets; 111. Offers additional counseling, information, training, or assistance, including financial management services: 1. At the request ofthe participant for any reason; or 2. When the State has determined the participant is not effectively managing their services identified in their service plans or budgets. F. The State assures that an annual report will be provided to CMS on the number of individuals served through this State Plan Option and total expenditures on their behalf, in the aggregate. G. The State assures that an evaluation will be provided to CMS every 3 years, describing the overall impact ofthis State Plan Option on the health and welfare ofparticipating individuals, compared to individuals not self-directing their personal assistance services. H. The State assures that the provisions ofsection 1902(a)(27) of the Social Security Act, and Federal regulations 42 CFR 431.107, governing provider agreements, are met. TN No. 09-006 Approval Date: SEP 292009 _ Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement ---..L to Attachment 3.I-A Page 7 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA I. The State assures that a service plan and service budget will be developed for each individual receiving self-directed PAS. These are developed based on the assessment of needs. J. The State assures that the methodology used to establish service budgets will meet the following criteria: 1. Objective and evidence based, utilizing valid, reliable cost data. 11. Applied consistently to participants. 111. Open for public inspection. IV. Includes a calculation of the expected cost ofthe self-directed PAS and supports ifthose services and supports were not self-directed. v. Includes a process for any limits placed on self-directed services and supports and the basislbases for the limits. VI. Includes any adjustments that will be allowed and the basislbases for the adjustments. V11. Includes procedures to safeguard participants when the amount of the limit on services is insufficient to meet a participant's needs. V11l. Includes a method of notifying participants ofthe amount of any limit that applies to a participant's self-directed PAS and supports. IX. Does not restrict access to other medically necessary care and services furnished under the plan and approved by the State but not included in the budget. x. Service Plan The State has the following safeguards in place, to permit entities providing other Medicaid State Plan services to be responsible for developing the self-directed personal assistance services service plan, to assure that the service provider's influence on the planning process is fully disclosed to the participant and that procedures are in place to mitigate that influence. Entities or individuals that have responsibility to develop service plans do not provide other direct services to participants. TN No. 09-006 Approval Date: SEP 2 9 2009 Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement ~ to Attachment 3.I-A Page 8 State Plan Under Title XIX ofthe Social Security Act STATE/TERRITORY: CALIFORNIA Xl. Quality Assurance and Improvement Plan A. The State's quality assurance and improvement plan is described below, including: 1. How it will conduct activities of discovery, remediation, and quality improvement in order to ascertain whether the program meets assurances, corrects shortcomings, and pursues opportunities for improvement; and 11. The system performance measures, outcome measures, and satisfaction measures that the State will monitor and evaluate. The following describes the system-wide quality assurance and improvement plan CDSS, in conjunction with the 58 counties, has that includes the activities of discovery, remediation and quality improvement. This plan will help to ascertain whether the program meets assurances, corrects shortcomings, and pursues opportunities for improvement to ensure the health and welfare of our self­ directed PAS recipients. County Each county must maintain an annual Quality Assurance/ Quality Improvement (QAlQI) plan that specifies the procedures for addressing discovery, remediation, and overall system improvement. The procedures must provide for reporting findings to program staff and supervisors for remediation. County QA staff collect data during program monitoring. County staff also review reports generated by the CDSS CMIPS and data provided by outside entities (e.g. State Controller's Office). The staff analysis of compiled data is used for annual plan development, refinement and improvement activities. The procedures outlined in the annual QAlQI plans are designed to assure the timeliness and effectiveness of the county's actions to protect participant health and welfare, and financial accountability. TN No. 09-006 Approval Date: SEP 292009 _ Effective date: October I, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement --L to Attachment 3.I-A Page 9 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA Discovery The focus of discovery is to monitor the participants' quality of services and supports through the collection ofdata. The data gathered is used to assess the ongoing implementation of the program and identify strengths as well as opportunities for improvement. County QA activities include: • Home visits; • Routine case file reviews; • Targeted case review studies; • Scheduled reviews of supportive services; • Identification of potential sources ofthird-party liability; and • Monitoring of supportive service delivery to detect and prevent fraud. Routine case file reviews conducted by county QA staff are the primary monitoring component of data collection. Counties are required to review a certain number of cases and conduct home visits based on the number of employees they have allocated for QA activities. Each full-time county QA staff must complete case file reviews and conduct home visits annually. The case reviews are designed to confirm that participant needs are correctly assessed and that case files contain appropriate documentation. Moreover, critical incident information discovered during a case file review is analyzed to ensure that proper resolution took place and that the relevant information was reported. Critical incident information is documented on the Quarterly Report form, SOC 824. The SOC 824 form is submitted to CDSS QA Bureau. A standardized county-specific questionnaire is used for all QA home visits. It is designed to elicit each participant's personal preferences and experiences with the IHSS programs. Counties have flexibility in developing the home visit monitoring criteria and forms; however the core QA components must include: • Identifying the participant; • Discussion ofthe participant's health issues/physical limitations; • Inquiry on changes in the participant's condition or functional abilities; • Verify the participant's understanding of services and hours as authorized; • Note whether participant's housing needs have an impact on the assessment; SEP 292009 TN No. 09-006 Approval Date: Effective date: October I, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement _5_ to Attachment 3.l-A Page 10 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA • Discussion on whether the supportive services provided meet the participant's needs; • Inquiry as to the quality of supportive services rendered by the provider and the county; • Discussion if additional services and medical appointments are needed; • Confirmation that the participant's understanding of the Emergency Back-Up Form; • Discuss the availability of alternative resources; • Inquiry on potential abuse, neglect and exploitation or need for protective services; • Note whether there have been critical incident(s) identified/observed; • Confirm that all individual participant service needs identified are addressed in the individual plan of care; • Confirm that the participant understands the right to request a fair hearing including the provision for continuation ofdisputed services until a fair hearing decision is rendered in response to the participant request for a Fair Hearing, if appropriate; and • Assess participant satisfaction with services received, provider respect for participant rights, and overall quality ofcare and quality oflife. The county staff home visits are used to validate case file information, affirm assessments and ensure that authorized services are consistent with the participant's needs. It is the combination ofthese efforts that allows a participant to remain safely and independently at home. The expected outcomes ofthis process include statewide uniformity of services and a program ofhigh quality and integrity. Each county monitors the results oftheir QA efforts by evaluating data available from a variety ofsources including: • Appeals data; • Public Authorities; • Quarterly Reports; • CMIPS ad hoc reports; TN No. 09-006 Approval Date: SEP 29 2009 Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement ~ to Attachment 3.1-A Page 11 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA • CMIPS monthly reports; and • Consumer satisfaction surveys. The data gleaned during the discovery process are documented in the county Quarterly Reports. The goal ofcontinuous monitoring is to identify areas requiring remediation and make provisions for continuous system improvement Remediation The information collected during the discovery process may reveal a specific problem and/or a program weakness. County QA staff must act to correct the problem, identify the weakness and address the cause to prevent recurrence. The county QA staff must: • Take action to resolve the issue; • Ensure each issue discovered is resolved; • Document that the resolution and action taken is noted in the case file; and • Provide training to county social service staff specific to the issue discovered. System Improvement County QA staff are required to take action to resolve issues that are systemic in nature. Staff identify opportunities for systemic improvement by analyzing program data. The findings provide insight for determining whether issues are program deficiencies/county-wide trends. Staff seek effective remediation measures and develop continuous improvement processes. Corrective actions designed to eliminate systemic problems may include written program directives, modified procedures, and/or targeted case reviews. In all cases involving a systemic issue, county QA staff perform follow-up activities including training and technical assistance. QA staff document that remedial actions have been taken according to their county protocols. Each county submits a completed Quarterly Report form (SOC 824) bye-mail or fax to the CDSS QA Bureau covering the QA/QI activities conducted during the reporting quarter. The report includes the number of, and information gathered from, routine scheduled reviews, home visits, and fraud detection and prevention TN No. 09-006 Approval Date: s~p 292009 _ Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement --L to Attachment 3.l-A Page 12 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA activIties. It also includes critical events/incidents identified, actions taken on critical events/incidents, targeted reviews, and any system improvement efforts made as a result of issues identified during the quarter. System improvement includes the annual QAlQI plan that is to be submitted no later than June 1 51 to CDSS. The plan must include detailed information regarding how the county will accomplish discovery, remediation and system improvement activities. CDSS The CDSS has two roles in the QAlQI Plan, as reviewer of county discovery, remediation and system improvement plans and activities, and as conductor of its own discovery, remediation and system improvement activities. These two functions are separate but often overlap, and together provide an additional layer of validation ofquality assurance and program integrity. CDSS Review ofCounties Discovery, Remediation and System Improvement The CDSS QA staff monitor county discovery, remediation and system improvement activities. Monitoring is accomplished by: reviewing Quarterly Reports, annual QAlQI plans and Quality Improvement Action Plans (QIAPs) received from the counties; performing case reviews, including previously reviewed files; and observing county QA home visits. Based on the findings from these reviews, CDSS helps counties by: • Collaborating on the creation of county action plans; • Collaborating on the development of new county practices and policies; • Providing technical assistance in the development of annual QAlQI plans; and • Providing training on specific issues to individual counties as well as statewide. The CDSS review ofcounty discovery, remediation, and system improvement activities ensures that initial assessments and reassessments are conducted in a timely and uniform manner, participant needs are correctly assessed, and the health and welfare ofparticipants are maintained. TN No. 09-006 Approval Date: SEP 29 2009 Effective date: October 1, 2009 Supersedes TN No. None

OMS Approved 0938-1024 Supplement ---.i.-. to Attachment 3.1-A Page 13 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA Discovery As part of its discovery activities, CDSS carries out regularly scheduled county visits, during which the QA staff perform case file reviews and observe county QA staff conducting home visits. The CDSS QA monitoring staff conduct a minimum of one annual monitoring visit to each of the State's 58 counties. A CDSS county site visit includes the following discovery activities: At the county office, CDSS QA staff review: • Case files for correct application of federal and State regulations and requirements, proper use of required documents, appropriate and well documented justification for services, and evidence that individualized risk planning has occurred; • A sample of case files reviewed by county QA staff is evaluated for QA activities, the appropriateness of the forms, and any corrective actions taken; • Appropriateness ofdenied and disenrolled cases is conducted to ensure that denial of likely cases and involuntary disenrollments from the program were appropriate; • County policies and procedures for service registries, background checks, and training available to providers and participants; • Intake and enrollment procedures, including the participants' assessment/annual reassessment and level of assistance; • Provider enrollment forms and qualifications; and • Procedures for identification, remediation, and prevention of abuse. During a home visit, CDSS QA staff: • Observe county QA staff during the participant interview conducted to determine consumer satisfaction with program services; • Review services provided are appropriate to the specific needs of the participant; • Review coordination ofthe participant's services; • Review procedures for ensuring the participant has been provided information regarding available community resources; TN No. 09-006 Approval Date: SEP 292009 _ Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement -----L to Attachment 3.1-A Page 14 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA • Survey participants regarding quality of care issues; • Observe the participant's living arrangements, with consideration for the participant's safety in the home; • Review the individual emergency back-up plan with the participant; and • Review policies and procedures for addressing reportable events, incidents, complaints, and fair hearings. During the county office segment of the site visit, CDSS QA staff review the case narratives to identify possible issues. These issues include provider problems, timesheet issues or questions related to the participant's assessment/reassessment needs. CDSS QA staff evaluate the issues raised in the call and the county responses. The reviewer can immediately bring the issues to the attention of county QA staff. Alternatively, CDSS staff may make comments and/or recommendations to the county at the conclusion ofthe county review. These comments/recommendations are given to the county QA staff to ensure follow up with the participant's social worker. The CDSS QA staff may question an issue identified during monitoring that triggers an investigation. An investigation may take the fonn of targeted reviews and, where appropriate, reinforcement of acceptable levels ofcompliance. For example, counties must maintain a completion rate of 90% for reassessments. Failure to comply results in a CDSS corrective action letter that is sent to the county welfare director. Similarly, if county Quarterly Reports show significant levels of fraud, provider overpayments, or cases with 300+ paid provider hours (283 hours per month is the statutory limit in California), a targeted review is conducted by CDSS QA staff to identify the cause ofthe problem(s) and detennine if corrective action is needed. Areas of focus for targeted reviews can be: • Cases with 300+ paid provider hours; • Compliance level for reassessments; • Cases that may have been underpaid; • Suspected fraudulent activity; • Cases identified as overpaid (other than fraud); • Cases identified with participant neglect or abuse; and • Cases with Adult Protective Services (APS)/Child Protective Services (CPS) referrals. TN No. 09-006 Approval Date: SEP ') 9 ,on~ _ Effective date: October 1, 2009 Supersedes TN No. None

OMS Approved 0938-1024 Supplement -L to Attachment 3.l-A Page 15 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA For the home visits, CDSS QA staff accompanies county QA staff. The visits are planned to allow observation of a sample designed to validate case file information and to ensure participant needs have been assessed correctly. The State's annual monitoring visit concludes with a face-to-face discussion among State and county QA staff. The topics covered are best practices, how state requirements were met, and positive findings and/or needed improvements. CDSS QA staff provide any necessary technical assistance at the time ofthe meeting or at a future date. The CDSS conducts monthly electronic data reviews in the State office. Data review activities include analysis of: • CMIPS Online Reports including CMIPS ad hoc reporting for targeted data collection and review; • Error-rate studies (verification ofprovider payments using CMIPS and MIS/DSS or data provided by the California Department of Health Care Services (DHCS); • Payments for deceased recipients; • Out-of-state (provider or participant or either/both) payments; • In patient hospital stay over 5 days; and • Death match review using Vital Statistics/Social Security Administration (SSA) data. Remediation The complete array of information collected during the discovery process forms the basis for the remediation actions that are taken by CDSS QA staff. Staff use this information to evaluate, improve and refine the quality ofthe program provided to participants. The issues discovered during a county visit are addressed by CDSS QA staff during the exit interview with county QA staff. The county is advised that CDSS QA staff are available to work with the county QA staff to remediate the issue(s), as well as to provide technical assistance with developing the annual QA plan, which along with all county-visit documents are included in the county annual visit file. TN No. 09-006 Approval Date: SEP 292009 _ Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement _5_ to Attachment 3.l-A Page 16 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA Upon return to the State office, CDSS QA staff compose a findings letter that documents the site visit findings and the exit interview. Feedback is also provided in the form of a monitoring summary. Both the findings letter and the monitoring summary may contain positive feedback and negative issues. The material is sent to the county welfare director. Copies are sent to the county QA staff, the IHSS program manager and other appropriate staff. In preparation for subsequent county monitoring visits, CDSS QA staff review any existing monitoring documentation and corrective action plans to ensure the county has initiated the required quality improvement measures in the areas identified during previous visits. System Improvement Data analysis is used to determine whether an issue identified during discovery is county specific or statewide. When a systemic issue or a trend is identified, actions are taken by CDSS QA staff to move toward resolution. Measures with the potential to be the most effective and that foster continuous system improvement processes are developed for the program. Based on the determination, an appropriate remediation measure is identified. The CDSS QA staff use the face-to-face exit interview with the county as the initial opportunity to share information with county staff regarding problems or issues that appear to be systemic. Subsequently, the county is sent a written findings follow-up report. Some issues documented in the report may require technical assistance from CDSS QA staff and corrective action by the county. When CDSS requests a QIAP from a county, the county must include in their QIAP how and when an issue will be resolved. The QIAP is due to CDSS from the county within 30 days of receipt of the request. The QIAPs are reviewed and approved by CDSS staff. County progress toward continuous improvement is monitored via regular communication between the county and CDSS staff. A copy ofthe QIAP is forwarded to DHCS within 60 days of the end of the quarter in which it was received by CDSS. When statewide systemic issues and trends are identified, CDSS QA staff initiate an all-county distribution of an ACIN or an All County Letter (ACL) that contains pertinent information regarding problem areas and states the actions needed for TN No. 09-006 Approval Date: SEP 292009 _ Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement----L to Attachment 3.l-A Page 17 State Plan Under Title XIX ofthe Social Security Act STATE/TERRITORY: CALIFORNIA resolution and continuous system improvement statewide. This is accomplished through: • Updating regulations, as needed; • QA monitoring visits to all counties; • Presenting at CWDA regional meetings; • Attending monthly regional QA meetings; • Conducting workshops at annual CWDA Conferences; • Attending monthly Long-Term Care Operations meetings; • Updating the program material in the IHSS Training Academy; and • Issuing statewide policy directives that reflect systemic issues and system improvement. The goal for each activity is to promote remediation and system improvement statewide. B. The system performance measures, outcome measures, and satisfaction measures that the State will monitor and evaluate. The following are the performance measures set forth for the self-directed PAS State Plan Amendment. CDSS Statewide Petformance Measures Performance measures are an important element of the CDSS QAlQI plan design. The measures are designed to determine the effectiveness and functionality of the program and to identify areas where attention should be focused to assure improved outcomes. When the measures are applied and the results analyzed, these performance measures provide information used in making recommendations for continuous system improvement. The following are performance measures that focus on the QAlQI plan target areas, participant health and welfare and financial accountability. TN No. 09-006 Approval Date: SEP 2 9 2009 Effective date: October I, 2009 Supersedes TN No. None

OMS Approved 0938-1024 Supplement----L to Attachment 3.I-A Page 18 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA Participant Health and Welfare Performance Measure 1: Face-to-Face Visits Desired Outcome: A participant and hislher caseworker have a face-to-face visit at least once a year. la QA Function: CMIPS data is reviewed by CDSS staff to ensure that this visit is occurring within the 12-month timeframe for participants. 2a CDSS QA Function: CDSS QA staff review case files to confirm that this visit is occurring within the 12-month timeframe for participants. Performance Measure la - County Face-to-FaceV'isitC8J,ctllanon ....••••.... # of statewide cases with face-to-face visits completed within 12 months / # of statewide cases = % of statewide compliance Performance Measure Ib - CDSS QA Face..to-Face Visit CalcUlation .... # of statewide cases reviewed with face-to-face visits completed within 12 months / # of statewide cases reviewed = % of statewide compliance Petformance Measure 2: Emergency Back-Up Plans Desired Outcome: An emergency back-up plan is in place for 'each participant. During the initial and annual face-to-face visits, a participant and hislher case worker collaborate to determine the best plan for the participant. Together, the participant and the case worker complete or update the Emergency Back-Up Plan form (SOC 827) to capture the action elements ofthe back-up plan. A copy ofthe completed form is retained by the participant, ideally in a readily accessible location. The case worker places a second copy of the form in the participant's case file. QA Function: County and CDSS QA staff review case files to confirm that an emergency back-up plan is in place and a copy of the Emergency Back-Up Plan form is present in each participant's case file. During a home visit, QA staff confirm that the participant possesses an up-to-date copy oftheir plan. TN No. 09-006 Approval Date: SEP 2 9 2009 Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement~ to Attachment 3.1-A Page 19 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA # of statewide cases reviewed that includes a completed Emergency Back-Up Plan / # of statewide cases reviewed = % of statewide compliance # of statewide cases reviewed that includes a completed Emergency Back-Up Plan / # of statewide cases reviewed = % of statewide compliance Performance Measure 3: Critical Incidents A critical incident is one in which there is an immediate threat to the health and/or safety ofa participant. Critical incidents include, but are not limited to: serious injuries caused by accident, medication error/reaction; physical, emotional or financial abuse or neglect. Desired Outcome: When a critical incident occurs, the county social service staff responds appropriately and notes the incident in the case file, and the resolution, if known. QA Function: County and CDSS QA staffreview case files for evidence of critical incidents and the resolution, if stated. # of statewide cases reviewed that include a critical incident / # of statewide cases reviewed = % of statewide cases involving critical incidents # of statewide cases reviewed that include a critical incident / # of statewide cases reviewed = % of statewide cases involving critical incidents TN No. 09-006 Approval Date: SEP 2 9 2009 Effective date: October 1, 2009 Supersedes TN No. None

OMS Approved 0938-1024 Supplement ~ to Attachment 3.l-A Page 20 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA # of statewide cases reviewed with a resolved critical incident / # of statewide county cases reviewed that include a critical incident = % of statewide resolution Outcome Measure 1: County Plans Desired Outcome: Counties are in compliance with their annual County QAlQI Plan. QA Function: Prior to a county monitoring visit, CDSS QA staff review the county's annual QA/QI plan, quarterly reports, and any other information available. Upon completion ofthe county visit, CDSS QA staff determine the extent to which the county is in compliance with their annual plan based on data gathered from the case reviews and home visits. # ofcounties in compliance with their County QAlQI Plan / # of counties that have submitted their QAlQI Plan = % of statewide compliance Outcome Measure 2: QA Improvement Action Plans (QAIPs) Desired Outcome: All counties with a QAIP make the indicated corrections and institute the plan recommended by CDSS. QA Function: Upon completion of the county visit, if there are issues that CDSS discovers, a QAIP may be in order. If so, CDSS will issue a QAIP and request that the county explain how it will improve the issue(s). Upon completion of the next county visit, CDSS QA monitoring staff determines whether the county instituted the QAIP recommended by CDSS. # ofcounties with instituted QAIPs / # ofcounties with QAIPs = % ofcounty compliance SEP 292009 TN No. 09-006 Approval Date: _ Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement ~ to Attachment 3.l-A Page 21 State Plan Under Title XIX ofthe Social Security Act STATE/TERRITORY: CALIFORNIA Satisfaction Measure 1: Customer Service Evaluation Desired Outcome: Program participants are satisfied their in-home care needs are being met by the program, they are able to contact the appropriate people when needed, and are able to satisfactorily self-direct their services. QA Function: Appropriate questions will be created and asked to participants regarding their satisfaction ofthe program, services and self-direction options. Upon completion ofeach survey, percentages will be calculated and reviewed. QA will then use this data to determine if changes in the program are needed. The survey(s) will be comprehensive and the results will be validated. Data Collection Methods Data collected for the performance measures (one through five) are obtained during the county and CDSS case reviews and home visits. County data are reported to CDSS in the County QA Quarterly Reports. CDSS data are collected throughout the year and included in the CDSS QA Monitoring Summary. Sampling Approach The methodology for sampling the QA/QI-related data is consistent with the statistically valid sample calculator described at the Raosoft website: www.raosoft.com/samplesize. The Sample Size Calculator was suggested by CMS. A statistically valid sample ofthe population of 26,000, with a 5% margin oferror, is 379 cases. This will be the minimum number ofcase files reviewed for this population each fiscal year. Counties have the flexibility to determine a sampling approach, however, each county is required to have at a minimum 250 cases reviewed and 50 home visits conducted, per QA position. The QA staff are to document the sampling approach in the annual county QA/QI plan. During the county plan approval process, CDSS QA staff work with the county QA staff to verify a reasonable sampling approach based on the CDSS QA guidelines. SEP. 2 9 2009 TN No. 09-006 Approval Date: _ Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement ~ to Attachment 3.1-A Page 22 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA Frequency of Data Collection Data collection takes place annually and on an ongoing basis within each aspect of the program. Performance measure data will be finalized at the end of each State fiscal year and available upon request. Counties work throughout the year to meet their individual targets and goals to assure maximum review. CDSS QA monitoring staff visit all 58 counties each year. Roles and Responsibilitiesfor Data Collection County QA staff are responsible for gathering data in keeping with the criteria set forth in the annual county QA plan. QA staff are also responsible for maintaining this data. Processfor Tracking and Analyzing Collected Data Roles and Responsibilitiesfor Tracking andAnalyzing Collected Data Counties are responsible for tracking and analyzing data gathered during QA activities. Moreover, QA staffreview online CMIPS data to identify program issues specific to that county. The methodology for tracking and analyzing these data can allow for ease in reporting on the SOC 824 form. County QA staff are responsible for assuring that the data are analyzed for trends and/or program shortfalls. The CDSS QA staff are responsible for tracking and analyzing data reported quarterly by the counties and gathered during CDSS QA county monitoring visits. CDSS staff analyze online CMIPS data and data reported on the quarterly SOC 824 forms to identify program issues specific to a particular county or statewide. xu. Risk Management A. The risk assessment methods used to identify potential risks to participants are described below. During the intake and reassessment process: 1. The social worker assesses participant's functional abilities in all activities of daily living utilizing the following process: TN No. 09-006 Approval Date: SEP 292009 _ Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement ~ to Attachment 3.I-A Page 23 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA • County social service staff determines the participant's level of ability and dependence upon verbal or physical assistance by another for each of the program functions. • This assessment process evaluates the effect of the participant's physical, cognitive and emotional impairment on functioning. • The social service staff observes the participant in their own environment. • Staff quantify the recipient's level of functioning using the following hierarchical five-point scale: Rank I: Independent: able to perform function without human assistance, although the recipient may have difficulty in performing the function, but the completion ofthe function, with or without a device or mobility aid, poses no substantial risk to hislher safety. A recipient who ranks a "I" in any function shall not be authorized the correlated service activity. Rank 2: Able to perform a function, but needs verbal assistance, such as reminding, guidance, or encouragement. Rank 3: Can perform the function with some human assistance, including, but not limited to, direct physical assistance from a provider. Rank 4: Can perform a function but only with substantial human assistance. Rank 5: Cannot perform the function, with or without human assistance. 2. A discussion ofparticipant's living arrangements, during the face­ to-face visit, in the participant's home, the county social service staff evaluates the home for any potential hazards; how the participant deals with ambulation issues, whether they use assistive devices, what their shared living arrangement is, whether there are other individuals (non-providers) to help, etc. TN No. 09-006 Approval Date: SEP 292009 _ Effective date: October I, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement ~ to Attachment 3.1-A Page 24 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA 3. A discussion of the participant's support system, during the face­ to-face visit a discussion occurs with the participant regarding who they would like to have involved in their care. Do they want a representative, a supports broker/consultant, or any other individual such as a neighbor or friend included in all discussions. 4. The social worker/case manager reviews all documents pertaining to the participants physical or mental condition to identify potential risks to participants , and 5. Designated coding of CMIPS to indicate the participants' special needs during an emergency. • The participants' special needs are coded in CMIPS to allow county social service staff, in the event of an emergency or natural disaster, to inform first responders which participants need to be checked on first, and their special needs, e.g. insulin. B. The tools or instruments used to mitigate identified risks are described below. • Program Uniform Assessment Tool- The process described in A. 1., above helps the social worker and participant identify and mitigate risks that may be present. If risks cannot be or are not chosen to be mitigated, risk may be assumed by the participant during this process. • Emergency Back-Up Plan - This tool is completed during the assessment process with input from the participant and their chosen representative. This tool identifies the participants' support system, addresses back-up plan to mitigate risks, and allows the participant to understand their roles and responsibilities in obtaining self-directed PAS. • RecipientlEmployer Responsibility Check-List - This tool ensures that the recipient understands their responsibilities as the employer of their service provider. TN No. 09-006 Approval Date: SEP 2 9 2009 Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement _5_ to Attachment 3.I-A Page 25 State Plan Under Title XIX ofthe Social Security Act STATE/TERRITORY: CALIFORNIA • Criminal & Worker Background Checks - Counties perform background and references checks for all providers wishing to be listed on the Provider Registry. C. The State's process for ensuring that each service plan reflects the risks that an individual is willing and able to assume, and the plan for how identified risks will be mitigated, is described below. The process used for ensuring that each service plan reflects the risks that an individuals' willing and able to assume is as follows: • All tools and instruments used to identify, mitigate and assume risks become part ofthe participants' case file. • The service plan is developed utilizing all documents contained in the case file. The plan for how identified risks will be mitigated is as follows: • The social worker discusses with each individual the risks identified and how they may be mitigated. For example, the following are potential ways a social worker and participant may work together to mitigate potential risks: 1) If there is an extension cord lying across a walk path, the social worker and participant (and/or their representative) will discuss what to do to mitigate the risk. Options may be to move the cord to a different place, purchase a newer, longer cord to allow the cord to be placed out of the way or move the item plugged into the cord to a different place, and thereby mitigating the risk. 2) A participant is having slipping troubles in the shower needs some sort ofhelp. The social worker and participant (and/or their representative) will discuss what to do to mitigate the risk. Options may be, putting in slip guards, and/or handrails, and thereby mitigating the risk. TN No. 09-006 Approval Date: SEP 292009 _ Effective date: October 1, 2009 Supersedes TN No. None

OMS Approved 0938-1024 Supplement ~ to Attachment 3.I-A Page 26 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA 3) A participant, with a mental impairment, plays with the knobs on the stove. The social worker and participant (and/or their representative) will discuss what to do to mitigate the risk. Options may be to take the knobs off the stove, make the stove inaccessible to the participant, and thereby mitigating the risk. 4) A participant needs oxygen treatments and there is a power outage. The social worker and participant can discuss what to do to mitigate this risk. Options, Social Worker codes the special need in CMIPS to ensure first response notification, identify neighbors or friends who can check up on participant in case of an emergency or natural disaster, etc. If a risk cannot be mitigated, such as a person has troubles with stairs due to their impairment, but chooses not to move to a one-level home with no stairs, they can assume this risk during the discussion. D. The State's process for ensuring that the risk management plan is the result of discussion and negotiation among the persons designated by the State to develop the service plan, the participant, the participant's representative, if any, and others from whom the participant may seek guidance, is described below. • Others that participants may include in the discussions and negotiations include family, friends and professionals (as desired or required). County social services staffhave been trained to provide support to participants. Examples of the variety of support they offer are: • During the intake and screening process, the county social services staff assists participants (and/or their representative) with access to services and provides information about other community programs available (e.g. a participant needs a walker, the social worker would refer them to the appropriate entity); • Face-to-face assessments and reassessments take place in the participant's residence. This enables county social services staff to visit with the participants (and/or their representative) and observe them in a setting where they are comfortable. They will also discuss concerns and safety issues. The resulting assessments are more reflective ofthe participants' needs; TN No. 09-006 Approval Date: SEP 292009 _ Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement ~ to Attachment 3.I-A Page 27 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA • County social services staff visit participants who are in hospitals and nursing facilities to develop a transition plan to allow the participant to safely return home; • County social services staff explain the rights and responsibilities of the employer/employee relationships; • Act as a point ofcontact for participants (and/or their representative) who need to contact the county office with questions or problems; • Refer participants (and/or their representative) to other community resources when participant's care needs exceed the scope of services or hours permitted under the program; and • Work with the participant (and/or their representative) and provider to resolve emergency payroll situations. • Participants and providers handbooks are available to inform individuals oftheir roles, responsibility and program details, including: o Participant - roles as employer, supervising provider, communicating with provider, timesheet responsibilities, etc. o Provider - Goals of the program, hiring process, understanding their responsibilities, etc. • If a risk is identified, such as the following, a discussion takes place to identify ways to mitigate the issues. o A throw rug is on a slippery surface. o An extension cord is lying across a walk path. o A participant is having slipping troubles in the shower. o A participant, with a mental impairment, plays with the knobs on the stove. TN No. 09-006 Approval Date: SEP 292009 _ Effective date: October I, 2009 Supersedes TN No. None

OMS Approved 0938-1024 Supplement ~ to Attachment 3.I-A Page 28 State Plan Under Title XIX ofthe Social Security Act STATE/TERRITORY: CALIFORNIA X111. Qualifications of Providers ofPersonal Assistance A. --lL The State elects to permit participants to hire legally liable relatives, as paid providers ofthe personal assistance services identified in the service plan and budget. B. __ The State elects not to permit participants to hire legally liable relatives, as paid providers of the personal assistance services identified in the service plan and budget. xiv. Use of a Representative A. X The State elects to permit participants to appoint a representative to direct the provision of self-directed personal assistance services on their behalf. 1. __ The State elects to include, as a type of representative, a State­ mandated representative. Please indicate the criteria to be applied. B. ------..J..- The State elects not to permit participants to appoint a representative to direct the provision ofself-directed personal assistance services on their behalf. xv. Permissible Purchases A. --lL The State elects to permit participants to use their service budgets to pay for items that increase a participant's independence or substitute for a participant's dependence on human assistance. This will be limited to those participants choosing the Restaurant Meal Allowance (RMA). • RMA allows the participant to use their service budget for meal preparation, meal clean-up, and shopping for food, to purchase restaurant meals. • Individuals who do not have assessed needs for the above services would not be eligible for RMA. • RMA is a self-directed option for participants that increases their independence and is a substitute for their dependence on human assistance. • RMA fits within the self-directed principles and provides participants greater choice. SEP 292009 TN No. 09-006 Approval Date: _ Effective date: October I, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement _5_ to Attachment 3.I-A Page 29 State Plan Under Title XIX ofthe Social Security Act STATE/TERRITORY: CALIFORNIA B. __ The State elects not to permit participants to use their service budgets to pay for items that increase a participant's independence or substitute for a participant's dependence on human assistance. XVI. Financial Management Services A. __ The State elects to employ a Financial Management Entity to provide financial management services to participants self-directing personal assistance services, with the exception of those participants utilizing the cash option and performing those functions themselves; 1. ~_ The State elects to provide financial management services through a reporting or subagent through its fiscal intermediary in accordance with section 3504 ofthe IRS Code and Revenue Procedure 80-4 and Notice 2003-70; or 11. __ The State elects to provide financial management services through vendor organizations that have the capabilities to perform the required tasks in accordance with section 3504 ofthe IRS Code and Revenue Procedure 70-6. (When private entities furnish financial management services, the procurement method must meet the requirements set forth Federal regulations in 45 CFR section 74.40 - section 74.48.) 111. __ The State elects to provide financial management services using "agency with choice" organizations that have the capabilities to perform the required tasks in accordance with the principles of self-direction and with Federal and State Medicaid rules. B. X The State elects to directly perform financial management services on behalf of participants self-directing personal assistance services, with the exception ofthose participants utilizing the cash option and performing those functions themselves. TN No. 09-006 Approval Date: SEP 2 9 2009 Effective date: October I, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement-l to Attachment 3.1-B Page 1 State Plan Under Title XIX ofthe Social Security Act STATEITERRITORY: CALIFORNIA Notwithstanding anything else in this State Plan provision, the coverage will be subject to such other requirements that are promulgated by CMS through interpretive issuance or final regulation. 1. Eligibility The State determines eligibility for Self-Directed Personal Assistance Services: A. X In the same manner as eligibility is determined for traditional State Plan personal care services, described in Item 26 of the Medicaid State Plan. B. __In the same manner as eligibility is determined for services provided through a 1915(c) Home and Community-Based Services Waiver. 11. Service Package The State elects to have the following included as Self-Directed Personal Assistance Services: A. X State Plan Personal Care and Related Services, to be self-directed by individuals eligible under the State Plan. B. __ Services included in the following section 1915(c) Home and Community­ Based Services waiver(s) to be self directed by individuals eligible under the waiver(s). The State assures that all services in the impacted waiver(s) will continue to be provided regardless of service delivery model. Please list waiver names and services to be included. lll. Payment Methodology A. .-X- Payment rates will be calculated using the approved State plan personal care services rate or section 1915(c) Home and Community-Based waiver services rate. TN No. 09-006 Approval Date: SEP , 9 '009 Effective date: October 1, 2009 Supersedes TN No. None

OMS Approved 0938-1024 Supplement ~ to Attachment 3.1-B Page 2 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA B. __The State will use a different payment methodology for individuals self­ directing their PAS under section 1915(j) than that approved for State plan personal care services or for section 1915(c) Home and Community-Based waiver services. Amended Attachment 4.19-B page(s) are attached. IV. Use of Cash A. -----.2L The State elects to disburse cash prospectively to participants self-directing personal assistance services. The State assures that all Internal Revenue Service (IRS) requirements regarding payroll/tax filing functions will be followed, including when participants perform the payroll/tax filing functions themselves. Only for participants receiving the following options: • Restaurant Meal Allowance (please see Permissible Purchases, section xv.); and • Severely impaired recipients who have chosen the Cash Option. o California regulation limits the receipt ofAdvance Pay (Cash Option) to severely impaired recipients. o California Department of Social Services (CDSS), Manual of Policies and Procedures (MPP) 30-701(s) (1) Severely Impaired Individual means a recipient with a total assessed need...for 20 hours or more per week of service in one or more of the following areas: (A) Any personal care service listed in Section 30-757.14. (B) Preparation of meals. (C) Meal cleanup when preparation of meals and consumption offood (feeding) are required. (D) Paramedical services. B. __ The State elects not to disburse cash prospectively to participants self­ directing personal assistance services. TN No. 09-006 Approval Date: SEP 2 9 2009 Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement -.2- to Attachment 3.1-B Page 3 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA v. Voluntary Disenrollment The State will provide the following safeguards in place to ensure continuity of services and assure participant health and welfare during the period oftransition between self­ directed and traditional service delivery models. There will be no break in service for those voluntary disenrolling and transitioning to State Plan Personal Care Services, thus assuring participant health and welfare. Participants or their authorized/legal representative(s) may initiate disenrollment at any time by contacting the county social services office. If a voluntary disenrollment is received by mail, or is initiated by the participant's authorized/legal representative, the county will contact the participant to ensure the disenrollment request represents the wishes of the participant. The Case Management Information and Payrolling System (CMIPS) updates eligibility status changes immediately upon data entry. VI. Involuntary Disenrollment A. The circumstances under which a participant may be involuntarily disenrolled from self-directing personal assistance services, and returned to the traditional service delivery model are noted below. Circumstances for involuntary disenrollment, which may be initiated by the county, include but are not limited to the following: • Participant moved out of State; • Participant no longer resides in a dwelling that meets the Federal requirement under Section 19150)(1); • Participant has lost Medi-Cal eligibility; • Participant no longer requires personal care services or assistance with Activities of Daily Living (ADL) and/or Instrumental Activities of Daily Living (lADL); • Participant is no longer in the population served under the State Plan option; TN No. 09-006 Approval Date: SEP 292009 - Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement.-L to Attachment 3.1-B Page 4 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA • Participant is institutionalized; • ,Participant cannot comply with the 19150) program requirements. B. The State will provide the following safeguards in place to ensure continuity of services and assure participant health and welfare during the period of transition between self-directed and traditional service delivery models. The State will provide all appropriate safeguards available to ensure continuity of services. For example, if a participant cannot comply with the program requirements due to mental or physical inability to self-direct (e.g. the participant is no longer capable of managing their cash option funds), the county social worker/case manager would first work with the participant to assist them in proper management oftheir funds in order to prevent involuntary disenrollment. If the participant is still unable to properly manage their funds, and the cash option is their only link to this State Plan Option, then the county social worker/case manager would initiate disenrollment and transition the participant to the traditional service delivery model. Once this transition is initiated, CMIPS updates eligibility status changes immediately upon data entry. Vll. Participant Living Arrangement Any additional restrictions on participant living arrangements, other than homes or property owned, operated, or controlled by a provider of services, not related by blood or marriage to the participant are noted below. No additional restrictions on participant living arrangements. Vlll. Geographic Limitations and Comparability A. X The State elects to provide self-directed personal assistance services on a statewide basis. B. __ The State elects to provide self-directed personal assistance services on a targeted geographic basis. Please describe: _ TN No. 09-006 Approval Date: SEP 29 ?009 Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement ~ to Attachment 3.1-B Page 5 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA C. __ The State elects to provide self-directed personal assistance services to all eligible populations. D. -----.1L The State elects to provide self-directed personal assistance services to targeted populations. Please describe: _ This program option is only for those participants that: • have chosen Restaurant Meal Allowance; and/or • are severely impaired and have chosen the Advanced Pay (cash option); and/or • have chosen a legally liable relative provider. E. X The State elects to provide self-directed personal assistance services to an unlimited number ofparticipants. F. __ The State elects to provide self-directed personal assistance services to __ (insert number of) participants, at any given time. IX. Assurances A. The State assures that there are traditional services, comparable in amount, duration, and scope, to self-directed personal assistance services. B. The State assures that there are necessary safeguards in place to protect the health and welfare of individuals provided services under this State Plan Option, and to assure financial accountability for funds expended for self-directed personal assistance services. C. The State assures that an evaluation will be performed ofparticipants' need for personal assistance services for individuals who meet the following requirements: i. Are entitled to medical assistance for personal care services under the Medicaid State Plan; or 11. Are entitled to and are receiving home and community-based services under a section 1915(c) waiver; or 111. May require self-directed personal assistance services; or TN No. 09-006 Approval Date: _SE_P_2_9_2_00_9 Effective date: October 1, 2009 Supersedes TN No. None

OMS Approved 0938-1024 Supplement ~ to Attachment 3.1-B Page 6 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA IV. May be eligible for self-directed personal assistance services. D. The State assures that individuals are informed of all options for receiving self­ directed and/or traditional State Plan personal care services or personal assistance services provided under a section 1915(c) waiver, including information about self­ direction opportunities that is sufficient to inform decision-making about the election of self-direction and provided on a timely basis to individuals or their representatives. E. The State assures that individuals will be provided with a support system meeting the following criteria: 1. Appropriately assesses and counsels individuals prior to enrollment; 11. Provides appropriate counseling, information, training, and assistance to ensure that participants are able to manage their services and budgets; 111. Offers additional counseling, information, training, or assistance, including financial management services: 1. At the request ofthe participant for any reason; or 2. When the State has determined the participant is not effectively managing their services identified in their service plans or budgets. F. The State assures that an annual report will be provided to CMS on the number of individuals served through this State Plan Option and total expenditures on their behalf, in the aggregate. G. The State assures that an evaluation will be provided to CMS every 3 years, describing the overall impact of this State Plan Option on the health and welfare of participating individuals, compared to individuals not self-directing their personal assistance services. H. The State assures that the provisions of section 1902(a)(27) of the Social Security Act, and Federal regulations at 42 CFR 431.107, governing provider agreements, are met. TN No. 09-006 Approval Date: _S_EP_2_9_2_00_9 Effective date: October 1, 2009 Supersedes TN No. None

OMS Approved 0938-1024 Supplement _5_ to Attachment 3.1-B Page 7 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA I. The State assures that a service plan and service budget will be developed for each individual receiving self-directed PAS. These are developed based on the assessment ofneeds. J. The State assures that the methodology used to establish service budgets will meet the following criteria: 1. Objective and evidence based, utilizing valid, reliable cost data. ii. Applied consistently to participants. 111. Open for public inspection. IV. Includes a calculation of the expected cost of the self-directed PAS and supports ifthose services and supports were not self-directed. v. Includes a process for any limits placed on self-directed services and supports and the basislbases for the limits. VI. Includes any adjustments that will be allowed and the basislbases for the adjustments. V11. Includes procedures to safeguard participants when the amount of the limit , on services is insufficient to meet a participant's needs. V111. Includes a method of notifying participants of the amount ofany limit that applies to a participant's self-directed PAS and supports. IX. Does not restrict access to other medically necessary care and services furnished under the plan and approved by the State but not included in the budget. x. Service Plan The State has the following safeguards in place, to permit entities providing other Medicaid State Plan services to be responsible for developing the self-directed personal assistance services service plan, to assure that the service provider's influence on the planning process is fully disclosed to the participant and that procedures are in place to mitigate that influence. Entities or individuals that have responsibility to develop service plans do not provide other direct services to participants. TN No. 09-006 Approval Date: SEP ~ 9 7009 Effective date: October 1, 2009 Supersedes TN No. None

OMS Approved 0938-1024 Supplement ~ to Attachment 3.l-B Page 8 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA Xl. Quality Assurance and Improvement Plan A. The State's quality assurance and improvement plan is described beiow, including: i. How it will conduct activities of discovery, remediation, and quality improvement in order to ascertain whether the program meets assurances, corrects shortcomings, and pursues opportunities for improvement; and ii. The system performance measures, outcome measures, and satisfaction measures that the State will monitor and evaluate. The following describes the system-wide quality assurance and improvement plan CDSS, in conjunction with the 58 counties, has that includes the activities of discovery, remediation and quality improvement. This plan will help to ascertain whether the program meets assurances, corrects shortcomings, and pursues opportunities for improvement to ensure the health and welfare ofour self­ directed PAS recipients. County Each county must maintain an annual QAlQI plan that specifies the procedures for addressing discovery, remediation, and overall system improvement. The procedures must provide for reporting findings to program staff and supervisors for remediation. County QA staff collect data during program monitoring. The staff also review reports generated by the CDSS Case Management Information and Payrolling System (CMIPS) and data provided by outside entities (e.g. State Controller's Office). The staff analysis ofcompiled data is used for annual plan development, refinement and improvement activities. The procedures outlined in the annual QAlQI plans are designed to assure the timeliness and effectiveness of the county's actions to protect participant health and welfare, ahd financial accountability. TN No. 09-006 Approval Date: SEP 29 2009 Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement -2- to Attachment 3.1-B Page 9 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA Discovery The focus of discovery is to monitor the participants' quality of services and supports through the collection of data. The data gathered is used to assess the ongoing implementation ofthe program and identify strengths as well as opportunities for improvement. County QA activities include: • Home visits; • Routine case file reviews; • Targeted case review studies; • Scheduled reviews of supportive services; • Identification of potential sources ofthird-party liability; and • Monitoring of supportive service delivery to detect and prevent fraud. Routine case file reviews conducted by county QA staff are the primary monitoring component of data collection. Counties are required to review a certain number of cases and conduct home visits based on the number of employees they have allocated for QA activities. Each full-time county QA staff must complete case file reviews and conduct home visits annually. The case reviews are designed to confirm that participant needs are correctly assessed and that case files contain appropriate documentation. Moreover, critical incident information discovered during a case file review is analyzed to ensure that proper resolution took place and that the relevant information was reported. Critical incident information is documented on the Quarterly Report form, SOC 824. The SOC 824 form is submitted to CDSS QA Bureau. A standardized county-specific questionnaire is used for all QA home visits. It is designed to elicit each participant's personal preferences and experiences with the IHSS programs. Counties have flexibility in developing the home visit monitoring criteria and forms; however the core QA components must include: • Identifying the participant; • Discussion of the participant's health issues/physical limitations; • Inquiry on changes in the participant's condition or functional abilities; • Verify the participant's understanding of services and hours as authorized; • Note whether participant's housing needs have an impact on the assessment; SEP 292009 TN No. 09-006 Approval Date: _ Effective date: October 1,2009 Supersedes TN No. None

OMS Approved 0938-1024 Supplement --.i..- to Attachment 3.1-B Page 10 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA • Discussion on whether the supportive services provided meet the participant's needs; • Inquiry on potential abuse, neglect and exploitation or need for protective servIces; • Note whether there have been critical incident(s) identified/observed; • Confirm that all individual participant service needs identified are addressed in the individual plan ofcare; • Confirm that the participant understands the right to request a fair hearing including the provision for continuation ofdisputed services until a fair hearing decision is rendered in response to the participant request for a Fair Hearing, ifappropriate; and • Assess participant satisfaction with services received, provider respect for participant rights, and overall quality ofcare and quality of life. The county staff home visits are used to validate case file information, affirm assessments and ensure that authorized services are consistent with the participant's needs. It is the combination ofthese efforts that allows a participant to remain safely and independently at home. The expected outcomes ofthis process include statewide uniformity of services and a program ofhigh quality and integrity. Each county monitors the results oftheir QA efforts by evaluating data available from a variety ofsources including: • Appeals data; • Public Authorities; • Quarterly Reports; • CMIPS ad hoc reports; • CMIPS monthly reports; and • Consumer satisfaction surveys. The data gleaned during the discovery process are documented in the county Quarterly Reports. The goal ofcontinuous monitoring is to identify areas requiring remediation and make provisions for continuous system improvement. TN No. 09-006 Approval Date: S~p 2 9 2009 Effective date: October 1, 2009 Supersedes TN,No. None

OMS Approved 0938-1024 Supplement ~ to Attachment 3.1-B Page 11 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA Remediation The information collected during the discovery process may reveal a specific problem and/or a program weakness. County QA staff must act to correct the problem, identify the weakness and address the cause to prevent recurrence. The county QA staff must: • Take action to resolve the issue; • Ensure each issue discovered is resolved; • Document that the resolution and action taken is noted in the case file; and • Provide training to county social service staff specific to the issue discovered. System Improvement County QA staff are required to take action to resolve issues that are systemic in nature. Staff identify opportunities for systemic improvement by analyzing program data. The findings provide insight for determining whether issues are program deficiencies/county-wide trends. Staff seek effective remediation measures and develop continuous improvement processes. Corrective actions designed to eliminate systemic problems may include written program directives, modified procedures, and/or targeted case reviews. In all cases involving a systemic issue, county QA staff perform follow-up activities including training and technical assistance. QA staff document that remedial actions have been taken according to their county protocols. Each county submits a completed Quarterly Report form (SOC 824) bye-mail or fax to the CDSS QA Bureau covering the QAlQI activities conducted during the reporting quarter. The report includes the number of, and information gathered from, routine scheduled reviews, home visits, and fraud detection and prevention activities. It also includes critical events/incidents identified, actions taken on critical events/incidents, targeted reviews, and any system improvement efforts made as a result of issues identified during the quarter. System improvement includes the annual QAlQI plan that is to be submitted no later than June 1st to CDSS. The plan must include detailed information regarding how the county will accomplish discovery, remediation and system improvement activities. TN No. 09-006 Approval Date: SEP 292009 _ Effective date: October 1, 2009 Supersedes TN No. None

OMS Approved 0938-1024 Supplement ~ to Attachment 3.l-B Page 12 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA CDSS The CDSS has two roles in the QAlQI Plan, as reviewer of county discovery, remediation and system improvement plans and activities, and as conductor of its own discovery, remediation and system improvement activities. These two functions are separate but often overlap, and together provide an additional layer of validation of quality assurance and program integrity. CDSS Review ofCounties Discovery, Remediation and System Improvement The CDSS QA staff monitor county discovery, remediation and system improvement activities. Monitoring is accomplished by: reviewing Quarterly Reports, annual QAlQI plans and Quality Improvement Action Plans (QIAPs) received from the counties; performing case reviews, including previously reviewed files; and observing county QA home visits. Based on the findings from these reviews, CDSS helps counties by: • Collaborating on the creation of county action plans; • Collaborating on the development of new county practices and policies; • Providing technical assistance in the development ofannual QAlQI plans; and • Providing training on specific issues to individual counties as well as statewide. The CDSS review ofcounty discovery, remediation, and system improvement activities ensures that initial assessments and reassessments are conducted in a timely and uniform manner, participant needs are correctly assessed, and the health and welfare of participants are maintained. Discovery As part of its discovery activities, CDSS carries out regularly scheduled county visits, during which the QA staff perform case file reviews and observe county QA staff conducting home visits. The CDSS QA monitoring staff conduct a minimum of one annual monitoring visit to each of the State's 58 counties. A CDSS county site visit includes the following discovery activities: SEP 292009 TN No. 09-006 Approval Date: Effective date: October 1, 2009 Supersedes TN No. None

OMS Approved 0938-1024 Supplement ~ to Attachment 3.1-B Page 13 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA At the county office, CDSS QA staff review: • Case files for correct application of federal and State regulations and requirements, proper use of required documents, appropriate and well documented justification for services, and evidence that individualized risk planning has occurred; • A sample of case files reviewed by county QA staff is evaluated for QA activities, the appropriateness of the forms, and any corrective actions taken; • Appropriateness of denied and disenrolled cases is conducted to ensure that denial of likely cases and involuntary disenrollments from the program were appropriate; • County policies and procedures for service registries, background checks, and training available to providers and participants; • Intake and enrollment procedures, including the participants' assessment/annual reassessment and level of assistance; • Provider enrollment forms and qualifications; and • Procedures for identification, remediation, and prevention of abuse. During a home visit, CDSS QA staff: • Observe county QA staff during the participant interview conducted to determine consumer satisfaction with program services; • Review services provided are appropriate to the specific needs of the participant; • Review coordination of the participant's services; • Review procedures for ensuring the participant has been provided information regarding available community resources; • Survey participants regarding quality of care issues; • Observe the participant's living arrangements, with consideration for the participant's safety in the home; • Review the individual emergency back-up plan with the participant; and • Review policies and procedures for addressing reportable events, incidents, complaints, and fair hearings. SEP 292009 TN No. 09-006 Approval Date: _ Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement ~ to Attachment 3.l-B Page 14 State Plan Under Title XIX ofthe Social Security Act STATE/TERRITORY: CALIFORNIA During the county office segment of the site visit, CDSS QA staff review the case narratives to identify possible issues. These issues include provider problems, timesheet issues or questions related to the participant's assessment/reassessment needs. CDSS QA staff evaluate the issues raised in the call and the county responses. The reviewer can immediately bring the issues to the attention of county QA staff. Alternatively, CDSS staff may make comments and/or recommendations to the county at the conclusion of the county review. These comrnentslrecomrnendations are given to the county QA staff to ensure follow up with the participant's social worker. The CDSS QA staff may question an issue identified during monitoring that triggers an investigation. An investigation may take the form oftargeted reviews and, where appropriate, reinforcement ofacceptable levels ofcompliance. For example, counties must maintain a completion rate of 90% for reassessments. Failure to comply results in a CDSS corrective action letter that is sent to the -county welfare director. Similarly, if county Quarterly Reports show significant levels offraud, provider overpayments, or cases with 300+ paid provider hours (283 hours per month is the statutory limit in California), a targeted review is conducted by CDSS QA staff to identify the cause ofthe problem(s) and determine if corrective action is needed. Areas of focus for targeted reviews can be: • Cases with 300+ paid provider hours; • Compliance level for reassessments; • Cases that may have been underpaid; • Suspected fraudulent activity; • Cases identified as overpaid (other than fraud); • Cases identified with participant neglect or abuse; and • Cases with Adult Protective Services (APS)/Child Protective Services (CPS) referrals. For the home visits, CDSS QA staff accompanies county QA staff. The visits are planned to allow observation of a sample designed to validate case file information and to ensure participant needs have been assessed correctly. TN No. 09-006 Approval Date: SEP , 9 ?nnq _ Effective date: October I, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement ~ to Attachment 3.1-B Page 15 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA The State's annual monitoring visit concludes with a face-to-face discussion among State and county QA staff. The topics covered are best practices, how state requirements were met, and positive findings and/or needed improvements. CDSS QA staff provide any necessary technical assistance at the time of the meeting or at a future date. The CDSS conducts monthly electronic data reviews in the State office. Data review activities include analysis of: • CMIPS Online Reports including CMIPS ad hoc reporting for targeted data collection and review; • Error-rate studies (verification of provider payments using CMIPS and MIS/DSS or data provided by the California Department of Health Care Services (DHCS); • Payments for deceased recipients; • Out-of-state (provider or participant or either/both) payments; • In patient hospital stay over 5 days; and • Death match review using Vital Statistics/Social Security Administration (SSA) data. Remediation The complete array of information collected during the discovery process forms the basis for the remediation actions that are taken by CDSS QA staff. Staff use this information to evaluate, improve and refine the quality of the program provided to participants. The issues discovered during a county visit are addressed by CDSS QA staff during the exit interview with county QA staff. The county is advised that CDSS QA staff are available to work with the county QA staffto remediate the issue(s), as well as to provide technical assistance with developing the annual QA plan, which along with all county-visit documents are included in the county annual visit file. Upon return to the State office, CDSS QA staff compose a findings letter that documents the site visit findings and the exit interview. Feedback is also SEP 292009 TN No. 09-006 Approval Date: _ Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement ~ to Attachment 3.1-B Page 16 State Plan Under Title XIX of the Social Security Act STATEITERRITORY: CALIFORNIA provided in the fonn of a monitoring summary. Both the findings letter and the monitoring summary may contain positive feedback and negative issues. The material is sent to the county welfare director. Copies are sent to the county QA staff, the IHSS program manager and other appropriate staff. In preparation for subsequent county monitoring visits, CDSS QA staff review any existing monitoring documentation and corrective action plans to ensure the county has initiated the required quality improvement measures in the areas identified during previous visits. System Improvement Data analysis is used to detennine whether an issue identified during discovery is county specific or statewide. When a systemic issue or a trend is identified, actions are taken by CDSS QA staff to move toward resolution. Measures with the potential to be the most effective and that foster continuous system improvement processes are developed for the program. Based on the detennination, an appropriate remediation measure is identified. The CDSS QA staff use the face-to-face exit interview with the county as the initial opportunity to share infonnation with county staff regarding problems or issues that appear to be systemic. Subsequently, the county is sent a written findings follow-up report. Some issues documented in the report may require technical assistance from CDSS QA staff and corrective action by the county. When CDSS requests a QIAP from a county, the county must include in their QIAP how and when an issue will be resolved. The QIAP is due to CDSS from the county within 30 days of receipt of the request. The QIAPs are reviewed and approved by CDSS staff. County progress toward continuous improvement is monitored via regular communication between the county and CDSS staff. A copy of the QIAP is forwarded to DHCS within 60 days ofthe end of the quarter in which it was received by CDSS. When statewide systemic issues and trends are identified, CDSS QA staff initiate an all-county distribution of an ACIN or an All County Letter (ACL) that contains pertinent infonnation regarding problem areas and states the actions needed for SEP 292009 TN No. 09-006 Approval Date: _ Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement .l to Attachment 3.1-B Page 17 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA resolution and continuous system improvement statewide. This is accomplished through: • Updating regulations, as needed; • QA monitoring visits to all counties; • Presenting at CWDA regional meetings; • Attending monthly regional QA meetings; • Conducting workshops at annual CWDA Conferences; • Attending monthly Long-Term Care Operations meetings; • Updating the program material in the IHSS Training Academy; and • Issuing statewide policy directives that reflect systemic issues and system improvement. The goal for each activity is to promote remediation and system improvement statewide. B. The system performance measures, outcome measures, and satisfaction measures that the State will monitor and evaluate. The following are the performance measures set forth for the self-directed PAS State Plan Amendment. CDSS Statewide Petformance Measures Performance measures are an important element of the CDSS QAlQI plan design. The measures are designed to determine the effectiveness and functionality of the program and to identify areas where attention should be focused to assure improved outcomes. When the measures are applied and the results analyzed, these performance measures provide information used in making recommendations for continuous system improvement. The following are performance measures that focus on the QAlQI plan target areas, participant health and welfare and financial accountability. TN No. 09-006 Approval Date: SEP 29 2009 Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement -L to Attachment 3.1-B Page 18 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA Participant Health and Welfare Performance Measure 1: Face-to-Face Visits Desired Outcome: A participant and hislher caseworker have a face-to-face visit at least once a year. la QA Function: CMIPS data is reviewed by CDSS staffto ensure that this visit is occurring within the 12-month timeframe for participants. 2a CDSS QA Function: CDSS QA staff review case files to confirm that this visit is occurring within the 12-month timeframe for participants. Performance Measure la - County Face-to-Face Visit Calculation . # of statewide cases with face-to-face visits completed within 12 months / # of statewide cases = % of statewide compliance Performance Measure Ib - CDSS QA Face-to-FaceVisitCalcula.tib1i # of statewide cases reviewed with face-to-face visits completed within 12 months / # of statewide cases reviewed = % of statewide compliance Performance Measure 2: Emergency Back-Up Plans Desired Outcome: An emergency back-up plan is in place for each participant. During the initial and annual face-to-face visits, a participant and hislher case worker collaborate to determine the best plan for the participant. Together, the participant and the case worker complete or update the Emergency Back-Up Plan form (SOC 827) to capture the action elements of the back-up plan. A copy of the completed form is retained by the participant, ideally in a readily accessible location. The case worker places a second copy of the form in the participant's case file. QA Function: County and CDSS QA staff review case files to confirm that an emergency back-up plan is in place and a copy of the Emergency Back-Up Plan form is present in each participant's case file. During a home visit, QA staff confirm that the participant possesses an up-to-date copy oftheir plan. TN No. 09-006 Approval Date: SEP ? 9 ?nnq Effective date: October 1, 2009 Supersedes TN No. None

OMS Approved 0938-1024 Supplement ~ to Attachment 3.1-B Page 19 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA # of statewide cases reviewed that includes a completed Emergency Back-Up Plan / # of statewide cases reviewed = % of statewide compliance i;IIII_~~;'; # of statewide cases reviewed that includes a completed Emergency Back-Up Plan / # of statewide cases reviewed = % of statewide compliance Peiformance Measure 3: Critical Incidents A critical incident is one in which there is an immediate threat to the health and/or safety of a participant. Critical incidents include, but are not limited to: serious injuries caused by accident, medication error/reaction; physical, emotional or financial abuse or neglect. Desired Outcome: When a critical incident occurs, the county social service staff responds appropriately and notes the incident in the case file, and the resolution, if known. QA Function: County and CDSS QA staffreview case files for evidence of critical incidents and the resolution, if stated. # of statewide cases reviewed that include a critical incident / # of statewide cases reviewed = % of statewide cases involving critical incidents # of statewide cases reviewed that include a critical incident / # of statewide cases reviewed = % of statewide cases involving critical incidents TN No. 09-006 SEP , 9 ,nnq Approval Date: _ Effective date: October 1, 2009 Supersedes TN No. None

OMS Approved 0938-1024 Supplement ---..L to Attachment 3.1-B Page 20 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA # of statewide cases reviewed with a resolved critical incident / # of statewide cases reviewed that include a critical incident = % of statewide resolution Outcome Measure 1: County Plans Desired Outcome: Counties are in compliance with their annual County QA/QI Plan. QA Function: Prior to a county monitoring visit, CDSS QA staffreview the county's annual QA/QI plan, quarterly reports, and any other information available. Upon completion of the county visit, CDSS QA staff determine the extent to which the county is in compliance with their annual plan based on data gathered from the case reviews and home visits. # ofcounties in compliance with their County QA/QI Plan / # of counties that have submitted their QA/QI Plan = % of statewide compliance Outcome Measure 2: QA Improvement Action Plans (QAIPs) Desired Outcome: All counties with a QAIP make the indicated corrections and institute the plan recommended by CDSS. QA Function: Upon completion of the county visit, if there are issues that CDSS discovers, a QAIP may be in order. If so, CDSS will issue a QAIP and request that the county explain how it will improve the issue(s). Upon completion of the next county visit, CDSS QA monitoring staff determines whether the county instituted the QAIP recommended by CDSS. # ofcounties with instituted QAIPs / # ofcounties with QAIPs = % of statewide compliance TN No. 09-006 Approval Date: SEP 2 9 2009 Effective date: October 1, 2009 Supersedes TN No. None

OMS Approved 0938-1024 Supplement --L to Attachment 3.1-B Page 21 State Plan Under Title XIX of the Social Security Act STATEITERRITORY: CALIFORNIA Satisfaction Measure 1: Customer Service Evaluation Desired Outcome: Program participants are satisfied their in-home care needs are being met by the program, they are able to contact the appropriate people when needed, and are able to satisfactorily self-direct their services. QA Function: Appropriate questions will be created and asked to participants regarding their satisfaction of the program, services and self-direction options. Upon completion of each survey, percentages will be calculated and reviewed. QA will then use this data to determine if changes in the program are needed. The survey(s) will be comprehensive and the results will be validated. Data Collection Methods Data collected for the performance measures (one through five) are obtained during the county and CDSS case reviews and home visits. County data are reported to CDSS in the County QA Quarterly Reports. CDSS data are collected throughout the year and included in the CDSS QA Monitoring Summary. Sampling Approach The methodology for sampling the QA/QI-related data is consistent with the statistically valid sample calculator described at the Raosoft website: www.raosoft.com/samplesize. The Sample Size Calculator was suggested by CMS. A statistically valid sample of the population of 26,000, with a 5% margin of error, is 379 cases. This will be the minimum number of case files reviewed for this population each fiscal year. Counties have the flexibility to determine a sampling approach, however, each county is required to have at a minimum 250 cases reviewed and 50 home visits conducted, per QA position. The QA staff are to document the sampling approach in the annual county QA/QI plan. During the county plan approval process, CDSS QA staff work with the county QA staff to verify a reasonable sampling approach based on the CDSS QA guidelines. TN No. 09-006 Approval Date: SEP 29 2009 Effective date: October 1, 2009 Supersedes TN No. None

OMS Approved 0938-1024 Supplement ~ to Attachment 3.1-B Page 22 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA Frequency of Data Collection Data collection takes place annually and on an ongoing basis within each aspect ofthe program. Performance measure data will be finalized at the end ofeach State fiscal year and available upon request. Counties work throughout the year to meet their individual targets and goals to assure maximum review. CDSS QA monitoring staffvisit all 58 counties each year. Roles and Responsibilitiesfor Data Collection County QA staff are responsible for gathering data in keeping with the criteria set forth in the annual county QA plan. QA staff are also responsible for maintaining this data. Process for Tracking and Analyzing Collected Data Roles and Responsibilitiesfor Tracking andAnalyzing Collected Data Counties are responsible for tracking and analyzing data gathered during QA activities. Moreover, QA staff review online CMIPS data to identify program issues specific to that county. The methodology for tracking and analyzing these data can allow for ease in reporting on the SOC 824 form. County QA staff are responsible for assuring that the data are analyzed for trends and/or program shortfalls. The CDSS QA staff are responsible for tracking and analyzing data reported quarterly by the counties and gathered during CDSS QA county monitoring visits. CDSS staff analyze online CMIPS data and data reported on the quarterly SOC 824 forms to identify program issues specific to a particular county or statewide. xii. Risk Management A. The risk assessment methods used to identify potential risks to participants are described below. During the intake and reassessment process: 1. The social worker assesses participant's functional abilities in all activities ofdaily living utilizing the following process: SEP 292009 TN No. 09-006 Approval Date: _ Effective date: October I, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement ~ to Attachment 3.1-B Page 23 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA • County social service staff determines the participant's level of ability and dependence upon verbal or physical assistance by another for each of the program functions. • This assessment process evaluates the effect ofthe participant's physical, cognitive and emotional impairment on functioning. • The social service staffobserves the participant in their own environment. • Staffquantify the recipient's level of functioning using the following hierarchical five-point scale: Rank 1: Independent: able to perform function without human assistance, although the recipient may have difficulty in performing the function, but the completion of the function, with or without a device or mobility aid, poses no substantial risk to hislher safety. A recipient who ranks a "1 " in any function shall not be authorized the correlated service activity. Rank 2: Able to perform a function, but needs verbal assistance, such as reminding, guidance, or encouragement. Rank 3: Can perform the function with some human assistance, including, but not limited to, direct physical assistance from a provider. Rank 4: Can perform a function but only with substantial human assistance. Rank 5: Cannot perform the function, with or without human assistance. 2. A discussion of participant's living arrangements, during the face­ to-face visit, in the participant's home, the county social service staff evaluates the home for any potential hazards; how the TN No. 09-006 A 1D t pprova a e: SEP 2 9 2009 _ Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938·1024 Supplement --L to Attachment 3.l-B Page 24 State Plan Under Title XIX of the Social Security Act STATEITERRITORY: CALIFORNIA participant deals with ambulation issues, whether they use assistive devices, what their shared living arrangement is, whether there are other individuals (non-providers) to help, etc. 3. A discussion ofthe participant's support system, during the face­ to-face visit a discussion occurs with the participant regarding who they would like to have involved in their care. Do they want a representative, a supports broker/consultant, or any other individual such as a neighbor or friend included in all discussions. 4. The social worker/case manager reviews all documents pertaining to the participants physical or mental condition to identify potential risks to participants, and 5. Designated coding of CMIPS to indicate the participants' special needs during an emergency. • The participants' special needs are coded in CMIPS to allow county social service staff, in the event of an emergency or natural disaster, to inform first responders which participants need to be checked on first, and their special needs, e.g. insulin. B. The tools or instruments used to mitigate identified risks are described below: • Program Uniform Assessment Tool- The process described in A. 1., above helps the social worker and participant identify and mitigate risks that may be present. If risks cannot be or are not chosen to be mitigated, risk may be assumed by the participant during this process. • Emergency Back-Up Plan - This tool is completed during the assessment process with input from the participant and their chosen representative. This tool identifies the participants' support system, addresses back-up plan to mitigate risks, and allows the participant to understand their roles and responsibilities in obtaining self-directed PAS. • RecipientlEmployer Responsibility Check-List - This tool ensures that the recipient understands their responsibilities as the employer oftheir service provider. SEP 2 9 2009 TN No. 09-006 Approval Date: _ Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement ~ to Attachment 3.1-B Page 25 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA • Criminal & Worker Background Checks - Counties perfonn background and references checks for all providers wishing to be listed on the Provider Registry. C. The State's method of ensuring that each service plan reflects the risks that an individual is willing and able to assume, and the plan for how identified risks will be mitigated is described below. The process used for ensuring that each service plan reflects the risks that an individuals' willing and able to assume is as follows: • All tools and instruments used to idelltify, mitigate and assume risks become part of the participants' case file. • The service plan is developed utilizing all documents contained in the case file. The plan for how identified risks will be mitigated is as follows: • The social worker discusses with each individual the risks identified and how they may be mitigated. For example, the following are potential ways a social worker and participant may work together to mitigate potential risks: 1) If there is an extension cord lying across a walk path, the social worker and participant (and/or their representative) will discuss what to do to mitigate the risk. Options may be to move the cord to a different place, purchase a newer, longer cord to allow the cord to be placed out of the way or move the item plugged into the cord to a different place, and thereby mitigating the risk. 2) A participant is having slipping troubles in the shower needs some sort of help. The social worker and participant (and/or their representative) will discuss what to do to mitigate the risk. Options may be, putting in slip guards, and/or handrails, and thereby mitigating the risk. A participant, with a mental impainnent, plays with the knobs on the stove. The social worker and participant (and/or their representative) will discuss what to do to mitigate the risk. TN No. 09-006 Approval Date: SEP 292009 _ Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement -L to Attachment 3.1-B Page 26 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA Options may be to take the knobs off the stove, make the stove inaccessible to the participant, and thereby mitigating the risk. 4) A participant needs oxygen treatments and there is a power outage. The social worker and participant can discuss what to do to mitigate this risk. Options, Social Worker codes the special need in CMIPS to ensure first response notification, identify neighbors or friends who can check up on participant in case of an emergency or natural disaster, etc. If a risk cannot be mitigated, such as a person has troubles with stairs due to their impairment, but chooses not to move to a one-level home with no stairs, they can assume this risk during the discussion. D. The State's method for ensuring that the risk management plan is the result of discussion and negotiation among the persons designated by the State to develop the service plan, the participant, the participant's representative, if any, and others from whom the participant may seek guidance, is described below. • Others that participants may include in the discussions and negotiations include family, friends and professionals (as desired or required). County social services staffhave been trained to provide support to participants. Examples of the variety of support they offer are: • During the intake and screening process, the county social services staff assists participants (and/or their representative) with access to services and provides information about other community programs available (e.g. a participant needs a walker, the social worker would refer them to the appropriate entity); • Face-to-face assessments and reassessments take place in the participant's residence. This enables county social services staff to visit with the participants (and/or their representative) and observe them in a setting where they are comfortable. They will also discuss concerns and safety issues. The resulting assessments are more reflective ofthe participants' needs; • County social services staff visit participants who are in hospitals and nursing facilities to develop a transition plan to allow the participant to safely return home; TN No. 09-006 Approval Date: _SE_P_2_9_2_00_9 Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement ~ to Attachment 3.1-B Page 27 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA • County social services staff explain the rights and responsibilities of the employer/employee relationships; • Act as a point of contact for participants (and/or their representative) who need to contact the county office with questions or problems; • Refer participants (and/or their representative) to other community resources when participant's care needs exceed the scope of services or hours permitted under the program; and • Work with the participant (and/or their representative) and provider to resolve emergency payroll situations. • Participants and providers handbooks are available to inform individuals of their roles, responsibility and program details, including: o Participant - roles as employer, supervising provider, communicating with provider, timesheet responsibilities, etc. o Provider - Goals of the program, hiring process, understanding their responsibilities, etc. • If a risk is identified, such as the following, a discussion takes place to identify ways to mitigate the issues. o A throw rug is on a slippery surface. o An extension cord is lying across a walk path. o A participant is having slipping troubles in the shower. o A participant, with a mental impairment, plays with the knobs on the stove. Xlll. Qualifications of Providers of Personal Assistance A. X The State elects to permit participants to hire legally liable relatives, as paid providers of the personal assistance services identified in the service plan and budget. B. __ The State elects not to permit participants to hire legally liable relatives, as paid providers of the personal assistance services identified in the service plan and budget TN No. 09-006 Approval Date:SEP 29 2009 Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement -----L to Attachment 3.1-B Page 28 State Plan Under Title XIX ofthe Social Security Act STATE/TERRITORY: CALIFORNIA xiv. Use of a Representative A. X The State elects to permit participants to appoint a representative to direct the provision ofself-directed personal assistance services on their behalf. i. __ The State elects to include, as a type of representative, a State­ mandated representative. Please indicate the criteria to be applied. B. __ The State elects not to permit participants to appoint a representative to direct the provision of self-directed personal assistance services on their behalf. xv. Permissible Purchases A. X The State elects to permit participants to use their service budgets to pay for items that increase a participant's independence or substitute for a participant's dependence on human assistance. This will be limited to those participants choosing the Restaurant Meal Allowance (RMA). • RMA allows the participant to use their service budget for meal preparation, meal clean-up, and shopping for food, to purchase restaurant meals. • Individuals who do not have assessed needs for the above services would not be eligible for RMA. • RMA is a self-directed option for participants that increases their independence and is a substitute for their dependence on human assistance. • RMA fits within the self-directed principles and provides participants greater choice. B. The State elects not to permit participants to use their service budgets to pay for items that increase a participant's independence or substitute for a participant's dependence on human assistance. TN No. 09-006 Approval Date: SEP 2 9 2009 _ Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938-1024 Supplement ~ to Attachment 3.1-B Page 29 State Plan Under Title XIX ofthe Social Security Act STATE/TERRITORY: CALIFORNIA XVI. Financial Management Services A. __ The State elects to employ a Financial Management Entity to provide financial management services to participants self-directing personal assistance services, with the exception of those participants utilizing the cash option and performing those functions themselves. i.__ The State elects to provide financial management services through a reporting or subagent through its fiscal intermediary in accordance with section 3504 of the IRS Code and Revenue Procedure 80-4 and Notice 2003-70; or U._ The State elects to provide financial management services through vendor organizations that have the capabilities to perform the required tasks in accordance with Section 3504 of the IRS Code and Revenue Procedure 70-6. (When private entities furnish financial management services, the procurement method must meet the requirements set forth by Federal regulations in 45 CFR section 74.40 - section 74.48.) Ui.__ The State elects to provide financial management services using "agency with choice" organizations that have the capabilities to perform the required tasks in accordance with the principles of self­ direction and with Federal and State Medicaid rules. B. X The State elects to directly perform financial management services on behalf of participants self-directing personal assistance services, with the exception of those participants utilizing the cash option and performing those functions TN No. 09-006 Approval Date: _ Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938·1024 Attachment 4.1 9 -B Page 26 Slate Plan Under Title XIX ofthe Social Security Act STATE/TERRITORY: CALIFORNIA REIMBURSEMENT FORMEIJ[·CAL PERSONAL CARE SERVICES A. GENERAL PROVISIONS Medi-Cul Personal Care Services (referred to in this document as Personal Care Services) are services provided pursuant to 42 Code of Federal Regulations 440.167 in accordance with the rules and regulations of the California Department of Health Care Services and the California Department of Social Services. B. REIM BURSEMENT RATE LIMITAnONS FOR PERSONAL CARE SERVICES (l) A county may contract with an agency ofa city. county. or city and county, a local health district, a voluntary nonprofit agency. a proprietary agency. or an individual for the purpose of providing personal care services. The rate of reimbursement will be negotiated between the county and its contractor or its contractors, consistent with applicable regulations promulgated by the California Department of Social Services or the Department of Health Care Services. (2) The rate of reimbursement for individual providers will be negotiated between the provider union and the individual county. or the provider union and the public authorities/non-profit consortiums, as applicable. SEP 292009 TN No. 09-006 Approval Date: _ Effective date: October 1.2009 Supersedes TN No. 94-006

OMB Approved 0938-1024 Attachment 4.19-B Page 27 State Plan Under Title XIX of the Social Security Act STATE/TERRITORY: CALIFORNIA C. PUBLICATION OF INDIVIDUAL AND CONTRACTED PROVIDER RATES OF PERSONAL CARE SERVICES State approved county governmental, contracted, and private individual provider rates are documented in a fee schedule and that fee schedule was last updated on October I, 2009, and effective for services provided after that date. This fee schedule is published on the California Department of Social Services website at www.cdss.ca.gov/agedblinddisabled/PGI996.htm. TN No. 09-006 Approval Date.:....: SEP 2. 9 2009 _ Effective date: October 1, 2009 Supersedes TN No. None

OMB Approved 0938·1024 Attachment 4.19 -B Page 28 State Plan Under Title XIX ofthe Social Security Act STATEITERRITORY: CALIFORNIA D. PAYMENTS AND UNITS OF SERVICE (1) Reimbursements for services will be made only to providers authorized by the California Department of Social Services to provide Personal Care Services to beneficiaries. The rates will be based upon a time-based unit of service. The time·based unit of service is per minute based on 60 minutes per hour. (2) The methodology for determining the beneficiary's service budget is based on the assessment of needs for the beneficiary and the development of the service plan. The cost of providing the services included in the service plan is calculated based on the expected reimbursement for such services under the state plan and is adjusted to account for the self-directed services delivery model served in the Sec. 1915 [42 U.S.C. 1396n] G) program. In cases where the beneficiary chooses not to have the assessed Personal Care Services of meal preparation, meal cleanup and/or shopping tor food services provided in-home, the beneficiary can choose to have their service budget reduced by the amount calculated based on hours allocated for these services and reimbursement of S15.50 per week per person or $31 per week per couple is provided for meal preparation. meal cleanup and/or shopping for fbod related activities in the Sec. 1915 (42 U.S.C. 13960] G) program. SEP 292009 TN No. 09-006 Approval Date: _ Effective date: October 1, 2009 Supersedes 'IN No. 94-006

Attachment 4.19-B Page 29 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: CALIFORNIA RESERVED FOR USE TN No. 09-006 SEP 2 9 200Q . Supersedes Approval Date ~ffectlve Date: October 1, 2009 TN No. 94-006

Attachment 4.19-B Page 30 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: CALIFORNIA RESERVED FOR USE TN No. 09-006 SEP 2920no Supersedes Approval Date ~1fective Date: October 1, 2009 TN No. 94-006

Attachment 4.19-8 Page 31 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: CALIFORNIA RESERVED FOR USE TN No. 09-006 Supersedes Approval Date SEP ? 9 20D9fective Date: October 1, 2009 TN No. 94-006

Attachment 4.19-8 Page 32 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: CALIFORNIA RESERVED FOR USE TN No. 09-006 SEP , 920nQ Supersedes Approval Date . ~rfective Date: October 1, 2009 TN No. 94-006

Attachment 4.19-B Page 33 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: CALIFORNIA RESERVED FOR USE TN No. 09-006 SEP 2920nQ Supersedes Approval Date ~rfective Date: October 1, 2009 TN No. 94-006

Attachment 4.19-B Page 34 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: CALIFORNIA RESERVED FOR USE TN No. 09-006 SEP ? 92009 Supersedes Approval Date Effective Date: October 1, 2009 TN No. 94-006

Attachment 4.19-8 Page 35 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: CALIFORNIA RESERVED FOR USE TN No. 09-006 Supersedes Approval Date SEP 29 2~ective Date: October 1, 2009 TN No. 94-006

Attachment 4.19-8 Page 36 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: CALIFORNIA RESERVED FOR USE TN No. 09-006 Supersedes Approval Date SEP '- 9 20~fective Date: October 1, 2009 TN Nu. 94-006

Attachment 4.19-8 Page 37 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: CALIFORNIA RESERVED FOR USE TN No. 09-006 Supersedes Approval Date SEP 29 ZY0gective Date: October 1, 2009 TN No. 94-006

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMS NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL 1. TRANSMITTAL NUMBER: 09-006 2. STATE CALIFORNIA FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE Att~!It..].,2QQ9 P2V)~i.'\K Cho..nc(e' cttb\gef I, zOOq 5. TYPE OF PLAN MATERIAL (Check One): o NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN [8J AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT Se arate Transmittal or each amendment) 6. FEDERAL STATUTEIREGULATION CITATION: 42 CFR Part 441 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Attachment 3.1 7. FEDERAL BUDGET IMPACT: a. FFY 2009-2010 $0.00 b. FFY 2010-2011 $0.00 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (IfApplicable): 10. SUBJECT OF AMENDMENT: The approved five-year 1115 Demonstration project for the In-Home Supportive Services Plus Waiver is set to expire July 31, 2009. eMS will no longer renew or approve 1115 Demonstrations for Personal Assistance Services (PAS). The 1915(j) is being submitted for consideration and transferring all IHSS Plus clients into the 1915(j) State Plan Option. 11. GOVERNOR'S REVIEW (Check One): o GOVERNOR'S OFFICE REPORTED NO COMMENT [8J OTHER, AS SPECIFIED: o COMMENTS OF GOVERNOR'S OFFICE ENCLOSED The Governor's Office does not o NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL wish to review the State Plan Amendment. 16. RETURN TO: Department of Health Care Services ----:-,----:::=-::::c----.c::....:.."'-"-----'-C-I:l.--------------j Attention: State Plan Coordinator 14. TITLE: 1501 Capitol Avenue, Third Floor _______....:::C:..:.:h::;:ie:.::...f=D-=.Jer:..:u::..::toL..=.D.:..:ir..:..ec=..:t..:..:or=---- Sacramento, CA 95814 15. DATE SUBMITTED: 13. TYPED NAME: Tob Dou las FORM HCFA-I79 (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 SEP 2 ~ 2009 Toby Douglas Chief Deputy Director of Health Care Programs California Department of Health Care Services 1501 Capitol Avenue, MS 0002 P.O. Box 997413 Sacramento, CA 95899-7413 Dear Mr. Douglas: Enclosed is an approved copy of California State plan amendment (SPA) No. 09-010, effective July 1,2009. This SPA implements a new coverage group for individuals who would otherwise qualify for Medi-Cal benefits under the Pickle Amendment through the use ofmore liberal income disregards under Section 1902(r)(2) of the Social Security Act. This SPA adds page 9c2 to Attachment 2.2A and page 11 to Supplement 8a to Attachment 2.6A of the State plan. If you have any questions please contact Michelle Baldi at (415) 744-3656. Sincerely, ~----NLc­ .\\( Gloria Nagle, Ph.D., M.P.A. Associate Regional Administrator Division of Medicaid & Children's Health Operations cc: Kathryn Waje, California Department of Health Care Services Vivian Auble, California Department of Health Care Services Brenda Sheppard, Center for Medicaid and State Operations

Attachment 2.2-A Page 9c2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT StatefTerritory: California Sections 1634 [Fn 99], And 1902(a)(1 O)(A)(ii)(l) of the Social Security Act 42 CFR, Sections 435.210 and 435.135 Individuals Otherwise Eligible Under The Pickle Amendment Beginning on July 1, 2009, aged, blind or disabled individuals who would otherwise be eligible for Medi-Cal benefits under the Pickle Amendment if not for the July 1, 2009 reduction in the SSI/SSP payment levels, and any subsequent SSI/SSP payment level reductions, will be eligible if their income and resources, applying the methodologies of • the SSI/SSP program, and • more liberal income methodologies described in Supplement 8a of Attachment 2.6-A, Page 11 are under the standards of the SSI/SSP program. This program shall remain in effect until and unless the SSI/SSP payment levels increase to a point that is above the levels in effect on June 30,2009. TN No. 09-010 Approval Date: SEP 2 ~ 2009 Effective Date: July 1! 2009 Supersedes TN No. None

Supplement 8a to Attachment 2.6-A Page 11 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT StatefTerritory: California METHODOLOGIES FOR TREATMENT OF INCOME THAT DIFFER FROM THOSE OF THE SSI/SSP PROGRAM (Less Restrictive Than SSI/SSP) Beginning on July 1, 2009, an amount of otherwise countable income equal to the difference between the applicable SSI/SSP payment level and the applicable SSI/SSP payment level in effect on June 30, 2009 shall be exempt until and unless the SSIISSP payment levels increase to a point that is above the levels in effect on June 30, 2009. The methodologies under the Pickle Amendment shall also apply. These exemptions shall be applied to the following coverage groups: • 1902(a)(1 O)(A)(ii)(I) - Individuals Otherwise Eligible Under The Pickle Amendment (See Attachment 2.2-A, Page 9c2) TN No. 09-010 Approval Date:-SEP 242009 Effective Date: July 1! 2009 Supersedes TN No. None

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMS NO. 0938-0193 2. STATE CA TRANSlVIITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: STATE PLAN MATERIAL 09-010 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE FOR: HEALTH CARE FINANCING ADMINISTRAnON SOCIAL SECURITY ACT (MEDICAID TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES July 1, 2009 5. TYPE OF PLAN MATERIAL (Check One): D NEW STATE PLAN D AMENDMENT TO BE CONSIDERED AS NEW PLAN [g] AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Se arate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: Title XIX of the Social Security Act, Section 1902(r)(2) a. FFY 2009-2010 $ None Title XIX of the Social Security Act, Section 1902(a)(10)(A)(ii)(I) b. FFY 2010-2011 $ None 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (IfApplicable): Attachment 2.2-A N/A Page 9c2 Supplement 8a to Attachment 2.6-A Page 11 10. SUBJECT OF AMENDMENT: New Program and Income Exemption for those Individuals Who Would Otherwise Be Eligible Under the Pickle Amendment 11. GOVERNOR'S REVIEW (Check One): D GOVERNOR'S OFFICE REPORTED NO COMMENT [g] OTHER, AS SPECIFIED: D COMMENTS OF GOVERNOR'S OFFICE ENCLOSED The Governor's Office does not D NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL wish to review the State Plan Amendment. 16. RETURN TO: 13. TYPED N Tob Dou las Department of Health Care Services Attn: State Plan Coordinator 1501 Capitol Avenue, Suite 71.3.26 P.O. Box 997417 Sacramento, CA 95899-7417 14. TITLE: Chief De ut Director 15. DATE SUBMITTED: FOR REGIONAL OFF~IC,::.;E:;:....;:U..::S.::::E.....:O:...:N.....:L::..Y~--=-,------ _ 17. DATE RECEIVED: 18. DATE APPROVED: July 8, 2009 1 Of· ?j. 'tA>01 PLAN APPROVED - ONE COpy ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGN F REGIONAL OFFICIAL: 2 (rU ~ft 21. TYPED AME: 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 SEP 2 ~2009 Toby Douglas Chief Deputy Director of Health Care Programs California Department of Health Care Services 1501 Capitol Avenue, MS 0002 P.O. Box 997413 Sacramento, CA 95899-7413 Dear Mr. Douglas: Enclosed is an approved copy of California State plan amendment (SPA) No. 09-011, effective July 1,2009. This SPA implements a new coverage group for individuals who would otherwise qualify for Medi-Cal benefits as Childhood Disability Beneficiaries through the use ofmore liberal income disregards under Section 1902(r)(2) ofthe Social Security Act. This SPA adds page 9c3 to Attachment 2.2A and page 12 to Supplement 8a to Attachment 2.6A of the State plan. If you have any questions please contact Michelle Baldi at (415) 744-3656. Sincerely, t<- Gloria Nagle, Ph.D., M.P.A. Associate Regional Administrator Division of Medicaid & Children's Health Operations cc: Kathryn Waje, California Department of Health Care Services Vivian Auble, California Department of Health Care Services Brenda Sheppard, Center for Medicaid and State Operations

Attachment 2.2-A Page 9c3 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT StatelTerritory: California Sections 1634(c) And 1902(a)(10)(A)(ii)(I) of the Social Security Act Individuals Otherwise Eligible As Childhood Disability Beneficiaries. Beginning on July 1, 2009 blind or disabled individuals who would otherwise be eligible for Medi-Cal benefits as Childhood Disability Beneficiaries if not for the July 1, 2009 reduction in the SSIISSP payment levels, and any subsequent SSI/SSP payment level reductions, will be eligible if their income and resources, applying the methodologies of • the SSI/SSP program, and • more liberal income methodologies described in Supplement 8a of Attachment 2.6-A, Page 12. are under the standards of the SSI/SSP program. This program shall remain in effect until and unless the SSI/SSP payment levels increase to a point that is above the levels in effect on June 30,2009. TN No. 09-011 Approval Date: SEp 24 2009Effective Date: July 1, 2009 Supersedes TN No. None

Supplement 8a to Attachment 2.6-A Page 12 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT StatefTerritory: California METHODOLOGIES FOR TREATMENT OF INCOME THAT DIFFER FROM THOSE OF THE SSI/SSP PROGRAM (Less Restrictive Than SSI/SSP) Beginning on July 1, 2009 an amount of otherwise countable income equal to the difference between the applicable SSI/SSP payment level and the applicable level in effect on June 30, 2009 shall be exempt until and unless the SSI/SSP payment levels increase to a point that is above the levels in effect on June 30, 2009. The methodologies applied for Childhood Disability Benefits under Section 1634(c) of the Social Security Act shall also apply. These exemptions shall be applied to the following coverage groups: • 1902(a)(1 O)(A)(ii)(I) - Individuals Otherwise Eligible for Childhood Disability Benefits (See Attachment 2.2-A, Page 9c3) TN No. 09-011 Approval Date:--S£p ~ 4 2009 Effective Date: July 1, 2009 Supersedes TN No. None

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE fiNANCING ADMINISTRATION OMS NO 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL 1. TRANSMITTAL NUMBER: 09-011 2. STATE CA FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE July 1, 2009 5. TYPE OF PLAN MATERIAL (Check One): o NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN ~ AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Se arate Transmittal or each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: Title XIX of the Social Security Act, Section 1902(a)(1O)(A)(ii)(I) a. FFY 2009-2010 $ None Title XIX of the Social Security Act, Section 1902(r)(2) b. FFY 2010-2011 $ None 8. PAGE NUMBER OF THE PLAN SECTION OR AITACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (IfApplicable): Attachment 2.2-A N/A Page 9c3 Supplement 8a to Attachment 2.6-A Page 12 10. SUBJECT OF AMENDMENT: Individuals Otherwise Eligible as Disabled Adult Children 11. GOVERNOR'S REVIEW (Check One): o GOVERNOR'S OFFICE REPORTED NO COMMENT ~ OTHER, AS SPECIFIED: o COMMENTS OF GOVERNOR'S OFFICE ENCLOSED The Governor's Office does not o NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL wish to review the State Plan Amendment. 13. TYPEDNA Toby Douglas 16. RETURN TO: Department of Health Care Services Attn: State Plan Coordinator 1501 Capitol Avenue, Suite 71.3.26 P.O. Box 997417 Sacramento, CA 95899-7417 14. TITLE: Chief De ut Director 15. DATE SUBMITTED: FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: U 7. 2009 0).2-'-4. '2..-z)U"\ PLAN APPROVED - ONE COPY ATTACHED 21. TYPED NAME: 22. TITLE: 1 e Ph 0 P Associate dmfnistrator DMCHO 23. REMARKS: 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 SEP 24 2009 Toby Douglas Chief Deputy Director of Health Care Programs California Department of Health Care Services 1501 Capitol Avenue, MS 0002 P.O. Box 997413 Sacramento, CA 95899-7413 Dear Mr. Douglas: Enclosed is an approved copy of California State plan amendment (SPA) No. 09-012, effective July 1,2009. This SPA implements a new coverage group for individuals who would otherwise qualify for Medi-Cal benefits as Disabled Widow(er)s or Early Disabled Widow(er)s through the use of more liberal income disregards under Section 1902(r)(2) of the Social Security Act. This SPA adds page 9c4 to Attachment 2.2A and page 13 to Supplement 8a to Attachment 2.6A ofthe State plan. If you have any questions please contact Michelle Baldi at (415) 744-3656. Sincerely, ~(Gloria Nagle, Ph.D., M.P.A. Associate Regional Administrator Division of Medicaid & Children's Health Operations cc: Kathryn Waje, California Department of Health Care Services Vivian Auble, California Department of Health Care Services Brenda Sheppard, Center for Medicaid and State Operations

Attachment 2.2-A Page 9c4 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT StatefTerritory: California Section 1634(a) and 1634(d) And 1902(a)(10)(A)(ii)(I) of the Social Security Act 42 CFR, Sections 435.137 and 435.138 Individuals Otherwise Eligible As Disabled Widow(ers) or Early Disabled Widow(er)s. Beginning on July 1, 2009 disabled individuals who would otherwise be eligible for Medi-Cal benefits as a Disabled Widow(er) or an Early Disabled Widow(er) if not for the July 1, 2009 reduction in the SSI/SSP payment levels, and any subsequent SSI/SSP payment level reductions, will be eligible if their income and resources, applying the methodologies of • the SSI/SSP program, and • more liberal income methodologies described in Supplement 8a of Attachment 2.6-A, Page 13 are under the standards of the SSI/SSP program. This program shall remain in effect until and unless the SSIISSP payment levels increase to a point that is above the levels in effect on June 30,2009. TN No. 09-012 Approval Date: SEP 24 2009 Effective Date: July 1, 2009 Supersedes TN No. None

Supplement 8a to Attachment 2.6-A Page 13 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Statefferritory: California METHODOLOGIES FOR TREATMENT OF INCOME THAT DIFFER FROM THOSE OF THE SSI/SSP PROGRAM (Less Restrictive Than SSI/SSP) Beginning on July 1, 2009 an amount of otherwise countable income equal to the difference between the applicable SSIISSP payment level and the applicable level in effect on June 30,2009 shall be exempt until and unless the SSIISSP payment levels increase to a point that is above the levels in effect on June 30, 2009. The methodologies applied to Disabled Widow(er)s or Early Disabled Widow(er)s under Section 1634, subsections (a) or (d), of the Social Security Act shall also apply. These exemptions shall be applied to the following coverage groups: • 1902(a)(10)(A)(ii)(l) - Individuals Otherwise Eligible As Disabled Widow(er)s or Early Disabled Widow(er)s (See Attachment 2.2-A, Page 9c4) SEP Z~2009 . TN No. 09-012 Supersedes TN No. None

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRAnON OMS NO. 0938-0193 ,TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL 1. TRANSMITTAL NUMBER: 09-012 2. STATE CA FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE July 1,2009 5. TYPE OF PLAN MATERIAL (Check One): D NEW STATE PLAN D AMENDMENT TO BE CONSIDERED AS NEW PLAN I:8J AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Se arate Transmittal or each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: Title XIX ofthe Social Security Act, Section 1902(a)(lO)(A)(ii)(I) a. FFY 2009-2010 $ None Title XIX of the Social Security Act, Section 1902(r)(2) b. FFY 2010-2011 $ None 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (IfApplicable): Attachment 2.2-A N/A Page 9c4 Supplement 8a to Attachment 2.6-A Page 13 10. SUBJECT OF AMENDMENT: Individuals Who Would Otherwise Be Eligible For The Early Disabled Widow(er)s Program 11. GOVERNOR'S REVIEW (Check One): D GOVERNOR'S OFFICE REPORTED NO COMMENT I:8J OTHER, AS SPECIFIED: D COMMENTS OF GOVERNOR'S OFFICE ENCLOSED The Governor's Office does not D NO REPLY RECEIVED WITHIN 45 DAY F SUBMITTAL wish to review the State Plan Amendment. 16. RETURN TO: 13. TYPEDN Tob Dou las 14. TITLE: Chief Deputy Director Department of Health Care Services Attn: State Plan Coordinator 1501 Capitol Avenue, Suite 71.3.26 P.O. Box 997417 Sacramento, CA 95899-7417 15. DATE SUBMITTED: FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: Ju ]. 2009 '1. 'Z--<t z"" "1 PLAN APPROVED - ONE COPY ATTACHED 20. SIGNATURE OF REGIONAL OFFICIAL: F1>1t­ (j-W l-t Pr t-JA-v~ 19. EFFECTIVE DATE OF APPROVED MATERIAL: 1 2 21. TYPED NAME: FORM HCFA-I79 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES Ccnrcrs for Medicare & Mcdit:aid Services --------------------------------------------------------------- Toby Douglas Rcg•on IX Division of Medicaid & Children' s lleahh Operali<m" 90 Seventh Street, Suite 5-300 (5W) San Francisco, CA 94103-()706 MAY 2 5 2010 Chief Deputy Director of Health Care Programs California Department of Health Care Services 1 50 l Capitol A venue, MS 0002 P.O. Box 997413 Sacramento, CA 95899-7413 Dear Mr. Douglas: Enclosed is an approved copy of California State plan amendment (SPA) No. 09-014, effective April 1, 2009. This SPA implements the option authorized by the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) to provide fulJ Medicaid coverage qualified alien children and pregnant women who are lawfully residing in the U.S .. but have either not met the 5-year waiting period or "5-year bar" under Section 403 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, or are non- qualified aliens lawfully residing in the U.S. who are other otherwise eligible for such assistance. This SPA amends Attachment 2.6A, pages 2-2b of the State plan. If you have any questions please contact Beverly Binkier at (415) 744-3580. Sincerely, Jpi- -J~ Gloria Nagle, Ph.D., M.P.A. Associate Regional Administrator Division of Medicaid & Children's Health Operations cc: Kathryn Waje, California Department of Health Care Services Vivian Auble, California Department of Health Care Services Bill Walsh, California Department of Health Care Services Bob Tomlinson, Center for Medicaid and State Operations

Revision: CMS-PM- State: CALIFORNIA A IT ACHMENT 2.6-A Page 2a OMB No.: ELIGffiiLITY CONDITIONS AND REQUIREMENTS Citation(s) Condition or Requirement (1) A "Qualified alien" otherwise subject to the 5-year waiting period per section 403 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996; (2) A citizen of a Compact ofFree Association State (i.e., Federated States of Micronesia, Republic ofthe Marshall Islands, and the Republic of Palau) who has been admitted to the U.S. as a non-immigrant and is permitted by the Department of Homeland Security to reside permanently or indefinitely in the U.S.; (3) An individual described in 8 CFR section l03.12(a)(4) who does not have a permanent residence in the country of their nationality and is in a status that permits the individual to remain in the U.S. for an indefinite period of time, pending adjustment of status. These individuals include: (a) An individual currently in temporary resident status as an Amnesty beneficiary pursuant to section 210 or 245A of the Immigration and Nationality Act (INA); (b) An individual currently under Temporary Protected Status pursuant to section 244 of the INA; (c) A family Unity beneficiary pursuant to section 301 of Public Law 101-649 as amended by, as well as pursuant to, section 1504 of Public Law 1 06-554; (d) An individual currently under Deferred Enforced Departure pursuant to a decision made by the President; and (e) An individual who is the spouse or child of a U.S. citizen whose visa petition has been approved and who has a pending application for adjustment of status; and (4) An individual in non-immigrant classifications under the INA who is permitted to remain in the U.S. for an indefmite period, including the following as specified in section 101 (a)(l5) of the INA: • A parent or child of an individual with special immigrant status under section l01(a)(27) of the INA, as permitted under section l0l(a)(15)(N) of the INA; • A Fiance of a citizen, as permitted under section 10l(a)(I5)(K) of the INA; • A religious worker under section 10 I (a)(l5)(R); TN No: 09-014 Supersedes TN No. 92-19 MAY 2 5 ?010 04/01/2009 Approval Date__ Effective Date ____ _

DEPARTMENT Of HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION FORM APPROVED OMB N0. 0938-0193 TRANSMITI ALAND NOTICE OF APPROY AL OF I. TRANSMITTAL NUMBER: 2. STATE California STATE PLAN MATERIAL 09-014 FOR: HEALTH CARE FINANCING ADMINISTRATION TO: REGIONAL ADMfNISTRATOR HEALTH CARE FiNANCING ADMlNlSTRA TION DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERJAL (Check One): 3. PROGRAM IDENTIFICA TJON: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE Aprill, 2009 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN 181 AMENDMENT COMPLETE BLOCKS 6 THRU I 0 IF THIS IS AN AMENDMENT (Se arate Transmittal or each amendment 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: 42 USC l396b(v)(4)(A) a. FFY 2009-1010 $ 487,000 b. FFY $ 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 61,.1Ja Attachment 2.6-A pages J4 ;_ .. ,_ b ~f> '?iJ y 10. SUBJECT OF AMENDMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Attachment 2.6-A pages l-3 Covering New Qualified Immigrant and Lawfully Present Pregnant Women and Children. 11. GOVERNOR'S REVIEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WJTHrN 45 DAYS OF SUBMITTAL ~OTHER. AS SPEClFJED: The Governor's Office does not wish to revi<:W the State Plan Amendment. 16. RETURN TO: -----.,.~~~~~-4,.ot::4 "---.."---~L-----1 Department of Health Care Services Attn: State Plan Coordinator """7":-==::?-=::ra=;:::;.._ _____ .....:..... _______ ~ I SOt Capitol Avenue, Suite 71.3.26 P.O. Box997417 ~~~~=:~~~=~==-.:=.::....::...;:..:;J0:==-------1 Sacramento CA 95899-7417 FOR REGIONAL omCE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: ~L OFFICIAL: 2 I. TYPED NAME: Gloria Nagle, Ph .D .• M. P.A. 23. REMARKS: FORM HCFA-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Toby Douglas, Director Region IX Division ofMedicaid & Children's Health Operations 90 Seventh Street, Suite 5-300 (5W) San Francisco, CA 94103-6706 SEP Q,g 2011 California Department of Health Care Services 1501 Capitol A venue, P.O. Box 997413, MS 0000 Sacramento, CA 95899-7413 Dear Mr. Douglas: Enclosed is an approved copy of California State Plan Amendment (SPA) Number 10-008a, which revises the target populations receiving services through the Targeted Case Management Program. SPA 1 0-008a targets categories of children under the age of 21. Previously California had defined target groups by the provider type delivering TCM services, and these revisions change the definition of the target group to the population targeted for services. The revisions conform to Centers for Medicare and Medicaid Services 2237-Final, which revised Title 42, Code of Federal Regulations, Parts 431,440 and 441. Attached are copies of the following new pages to be incorporated into your State Plan: Supplement 1a to Attachment 3.1-A, Pages 1-5 Supplement 1h to Attachment 3.1-A, Pages 1-5 Ifyou have any questions, please contact Rodd Mas at (415) 744-2978 or via email at rodd.mas@cms.hhs.gov. Enclosure Sincerely, ~J&v-,r, fen- Gloria Nagle, Ph.D., M.P.A. Associate Regional Administrator Division of Medicaid & Children's Health Operations cc: Vickie Orlich, California Department ofHealth Care Services Tracy Albano, California Department ofHealth Care Services Kathyryn Waje, California Department ofHealth Care Services Michael Tankersley, Centers for Medicare and Medicaid Services Susan Ruiz, Centers for Medicare and Medicaid Services

Supplement 1 a to Attachment 3.1-A Page 1 State Plan under Title XIX of the Social Security Act Stat efT erritorY: CALl FORN lA TARGETED CASE MANAGEMENT SERVICES CHILDREN UNDER THE AGE OF 21 Target Group (42 Code of Federal Regulations 441.18(a)(8)(i) and 441.18(a)(9)): Medi-Cal eligible children, under the age of 21 years old, who are: a) At high risk for medical compromise due to one of the following conditions: i) Failure to take advantage of necessary health care services, or ii) Noncompliance with their prescribed medical regime, or iii) An inability to coordinate multiple medical, social and other services due to the existence of an unstable medical condition in need of stabilization, or iv) An inability to understand medical directions because ofcti'mprehension barriers, or v) A lack of community support system to assist in appropriate follow-up care at home, or vi) Substance abuse, or vii) A victim of abuse, neglect or violence; and b) In need of assistance in accessing necessary medical, social, educational, or other services, when comprehensive case management is not being provided elsewhere. For those individuals in this target group, who may receive case management services under a waiver program, case management services shall not be duplicated, in accordance with Section 1915{g) of the Social Security Act. This target group excludes persons enrolled in a Home and Community-Based Services waiver program from receipt of Targeted Case Management {TCM) services. There shall be a county-wide system to ensure coordination among TCM providers of case management services provided to Medi-Cal beneficiaries who are eligible to receive case management services from two or more programs. Areas of State in which services will be provided (§1915(g)(1) of the Act):: Entire State _lL Only in the following geographic areas: Counties of Alameda, Amador, Butte, Contra Costa, El Dorado, Fresno, Humboldt, Imperial, Kern, Kings, Lake, Los Angeles, Madera, Marin, Merced, Monterey, Napa, Orange, Placer, Riverside, Sacramento, San Diego, San Francisco, San Luis Obispo, San Mateo, Santa Barbara, Santa Clara, Santa Cruz, Solano, Sonoma, Stanislaus, Tulare, Tuolumne, Ventura, Yolo, Yuba, City of Berkeley, and City of Long Beach Comparability of Services (§§1902(a)(1 O)(B) and 1915(g)(1)) _ Services are provided in accordance with Section 1902(a){1 O)(B) of the Act. .X. Services are not comparable in amount, duration, and scope (§1915(g)(1)). Definition of Services (42 CFR 440.169): Targeted case management services are defined as services furnished to assist individuals, eligible under the State Plan, in gaining access to needed medical, social, educational and other services. Targeted Case Management includes the following assistance: 1. Comprehensive assessment and periodic reassessment of individual needs, to determine the need for any medical, educational, social or other services. These assessment activities include: TN No. 1 0-008a Approval Date SEP 0' 9 2011 Effective Date 7/1/2011 Supersedes TN No. 04-007a

Supplement 1 a to Attachment 3.1-A Page2 State Plan under Title XIX of the Social Security Act . State!Territory: CALIFORNIA TARGETED CASE MANAGEMENT SERVICES CHILDREN UNDER THE AGE OF 21 • Taking client history; • Identifying the individual's needs and completing related documentation; and • Gathering information from other sources such as family members, medical providers, social workers, and educators (if necessary), to form a complete assessment of the eligible individual; Assessment and/or periodic reassessment to be conducted at a minimum of once every six months to determine if an individual's needs, conditions, and/or preferences have changed. ''·'Jc ' ·. ,._~, 2. Development (and periodic revision) of a specific care plan that is based on fhe information collected through the assessment that: • Specifies the goals and actions to address the medical, social, educational, and other services needed by the individual; • Includes activities such as ensuring the active participation of the eligible individual, and working with the individual (or the individual's authorized health care decision maker) and others to develop those goals; and • Identifies a course of action to respond to the assessed needs of the eligible individual; 3. Referral and related activities (such as scheduling appointments for the individual) to help the eligible individual obtain needed services including: • Activities that help link the individual with medical, social, educational providers, or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan; 4. Monitoring and follow-up activities: • Activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the eligible individual's needs, and which may be with the individual, family members, service providers, or other entities or individuals and conducted as frequently as necessary, and including at least one annual monitoring, to determine whether the following conditions are met: o Services are being furnished in accordance with the individual's care plan; o Services in the care plan are adequate; and o Changes in the needs or status of the individual are reflected in the care plan. Monitoring and follow-up activities include making necessary adjustments in the care plan and service arrangements with providers. Periodic Reviews will be completed at least every six months. These activities may be conducted as specified in the care plan, or as frequently as necessary to ensure execution of the care plan. Monitoring does not include ongoing evaluation or check-in of an individual when all care plan goals have been met. .JL.Case management includes contacts with non-eligible individuals that are directly related to identifying the eligible individual's needs and care, for the purposes of helping the eligible individual access services; identifying needs and supports to assist the eligible individual in obtaining services; providing case managers with useful feedback, and alerting case managers to changes in the eligible individual's needs. ( 42 CFR 440.169( e)) TN No. 1 0-008a Approval Date SEP 0 · 9 2011 Effective Date 7/1/2011 Supersedes TN No. 95-006

Supplement 1 a to Attachment 3.1-A Page3 State Plan under Title.XIX of the Social Security Act State/Territory: CALl FORNIA TARGETED CASE MANAGEMENT SERVICES CHILDREN UNDER THE AGE OF 21 Qualifications of providers (42 CFR 441.18(a)(8)(v) and 42 CFR 441.18(b)): TCM Provider Agency Qualifications: • Establish a system to coordinate services for individuals who may be covered under another program which offers components of case management or coordination similar to TCM including, but not limited to, the coordination of services with Managed Care providers, California Children's Services, as well as State waiver programs (e.g. HIV/AIDS, etc.); and • Demonstrated programmatic and administrative experience ;ri"providing pomprehensive case management services and the ability to increase their capability to provide their services to the target group; and • Must be an agency employing staff with case management qualifications; and • Establish referral systems and demonstrated linkages and referral ability with essential social and health service agencies; and • Have a minimum of five years providing comprehensive case management services to the target group; and • Administrative capacity to ensure quality of services in accordance with state and federal requirements; and • Financial management capacity and system that provides documentation of services and costs in accordance with OMB A-87 principles; and • Capacity to document and maintain individual case rf;}cords in accordance with state and federal requirements; and • Demonstrated ability to meet state and federal requirements for documentation, billing and audits; and • Ability to evaluate the effectiveness, accessibility, and quality of TCM services on a community-wide basis. TCM Case Manager Qualifications: Case managers employed by the case management agency must meet the requirements for education and/or experience as defined below: • A Registered Nurse, or a Public Health Nurse with a license in active status to practice as a registered nurse in California; individual shall have met the educational and clinical experience requirements as defined by the California Board of Registered Nursing, or • An individual with at least a Bachelor's degree from an accredited college or university, who has completed an agency-approved case management training course, or • An individual with at least an Associate of Arts degree from an accredited college, who has completed an agency-approved case management training course and has two years of experience performing case management duties in the health or human services field, or • An individual who has completed an agency-approved case management training course and has four years of experience performing case management duties in a health or human services field. Freedom of choice (42 CFR 441.18(a)(1): The State assures that the provision of case management services will not restrict an individual's free choice of providers in violation of section 1902(a)(23) of the Act. TN No. 10-008a Approval Date SEP 0:9 1011 Effective Date 7/1/2011 Supersedes TN No. 95-006

Supplement 1 a to Attachment 3.1-A Page4 State Plan under Title XIX of the Social Security Act State!Territory: CALl FORNIA TARGETED CASE MANAGEMENT SERVICES CHILDREN· UNDER THE AGE OF 21 1. Eligible individuals will have free choice of any qualified Medicaid provider within the specified geographic area identified in this plan. 2. Eligible individuals will have free choice of any qualified Medicaid providers of other medical care under the plan. Access to Services (42 CFR 441.18(a)(2). 42 CFR 441.18(a)(3). 42 CFR 441.18(a)(6): The State assures the following: • Case management (including targeted case management) services·will not be used to restrict an individual's access to other services under the plan. • Individuals will not be compelled to receive case management services, condition receipt of case management (or targeted case management) services on the receipt of other Medicaid services, or condition receipt of other Medicaid services on receipt of case management (or targeted case management) services; and • Providers of case management services do not exercise the agency's authority to authorize or deny the provision of other services under the plan. Payment(42 CFR 441.18(a)(4)): , Payment for case management or targeted case management services under the plan does not duplicate payments made to public agencies or private entities under other program authorities for this same purpose. Case Records (42 CFR 441.18(a)(7)): Providers maintain case records that document for all individuals receiving case management as follows: (i)The name of the individual; (ii) The dates of the case management services; (iii) The name of the provider agency (if relevant) and the person providing the case management service; (iv) The nature, content, units of the case management services received and whether goals specified in the care plan have been achieved; (v) Whether the individual has declined services in the care plan; (vi) The need for, and occurrences of, coordination with other case managers; (vii) A timeline for obtaining needed services; (viii) A timeline for reevaluation of the plan. Limitations: Case management does not include, and Federal Financial Participation (FFP) is not available in expenditures for, services defined in § 440.169 when the case management activities are an integral and inseparable component of another covered Medicaid service (State Medicaid Manual (SMM) 4302.F). Case management does not include, and FFP is not available in expenditures for, services defined in § 440.169 when the case management activities constitute the direct delivery of underlying medical, educational, social, or other services to which an eligible individual has been referred, including for foster care programs, services such as, but not limited to, the following: research gathering and completion of documentation required by the foster care program; assessing adoption placements; recruiting or interviewing potential foster care parents; serving legal papers; home investigations; providing transportation; administering foster care subsidies; making placement arrangements. (42 CFR 441.18(c)) TN No. 1 0-008a Approval Date SEP 0' 9 ZO 11 Effective Date 7/1/2011 Supersedes TN No. 95-006

Supplement 1 a to Attachment 3.1-A PageS State Plan under Title XIX of the Social Security Act Statefferritory: CALIFORNIA TARGETED CASE MANAGEMENT SERVICES CHILDREN UNDER THE AGE OF 21 FFP only is available for case management services or targeted case management services if there are no other third parties liable to pay for such services, including as reimbursement under a medical, social,. educational, or other program except for case management that is included in an individualized education program or individualized family service plan consistent with §1903(c) of the Act. (§§1902(a)(25) and 1905(c)) Limitations on translation: Arranging for translation activities and/or providing translation as part of the TCM service, including the costs of purchasing translation serVices foom ~ vendor to enable communication between the client and case manager, is included in the TCM rate. When a case manager provides translation that is unrelated to providing the TCM service, the translation is not claimable as TCM. Case Management Services Do Not Include: • Program activities of the agency itself that do not meet the definition of TCM, • Administrative activities necessary for the operation of the agency providing case management services rather than the overhead costs directly attributable to targeted case management, • Diagnostic and/or treatment services, • Restricting or limiting access to services, such as through prior authorization, • Activities that are an essential part of Medicaid administration, such as outreach, intake processing, eligibility determination, or claims processing, • Services that are an integral part of another service already reimbursed by Medicaid. TN No. 10-008a Approval Date SEP Q, 9 2011 Effective Date 7/1/2011 Supersedes TN No. 95-006

SUPPLEMENT 1h TO ATTACHMENT 3.1-A Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State!Territory: CALIFORNIA CASE MANAGEMENT SERVICES This Page Intentionally Left Blank TN No. 10-00Ba Approval Date SEP 0~9 26ll Effective Date 7/1/2011 Supersedes TN No. 04-007d

SUPPLEMENT 1h TO ATTACHMENT 3.1-A Page2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Statefrerritory: CALIFORNIA CASE MANAGEMENT SERVICES This Page Intentionally Left Blank TN No. 1 0-008a Approval DE8t P 0, 9 Z 011 Effective Date 7/1/2011 Supersedes TN No. 00-013

SUPPLEMENT 1h TO ATTACHMENT 3.1-A Page3 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: CALIFORNIA CASE MANAGEMENT SERVICES This Page Intentionally Left Blank TN No.10-008a Approval Date SEP o,g Z011 Effective Date7/1/2011 Supersedes TN No. 00-013

SUPPLEMENT 1h TO ATTACHMENT 3.1-A Page4 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: CALIFORNIA CASE MANAGEMENT SERVICES This Page Intentionally Left Blank TN No. 10-008a Approval Date SEP Q, 9 2011 Effective Date 7/1/2011 Supersedes TN No. 00-013

SUPPLEMENT 1h TO ATTACHMENT 3.1-A PageS STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Statefferritory: CALIFORNIA CASE MANAGEMENT SERVICES This Page Intentionally Left Blank TN No. 10-ooaa Approval DateSEP Oi 9 2011 Effective Date 7/1/2011 Supersedes TN No. 00-013

DEPARTMENT OF HEAL 11i AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION · TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): I. TRANSMITTAL NUMBER: 10-00Ba FORM APPROVED OMS NO. 0938-0193 2. STATE California 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE ~ATE July 1, 2011 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN 181 AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT e arate Transmittal or each amendment 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: a. FFY 2011~1(;1( $0 mm~ Section 1915 ) Social Securi Act 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Supplement la to Attachment 3.1-A, page 1-5 Supplement 1h to Attachment 3.1-A, Pages 1-5 I 0. SUBJECT OF AMENDMENT: b. FFY 2012tlltl' $0,•· ~1'MK 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Supplement Ia to Attachment 3.1-A pages 1-5, and ~~}lt)(tij(A,l~~t3~~~i§)4.X4 Supplement 1h to Attachment 3.r.::.A, Pages 1-5 Targeted Case Management-·JJ"It~Jt~"f~t~Children Under the Age of 21 II. GOVERNOR'S REVIEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 13.T E Toby Douglas 14. TITLE: Chief De u Director 15. DATE SUBMITTED: October 5, 2010 181 OTHER, AS SPECIFIED: The Governor's Office does not wish to review the State Plan Amendment. 16. RETURN TO: Department of Health Care Services Attn: State Plan Coordinator 1501 Capitol Avenue, Suite 71.3.26 P.O. Box 997417 Sacramento, CA 95899-7417 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: SEP 0~9 2011 21. TYPED NAME: 23. REMARKS: Box 7 Pen and Ink. ch.a,n~e approved vi.a, RAI' re~pons;e on 6(17/ll i;\nd vi.a, ell)ai.l on 8/4(11 Box 10 Pen and Ink ct\a,n~e approved v i;a RAI ·respons,e on 6/17'/11, Boxes; 8,9 and 15 ~en and Ink· ch.a,.nge approved v1:ct emai:1 on 8(4fl1, 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 FEB 0 4 2011 Toby Douglas Chief Deputy Director ofHealth Care Programs California Department ofHealth Care Services P.O. Box 997413, MS 0000 Sacramento, CA 95899-7413 Dear Mr. Douglas: Enclosed is an approved copy of California State Plan Amendment (SPA) Number 10-009, which prohibits the estate recovery of Medicare cost sharing benefits for dual eligible beneficiaries age 55 and over. This SPA is effective October 1, 201 O. Ifyou have any questions, please contact Kristin Curran at (415) 744-3579 or at kristin.curran@cms.hhs.gov. Sincerely, ~~~r Gloria Nagle, Ph.D., M.P.A. Associate Regional Administrator Division of Medicaid & Children's Health Operations Encl. cc: Kathryn Waje, California Department of Health Care Services Margaret Hoffeditz, ~alifornia Department of Health Care Services Barry Levin, CMS Center for Medicaid, CHIP and Survey & Certification

Page 53a-l Revision: HCFA-PM-95-3 (MB) May 1995 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT StateiTerritory: _C~alio!.!it1~om~ia~________ 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 ofservice on or after January I, 201 O. 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 of duals referenced above. TN No.: 10-009 fEB 0 4 2011 ocr 0 12010 Supersedes Approval Date: ____ Effective Date: _____ TN No.: N=on=e"--__

53a . Revision: HCFA-PM-95-3 (MB) MAY 1995 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT StatelTerritory: California (b) Adjustments or Recoveries The State complies with the requirements of section 1917(b) of the Act and regulations at 42 CFR 433.36(h) - (i). Adjustments or recoveries for Medicaid claims correctly paid are as follows: (1) For permanently institutionalized individuals, adjustments or recoveries are made from the individual's estate or upon sale of the property subject to a lien imposed because of medical assistance paid on behalf of the individual for services provided in a nursing facility, ICFIMR. or other medical institution. X Adjustments or recoveries are made for all other medical assistance paid on behalf of the 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 section 1917(a)(1 )(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 of payments are made from the individual's estate for nursing facility services, home and community-based services. and related hospital and prescription drug services. X 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 listed below: All services included in State plan for recipients age 55 and over except: those payments made for personal care services provided under In­ Home Support Services, and all Medicare cost sharing as identified in section 4.17(b)(3) (Continued). TN No. 10-009 FEB 642011 OCT 0 1201D Supersedes Approval Date _______ Effective Date _______ TN No. 06-011

FORM APPROVED ~ DEPARTMENT OF HEALTH AND HUMAN SERVI('~ OMS NO. 0938-0193 HEALTH CARE FINANCING ADMINISTRATION·"" ...-'.~--------.---:-=~-=-::c:-:=~" . TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITIACNUMBER: 2. STATE California STATE PLAN MATERIAL 10-009 FOR: HEALTH CARE FINANCING ADMINISTRATION TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE October 1,2010 5. TYPE OF PLAN MATERIAL (Check One): o NEW STATE PLAN o AMENDMENT TO BE CONSIDERED AS NEW PLAN r8l AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT Se arate Transmittal or each amendment 6. FEDERAL STATUTEIREGULATION CITATION: 7. FEDERAL BUDGET IMPACT: 42 CFR 433.36(h) - (i), 1917 (b) of the Social Security a. FFY 2010/11 $619,000 Act h. FFY 2011/12 $550,000 8. PAGE NUMBER OF THE PLAN SECTION OR A TIACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (IfApplicable): Section 4.17, page 53a-l,"$.30. 10. SUBJECT OF AMENDMENT: 16. TO: Department of Health Care Services Attn: State Plan Coordinator 1501 Capitol Avenue, Suite 71.3.26 P.O. Box 997417 Sacramento, CA 95899-7417 FORM HCFA·179 (07-92)

Table of Contents State/Territory Name: California State Plan Amendment (SPA) #: 10-012B This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Region IX Division ofMedicaid & Children's Health Operations 90 Seventh Street, Suite 5·300 (5W) San Francisoo, CA 94103·6706 DEC 2 0 Toby Douglas Chief Deputy Director Health Care Programs California Department of Health Care Services P.O. Box 997413, MS 0000 Sacramento, CA 95899-7413 Dear Mr. Douglas: Enclosed is an approved copy ofCalifornia State Plan Amendment (SPA) Number 10­ 012B, effective July 1, 2010. This SPA updates the Mentally Disabled target group language to reflect current practice and align with Federal regulations. During the review of this SPA, CMS perfonned an analysis of the reimbursement provisions, which revealed reimbursement issues already identified through the review of CA 09-004 (currently off the clock). These issues will be resolved through the 09-004 SPA review process. Ifyou have any questions, please contact Kristin Curran at (415) 744-3579 or at kristin.curran@cms.hhs.gov. Sincerely, Gloria Nagle, Ph.D., MP A Associate Regional Administrator Division of Medicaid & Children's Health Operations Enclosure cc: Dina Kokkos-Gonzales, California Department ofHealth Care Services Vickie Orlich, CA Department ofHealth Care Services

FORM APPROVED DEPAR'rMENT OF HEAL11i AND HUMAN SERVICES OMB NO. 0938..0193 HEAL11i CARE FINANCING ADMINISTRATION TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL I. TRANSMITTAL NUMBER: 2. STATE 10-8128 CA FOR: HEALTH CARE FINANCING ADMINISTRATION TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 3. PROGRAM IDENTIFICAnON: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE July 1,2010 5. TYPE OF PLAN MATERIAL (Check One): o NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN 181 AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (8. ate Transmittal or each amendment 6. fEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: Social Security Ad ]905(a)(19) a. FFY N/A $ N/A 42 USC Se(;tion 1396 n(g)/Social Security Ad 19I5(g) b. FFY N/A S N/A 42 CFR 431.5 1,440.169 and 441.18 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9, PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (IfApplieable): Supplement I to Attachment 3.1·A. Pagesf-t+' cg ..\(eI Supplement I to Aaacbment 3.t-A, Pages L-JA ~ ... ("'1 10. SUBJECT OF AMENDMENT: Targeted Case Management for the Mentally Disabled Target Group II. GOVERNOR'S REVIEW (Checle One): o GOVERNOR'S OFFICE REPORTED NO COMMENT 181 OTHER, AS SPECIF[ED: o COMMENTS OF GOVERNOR'S OFFICE ENCLOSED The Governor's Office does not o NO REPLV RECEJVE WITHIN 4S D S OF SUBMITTAL wish 10 review the State Plan Amendment. 16. RETURN TO: Department or Healtla Care Services Alta: State P"n Coordiaator 1501 Capitol Avenue. Saite 71.3.26 P.O. 801: 997417 Sacramento, CA 95899-7417 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: DEC 2 0 21. TYPED NAME: 23. REMARKS: Pen and i'nk change to B~x 8,confi.rmed by emai.l on 12/21/10 Pen and tnk change to Box 9 eonfi'rrned by; eman on 12/21/10 FORM HCFA-179 (07·92)

SUPPLEMENT 1 TO ATTACHMENT 3.1·A Page 8 State Plan under Title XIX of the Social Security Act StatelTerrltory: CALIFORNIA TARGETED CASE MANAGEMENT SERVICES A. Target Group (42 Code of Federal Regulations (CFR) 441.1S(a)(S)(i) and 441.1S(a)(9» . Targeted case management services are provided as part of a comprehensive specialty mental health services program available to Medi-Cal beneficiaries that meet medical necessity criteria established by the State, based on the beneficiary's need for targeted case management established by an assessment and documented in the client plan. 1. For members of the target group who are transitioning to a community setting targeted case management services will be made available for up to 30 calendar days for a maximum of three non-consecutive periods of 30 calendar days or less per hospitalization or inpatient stay prior to the discharge of a covered stay in a medical institution. The target group does not include individuals between ages 22 and 64 who are served in Institutions for Mental Disease or individuals who are inmates of public institutions (State Medicaid Directors Letter (SMDL), July 25, 2000). B. Areas of State in which services will be provided (Section 1915 (g)(1) of the Act) X Entire State ___ Only in the following geographic areas C. Comparabilitv of services (Sections 1902(a)(10)(B) and 1915la)(1) ___ Services are provided in accordance with Section 1902(a)(10)(B) ofthe Act X Services are not comparable in amount duration and scope (Section 1915(g)(1» D. D@finition of Services (42 CFR 440.169) Targeted case management services are defined as services furnished to assist individuals, eligible under the State Plan, in gaining access to needed medical, alcohol and drug treatment, social, educational and other services. TN No.l0-012B Supersedes Approval Date iJ iT: 2 0 'I[l!O Effective Date IJUL ". TN No. 95-003

----- SUPPLEMENT 1 TO ATTACHMENT 3.1-A Page 9 Targeted case management may be provided face-to-face, by telephone, or by telemedicine with the beneficiary or significant support person and may be provided anywhere in the community. Targeted case management contacts with significant support persons may include helping the eligible beneficiary access services, identifying needs and supports to assist the eligible beneficiary in obtaining services, providing case managers with useful feedback, and alerting case managers to changes in the eligible benefiCiary's needs (42 CFR 440.169(e». Targeted case management means services that assist a beneficiary to access needed medical, alcohol and drug treatment, educational, social, prevocational, vocational, rehabilitative, or other community services. The service activities include (dependent upon the practitioner's judgment regarding the activities· needed to assess and/or treat the beneficiary): communication, coordination, and referral; monitoring service delivery to ensure beneficiary access to service and the service delivery system; monitoring of the beneficiary's progress; placement services; and plan development. Targeted case management includes the following assistance: 1. Comprehensive assessment and periodic reassessment of individual needs to determine the need for establishment or continuation of targeted case management services to access any medical, educational, social, or other services. These assessment activities include: a. Taking client history; b. Identifying the individual's needs and completing related documentation, reviewing all available medical, psychosocial, and other records, and gathering information from other sources such as family members, medical providers, social workers, and educators (if necessary) to form a complete assessment of the individual; and c. Assessing support network availability, adequacy of living arrangements, financial status, employment status, and potential and training needs. Assessments are conducted on an annual basis or at a shorter interval as appropriate. 2. Development and Periodic Revision of a Client Plan that is: a. Based on the information collected through the assessment; b. SpeCifies the goals, treatment, service activities, and assistance to address the negotiated objectives of the plan and the medical, social, educational, and other services needed by the individual; c. Includes activities such as ensuring the active participation of the eligible individual, and working with the individual (or the individual's authorized health care decision maker) and others to develop those goals; TN No.10-012B 2 0 Supersedes Approval Date Effective Date JJL ­ TN No. 05-001

SUPPLEMENT 1TO AITACHMENT 3.1·A Page 10 d. Identifies a course of action to respond to the assessed needs of the eligible individual; and e. Develops a transition plan when a child has achieved the goals of the Client Plan. 3. Referral and Related Activities: a. To help an eligible individual obtain needed services including activities that help link an individual with medical, alcohol and drug treatment, social, educational providers or other programs and services that are capable of providing needed services, such as making referrals to providers for needed services and scheduling appointments for the individual; . b. To intervene with the client/others at the onset of a crisis to provide assistance in problem resolution and to coordinate or arrange for the provision of other needed services; c. To identify, assess, and mobilize resources to meet the client's needs. Services would typically include consultation and intervention on behalf of the client with Social Security, schools, social services and health departments, and other community agencies, as appropriate; and d. Placement coordination services when necessary to address the identified mental health condition, including assessing the adequacy and appropriateness of the client's living arrangements when needed. Services would typically include locating and coordinating the resources necessary to facilitate a successful and appropriate placement in the least restrictive setting and consulting, as required, with the care provider. 4. Monitoring and Follow-Up Activities: a. Activities and contacts that are necessary to ensure the Client Plan is implemented and adequately addresses the individual's needs, and which may be with the individual, family members, providers, or other entities or individuals and conducted as frequently as necessary, and including at least one annual monitoring, to determine whether the following conditions are met: • Services are being fumished in accordance with the individual's Client Plan; • Services in the Client Plan are adequate; and • There are changes in the needs or status of the individual, and if so, making necessary adjustments in the Client Plan and service arrangements with providers. b. Activities to monitor, support, and assist the client on a regular basis in developing or maintaining the skills needed to implement .and achieve the goals of the Client Plan. Services would typically include support in the use of psychiatric, medical, educational, socialization, rehabilitation, and other social services. TN No.10-012B Supersedes Approval Date _'~_'__2._0_1__ Effective Date --"-''-'''-_ TN No. 91-09

SUPPLEMENT 1 TO AITACHMENT 3.1-A Page 11 Monitoring and update of the Client Plan is conducted on an annual basis or at a shorter interval as appropriate. E. Qualification of Providers (42 CFR 441.1S(a)(S)(v) and 42 CFR 441.1S(b» Targeted Case Management services are provided by certified mental health organizations or agencies and by mental health professionals who are credentialed according to state requirements or non-licensed providers who agree to abide by the definitions, rules, and requirements for Targeted Case Management services established by the Department of Mental Health in conjunction with the Department of Health Care Services, to the extent authorized under state law. Targeted case management services may be provided by or under the direction (for those providers that may direct services) of the following Licensed Mental Health Professional providers or teams of providers determined to be qualified to provide the service, consistent with state law. "Licensed Mental Health Professional" means licensed physicians, licensed psychologists, licensed clinical social workers, licensed marriage and family therapists, registered nurses (includes certified nurse specialists and nurse practitioners), licensed vocational nurses, and licensed psychiatric technicians. "Under the direction of means that the individual directing service is either directly providing the service, or acting as a clinical team leader, providing direct or functional supervision of service delivery, or review, approval, and signing client plans. An individual directing a service is not required to be physically present at the service site to exercise direction. The licensed professional directing a service assumes ultimate responsibility for the targeted case management service provided. Services are provided under the direction of a physician, a psychologist, a waivered psychologist, a licensed clinical social worker, a registered licensed clinical social worker, a marriage and family therapist, a registered marriage and family therapist, or a registered nurse (including a certified nurse specialist, or a nurse practitioner). "Waivered/Registered Professional" means: (1) For a psychologist candidate, an individual who has a professional licensing waiver to the extent authorized under State law; or (2) For a marriage and family therapist candidate or a licensed clinical social worker candidate, an individual who has registered with the corresponding state licensing authority for marriage and family therapists or clinical social workers to obtain supervised clinical hours for marriage and family therapist or clinical social worker licensure, to the extent authorized under state law. TN No.l0-012B Supersedes Approval Date Effective Date .lUl - 1 TN No. 95-003 --=......::::-..........­

SUPPLEMENT 1 TO ATTACHMENT 3.1-A Page 12 The following specific minimum provider qualifications apply for each individual delivering or directing services. 1) Physicians Physicians must be licensed in accordance with applicable State of Califomia licensure requirements. Physicians may direct services. 2) Psychologists Psychologists must be licensed in accordance with applicable State of California licensure requirements. Psychologists may direct services. A psychologist may also be a Waiver8dJRegistered Professional who has a waiver of psychologist licensure to the extent authorized under State law. Waivered Psychologists may also direct services under the supervision of a Licensed Mental Health Professional in accordance with laws and regulations governing the waiver. 3) Licensed Clinical Social Workers (LCSW) Licensed clinical social workers must be licensed in accordance with applicable State of Califomia licensure requirements. Licensed clinical social workers may direct services. A clinical social worker may also be a WaiveredlRegistered Professional who has registered with the state licenSing authority for clinical social workers to obtain supervised clinical hours for clinical social worker licensure. Registered clinical social workers may also di'rect services under the supervision of a Licensed Mental Health Professional in accordance with laws and regulations goveming the registration. 4) Marriage and Family Therapists (MFT) Marriage and family therapists must be licensed in accordance with applicable State of California licensure requirements. Marriage and family therapists may direct services. A marriage and family therapist may also be a WaiveredlRegistered Professional who has registered with the state licensing authority for marriage and family therapists to obtain supervised clinical hours for marriage and family therapist licensure, to the extent authorized under state law. Registered marriage and family therapists may also direct services under the supervision of a Licensed Mental Health Professional in accordance with laws and regulations goveming the registration. TN No.10-012B Supersedes Approval Date _______~"--'-~ Effective Date JUl - 1 TN No. 91-09

SUPPLEMENT 1 TO ATIACHMENT 3.1-A Page 13 5) Registered Nurses (RN) Registered nurses must be licensed in accordance with applicable State of Califomia licensure requirements. Registered nurses may direct services. 6) Certified Nurse Specialists (CNS) Certified nurse specialists must be licensed in accordance with applicable State of Califomia license reqUirements. Certified nurse speCialists may direct services. 7) Nurse Practitioners Nurse practitioners may be licensed in accordance with applicable State of Califomia licensure requirements. Nurse practitioners may direct services. The following providers may provide services under the direction of those Licensed Mental Health Professionals (listed above) who may direct a service. 8) Licensed Vocational Nurses (LVN) Licensed vocational nurses must be licensed in accordance with applicable State of Califomia licensure requirements. 9) Psychiatric Technicians (PT) Psychiatric technicians must be licensed in accordance with. applicable State of Califomia licensure requirements. 10) Mental Health Rehabilitation SpeCialists (MHRS) A mental health rehabilitation specialist shall be an individual who has a baccalaureate degree and four years of experience in a mental health setting as a specialist in the fields of physical restoration, social adjustment, or vocational adjustment. Up to two years of graduate professional education may be substituted for the experience requirement on a year-for-year basis; up to two years of post associate arts clinical experience may be substituted for the required educational experience in addition to the requirement of four years' experience in a mental health setting. 11) Physician Assistants (PA) Physician assistants must be licensed in accordance with applicable State of Califomia licensure reqUirements. TN No.10-012B _____ Supersedes Approval Date Effective Date ,JUi - 'I TN No. 91-09

SUPPLEMENT 1TO ATTACHMENT 3.1-A Page 14 12) Pharmacists Pharmacists must be licensed in accordance with applicable State of California licensure requirements. 13) Occupational Therapists (OT) Occupational therapists must be licensed in accordance with applicable State of California licensure requirements. 14) Other Qualified Provider An individual at least 18 years of age with a high school diploma or equivalent degree determined to be qualified to provide the service by the County Department of Mental Health. F. Freedom of Choice (42 CFR 441.18(A)(1» The State assures that the provision of case management services will not restrict an individual's free choice of providers in violation of section 1902(a)(23) of the Act. 1. Eligible individuals will have free choice of any qualified Medicaid provider within the speCified geographic area identified in this plan. 2. Eligible individuals will have free choice of any qualified Medicaid providers of other medical care under the plan. G. Freedom of Choice Exception (Section 1915(g)(1) and 42 CFR 441.18(b» X Target group consists of eligible individuals who meet medical necessity criteria for specialty mental health services. Providers are limited to qualified Medicaid providers of case management services employed by or contracted with the County Department of Mental Health who are capable of ensuring that individuals receive needed services. H. Access to Services (42 CFR 441.18(A)(2), 42 CFR 441.18(a«3), 42 CFR 441.18(a)(6) The State assures the following: • Targeted case management services will not be used to restrict an individual's access to other services under the plan. • Individuals will not be compelled to receive case management services, condition receipt of targeted case management on the receipt of other Medicaid services, or condition receipt of other Medicaid services on receipt of targeted case management services; and • Providers of case management services do not exercise the agency's authority to authorize or deny the provision of other services under the plan. TN No.10-012B Supersedes Approval Date .: ,', 2 0 Effective Date ""-"'-----' TN No.

I SUPPLEMENT 1 TO ATTACHMENT 3.1-A Page 16 nanagement services if there are no services, including as reimbursement other program except for case 'idualized education program or itent with section 1903(c) of the Act. Ire not reimbursable on days when Psychiatric Health FacUity Services or ! reimbursed, except for the day of urpose of coordinating placement of the ment for Targeted Case Management will Jnity and not to institutions. I. Payment (42 CFR 441.18(a)(4» Payment for targeted case manager duplicate payments made to public ~ program authorities for this same pu J. Case Records (42 CFR 441.18(a){T Providers maintain case records tha targeted case management as folio" 1. The name of the individual 2. The dates of the targeted cal 3. The name of the provider agl the case management servic 4. The nature, content, units of received and whether goals achieved 5. Whether the individual has d 6. The need for, and occurreno 7. A timeline for obtaining need 8. A timeline for reevaluation of K. Limitations Targeted case management does "' Participation (FFP) is not available iI CFR section 441.169 when the targi integral and inseparable component Medicaid Manual (SMM) 4302.F). Targeted case management does n Participation (FFP) is not available il CFR section 441.169 when the targl the direct delivery of underlying mec which an eligible individual has beel services such as, but not limited to, completion of documentation requin adoption placements; recruiting or ir serving legal papers; home investig, foster care subsidies; and making p Effective DateJUL h~ 1 TN No.10-012B Supersedes Approval Date 2 TN No. None

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1'1AR 2 4 2011 Toby Douglas, Director Region IX Division of Medicaid & Children's Health Operations 90 Seventh Street, Suite 5-300 (5W) San Francisco, CA 94103-6706 California Department ofHealth Services P.O. Box 997413 MS: 0000 Sacramento, CA 95899-7413 Dear Mr. Douglas: Enclosed is an approved copy of California State Plan Amendment (SPA) Number 10-014, which incorporates the State Eligibility Option for Family Planning Services. This SPA is effective July 1, 2010. Ifyou have any questions, please contact Kristin Curran at (415) 744-3579 or at kristin.curran@cms.hhs.gov. Encl. Sincerely, ~?(~ Gloria Nagle, Ph.D., M.P.A. Associate Regional Administrator Division of Medicaid & Children's Health Operations cc: Rebecca Bruno, Centers for Medicare and Medicaid Services Rebecca Burch Mack, Centers for Medicare and Medicaid Services Annese Higgs, Centers for Medicare and Medicaid Services Dina Kokkos-Gonzales, California Department of Health Care Services Kathryn Waje, California Department of Health Care Services

StatefT erritory: California Attachment 3. 1-A Page 2 OMBNo.: AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO 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. __ P.rovided __ No limitations _lL 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 and for individuals eligible pursuant to Att. 2.2-A, 8, if this eligibility option is elected by the State. Provided: No limitations X With limitations Please describe any limitations: 4.c.1 Family planning-related services provided under the above State Eligibility Option. 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* 5.a.1 Sign language interpreter services (in connection with physician's services). X Provided __ No limitations X With limitations* b. · Medical and surgical services furnished by a dentist (in accordance with section 1905(a)(5)(8) of the Act). __ Provided __ No limitations X With limitations* 6. Medical care and any other type 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 __lL With limitations* *Description provided on attachment TN No. 10-014 Supersedes TN No. 00-026 Approval Date: MAR 2 4 2011 Effective Date: July 1. 2010

Revision: CMS-PM- ATTACHMENT 2.2-A Page 23h OMBNo.: Statefferritory California Citation B. 1902(a)(lO)(A)(ii)(XXI) 1902(ii) Groups Covered Optional Groups Other Than the Medically Needy (Continued) 28. ~ Individuals who are not pregnant and whose income does not exceed the State established income standard of 200% of the Federal Poverty Level. This amount does not exceed the highest income limit for pregnant women in this State Plan, which is 200% of the Federal Poverty Level. 0 In determining eligibility for this group, the State considers only the income of the applicant or recipient. ~ In determining eligibility for this group, the State will exclude parental income, consistent with the methodology the State uses for pregnant women as specified on page 4 of Supplement 8a to Attachment 2.6 of the State Plan. ~ California exercises the option to define this group as individuals who would have been eligible for family planning benefits pursuant to the standards and processes imposed by the State on January 1, 2007 under a waiver granted pursuant to Section 1115. The period of eligibility begins on the day the client is enrolled at the point-of-service, and such eligibility is to be recertified annually. Retroactive eligibility is available for qualifying beneficiaries for up to 3 months prior to the frrst day of the month of application to the Family PACT program. TN No.10-014 Approval Date Jt1AR 2 4 2011 Effective Date: July 1, 2010 Supersedes TNNo: None

Revision: Citation 1920C TN No.l0-014 Supersedes TNNo: None CMS-PM- Statefferritory California Groups Covered ATTACHMENT 2.2-A Page 23i OMBNO.: A total of 13.95 percent is deducted from the total expenditures to account for those expenditures funded solely through State dollars pursuant to the standards and processes in place under the Section 1115 waiver on January 1, 2007. Note: Services are limited to family planning services and family planning-related services as described in section 4.c(ii) of Attachment 3.1-A. Presumptive Eligibility for Family Planning: 0 The State provides a period of presumptive eligibility for family planning services to individuals determined by a qualified entity, based on preliminary information from the individual, described in the group the State has elected to make eligible under the above option. The period of presumptive eligibility ends on the earlier of the date a formal determination of Medicaid eligibility is made under 1902(a)(10)(A)(ii)(XXI), or, when no application has been filed, the last day of the month following the month during which the qualified entity determines the individual presumptively eligible. 0 In addition to family planning services, the State covers family planning-related services to such individuals during the period of presumptive eligibility. MAR 2 4 2011 . Approval Date Effective Date: July 1, 2010

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION FORM APPROVED OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 10-014 CA FOR: HEALTH CARE FINANCING ADMINISTRATION TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE July 1, 2010 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN ~AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT Se arate Transmittal or each amendment 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: 1905(a)(4)(C) and 1902(a)(10)(A)(ii)(XXI) 1902(ii)/ a. FFY 2009-2010 $"455 mil:ii"t1n .:in~~ \\io<'l H.R 3590 SEC. 2303 b. FFY 2010-2011 $ 506 million 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Attachment 3.1-A page 2 A~tachment 2.2-A pages 23h,23i,~ 10. SUBJECT OF AMENDMENT: State Eligibility Option for Family Planning Services 11. GOVERNOR'S REVIEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL Chief De ut Director 15. DATE SUBMITTED: OR ATTACHMENT (If Applicable): Attachment 3.1-A page 2 ~ OTHER, AS SPECIFIED: The Governor's Office does not wish to review the State Plan Amendment. 16. RETURN TO: Department of Health Care Services Attn: State Plan Coordinator 1501 Capitol Avenue, Suite 71.3.26 P.O. Box 997417 Sacramento, CA 95899-7417 FOR REGIONAL OFFICE USE ONLY 9/30/10 118. DATEAPPRO~A~: 2 4 ZOH 17. DATE RECEIVED: 21 . TYPED NAME: Gloria Nagle Associate Regional Administrator 23. REMARKS: Pen and ink changes to Boxes 7,8, and 15 verified in RAI response submitted 3/16/11. FORMHCFA-179 (07-92)

Table of Contents

State/Territory Name: California State Plan Amendment (SPA) #: 11-030 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services San Francisco Regional Office 90 Seventh Street, Suite 5-300 (5W) San Francisco, CA 94103-6706

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

July 23, 2014 Toby Douglas, Director California Department of Health Care Services P.O. Box 997413, MS 0000 Sacramento, CA 95899-7413

Dear Mr. Douglas:

Enclosed is an approved copy of California State Plan Amendment (SPA) 11-030. SPA 11-030 was submitted to my office on December 7, 2011 in response to CMS’ companion letter for California SPA 11-012. This SPA serves to clarify coverage provisions related to Durable Medical Equipment, and reimbursement provisions related to hearing aids.

The effective date of this SPA is November 1, 2011. Enclosed are the following approved SPA pages that should be incorporated into your approved State Plan:

• Limitations on Attachment 3.1-A, page 14 • Limitations on Attachment 3.1-B, page 14 • Attachment 4.19-B, pages 3i, 3i.1, 3i.2, 3j

If you have any questions, please contact Tom Schenck by phone at (415) 744-3589 or by email at Tom.Schenck@cms.hhs.gov.

Sincerely,

Hye Sun Lee

Acting Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosure

cc: Connie Florez, California Department of Health Care Services

Nate Emery, California Department of Health Care Services

This updated HCFA 179, submitted 6/7/14 (see box 15) replaces the original HCFA 179 (included as part of this package), that was submitted on 12/7/11. The original submittal date secured the approved effective date of 11/1/11. (TS) 6/19/2014 11/1/2011 Hye Sun Lee Associate Regional Administrator July 23, 2014 /s/ page 1 of 2

page 2 of 2

STATE PLAN CHART (Note: This chart is an overview only)

Limitations on Attachment 3.1-A

TYPE OF SERVICE PROGRAM COVERAGE** PRIOR AUTHORIZATION OR OTHER REQUIREMENTS

7c.2

Durable medical equipment

Covered when prescribed by a licensed physician and reviewed annually.

DME commonly used in providing SNF and ICF level of care is not separately billable.

Common household items are not covered.

Prior authorization is required when the purchase exceeds $100. Prior authorization is required when price, repairs, maintenance, or cumulative rental of listed items exceeds $25, except that the provision of more than two “H” oxygen tanks in any one month requires prior authorization. Purchase or rental of “By Report” (unlisted) items are subject to prior authorization regardless of purchase price. Authorization shall be granted only for the lowest cost item that meets medical needs of the patient.

7c.3

Hearing aids

Refer to Type of Service “12c Prosthetic and orthotic appliances, and hearing aids.”

Refer to Type of Service “12c Prosthetic and orthotic appliances, and hearing aids.”

7c.4

Enteral Formulae

Covered only when supplied by a pharmacy provider upon the prescription of a licensed physician within the scope of his or her practice.

Enteral Formulae commonly used in providing SNF and ICF level of care is not separately billable.

Common household items (food) are not covered.

Prior authorization is required for all products. Authorization is given when the enteral formulae is used as a therapeutic regimen to prevent serious disability or death in patients with medically diagnosed conditions that preclude the full use of regular food.

Dietary supplements or products that cannot be used as a complete source of nutrition are considered non-benefits, except that the program may deem such a product a benefit when it determines that the use of the product is neither investigational nor experimental when used as a therapeutic regimen to prevent serious disability or death in patients with medically diagnosed conditions.

* Prior authorization is not required for emergency services. ** Coverage is limited to medically necessary services

.

TN 11-030

Approval date: _______________

Effective date: 11/1/2011 Supersedes TN 11-012

-14- July 23, 2014

STATE PLAN CHART (Note: This chart is an overview only)

Limitations on Attachment 3.1-B

TYPE OF SERVICE PROGRAM COVERAGE** PRIOR AUTHORIZATION OR OTHER REQUIREMENTS

7c.2

Durable medical equipment

Covered when prescribed by a licensed physician and reviewed annually.

DME commonly used in providing SNF and ICF level of care is not separately billable.

Common household items are not covered.

Prior authorization is required when the purchase exceeds $100. Prior authorization is required when price, repairs, maintenance, or cumulative rental of listed items exceeds $25, except that the provision of more than two “H” oxygen tanks in any one month requires prior authorization. Purchase or rental of “By Report” (unlisted) items are subject to prior authorization regardless of purchase price. Authorization shall be granted only for the lowest cost item that meets medical needs of the patient.

7c.3

Hearing aids

Refer to Type of Service “12c Prosthetic and orthotic appliances, and hearing aids.”

Refer to Type of Service “12c Prosthetic and orthotic appliances, and hearing aids.”

7c.4

Enteral Formulae

Covered only when supplied by a pharmacy provider upon the prescription of a licensed physician within the scope of his or her practice.

Enteral Formulae commonly used in providing SNF and ICF level of care is not separately billable.

Common household items (food) are not covered.

Prior authorization is required for all products. Authorization is given when the enteral formulae is used as a therapeutic regimen to prevent serious disability or death in patients with medically diagnosed conditions that preclude the full use of regular food.

Dietary supplements or products that cannot be used as a complete source of nutrition are considered non-benefits, except that the program may deem such a product a benefit when it determines that the use of the product is neither investigational nor experimental when used as a therapeutic regimen to prevent serious disability or death in patients with medically diagnosed conditions

* Prior authorization is not required for emergency services. ** Coverage is limited to medically necessary services

TN 11-030

Approval date: _______________

Effective date: 11/1/2011 Supersedes TN 11-012

-14-

July 23, 2014

Attachment 4.19-B

Page 3i

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: California

REIMBURSEMENT METHODOLOGY FOR HEARING AID SERVICES

(1) Definitions:

(a) Billed Amount: Includes actual product cost and related provider costs that include, but are not limited to, shipping, handling storage, and delivery.

(b) Retail Price: The usual and customary price charged to consumers for a particular product or service.

(c) Wholesale Cost: The unit price, or “the single unit” price as identified in the manufacturer’s wholesale catalog, not including taxes, rebates and discounts.

(2) Reimbursement for hearing aid services as specified in the State Plan, Attachment 3.1-A entitled, “Amount, Duration, and Scope of Medical and Remedial Care and Services Provided to the Categorically Needy” and in Attachment 3.1-B entitled, “Amount, Duration and Scope of Services Provided to Medically Needy Groups,” item 12c., entitled, “Prosthetic devices and hearing aids,” will be subject to the following limitations:

(a) The reimbursement rate for hearing aids shall be the lowest of the following:

(1) The maximum allowable amount established by the Department of Health Care Services (Department). (2) The one-unit wholesale cost, plus a markup determined by the Department. (3) The billed amount.

(b) The reimbursement rate for hearing aid supplies and

accessories shall be the lowest of the following:

(1) The retail price. (2) The wholesale cost, plus a markup determined by the Department. (3) The billed amount.

TN No. 11-030 Supersedes Approval Date___________ Effective Date: November 1, 2011 TN No. None

July 23, 2014

Attachment 4.19-B

Page 3i.1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: California

(c) The reimbursement rate for molds or inserts shall be the lower of the following:

(1) The maximum amount allowable established by the Department. (2) The billed amount.

(d) The reimbursement for repairs, subsequent to the

guarantee period, shall be the lower of the following:

(1) The invoice cost plus a markup determined by the Department. (2) The billed amount.

(3) Hearing aid services, as specified in the State Plan, Attachment 3.1-A entitled, “Amount, Duration, and Scope of Medical and Remedial Care and Services Provided to the Categorically Needy” and Attachment 3.1-B entitled, “Amount, Duration and Scope of Services Provided to Medically Needy Groups,” item 12c., entitled “Prosthetic devices and hearing aids,” are subject to a “benefit cap amount” of $1,510. The “benefit cap amount” is the maximum amount of Medi-Cal coverage for hearing aid services for each beneficiary, for each fiscal year, as specified in California Welfare and Institutions Code section 14131.05 (as in effect on November 1, 2011).

Among the exceptions set forth in California law, the hearing aid “benefit cap amount” does not apply to the following:

(a) Replacement of hearing aids that are lost, stolen, or irreparably damaged due to circumstances beyond the beneficiary’s control. (b) Pregnancy-related benefits and benefits for the treatment of other conditions that might complicate the pregnancy. (c) Beneficiaries under the Early and Periodic Screening, Diagnosis, and Treatment Program.

TN No. 11-030 Supersedes Approval Date___________ Effective Date: November 1, 2011 TN No. None

July 23, 2014

Attachment 4.19-B

Page 3i.2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: California

(4) The State Agency’s rates for the services, as discussed on pages 3i and 3i.1, were posted as of May 15, 2013, and are effective for dates of service on or after that date. The rates for these services are posted on the Medi-Cal Rates website at: http://files.medi-cal.ca.gov/pubsdoco/rates/rateshome.asp

TN No. 11-030 Supersedes Approval Date___________ Effective Date: November 1, 2011 TN No. None

July 23, 2014

Attachment 4.19-B

Page 3j

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: California

REIMBURSEMENT METHODOLOGY FOR ENTERAL FORMULAE

(1) Reimbursement for enteral formulae, in accordance with California Welfare and Institutions Code section 14105.85, and as described in the State Plan Limitations in Attachment 3.1-A entitled, “Amount, Duration, and Scope of Medical and Remedial Care and Services Provided to the Categorically Needy,” and Attachment 3.1-B entitled, “Amount, Duration and Scope of Services Provided to Medically Needy Groups,” will be based on the estimated acquisition cost for that product plus a percentage markup determined by the department.

(2) The State Agency’s rates for the services listed in this section were posted as of May 15, 2013, and are effective for dates of service on or after that date. The rates for these services are posted on the Medi-Cal Rates website at: http://files.medi-cal.ca.gov/pubsdoco/rates/rateshome.asp.

TN No. 11-030 Supersedes Approval Date___________ Effective Date: November 1, 2011 TN No. None

July 23, 2014

Table of Contents State/Territory Name: California State Plan Amendment (SPA) #: 11-037A This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

oo sem e “Y j DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Region IX Nena Division of Medicaid & Children’s Health Operations

90 Seventh Street, Suite 5-300 (SW) San Francisco, CA 94103-6706

FEB 2 8 2012

Toby Douglas, Director : on » California Department of Health Care Services

P.O. Box 997413, MS 0000

Sacramento, CA 95899-7413

Dear Mr. Douglas:

Enclosed is an approved copy of California State Plan Amendment (SPA) 11-037a. SPA 11- 037 was originally submitted to my office on December 16, 2011 to address the issues related to chronic dialysis and heroin detoxification that were initially identified in the companion letter issued with the approval of SPA 11-014. On February 22, 2012, the State requested that SPA 11-037 be split such that 11-037a amends the State Plan to delay the effective date of the elimination of the coverage of Adult Day Health Care (ADHC) services to April 1, 2012. The elimination was previously approved effective September 1, 2011 via SPA 11- 014, December 1, 2011 via SPA 11-026, and March 1, 2012 via SPA 11-035.

The effective date of this SPA is April 1, 2012. Enclosed are the following approved SPA pages that should be incorporated into your approved State Plan:

Limitations on Attachment 3.1-A, page 19 Limitations on Attachment 3.1-B, page 19 Attachment 4.19B, page 6C

Attachment 4.19-B, page 6D

Supplement 6 to Attachment 4.19-B, page 2

The approval of this State Plan Amendment relates solely to the availability of Federal Financial Participation (FFP) for Medicaid covered services. This action does not in any way address the State’s independent obligations under the Americans with Disabilities Act or the Supreme Court’s Olmstead decision.

CMS will continue to work with you on SPA 11-037b, which addresses the issues related to chronic dialysis and heroin detoxification that were initially identified in the companion letter issued with the approval of SPA 11-014.

If you have any questions, please contact Kristin Dillon by phone at (415) 744-3579 or by email at Kristin. Dillon@cms.hhs.gov.

Sincerely,

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

Enclosure

cc: Jean Close, Centers for Medicare and Medicaid Services Elizabeth Garbarczyk, Centers for Medicare and Medicaid Services Stephen Halley, California Department of Health Care Services Christopher Thompson, Centers for Medicare and Medicaid Service Kathyryn Waje, California Department of Health Care Services

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION

FORM APPROVED OMB NO. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION

2. STATE California

1. TRANSMITTAL NUMBER: 11-037a

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

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

4, PROPOSED EFFECTIVE DATE April 1, 2012

5, TYPE OF PLAN MATERIAL (Check One):

(C1) NEW STATE PLAN

(] AMENDMENT TO BE CONSIDERED AS NEW PLAN

X AMENDMENT

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

6, FEDERAL STATUTE/REGULATION CITATION: 42 C.F.R, Part 440

7, FEDERAL BUDGET IMPACT: FFY 2012 $16,137,000 (increase)

8, PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Limitations on Attachment 3.1-A, page 19 Limitations on Attachment 3.1-B, page 19 Attachment 4,19-B, page 6C

Attachment 4,19-B, page 6D

Supplement 6 Attachment 4.19-B, page 2

eaeesee

9, PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):

Limitations on Attachment 3.1-A, page 19

Limitations on Attachment 3,1-B, page 19

Attachment 4.19-B, page 6C

Attachment 4.19-B, page 6D

Supplement 6 Attachment 4.19-B, page 2

10, SUBJECT OF AMENDMENT:

Amended effective date for the elimination of Adult Day Health Care (pursuant to SPA 11-014, SPA 11-026, and SPA 11-035).

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

tl

OTHER, AS SPECIFIED: The Governor’s Office does not wish to review the State Plan Amendment.

ICY O!

12. SIGNATURE 0}

13. TYP Toby Douglas

14, TITLE: Director

15, DATE SUBMITTED:

2/eolje-

16. RETURN TO:

Department of Health Care Services Attn: State Plan Coordinator

1501 Capitol Avenue, Suite 71.3.26 MLS. 4506

P.O, Box 997417

Sacramento, CA 95899-7417

382

FORM HCFA-179 (07-92)

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Attachment 4.19-B Page 6C

midwife, clinical psychologist, licensed clinical social worker, or visiting nurse, hereafter referred to as a “health professional,” to the extent the services are reimbursable as covered benefits under C.1.(a). For purposes of this subparagraph 2(a), “physician” includes the following:

@) A doctor of medicine or osteopathy licensed by the State to practice medicine and/or surgery and who is acting within the scope of his/her license.

(ii) A doctor of podiatry licensed by the State to’practice podiatric medicine and who is acting within the scope of his/her license.

iii) A doctor of optometry licensed by the State to practice optometry and who is acting within the scope of his/her license.

(iv) | Acchiropractor licensed by the State in the practice of chiropractic and who is acting within the scope of his/her license.

(v) | A doctor of dental surgery (dentist) licensed by the State to practice dentistry and who is acting within the scope of his/her license.

Inclusion of a professional category within the term “physician” is for the purpose of defining the professionals whose services are reimbursable on a per visit basis, and not for the purpose of defining the types of services that these professionals may render during a visit (subject to the appropriate license).

b) Comprehensive perinatal services when provided by a comprehensive perinatal services p’ Pp y Pp’ practitioner.

***The elimination of Adult Day Health Care previously scheduled to take place on 3/1/12 (approved via SPA 11-035) has been postponed and will be effective as of 4/1/2012.

TN No. _11-037a Supersedes Approval Date: TN No. 11-035

FEB 2 8 2012 serective Date: 4/1/2012

Attachment 4.19-B Page 6D

3. Encounters with more than one health professional and multiple encounters with the same health professional that take place on the same day and at a single location constitute a single visit. More than one visit may be counted on the same day (which may be at a different location) in either of the following situations:

(a) When the clinic patient, after the first visit, suffers illness or injury requiring another diagnosis or treatment, two visits may be counted.

(b) The clinic patient has a face-to-face encounter with a.dentist and then also has a face-to-face encounter with any one of the following providers: physician (as defined in subparagraphs C.2(a)(i)-(iv)), physician assistant, nurse practitioner, certified nurse midwife, clinical psychologist, licensed clinical social worker, visiting nurse, or a comprehensive perinatal services practitioner.

D. Prospective Payment Reimbursement

An FQHC or RHC that does not elect the alternative payment reimbursement methodology under Section E will receive reimbursement under the following prospective payment reimbursement methodology provisions:

1. On July 1, 2001, DHS implemented a prospective payment reimbursement methodology on a phased-in basis. Each FQHC or RHC receives payment in an amount calculated using the methodology described under paragraphs D.2 and D.4 effective the first day of the fiscal year on or after July. 1, 2001. For the period January 1, 2001, until the payment methodology described in this Section D became effective for a particular facility, each FQHC or RHC was paid in accordance with Section H.

2. (a) Beginning on January 1, 2001, the prospective payment reimbursement rate for an FQHC or RHC was equal to 100 percent of the average reported cost-based reimbursement rate per visit for fiscal years 1999 and 2000 for the FQHC or the RHC, as determined in accordance with cost reimbursement principles for allowable costs explained in 42 CFR Part 413, as well as, Generally Accepted Accounting Principles. For each FQHC or

TN No. 11-037a Supersedes Approval Date: FEB 2 8 2012 Effective Date: 4/1/2012 TN No. 11-035

State Plan for Title XIX Supplement 6 Attachment 4.19B California Page 2

REIMBURSEMENT FOR INDIAN HEALTH SERVICES AND TRIBAL 638 HEALTH FACILITIES

A. Below is a list of health professionals that may bill under the IHS all-inclusive rate:

Physician

Physician Assistant

Nurse Practitioner

Nurse Midwife

Clinical Psychologist, when provided to beneficiaries identified under Item C below. Clinical Social Worker, when provided to beneficiaries identified under Item C below. Visiting Nurse if services are provided in the Tribal facilities .

Comprehensive Perinatal Services Program (CPSP): Registered Nurse, Dietitian, Health Educator, Childbirth Educator, Licensed Vocational Nurse, and Comprehensive Perinatal Health Worker. A September17, 1985 HCFA letter allows these services as a physician or clinic service.

e Under the Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT), the services of Licensed Marriage, Family and Child Counselors are available as ‘other health visit’ to persons under 21 years of age, as a result of an EPSDT screening which identifies the need for a service which is necessary to correct or ameliorate a mental illness or condition.

B. Except for the services specified under C below, the following other ambulatory services, but not limited to, provided by health professional can be billed under the IHS all-inclusive rate.

e¢ Medical and surgical services provided by a doctor of dental medicine or dental surgery, which if provided by a physician would be considered physician services

Physical Therapy

Occupational Therapy

Drug and Alcohol visits (Subject to Medi-Cal provider participation requirements) Telemedicine

Optometry (Eyeglasses and other eye appliances are restricted to beneficiaries identified under Item C below)

*** The elimination of Adult Day Health Care previously scheduled to take place on 3/1/12 (approved via SPA 11-035) has been postponed and will be effective as of 4/1/2012.

C. Dental service, acupuncture, audiology, chiropractic, eyeglasses and other eye appliances, podiatry, psychology and speech therapy are covered benefits under this state plan only for the following beneficiaries:

1. Pregnant women if these optional benefits are part of their pregnancy-related services or for services to treat a condition that might complicate the pregnancy.

2. Individual who is an eligible beneficiary under the Early and Periodic Screening Diagnosis and Treatment Program.

TN No. _11-037a Supersedes Approval Date FEB 2 8 2012 Effective Date 4/1/2012 TN No._11-035

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

Toby Douglas, Director NOV 21 Pore .

California Department of Health Care Services P.O. Box 997413, MS 0000 Sacramento, CA 95899-7413

Dear Mr. Douglas: Enclosed is an approved copy of California State Plan Amendment (SPA) 12-008. SPA 12-008 was submitted to my office on March 30, 2012 to assure compliance with the Provider Screening and Enrollment provision

requirements as outlined under Section 6401 (a) of the Affordable Care Act and 42 CFR Part 455 Subpart E.

The effective date of this SPA is January 1, 2013. Enclosed are the following approved SPA pages that should be incorporated into your approved State Plan:

e Section 4.46, pages 86 & 87 If you have any questions, please contact Kristin Dillon by phone at (415) 744-3579 or by email at Kristin.Dillon@cms.hhs.gov.

Sincerely,

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

Enclosure cc: John Mendoza, California Department of Health Care Services

Christopher Thompson, Centers for Medicare and Medicaid Services Kathyryn Waje, California Department of Health Care Services

7 te DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION : OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2, STATE cA

STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION

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

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

4, PROPOSED EFFECTIVE DATE January 1, 2013

5, TYPE OF PLAN MATERIAL (Check One):

[_] NEW STATE PLAN (1) AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION: 1902(a)(77), 1902(a)(39), 1902(kk); P.L. 111-148 and P.L, 111-152 42 CFR 455 Subpart E

7, FEDERAL BUDGET IMPACT: (*estimated based on impact

identified at this time) a, FFY 2012 $ 264,801* b. FFY 2013 ® 2 $ 353,068*

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: General Program Administration — Section 4.46, pages 86, 87

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

10, SUBJECT OF AMENDMENT: Provider Screening and Enrollment

11, GOVERNOR’S REVIEW (Check One): [] GOVERNOR'S OFFICE REPORTED NO COMMENT [] COMMENTS OF GOVERNOR’S OFFICE ENCLOSED [INO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

-

’ BX] OTHER, AS SPECIFIED: The Governor’s Office does not wish to review the State Plan Amendment.

13, TYPED NAME; Toby Douglas

eZ. .

14, TITLE: Director

15. DATE SUBMITTED: MAR 30 cute

16. RETURN TO:

Department of Health Care Services Attn: State Plan Coordinator

1501 Capitol Avenue, Suite 71.326 P.O. Box 997417

Sacramento, CA 95899-7417

FORM HCFA-179.(07-92)

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

1902(a)(77) 1902(a)(39) 1902(kk);

P.L. 111-148 and PL. 111-152

42 CFR 455 Subpart E

42 CFR 455.410

42 CFR 455.412

42 CFR 455.414

42 CFR 455.416

42 CFR 455.420

42 CFR 455.422

TN No. 12-008 Supersedes TN No. None

State/Territory: CALIFORNIA

Page: 86

4.46 Provider Screening and Enrollment The State Medicaid agency gives the following assurances:

PROVIDER SCREENING °

_X__Assures that the State Medicaid agency complies with the process for screening providers under section 1902(a)(39), 1902(a)(77) and 1902(kk) of the Act.

ENROLLMENT AND SCREENING OF PROVIDERS X_Assures enrolled providers will be screened in accordance with 42 CFR 455.400 et seq.

X__Assures that the State Medicaid agency requires all ordering or referring physicians or other professionals to be enrolled under the State plan or under a waiver of the Plan as a participating provider.

VERIFICATION OF PROVIDER LICENSES

_X__Assures that the State Medicaid agency has a method for verifying providers licensed by a State and that such providers licenses have not expired or have no current limitations.

REVALIDATION OF ENROLLMENT X__Assures that providers will be revalidated regardless of provider type at least every 5 years.

TERMINATION OR DENIAL OF ENROLLMENT

_X__Assures that the State Medicaid agency will comply with section 1902(a)(39) of the Act and with the requirements outlined in 42 CFR 455.416 for all terminations or denials of provider enrollment.

REACTIVATION OF PROVIDER ENROLLMENT

_X_Assures that any reactivation of a provider will include re-screening and payment of application fees as required by

42 CFR 455.460.

APPEAL RIGHTS

_X__Assures that all terminated providers and providers denied enrollment as a result of the requirements of 42 CFR 455.416 will have appeal rights available under procedures established by State law or regulation.

NOV 2 7 2012

Approval Date: Effective Date: January 1, 2013

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

42 CFR 455.432

42 CFR 455.434

42 CFR 455.436

42 CFR 455.440

42 CFR 455.450

42 CFR 455.460

42 CFR 455.470

TN No. 12-008 Supersedes TN No. None

State/Territory: CALIFORNIA Page: 87

SITE VISITS X_Assures that pre-enrollment and post-enrollment site visits of providers who are in “moderate” or “high” risk categories will occur.

CRIMINAL BACKGROUND CHECKS

_X__Assures that providers, as a condition of enrollment, will be required to consent to criminal background checks including fingerprints, if required to do so under State law, or by the level of screening based on risk of fraud, waste or abuse for that category of provider.’

FEDERAL DATABASE CHECKS

_X__Assures that the State Medicaid agency will perform Federal database checks on all providers or any person with an ownership or controlling interest or who is an agent or managing employee of the provider.

NATIONAL PROVIDER IDENTIFIER

_X_Assures that the State Medicaid agency requires the National Provider Identifier of any ordering or referring physician or other professional to be specified on any claim for payment that is based on an order or referral of the physician or other professional.

SCREENING LEVELS FOR MEDICAID PROVIDERS

_X_Assures that the State Medicaid agency complies with 1902(a)(77) and 1902(kk) of the Act and with the requirements outlined in 42 CFR 455.450 for screening levels based upon the categorical risk level determined for a provider.

APPLICATION FEE

_X__Assures that the State Medicaid agency complies with the requirements for collection of the application fee set forth in section 1866(j)(2)(C) of the Act and 42 CFR 455.460.

TEMPORARY MORATORIUM ON ENROLLMENT OF NEW PROVIDERS OR SUPPLIERS

_X__Assures that the State Medicaid agency complies with any temporary moratorium on the enrollment of new providers or provider types imposed by the Secretary under section 1866(j)(7) and 1902(kk)(4) of the Act, subject to any determination by the State and written notice to the Secretary that such a temporary moratorium would not adversely impact beneficiaries’ access to medical assistance.

NOV 21 202 Approval Date: Effective Date: January 1, 2013

Table of Contents State/Territory Name: California State Plan Amendment (SPA) #: 13-004 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 Toby Douglas Director California Department of Health Care Services P.O. Box 997413, MS 0000 Sacr8l)lento, CA 95899-7413 RE: California State Plan Amendment 13-004 Dear Mr. Douglas: CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES We have reviewed the proposed amendment to Attachment 4.19-A of your Medicaid state plan submitted under transmittal number (TN) 13-004. This amendment provides that inpatient hospital services furnished by private hospitals will be reimbursed under an All Patient Refined Diagnosis Related Group (APR-DRG) prospective payment methodology, effective July 1, 2013. We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(13), 1902(a)(30), 1903(a), and 1923 of the Social Security Act and the implementing Federal regulations at 42 CFR 447 Subpart C. This is to inform you that Medicaid State plan amendment TN 13-004 is approved effective July 1, 2013. We are enclosing the HCFA-179 and the amended plan pages. If you have any questions, please call Mark Wong 744-3561 or Annalisa Fichera at 415-744-3577. Enclosures Sinc~ely, /;I ~indyMlum Director

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARB FINANCING ADMINISTRATION FORM APPROVED OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF I. TRANSMITTAL NUMBER: 2.STATB CA STATE PLAN MATERIAL 13-004 FOR: HEALTH CARE FINANCING ADMINISTRATION TO: REGIONAL ADMLNISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES S. TYPE OF PLAN MATERIAL (Check One); 3. PROGRAM IDENTIFICATION: TITLE XIX OF THB SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE July 1, 2013 1&1 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN 0 AMENDMENT . COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT e arate Transmittal or each amendment 6. FEDERAL STATUTEI.RBGULATION CITATION: 7. FEDERAL BUDGET IMPACT: 42 CFR Part 447, Subpart C. 1902(a)(13), 1923, l861(v)(l)(G) ofthe a. FFY 201311:4 $ {44;.93~009)-( 12,605, 537) Act ·b. FFY 20141M $-(89;62-1-,000: 50,422,147 8. PAOE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAOE NUMBER OF THE SUPERSEDED PLAN SECTION Attachment 4-19-A, pages 17.38-1:~53- 17.61 Appendix 6 to Attachment 4.19-A pages 1-2. 3 Limitations on Attach 3.1-A, pages 1, 1a, and 1b Limitations on Attach 3.1-B, pages 1, 1a, and 1b 10. SUBJECT OF AMENDMENT: 11. GOVERNOR•S REVIEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT · 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITiflN 45 DAYS OF SUBMI'IT..AJ- 12.SlGN CY ,. .... ·--·- OR ATTACHMENT (If Applicable): None- Limitations on Attach 3.1-A, pages 1, 1a, and 1b Limitations on Attach 3.1-B, pages 1, 1 a, and 1 b 1&1 OTHER, AS SPECIFIED: The Governor's Office does not wish to review the State Plan Amendment. 16, RETURN TO: Department of Health Care Servh:es Attn: State Plan Coordinator 1501 Capitol Avenue, Suite 71.326 Director ·-1'1.'., ·. .1 P.O. Box 997417 ....=.;:.:..;=::;::,:,,....,=-=-==-----------......_---1 ,J Sacramento, CA 95899-7417 15' DATE SUBMI'ITED: APR 1 5 2013 MAY 31 2013 ·,~ . ! i I ,, I _21.~~~~~~----------~~~~~~~~~~~-sl 23. ~u.>JLn.n.n.L~''-'" ! 19. P-eN -?l tJ o -J N k c.hArV~:rs i1Aoe.. + o fux-es 7 f o-.rv o 9 by ~oJI'r j I 0 F Ftc e. wt+·~ Co"' c.Dt'\1\£ h.lc..e_ by 01-M-e_ d ~eo{ 5/ [}£1 / 8J 13 \

Attachment 4.19 -A Page 17.38

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

STATE: CALIFORNIA

REIMBURSEMENT TO GENERAL ACUTE CARE HOSPITALS FOR ACUTE

INPATIENT SERVICES

Notwithstanding any other provision of this State Plan, for admissions dated July 1, 2013 and

after, reimbursement to private general acute care hospitals (GACH) for acute inpatient services

that are provided to Medi-Cal beneficiaries is described and governed by this segment of Attachment 4.19-A.

A. Definitions

1.

“APR-DRG?” or “All Patient Refined Diagnosis Related Groups” is a specific code assigned to each claim by a grouping algorithm that utilizes the diagnoses code(s), procedure code(s), patient birthdate, patient age, patient gender, admit date, discharge

date, and discharge status on that claim.

“APR-DRG Base Price” is the statewide base price amount before the relative weight of the APR-DRG, any adjustors, and/or add-on payments are applied. APR-DRG Base Prices are determined by parameters defined in Welfare and Institutions (W&I) Code section 14105.28, as the law was in effect on July 1, 2013.

“APR-DRG Grouper” is the software application used to assign the APR-DRG to a DRG

Hospital claim.

“APR-DRG Payment” is the payment methodology for admissions on or after July 1, 2013 for acute inpatient services provided to Medi-Cal beneficiaries at DRG Hospitals.

TN No. 13-004 MAY 3 Supersedes Approval Date 1 ag Effective Date: July 1, 2013 TN No. None

Attachment 4.19 -A Page 17.39

5. “APR-DRG Relative Weight” is a numeric value representing the average resources utilized per APR-DRG. The relative weights associated with each APR-DRG are calculated from a two-year dataset of 15.5.million stays in the Nationwide Inpatient Sample, which includes general acute care hospitals including freestanding children’s

hospitals.

6. “DRG Hospital Specific Transitional APR-DRG Base Price” is a DRG Hospital specific APR-DRG Base Price calculated to assist DRG Hospitals to adapt to the change in payment methodologies. Transitional base prices are used during the three year

implementation phase for qualifying hospitals.

7. “DRG Hospitals” are private general acute care hospitals reimbursed for acute inpatient services based on APR-DRG pricing for admissions dated on or after July 1, 2013. “DRG Hospitals” are currently all private general acute care hospitals not excluded as

outlined in (Section B; paragraph 2).

8. “Estimated Gain” is the amount a DRG Hospital is estimated to gain on a final discharge

claim for which the final APR-DRG Payment exceeds estimated costs.

9. “Estimated Loss” is the amount a DRG Hospital is estimated to lose on a final discharge

claim for which the final APR-DRG Payment does not exceed estimated costs.

10. “Exempt Hospitals, Services, and Claims” are those hospitals, services, and claims as defined in Welfare & Institutions Code section 14105.28, as the law was in effect on July 1, 2013.

11. “High Cost Outlier Threshold 1” is the amount that an estimated loss for a single

complete discharge claim must exceed to be paid an outlier payment at the Marginal Cost

Factor 1. TN No. 13-004 3 Supersedes Approval Date MAY $7 2013 Effective Date: July 1, 2013

TN No. None

Attachment 4.19 —A Page 17.40

12. “High Cost Outlier Threshold 2” is the amount that an estimated loss for a single complete discharge claim must exceed to be paid an outlier payment at-the Marginal Cost Factor 2.

13. “Low Cost Outlier Threshold” is the amount that the Estimated Gain needs to be greater than to have the gained amount reduced by Marginal Cost Factor 1.

14. “Marginal Cost Factor 1” is the factor used for payment reductions and for determining outlier payments to DRG Hospitals for claims that have estimated losses between High Cost Outlier Threshold 1 and High Cost Outlier Threshold 2.

15. “Marginal Cost Factor 2” is the factor used for determining outlier payments to DRG Hospitals for claims that have estimated losses greater than High Outlier Threshold 2.

16. “Medi-Cal” is the name of California’s Federal Medicaid program.

17. “Remote Rural Hospital” is a California hospital that is defined as a rural hospital by the Office of Statewide Health Planning and Development (OSHPD), is at least fifteen (15) miles in driving distance from the nearest GAC hopital that has a basic level emergency room, and does not operate under a combined license or bill under a common National

Provider Index (NPI) number with a non-remote rural hospital.

18. “State Fiscal Year” (SFY) is California state government’s fiscal year which begins on July 1 and ends the following June 30.

TN No. 13-004 Supersedes Approval Datel“AY 31 2013 TN No. None

Effective Date: July 1, 2013

Attachment 4.19 —A Page 17.41

B. Applicability

1. Except as specified below in Paragraph 2, for admissions dated July 1, 2013 and after, the Department of Health Care Services (DHCS) will reimburse “DRG Hospitals” through a prospective payment methodology based upon APR-DRG.

2. The following are “Exempt Hospitals, Services, and Claims” that are not be reimbursed based upon APR-DRG:

a. Psychiatric hospitals and psychiatric units

s

Rehabilitation hospitals, rehabilitation units, and rehabilitation stays at general acute _care hospitals

Designated Public Hospitals

9

Non-Designated Public Hospitals Indian Health Services Hospitals Inpatient Hospice

Swing-bed stays

Sm m 9

Managed Care stays

i. Administrative Day Reimbursement claims i. Level 1

ii. Level 2

3. For Medi-Cal Managed Care, as required by Welfare & Institutions Code 14091.3 (c) (2), emergency out-of-network stays are priced by APR-DRGs.

TN No. 13-004 Supersedes Approval Date MAY 31 2018

TN No. None

Effective Date: July 1, 2013

Attachment 4.19 —A Page 17.42

C. APR-DRG Reimbursement

For admissions dated July 1, 2013 and after, reimbursement to DRG Hospitals for services provided to Medi-Cal beneficiaries are based on APR-DRG. APR-DRG Payment is determined by multiplying a specific APR-DRG relative weight by a DRG Hospital’s specific APR-DRG Base Price with the application of adjustors and add-on payments, as applicable. Provided all pre-payment review requirements have been approved by DHCS, APR-DRG Payment is for each admit through discharge claim, unless otherwise specified in this segment of Attachment 4.19-A.

1. APR-DRG Relative Weight

The assigned APR-DRG code is determined from the information contained on a DRG Hospital’s submitted UB-04 or 8371 acute inpatient claim. The grouping algorithm utilizes the diagnoses codes, procedure codes, admit date, discharge date, patient birthdate, patient age, patient gender, and discharge status present on the submitted claim to group the claim to one of 314 specific APR-DRG groups. Within each specific group of 314, there are four severities of illness and risk of mortality sub classes: minor (1), moderate (2), major (3), and extreme (4). This equates to a total of 1256 different APR- DRG (with two error code possibilities). Each discharge claim is assigned only one APR-DRG code. For each of the 1256 APR-DRG codes there is a specific APR-DRG Relative Weight assigned to it by the APR-DRG grouping algorithm. The APR-DRG Relative Weights are calculated from a Nationwide Inpatient Sample. Each version of the APR-DRG grouping algorithm has its own set of APR-DRG specific relative weights assigned to it. The APR-DRG relative weights are published in the Medi-Cal DRG Pricing Calculator posted on the DHCS website at http://www.dhcs.ca.gov/provgovpart/Pages/DRG.aspx.

TN No. 13-004 MAY 3 1 2013 . Supersedes Approval Date Effective Date: July 1, 2013 TN No. None

Attachment 4.19 —A Page 17.43

2. APR-DRG Statewide Base Prices Beginning SFY 2016-17

i. In determining the APR-DRG Payment, California DRG Hospitals and out-of- state hospitals will utilize the statewide APR-DRG Base Price, except for California Remote Rural Hospitals, which will utilize the remote rural APR-DRG Base Price as reflected in Appendix 6 to Attachment 4.19-A.

3. DRG Hospital Specific Transitional APR-DRG Base Prices for SFYs 2013-14 through SFY 2015-16

a. Similar to implementation of DRGs in Medicare, DHCS is implementing a three-year transition period to allow California DRG Hospitals moving to the APR-DRG Payment methodology to adapt to the change in payment methodologies. A DRG Hospital Specific Transitional APR-DRG Base Price is utilized for qualifying DRG Hospitals for each of SFYs 2013-14, 2014-15, and 2015-16, in accordance with this section. The statewide APR-DRG base rates will be fully utilized by all DRG Hospitals beginning SFY 2016-17.

b. First year DRG Hospital Specific Transitional APR-DRG Base Prices apply to DRG hospitals that were projected in general to see a change in estimated payments of more than five percent from their projected baseline payments. Some DRG Hospitals will receive a DRG Hospital Specific Transitional APR-DRG Base Prices that is higher than the APR-DRG Statewide Base Price. Other DRG Hospitals will receive a DRG Hospital Specific Transitional APR-DRG Base Price lower than the statewide base price, but with a floor of fifty percent of the statewide base rate (due to the fifty

percent floor, some DRG Hospitals are may have increases greater than five percent).

TN No. 13-004 Supersedes Approval Date MAY 3 1 2013 Effective Date: July 1, 2013 TN No. None

Attachment 4.19 —A Page 17.44

c. In determining the first year DRG Hospital Specific Transitional APR-DRG Base Price, a twelve month dataset was established using paid claims with discharge dates between January 1, 2009, and December 31, 2009, and paid dates through December 27, 2010, extracted from the CA-MMIS processing system and the 2009 patient discharge dataset from OSHPD. Payments from CY 2009 were trended forward to 2013-14 based on (1) actual contract rate increases for contract hospitals, (2) the hospital fee UPL trend factors for non-contract hospitals, or (3) a combination of these two if a hospital had a change in contract status since 2009; the payment trends for this purpose assume payments for services in SFY 2013-14 are based on rates in effective at the end of SFY 2013. Case mix based on projected actual case mix growth and growth from improved documentation were trended forward from CY 2009 to SFY 13-14 by 5.85%. For outlier payment projection purposes, billed

_charges from CY 2009 were trended to SFY 13-14 by 28.98%, and cost-to-charge ratios were derived from the hospital's latest accepted cost report. The 2009 data set trended forward to 2013-14 as described in this paragraph was utilized to develop 2013-14 DRG base prices. Without further trending or other adjustments, the same data set was also used to develop 2014-15 and 2015-16 transitional base prices.

d. A statewide base price was calculated that would result in the same level of overall payments if all hospitals received the same underlying base price (or the remote rural base price for remote rural hospitals), which was adjusted by the Medicare local wage area index value reflecting the various hospital-specific adjustments that Medicare

uses (from the Medicare hospital impact file).

e. A shadow base price was calculated for each hospital that would result in the same level of projected payments in 2013-14 for each hospital under DRGs as projected under the prior methodology. The wage index was not relevant to this calculation because it was based on setting a final price at a level that results in the same amount

of projected payments as under the prior methodology.

TN No, [2-00 MAY 31 2013 ; Supersedes Approval Date. Effective Date: July 1, 2013 TN No. None

Attachment 4.19 —A Page 17.45

f. DRG Hospitals that would have a minimal projected impact will be assigned to the statewide base price or remote rural base price (adjusted by the wage area index

value) during the transition period if any of the following apply:

i. The estimated impact (up or down) on total projected payments of APR-DRG Payment is less than five percent. \ ii. Ifthe estimated impact (up or down) on total projected payments of APR-DRG Payment is less than $50,000. iii. If the DRG Hospital had fewer than 100 Medi-Cal Fee for Service stays and these stays were estimated to represent less than two percent of the DRG Hospital’s total inpatient volume based on data submitted to OSHPD.

iv. Ifthere were no stays in the simulation dataset for a particular DRG Hospital.

g. For remaining DRG Hospitals that had a shadow base price that results in projected payments above projected payments at the statewide base price (adjusted for their wage area index value), a hospital specific base price was calculated that resulted in a 5 percent reduction in projected payments. The wage index was not relevant to this calculation because it was based on setting a final price at a level that results in projected payments that are 5 percent less than projected under the prior methodology. A minimum base price that is 50 percent of the statewide price (adjusted for the hospital-specific wage area index value) was established. DRG Hospitals with a shadow base price below this threshold were increased to this level. To the extent projected savings from the 5 percent reduction exceeded the projected cost of establishing a floor of 50 percent of the statewide base price, the difference was provided to all remaining transition hospitals. Remaining hospitals defined as remote, rural hospitals received a base price that will result in a 5 percent increase in projected payments. The remaining non-remote, rural hospitals received base prices

that provide for a proportional increase in projected payments, whichis approximately

TN No. 13-004 4 Supersedes Approval Date MAY 1 2013 TN No. None

Effective Date: July 1, 2013

Attachment 4.19 —A Page 17.46

2 percent under DRGs in 2013-14 compared to projected 2013-14 payments under the prior methodology. All base prices were rounded to the nearest whole dollar. A hospital specific transitional base price was calculated accordingly for each of these hospitals. Because this final calculation was based on setting payments at a specific

level above the shadow base price, the wage area index value was not a consideration.

h. Second year and third year DRG Hospital Specific Transitional APR-DRG Base Prices apply to DRG hospitals that were projected in general to.see a change in estimated payments of more than ten percent from their projected baseline payments (SFY 2014-15) and fifteen percent from their projected baseline payments (SFY 2015-16). Some DRG Hospitals will receive a DRG Hospital Specific Transitional APR-DRG Base Price that is higher than the APR-DRG Statewide Base Price. Other DRG Hospitals will receive a DRG Hospital Specific Transitional APR-DRG Base Price lower than the statewide base price, but with a floor of fifty percent of the statewide base rate (due to the fifty percent floor, some DRG Hospitals may have

increases greater than five percent in 2013-14).

i. To develop 2014-15 hospital-specific transitional base prices, hospitals with projected payments in 2013-14 above projected payments at the statewide base price had base prices calculated that would result in an additional 5 percent reduction in projected payments as compared to projected baseline payments. To the extent this results in a transitional base price below the statewide base price for a hospital, the hospital receives the statewide base price and therefore receives less than an additional 5 percent reduction in projected payments. Savings that results from the reduction described in this paragraph will be utilized to provide a uniform percentage increase in projected payments for hospitals with projected 2013-14 payments that are less than their projected payments at the statewide base price. However, no hospital shall receive a percentage increase that would result in a transitional base price above the

statewide base price.

TN No. 13-004 ; Supersedes Approval DatelAY 31 2013 TN No. None

Effective Date: July 1, 2013

Attachment 4.19 —A Page 17.47

j. To develop 2015-16 hospital-specific transitional base prices, hospitals with projected payments in 2014-15 (which is the projected 2013-14 payments reduced by 5 percent per subparagraph i above) above projected payments at the statewide base price had base prices calculated that would result in an additional 5 percent reduction in projected payments as compared to projected baseline payments. To the extent this results in a transitional base price below the statewide base price for a hospital, the hospital receives the statewide base price and therefore receives less than an additional 5 percent reduction in projected payments. Savings that results from the reduction described in this paragraph will be utilized to provide a uniform percentage increase in projected payments for hospitals with projected 2014-15 payments that are less than their projected payments at the statewide base price. However, no hospital shall receive a percentage increase that would result in a transitional base price above

the statewide base price.

k. The DRG Hospital Specific Transitional APR-DRG Base Price for SFY 2013-14 were sent to hospitals January 30, 2013.

1. The DRG Hospital Specific Transitional APR-DRG Base Price for SFY 2014-15 and

SFY 2015-16 will be provided to hospitals no later than July 31, 2013. Beginning in 2016-17 all hospitals will receive the statewide base price.

4. Wage Area Adjustor

TN No. 13-004 4 Supersedes Approval Date MAY 3 1 2013 Effective Date: July 1, 2013 TN No. None

Attachment 4.19 -A Page 17.48

a. The “Wage Area Adjustor” adjusts the APR-DRG Base Price of a DRG Hospital depending on the wage area Medicare has assigned to them. DHCS will utilize the same wage area boundaries, wage area index values, labor share calculation, and any other wage area or index value adjustments as Medicare. DHCS will also use the Medicare reclassifications of DRG Hospitals into adjacent wage areas. Out of state hospitals will receive a wage area adjustor of 1.00. The wage area adjustor is applied to

. the labor share percentage, as specified in Appendix 6, of the statewide base price or the remote rural base price. Medicare published the Medicare impact file for FFY 2013 in October, 2012 and it was used for the transitional base prices for state Fiscal Year (SFY) 2013-14. Similarly, final changes to all DRG hospitals wage area, index value, or labor share calculation published for future federal fiscal years will be used for the state fiscal year beginning after the start of each respective federal fiscal year. All wage area index values can be viewed on the Medi-Cal DRG Pricing Calculator posted

on the DHCS website at http://www.dhcs.ca.gov/provgovpart/Pages/DRG.aspx.

b. The wage area adjustor is not applied to the hospital-specific transitional base price

(determined in paragraph C.3 above). 5. Policy Adjustors

The implementation of APR-DRG Payment includes the functionality of policy adjustors. These adjustors are created to allow the DHCS to address any current, or future, policy goals and to ensure access to care is preserved. Policy adjustors may be used to enhance payment for services where Medi-Cal plays a major role. This functionality of policy adjustors allows DHCS the ability to ensure access to quality care is available for all services. A list of the current policy adjustors is reflected in Appendix 6 of Attachment

4.19-A. These policy adjustors are used to adjust payment weights for care categories.

TN No. 13-004 Supersedes Approval Date MAY 31 203 TN No. None

Effective Date: July 1, 2013

Attachment 4.19 -A Page 17.49

The projected financial impact of the policy adjustors was considered in developing

budget-neutral base prices.

6. Cost Outlier Payments

Outlier payments are determined by calculating the DRG Hospital’s estimated cost and comparing it to the APR-DRG Payment to see if there is a loss or gain for the hospital for a discharge claim. The DRG Hospital’s estimated cost on a discharge claim is determined by multiplying the Medi-Cal covered charges by the DRG Hospital’s most currently accepted cost-to-charge ratio (CCR) from a hospital’s CMS 2552-10 cost report. The CCR is calculated from a hospital’s Medicaid costs (reported on worksheet E-3, part VII, line 4) divided by the Medicaid charges (reported on worksheet E-3, part VII, line 12). All hospital CCRs will be updated on a quarterly basis after the acceptance of the CMS 2552- 10 by DHCS.

a. Subtracting the APR-DRG Payment from the DRG Hospital’s estimated cost on a given discharge claim gives the estimated loss. If the Estimated Loss is greater than the High Cost Outlier Threshold 1, then the Cost Outlier Payment is the Estimated Loss less the High Cost Outlier Threshold 1 (but to a maximum of High Cost Outlier Threshold 2 less High Cost Outlier Threshold 1) multiplied by the Marginal Cost

Factor 1.

b. For extreme outlier cases, if the Estimated Loss on a discharge claim is greater than the High Cost Outlier Threshold 2, then the Cost Outlier Payment is the Estimated Loss less the High Cost Outlier Threshold 1 (but to a maximum of High Cost Outlier Threshold 2 less High Cost Outlier Threshold 1) multiplied by the Marginal Cost Factor 1, plus the Estimated Loss less High Cost Outlier Threshold 2 multiplied by the Marginal Cost Factor 2.

TN No. 13-004 Supersedes Approval Date_MAY 31 2013 Effective Date: July 1, 2013 TN No. None

Attachment 4.19 —A Page 17.50

c. APR-DRG Payment also utilizes a low-side outlier similar to the high side outlier adjustment calculations. The estimated gain is determined by subtracting the APR- DRG Payment from the DRG Hospital’s estimated cost . If the Estimated Gain is greater than the Low Cost Outlier Threshold, payment will be decreased by the Estimated Gain less the Low Cost Outlier Threshold, and then multiplied by the Marginal Cost Factor 1.

d. Values for High Cost Outlier Threshold 1, High Cost Outlier Threshold 2, Low Cost Outlier Threshold, Marginal Cost Factor 1, and Marginal Cost Factor 2 are reflected in Appendix 6 of Attachment 4.19-A.

7. Transfer Adjustments

When a Medi-Cal beneficiary is transferred from a DRG Hospital (DRG Hospital 1), to another hospital, DRG Hospital 1’s payment for the transfer is determined by calculating a per diem payment amount for the assigned APR-DRG and multiplying it by: one plus the actual length of stay. The per diem amount is calculated by pricing the stay at its assigned APR-DRG payment and dividing by the nationwide average length of stay for the assigned APR-DRG. If DRG Hospital 1’s actual length of stay plus one is greater than the nationwide average length of stay, payment for this particular transfer would pay the full DRG. If the receiving hospital is a DRG Hospital, they would receive an APR-DRG payment based on a final discharge claim. Discharge status values defining an acute care transfer are reflected in Appendix 6 of Attachment 4.19-A. The various relative weights, including average length of stay are published in the Medi-Cal DRG Pricing Calculator posted on the DHCS website at http://www.dhes.ca.gov/provgovpart/Pages/DRG.aspx.

TN No. 13-004 Supersedes Approval Date MAY 3 1 2013 TN No. None

Effective Date: July 1, 2013

Attachment 4.19 —A Page 17.51

8. Interim Payments

For stays exceeding twenty- nine (29) days, a DRG Hospital may submit an interim claim for payment every thirty (30) days. For example, if a stay is for sixty-one (61) days, two interim claims may be submitted for payment, as well as one final claim. Interim claims are paid a per diem amount for each day of service. When the Medi-Cal beneficiary is discharged, the DRG Hospital submits a full admit through discharge claim. The final discharge claim is priced as any other final discharge claim and will be paid accordingly. All previously paid interim payments related to the final discharge claim are removed from the DRG Hospital’s next check-write through the remittance advice detail (RAD). The interim per diem amount is reflected in Appendix 6 of Attachment 4.19-A.

9. Separately Payable Services, Supplies, and Devices

a. A separate outpatient claim may be submitted for certain services, supplies, and devices as determined by DHCS, reflected in Appendix 6 of Attachment 4.19-A, and

will be reimbursed in accordance with Attachment 4.19-B.

b. Professional services furnished by provider-based physicians and practitioners should be billed as professional claims and are reimbursed outside of the DRG reimbursement. All physician professional services should be billed as professional

claims. 10. Out-of-State Hospital Reimbursement a. For admissions beginning July 1, 2013, when acute inpatient medical services are

provided out-of-state pursuant to Section 2.7 of the State Plan and have been certified

for payment at the acute level of an emergency nature for which prior Medi-Cal

TN No. 13-004 Supersedes Approval Date_MAY 3 1 2013 Effective Date: July 1, 2013 TN No. None

Attachment 4.19 -A Page 17.52

authorization has been obtained, then such inpatient services are reimbursed utilizing

the statewide APR-DRG Base Price for the services provided.

When Medi-Cal is required to provide acute inpatient services that are not available in the State to comply with paragraph (3) of part 431.52(b) of Title 42 of the Code of Federal Regulations, and the out-of-state hospital refuses to accept the APR-DRG rate, then DHCS may negotiate payment in excess of the APR-DRG rate for the acute inpatient services provided but no more than what the out-of-state hospital charges

the general public.

DHCS will adjust payment to out-of-state inpatient hospitals for provider preventable conditions, as described in Attachment 4.19-A. When treating a Medi-Cal

beneficiary, out-of-state providers must comply with the reporting provisions for

provider preventable conditions described in Attachment 4.19-A pages 52 through 54, OMB No. 0938-1136.

D. Updating Parameters

1,

DHCS will review all base prices, policy adjustors, and other payment parameters as needed to ensure projected payments for any given year are kept within the parameters as defined in Welfare & Institutions Code section 14105.28, as the law was in effect on July 1, 2013. Any needed changes may be implemented as outlined

in paragraph 4 of this section.

The APR-DRG Relative Weights are specific to the APR-DRG Grouper version and are released annually. DHCS will perform a review of each released version to

determine if an update to the current grouper and hospital acquired condition (HAC)

eNO 53008 MAY 31 2013 Supersedes Approval Date Effective Date: July 1, 2013 TN No. None

Attachment 4.19 —A Page 17.53

utility are necessary. The APR-DRG Grouper version and HAC Utility version DHCS is utilizing is reflected in Appendix 6 of Attachment 4.19-A. Changes to the APR-DRG Grouper version and HAC Utility version may be implemented purusant to an approved State Plan Amendment.

3. DHCS will review and update Appendix 6 of Attachment 4.19-A as necessary and . pursuant to an approved State Plan Amendment. When reviewing, DHCS shall consider: access to care for specific and overall care categories; hospital coding

trends, and any other issues warranting review.

4. The effect of all transition base rates, policy adjustors and values as referenced in Appendix 6 of Attachement 4.19A will be monitored by DHCs on a quarterly basis. .If DHCS determines that adjustments to any values or parameters specified in Appendix 6 of Attachment 4.19-A are necessary to ensure access for all Medi-Cal beneficiaries, program integrity, or budget neutrality, DHCS may adjust those values

or parameters upon approval of a State Plan Amendment.

E. Pre-Payment and Post-Payment Review

1. All claims paid using the APR-DRG Payment methodology are subject to DHCS’

pre-payment medical necessity review and discretionary post-payment review.

2. Outlier claims may be subject to post-payment review and adjustment in accordance with the following protocols: i. Amounts paid for services provided to Medi-Cal beneficiaries shall be audited by the department in the manner and form prescribed by the department as defined in Welfare and Institutions Code 14170.

TN No. 13-004 4 Supersedes Approval Date MAY 31 2013 TN No. None

Effective Date: July 1, 2013

Attachment 4.19 -A Page 17.54

ii. When there is a material change between the reported CCR and the final audited CCR, outlier payments may be subject to recalculation based upon the audited CCR. A material change is defined as a change that would result in outlier payment adjustments exceeding $10,000.00 for a hospital

during a state fiscal year.

F. End of the Selective Provider Contracting Program

Effective July 1, 2013, the Selective Provider Contracting Program (SPCP) will be discontinued for private hospitals. Reimbursement for hospital inpatient services provided to Medi-Cal beneficiaries will be based on the new diagnosis-related group (DRG) methodology. As part of this, the Selective Provider Contracting Program will no longer be in effect and is discontinued upon DRG implementation. Additionally, hospitals will no longer be designated as contract or

non-contract facilities.

TN No. 13-004 Supersedes Approval Date MAY 31 2013

TN No. None

Effective Date: July 1, 2013

Attachment 4.19 -A Page 17.55

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

STATE: CALIFORNIA

REIMBURSEMENT TO HOSPITALS FOR ADMINISTRATIVE LEVEL 1 SERVICES

Notwithstanding any other provision of this State Plan, for admissions dated July 1, 2013 and

after, reimbursement for Hospital Administrative Level 1 Services that are provided to Medi-

Cal beneficiaries by general acute care hospitals is described and governed by this segment of Attachment 4.19-A.

A. Definitions

“Administrative Level 1 Services” are defined as services provided by acute inpatient providers for services rendered to a patient awaiting placement in a Nursing Facility Level-A or Nursing Facility Level B, that are billed under the existing methodology and criteria associated with revenue code 169, as outlined in the Medi-Cal Provider Manual’s Inpatient Services “Administrative Days”, and as defined in Welfare and Institutions Code section 14091.21, as they were in effect on July 1, 2013.

B. Applicability

For admissions dated July 1, 2013 and after, the Department of Health Care Services (DHCS) will reimburse acute inpatient providers for Administrative Level 1 Services through an Administrative Day Level 1 per diem payment.

C. Administrative Day Level 1 Reimbursement

Payment for Administrative Day Level 1 Services follow the current DP/NF-B payment methodology used for DP/NF-Bs services for beneficiaries as outlined in Attachment 4.19-D of

TN No. 13-004 MAY 31 2018 ; Supersedes Approval Date Effective Date: July 1, 2013 TN No. None

Attachment 4.19 -A Page 17.56

the State Plan and section 51542 of Title 22 of California Code of Regulations. Hospitals

without a DP/NF-B will receive the statewide median rate.

D. Updating Parameters Rates paid to DP/NF-Bs for services to Medi-Cal beneficiaries are currently reviewed and updated by DHCS in accordance with Attachment 4.19-D. Administrative Day Level 1 rates will be updated concurrently when DHCS releases subsequent state fiscal year DP/NF-B rates.

E. Pre-Payment and Post Payment Review

All claims paid under Administrative Day Level 1 are subject to DHCS’ pre-payment medical necessity review and discretionary post-payment review.

TN No. 13-004 4 Supersedes Approval Date. MAY 31 2013 Effective Date: July 1, 2013 TN No. None

Attachment 4.19 —A Page 17.57

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

STATE: CALIFORNIA

REIMBURSEMENT TO DRG HOSPITALS FOR ADMINISTRATIVE LEVEL 2 SERVICES Notwithstanding any other provision of this State Plan, for admissions dated July 1, 2013 and after, reimbursement for Diagnosis Related Group (DRG) Hospital Administration Level 2 Services that are provided to Medi-Cal beneficiaries by DRG Hospitals is described and governed by this segment of Attachment 4.19-A.

A. Definitions

1. “Administrative Level 2 Services” are defined as services provided by a DRG Hospital requiring more services, supplies, and/or resources than needed for the current administrative day that are billed under the existing methodology and criteria associated with revenue code 169, as outlined in the Medi-Cal Provider Manual’s Inpatient Services “Administrative Days,” but less than or equal to those required for a Sub-Acute

environment as outlined in Attachment 4.19-D of the State Plan. 2. “DRG Hospitals” as defined in Attachment 4.19-A. B. Applicability 1. For admissions dated July 1, 2013 and after, the Department of Health Care Services

(DHCS) will reimburse DRG Hospitals for Administrative Level 2 Services through an Administrative Day Level 2 per diem payment.

TN No. 13-004

Supersedes Approval Date_MAY J1 2013 Effective Date: July 1, 2013 TN No. None

Attachment 4.19 -A Page 17.58

2. For admissions dated July 1, 2013 and after, the Department of Health Care Services (DHCS) will reimburse all non-DRG Hospitals for Administrative Level 2 Services as a

general acute care stay based on their current reimbursement methodology.

C. Administrative Day Level 2 Reimbursement

For a hospital that operates a distinct part sub-acute facility, payment for Administrative Day Level 2 Services will be at the lower of the current statewide median Sub-Acute rate or the facility-specific cost rate used for distinct part sub-acute facilities providing sub-acute services for both pediatric and adult Medi-Cal beneficiaries as outlined in Attachment 4.19-D of the State Plan. Each of the pediatric and adult Administrative Day Level 2 rate is the average of the

respective Sub-Acute ventilator and non-ventilator rates.

For a hospital that does not operate a distinct part sub-acute facility, payment for Administrative Day Level 2 serivces will be at the current statewide median Sub-Acute rate used for distinct part sub-acute facilities providing sub-acute services for both pediatric and adult Medi-Cal beneficiaries as outlined in Attachment 4.19-D of the State Plan. Each of the pediatric and adult Administrative Day Level 2 rate is the average of the respective Sub-Acute ventilator and non-

ventilator rates.

D. Updating Parameters

Pediatric and adult sub-acute rates paid to distinct part facilities providing sub-acute services to Medi-Cal beneficiaries are currently reviewed and updated by DHCS in accordance with Attachment 4.19-D. Administrative Day Level 2 rates will be updated concurrently when

DHCS releases subsequent state fiscal year sub-acute rates.

TN No. 13-004 5 Supersedes Approval Date_MAY 1 2013 Effective Date: July 1, 2013 TN No. None

Attachment 4.19 -A Page 17.59

E. Pre-Payment and Post Payment Review

All claims paid under Administrative Day Level 2 are subject to DHCS’ pre-payment medical

necessity review and discretionary post-payment review.

Supersedes Approval Date Effective Date: July 1, 2013 TN No. None .

Attachment 4.19 -A Page 17.60

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

STATE: CALIFORNIA

REIMBURSEMENT TO DRG HOSPITALS FOR REHABILITATION SERVICES

Notwithstanding any other provision of this State Plan, for admissions dated July 1, 2013 and after, reimbursement for Rehabilitation Services that are provided to Medi-Cal beneficiaries by Diagnosis Related Group (DRG) Hospitals is described and governed by this segment of Attachment 4.19-A.

A. Definitions 1. “DRG Hospitals” as defined in Attachment 4.19-A. 2. “Rehabilitation Services” are defined as acute inpatient intensive rehabilitation services provided to Medi-Cal beneficiaries, in accordance with Sections 14064 and 14132.8 of the Welfare and Institutions Code as the laws were in effect on July 1, 2013. B. Applicability For admissions dated July 1, 2013 and after, the Department of Health Care Services’ (DHCS) will reimburse Rehabilitation Services rendered by DRG Hospitals, through a per diem rate for Rehabilitation Services provided to a Medi-Cal beneficiary. C. Rehabilitation Reimbursement Provided all requirements for a pre-payment review have been approved by DHCS,

Rehabilitation Services are paid a per diem amount for each day of service that is authorized,

unless otherwise specified in Attachment 4.19-A. The specific per diem rates for pediatric and

TN No. 13-004 Supersedes Approval Date MAY 31 2013

TN No. None

Effective Date: July 1, 2013

Attachment 4.19 -—A Page 17.61

adult rehabilitation services are specified in Appendix 6 and are statewide rates. The specific pediatric and adult rehabilitation per diem rates were set at a level that is budget neutral on a statewide basis for both adult and pediatric rehabilitation services based on rates in effect June 30, 2013. The specific per diem rate for a hospital that provided services to both the adult and pediatric population is based on the blend of pediatric and adult rehabilitation services provided at that specific hospital. A facility-specific blended rate is the weighted average of the statewide adult and statewide pediatric per diem rates, weighted by the individual facility's number of adult and pediatric rehabilitation days in the base period used to determine the statewide per diem rates. All rehabilitation rates are further adjusted by the labor portion (68.8%) of the hospital-specific Medicare Wage Index value for each specific hospital.

D. Updating Parameters

DHCS will review and update the Rehabilitation Services payment parameters through the State Plan Amendment process. When reviewing and updating, DHCS shall consider: access to care related to Rehabilitation Services provided at a DRG Hospital, and any other issues warranting

review. E. Pre-Payment and Post Payment Review

All claims paid under the rehabilitation per diem are subject to DHCS’ pre-payment medical

necessity review and discretionary post-payment review.

TN No. 13-004 4 Supersedes Approval Date MAY 31 2013 Effective Date: July 1, 2013 TN No. None

Appendix 6 to Attachment 4.19 - A Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

STATE: CALIFORNIA

Appendix 6 1. APR-DRG Payment Parameters ‘ Parameter Value Description Remote Rural APR-DRG Base Price | $10,218 | Statewide Remote Rural APR-DRG Base Price Statewide APR-DRG Base Price $6,223 Statewide APR-DRG Base Price (non-Remote Rural) Policy Adjustor - Age 1.25 Policy Adjustor for claims whose patients are less than 21 years old with a DRG in the ‘miscellaneous pediatric’ or ‘respiratory pediatric’ care categories. Policy Adjustor — NICU services 1.25 Policy Adjustor for all NICU DRGs (i.e. DRGs : assigned to the ‘neonate’ care category, except for those receiving the NICU Surgery policy adjuster below). Policy Adjustor — NICU surgery 1.75 Enhanced Policy Adjustor for all designated NICU facilities and surgery sites recognized by California Children’s Services (CCS) Program to perform neonatal surgery. For all DRGs assigned to the neonate care category Policy Adjustor — Each other category 1.00 Policy adjustor for each other category of service. of service Wage Index Labor Percentage 68.8% | Percentage of DRG Base Price or Rehabilitation per diem rate adjusted by the wage index value. High Cost Outlier Threshold 1 $40,000 Used to determine Cost Outlier payments High Cost Outlier Threshold 2 $125,000 Used to determine Cost Outlier payments Low Cost Outlier Threshold 1 $40,000 Used to determine Cost Outlier payments Marginal Cost Factor 1 60% Used to determine Cost Outlier payments Marginal Cost Factor 2 80% Used to determine Cost Outlier payments Outlier Percentage, upper bound 18% Outlier payments as percentage of total Outlier Percentage, lower bound 16% Outlier payments as percentage of total Casemix Corridor, upper bound 0.6684 Projected upper bound of patient acuity Casemix Corridor, lower bound 0.6484 Projected lower bound of patient acuity Discharge Status Value 02 02 Transfer to a short term hospital Discharge Status Value 05 05 Transfer to a designated cancer center Discharge Status Value 65 65 Transfer to a psychiatric hospital Discharge Status Value 66 66 Transfer to a critical access hospital TN No. 13-004 Supersedes Approval Date MAY 31 2013 Effective Date: July 1, 2013

TN No. None

Appendix 6 to Attachment 4.19- A

Page 2 Interim Payment $600 Per diem amount for Interim Claims APR-DRG Grouper Version Vv29 3M Software version used to group claims to a DRG HAC Utility Version V30 3M Software version of the Healthcare Acquired Conditions Utility

Pediatric Rehabilitation Rate $1,842 | Daily rate for rehabilitation services provided to a

beneficiary under 21 years of age on admission. Adult Rehabilitation Rate $1,032 | Daily rate for rehabilitation services provided to a

beneficiary 21 years of age or older on admission.

2. Separately Payable Services, Devices, and Supplies

Management of recipient hematopoietic progenitor cell donor search and acquisition

J7183/37184/Q2041 | Blood factor Von Willebrand —injection J7185/37190/J7192 | Blood factor ‘VII

J7186 Blood factor VIII/ Von Willebrand J7187 Blood factor Von Willebrand

J7189 Blood factor VIla

J7193/37194/J7195 | Blood factor IX

J7197 Blood factor Anti-thrombin III

J7198 Blood factor Anti-inhibitor

3. List of Hospitals to receive the “Policy Adjustor - NICU Surgery”

1) California Hosp Medical Center of Los Angeles 2) California Pacific Medical Center - Pacific

3) Cedars Sinai Medical Center

4) Children’s Hospital & Research Center of Oakland 5) Children’s Hospital of Central California

6) Children’s Hospital of Los Angeles

7) Children’s Hospital of Orange County

8) Citrus Valley Medical Central — Queen of the Valley 9) Earl & Lorraine Miller Children’s Hospital

10) Good Samaritan — Los Angeles

TN No. 13-004 Supersedes TN No. None

Approval Date.

MAY 31 2013

Effective Date: July 1, 2013

Appendix 6 to Attachment 4.19 - A Page 3

11) Good Samaritan - San Jose

12) Huntington Memorial Hospital

13) Kaiser Permanente Medical Center - Oakland 14) Kaiser Foundation Hospital - Roseville

15) Loma Linda University Medical Center

16) Lucille Salter Packard Children’s Hospital - Stanford 17) Pomona Valley Hospital Medical Center

18) Providence Tarzana

19) Rady Children’s Hospital - San Diego

20) Santa Barbara Cottage Hospital

21) Sutter Memorial Hospital

For purposes of receiving the NICU policy adjustor, the hospital stay must be assigned to the neonate care category. For purposes of receiving the enhanced NICU Surgery policy adjustor, the hospital must meet the definition of a Regional NICU as defined in the CCS Manual of Procedures, Section 3.25.1 or a Community NICU with a neonatal surgery as defined in the CCS Manual of Procedures Sections 3.25.2.

Periodic reviews of CCS-approved NICUs may be conducted on an annual basis or as deemed necessary by the CCS program. If an NICU does not meet CCS program requirements, the NICU may be subject to losing CCS approval. If a hospital loses CCS approval as a designated NICU, the hospital will no longer qualify for the enhanced DRG Policy Adjustor — NICU surgery and be dropped from the list

above. Additionally, hospitals that apply and receive NICU approval from CCS will be added to the list above.

TN No. 13-004 Supersedes Approval Date__MAY 31 2013 Effective Date: July 1, 2013 TN No. None

STATE PLAN CHART

(Note: This chart is an overview only)

Limitations on Attachment 3.1-A

TYPE OF SERVICE

PROGRAM COVERAGE* *

PRIOR AUTHORIZATION OR OTHER REQUIREMENTS*

1. Inpatient hospital services

TN No. 13-004 Supersedes TN No. 10-016

Inpatient services are covered as medically necessary except that services in an institution for mental disease are covered only for persons under 21 years of age or for persons 65 years of age and over.

It includes Administrative Day Level 1 and Administrative Day Level 2 Services.

Administrative Day Level 1 and Level 2 Services are inpatient hospital services provided to a beneficiary who has been admitted to the hospital for general acute care inpatient services, and the beneficiary’s stay at the hospital must be continued beyond the beneficiary’s need for general acute care inpatient services due to a temporary lack of placement options to a nursing home, subacute, or post acute care that is not yet available that meets the needs of the beneficiary. The beneficiary must meet a nursing home level A or nursing home level B level of care to be eligible for Administrative Day Level 1 Services and subacute care to be

Page -1-

Approval Date: MAY 3 1 2013

*Pprior authorization is not required for emergency services. **Coverage is limited to medically necessary services.

Prior authorization is required for all nonemergency hospitalization except for the first two days of obstetrical delivery or subsequent newborn care services. Certain procedures will only be authorized in an outpatient setting unless medically contraindicated.

Effective Date: July 1, 2013

STATE PLAN CHART

(Note: This chart is an overview only)

Limitations on Attachment 3.1-A

TYPE OF SERVICE PROGRAM COVERAGE** PRIOR AUTHORIZATION OR OTHER REQUIREMENTS* 1. Inpatient hospital eligible for Administrative Day services (Continued) Level 2 Services.

Services in the psychiatric unit of a general hospital are covered for all age groups.

It includes Psychiatric Inpatient Hospital Services.

Psychiatric Inpatient Hospital Services are both acute psychiatric inpatient hospital services and administrative day services provided in a hospital.

Acute psychiatric inpatient hospital services are those services provided by a hospital to beneficiaries for whom the facilities, services, and equipment are medically necessary for diagnosis or treatment of a mental disorder.

Administrative day services are psychiatric inpatient hospital services provided to a beneficiary who has been admitted to the

TN No. 13-004 Page -la- Supersedes TN No. 10-016 “Approval Date: MAY 31 2013

*Prior authorization is not required for emergency services. **Coverage is limited to medically necessary services.

Emergency admissions are exempt from prior authorization, but the continuation of the hospital stay beyond the admission is subject to prior authorization by the Medi-Cal Consultant.

Beneficiaries must meet medical necessity criteria.

Effective Date: July 1, 2013

STATE PLAN CHART

(Note: This chart is an overview only) : Limitations on Attachment 3.1-A

TYPE OF SERVICE PROGRAM COVERAGE** PRIOR AUTHORIZATION OR OTHER REQUIREMENTS*

1. Inpatient hospital hospital for acute psychiatric

services (Continued) inpatient hospital services, and the beneficiary’s stay at the hospital must be continued beyond the beneficiary’s need for acute psychiatric inpatient hospital services due to a temporary lack of residential placement options and non-acute residential treatment facilities that meet the needs of the beneficiary.

Psychiatric Inpatient Hospital Services are provided in accordance with

1902 (a) (20) (A), (B), (C) and 1902(a) (21) of the Social Security Act (the Act) for beneficiaries ages 65 and over and with

1905(a) (16) and (h) of the Act for beneficiaries under age 21.

TN No. 13-004 Page’ -1b-

Supersedes L MAY 5} 1 2013

TN No. 10-016 Approval Date: Effective Date: July 1, 2013

*Pprior authorization is not required for emergency services. **Coverage is limited to medically necessary services.

STATE PLAN CHART

(Note: This chart is an overview only)

Limitations on Attachment 3.1-B

TYPE OF SERVICE PROGRAM COVERAGE** PRIOR AUTHORIZATION OR OTHER REQUIREMENTS*

1. Inpatient hospital Inpatient services are covered as Prior authorization is required for all

services medically necessary except that nonemergency hospitalization except for

services in an institution for mental disease are covered only for persons under 21 years of age or for persons 65 years of age and over.

It includes Administrative Day Level 1 and Administrative Day Level 2 Services.

Administrative Day Level 1 and Level 2 Services are inpatient hospital services provided to a beneficiary who has been admitted to the hospital for general acute care inpatient services, and the beneficiary’s stay at the hospital must be continued beyond the beneficiary’s need for general acute care inpatient services due to a temporary lack of placement options to a nursing home, subacute, or post acute care that is not yet available that meets the needs of the beneficiary. The beneficiary must meet a nursing home level A or nursing home level B level of care to be eligible for Administrative Day Level 1 Services and subacute care to be

TN No. 13-004 Page -1- Supersedes TN No. 10-016 “approval Date: MAY 31 2019

*Prior authorization is not required for emergency services. **Coverage is limited to medically necessary services.

the first two days of obstetrical delivery or subsequent newborn care services. Certain procedures will only be authorized in an outpatient setting unless medically contraindicated.

Effective Date: July 1, 2013

STATE PLAN CHART

(Note: This chart is an overview only)

Limitations on Attachment 3.1-B

TYPE OF SERVICE

PROGRAM COVERAGE**

PRIOR AUTHORIZATION OR OTHER REQUIREMENTS*

1. Inpatient hospital services (Continued)

TN No. 13-004 Supersedes TN No. 10-016

eligible for Administrative Day Level 2 Services.

Services in the psychiatric unit of a general hospital are covered for all age groups.

It includes Psychiatric Inpatient Hospital Services.

Psychiatric Inpatient Hospital Services are both acute psychiatric inpatient hospital services and administrative day services provided in a hospital.

Acute psychiatric inpatient hospital services are those services provided by a hospital to beneficiaries for whom the facilities, services, and equipment are medically necessary for diagnosis or treatment of a mental disorder.

Administrative day services are psychiatric inpatient hospital services provided to a beneficiary who has been admitted to the

Page’ -la-

Approval Date: MAY 31 2013

*Prior authorization is not required for emergency services. **Coverage is limited to medically necessary services.

Emergency admissions are exempt from prior authorization, but the continuation of the hospital stay beyond the admission is subject to prior authorization by the Medi-Cal Consultant.

Beneficiaries must meet medical necessity criteria.

Effective Date: July 1, 2013

STATE PLAN CHART

(Note: This chart is an overview only) Limitations on Attachment 3.1-B

TYPE OF SERVICE PROGRAM COVERAGE** PRIOR AUTHORIZATION OR OTHER REQUIREMENTS*

1. Inpatient hospital hospital for acute psychiatric

services (Continued) inpatient hospital services, and the beneficiary’s stay at the hospital must be continued beyond the beneficiary’s need for acute psychiatric inpatient hospital services due to a temporary lack of residential placement options and non-acute residential treatment facilities that meet the needs of the beneficiary.

Psychiatric Inpatient Hospital Services are provided in accordance with

1902 (a) (20) (A), (B), (C) and 1902(a) (21) of the Social Security Act (the Act) for beneficiaries ages 65 and over and with

1905(a) (16) and (h) of the Act for beneficiaries under age 21.

TN No. 13-004 Page -1b- Supersedes TN No. 10-016 . Approval Date: MAY 31 2013 Effective Date: July 1, 2013

*prior authorization is not required for emergency services. **Coverage is limited to medically necessary services.

Table of Contents State/Territory Name: California State Plan Amendment (SPA) #: 13-005 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Farm/Summary Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services San Francisco Regional Office 90 Seventh Street, Suite 5-300 (SW) San Francisco, CA 94103-6706 DIVISION OF MEDICAID & CHILDREN'S HEALTH OPERATIONS Toby Douglas, Director California Department of Health Care Services P.O. Box 997413, MS 0000 Sacramento, CA 95899-7413 Dear Mr. Douglas, Enclosed is an approved copy of California State Plan Amendment (SPA) CA-13-005. SPA CA-13-005 was submitted to my office on May 31, 2013 to introduce coverage for Optional Targeted Low-Income Children, to transition children from California's Children's Health Insurance Program (CHIP) to Medicaid, and to impose premium payments. Specifically, this SPA disregards family income above 200 percent ofthe federal poverty level and up to and including 250 percent of the federal poverty level for targeted low-income children. This SPA also imposes premiums for children whose family income is above 150 percent and up to and including 250 percent of the federal poverty level. · The effective date ofthis SPA is November I, 2013. Enclosed are the following approved SPA pages that should be incorporated into your approved State Plan: • Attachment 2.2-A, pages 23b and 23c • Supplement 8 to Attachment 2.6-A, page 14 • Supplement 8b to Attachment 2.6-A, page 15 • Attachment4.18-F, pages 1-10 • Title of Attachments, page 4 Ifyou have any questions, please contact Tyler Sadwith by phone at (415) 744-3563 or by email at tyler.sadwitM12cms.hhs.gov. Enclosure Sincerely, /s/ Gloria Nagle, Ph.D., MPA Associate Regional Administrator Division of Medicaid & Children's Health Operations cc: Clarissa Poole-Sims, California Department of Health Care Services Kathryn Waje, California Department of Health Care Services

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION FORM APPROVED OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE CA STATE PLAN MATERIAL 13-005 FOR: HEALTH CARE FINANCING ADMINISTRATJON TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE September 1, 2013 November 1, 2013 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN ~AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Se arate Transmittal or each amendment 6. FEDERAL STATUTE/REGULATION CITATION: 1902(a)(lO)(A)(ii)(XIV), Section 1902(r)(2), l905(u)(2)(B) and 1916A, of the Social Security Act. 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Attachment 2.2-A pages 23b and 23c Supplement Sa to Attachment 2.6-A, page 14 Supplement 8b to Attachment 2.6-A, page 15 Attachment 4.18-F, pages l-9 10 Title of Attachment, page 4 Premiums Imposed on Optional Targeted Low-Income Children 10. SUBJECT OF AMENDMENT: 7. FEDERAL BUDGET IMPACT: a. FFY 2012 9/1-30/20132014 $53,749,000 $636,808,000 b. FFY 2013 2015 $644,980.000$656,619,000 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Attachment 2.2-A pages 23b and 23c Title of Attachment page 4 Premiums Imposed on Optional Targeted Low-Income Children Implementation of targeted low~ income children with family incomes above 200 percent of the federal poverty level and up to and including 250 percent of the federal poverty level; less restrictive income and resource methodologies; and the option to impose remiums 11. GOVERNOR'S REVIEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL . . ~OTHER, AS SPECIFIED: The Governor's Office does not wish to review the State Plan Amendment. 16. RETURN TO: Department of Health Care Services Attn: State Plan Coordinator 1501 Capitol Avenue, MS 4506 P.O. Box 997417 Sacramento, CA 95899-7417 . Pen-and-ink changes completed by the state on December 1712013 FORM HCFA-179 (07-92)

Attachment 2.2-A Page 23b State Plan Under Title XIX Of The Social Security Act State: California Citation 1902(a)(1 O)(A) (ii) (XIV) of the Act TN No. 13-005 Supersedes TN No. 97-16 Groups Covered Optional Coverage Other Than the Medically Needy (Continued) _lL 21. Optional Targeted Low Income Children who: a. are not eligible for Medicaid under any other optional or mandatory eligibility group or eligible as medically needy (without spenddown liability); b. would not be eligible for Medicaid under the policies in the State's Medicaid plan as in effect on March 31 , 1997, (other than because of the age expansion provided for in § 1902 (I)( 1 )(D)); c. are not covered under a group health plan or other group health insurance (as such terms are defined in §2791 of the Public Health Service Act coverage) other than under a health insurance program in operation before July 1, 1997, offered by a State which receives no Federal funds for the program; d. have family income at or below: 200 percent of the Federal Poverty Level (FPL) for the size family involved, as revised annually in the Federal Register; or a percentage of the FPL, which is in excess of the "Medicaid applicable income level" (as defined in §211 O(b)(4) of the Act), but by no more than 50 percentage points. OEC 2 0 201~ . Approval Date Effect1ve Date November 1 , 2013

Attachment 2.2-A Page 23c State Plan Under Title XIX Of The Social Security Act State: California Citation 1902(e)(12) of the Act 1920A of the Act Groups Covered B. Optional Coverage Other Than the Medically Needy (Continued) The State covers: .lL All children described above, who are under age _jJL (18, 19), with family income at·or below 200 percent of the Federal poverty level (FPL). The following reasonable classifications of children described above, who are under age N (18, 19), with family income at or below the percent of the FPL specified for the classification: (ADD NARRATIVE DESCRIPTION(S) OF THE REASONABLE CLASSIFICATION(S) AND THE PERCENT OF THE FPL USED TO ESTABLISH ELIGILBILITY FOR EACH CLASSIFICATION.) _lL 22. A child under age 19 (not to exceed age 19), who has been determined eligible, is deemed to be eligible for a total of 12 months (not to exceed 12 months) regardless of changes in circumstances other than attainment of the maximum age stated above . .lL 23. Children under age 19, who are determined by a ~~qualified entity 11 (as defined in 1920A(b)(3)(A)) based on preliminary information, to meet the highest applicable income criteria specified in this plan. The Single Point of Entry Clearinghouse TN No. 13-005 Approval Date OEC 2 O 20~ective Date November 1, 2013 Supersedes TN No. 02-004

Supplement Sa to Attachment 2.6-A Page 14 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Statefferritory: California METHODOLOGIES FOR TREATMENT OF INCOME THAT DIFFER FROM THOSE OF THE SSI AND AFDC PROGRAM (Less Restrictive Than SSI and AFDC) Beginning on November 1, 2013, apply an income disregard pursuant to 1902(r)(2) for income at 200 percent up to and including 250 percent of the federal poverty level to all Optional Targeted Low-Income Children, under Section 1902(a)(1 O)(A)(ii)(XIV) of the Act. TN No.13-005 Approval Date OEC 2 O ZOl~ffective Date November 1. 2013 'Supersedes: TN No. None

Supplement Bb to Attachment 2.6-A Page 15 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: California METHODOLOGIES FOR TREATMENT OF RESOURCES THAT DIFFER FROM THOSE OF THE SSI AND AFDC PROGRAM (Less Restrictive Than SSI and AFDC) Beginning on November 1, 2013, exempt all resources pursuant to the option in 1902(r)(2) for Optional Targeted Low-Income Children under Section 1902(a)(1 O)(A)(ii)(XIV) of the Act. TN NO. 13-005 Supersedes TN NO. None OEC 2 0 2013 Approval Date: Effective Date: November 1, 2013

Attachment 4.18-F Page 1 STATE PLAN UNDER TITLE X:IX OF THE SOCIAL SECURITY ACT State(ferritory: CALIFORNIA Alternative Premiums and Cost Sharing Changes The following alternative premiums and cost sharing changes 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 Federal Poverty Level (FPL): 1. Cost Sharing a. Amount of Cost Sharing i. _X_/ No cost sharing iis imposed. ii. _/ Nominal cost sharing is imposed under section 1916 of the 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 1 00 percent of FPL. B. For groups of individuals with family income above 100 percent, but at or below 150 percent of FPL: 1 . Cost Sharing a. Amount of Cost Sharing i. _X_/ No cost sharing is imposed. ii. _/ Nominal cost sharing is imposed under section 1916 of the Act (See Attachment 4.18-A and/or 4.18-C). iii. _/ Alternative cost sharing is imposed under section 1916A of the Act as TN No.13-005 Supersedes TN No.: None follows (specify the amounts of group and services (see below)): OEC 2 0 2013 Approval Date Effective Date: November 1, 2013

Attachment 4.18-F Page 2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: CALIFORNIA 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 _XX_ monthly or_ quarterly basis as specified by the State. • Cost sharing with respect to any item or service may not exceed 1 0 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: None c. Enforcement _I 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 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 1 00 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 i. X/ No cost sharing is imposed. ii. _/ Nominal cost sharing is imposed under section 1916 of the Act (see Attachment 4.18-A page 1 and/or 4.18-C page 1 . iii. _/ Alternative cost sharing is imposed under section 1916A of the Act as follows (specify the amounts of group and services (see below)): TN No.13-005 Supersedes TN No.: None Approval Date OEC 2 0 20~ective Date: November 1, 2013

Attachment 4.18-F Page3 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State!T erritory: CALl FO RN lA 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 _X_ monthly or_ 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: None c. Enforcement _I 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, 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 i. _I No premiums are imposed. ii. _X I Premiums are imposed under section 1916A of the Act as follows (specify TN No.13-005 Supersedes TN No.: None the premium amount by group and income level. OEC 2 0 2013 Approval Date Effective Date: November 1. 2013

Attachment 4.18-F Page 4 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State[Territory: CALIFORNIA Optional targeted low-income children (OTLIC) ages 1 up to the month of their 191h birthday, who have family incomes above150 percent and up to and including 250 percent. b. Limitation: $13 per month 1 child $26 per month 2 children $39 per month 3 or more children The methodology used for determining eligibility, includes, a disregard of income between 200 percent of the federal poverty level up to and including 250 percent of the federal poverty level. *The method of income determination changes January 1, 2014; at that time income disregards are no longer applicable due to implementation of the Affordable Care Act. • 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 X 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: Section 5006(a) of the American Recovery and Reinvestment Act and 42 CFR Part 447 exempts American Indian/Alaskan Native (AI/ANs) from premiums and enrollment fees, if they are eligible to receive or have received an item or service from an Indian Health Service (IHS)/Tribal 638/Urban Indian Health Program (UIHP) (1/T/U} or through a referral under contract health services. The State is in the process of developing a means for exempting AI/ANs. California anticipates January 1, 2014 as the completion date for the development process to exempt AI/ANs from cost-sharing and premium payments. If the parent/guardian self attests that the AI/AN applying is eligible to receive or has received a service from an Indian Health Service (IHS)/Tribal 638/Urban Indian Health Program (UIHP) (1/T/U} or through a referral under contract health services, the AI/AN will not have to pay premium payments. If the parent/guardian does not provide self-attestation, then the parent/guardian must submit a letter to the county on 1/T/U letterhead that exempts the AI/AN under section 5006(a) of the American Recovery and Reinvestment Act and 42 CFR Part 447. The county will upon receipt of the letter or self-attestation, submit a transaction with an indicator/aid code to identify AI/ANs on the State's Medi-Cal Eligibility Data System (MEDS). This indicator/aid code identifies the AI/AN as exempt from paying premiums or copays. The state's premium payment processor receives monthly files from MEDS that display only the indicator/aid code of those beneficiaries paying a premium. Only those beneficiaries with a premium aid code receive invoices for premium payment. Until the State has this new process in place, the State will temporarily use the existing process under the Healthy Families Program, which is to exempt AI/ANs from cost sharing and premiums under Medi-Cal based on the individual being an AI/AN. In addition to the exclusion of an AI/AN individual, non AI/AN individuals exempt from copays also receive an indicator/aid code that precludes them from receivinQ copays. TN No.13-005 Supersedes TN No.: None Approval Date DEC 2 0 20~ective Date: November 1. 2013

Attachment 4.18-F Page 5 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State{ferritory: CALIFORNIA c. Enforcement i. _I Prepayment is required for the following groups of applicants when they apply for Medicaid: ii._l Prepayment is required for the following groups of beneficiaries as a condition for receiving Medicaid services for the premium period: iii. X I Eligibility is terminated for failure to pay premiums after a grace period of 901120 days after the premium due date (at least 60 days) for the following groups of Medicaid beneficiaries: Beneficiaries in the following age categories will terminate after a grace period of 901120 days: • 1-19 years of age, with family income above 150 percent of the FPL and up to and including 200 percent of the FPL (with an income disregard up to and including 250 percent of the FPL) will terminate after 90 days from age 1 - 19 years of age. • Ages 1-2, for infants previously covered under the Access for Infants and Mothers (AIM) Program, with family incomes above 200 percent up to and including 250 percent FPL will terminate after a Qrace period of 120 days iv._l 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. _I Quarterly XI Monthly 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. RESPONSE: California will use aid codes to identify beneficiaries with family incomes above 150 percent FPL. These individuals will have premium payments and will require cost sharing tracking. Family incomes at or below 150 percent of the FPL do not require premiums tracking. The cost sharing tracking process is outlined in the response below. TN No.13-005 Supersedes TN No.: None OEC 2 0 20fj Approval Date E:ffective Date: November 1, 2013

Attachment 4.18-F Page 6 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: CALIFORNIA 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. RESPONSE California notifies providers by Medi-Cal Provider bulletins, Provider manual updates and Provider training. 3. Describe the State's processes (that do not rely on beneficiaries) used for tracking beneficiaries' incurred premiums and cost sharing under section 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. RESPONSE California does not anticipate or expect the families with children in the Optional Targeted Low Income Children's (OTLIC) Program to reach or exceed the five percent monthly aggregate limit imposed by federal regulations on the assessed premiums or cost sharing. However, to ensure the family does not exceed the monthly aggregate limit imposed, California intends to implement a process that uses the family income and any applicable copayments incurred by all members in the family* reported to the counties to determine the maximum five percent cap and assess that amount against the premiums (or applicable copayments) required of the family each month. This five percent cap displays on the monthly premium statement of the beneficiary subject to premiums to inform them of the maximum dollar amount incurred each month before the family is no longer subject to further premium or cost sharing provisions. Currently, California only charges premiums for children in families with family income above 150 percent FPL. There are no enforceable copayments for these children but if their family members are subject to cost sharing, those charges will be counted towards the aggregate family limit. The state's premium payment processor receives monthly files from MEDS for premium payment billing. Only those beneficiaries with a premium aid code appear on those monthly files. Through the provision of a letter or self-attestation, AI/AN parents who meet the cost sharing exemption, will not be subject to nominal cost sharing For copayment reporting, the anticipation is to work within the same logic currently used to report a share-of-cost amount. This system notifies the provider when a beneficiary TN No.13-005 Supersedes TN No.: None Approval Date OEC 2 0 2(\!~ective Date: November 1. 2013

Attachment 4.18-F Page 7 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State[rerritory: CALIFORNIA meets their monthly share-of cost (SOC) so that the provider does not continue to bill the beneficiary. The current process displays a $0 amount when the beneficiary meets their SOC. The new process will follow similarly the same logic and display $0 capay when the beneficiary or family reaches their 5 Percent cap. California will use the process described above to track the cost sharing for the OTLIC Program and other Medi-Cal populations come 2014 and notify the beneficiary or family when they reach their 5 Percent cap. The process of notifying the beneficiary outside of provider notification is currently being developed. The anticipated completion of notifying the beneficiary is July 2014. *(Starting in 2014, even nominal, unenforceable copays that the beneficiary or family members may be subject to are included in the maximum aggregate five percent of family income cap ) 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. RESPONSE To request a reassessment of the family's aggregate limit, beneficiaries need to contact their county eligibility worker (EW). The EW requests information pertinent to the change in order to conduct a redetermination based on a change in circumstance in accordance with current policy and then either finds the beneficiary eligible to a full scope, no share-of-cost, no premium Medi-Cal program or reassesses the family limit accordingly. Beneficiaries terminated due to nonpayment of a premium may request a fair hearing to review and reassess the family's premiums when they object to the termination. The beneficiary may at any time there is a change in circumstance, contact their county EW for a reassessment of income. 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, applicant, beneficiaries, and providers: TN No.13-005 Supersedes TN No.: None OEC 2 0 2013 Approval Date Effective Date: November 1, 2013

Attachment 4.18-F Page 8 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: CALIFORNIA RESPONSE California began notifying the public of its premium policy, including differences based on income, through an established venue of public forums, departmental web pages, program notices, legislation and regulations, and stakeholder meetings and webinars in late 2012. California continues to work with stakeholders and the public on outreach concerning this policy. Applicants and beneficiaries receive information from county agencies in the following forms: the Medi-Cal brochure, application, and evidence of coverage documentation, enrollment materials, and program regulations at the time of eligibility determination and redetermination. · Through outreach and training, individuals such as certified application assistors, who help families with their application, will also be familiar with the program's requirements and be able to communicate them to families when discussing the program. Any changes to the premiums would be presented in public forums. 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 of the Act. (Note: The State must submit documentation with the SPA to demonstrate that this requirement was met.) RESPONSE On October 31, 2012, the State distributed draft pages in the SPA 12-018 to various stakeholder groups and posted all documents publicly on the department's website at http://www.dhcs.ca.gov/services/Pages/HealthyFamiliesTransition.aspx with a request for feedback by 3p.m. on November 9, 2012. All interested parties were encouraged to send their questions and feedback in writing to the email inbox dhcshealthyfamiliestransition@dhcs.ca.gov. The State also conducted public webinars on September 13, 2012 and October 23, 2012 in which proposed amendments in SPA 12-018 were presented to stakeholders and interested parties in person and over the Internet. On December 4, 2012, the State forwarded copies of emails to CMS that the State had sent to stakeholders requesting comments on the waiver amendment and draft SPA, and copies of webinar presentations. In addition, the State distributed a Tribal Notice to the California IHS/UIHP on August 24, 2012. The tribal notice informed tribal organizations of the proposed amendments in SPA 12-018 and the potential impact on the tribal organizations and its ·beneficiaries. The provisions in SPA 12-018 were also presented at the quarterly webinar held for tribal organizations on August 30, 2012. Subsequent to this the State TN No.13-005 Supersedes TN No.: None Approval DatQEC 2 O 2013Effective Date: November 1, 2013

Attachment 4.18-F Page9 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State!T erritory: CALl FO RN lA distributed a follow-up Tribal Notice to the California HIS/UIHP on April 26, 2013 updating. the change in SPA number to 13-005 and reemphasizing the Medicaid expansion OTLIC Program. In addition, the State presented this information at the Indian Health Conference held on March 6, 2013. The following are the specific public notices provided concerning premiums from the weblink:http://www.dhcs.ca.gov/services/Pages/HealthyFamiliesTransition.aspx HFP Transition Resources http://www .dhcs.ca.gov/services/hf/Pages/H FPStakeHoldersMeetingsByMonth .aspx Stakeholder Meetings , August Transition documents: General Transition Notice Stakeholder Presentation What we Tell Families. September Stakeholder Meeting: HFP to Medi-Cal Transition Strategic Plan (PDF) page 9 February Stakeholder Meeting Toolkit Links: Healthy Families Program Transition to Medi-Cal: Frequently Asked Questions ACWDL 12-33, Page 12 General Information: http://www.dhcs.ca.gov/services/hf/Pages/FAQEiigibility.aspx Reminder Notices and FAQs sent at each phase contain a letter and a booklet for frequently asked questions of which premiums are a part of the questions. Additional information Notices provided to the public state premiums apply for income above 150 percent to 250 percent FPL. The State provides a webpage where all interested stakeholders such as advocates, consumers, counties, legislative staff, providers, and state associations may receive relevant updates on department program initiatives or new projects. The website to find the sign up for emails is: http://www.dhcs.ca.gov/Pages/DHCSListServ.aspx. The email to sign up is: http://apps.dhcs.ca.gov/listsubscribe/default.aspx?list=DhcsStakeHolders Distributed Notices and Letters: http://www.dhcs.ca.gov/services/hf/Pages/HFPTransitionNoticesLetters.aspx TN No.13-005 Supersedes TN No.: None OEC 2 0 2Qn Approval Date Effective Date: November 1, 2013

Attachment 4.18-F Page 10 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State!T erritory: CALl FO RN lA Ref.: ACWDL 12-30 pages 2 and 3, http://www.dhcs.ca.gov/services/Documents/12- 30.pdf Stakeholder comments to ACWDL 12-30 http://www.dhcs.ca.gov/services/hf/Pages/ACWDL 12-30Comments.aspx ACWDL 12-33, page 2, http://www.dhcs.ca.gov/services/medi-cal/eligibility/Documents/12-33.pdf Comments to http://www.dhcs.ca.gov/services/hf/Pages/ACWDL 12-33Comments.aspx FAQs Eligibility #4, #8, http://www.dhcs.ca.gov/services/hf/Pages/FAQEiigibility.aspx FAQs Phase 4A, page 7 http://www.dhcs.ca.gov/services/Documents/HFP%20Phase%204A%20-%20FAQ.pdf TN No.13-005 Supersedes TN No.: None DEC 2 0 2013 Approval Date ____ Effective Date: November 1, 2013

Page4 No. Title of Attachment .*4.18-D Premiums Imposed on Low Income Pregnant Women and Infants *4.18-E Premiums Imposed on Qualified Disabled and Working Individuals 4.18-F Premiums Imposed on Targeted Low-Income Children 4.19-A Methods and Standards for Establishing Payment Rates- Inpatient Hospital Care 4.19-B Methods and Standards for Establishing Payment Rates - Other Types of Care • Supplement 1 - Methods and Standards for Establishing Payment Rates for Title XVIII Deductible/Coinsurance 4.19-C Payments for Reserved Beds 4.19-D Methods and Standards for Establishing Payment Rates - Skilled Nursing and Intermediate Care Facility Services 4.19-E Timely-Claim Payment - Definition of Claim 4.20-A Conditions for Direct Payment for Physicians' and Dentists' Services 4.22-A Requirements for Third Party Liability- Identifying Liable Resources 4.22-B Requirements for Third Party Liability - Payment of Claims *4.22-C Cost-Effective Methods for Employer-Based Group Health Plans *4.32-A Income and Eligibility Verification System Procedures: Requests to Other State Agencies *4.33-A Method for Issuance of Medicaid Eligibility Cards to Homeless Individuals 4.34-A Requirements for Advance Directives Under State Plans for Medical Assistance 4.35-A Criteria for the Application of Specified Remedies for SNFs 4.35-B Alternative Remedies to Specified Remedies to Specified Remedies for SNFs 5.3-A Training Programs; Sub-professional and Volunteer Programs 7 .2-A Methods of Administration - Civil Rights (Title VI) 7.2-B Methods of Administration- Section 504 Rehabilitation Act *Forms Provided TN No. 13-005 Supersedes TN No. 03-009 Approval DateOEC 2 0 2013 Effective Date: November 1, 2013

Table of Contents State/Territory Name: California State Plan Amendment (SPA) #: CA-13-0021-MM1 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

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

April 29, 2015

Mari Cantwell Chief Deputy Director, Health Care Programs California Department of Health Care Services P.O. Box 997413, MS 0000 Sacramento, CA 95899-7413

Dear Ms. Cantwell:

Enclosed is an approved copy of California State Plan Amendment (SPA) 13-0021-MM1. In accordance with the Affordable Care Act, SPA CA-13-0021-MM1 was submitted to my office on September 11, 2013 to incorporate MAGI-based eligibility groups into California’s Medicaid State Plan.

The effective date of this SPA is January 1, 2014. Enclosed are the following approved SPA pages that should be incorporated into your approved State Plan:

• Superseding Pages Document • S14, pages 1-5 • S25, pages 1-3 • S28, pages 1-5 • S30, pages 1-8 • S33, page 1 • S50, page 1 • S51, page 1 • S52, pages 1-8 • S53, pages 1-2 • S54, pages 1-3 • S55, pages 1-2 • S57, pages 1-2 • S59, pages 1-2 • Attachment to S59 – Statement related to individuals eligible for family planning services

Please note that there is a corrective action plan associated with this SPA. Over the course of review, a number of items were identified that will need to be addressed over the coming months. The Department of Health Care Services (DHCS) verified via e-mail on February 23, 2015 that the following changes will be made by the following dates:

Page 2 – Mari Cantwell

Systems Changes

• Correct the Presumptive Eligibility (PE) beginning and ending dates for PE for pregnant women, including a requirement to check for a Medicaid application: 10/31/15

• Automate PE for pregnant women: 10/31/15

• Correct the limit in the number of PE periods for children to two every 12 months: 10/31/15

PE for Pregnant Women Provider Manual

• Implement DHCS’ revised PE for pregnant women provider manual: within 60 days of the approval of this SPA

The CMS San Francisco Regional Office will continue to follow up with DHCS eligibility staff on the status of these required corrective actions during regularly scheduled phone calls.

CMS will also continue ongoing discussions with DHCS regarding its pregnancy related services benefit package and minimum essential coverage.

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,

/s/

Hye Sun Lee

Acting Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosure

cc: Nate Emery, California Department of Health Care Services

Alice Mak, California Department of Health Care Services

CA.0309.R00.00 - Jan 01, 2014

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name:

California

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. CA-13-0021

Proposed Effective Date 01/01/2014 _ (mum/add/yyyy)

Federal Statute/Regulation Citation 42 CFR 435.150; 1902(a)(10)(A)()(TX); 42 CFR 435.110; 1902(a)(10)(A)G)Q); 1931(b) and (d); 42 CFR 435.116;1902(a)(10)(A)(i)(

Federal Budget Impact Federal Fiscal Year Amount

First Year 2014 $ 3390040000.00

Second Year 2015

$ 4746056000.00

Subject of Amendment MAGI-Based Eligibility Groups

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

©) Comments of Governor's office received Describe:

© No reply received within 45 days of submittal

@ Other, as specified Describe: The Governor's Office does not wish to review the State Plan Amendment

Signature of State Agency Official Submitted By: Nathaniel Emery Last Revision Date: Jan 22, 2015 Submit Date: Sep 11, 2013

1

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

13-0021 MM

STATE:

California

Pages or sections of pages being superseded by S25, S28, S30, S51, S52, S53, S54, S55, S57,and S14 and related pages or sections of pages being deleted as obsolete

State Plan Section

Complete Pages Removed

Partial Pages Removed Attachment 2.2-A

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

Page 2a, A.3 Page 9c, B.1 remove “caretaker relatives & pregnant women” Page 20, B.14 Page 23a, B.20 Page 23c, B.21 Page 23c, B.23 Page 23d, B.23 Page 23e, B.25

Supplement 1 to Attachment 2.2-A

Page 1

Attachment 2.6-A

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

Page 1, A.2.a.(i) & (iii) Page 6 related to AFDC recipients, pregnant women, infants, and children Page 8, C.e(1) Page 18, C.5.e Page 25, 11.a.(3)

Supplement 1 to Attachment 2.6-A

Pages 1-4

2

Supplement 2 to Attachment 2.6-A

Pages 1-5 Supplement 8a to Attachment 2.6-A

Page 1 Page 2 Page 3 Page 4 Page 14

Page 8, 9, 10 for AFDC-related categorically needy groups

Supplement 8b to Attachment 2.6-A Page 3 Page 4 Page 15

Pages 2, 5, 6, 8-13 for AFDC-related categorically needy groups Supplement 12 to Attachment 2.6-A

Pages 1-2

Supplement 12a to Attachment 2.6-A Pages 1-3 Pages 5-7

Supplement 12b to Attachment 2.6-A Page 1-22 Page 26

Appendix to Supplement 12b to Attachment 2.6-A Pages 1-25

Supplement 14 to Attachment 2.6-A Page 1

Medicaid Eligibility

OMB Control Number 0938-1148 OMB iration 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.

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

426 Increment amount $ |52

666

827

987

1,133

1,279

1,412

1,548

1,680

10 1,812

The dollar amounts increase automatically each year

© Yes @No

TN No: CA-13-0021-MM1 Approvalbate: APR @ 2015 Effective Date: 1/1/2014

California Page 1 of S

The standard is as follows: @) Statewide standard © Standard varies by region

© Standard varies by living arrangement

© Standard varies in some other way

Medicaid Eligibility

Household size | Standard ($)

326

535

663

788

899

1,010

1,109

1,209

1,306

10 1,403

Additional incremental amount

@ Yes ONo

Increment amount $ |14

© Yes @No

The dollar amounts increase automatically each year

'The standard is as follows:

@ Statewide standard

© Standard varies by region

a Oanqe 5 ACK z ALU Effective-D 26 Approv: 5 . :

TIVINOS CART SOUL TANT California

Page 2 of 5

Medicaid Eligibility

© Standard varies by living arrangement

© Standard varies in some other way

Additional incremental amount

Household size | Standard ($) @ Yes ONo

439 Increment amount $ [53

687

854

1,017

1,167

1,317

1,455

1,594

1,730

10 1,866

The dollar amounts increase automatically each year

© Yes @No

'The standard is as follows:

C© Statewide standard

© Standard varies by region © Standard varies by living arrangement

© Standard varies in some other way

The dollar amounts increase automatically each year

© Yes ONo TN No: CA-13-0021-MM1 Approval Date. APR Y 97015 Effective Date: 1/1/2014 California

Page 3 of 5

The standard is as follows: © Statewide standard © Standard varies by region © Standard varies by living arrangement

© Standard varies in some other way

The dollar amounts increase automatically each year © Yes ONo

The standard is as follows:

© Statewide standard © Standard varies by region © Standard varies by living arrangement

© Standard varies in some other way

The dollar amounts increase automatically each year © Yes ©No

The standard is as follows:

© Statewide standard © Standard varies by region © Standard varies by living arrangement

C Standard varies in some other way

TN NO? CA-T3-002T-MMT

Approvat " California

Page 4 of 5

Medicaid Eligibility

The dollar amounts increase automatically each year © Yes © No

The standard is as follows:

C Statewide standard © Standard varies by region © Standard varies by living arrangement

© Standard varies in some other way

The dollar amounts increase automatically each year © Yes ONo

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN No: CA-13-0021-MM1 Approval Date: APR 2 99015 Effective Date: 1/1/2014 California

Page 5 of 5

Medicaid Eligibility

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

42 CFR 435.110

1902(a)(10)(A)()() 1931(b) and (d)

wl 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: [B] Individuals qualifying under this eligibility group must meet the following criteria:

ry Are parents or other caretaker relatives (defined at 42 CFR 435.4), including pregnant women, of dependent children (defined at 42 CFR 435.4) under age 18. Spouses of parents and other caretaker relatives are also included.

The state elects the following options:

This eligibility group includes individuals who are parents or other caretakers of children who are 18 years old, provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training.

] Options relating to the definition of caretaker relative (select any that apply):

The definition of caretaker relative includes the domestic partner of the parent or other caretaker relative, <* even after the partnership is terminated.

The domestic partner of the child's father, mother, grandfather, grandmother, Definition of domestic brother, sister. stepfather, stepmother, stepbrother, stepsister, great partner: grandparent, uncle, aunt, nephew, niece, great-great grandparent, great uncle,

great aunt, first cousin, great-great-grandparent, great-great uncle, great-great aunt, or first cousin once removed.

BR The definition of caretaker relative includes other relatives of the child based on blood (including those of half-blood), adoption or marriage.

Other relatives include the child's grandfather, grandmother, brother, sister. as father, stepmother, s rother, sis a 2 Q Description of other stepfathe _ stepmo ‘ e steph: ‘other, stepsister, great grandparent, uncle, aunt, relatives: nephew, niece, great-great grandparent, great uncle, great aunt, first cousin, . great-great-grandparent, great-great uncle, great-great aunt, or first cousin once removed.

oO The definition of caretaker relative includes any adult with whom the child is living and who assumes primary responsibility for the dependent child's care.

X Options relating to the definition of dependent child (select the one that applies):

TN No: CA-13-0021-MM1 Approval Date: APR Y 99015 Effective Date: 1/1/2014 California

Page 1 of 3

Medicaid Eligibility

The state elects to eliminate the requirement that a dependent child must be deprived of parental support or (@ care by reason of the death, physical or mental incapacity, or absence from the home or unemployment of at least one parent.

, The child must be deprived of parental support or care, but a less restrictive standard is used to measure ~ unemployment of the parent (select the one that applies):

[lM] 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 S10 MAGI- Based Income Methodologies, completed by the state.

[B] Income standard used for this group {H] 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.

w The state certifies that it has submitted and received approval for its converted May 1, 1988 AFDC payment standard.

[B] Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for parents and other caretaker relatives to MAGI-equivalent standards and the determination of the maximum income standard to be used for parents and other caretaker relatives under this eligibility group.

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.

Co 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:

TN No: CA-13-0021-MM1 Approval Date: APR vA $ 2015 Effective Date: 1/1/2014 California , Page 2 of3

CCMS Medicaid Eligibility

©@ A percentage of the federal poverty level: |109 %

ra} The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent standard. The ~” standard is described in S14 AFDC Income Standards.

The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date, converted to a MAGI- equivalent standard. The standard is described in S14 AFDC Income Standards.

O The state's TANF payment standard, converted to a MAGI-equivalent standard. The standard is described in $14 ~~” AFDC Income Standards.

fe)

Other dollar amount

{H] Income standard chosen: Indicate the state's income standard used for this eligibility group: © The minimum income standard @ The maximum income standard

The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage © increase in the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in S14 AFDC Income Standards.

© Another income standard in-between the minimum and maximum standards allowed [ii] There is no resource test for this eligibility group. [i] Presumptive Eligibility

The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible.

© Yes @No

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

TN No: CA-13-0021-MM1 Approval Date: APR Z 97015 Effective Date: 1/1/2014 California : Page 3 of 3

‘EMS Medicaid Eligibility

State Name: |California OMB Control Number: 0938-1148

Transmittal Number: -

Expiration date: 10/31/2014

42 CFR 435.116 1902(a)(10)(A)G@)(ID and (IV) 1902(a)(10)(A)(Gi)(), (IV) and (EX) 1931(b) and (d)

1920

[a] Pregnant Women - Women who are pregnant or post-partum, with household income at or below a standard established by the state. The state attests that it operates this eligibility group in accordance with the following provisions: [] Individuals qualifying under this eligibility group must be pregnant or post-partum, as defined in 42 CFR 435.4. Pregnant women in the last trimester of their pregnancy without dependent children are eligible for full benefits under this group in accordance with section 1931 of the Act, if they meet the income standard for state plan Parents and Other Caretaker Relatives at 42 CFR 435.110. @ Yes © No

ry MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI-Based Income Methodologies, completed by the state.

[B] 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

Enter the amount of the minimum income standard (no higher than 185% FPL):/185 | % FPL

(#] Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for pregnant [Z] 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)@)(IID) (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)(ii)(IV)

(institutionalized pregnant women) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

TN No: CA-13-0021-MM1 Approval Date: APR 4 92015

Effective Date: 1/1/2014 California

Page 1 of 5

Sy, Medicaid Eligibility

COMER RAR AIO A MRR SSAC

The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)()CI) (qualified pregnant women), 1902(a)(10)(A)(i)(V) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(CX) (optional poverty level-related pregnant women), 1902(a)(10)

© (A)Gi)(D (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as

© of December 31, 2013, converted to a MAGI-equivalent percent of FPL. © 185% FPL The amount of the maximum income standard is:}208 % FPL.

[i] 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. [i] There is no resource test for this eligibility group. [B] Benefits for individuals in this eligibility group consist of the following: © All pregnant women eligible under this group receive full Medicaid coverage under this state plan.

@ Pregnant women whose income exceeds the income limit specified below for full coverage of pregnant women receive ~ only pregnancy-related services.

Pregnancy-related services, as defined at 42 CFR 440.210 (a)(2), include prenatal, delivery, postpartum and family planning services, as well as services related to conditions which may complicate pregnancy.

Full Medicaid coverage is provided only for pregnant women with income at or below the income limit described below:

[i] Minimum income limit for full Medicaid coverage

The minimum income standard used for full coverage under this group is the state's AFDC payment standard in effect as of May 1, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in S14 AFDC Income Standards.

The state certifies that it has submitted and received approval for its converted May 1, 1988 AFDC payment standard.

[@] Maximum income limit for full Medicaid coverage

TN No: CA-13-0021-MM1 Approval Date: APR B T015 Effective Date: 1/1/2014 California

Page 2 of 5

Medicaid Eligibility

The highest effective income level for coverage under section 1902(a)(10)(A)(i)(IID) (qualified pregnant (@) women) or section 1931(b) and (d) (ow-income families) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent standard.

The highest effective income level for coverage under section 1902(a)(10)(A)(i)(II]) (qualified pregnant © women) or section 1931(b) and (d) (low-income families) in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent standard.

ro) The state's effective income level for any population of pregnant women under a Medicaid 1115 “ demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

. The state's effective income level for any population of pregnant women under a Medicaid 1115 ~ demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

The amount of the maximum income limit for full Medicaid coverage is:

@ A percentage of the federal poverty level: |109 %

© A dollar amount [#] Income limit chosen for full Medicaid coverage: © The minimum income limit © The maximum income limit @ Another income limit in-between the minimum and maximum standards allowed.

The amount of the income limit for full Medicaid coverage is:

@A percentage of the federal poverty level: [60 %

OA dollar amount

[&] Presumptive Eligibility

The state covers ambulatory prenatal care for individuals under this group when determined presumptively eligible by a qualified entity.

@ Yes ©ONo [Hi] The presumptive period begins on the date the determination is made.

[ii] The end date of the presumptive period is the earlier of:

The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or

The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date.

[| There may be no more than one period of presumptive eligibility per pregnancy.

A written application must be signed by the applicant or representative.

@ Yes © No

on » Onis PRB tuts EWSCHVE Date: 71/2014

A TN No: CA-T3-0021-MM1 Approval Date:

California Page 3 of 5

Medicaid Eligibility

©The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS.

@ i state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the ~ application form is included.

[mM] The presumptive eligibility determination is based on the following factors: [®] The woman must be pregnant [&] Household income must not exceed the applicable income standard at 42 CFR 435.116. State residency

(CQ Citizenship, status as a national, or satisfactory immigration status

i The state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively for this eligibility group.

A qualified entity is an entity that is determined by the agency to be capable of making presumptive eligibility determinations based on an individual’s household income and other requirements, and that meets at least one of the following requirements. Select one or more of the following types of entities used to determine presumptive eligibility for this eligibility group:

oO Furnishes health care items or services covered under the state's approved Medicaid state plan and is eligible to receive payments under the plan

oO Is authorized to determine a child's eligibility to participate in a Head Start program under the Head Start Act

oO Is authorized to determine a child's eligibility to receive child care services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990

Is authorized to determine a child's eligibility to receive assistance under the Special Supplemental (C] Food Program for Women, Infants and Children (WIC) under section 17 of the Child Nutrition Act of 1966

oO Is authorized to determine a child's eligibility under the Medicaid state plan or for child health assistance under the Children's Health Insurance Program (CHIP)

Oo Is an elementary or secondary school, as defined in section 14101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 8801)

{71 Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs (1 Isa state or Tribal child support enforcement agency under title IV-D of the Act

oO Is an organization that provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act

Is a state or Tribal office or entity involved in enrollment in the program under Medicaid, CHIP, or ‘ title IV-A of the Act

TN No: CA-13-0021-MM1 Approval Date: APR Z 92015 Effective Date: 1/1/2014

California

Page 4 of 5

Medicaid Eligibility

Is an organization that determines eligibility for any assistance or benefits provided under any program

o of public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.)

Is a health facility operated by the Indian Health Service, a Tribe, or Tribal organization, or an <' Urban Indian Organization

Other entity the agency determines is capable of making presumptive eligibility determinations:

Name of entity Description

Provides affordable health care and education for

_| Planned Parenthood women on reproductive health.

Must be in good standing and authorized to provide Medi-Cal Provider prenatal services under the state's approved state plan and eligible to receive payment under the plan.

The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and has provided adequate training to the entities and organizations involved. A copy of the training materials has been included.

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

V.20140415

TN No: CA-13-0021-MM1 Approval Date: APR J 97015 Effective Date: 1/1/2014 California Page 5 of 5

cems Medicaid Eligibility

OMB Control Number 0938-1148

42 CFR 435.118 1902(a)(10)(A)(i)(IID, (IV), (VI) and (VIN) 1902(a)(10)(A)(ii)(IV) and (IX)

1931(b) and (d)

@ Infants and Children under Age 19 - Infants and children under age 19 with household income at or below standards established by the state based on age group.

The state attests that it operates this eligibility group in accordance with the following provisions: [i] Children qualifying under this eligibility group must meet the following criteria: [MH Are under age 19 [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 S10 MAGI- Based Income Methodologies, completed by the state.

[@| Income standard used for infants under age one [#] Minimum income standard

The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for infants under age one, or as of July 1, 1989, had authorizing legislation to do so.

@ Yes ONo

Enter the amount of the minimum income standard (no higher than 185% FPL):}185 % FPL

{Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for infants under age one to MAGI-equivalent standards and the determination of the maximum income standard to be used for infants under age one.

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)(@)(ID (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)(TV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL.

TN No: CA-13-0021-MM1 Approval Date: APR 2 9.2015 Effective Date: 1/41/2014 California Page 1 of 8

Medicaid Eligibility

The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)()(IID) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related

© infants), 1902(a)(10)(A)(@i)(EX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(V) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-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.

ro The state's effective income level for any population of infants under age ohe under a Medicaid 1115 “ demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

© 185% FPL

Enter the amount of the maximum income standard: |208 % FPL

[iH] Income standard chosen The state's income standard used for infants under age one is: @ The maximum income standard

If not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(IL) (qualified children), 1902(a)(10)

© (A)@CV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(LX) (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)(I) (qualified children), 1902(a)(10) (A)@)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(LX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

, Another income standard in-between the minimum and maximum standards allowed, provided it is higher than ~ the effective income standard for this age group in the state plan as of March 23, 2010.

[H) Income standard for children age one through age five, inclusive

[—] Minimum income standard

9 555% fa TN No: CA-13-0021-MM1 Approval Date: APK PLUS Effective Date: 1/1/2014 California Page 2 of 8

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)((1I1) (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.

The state's highest effective income level for coverage of children age one through five under sections 1931 (low-

fe income families), 1902(a)(10)(A)()(IID) (qualified children), 1902(a)(10)(A)@)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(V) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

, The state's effective income level for any population of children age one through five under a Medicaid 1115 ~” demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

The state's effective income level for any population of children age one through five under a Medicaid 1115 ~” demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

Enter the amount of the maximum income standard: |142 % FPL

Income standard chosen The state's income standard used for children age one through five is: (@ The maximum income standard

Tf 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)@(ID (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 toa 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)(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.

TN No: CA-13-0021-MM1 Approval Date: APR 2 92015 Effective Date: 1/1/2014

California

Page 3 of 8

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 toa 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.

oO Another income standard in-between the minimum and maximum standards allowed, provided it is higher than ~” the effective income standard for this age group in the state plan as of March 23, 2010. Income standard for children age six through age eighteen, inclusive ig 8 [| 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 re) (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)()(VID) (mandatory poverty ~“ Jevel-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

The state's highest effective income level for coverage of children age six through eighteen under sections 1931 C (low-income families), 1902(a)(10)(A)(i)(IIT) (qualified children), 1902(a)(10)(A)(i)(VID (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.

oC 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 toa MAGI-equivalent percent of FPL.

oO 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 MAGT-equivalent percent of FPL.

@ 133% FPL -

[Mf] Income standard chosen

The state's income standard used for children age six through eighteen is:

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California Page 4 of 8

TEMS 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)@)(I) (qualified children),

© 1902(a)(10)(A)(@)(VI) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)V) (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)(II1) (qualified children), 1902(a)(10)(A)(@)(VI) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(V) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL.

, Another income standard in-between the minimum and maximum standards allowed, provided it is higher than “ the effective income standard for this age group in the state plan as of March 23, 2010.

[lM] There is no resource test for this eligibility group. [#] Presumptive Eligibility The state covers children when determined presumptively eligible by a qualified entity.

@ Yes O©ONo

1902(a)(47) 1920A

42 CFR 435.1101 42 CFR 435.1102

iw The state provides Medicaid coverage to children when determined presumptively eligible by a qualified entity under the following provisions:

TN No: CA-13-0021-MM1 Approval Date: APR 2 9 2015 Effective Date: 1/1/2014 California Page 5 of 8

sS Medicaid Eligibility

If the state has elected to cover Optional Targeted Low-Income Children (42 CFR 435.229), the income standard for presumptive eligibility is the higher of the standard used for Optional Targeted Low-Income Children or the standard used for Infants and Children under 19 (42 CFR 435.118), for that child’s age.

If the state has not elected to cover Optional Targeted Low Income Children (42 CFR 435.229), the income standard for presumptive eligibility is the standard used under the Infants and Children under Age 19 eligibility group (42 CFR 435.118), for that child’s age.

[Hi] Children under the following age may be determined presumptively eligible:

Under age {19

[ii] The presumptive period begins on the date the determination is made.

[ll] The end date of the presumptive period is the earlier of:

The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by

the last day of the month following the month in which the determination of presumptive eligibility is made; or

The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date.

[ii] Periods of presumptive eligibility are limited as follows: © No more than one period within a calendar year. © No more than one period within two calendar years.

fe) No more than one period within a twelve-month period, starting with the effective date of the initial ~ presumptive eligibility period.

©@ Other reasonable limitation:

Name of limitation Description

No more than two periods within a twelve-month period, starting with the effective date of the initial presumptive eligibility period.

Children Limitations

The state requires that a written application be signed by the applicant, parent or representative, as appropriate. @® Yes ONo ©The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS.

5, The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the ~ application form is included.

[mi] The presumptive eligibility determination is based on the following factors:

[i] Household income must not exceed the applicable income standard described above, for the child's age.

State residency

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California Page 6 of 8

coms. Medicaid Eligibility

[2] Citizenship, status as a national, or satisfactory immigration status

The state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively for this eligibility group.

A qualified entity is an entity that is determined by the agency to be capable of making presumptive . eligibility determinations based on an individual’s household income and other requirements, and that meets at least one of the following requirements. Select one or more of the following types of entities used to determine presumptive eligibility for this eligibility group:

Furnishes health care items or services covered under the state's approved Medicaid state plan and ' is eligible to receive payments under the plan

oO Is authorized to determine a child's eligibility to participate in a Head Start program under the Head Start Act

oO Is authorized to determine a child's eligibility to receive child care services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990

Is authorized to determine a child's eligibility to receive assistance under the Special Supplemental (C1) Food Program for Women, Infants and Children (WIC) under section 17 of the Child Nutrition Act of 1966 Oo Is authorized to determine a child's eligibility under the Medicaid state plan or for child health assistance under the Children's Health Insurance Program (CHIP)

oO Is an elementary or secondary school, as defined in section 14101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 8801)

(71 Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs (1 Is a state or Tribal child support enforcement agency under title IV-D of the Act

oO Is an organization that provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act

Oo Is a state or Tribal office or entity involved in enrollment in the program under Medicaid, CHIP, or title 1V-A of the Act

Is an organization that determines eligibility for any assistance or benefits provided under any program

Oo of public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.)

Is a health facility operated by the Indian Health Service, a Tribe, or Tribal organization, or an Urban Indian Organization

Ol

Other entity the agency determines is capable of making presumptive eligibility determinations:

Name of entity Description

Child Health and Disability Prevention Program

CHDP Providers . providers.

TN No: CA-13-0021-MM1 Approval Date: APR 2 $ 2015 Effective Date: 1/1/2014

California

Page 7 of 8

Medicaid Eligibility

Name of entity

Description

CalHEERS

Retention System

California Healthcare Eligibility, Enrollment and

California Schools

California schools participating in the National School Lunch Program Medicaid Expansion

materials has been included.

The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and provided adequate training to the entities and organizations involved. A copy of the training

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

TN No: CA-13-0021-MM1 California

Approval Date: APR Z 97075

Effective Date: 1/1/2014 Page 8 of 8

‘“CRAS Medicaid Eligibility

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

42 CFR 435.150 1902(a)(10)(A)()(EX)

im 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.

[Y] 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: [Are under age 26. aw 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 [i] 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.

@yYes ONo 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.

CYes @No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN No: CA-13-0021-MM1 Approval Date: APR 3 9.9075 Effective Date: 1/1/2014 California

Page | of 1

<cMs Medicaid Eligibility

OMB Control Number 0938-1148 OMB Expir i ;

1902(a)(10)(A)(H)XX) 1902(hh) 42 CFR 435.218

Individuals above 133% FPL - The state elects to cover individuals under 65, not otherwise mandatorily or optionally eligible, with income above 133% FPL and at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.218.

© Yes @No

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

Asan TN No: CA-13-0021-MM1 Approval Date: APR 4 a FLL Effective Date: 1/1/2014 California Page 1 of 1

Medicaid Eligibility

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

42 CFR 435,220 1902(a)(10)(A)(ii)(1)

Optional Coverage of Parents and Other Caretaker Relatives - The state elects to cover individuals qualifying as parents or other

caretaker relatives who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.220. .

© Yes ©@No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN No: CA-13-0021-MM1 Approval Date: APR 2 5 2015

Effective Date: 1/1/2014 California

Page 1 of 1

State Name:|California OMB Control Number: 0938-1148

Transmittal Number: - Expiration date: 10/31/2014

42 CFR 435.222 1902(a)(10)(A)Gi)() 1902(a)(10)(A)(ii)V)

Reasonable Classification of Individuals under Age 21 - The state elects to cover one or more reasonable classifications of individuals under age 21 who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.222.

@ Yes © No

[¥] The state attests that it operates this eligibility group in accordance with the following provisions:

TH Individuals qualifying under this eligibility group must qualify under a reasonable classification by meeting the following criteria:

[Bi] Be under age 21, or a lower age, as defined within the reasonable classification.

m= Have household income at or below the standard established by the state, if the state has an income standard for the reasonable classification.

[i] Not be eligible and enrolled for mandatory coverage under the state plan.

fal MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state.

The state covered at least one reasonable classification under this eligibility group under its Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013, with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age.

@® Yes © No

The state also covered at least one reasonable classification under this group in the Medicaid state plan as of March 23, 2010 with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age.

@ Yes ©No

TN No: CA-13-0021-MM1 Approval Date: APR Z 5 015 Effective Date: 1/1/2014

California Page 1 of 8

The state attaches the approved pages from the Medicaid state plan as of March 23, 2010 to indicate the age groups, reasonable classifications, and income standards used at that time for this eligibility group.

Current Coverage of All Children under a Specified Age

The state covers all children under a specified age limit, equal to or higher than the age limit and/or income standard used in the Medicaid state plan as of March 23, 2010, provided the income standard is higher than the current mandatory income standard for the individual's age. The age limit and/or income standard used must be no higher than any age limit and/or income standard covered in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Higher income standards may include the disregard of all income.

© Yes @No ‘urrent Coverage of Reasonable Classifications Covered i edicaid State P! f March 23, 2010

The state covers reasonable classifications of children previously covered in the Medicaid state plan as of March 23, 2010, with income standards higher than the current mandatory income standard for the age group. Age limits and income standards are equal to or higher than the Medicaid state plan as of March 23, 2010, but no higher than any age limit and/or income standard for this classification covered in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Higher income standards may include the disregard of all income.

@ Yes © No

Indicate the reasonable classifications of children that were covered in the state plan in effect as of March 23, 2010 with income standards higher than the mandatory standards used for the child's age, using age limits and income standards that are not mote restrictive than used in the state plan as of as March 23, 2010 and are not less restrictive than used in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

([] Individuals for whom public agencies are assuming full or partial financial responsibility.

(1 Individuals in adoptions subsidized in full or part by a public agency (J Individuals in nursing facilities, if nursing facility services are provided under this plan

Individuals receiving active treatment as inpatients in psychiatric facilities or programs, if such services are provided under this plan

Indicate the age which applies:

@ Under age 21 (©Underage 20 (Underage19 (Under age 18

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ccms Medicaid Eligibility

[7] Other reasonable classifications

Enter the income standard used for these classifications. The income standard must be higher than the mandatory standard for the child's age. It may be no lower than the income standard used in the state plan as of March 23, 2010 and no higher than the highest standard used in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

[i] Income standard used

[i] Minimum income standard

The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards.

(@] Maximum income standard

No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

@® Yes ©No

[Bi] No income test was used (all income was disregarded) for this classification under: (check all that apply) The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. (1) A Medicaid 1115 Demonstration as of March 23, 2010. (71 A Medicaid 1115 Demonstration as of December 31, 2013.

The state's maximum standard for this classification of children is no income test (all income is disregarded).

[lf Income standard chosen Individuals qualify under this classification under the following income standard:

This classification does not use an income test (all income is disregarded).

Other Reasonable Classifications Previously Covered

TN No: CA-13-0021-MM1 Approval Date: APR 2 5.7015 Effective Date: 1/1/2014 California Page 3 of 8

Medicaid Eligibility

The state covers reasonable classifications of children not covered in the Medicaid state plan as of March 23, 2010, but covered under the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013 with an income standard higher than the current mandatory income standard for the age group.

@ Yes O©ONo

The additional previously covered reasonable classifications to be included are:

Individuals for whom public agencies are assuming full or partial financial responsibility.

Individuals placed in foster care homes by public agencies

Indicate the age which applies: @Under age 21 (Underage 20 (Underage 19 ©Under age 18

(1 Individuals placed in foster care homes by private, non-profit agencies

(71 Individuals placed in private institutions by public agencies

[7] Individuals in adoptions subsidized in full or part by a public agency [7] Individuals in nursing facilities, if nursing facility services are provided under this plan

oO Individuals receiving active treatment as inpatients in psychiatric facilities or programs, if such services are provided under this plan

Other reasonable classifications

Name of classification Description Age Limit

All children who were enrolled in Medicaid on 12/31/13 and would otherwise become ineligible for Medicaid at their first redetermination 2101(f)-Like Children using MAGI methodologies solely due ||Under age 19 to the loss of income disregards will remain Medicaid eligible until their next redetermination using MAGI methodologies.

TN No: CA-13-0021-MM1 Approval Date: APR 2 205 Effective Date: 1/1/2014 California Page 4 of 8

Medicaid Eligibility

Name of classification Description Age Limit

nmarried Pregnant Women | (a) Living with her parent(s), and is not nder Age 21 going to file a tax return for the taxable

Unmarried pregnant women, who are not eligible under any other mandatory or optional categorically needy coverage group and who are either:

Under age 21

year, or (b) is going to be claimed as a tax dependents by her parent(s) in the taxable year.

[H) Income standard used

Standards.

Enter the income standard used for these classifications (which must be higher than the mandatory standard for the child's age but may be no higher than the highest standard used in the state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013).

[#] Minimum income standard

The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in $14 AFDC Income

[Maximum income standard

No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. @ Yes ©No [Hi] No income test was used (all income was disregarded) for this classification under:

(check all that apply)

Oo The Medicaid state plan as of March 23, 2010.

The Medicaid state plan as of December 31, 2013.

(1) A Medicaid 1115 Demonstration as of March 23, 2010.

(J A Medicaid 1115 Demonstration as of December 31, 2013.

The state's maximum standard for this classification of children is no income test (all income is disregarded).

[m] Income standard chosen

TN No: CA-13-0021-MM1 California

Approval Date: APR 4 50 Effective Date: 1/1/2014

Page 5 of 8

eter

EMS Medicaid Eligibility

Individuals qualify under this classification under the following income standard: @ This classification does not use an income test (all income is disregarded).

© The minimum standard

re} Another income standard higher than both the minimum income standard and the effective income ” level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent.

{H] Income standard used

(i) Minimum income standard

The minimum income standard for this classification of children must exceed the lowest income standard chosen for children under this age under the Infants and Children under Age 19 eligibility group.

[im] Maximum income standard

No income test was used (all income was disregarded) for this classification either in the Medicaid state

plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

@ Yes ©No

[i] No income test was used (all income was disregarded) for this classification under: (check all that apply) [[] The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. (C1) A Medicaid 1115 Demonstration as of March 23, 2010.

[7] A Medicaid 1115 Demonstration as of December 31, 2013.

The state's maximum standard for this classification of children is no income test (all income is disregarded).

[ml Income standard chosen Individuals qualify under this classification under the following income standard:

(@> This classification does not use an income test (all income is disregarded).

Another income standard higher than both the minimum income standard and the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent.

[Ml] Income standard used

a TN No: CA-13-0021-MM1 Approval Date: APR 2 ¥ ON

California

Effective Date: 1/1/2014

Page 6 of 8

ccms Medicaid Eligibility

[i] Minimum income standard

The minimum income standard for this classification of children is the AFDC payment standard in effect

as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in $14 AFDC Income Standards.

[#] Maximum income standard

No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or

December 31, 2013. @ Yes ONo

[] No income test was used (all income was disregarded) for this classification under: (check all that apply) [1] The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. (-] A Medicaid 1115 Demonstration as of March 23, 2010. (C1 A Medicaid 1115 Demonstration as of December 31, 2013.

The state's maximum standard for this classification of children is no income test (all income is disregarded).

[Hi] Income standard chosen Individuals qualify under this classification under the following income standard: ©@ This classification does not use an income test (all income is disregarded).

© The minimum standard

oO Another income standard higher than both the minimum income standard and the effective income “ level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent.

Additional new age groups or reasonable classifications covered

If the state has not elected to cover the Adult Group (42 CFR 435.119), it may elect to cover additional new age groups or reasonable classifications that have not been covered previously. If the state covers the Adult Group, this additional

option is not available, as the standard for the new age groups or classifications is lower than that used for mandatory coverage.

The state does not cover the Adult Group and elects the option to include in this eligibility group additional age groups or reasonable classifications that have not been covered previously in the state plan or under a Medicaid 1115 Demonstration. Any additional age groups or reasonable classifications not previously covered are restricted to the AFDC income standard from July 16, 1996, not converted to a MAGI-equivalent standard.

C Yes @No

[] There is no resource test for this eligibility group.

TN No: CA-13-0021-MM1 Approval Date: APR F4 o2ON5 Effective Date: 1/1/2014 California Page 7 of 8

Medicaid Eligibility

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

V.20140415

TN No: CA-13-0021-MM1 Approval Date: APR 2 32075 Effective Date: 1/1/2014

California Page 8 of 8

“CMs. Medicaid Eligibility

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

42 CFR 435.227 1902(a)(10)(A)(i)(VIL)

Children with Non IV-E Adoption Assistance - The state elects to cover children with special needs for whom there is a non IV-E

adoption assistance agreement in effect with a state, who were eligible for Medicaid, or who had income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.227.

@® Yes O©No The state attests that it operates this eligibility group in accordance with the following provisions:

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

wl The state adoption agency has determined that they cannot be placed without Medicaid coverage because of special . needs for medical or rehabilitative care;

[B] Are under the following age (see the Guidance for restrictions on the selection of an age): ©@ Under age 21 © Under age 20 © Under age 19 © Under age 18

ry MAGI-based income methodologies are used in calculating household income. Please refer as necessary to SLO MAGI- Based Income Methodologies, completed by the state.

The state covered this eligibility group in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

@ Yes © No

The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. @ Yes ONo

rl Individuals qualify under this eligibility group if they were eligible under the state's approved state plan prior to the execution of the adoption agreement.

The state used an income standard or disregarded all income for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

@® Yes ONo [@| Income standard used for this eligibility group [] Minimum income standard

The minimum income standard for this eligibility group is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards.

[i] Maximum income standard

a TN No: CA-13-0021-MM1 Approvaibate: APR 2 B2075 Effective Date: 1/1/2014 California

Page 1 of 2

Medicaid Eligibility

No income test was used (all income was disregarded) for this eligibility group either in the Medicaid state

plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

@ Yes ©No

ia No income test was used (all income was disregarded) for this eligibility group under (check all that apply):

(C1) The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. (C1) A Medicaid 1115 Demonstration as of March 23, 2010. (C) A Medicaid 1115 Demonstration as of December 31, 2013. The state's maximum standard for this eligibility group is no income test (all income is disregarded).

[ii] Income standard chosen

Individuals qualify under this eligibility group under the following income standard, which must be higher than the minimum for this child's age:

© The minimum standard.

@ This eligibility group does not use an income test (all income is disregarded).

Another income standard higher than both the minimum income standard and the effective income level ~" for this eligibility group in the state plan as of March 23, 2010, converted to a MAGI-equivalent.

[B| There is no resource test for this eligibility group.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

A TN No: CA-13-0021-MM1 Approval Date: APR Z v 2015

Effective Date: 1/1/2014 California

Page 2 of 2

Medicaid Eligibility

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

1902(a)(10)(A)(ii)(XTV) 42 CFR 435.229 and 435.4 1905(u)(2)(B)

Optional Targeted Low Income Children - The state elects to cover uninsured children who meet the definition of optional targeted low income children at 42 CFR 435.4, who have household income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.229.

@ Yes ©No The state attests that it operates this eligibility group in accordance with the following provisions: [i] Individuals qualifying under this eligibility group must not be eligible for Medicaid under any mandatory eligibility group.

wl MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state.

The state covered this eligibility group in the state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

@ Yes ONo

The state also covered this eligibility group in the state plan as of March 23, 2010. © Yes @ No [i] Individuals are covered under this eligibility group, as follows: @ All children under age 18 or 19 are covered: @ Under age 19

© Under age 18

© The reasonable classification of children covered is: (7 Income standard used for this classification [BH] Minimum income standard

The minimum income standard for this classification of children must exceed the lowest income standard

chosen for children in the age group selected above, under the mandatory Infants and Children under Age 19 eligibility group.

[@] Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for this classification of children to MAGI-equivalent standards and the determination of the maximum income standard to be used for this classification of children under this eligibility group.

TN No: CA-13-0021-MM1 Approval Date: APR @ 5 Wis Effective Date: 1/1/2014 California

Page 1 of 3

Medicaid Eligibility

The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is:

@ The state's effective income level for this classification of children under the Medicaid state plan as of * December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size.

The state's effective income level for this classification of children under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size.

ro The state's effective income level for this classification of children under a Medicaid 1115 demonstration as ~ of December 31, 2013, converted to a MAGT-equivalent percent of FPL or amounts by household size.

© 200% FPL.

ra A percentage of the FPL which may exceed the Medicaid Applicable Income Level, defined in section ~ 2110(b)(4) of the Act, but by no more than 50 percentage points.

ry The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is:

261 % FPL

[HB] Income standard chosen, which must exceed the minimum income standard Individuals qualify under the following income standard:

(@ The maximum income standard.

re} The state's effective income level for this eligibility group under the Medicaid state plan as of December ~” 31, 2013, converted to a MAGT-equivalent percent of FPL.

ra} The state's effective income level for this eligibility group under a Medicaid 1115 demonstration as of ~~ March 23, 2010, converted to a MAGI-equivalent percent of FPL.

., The state's effective income level for this eligibility group under a Medicaid 1115 demonstration as of ~” December 31, 2013, converted to a MAGI-equivalent percent of FPL.

© 200% FPL.

oC A percentage of the FPL which may exceed the Medicaid Applicable Income Level, defined in section SY 2110(b)(4) of the Act, but by no more than 50 percentage points.

© Another income standard in-between the minimum and maximum standards allowed.

The income standard for this eligibility group is: |261 % FPL

[i] There is no resource test for this eligibility group. [lM] Presumptive Eligibility

Presumptive eligibility for this group depends upon the selection of presumptive eligibility for the Infants and Children [B] under Age 19 eligibility group. If presumptive eligibility is done for that group, it is done for this group under the same provisions.

PRA Disclosure Statement

TN No: CA-13-0021-MM1 Approval Date: APR 4 5.7015 Effective Date: 1/1/2014

California Page 2 of 3

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.

TN No: CA-13-0021-MM1 Approval Date: APR 2 22015

Effective Date: 1/1/2014 California

Page 3 of 3

Medicaid Eligibility

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

1902(a)(10)(A)(ii)(XI1) 1902(z)

Individuals with Tuberculosis - The state elects to cover individuals infected with tuberculosis who have income at or below a standard established by the state, limited to tuberculosis-related services.

@ Yes © No The state attests that it operates this eligibility group in accordance with the following provisions: Pp ig P [i] Individuals qualifying under this eligibility group must meet the following criteria: [Wf] Are infected with tuberculosis. [i] Are not otherwise eligible for mandatory coverage under the Medicaid state plan. [| Have household income under a standard established by the state.

ry MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state.

[HB] Income standard used for this group

[i] Maximum income standard

First indicate the maximum income standard that could be used for this group and then indicate the income standard the state uses for the group.

The state elects to convert the effective income level for coverage of this eligibility group in effect in the Medicaid state plan as of March 23, 2010 and December 31, 2013 to MAGI-equivalent standards.

© Yes @No The state's maximum income standard for this eligibility group is: @) The break-even point for earned income under the SSI program.

oO The effective income level for this eligibility group under the Medicaid state plan in effect as of March 23, 2010, not converted to a MAGI-equivalent standard.

O The effective income level for this eligibility group under the Medicaid state plan in effect as of ~ December 31, 2013, not converted to a MAGI-equivalent standard.

[i] Income standard chosen

The state's income standard used for this eligibility group is:

@ The maximum income standard. © If not chosen as the maximum income standard, the break-even point for earned income under the SSI program. © Another income standard less than the maximum standard allowed.

iw Individuals qualifying under this group are eligible only for the following services, provided the service is related to the diagnosis, treatment or management of the individual's tuberculosis.

[| Prescribed drugs, described in 42 CFR 440.120

TN No: CA-13-0021-MM1 Approval Date: APR 2 21015 Effective Date: 1/1/2014 California Page 1 of 2

Medicaid Eligibility

[i] Physician services, described in 42 CFR 440.50 [| Outpatient hospital and rural health clinic described in 42 CFR 440.20 and Federally-qualified health center services [i] Laboratory and x-ray services (including services to confirm the presence of the infection), described in 42 CFR 440.30 [Ml Clinic services, described in 42 CFR 440.90

[®] Case management services defined in 42 CFR 440.169

ia Services other than room and board designed to encourage completion of regimens of prescribed drugs by out-patients, including services to observe directly the intake of prescription drugs. .

[B] Limitations related to tuberculosis-related services may be found in the Benefits section.

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.

A TN No: CA-13-0021-MM1 Approval Date: APR Z ev 2015 Effective Date: 1/1/2014 California Page 2 of 2

Medicaid Eligibility

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

42 CFR 435.226 1902(a)(10)(A)(ii)(XVID)

Independent Foster Care Adolescents - The state elects to cover individuals under an age specified by the state, less than age

21, who were in state-sponsored foster care on their 18th birthday and who meet the income standard established by the state and in accordance with the provisions described at 42 CFR 435.226.

@ Yes ©No The state attests that it operates this eligibility group in accordance with the following provisions: [iM] Individuals qualifying under this eligibility group must meet the following criteria:

[i] Are under the following age @ Under age 21 © Under age 20 © Under age 19

[i] Were in foster care under the responsibility of a state on their 18th birthday.

[Ml Are not eligible and enrolled for mandatory coverage under the Medicaid state plan.

[&] Have household income at or below a standard established by the state.

wl MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state.

The state covered this eligibility group under its Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 demonstration as of March 23, 2010 or December 31, 2013.

@ Yes © No

The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. @ Yes ©ONo

The state covers children under this eligibility group, as follows (selection may not be more restrictive than the coverage in the Medicaid state plan as of March 23, 2010 until October 1, 2019, nor more liberal than the most

a) liberal coverage in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 demonstration as of March 23, 2010 or December 31, 2013):

@ All children under the age selected © A reasonable classification of children under the age selected:

[H] Income standard used for this eligibility group

[@]) Minimum income standard

The minimum income standard for this classification of children is the AFDC payment standard in effect

as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards.

TN No: CA-13-0021-MM1 Approval Date: APR Z 97015 Effective Date: 1/1/2014 California

Page 1 of 2

cCcmMs Medicaid Eligibility

[H] Maximum income standard

No income test was used (all income was disregarded) for this eligibility group either in the

Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

@© Yes ONo

rH No income test was used (all income was disregarded) for this eligibility group under (check all that apply):

I] The Medicaid state plan as of March 23, 2010.

The Medicaid state plan as of December 31, 2013.

(1 A Medicaid 1115 demonstration as of March 23, 2010.

(1) A Medicaid 1115 demonstration as of December 31, 2013.

The state's maximum standard for this eligibility group is no income test (all income is disregarded).

[H) Income standard chosen Individuals qualify under this eligibility group under the following income standard:

This eligibility group does not use an income test (all income is disregarded).

[i] There is no resource test for this eligibility group.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN No: CA-13-0021-MM1 Approval Date: APR 2 32018

Effective Date: 1/1/2014 California

Page 2 of 2

State Name:|California OMB Control Number: 0938-1148

1902(a)(10)(A)(i)(XXD) 42 CER 435.214

Transmittal Number: - Expiration date: 10/31/2014

Individuals Eligible for Family Planning Services - The state elects to cover individuals who are not pregnant, and have household income at or below a standard established by the state, whose coverage is limited to family planning and related services and in accordance with provisions described at 42 CFR 435.214.

@ Yes ©No

[7] The state attests that it operates this eligibility group in accordance with the following provisions: [B] The individual may be a male or a female. [i] Income standard used for this group

[B] 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 this eligibility group.

The state's maximum income standard for this eligibility group is the highest of the following:

@ The state's current effective income level for the Pregnant Women eligibility group (42 CFR 435.116) under the ? Medicaid state plan.

©The state's current effective income level for pregnant women under a Medicaid 1115 demonstration. © The state's current effective income level for Targeted Low-Income Pregnant Women under the CHIP state plan.

©The state's current effective income level for pregnant women under a CHIP 1115 demonstration.

The amount of the maximum income standard is: |208 % FPL

[Bl Income standard chosen The state's income standard used for this eligibility group is: ©The maximum income standard

@ Another income standard less than the maximum standard allowed.

The amount of the income standard is: |200 % FPL

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.

TN No: CA-13-0021-MM1 Approval Date: ADR 5 9045 Effective Date: 1/1/2014 California

Page 1 of 2

FORM HCFA-179 (07-92)

INDIVIDUALS ELIGIBLE FOR FAMILY PLANNING SERVICES (Attachment to S59)

TRANSMITTAL NUMBER:

13-0021-MM STATE:

California

The state is covering two categorical populations listed under section 1902(a)(10)(A)(ii)(XXI) of the Social Security Act and 42 CFR 435.214: (1) Individuals described at clause (xvi) of section 1905(a) (i.e., all individuals described in 1902(ii)); and (2) individuals described in clause (i) of 1905(a) (i.e., individuals under age 21).

In determining eligibility for this reasonable classification of children, the elections made in S59 apply to the group covering individuals under age 18 who also are described in section 1902(ii) except that, in determining eligibility for this group, the state considers only the income of the applicant.

In addition, in determining eligibility for this group as a whole, the state exercises the option to define the groups as individuals who would have been eligible for family planning benefits pursuant to the standards and processes imposed by the state on January 1, 2007 under a waiver granted pursuant to section 1115, including but not limited to allowing self-attestation from an applicant or recipient which shall not require the individual to produce any subsequent documents to verify stated attestations for program eligibility.

Table of Contents

State/Territory Name: California State Plan Amendment (SPA) #: 13-0022 MM2

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

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

IESE te

all

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

Toby Douglas, Director

California Department of Health Care Services bec 1 0 2013 P.O. Box 997413, MS 0000 _ Sacramento, CA 95899-7413

Dear Mr. Douglas:

Enclosed is an approved copy of California’s state plan amendment (SPA) 13-0022-MM2, which was submitted to CMS on September 11, 2013. SPA 13-0022-MM2 incorporates the MAGI- based eligibility process requirements, including the single streamlined application, into California’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 13-0022-MM2 includes full approval of your state’s alternative paper application used to apply for multiple human service programs. The state is using an interim online application used to apply for multiple human services programs and by July 1, 2014 will implement a revised application that addresses CMS concerns outlined in the companion letter issued with this SPA approval.

‘In addition, the state is using interim alternative single streamlined paper and online applications. By July 1, 2014 the state will implement a revised alternative single streamlined paper application and by December 31, 2014, the state will implement a revised alternative single streamlined online application. These revised applications must address CMS concerns outlined in the companion letter issued with this SPA approval.

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

e .$94, pages $94-1, $94-2, $94-3

e Attachment 1 - California Multi-Benefit paper application -SAWS 2 PLUS, 7/13

e Attachment 2 - Statement of use for online application used to apply for multiple human

service programs e Attachment 3 - Statement of use for alternative single streamlined paper application e Attachment 4 - Statement of use for alternative single streamlined online application

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 Tom Schenck at

(415)744-3589, or tom.schenck@cms.hhs.gov.

Sincerely,

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

ce: Tara Naisbitt, California Department of Health Care Services Kathryn Waje, California Department of Health Care Services

CA.0311.R00.00 - Oct 01, 2013 Page | of 1

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name:

California

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.

CA-13-0022

Proposed Effective Date 10/01/2013. tnin/ ad yyy)

Federal Statute/Regulation Citation 42 CFR 435, Subpart J and Subpart M

Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $0.00 Second Year 2015 $10.00

Subject of Amendment Eligibility Process

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 does not wish to review the State Plan Amendment

_ Signature of State Agency Official Submitted By: Kathryn Waje Last Revision Date: Dec 9, 2013 Submit Date: Sep 11, 2013

file:///G:/DIVS/DMCD/Program%20Branch%20Files%20(2012-01-01%20Forward)/CA/... 12/10/2013

Medicaid Eligibility

* OMB Control Number 0938-1148 OM iration date: 10/31/2014

42 CFR 435, Subpart J and Subpart M

Eligibility Process

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

Application Processing

Indicate which application the agency uses for individuals applying for coverage who may be eligible based on the applicable modified adjusted gross income standard.

oO The single, streamlined application for all insurance affordability programs, developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act

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

An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs.

Indicate which application the agency uses for individuals applying for coverage who may be eligible on a basis other than the applicable modified adjusted gross income standard:

The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and {X] approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary.

oO An application designed specifically to determine eligibility on a basis other than the applicable MAGI standard which minimizes the burden on applicants, submitted to the Secretary.

The agency’s procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in 42 CFR 435.1200(f), by telephone, via mail, and in person.

The agency also accepts applications by other electronic means:

© XSSomitfar nMber: CA-13-0022-MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

Page 1 of 3

Medicaid Eligibility

ENTIRE NENT NAA MARDEN TIMID,

Indicate the other electronic means below:

Name of Method Description

County web portals Each county has a web portal that will accept applications with an intake process that operates independently from the federally required State online access portal (CalHEERS). County eligibility workers or individual applicants can enter their application data into their county-specific web portal. This web portal will then interface with the business rules engine in CalHEERS to determine what health programs the applicant’s case qualifies for. The eligibility determination will then be sent electronically back to the county web portal.

Fax Applications can also be submitted through facsimile.

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 1V-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:

[ll] Once every 12 months

im 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.

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

Once every 12 months

() Once every 6 months

([] Other, more often than once every 12 months Coordination of Eligibility and Enrollment

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

Transmittal Number: CA-13-0022-MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

Page 2 of 3

Medicaid Eligibility

ERE LEONE AE OHTNID LOI

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: CA-13-0022-MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

Page 3 of 3

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

C1 Paper Application Online Application

TRANSMITTAL NUMBER: STATE:

CA-13-0022-MM2 California

Through July 1, 2014, the state is using an interim multi-benefit application. After July 1, 2014, the state will use a revised multi-benefit application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference into the state plan.

Transmittal Number: CA-13-0022-MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

C1 Paper Application Online Application

TRANSMITTAL NUMBER: STATE:

CA-13-0022-MM2 California

Through December 31, 2014, the state is using an interim alternative single streamlined application. After December 31, 2014, the state will use a revised alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference into the state plan.

Transmittal Number: CA-13-0022-MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

xlPaper Application OOnline Application

TRANSMITTAL NUMBER: STATE:

CA-13-0022-MM2 California

Through July 1, 2014, the state is using an interim alternative single streamlined application. After July 1, 2014, the state will use a revised alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference into the state plan.

Transmittal Number: CA-13-0022-MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

APPLICATION FOR CALFRESH @ , CASH AID 6 , AND/OR

MEDI-CAL/HEALTH CARE PROGRAMS 3]

If you have a disability or need help with this application, let the County Welfare Department (County) know and someone will help you.

If you prefer to speak, read, or write in a language other than English, the County will get someone to help you at no cost to you.

How do | apply?

Use this application if you are applying for food assistance Fresh), cash aid (California Work ortunity and Responsibility to Kids or Refugee Cash Assistance). Medi-Cal and/or other health care programs. If you want to apply for CalFresh only, you can ask the County for the CalFresh only application. CalFresh is a food assistance program to help you with the cost of buying food for your household. If you want to apply for health care only, you can ask the county for a health care only application. Health care includes: low-cost insurance for Medi-Cal; affordable private health insurance; or a tax credit that can help you pay your premiums for health coverage. Do not use this application if you are applying for only health care.

You can also apply for these programs online by going to http://www.benefitscal.org/.

¢ Fill out the whole application form, if you can. You must at least give the County your name, address, and signature (question 1 on page 1 of the application) to begin the application process for CalFresh. For cash aid you must fill out questions 1 through 5 on pages 1 and 2 of the application and sign it to begin the application process.

¢ Each program has a symbol (shown at the top of this page) showing what questions pertain to what programs. For cash aid, it is a dollar sign; for CalFresh, it is a shopping cart; and for health coverage, it is an ambulance. For example, if you are not applying for cash aid, you don’t need to answer questions marked only with a dollar sign.

* Give the application to the County in person, by mail, by fax or online.

* The day the County receives your signed application starts the time to give you an answer on whether you can get benefits. If you are in an institution, this time starts from the day you leave.

What do I do next?

e Read about your rights and your responsibilities (Program Rules pages) before you sign the application.

¢ You must have an interview with the County to discuss your application. If you have a disability, other arrangements can be made.

* If you did not fill out all of the application, you can finish it during your interview.

* You will need to give proof of your income, expenses, and other circumstances to see if you are eligible.

How long will it take? it may take up to 30 days to process your application for CalFresh. For cash aid and Medi-Cal, it may take up to 45 days. Ask the County how to get your benefits or health care right away if you have an emergency.

You may be able to get CalFresh benefits within 3 calendar days if:

* Your household’s monthly gross income (income before deductions) is less than $150 and your cash on hand or in checking or savings accounts is not more than $100; or

* Your household’s housing costs (rent/mortgage and utilities) are more than your monthly gross income and money in checking or savings; or

* You are a migrant or seasonal farmworker household with less than $100 in checking or savings and 1) your income stopped, or 2) your income has started but you do not expect to get more than $25 in the next 10 days.

For cash aid, you may get immediate assistance if:

You are homeless or have an eviction notice or a notice to pay rent or move; or Your food will run out within three days;

Your utilities have been or will be shut off;

You don’t have sufficient clothing or diapers;

You have another kind of emergency important to health and safety.

Informational Page - Please take and keep for your records.

SAWS 2 PLUS (7/13) Cl SHEET PAGE 1 OF 2 . Tranemittal Number: CA-13-0022-MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013"

To help the County see if you can get benefits faster, please complete questions 1, 6 through 9, 15, and 24, and give the County proof of your identity (if you have it) with the application.

The County will send you a letter to let you know if your household is approved or denied for the benefits you applied for.

What do I need for my interview?

To avoid delays, bring proof of the following items with you to your interview. Keep your interview even if you do not have the proof. The County may be able to help if you need help getting proof. During the interview, the County will go over the information on the application and will ask you questions to see if you can get benefits and the amount of benefits you can get.

Proof Needed to Get Benefits Proof Needed to Get More CalFresh Benefits

* Identification (Driver's License, State ID card, ¢ Housing costs (rent receipts, mortgage bills, passport). property tax bill, insurance documents). * Birth certificates for everyone applying for cash * Phone and utility costs. aid. * Medical expenses for anyone in your household ¢ Proof of where you live (rental agreement, cur- who is elderly (60 and older) or disabled.

rent bill with your address listed). ¢ Child and adult care costs due to someone

* Social Security numbers for everyone applying working, looking for work, attending training or for aid (see note below about certain school, or participating in a required work activity. noncitizens). * Child support paid by a person in your

* Money in the bank for all the people in your household. household (recent bank statements).

* Earned income of everyone in your household for the past 30 days (recent pay stubs, a work statement from an employer). NOTE: If self-employed, income and expenses or tax records.

* Unearned income (Unemployment benefits, SSI,

Additional Proof Needed for Health Coverage

¢ Information about any job related health insurance available to your family.

* Policy numbers for any current health insurance.

Additional Proof Needed for Cash Aid

Social Security, Veteran’s benefits, child support, worker’s compensation, school grants or loans, rental income, etc.).

* Lawful immigration status ONLY for legal noncitizens applying for benefits (an Alien Registration Card, visa).

NOTE: Certain noncitizens applying for immigration status based on domestic violence, crime prosecution or trafficking may not need this proof. They also may not need a Social Security number.

What if | am homeless?

* Proof of immunizations for children six years of age or younger.

* Vehicle registration for vehicles owned by you or someone you are applying for.

Please let the County know right away if you are homeless so they can help you figure out an address to use to accept your application and get notices from the County regarding your case. For CalFresh and cash aid,

homeless means you are:

A. Staying in a supervised shelter, halfway house, or similar place. B. Staying at the home of another person or family for no more than 90 days straight. C. Sleeping in a place not designed for, or normally used as, a place to sleep (a hallway, a bus station, a

lobby, or similar places).

Informational Page - Please take and keep for your records.

SAWS 2 PLUS (7/13) Transmittal Number: CA-13-0022-MM2

Approval Date: December 10, 2013

COVERSHEET PAGE 2 OF 2 Effective Date: October 1, 2013

RIGHTS AND RESPONSIBILITIES

You have a responsibility to:

Give the County all information needed to determine your eligibility. Give the County proof of the information you have when it is needed.

Report changes as required. The County will give you information about what, when, and how to report. For CalFresh and cash aid if you don’t meet your household’s reporting requirements, your case may be closed or your benefits may be lowered or stopped.

Look for, get, and keep a job or participate in other activities if the County tells you that it is required in your case.

Fully cooperate with county, state, or federal personnel if your case is selected for review or investigation to ensure that your eligibility and benefit level were correctly figured. Failure to cooperate in these reviews will result in loss of your benefits.

Pay back any cash aid or CalFresh benefits that you were not eligible to get.

You have the right to:

Turn in an application for CalFresh giving only your name, address, and signature.

Have an interpreter provided by the State at no cost if you need one.

Have information given to the County kept confidential, unless directly related to the administration of County programs. Withdraw your application at any time prior to the County determining eligibility.

Ask for help to fill out your application or help getting the proof that you need and get an explanation of the rules.

Be treated with courtesy, consideration, and respect, and not be discriminated against.

Get CalFresh benefits within 3 days if you qualify for Expedited Service.

Get cash aid within one day if you qualify for Immediate Need.

Be interviewed in a reasonable amount of time by the County when you apply and to have your eligibility determined within 30 days for CalFresh or 45 days for cash aid and Medi-Cal.

Get at least 10 days to give to the County proof that is needed to make a determination of eligibility. Get written notice at least 10 days before the County lowers or stops your CalFresh or cash aid benefits. Discuss your case with the County and to review your case when you ask to do so.

Ask for a State hearing within 90 days if you do not agree with the County about your case. If you ask for a hearing before an action on your case takes place, your benefits will stay the same until the hearing or the end of your certification period, whichever is earlier. You can ask the County to let your benefits change until after the hearing to avoid having to pay back any overpaid benefits. If the Administrative Law Judge rules in your favor, the County will give back to you any benefits that were cut.

Ask about your hearing rights or for a legal aid referral at the toll-free phone numbers — 1-800-952-5253 or for hearing or speech impaired who use TDD, 1-800-952-8349. You may get free legal help at your local legal aid or welfare rights Office.

Bring a friend or someone with you to the hearing if you do not want to go alone. Get help from the County to register to vote. Report changes that you are not required to report, if it may increase your CalFresh benefits or cash aid.

Give proof of your household's expenses that may help you get more CalFresh benefits. Not giving proof to the County is the same as saying that you do not have that expense and you will not be able to get more. CalFresh benefits.

Let the County know if you would like someone else to use your CalFresh benefits for your household or help with your CalFresh case (Authorized Representative).

You are also giving the Medi-Cal agency the right to pursue and get medical support from a spouse or parent. If you think that cooperating to collect medical support will harm you or your children, you can tell the Medi-Cal agency and you may not have to cooperate.

Please take and keep for your records

SAWS 2 PLUS (7/13) PROGRAM RULES PAGE 1 OF 4

Transmittal Number: CA-13-0022-MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

Program Rules and Penalties ; You are committing a crime if you give false or wrong information, or do not give all the information on purpose to try to get CalFresh, cash aid, and Medi-Cal, that you are not eligible to receive, or to help someone else get benefits that they are not eligible to receive. You must pay back any benefits you get that you were not eligible to receive. If you do this on purpose and receive more than $950 in benefits you were not eligible to receive, you can be charged with a felony.

For CalFresh: | understand that if | commit an intentional program violation by doing any of the

following:

I may...

* hide information or make false statements « lose CalFresh benefits for 12 months for the first offense and be required to repay all CalFresh benefits overpaid to me

* use electronic benefit transfer (EBT) cards that belong * lose CalFresh benefits for 24 months for the second

to someone else or let someone else use my card offense and be required to repay all CalFresh benefits overpaid to me

* use CalFresh benefits to buy alcohol or tobacco * lose CalFresh benefits permanently for the third offense and be required to repay all CalFresh benefits overpaid to me

* trade, sell, or give away CalFresh benefits or EBT cards | * be fined up to $250,000, imprisoned up to 20 years, or bot! :

* lose CalFresh benefits for 24 months for the first offense

* trade CalFresh benefits for controlled substances, ¢ lose CalFresh benefits permanently for the second

such as drugs offense.

* give false information about who | am and where | live * “Jose CalFresh benefits for 10 years for each offense so | can get extra CalFresh benefits

* have been convicted of trading or selling CalFresh * lose CalFresh benefits forever benefits worth more than $500, or trading CalFresh benefits for firearms, ammunition, or explosives