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us-ca/policy/cms/medicaid-state-plan/spa · Axiom

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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)

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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)

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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)

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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 ____ _

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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

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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

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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

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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

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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}

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----- 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

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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

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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 --=......::::-..........

(ca-10-012b)(approval-document)(page-8)Page 8#

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

(ca-10-012b)(approval-document)(page-10)Page 10#

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.

(ca-11-030)(approval-document)(page-5)Page 5#

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.”

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

(ca-11-030)(approval-document)(page-6)Page 6#

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.

7c.3

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 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

(ca-11-037a)(approval-document)(page-8)Page 8#

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

(ca-11-037a)(approval-document)(page-9)Page 9#

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

(ca-12-008)(approval-document)(page-4)Page 4#

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

(ca-13-004)(approval-document)(page-3)Page 3#

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 \

(ca-13-004)(approval-document)(page-10)Page 10#

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

(ca-13-004)(approval-document)(page-11)Page 11#

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

(ca-13-004)(approval-document)(page-12)Page 12#

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

(ca-13-004)(approval-document)(page-14)Page 14#

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

(ca-13-004)(approval-document)(page-28)Page 28#

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

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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)

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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

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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

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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

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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

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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

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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

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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

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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

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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:

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

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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.

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.

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

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‘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

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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

[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

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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 %

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

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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

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California

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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

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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.

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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.

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

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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

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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.

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

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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:

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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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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

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.

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California

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‘“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

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

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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.

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

[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).

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.

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“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

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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:

@ 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.

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

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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

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

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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.

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.

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.

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

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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.

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

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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

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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

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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.

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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:

Page 1 of 3

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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

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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"

(ca-13-0022-mm2)(approval-document)(page-12)Page 12#

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

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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

(ca-13-0022-mm2)(approval-document)(page-14)Page 14#

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

For cash aid | understand that if I... I may... * am convicted of an intentional program violation « lose my cash aid * do not follow cash aid rules * be fined up to $10,000 and/or sent to jail/prison for 5 years * am found guilty by a court of law or an administrative * lose cash aid for 6 months, 12 months, 2 years, 4 years, hearing of committing certain types of fraud 5 years, or forever.

Important Information for Noncitizens

« You can apply for and get CalFresh benefits or cash aid for people who are eligible, even if your family includes others who are not eligible. For example, immigrant parents may apply for CalFresh benefits or cash aid for their U.S. citizen or qualified immigrant children, even though the parents may not be eligible.

: Getting food benefits will not affect you or your family’s immigration status. Immigration information is private and confidential.

* The immigration status of noncitizens who are eligible and apply for benefits will be checked with the U.S. Citizenship and Immigration Services (USCIS). Federal law says the USCIS cannot use the information for anything else except cases of fraud.

Opting Out

You do not have to give immigration information, Social Security numbers, or documents for any noncitizen family member(s) who are not applying for benefits. The County will need to know their income and resource information to correctly determine your household’s benefits. The County will not contact USCIS about the people who don’t apply for benefits.

Use of Social Security Numbers (SSN

CalFresh and Cash Aid: Everyone applying for CalFresh benefits or cash aid needs to provide a SSN, if you have one, or proof that you have applied for a SSN (such as a letter from the Social Security office). We can deny you or any member of your household who does not give us a SSN. Some people do not have to give SSNs to get help such as, victims of domestic abuse, crime prosecution witnesses, and trafficking victims.

Health Coverage/Medi-Cal: We need your SSN if you want health coverage and have a SSN. Providing your SSN can be helpful if you don’t want health coverage too since it can speed up the application process. We use SSNs to check income and other information to see who's eligible for help with health coverage costs. If someone wants help getting a SSN, Call 1-800-772-1213 or visit the website: www.socialsecurity.gov

Overissuance

This means you got more CalFresh benefits than you should have. You will have to pay it back even if the county made an error or if it wasn’t on purpose. Your benefits may be lowered or stopped. Your SSN may be used to collect the amount of benefits owed, through the courts, other collection agencies, or federal government collection action.

Please take and keep for your records

SAWS 2 PLUS (7/13) PROGRAM RULES PAGE 2 OF 4 Transmittal Number: CA-13-0022-MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

(ca-13-0022-mm2)(approval-document)(page-15)Page 15#

Overpayment

This means that you got more cash aid than you should have gotten. Just like with CalFresh benefits, you will have to pay it back even if the County made an error or if it wasn’t on purpose. Your cash aid may be lowered or stopped. Your SSN may be used to collect the amount of benefits owed, through the courts, other collection agencies, or federal government collection action.

Reporting

Every household that gets benefits must report certain changes. Your county will tell you what changes to report, how to report them, and when to report them. Failure to report the changes may result in your benefits being lowered or stopped. You can also report if things happen that may increase your benefits, such as getting less income.

State Hearings

You have the right to a State hearing if you do not agree with any action taken regarding your application or your ongoing benefits. You can request a State hearing within 90 days of the County’s action and you must tell why you want a hearing. The approval or denial notice you receive from the County will have information on how to request an appeal. If you ask for a hearing before the action happens, you may be able to keep your cash aid and CalFresh benefits the same until a decision is made. >

Privacy Act and Disclosure

You are giving personal information in the application. The County uses the information to see if you are eligible for benefits. If you do not give the information, the County may deny your application. You have a right to review, change, or correct any information that you gave to the County. The County will not show your information or give it to others unless you give them permission or federal and state law allows them to do so. The County will verify this information through computer matching programs, including the Income and Earnings Verification System (IEVS). This information will be used to monitor compliance with program regulations and for program management. The County may share this information with other federal and state agencies for official examination, with law enforcement officials for the purpose of arresting persons fleeing to avoid the law, and with private claims collection agencies for claims collection action. The County may verify immigration status of household members applying for benefits by contacting the USCIS. Information the County gets from these agencies may affect your eligibility and level of benefits.

The County will use the information from your application to check your eligibility for help with paying for health coverage. The County will check your answers using information in state and federal electronic databases and databases from the Internal Revenue Service (IRS), Social Security Administration, the Department of Homeland Security, and/or a consumer reporting agency. If the information doesn’t match, the County may ask you to send proof.

Nondiscrimination

Itis the State and County's policy that all people be treated equally, and with respect and dignity. In accordance with federal law and the U.S. Department of Agriculture (USDA) Policy, discriminating on the basis of race, color, national origin, sex, age, religion, political beliefs, or disabilities is strictly prohibited.

To file a complaint of discrimination, either contact your County’s Civil Rights Coordinator, or write to or call the USDA or California Department of Social Services (CDSS):

USDA, Director cDss

Office of Civil Rights, Room 326-W Civil Rights Bureau

Whitten Building ; P.O. BOX 944243, M.S. 8-16-70 1400 Independence Ave. Sacramento, CA 94244-2430 Washington D.C. 20250-9410 1-866-741-6241 (Toll-Free)

1-202-720-5964 (voice and TDD)

USDA is an equal opportunity employer.

Work Rules for CalFresh

The county may assign you to a work program. They will tell you if it is voluntary or if you must do the work program. If you have a mandatory work activity and you do not do it, your benefits may be lowered or stopped.

You may not be eligible for CalFresh if you have recently quit a job.

Please take and keep for your records

SAWS 2 PLUS (7/13) PROGRAM RULES PAGE 3 OF 4 Transmittal Number: CA-13-0022-MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

(ca-13-0022-mm2)(approval-document)(page-16)Page 16#

Work Rules for CalWORKs (Welfare-to-Work) If you get cash aid, you must participate in Welfare-to-Work (WTW) unless you are exempt. The county will tell you if you are exempt from WTW. If you do not do your assigned activities your cash aid may be lowered or stopped.

CalWORKs - Fingerprinting/Photo Imaging

Alll eligible adult household members for cash aid must be fingerprinted/photo-imaged. If anyone who is required to cooperate with these rules does not get fingerprinted/photo-imaged, no benefits will be issued to the entire household. The fingerprinted/photo-images are confidential and can only be used to prevent or prosecute welfare fraud.

How do | get/use my benefits? CalFresh and Cash Aid:

The County will mail or give you a plastic Electronic Benefit Transfer (EBT) card. Benefits will be put on the card when your application is approved. Sign your card when you get it. You will set up a Personal Identification Number (PIN) to get cash from ATMs or to buy food and/or other items.

If your EBT card is lost, stolen, or destroyed, call (877) 328-9677 right away. Also, you may call the County right away. Make sure your authorized representative also knows how to report a lost or stolen EBT card or PIN. Any benefits taken from your account before you report the EBT card or PIN lost or stolen will NOT be replaced.

You can use your CalFresh benefits to buy almost all foods, as well as seeds and plants to grow your own food. You cannot buy alcohol, tobacco, pet food, some types of cooked food, or anything that is not food (like toothpaste, soap, or paper towels).

CalFresh benefits are accepted at most grocery stores and other places that sell food. Cash aid can be used at most stores and most ATMs. Some ATMs may charge a fee. There may also be a fee if you use an ATM to get cash after three withdrawals. For a list of locations near you that accept EBT, please go to: https://www.ebt.ca.gov or https:/Awww.snapfresh.org. You can also find out where you can get cash without paying a fee.

CalFresh benefits are only for you and your household members. Your cash aid is only for you and the members of your family who were approved for cash aid. Your cash aid is to help meet the basic needs of your family (housing, food, clothing, etc.). Keep your benefits safe. Do not give out your PIN number. Do not keep your PIN number with your EBT card.

Any use of your EBT card by you, a household member, your authorized representative, or anyone you voluntarily give your EBT card and PIN to will be considered approved by you and any benefits taken from your account will NOT be replaced.

Medi-Cal and Health Care:

For Medi-Cal, you will receive a Benefits Identification Card (BIC).

* Sign your BIC when you get it and use it only to get necessary health care services.

* Never throw your BIC away (unless we give you a new BIC). You need to keep your BIC even if you stop getting Medi-Cal. You can use the same BIC if you get cash aid or Medi-Cal again.

* Take the BIC to your medical provider when you or a family member is sick or has an appointment.

* Take the BIC to the medical provider who treated you or your family member(s) in an emergency situation as soon as possible after the emergency.

For other health care programs you will receive a health plan card from your particular carrier.

Please take and keep for your records

SAWS 2 PLUS (7/13) PROGRAM RULES PAGE 4 OF 4

Transmittal Number: CA-13-0022-MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

(ca-13-0022-mm2)(approval-document)(page-17)Page 17#

Please use black or blue ink because it is easy to read and copies best. Please print your answers. tf you need more space to answer a question(s), attach additional sheets of paper to provide the information. Please be sure to identify which question you are writing about on the additional sheets of paper.

e@ ©

1. APPLICANT’S INFORMATION

FIRST, MIDDL! OTHER NAMES (MAIDEN, NICKNAMES, ETC. SOCIAL SECURITY NUMBER (iF YOU HAVE NAME (FIRS &. LAST ‘ ) ONE AND ARE APPLYING. FOR BENEFITS)

HOME ADDRESS OR DIRECTIONS TO YOUR HOME APARTMENT # City COUNTY STATE ZIP CODE MAILING ADDRESS (IF DIFFERENT FROM ABOVE) APARTMENT # CITY COUNTY STATE ZIP CODE

| want to get information about this I want to get messages about my case by email. ~ N application by email. Clyes [1] No g 9g y y CFlyes [No HOME PHONE WORIVALTERNATE/MESSAGE PHONE [EMAIL ADDRESS

What programs are you applying for?

Cl calFresh (€] Cash Aid C1 Health Coverage Do you have a disability and need help applying? ClYes [1 No

0o@e@

Are you homeless? [| Yes [] No If yes, 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 about your case.

What language do you prefer to read (if not English)? What language do you prefer to speak (if not English)?

The County will provide an interpreter at no cost to you. If you are deaf or hard of hearing please check here ia

Is your household's gross income less than Have your utilities been shut off or do you have

@ $180 and cash on hand, checking and C1 Yes [] No a shut-off notice? (Yes No savings accounts $100 or less?

Is your household's combined gross income , A —

e any liquid resouroes less than fhecombmed |C) Yes [J No 6 Will your food run out in 3 days or less? C1 Yes (1 No rent/mortgage and utilities?

2) Is your household a migrant/seasonal farm Do you need help with transportation to get |. _ worker household with liquid resources not |["] Yes [J No food, clothing, medical care or other | [1 Yes C1 No exceeding $100? emergency item(s)?

6 Do you have an eviction notice or a notice to jo Yes (] No Do you need essential clothing, such as | (7 Yes [7] No

pay rent or leave? diapers or clothing needed for cold weather?

is anyone pregnant? [7] Yes [] No If yes, did she get a Presumptive Eligibility card? [] Yes [] No

Does anyone in your household have a personal emergency? [1 Yes [] No If yes, check box: [[] Pregnancy

[1] immediate Medical Need [1 Child Abuse [1] Domestic Abuse 1] Elder Abuse [1 Other emergency which threatens health or safety. Explain:

| understand that by signing this application under penalty of perjury (making false statements), that:

| read, or had read to me, the information in this application and my answers to the questions in this application.

Any answers | have given on pages 1 through 18 and appendices A through C of the SAWS 2 Plus are true, correct, and complete to the best of my knowledge.

| read or had read to me and | understand and agree to the Rights and Responsibilities (Program Rules Page 1). | read, or had read to me, the Program Rules and Penalties (Program Rules Pages 2 - 4).

| understand that giving false or misleading statements or misrepresenting, hiding or withholding facts to establish eligibility is fraud and that | may be subject to penalties under federal law if | provide false or untrue information. Fraud can cause a criminal case to be filed against me and/or | may be barred for a period of time (or life) from getting CalFresh benefits and cash aid.

| understand that Social Security Numbers or Immigration Status for household members applying for benefits may be shared with the appropriate government agencies as required by federal law.

1 am giving the Medi-Cal agency the right to pursue and get any money from other health insurance, legal settlements, or other third parties.

SIGNATURE OF APPLICANT, CARETAKER RELATIVE (OR ADULT HOUSEHOLD MEMBER/ AUTHORIZED REPRESENTATIVE*/GUARDIAN) DATE

*If you have an Authorized Representative, please complete Question 2 on the next page.

SIGNATURE OF SPOUSE, OTHER PARENT, OTHER AIDED ADULT, OR REGISTERED DOMESTIC PARTNER DATE

SAWS 2 PLUS (7/13) PAGE 1 OF 18

Transmittal Number: CA-13-0022-MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

(ca-13-0022-mm2)(approval-document)(page-18)Page 18#

rs) 2. HOUSEHOLD’S AUTHORIZED REPRESENTATIVE

You may authorize someone 18 years or older to help your household with your CalFresh benefits. This person can also speak for you at the interview, help you complete forms, shop for you, and report changes for you. You will have to repay any benefits you may get by mistake because of information this person gives the County and any benefits you didn’t want them to spend will not be replaced. If you are an Authorized Representative you will need to give the County proof of identity for yourself and the applicant.

Do you want to name someone to help you with your CalFresh case? [] Yes [1 No If yes, complete the following section:

AUTHORIZED REPRESENTATIVE NAME AUTHORIZED REPRESENTATIVE PHONE NUMBER:

Do you want to name someone to receive and spend CalFresh Benefits for your household? [Yes [J No if yes, complete the following section: NAME re NUMBER

ADDRESS CITY, STATE, ZIP CODE

2a. HEALTH INSURANCE AUTHORIZED REPRESENTATIVES

You can give a trusted person permission to talk about your application for health insurance, see your information, and act for you on things about this part of your application. Do you want to choose an authorized representative for the health insurance part of

your application? [J Yes [J No If yes, fill out the information in Appendix C.

3. Are you or any member of your family American Indian or Alaskan Native? [J Yes [J] No lf yes, and applying for health care, please go to Appendix B for additional questions.

RACE/ETHNICITY

Race and ethnicity information is optional. It is requested to assure that benefits are given without regard to race, color, or national origin. Your answers will not affect your eligibility or benefit amount. Check all that apply to you. The law says the County must record your ethnic group and race.

[] Check this box if you do not want to give the County information about your race and ethnicity. If you do not, the County will enter this information for civil rights statistics only.

868\0

ARE YOU OF HISPANIC, LATINO, OR SPANISH ORIGIN? | IF YOU ARE OF HISPANIG, OR LATINO ORIGIN, DO YOU CONSIDER YOURSELF Ll Yes [1] No CJ Mexican [1] Puerto Rican [1 Cuban [) Other.

RACE/ETHNIC ORIGIN

rs) Clwhite [©] American Indian or Alaskan Native J Black or African American C Other or Mixed (7) Asian (If checked, please select one or more of the following):

fr) Cl Filipino [Chinese [Japanese [1 Cambodian [i Korean (J Vietnamese (1) Asian Indian J Laotian CO Other Asian (specify) (Cl Native Hawaiian or Other Pacific Islander (If checked, please select one or more of the following): (J Native Hawaiian [] Guamanian or Chamorro [1 Samoan

ETHNICITY

4. INTERVIEW PREFERENCE

© You will need to have an interview with the County to discuss your application and to receive cash aid or CalFresh benefits. Interviews for CalFresh are usually done by phone, unless you can be interviewed when giving your application to the County in person or would prefer an in-person interview. Cash aid applicants must have an in person interview. If you are applying for CalWORKs and CalFresh, your CalFresh interview will be done at the same time as your CalWORKs interview during normal office hours.

(1 Please check this box if you would prefer an in-person interview for CalFresh. (1) Please check this box if you need other arrangements due to a disability.

fe) 5. OTHER PROGRAMS Has anyone in your household ever received public assistance (Temporary Assistance for Needy Families, Tribal TANF, Medicaid,

@ Supplemental Nutrition Assistance Program [food stamps], General Assistance/General Relief, etc.)? [] Yes 1 No

IF YES, WHO? ~ WHERE (COUNTY/STATE)? IF YES, WHO? WHERE (COUNTY/STATE)? SAWS 2 PLUS (7/13) PAGE 2 OF 18

Transmittal Number: CA-13-0022-MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

(ca-13-0022-mm2)(approval-document)(page-22)Page 22#

2) 6f.

Sponsored Noncitizen Information - Please answer for sponsored noncitizens you are applying for. Did the sponsor sign an |-864? (1 Yes (] No If yes, please answer the rest of the question.

if the sponsor signed an |-134 then skip this question.

Does the sponsor regularly help with money? {J Yes [] No If yes, how much? $ Does the sponsor regularly help with any of the following (check all that apply)?

OClrent Cctothes [I food other.

SPONSOR'S NAME

WHO IS SPONSORED?

SPONSOR'S PHONE NUMBER

SPONSOR'S NAME

WHO IS SPONSORED?

SPONSOR'S PHONE NUMBER

6 6g.

ir) If no, please continue to the next question.

Does anyone listed in question 6 who is under the age of 21 have a parent who does not live in the home? (1 Yes [1] No If yes, please list the name of the child(ren) and the name(s) of the parents who do not live in the home.

rs) NAME OF CHILD

NAME OF PARENT(S) NOT LIVING IN THE HOME

S$) NAME OF CHILD

NAME OF PARENT(S) NOT LIVING IN THE HQME

& om. @

of the child?

(1 Yes [No If no, skip to the next question. If yes, who?

Does anyone in question 6 live with at least one child under the age of 19 and are they the main person taking care

3 6i.

Does anyone listed in question 6 have a physical, mental, emotional, or developmental disability that causes

limitations in activities (such as bathing, dressing, daily chores)? [Yes [] No If yes, please list the name(s) of the person with the disability. If no, please continue to the next question.

Name:

@ 6j.

Complete for each disabled person listed in question 6.

3) Name of person

ie)

Does this person need help with activities of daily living through personal assistance or a medical facility? [_] Yes No

If yes, explain:

Disability is expected to last: (] 30 days or more (J 12 months or more

Does this person work and have medical expenses that are needed to help them keep working? For example, a wheelchair, leg braces, etc.

Cl Yes [] No If yes, please explain.

Does this person need care so that someone else can work or attend school?

Clyes [No

Is this person in a medical facility or nursing home? [Yes [1 No If yes, what is the name of the medical facility or nursing home?

Name of person

Does this person need help with activities of daily living through personal assistance or a medical facility? L] Yes [] No If yes, explain:

Disability is expected to last: [] 30 days or more CJ 12 months or more

Does this person work and have medical expenses that are needed to help them keep working? For example, a wheelchair, leg braces, etc.

(1 Yes C1 No Ifyes, please explain.

Does this person need care so that someone else can work or attend school?

ClyYes [1 No

Is this person in a medical facility or nursing home? Cl yYes [1 No If yes, what is the name of the medical facility or nursing home?

i] 6k. \S] ©

Is there a child or disabled person in the household who needs care from another household member? OlyYes [I No if yes, please explain. If no, skip to the next question.

SAWS 2 PLUS (7/13) Transmittal Number: CA-13-0022-MM2

Approval Date: December 10, 2013

PAGE 6 OF 18 Effective Date: October 1, 2013

(ca-13-0022-mm2)(approval-document)(page-23)Page 23#

$) 61.

Is everyone between ages 6 and 18 listed in question 6b attending school regularly? If yes, please list the child’s name and the name and address of the school they attend.

If no, please explain why the child is not attending school regularly.

Cl Yes LJ No

NAME OF CHILD

NAME AND ADDRESS OF SCHOOL,

REASON FOR NOT ATTENDING SCHOOL

NAME OF CHILD

NAME AND ADDRESS OF SCHOOL,

REASON FOR NOT ATTENDING SCHOOL

6m. Students

\S ©

ls anyone who is applying for benefits attending a college or vocational school? If yes, please answer this queston. If no, skip to the next question.

ClYes (1 No

Name of Person

Name of Schooi/Training

Enrolled Status (Vv check one)

Working?

(1 Half-time or more (] Less than half-time

Number of Units’.

Average work hours per week:

C Half-time or more LJ Less than half-time

Number of Units:

Average work hours per week:

rs) 6n, Is anyone listed in question 6 or 6b pregnant or a teen parent? (Yes [1 No

If yes, please answer the question. If no, skip to the next question.

Name is this person under the age of 20? | School status if under the age of 20 Due date | How many ClyYes [No [J Has a high school diploma (if known) | babies are . Has a GED expected . Is attending school regularly with this Is this aay a ee [J Is not attending school | pregnancy? Yes LI No regularly (explain why): Name Is this person under the age of 20? | School status if under the age of 20 Due date | How many Clyes CINo [] Has a high school diploma (if known) | babies are (J Has aGED expected Is this person a teen parent? im Is attending schoo! regularly with this Tl yes CIN LJ Is not attending school pregnancy? es 0 regularly (explain why):

rs) 60.

Cai-Learn Program?

(] Yes C1 No

If yes, please answer the question. If no, skip to the next question.

Has anyone ever gotten a cash bonus or penalty, or help with child care, transportation or other service from the

Name

Where (County)

Date(s) Received

If yes, please explain.

Was anyone listed in question

6 ever in foster care? [_] Yes [1 No

Name: When: State: Is this person 26 years of age or younger and were they in foster care on their 18th birthday?

C2 Yes C1 No

Name: When: State:

Is this person 26 years of age or younger and were they in foster care on their 18th birthday?

C] Yes CJ No

SAWS 2 PLUS (7/13)

Transmittal Number: CA-13-0022-MM2

Approval Date: December 10, 2013

PAGE 7 OF 18

Effective Date: October 1, 2013

(ca-13-0022-mm2)(approval-document)(page-24)Page 24#

e 6q. Is there a foster child living in your home? Cl Yes €] No If yes, who? Please answer the following questions about the foster child(ren):

Was this child(ren) placed in your home under a dependency order of the court? OlyYes £J No Do you want the foster care child(ren) counted in your CalFresh case? (Yes C1 No if yes, the foster care income you receive will be counted as unearned income.

If no, the foster care income will not be counted as unearned income.

6r. Does everyone listed in question 6 live in California and expect to keep living here? C] Yes (No } If no, please explain.

rs) 6s. Does anyone listed in question 6 plan to leave California for more than 30 days? Clyes [] No if yes, please explain.

NAME, WHEN DO THEY PLAN TO LEAVE? DOES THIS PERSON PLAN TO RETURN TO CALIFORNIA? Oo YES O NO IF YES, WHEN:

NAME WHEN DO THEY PLAN TO LEAVE? DOES THIS PERSON PLAN TO RETURN TO CALIFORNIA? Clves [no irves, wHen:

7. Unearned Income

S Does anyone get income that does not come from work (unearned)? Cl Yes [1] No If yes, please answer this question. rr) If no, skip to the next question.

Check all types of unearned income that apply from these examples (there may be others not listed here):

(Social Security Disability C1 Sales of notes, contracts, trust deeds, [] Lottery/gambling winnings (1 ssvssp promissary notes LJ Help with rent/food/clothing [Cash aid (1 Veterans education benefits/income (_] Insurance or legal settlements |] CalWORKs/TANF/GA/GR/CAPI/RCA [] Government/railroad disability or retirement L] Private disability or retirement im Room and board (from a renter) LJ Veteran benefits or Military pension [J Dividend and interest income’ LI) Pension (_] Financial aid (school grants/loans/scholarships) (C] Strike benefits (J Child/Spousal support (1 Gifts of money or other loans C) Other. _ (_] Rental/Royalties (J Unemployment Insurance/ LJ Social Security retirement State Disability Insurance (SDI)

or survivors benefits {) Worker's Compensation L] Per capita payments C1 Net Farming/Fishing

Work study/welfare to work or other program

How Often Received? Expect to Person Getting the Money? From Where? How Much? (once, weekly, Continue?

monthly, or other) | (Check Yes or No)

Cl Yes [J No

(Cl Yes [1 No

{] Yes [7 No Cl] Yes [1] No

If this income is not expected to continue, please explain:

SAWS 2 PLUS (7/13) PAGE 8 OF 18 Transmittal Number: CA-13-0022-MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

(ca-13-0022-mm2)(approval-document)(page-25)Page 25#

aoe

8. Earned income

Does anyone get income from a job (earned income)? (yes []No If yes, please answer this question.

If no, skip to the next question.

NOTE: If self-employed, fill out question 8a below. Please list all income before taxes or other deductions are taken out (gross income). Examples of earned income are (these examples can be full-time, temporary seasonal work, or training, and there may be

others not listed here):

« Wages « Commissions e Tips e Salaries » Work study (students) e Include any paid jobs the County helped you get. Total Gross Earned , ., Hourly | Average| How Often Expect to Person Workin Employer’s Name Employer’s Rate | hours per Paid? Recon Continue? 9g and Address Phone Number week (Once weekly, “This (v Check monthly, other) Month? Yes or No) r $ $ LI Yes CO No $ $ $ $ $ $

if this income is not expected to continue, please explain:

Has anyone lost a job, changed jobs, quit a job, or reduced work hours within the last 60 days? ClyYes CI No

In the last year? (] Yes C1 No

Did the County help the person get this job? C1 Yes [1 No

iF YES, WHO? DATE OF JOB LOSS, DATE OF LAST PAY REASON? QUIT, OR CHANGE

1S ANYONE ON STRIKE? | IF YES, WHO? DATE WENT ON DATE OF LAST PAY |REASON?

= a STRIKE

Cl Yes [J No

YS) LS) ©

8a. Self-Employment

Self-employed household members may take actual self-employment expenses (or for CalFresh or cash aid, take a standard 40% deduction off of self-employment income). For cash aid, you may also choose to use a monthly average (yearly business costs divided by 12 months). If you choose actual expenses, you must list your business expenses on a separate sheet of

paper.

Person Self-Employed

Business Name

Date Business Started

Gross Monthly Income

Type of Business

Net Monthly Income

Self-Employment Expenses (please “ check one)

40% flat Rate (CalFresh/cash aid) Actual Expenses $_ 0 Monthly Average $

40% flat Rate (CalFresh/cash aid) Actual Expenses $ Monthly Average $

40% flat Rate (CalFresh/cash aid) Actual Expenses $ _ Monthly Average $____

O00 ;000 |Oo00

SAWS 2 PLUS (7/13)

Transmittal Number: CA-13-0022-MM2

Approval Date: December 10, 2013

* Net monthly income is gross monthly income minus expenses. PAGE 9 OF 18 Effective Date: October 1, 2013

(ca-13-0022-mm2)(approval-document)(page-27)Page 27#

@ 13. Spousal Support/Alimony

Is anyone listed in question 6 legally obligated to pay spousal support/alimony? OlvYes C1 No If yes, please answer the questions below. If no, skip to the next question.

Who pays spousal support/alimony? Amount paid? (weekly, pita Rete? ly other)

Does anyone have a special medical condition or situation that requires any of the following?

Special diet prescribed by a doctor? CO Yes [1 No Other special need? (specify) OYes 1 No

Special phone or other equipment? O Yes (1 No :

Housework (no one in the home can do it)? Cl Yes [No Please list the name of the person with the special need and explain: Very high use of utilities? CO Yes C1) No

Special laundry service? (Yes [No

@ 15. Household Expenses

Does anyone you purchase and prepare food with get billed for any household expenses? ClYes 1 No

If yes, please answer this question.

If no, skip to the next question.

NOTE: Do no enter amounts paid by housing assistance such as HUD or Section 8. The heating and cooling, telephone, other utilities, and the homeless shelter are set allowances. It is not necessary to fill in the actual amount owed.

Type of Expenses Have Amount How Often Billed? yp p Expense? Who Pays? Owed (weekly/monthly) Rent or house payment pay (Yes (] No $ Property taxes and insurance . (if billed separate from rent or mortgage) (Yes (No $

Gas, electric, or other fuel used for heating or cooling, such as firewood or propane Ci Yes C1 No (if separate from rent or mortgage)

Telephone/cell phone OlyYes (J No Homeless Shelter Expense O Yes (1 No Water, sewage, garbage OlyYes 1 No

Does anyone not in your household help you pay for the expenses listed above?

[Yes [1 No_ifyes, please complete.

Who helps pay? How much? | How often paid? $

Does your household get, or expect to get any payments from the

Low Income Home Energy Assistance Program (LIHEAP)? [] Yes [J No

SAWS 2 PLUS (7/13) PAGE 11 OF 18

Transmittal Number: CA-13-0022-MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

(ca-13-0022-mm2)(approval-document)(page-28)Page 28#

@ 16.

Medical Expenses: Are you or anyone you buy and prepare food with an elderly (60 or older) or disabled person that has any out-of-pocket

medical expenses? [_] Yes [_] No

{f yes, please answer this question.

If no, skip to the next question.

NOTE: Do not list spouses or children receiving dependent payments for an SSI or disability and blindness recipient. List expenses you expect to have in the near future. ‘

Allowable medical expenses are:

(] Medical or dental care (1 Medicare premiums (Medi-Cal share of CL] Cost of transportation (mileage or fee) {] Hospitalization/outpatient costs, etc.) and lodging to obtain medical treatment treatment/nursing care (1 Dentures, hearing aids and prosthetics or services {] Prescribed medications [J Maintaining an attendant necessary due (1 Prescribed eye glasses and contact (1 Health and Hospitalization to age, illness, or infirmity lenses insurance policy premiums im The number and cost of meals Cl Prescribed medical supplies and furnished to an attendant equipment C1 Prescribed over the counter medications [1 Service animals expenses (food, vet bills, etc. slow often paic!? what {Pet | Will the household be reimbursed low often paid? atinn for any medical expenses? Name of Elderly/Disabled Person | Amount of | (monthly, weekly, | (Prescriptions, (by Medi-Cal, insurance Expense other) dentures, # of meals: family member, etc. ) , for attendant, etc.) v 7 BIC. IF YES, BY WHO: $ HOW MUCH: $ IF YES, BY WHO: $ 4 HOW MUCH: $

17.

Other Tax-Deductible Expenses

If anyone pays for anything that can be deducted on a federal income tax return, telling us about it here could make the cost of health insurance a little lower. Do not include anything that you already included in self-employment expenses. If you have other deductible expenses, please answer this question. If no, skip to the next question.

How often paid?

Type of Expenses Have Expense? Who pays? (weekly/monthly) Alimony CO Yes [1 No Student loan interest ClyYes CINo Other deductions (please identify) CO yes CINo 18. Does anyone in question 6 get food from any of the following? OYes 1] No

If yes, please answer this question. If no, skip to the next question.

e Communal dining facility for the elderly/disabled Food distribution program operated e@ Other food program by a Native American reservation

IF YES, WHO?

WHAT PROGRAM?

IF YES, WHO?

WHAT PROGRAM?

=) 19. ©

Does anyone in question 6 live at any of the following? | Yes [1] No If yes, please answer this question. If no, skip to the next question.

« Homeless Shelter e Group living arrangement for the blind/disabled Q « Shelter for battered women « Federally subsidized housing « Reservation for Native Americans e Psychiatric hospital/mental institution e Drug/Alcohol rehabilitation center e Hospital e Correctional facility/Penal institution (Jail or Prison) « Long-Term Care or Board and Care Facility Expected Date of Release Person’s Name Name of Institution (Center, Shelter, Facility, etc.) (if applicable) SAWS 2 PLUS (7/13) PAGE 12 OF 18

Transmittal Number: CA-13-0022-MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

(ca-13-0022-mm2)(approval-document)(page-29)Page 29#

rs) 20. Is anyone getting In-Home Supportive Services (IHSS)? [_] Yes [J No If yes, fill in the information below. WHO GETS SERVICES? HOW MUCH DO YOU PAY EACH MONTH FOR THE SERVICES?

@ 21. Does everyone listed in question 6 buy and prepare food with you? [] Yes L) No If no, list the people who don’t buy and prepare food with you. NAME. NAME

NAME NAME

rs) 21a. Is anyone living with you age 60 or older and unable fo buy food and fix meals separately because of a disability? Cl] Yes LJ No Ifyes, who: Q 22. Answer these questions for anyone who needs health coverage. Is anyone enrolled in health coverage now from the following? [1] Yes C1 No If yes, check the type of coverage and write the person(s)’ name(s) next to the coverage they have.

C] Medicaid/Medi-Cal (Employer Insurance

Cl CHIP Name of health insurance [Medicare Policy number:

(_] TRICARE (Don’t check if you have direct | is this COBRA coverage? (_] Yes [] No

care or Line of Duty) Is this a retiree health plan? [] Yes LJ No

VA health care programs Is this a state employee benefit plan? Cl yes [No

[] Peace Corps C]_ Other

Name of health insurance

Policy Number:

Is this plan a limited-benefit plan_ _ like a school accident policy? [1] Yes C1 No

rr) 22a. Is anyone listed on this application offered health care coverage from a job? (Yes [J No If yes, you'll need to complete and include Appendix A.

Q 22b. Is anyone’s health insurance expected to end or has it ended in the last 90 days? [Yes (1 No \f yes, please answer the question. If no, skip to the next question.

Expiration ate

Insurance Company Person Insured Reason it ended or will end

@ 22c. Does anyone want help for medical bills from the last three months? OYes 1 No If yes,, who: @ 23. Does anyone listed in question 6 plan to file a federal income tax return next year? Cl Yes [J No If yes, complete the questions below for each tax filer. If no, skip to 23e. 23a. Please complete this section for each person who plans to file a federal income tax return next year if you answered yes to question 23. You can still apply for health insurance even if you don't file a federal income tax return.

23b. Name of person planning to file a federal income tax return:

23c. Will this person file jointly with a spouse? (J Yes (J No If yes, name of spouse:

23d. Will this person claim any dependents on their tax return: LJ] Yes L] No If yes, please list the name of the tax filer who will claim this:

23e. How is this person related to the tax filer who will claim them:

23f. To make it easier to determine my eligibility for paying health coverage in future years. | agree to allow you to use income data, including information from tax returns. You will send me a notice, let me make any changes, and | can opt out at any time. Yes, renew my eligibility automatically for the next (check one): (15 years (14 years [] 3 years [5 2 years (1 1 year No, don’t use information from tax returns to renew my coverage.

SAWS 2 PLUS (7/13) PAGE 13 OF 18 Transmittal Number: CA-13-0022-MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

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r=) 24. Household’s Resources Does anyone have any resources (cash, money in the bank, Certificate of Deposit, stocks and bonds, etc.)? [J Yes C1 No If yes, please answer this question. If no, skip to the next question. Optional for heaith care; only answer if someone applying is 65 or older or disabled. If applying for cash aid and CalFresh, you $1 must answer the question.

Check each resource listed below that you or anyone in your household has:

(1) Bank/Credit Union account (Checking) (0 Money Market Account(s) (1 Stocks

(9 Bank/Credit Union account (Savings) (1 Mutual funds/Trust funds ©) Bonds

{5 Safe Deposit box : (1 Certificate of Deposit (CD)/IRA [-] Uncashed checks

[5 Savings Bond(s) (1 Cash on hand (9 Life or Burial insurance (1 Oil, Mining or Mineral Rights (1 Notes, Mortgages, Deeds of Trust (1 Other:

If joint account with another person please say so below.

For each box checked above, complete the following information.

In Whose Name is the Type of Resource How Much is |Where is the Resource? (include the name of the bank or Resource Listed? it Worth? company where money is held) $ $ $ $ Have you or anyone in your household sold, traded, given away, or transferred a resource in the last thirty (30) months? (Yes (J No WHEN? WHAT WAS THE RESOURCE? WHAT WAS IT WORTH? HOW MUCH DID YOU GET FOR IT . $ $

if you traded or gave the resource away, please explain:

} Optional for health care; only answer if someone applying is 65 or older or disabled.

25. Personal Property Does anyone own any personal or business-related property? CJ Yes [J No if yes, please answer the question. If no, skip to the next question.

Tools C1 Sporting equipment, Guns Business inventory (1 Non-Motor boats and/or trailers Livestock (1 Camper shells

Business equipment (1 Personal tools

(Jewelry, Artwork, Antiques, Collections, Musical instruments (Piano, Organ, etc.)

Please include the item even if it is jointly owned with someone else. Do not include wedding or engagement rings, family heirlooms, etc. List any other jewelry worth $100 or more and household goods or personal items worth more than $500 per item.

Item Is tastes for |Purchase Price or Current Value| Amount Owed ale?

Cl yYes CI No | Cl Yes C1 No |$ Cl Yes LI No [§ Cl Yes Ci No |$ $ $ $ $

( Yes C1 No (1 Yes C1 No (1 Yes C1 No 1 Yes C] No

PALA Al W!|RMl wi als

SAWS 2 PLUS (7/13) PAGE 14 OF 18 Transmittal Number: CA-13-0022-MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

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S$] Optional for health care; only answer if someone applying is 65 or older or disabled. If you are applying for cash aid, you must answer the question.

@ 26. Vehicles Does anyone own, have the use of, or have their name on any registration of any motor vehicle, such as: a car, motorcycle, snowmobile, recreational vehicle (RV), or motorboat, etc., even if itisn’t running? _L] Yes LI No

Vehicle (1) Vehicle (2) Vehicle (3) Owner of vehicle Name of person who uses the vehicle ' Year/Make/Model | License plate number ; . : [T¥es CINo ifyes, check the [C1 Yes LJ No ifyes, check the |] Yes [J No if yes, check the Was this vehicle a gift A , . yes, ‘ ° ? appropriate box appropriate box appropriate box pel hana to you a gift LJ donation gift [J donation ea gift [_] donation y v ; (Cl transferred by family member |[_] transferred by family member |\_1 transferred by family member Estimated value $ $ $ How much do you still owe on the vehicle? $ $ $ alg? registration currently Clyes CINo Clyes [1 No CyYes [2 No Are you or someone else ~ : currently leasing the vehicle? Cl Yes [No Cl Yes CINo (Yes [No How do you use the vehicle? As a home? (Yes [1] No | Clyes [1 No Ol Yes (No fogote work, training, or job CyYes CINe Dyes CINo Cyes CINo For self-employment, “| 1 self-support, or business use? Ol Yes [No 0 Yes [No ClYes C1] No fo dive a disabled household Ol Yes 11 No O Yes C1 No Clyes C1 No fo get fuel or water for your (Yes (1 No CO Yes [] No Clyes C] No For recreational use only? C1 Yes [J No Dyes CJ No CyYes [1 No

6 27. Does anyone in question 6 own or are they buying a home, land, or property anywhere including in another state or country? (Yes (J No if yes, please explain. ie] Optional for health care; only answer if someone applying is 65 or older or disabled.

Is someone Not living in i now but owner Who owns or is buying the Address of the home/property renting the | How much rent does ex ects to move home from the the owner get? pects home/property? owner? jer gets back into the : home someday? _ (J Not Dyes CINo | § rented | (] Yes [1 No _ CINot Clyes CNo | § rented | (-] Yes [1 No

rs) 28. Diversion Program Has anyone received a Diversion cash payment or non-cash services from any county or other state? [J Yes [] No If yes, please answer the question. If no, skip to the next question.

County/State Amount | 1; i i Estimated | pate Last

Name List of Services Received t

. Received From Received Yalue of Received $ $

SAWS 2 PLUS (7/13) PAGE 15 OF 18

Transmittal Number: CA-13-0022-MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

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@ 29.

Duplicate Benefits Have you, or any member of your household been convicted of fraudulently receiving duplicate SNAP (federal name for food assistance program) benefits in any State after September 22, 1996? [] Yes [] No

If yes, who?

@ 30.

Trafficking Benefits Have you, or any member of your household, ever been convicted of trafficking (allowing use of or selling EBT cards to others) SNAP benefits of $500 or more after September 22, 1996? Cl Yes [] No

If yes, who?

Trading Benefits for Drugs Have you or any member of your household been found guilty of trading SNAP benefits for drugs after September 22, 1996? [] Yes [] No

If yes, who?

3] 32.

Trading Benefits for Firearms or Explosives Have you or any member of your household been found guilty of trading SNAP benefits for guns, ammunition or explosives after September 22, 1996? [] Yes [] No

If yes, who?

6 33. Fraud _ j Have you or anyone in your household had their cash aid stopped for being found guilty of Welfare Fraud? Cl Yes [J No lf yes, who? When?

Where?,

r$ ) 34. Non-Cooperation/Sanctions Have you or anyone in your household had their cash aid stopped for failure to cooperate with eligibility requirements, work/training sanctions or any other reason? ClYes [1 No If yes, who? When?

Where? Why?

@ 35. Fleeing Felon Are you or any member of your household hiding or running from the law to avoid prosecution, being taken into custody, or

6 going to jail for a felony crime or attempted felony crime? (Yes [1 No if yes, who?

6 violation of probation or parole? 1 Yes LJ No If yes, who?.

r $] controlled substance (illegal drugs or certain drugs for which a doctor’s prescription is required) after August 22, 1996? |] Yes C] No if yes, and the felony conviction was for possession, have you or that household member done (or will do) any of the following (CalFresh only):

a) Completed a government-recognized drug treatment program? Ci Yes [J No b) Participated in a government-recognized drug treatment program? Cl Yes (J No c) Enrolled in a government-recognized drug treatment program? Cl Yes (1 No d) Been placed on a waiting list for a government-recognized drug treatment program? [Yes [1 No e) Stopped the use of controlled substances and have evidence that you have stopped? Clyes CJ No If yes, please explain: SAWS 2 PLUS (7/13) PAGE 16 OF 18

Transmittal Number: CA-13-0022-MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

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You DON’T need to answer these questions unless someone in the household is eligible for health coverage from a job. If there is more than one person who is offered health coverage from a different employer, you can copy this page and use it for the second person (or as many as you need).

First, tell us about the job (employer) who offers coverage.

4. EMPLOYEE NAME (FIRST NAME, MIDDLE NAME, LAST NAME) 2. EMPLOYEE SOCIAL SECURITY NUMBER EMPLOYER Information 3. EMPLOYER NAME 4, EMPLOYER IDENTIFICATION NUMBER (EIN) 5. EMPLOYER ADDRESS 6. SRLOVER PHONE NUMBER: 7. CITY 8. STATE 9. C _ — 10, WHO CAN WE CONTACT ABOUT EMPLOYEE HEALTH COVERAGE AT THIS JOB? ° 41. PHONE NUMBER (IF DIFFERENT FROM EMPLOYER'S PHONE NUMBER) 12. EMPLOYER'S EMAIL ADDRESS (EMPLOYER'S REPRESENTATIVE) ( )

13. Are you currently eligible for coverage offered by this employer, or will you become eligible in the next three months?

(1 No (stop here for this section of the application) (Yes (continue)

13a. If you’re in a waiting or probationary period, when can you enroll in coverage? y 9 y y (MM/DD/YYYY)

List the names of anyone else who is eligible or will be eligible for coverage from this job.

Name: Name: Name:

Tell us about the health plan offered by this employer. 14. Does the employer offer a health plan that meets the minimum value standard*? LJ Yes L] No 14a. Is this a State employee benefit plan? _[_] Yes [] No 45. For the lowest-cost plan that meets the minimum value standard offered only to the employee (don’t include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/she received the

maximum discount for any tobacco cessation (that helps the employee to quit smoking) programs, and did not receive any other discounts based on wellness programs.

a. How much would the employee have to pay in premiums for this plan? $.

b. How often? CI Weekly (Bi-weekly (©) Twiceamonth [Cl Monthly [Quarterly C] Yearly () The employee doesn’t offer wellness programs.

16. What change will the employer make for the new plan year (if known)? [] Employer will no longer provide health coverage.

[] Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.

a. How much would the employee have to pay in premiums for this plan? §.

b. How often? C1] Weekly Cl] Bi-weekly [lTwiceamonth (ClMonthly [J Quarterly CJ Yearly

c. Date of change (mm/dd/yyyy):

CJ No changes are expected.

*An employer-sponsored health plan meets the “minimum value standard’ if the plan’s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)

SAWS 2 PLUS (7/13) APPENDIX A Transmittal Number: CA-13-0022-MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

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rr) Appendix B QUESTIONS FOR AMERICAN INDIAN AND ALASKAN NATIVE INDIVIDUALS

Complete this section if you or a family member (spouse and/or dependents) are American Indian or Alaskan Native. Submit this with your application.

Tell us about your American Indian or Alaskan Native family member(s).

American Indians and Alaskan Natives can get services from the Indian Health Services, tribal health programs, or urban Indian health programs. They also may not have to pay a cost share and may get special monthly enrollment periods. Answer the following questions to make sure your family gets the most help possible. If you have more than two people to tell us about, make a copy of this page and attach it. You may also use a separate piece of paper. Just remember to write the question number next to your answer.

AWV/AN Person 1 AI/AN Person 2 7" Name (First name, Middle name, Lastname) | First Middle First Middle Last Last 2. Member of a federally recognized tribe? Ol Yes C1 Yes If yes, tribe name If yes, tribe name [1 No [1 No 3. Has this person ever gotten a service from the Indian Health Service, a tribal health program, C) Yes CI Yes or through a referral from one of these [] No [] No programs? If no, is this person eligible to get If no, is this person eligible to get services from the Indian Health services from the Indian Health Services, tribal health program, Services, tribal health program, urban Indian health programs or urban Indian health programs or through a referral from one of these through a referral from one of these programs? programs? CJ Yes (J) no C] Yes (J no 4. Certain money may not be counted for Medicaid or the Children’s Health Insurance Program |] Yes - if yes, please complete (Yes - if yes, please complete (CHIP). List any income (amount and how information below: information below: often) reported on your application that includes money from these sources: [1 None to report (J) None to report e Per capita payments from a tribe that comes from natural resources, usage $e $ tights, leases, or royalties e Payments from natural resources, farming, How often? (daily, weekly, How often? (daily, weekly, ranching, fishing, leases or royalties from bi-weekly, monthly, yearly, etc.) bi-weekly, monthly, yearly, etc.) land designated as Indian trust land by the Department of the Interior (including reservations and former reservations) «Money from selling things that have cultural significance SAWS 2 PLUS (7/13) APPENDIX B

Transmittal Number: CA-13-0022-MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

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CMS Medicaid Eligibility

ERSTESTOR ORICON RMMEDSCRD RTEICAD

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

1902(e)(14) 42 CFR 435.603

rl The state will apply Modified Adjusted Gross Income (MAGI)-based methodologies as described below, and consistent with 42 CFR 435.603. .

In the case of determining ongoing eligibility for beneficiaries determined eligible for Medicaid on or before December 31, 2013, MAGI-based income methodologies will not be applied until March 31, 2014, or the next regularly-scheduled renewal of eligibility, whichever is later, if application of such methods results in a determination of ineligibility prior to such date.

In determining family size for the eligibility determination of a pregnant woman, she is counted as herself plus each of the children she is expected to deliver.

In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman:

C The pregnant woman is counted just as herself. ©The pregnant woman is counted as herself, plus one.

@The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions:

When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size.

When determining eligibility for current beneficiaries, financial eligibility is based on:

C Current monthly household income and family size

@ Projected annual household income and family size for the remaining months of the current calendar year

In determining current monthly or projected annual household income, the state will use reasonable methods to: Include a prorated portion of a reasonably predictable increase in future income and/or family size.

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

Except as provided at 42 CFR 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household.

In determining eligibility for Medicaid, an amount equivalent to 5 percentage points of the FPL for the applicable family size will be deducted from household income in accordance with 42 CFR 435.603(d).

Household income includes actually available cash support, exceeding nominal amounts, provided by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent.

CYes @No TN No: CA-13-0023-MM Approval Date: 9/30/13 Effective Date: 1/1/2014 California $10-1

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Medicaid Eligibility

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

1902(a)(46)(B)

8 U.S.C. 1611, 1612, 1613, and 1641 1903(v)(2),(3) and (4)

42. CFR 435.4

42 CFR 435.406

42 CFR 435,956

Citizenship and Non-Citizen Eligibility

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

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

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

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

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

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

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

@yYes CNo

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

@Yes (No The date benefits are furnished is: @ The date of application containing the declaration of citizenship or immigration status. © The date the reasonable opportunity notice is sent.

C Other date, as described:

TN: CA-13-0026-MM Approval Date: 11/18/2013 Effective Date: 01/01/2014 $89 (1-3 (3) Page | of 3

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CRASS Medicaid Eligibility

CACORE AMETRCRAR & RORCA ACS

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

@ Yes (No

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

@ Yes (No {X] Pregnant women [IX] Individuals under age 21: @ Individuals under age 21 C Individuals under age 20 C Individuals under age 19

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

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

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

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

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

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

[im] Granted employment authorization under 8 CFR 274a.12(c);

[m] Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended;

{m) Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; [™] Granted Deferred Action status;

{i Granted an administrative stay of removal under 8 CFR 241;

[ml] Beneficiary of approved visa petition who has a pending application for adjustment of status;

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

[i] Has been granted employment authorization; or [Mi] Is under the age of 14 and has had an application pending for at least 180 days;

ENE Bi BB TOV DNS TIT BIZOTS Effective-Date-01/04/2044-———---------- $89 (1-3)

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Medicaid Eligibility

6. Has been granted withholding of removal under the Convention Against Torture; 7. 1s a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C. 1101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or

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

childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition.

([] Other

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

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

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

TN: CA-13-0026-MM Approval Date: 11/18/2013 Effective Date: 01/01/2014

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Page 1 of 3 Medicaid Eligibility Transmittal Number: CA State Name: California OMB Control Number: 0938‐1148 Expiration date: 10/31/2014 - 13 - 0027 Presumptive Eligibility by Hospitals S21 42 CFR 435.1110 One or more qualified hospitals are determining presumptive eligibility under 42 CFR 435.1110, and the state is providing Medicaid coverage for individuals determined presumptively eligible under this provision. Yes No The state attests that presumptive eligibility by hospitals is administered in accordance with the following provisions: ✔ A qualified hospital is a hospital that: ■ Participates as a provider under the Medicaid state plan or a Medicaid 1115 Demonstration, notifies the Medicaid agency of its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with state policies and procedures. ■ Has not been disqualified by the Medicaid agency for failure to make presumptive eligibility determinations in accordance with applicable state policies and procedures or for failure to meet any standards that may have been established by the Medicaid agency. ■ Assists individuals in completing and submitting the full application and understanding any documentation requirements. Yes No The eligibility groups or populations for which hospitals determine eligibility presumptively are: ■ Pregnant Women ■ Infants and Children under Age 19 ■ Parents and Other Caretaker Relatives ■ Adult Group, if covered by the state ■ Individuals above 133% FPL under Age 65, if covered by the state ■ Individuals Eligible for Family Planning Services, if covered by the state ■ Former Foster Care Children ■ Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state ■ Other Family/Adult groups: Eligibility groups for individuals age 65 and over Eligibility groups for individuals who are blind Eligibility groups for individuals with disabilities Other Medicaid state plan eligibility groups Demonstration populations covered under section 1115 13-0027-MM7 California Approval Date: Effective Date: January 1, 2014 February 27, 2015

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Page 2 of 3 Medicaid Eligibility The state establishes standards for qualified hospitals making presumptive eligibility determinations. Yes No The presumptive period begins on the date the determination is made. ■ The end date of the presumptive period is the earlier of: ■ The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. Periods of presumptive eligibility are limited as follows: ■ No more than one period within a calendar year. No more than one period within two calendar years. 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 + Children Under 19 Years Old Presumptive Eligibility Periods Children under the age 19 years old, receive no more than Two PE periods within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. x + Former Foster Care Presumptive Eligibility Period Former Foster Care individuals, receive no more than One PE period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. x + Parents and Caretaker Relatives Presumptive Eligibility Period Parents and Caretaker Relatives, receive no more than One PE period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. x + Adults Presumptive Eligibility Period Adults, receive no more than One PE period within a twelve- month period, starting with the effective date of the initial presumptive eligibility period. x + Pregnant Women Presumptive Eligibility Period Pregnant Women, receive no more than One PE period, per pregnancy. x The state requires that a written application be signed by the applicant, parent or representative, as appropriate. Yes No The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS. The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the application form is included. An attachment is submitted. 13-0027-MM7 California Approval Date: Effective Date: January 1, 2014 February 27, 2015

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State of California - Health and Human Services Department of Health Care Services DHCS 7022 (Draft Rev 2/26/15) Page 1 of 4 Hospital Presumptive Eligibility (HPE) Medi-Cal Application

Complete this application with a Qualified HPE Provider to find out in real-time if you qualify for the Hospital Presumptive Eligibility (HPE) Program. The HPE Program offers qualified individuals (such as patients and family members) immediate access to temporary Medi-Cal while applying for permanent Medi-Cal coverage or other health coverage. WHO CAN QUALIFY FOR HPE? To qualify for HPE, individuals must meet the rules below.  Have income below the monthly limit for household size.  Be a California resident.  Not already have Medi-Cal.  If not pregnant, have not received PE Enrollment Period benefits from any Medi-Cal PE Program, up to the maximum limitation allowed within the past 12 months of applying. The Medi-Cal PE Programs are identified in the chart in Section 2. of the instructions.  If pregnant, have not had a PE Enrollment Period during this pregnancy.  And, be eligible in one of the following HPE groups below: IF YOU QUALIFY FOR HPE - WHAT HAPPENS NEXT?  On the day you are approved for HPE, the hospital will give you a temporary paper benefits identification card (BIC) to sign and use immediately to receive temporary covered Medi-Cal services such as, doctor visits, hospital care, and some prescription drugs.  If you are pregnant, you can get care at outpatient clinics or other places in the community. HPE will not cover the cost if you are admitted to the hospital and that’s why it is important to apply for Medi-Cal. Limited-scope pregnancy only Medi-Cal programs may cover your pregnancy, labor and delivery related hospitalization. Medi-Cal or other health coverage may cover additional hospital services. You may apply for the Access for Infants and Mothers (AIM) Program by calling 1-800-433-2611 or visit the AIM website at http://www.aim.ca.gov/Home/.  The hospital will give you an insurance affordability application to apply for Medi-Cal or other health coverage. If you do not fill out the insurance affordability application, your PE Enrollment Period will end on the last day of the following month in which you were approved for PE.  For example, if approved for PE coverage on July 3, PE coverage ends on the last day of August.  If you do fill out the insurance affordability application, your PE Enrollment Period for Medi-Cal coverage will end on the day in which the eligibility determination was made (approved or denied).  For example, if approved for PE coverage on July 3, and the insurance affordability application eligibility determination was made on August 25, PE coverage ends on August 25. INDIVIDUALS CAN APPLY FOR MEDI-CAL AND OTHER HEALTH COVERAGE If you prefer to file online or by phone you may do so at: Covered California  Online: https://www.coveredca.com/  English: (800) 300-1506 | TTY: (888) 889-4500  Español: (800) 300-0213 IF YOU DO NOT QUALIFY FOR HPE - WHAT HAPPENS NEXT? If you do not qualify for the HPE Program, you cannot appeal the PE eligibility decision, BUT you can still apply for Medi-Cal or other health insurance by completing the insurance affordability application. If there are errors or corrections needed due to system issues, individuals may call the Telephone Service Center at 1-800-541-5555 Monday through Friday, between 8 a.m. and 5 p.m.

HPE GROUPS Total PE Enrollment Periods Permitted within the Past 12 Months  Individuals between the ages 18-25 who were in foster care at age 18 (no income limit) 1 PE Enrollment Period  Children under 19 years old 2 PE Enrollment Periods  Parents and Caretaker Relatives 1 PE Enrollment Period  Adults between the ages 19-64, not pregnant, not enrolled in Medicare, and not eligible for any other group stated above. 1 PE Enrollment Period  Pregnant Women 1 PE Enrollment Period, Per Pregnancy

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State of California - Health and Human Services Department of Health Care Services DHCS 7022 (Draft Rev 2/26/15) Page 2 of 4 Hospital Presumptive Eligibility (HPE) Medi-Cal Application *Do Not Mail this Application* This application is used for internal purposes to assist applicants and retain for record keeping. Section 1. Tell us about yourself. Personal and Contact Information Last Name First Name Middle Name (Jr. Sr. II. etc.)

Date of birth (mm/dd/yyyy) / / Social Security Number (optional) - - Male Female

If homeless, check the box and tell us where we can reach you in the home address field below. If “Safe At Home” participant, check the box and answer the questions below. 1. What is your P.O. Box address, if known? __________________________________________ 2. What is your Safe At Home Participant ID, if known? _________________________________ Home Address (number & street) City State ZIP Code Mailing Address (if different than above) City State ZIP Code Living in California? Yes No County living in? Best contact phone number Other phone number Email address What language do you speak best? What language do you read best? Section 2. Additional Questions Yes No 1. Have you been enrolled in Medi-Cal through Presumptive Eligibility (PE) in the past 12 months? If yes, name the PE program(s) _______________________and if under age 19 how many times it was received? ______

2. Do you currently have Medicare?

3. Do you have a State of California Benefits Identification Card (BIC), also known as a Medi-Cal Card? If yes, what is the identification number on the card, (if available)? _____________________________

4. Are you between the ages of 18 – 25 and had Foster Care the month of his/her 18th Birthday?

5. Are you a parent of a child or caretaker relative of a child that lives with the patient?

6. Are you pregnant? If yes, what is the expected due date (mm/dd/yyyy)? _________ How many babies expected, if known? _______ Note: If the individual is pregnant, services received are limited to ambulatory prenatal services.

7. If you are pregnant, have you been enrolled in Medi-Cal through Presumptive Eligibility during this current pregnancy?

Section 3. Tell us about your household and income Information. How many family members live in your household? _________ (Include parent, spouse, and any children under age 21 living in the household) How much is your household income before taxes? $____________________ Monthly or $___________________Yearly Section 4. Signature and Declaration By signing, I declare that what I say below is true and correct.  I have read and understand this HPE Medi-Cal Application.  The information I provided is true, correct, and complete.  I understand that I must complete and submit the insurance affordability application by the end of my PE period in order to be eligible for continued coverage.  I have received the insurance affordability application. Signature of applicant or parent/spouse/guardian/emancipated minor

Relationship to the applicant (if applicable)

Date (mm/dd/yyyy)

An individual has a right to review records containing his/her personal information. The official entity responsible for keeping the information contained in this application is the California Department of Health Care Services and Covered California. This information may be shared with the County Department of Social Services in the county in which the individual resides. The individual’s medical information will be kept with the Hospital Presumptive Eligibility Provider and Covered California.

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State of California - Health and Human Services Department of Health Care Services DHCS 7022 (Draft Rev 2/26/15) Page 3 of 4 Important - Safe At Home program is California's confidential address program, which helps victims of violence by providing a free post office box mail service. HPE applicants, who are Safe At Home participants, are allowed to provide their Safe at Home P.O. Box address instead of providing their residence address. Safe At Home participants have a participant ID card.

Tell us about yourself. Personal and Contact Information

Personal Information  Enter your Last Name, First Name, Middle Name and Jr., Sr., II, if indicated, otherwise leave blank.  Enter your date of birth (month/date/full year). (Example: 07/07/2014)  Enter your Social Security Number, if available. Enter a check mark to indicate your gender. Homeless Question  Check the box if you are homeless. All applicants should complete the home address or mailing address field. Safe At Home Questions  Check the box if you are a “Safe At Home” participant. 1. Enter your P.O. Box, if available. Otherwise, select “Unknown”. 2. Enter the Safe At Home Participant ID, if available. Address and Contact Information  Enter your home address. (If homeless, enter an alternative address or location).  Enter your mailing address if different from the home address.  Check Yes or No you are living in California.  Enter the name of the County where you are living. (If homeless, your designated County general area)  Enter your phone numbers with area code, if available.  Enter your email address, if available.

Additional Questions

1. Check Yes or No if you have been enrolled in Medi-Cal through PE in the past 12 months. If yes, name the PE program(s) and if under age 19 how many times it was received? The Medi-Cal PE Programs are listed in the chart below. Note: PE Enrollment benefits received from any PE program are limited to the past 12 months prior to applying for HPE as indicated below.

Medi-Cal PE Programs Total PE Enrollment Periods Permitted 1 HPE - Individuals between the ages 18-25 who were in foster care at age 18 1 PE Enrollment Period 2 HPE - Children under 19 years old 2 PE Enrollment Periods 3 HPE - Parents and Caretaker Relatives 1 PE Enrollment Period 4 HPE - Adults between the ages 19-64 1 PE Enrollment Period 5 HPE - Pregnant Women 1 PE Enrollment Period, Per Pregnancy 6 Children Health and Disability Prevention (CHDP) Gateway 2 PE Enrollment Periods 7 Breast and Cervical Cancer Treatment Program (BCCTP) 1 PE Enrollment Period 8 PE for Pregnant Women 1 PE Enrollment Period, Per Pregnancy

2. Check Yes or No if you currently have Medicare. Note: Individuals eligible for the Adult group and currently have Medicare are not permitted to receive PE. 3. Check Yes or No if you have a BIC. If yes, enter the card number, if available. 4. Check Yes or No if you are between the ages of 18 – 25 and had Foster Care the month of your 18th Birthday.

INSTRUCTIONS Hospital Presumptive Eligibility (HPE) Medi-Cal Application (Page 1 of 2) Section 1. Section 2.

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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

February 27, 2015

Mari Cantwell, Chief Deputy Director California Department of Health Care Services Director’s Office, MS 0000 Sacramento, CA 95899-7413

Dear Ms. Cantwell:

This letter is being sent as a companion to our approval of California State Plan Amendment (SPA) CA-13-0027-MM7, which proposes to implement presumptive eligibility conducted by hospitals in the Medicaid state plan in accordance with the Affordable Care Act (ACA). This amendment was submitted on December 23, 2013, with an effective date of January 1, 2014.

Section 1902(a) of the Social Security Act (the Act) requires that states have a state plan for medical assistance that meets certain Federal requirements that set out a framework for the state program. Implementing regulations at 42 CFR 430.10 require that the state plan be a comprehensive written statement describing the nature and scope of the state’s Medicaid Program and that it contain all information necessary for the Centers for Medicare & Medicaid Services (CMS) to determine whether the plan can be approved to serve as the basis for Federal financial participation (FFP) in the state program. While this SPA is approvable, additional changes are needed in order to comply fully with the provisions specified at 42 CFR 435.1110. The specific items in need of correction are identified in the attached corrective action plan (CAP) that is enclosed with this companion letter.

To stay apprised of the state’s progress in implementing this CAP, CMS will request verbal updates from the state at least every 30 days via one of the regularly scheduled California-CMS calls. If the state is not able to provide adequate updates regarding the status of the CAP, we may request a more formal written status report. Within 30 days of this letter, please respond to formally acknowledge this companion letter and your understanding of the regular status updates required through implementation.

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Corrective Action Plan for California Hospital Presumptive Eligibility Page 1 of 2 CMS understands that California (“the state”) is pursuing system and policy changes related to hospital presumptive eligibility (HPE) to comply with CMS direction and has asked for additional time following the approval of State Plan amendment (SPA) CA 13-0027 to implement these changes to the existing California HPE Program. CMS and the state agreed to the following corrective action plan on 2/26/15. Implemented On 12/14/14 The state implemented changes to correct issues with the HPE period begin and end date. The HPE period means a period that begins on the date on which an applicant is determined presumptively eligible and ends either (1) For applicants who file a Medicaid application by the end of the month following the month of PE determination, the day on which a decision is made on that application, or (2) For applicants who do not file a Medicaid application, the last day of the month following the month in which the determination of presumptive eligibility was made. To Be Implemented No Later Than On or before this date, the state will implement the manual workaround to mitigate the system limitation that effectively prevents applicants from being determined for HPE if they were found eligible for Advanced Premium Tax Credits (APTC)/Cost Sharing Reduction (CSR) in a Qualified Health Plan (QHP). This mitigation approach is further described later in this document. To Be Implemented No Later Than 5/30/15 (i.e., No More Than 90 Days Following Approval of CA 13-0027 SPA) On or before this date, the state shall implement the following changes in the HPE Portal: • Remove any remaining language in the portal that refers to a HPE period being 60 days • Remove any remaining language for the backdate functionality that allowed the state to begin a HPE period earlier than the day on which the HPE determination was made • Modify the former foster care age category to age 18-25, meaning through age 25 and under age 26 • Re-print and distribute final paper applications that reflect the changes described in the three preceding bullets above, and which have already been made in the approved documents associated with this SPA On or before this date, the state shall implement the following changes to related HPE processes: • Update the online training portal to reflect the policy and process changes that the State has already made in the approved training materials associated with this SPA • Modify the HPE Provider agreement to incorporate language consistent with the State’s elimination of the backdating functionality and changes to HPE period limitations To Be Implemented No Later Than 10/31/15 On or before this date, the state will implement system changes to remove the restriction on HPE applicants who have been determined eligible for APTC/CSR in a QHP. Effective 4/20/15 and in the interim of this system change, the state will implement a manual workaround to mitigate this limitation that effectively prevents applicants from being determined for HPE (i.e., for all denied HPE applications through the online portal for the reason “APTC/CSR eligible”). As part of this mitigation approach, the state will manually review denied individuals and determine the individual’s eligibility for a specific 4/30/2015

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Medicaid Eligibility

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

1902(a)(10)(A)(i)(VOI) 42 CFR 435.119

The state covers the Adult Group as described at 42 CFR 435.119. @ Yes No ao {H] Adult Group - Non-pregnant individuals age 19 through 64, not otherwise mandatorily eligible, with income at or below 133% FPL. The state attests that it operates this eligibility group in accordance with the following provisions: [i] Individuals qualifying under this eligibility group must meet the following criteria: [i] Have attained age 19 but not age 65. [i] Are not pregnant.

[M Are not entitled to or enrolled for Part A or B Medicare benefits.

wl Are not otherwise eligible for and enrolled for mandatory coverage under the state plan in accordance with 42 CFR 435, subpart B.

Note: In 209(b) states, individuals receiving SSI or deemed to be receiving SSI who do not qualify for mandatory Medicaid eligibility due to more restrictive requirements may qualify for this eligibility group if otherwise eligible.

[i] Have household income at or below 133% FPL.

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

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

Parents or other caretaker relatives living with a child under the age specified below are not covered unless the child is [Mj receiving benefits under Medicaid, CHIP or through the Exchange, or otherwise enrolled in minimum essential coverage, as defined in 42 CFR 435.4.

@ Under age 19, or C A higher age of children, if any, covered under 42 CFR 435.222 on March 23, 2010: [mM] 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.

C Yes @ No

PRA Disclosure Statement

Transmittal Number: CA - 13-0028-MM1 Approval Date: December 13, 2013 Effective Date: January 1, 2014 $32-14

Page | of 2

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CCmMsS Alternative Benefit Plan

OMB Control Number: 0938-1148 Attachment 3.1-L OMB Expiration date: 10/31/2014

The state/territory has fully aligned its benefits in the Alternative Benefit Plan using Essential Health Benefits and subject to 1937 requirements with its Alternative Benefit Plan that is the state’s approved Medicaid state plan that is not subject to 1937 requirements. Therefore the state/territory is deemed to have met the requirements for voluntary choice of benefit package for individuals exempt from mandatory participation in a section 1937 Alternative Benefit Plan.

Yes

Explain how the state has fully aligned its benefits in the Alternative Benefit Plan using Essential Health Benefits and subject to 1937 requirements with its Alternative Benefit Plan that is the state’s approved Medicaid state plan that is not subject to 1937 requirements.

In accordance with CMS instruction and technical assistance, California has fully aligned its benefits in the ABP to reflect the State Plan, using the Blue Cross/Blue Shield FEHBP to define the EHBs. To the extent services are considered Long Term Services and Supports (LTSS), these services are only available under the ABP to individuals who meet the medically frail criteria. The criterion governing the availability of these State Plan services aligns with or is at least as stringent as the medically frail criteria. As such, those ABP recipients who qualify for State Plan LTSS services based on medical necessity will be considered medically frail and will not be subject to a separate determination beyond the applicable, service-specific needs assessment.

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 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130917

TN No: 13-035 Approval Date: 3/28/2014 California Effective Date: 1/01/2014 Page | of |

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CMS. Alternative Benefit Plan

OMB Control Number: 0938-1148

Attachment 3.1-L-[ | date: 10/31/2014

Select one of the following:

C The state/territory is amending one existing benefit package for the population defined in Section {.

@. The state/territory is creating a single new benefit package for the population defined in Section 1.

Name of benefit package: |ABP Adult Group

Selection of the Section 1937 Coverage Option

The state/territory selects as its Section 1937 Coverage option the following type of Benchmark Benefit Package or Benchmark- Equivalent Benefit Package under this Alternative Benefit Plan (check one):

@ Benchmark Benefit Package.

C Benchmark-Equivalent Benefit Package. The state/territory will provide the following Benchmark Benefit Package (check one that applies):

Cc The Standard Blue Cross/Blue Shield Preferred Provider Option offered through the Federal Employee Health Benefit Program (FEHBP).

(C State employee coverage that is offered and generally available to state employees (State Employee Coverage):

Cc A commercial HMO with the largest insured commercial, non-Medicaid enrollment in the state/territory (Commercial HMO):

@ = Secretary-Approved Coverage. @ The state/territory offers benefits based on the approved state plan.

The state/territory offers an array of benefits from the section 1937 coverage option and/or base benchmark plan benefit packages, or the approved state plan, or from a combination of these benefit packages.

@ The state/territory offers the benefits provided in the approved state plan.

C Benefits include all those provided in the approved state plan plus additional benefits.

C Benefits are the same as provided in the approved state plan but in a different amount, duration and/or scope. C The state/territory offers only a partial list of benefits provided in the approved state plan.

C The state/territory offers a partial list of benefits provided in the approved state plan plus additional benefits.

Please briefly identify the benefits, the source of benefits and any limitations:

State Plan benefits as described in the State Plan.

Selection of Base Benchmark Plan

TN No: 13-035 Approval Date: 3/28/2014 . California Effective Date: 1/01/2014 Page | of 2

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Alternative Benefit Plan

The state/territory must select a Base Benchmark Plan as the basis for providing Essential Health Benefits in its Benchmark or Benchmark-Equivalent Package.

The Base Benchmark Plan is the same as the Section 1937 Coverage option. |No

Indicate which Benchmark Plan described at 45 CFR 156.100(a) the state/territory will use as its Base Benchmark Plan: C Largest plan by enrollment of the three largest small group insurance products in the state's small group market. C Any of the largest three state employee health benefit plans by enrollment. @ Any of the largest three national FEHBP plan options open to Federal employees in all geographies by enrollment. c

Largest insured commercial non-Medicaid HMO.

Plan name: |Blue Cross/ Blue Shield FEHBP

Other Information Related to Selection of the Section 1937 Coverage Option and the Base Benchmark Plan (optional):

The state assures that all services in the base benchmark have been accounted for throughout the benefit chart found in ABP 5, The state assures the accuracy of all information in ABP 5 depicting amount, duration and scope parameters of services authorized in the currently approved Medicaid state plan.

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 5 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.201 30801

TN No: 13-035 Approval Date: 3/28/2014 California Effective Date: 1/01/2014 Page 2 of 2

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“CRAS Alternative Benefit Plan

CINEMATIC.

Scope Limit: None Remove |

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Inpatient Specialty Mental Health Services. Acute psychiatric inpatient hospital services, psychiatric health facility services and psychiatric inpatient professional services. The IMD payment exclusion applies to acute psychiatric inpatient hospital services, psychiatric health facility services, and psychiatric inpatient professional services only when those services are provided in a facility that is considered an IMD based on

42 CFR Sections 435.1009 and 435.1010. . Benefit Provided: Source: Rehabilitation: Substance Use Disorder Services State Plan 1905(a) “Remove _ Authorization: Provider Qualifications: Other Medicaid State Plan Amount Limit: Duration Limit: ‘None None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Outpatient Substance Use Disorder Services. Services include Outpatient Drug Free; Intensive Outpatient Treatment; Naltrexone Treatment: Narcotic Treatment Program. Post periodic review. Prior authorization is required for Narcotic Treatment Program counseling more than 200 minutes per month.

Benefit Provided: Source: Physician Service: Heroin/Opioid Detoxification State Plan 1905(a) [ Remove | Authorization: Provider Qualifications: Prior Authorization Medicaid State Plan Amount Limit: Duration Limit: None 21 consecutive days per treatment

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Outpatient heroin/opioid detoxification. Services include Narcotic Treatment Program. When medically necessary, additional 21-day treatments are covered after 28 days have passed since beneficiary completed a preceding course of treatment. Includes medically necessary services to diagnose and treat diseases that are concurrent with, but not part of, outpatient heroin or other opioid detoxification services.

TN No: 13-035 Approval Date: 3/28/2014 California Effective Date: 1/01/2014 Page 12 of 42

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CRAS

OPERA HORE & EME RI ENCE

Alternative Benefit Plan

Other information regarding this benefit, including the specific name of the source plan if it is not the base

benchmark plan:

Replacement hearing aids for those that are lost, stolen or damaged are not subject to the $1,510 cap.

Benefit Provided: Source: PT and Related Services: Speech Therapy/Audiology State Plan 1905(a) ~ Remove Authorization: Provider Qualifications: None Medicaid State Plan Amount Limit: Duration Limit: 2 per month None Scope Limit: Pregnant women and EPSDT covered. Other beneficiaries are only covered in hospital outpatient departments and organized outpatient clinics. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Outpatient services are limited to a maximum of two services in any one calendar month or any combination of two services per month from the following services: acupuncture, audiology, chiropractic, occupational therapy, podiatry and speech therapy: may exceed limit for medical necessity with a TAR. Benefit Provided: Source: PT and Related Services: Occupational Therapy State Plan 1905(a) [ - Remove |

Authorization: Provider Qualifications:

None Medicaid State Plan

Amount Limit: Duration Limit:

2 per month None

Scope Limit:

Pregnant women and EPSDT covered. Other beneficiaries are only covered in hospital outpatient departments and organized outpatient clinics.

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Outpatient services are limited to a maximum of two services in any one calendar month or any combination of two services per month from the following services: acupuncture, audiology, chiropractic, occupational therapy, podiatry and speech therapy; may exceed limit for medical necessity with a TAR.

Benefit Provided:

Source:

Other Licensed Practitioner: Acupuncture

State Plan 1905¢(a)

Authorization: Provider Qualifications:

None Medicaid State Plan TN No: 13-035 Approval Date: 3/28/2014 California Effective Date: 1/01/2014

Page 16 of 42

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CRS

CER SHE ARTREAE & EO A TIES

Alternative Benefit Plan

{m@] Essential Health Benefit 9: Preventive and wellness services and chronic disease management

Collapse All [7]

The state/territory must provide, at a minimum, a broad range of preventive services including: “A” and “B” services recommended by the United States Preventive Services Task Force; Advisory Committee for Immunization Practices (ACIP) recommended vaccines; preventive care and screening for infants, children and adults recommended by HRSA’s Bright Futures program/project; and additional preventive services for women recommended by the Institute of Medicine (IOM).

Benefit Provided:

Source:

Family Planning Services

State Plan 1905(a)

_ Remove

Authorization:

Provider Qualifications:

Other

Medicaid State Plan

Amount Limit:

Duration Limit:

See below

Scope Limit:

Individuals of childbearing age; must be 21 to receive sterilization

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Includes family planning visits and counseling, invasive contraceptive procedures/devices, tubal ligations, vasectomies, contraceptive drugs or devices, and laboratory procedures, radiology and drugs associated with family planning procedures. TAR required for inpatient sterilization. Frequency limits on certain contraceptives and other services. Informed consent required for sterilizations.

Benefit Provided:

Source: Physician Services: Smoking Cessation State Plan 1905(a) Remove

Authorization: Provider Qualifications:

‘None Medicaid State Plan

Amount Limit: Duration Limit:

‘None None

Scope Limit:

By or under supervision of physician

Other information regarding this benefit, including the specific name of the source plan if it is not the base

benchmark plan:

Includes diagnosis, treatment, smoking cessation products when used in conjunction with behavior

modification support, referral to 1-800 helpline and one face-to-face counseling session per quit attempt for

specific populations.

Add

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CRORE METRE 4 REGAN CSS

Base Benchmark Benefits Not Covered due to Substitution or Duplication Collapse All [7] Base Benchmark Benefit that was Substituted: Source: re ve Base Benchmark Cognitive Rehabilitation Therapy (CRT) Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 7 substitution: Rehabilitation, Cognitive Rehabilitation Therapy. Federally Qualified Health Center (FQHC) services are being used from the existing State Plan for substitution purposes. Cognitive Rehabilitation Therapy would be considered "Rehabilitation and Habilitative Services and Devices" EHB7 category. CRT aims to rehabilitate lost or altered cognitive skills, enabling individuals to reach functional and independent daily living. FQHCs provide numerous rehabilitative services.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Outpatient Hospital Services

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB | duplication: Outpatient Hospital and Clinic Services -- The following hospital outpatient and clinic services are limited to a maximum of two services in any one calendar month or any combination of two services per month: acupuncture, audiology, occupational therapy, podiatry and speech therapy; may exceed limit for medical necessity with Treatment Authorization Request (TAR). Includes Indian Health Services.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Ambulatory Surgical Center Services

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB | duplication: Outpatient Hospital Services, Outpatient Surgery -- Outpatient surgery includes anesthesiologist services.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark oy Podiatry . Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB | duplication: Other Licensed Practitioners, Podiatry. Outpatient services are limited to a maximum of two services in any one calendar month or any combination of two services per month from the following services: acupuncture, audiology, chiropractic, occupational therapy, podiatry and speech therapy: may exceed limit for medical necessity with a TAR.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Chiropractic

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB | duplication: Other Licensed Practitioners, Chiropractic -- Outpatient services are limited to a maximum of two services in any one calendar month or any combination of two services per month from

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ccms Alternative Benefit Plan

the following services: acupuncture, audiology, chiropractic, occupational therapy, podiatry and speech therapy; may exceed limit for medical necessity with a TAR.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Allergy Care

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB | duplication: Physician Services, Allergy Care -- Emergency treatment for allergy care does not require TAR.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Treatment Therapies

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB | duplication: Outpatient Hospital Services, Treatment Therapies -- Chemotherapy, radiation therapy. Intensive-Modulated Radiation Therapy (IMRT), renal dialysis, IV/infusion therapy. medication management.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Emergency Services/Accidents

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 2 duplication: Outpatient Hospital Services, Emergency -- All inpatient and outpatient services that are necessary for the treatment of an emergency medical condition, including emergency dental services, as certified by the attending physician or other appropriate provider.

[Remove |

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Ambulance

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 2 duplication: Medical Transportation, Ambulance Service -- Emergency Medical Transportation. Air transportation only covered when ground transportation is not feasible; emergency transportation does not require TAR.

Remove

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Surgical Procedures

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 3 duplication: Inpatient Hospital Services, Surgical Services -- Room and Board. Professional services performed by physicians, including surgery and consultation, within the scope of practice of medicine or osteopathy as defined by State law. Includes case management; respiratory care; laboratory and X-ray services; prescriptions for medication, DME and medical supplies; and Indian Health Services.

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CORRENTE 4 ROKK BATS

Base Benchmark Benefit that was Substituted: Source:

; an Base Benchmark - Gastric Restrictive Procedures

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 3 duplication -- Inpatient Hospital Services, Bariatric Surgery: Patient must be at or above specified BMI levels and meet certain conditions to qualify for bariatric surgery.

Base Benchmark Benefit that was Substituted: Source:

. Base Benchmark - Anesthesia Remove

EXURENERAE ROE

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 3 duplication -- Anesthesiologist Services: medically necessary services by an anesthesiologist.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Organ/Tissue Transplants

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 3 duplication: Inpatient Hospital Services, Organ & Tissue Transplantation -- Transplant surgery, pre- transplant evaluation, post-operative care and laboratory services for bone morrow, heart, liver, kidney, heart-lung, simultaneous kidney-pancreas, single lung, double lung, pancreas, small bowel and combined liver-small bowel surgeries.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Reconstructive Surgery

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 3 duplication: Inpatient Hospital Services, Reconstructive Surgery -- Reconstructive surgery is limited to that performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to improve function and/or to create a normal appearance, to the extent possible. Includes breast reconstruction after mastectomy.

Base Benchmark Benefit that was Substituted: Source:

; Base Benchmark Hospice Care Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB | duplication: Hospice Care -- Hospice includes routine home care, continuous home care, respite care and general inpatient care. Children may receive concurrent palliative care.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Prenatal Care

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CcmMs Alternative Benefit Plan

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate

section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 4 duplication: Physician Services, Prenatal Care -- Diagnostic services include sonography, genetic testing and cordocentesis: genetic screening of father for cystic fibrosis if he is a Medi-Cal beneficiary.

Base Benchmark Benefit that was Substituted: Source: 7 _ Base Benchmark (—grrernennn — Delivery and Postpartum Care Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 4: Inpatient Hospital Services, Delivery and Postpartum Care -- Medical services related to delivery and postpartum care. Hospital stay 48 to 96 hours post delivery.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Breastfeeding Education

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 4 duplication: Physician Services, Breastfeeding Education -- Breastfeeding education may be provided by physician, a registered nurse or a registered dietician working under physician.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

| Remove —

Maternity Care by a Nurse Midwife

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 4 duplication: Services Furnished by a Nurse-Midwife -- services provided by nurse midwife from conception through 60 days after delivery.

Base Benchmark Benefit that was Substituted: Source:

Base Benchmark ; Outpatient Hospital Services: Mental Health

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 5 duplication: Rehabilitation, Outpatient Mental Health -- Includes individual and group psychotherapy, psychological testing and medication management.

Base Benchmark Benefit that was Substituted: Source:

Base Benchmark Outpatient Hospital Services: Mental Health

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 5 duplication: Rehabilitation, Outpatient Specialty Mental Health -- Includes day treatment services; crisis intervention and stabilization; adult crisis residential; mental health services; medication support; and targeted case management.

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CCmMS Alternative Benefit Plan

AEM RE REE A EORTC

Base Benchmark Benefit that was Substituted: Source:

Base Benchmark Inpatient Hospital Services: Mental Health

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 5 duplication: Rehabilitation, Inpatient Specialty Mental Health Services -- Acute psychiatric inpatient hospital services, psychiatric health facility services and psychiatric inpatient professional services. The IMD payment exclusion applies to acute psychiatric inpatient hospital services, psychiatric health facility services, and psychiatric inpatient professional services only when those services are provided in a facility that is considered an IMD based on 42 CFR Sections 435.1009 and 435.1010.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark see Outpatient Hospital Services: SUD Remove |

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 5 duplication -- Rehabilitation: Outpatient Substance Use Disorder Services. Services include Outpatient Drug Free; Intensive Outpatient Treatment; Naltrexone Treatment; Narcotic Treatment Program. Post periodic review. Prior authorization is required for Narcotic Treatment Program counseling more than 200 minutes per month.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Physician Services: Heroin/opioid detoxification

Reinove_

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 5 duplication -- Rehabilitation: Outpatient heroin/opioid detoxification. Services include Narcotic Treatment Program. When medically necessary, additional 21-day treatments are covered after 28 days have passed since beneficiary completed a preceding course of treatment. Includes medically necessary services to diagnose and treat diseases that are concurrent with, but not part of, outpatient heroin or other opioid detoxification services.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Inpatient Hospital Services: Detoxification

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 5 duplication: Inpatient hospital, Voluntary Inpatient Detoxification -- Room and Board. Professional services performed by physicians to aid detoxification, including surgery and consultation, within the scope of practice of medicine or osteopathy as defined by State law. Includes case management; respiratory care; laboratory and X-ray services; prescriptions for medication, DME, and medical supplies. These facilities are not Institutions for Mental Disease (IMD) and the IMD payment exclusion applies.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Prescription Drug Benefits

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Cccms Alternative Benefit Plan

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

Remove EHB 6 duplication: Prescribed Drugs -- TAR required for more than six prescriptions per month. ~

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Physical Therapy

Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 7 duplication: Physical therapy -- Authorizations for physical therapy is valid for up to 120 days and must include a treatment plan. Prior authorization is not granted for more than 30 treatments at any one time.

Base Benchmark Benefit that was Substituted: Source:

7 — Base Benchmark Durable Medical Equipment

Explain the substitution or duplication, including indicating the substituted benetit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 7 duplication: Home Health Services, Durable Medical Equipment -- durable medical equipment prescribed by physician.

Base Benchmark Benefit that was Substituted: Source:

Base Benchmark Hearing Aids

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 7 duplication: Home Health Services, Hearing Aids -- $1,510 annual cap for hearing aid benefits may be exceeded for medical necessity.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark Speech Therapy/Audiology ase Benen ar

Explain the substitution or duplication, including indicating the substituted benetit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 7 duplication: Physical Therapy and Related Services, Speech Therapy/Audiology -- Outpatient services are limited to a maximum of two services in any one calendar month or any combination of two services per month from the following services: acupuncture, audiology, chiropractic, occupational therapy, podiatry, and speech therapy; may exceed limit for medical necessity with a TAR.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Occupational Therapy

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 7 duplication: Physical Therapy and Related Services, Occupational Therapy -- Outpatient services are limited to a maximum of two services in any one calendar month or any combination of two services per month from the following services: acupuncture, audiology, chiropractic, occupational therapy, podiatry

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cms Alternative Benefit Plan

CANES RTTOORER A MEO AE TENE,

land speech therapy; may exceed limit for medical necessity with a TAR. |

Base Benchmark Benefit that was Substituted: Source:

~ Base Benchmark Alternative Treatments: Acupuncture Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 7 duplication: Other Licensed Practitioners, Acupuncture -- Outpatient services are limited to a maximum of two services in any one calendar month or any combination of two services per month from the following services: acupuncture, audiology, chiropractic, occupational therapy, podiatry and speech therapy; may exceed limit for medical necessity with a TAR.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Outpatient Cardiac Rehabilitation

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 7 duplication: Rehabilitative Services, Cardiac Rehabilitation

Base Benchmark Benefit that was Substituted: Source:

Te Base Benchmark Pulmonary Rehabilitation

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 7 duplication: Rehabilitative Services: Pulmonary Rehabilitation

Base Benchmark Benefit that was Substituted: Source:

Base Benchmark z = Medical Supplies, Equipment, Devices

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 7 duplication: Home Health Services, Medical Supplies and DME; and Prosthetic Devices -- Certain medical supplies require TAR. Cochlear implant for one ear only; frequency limits on replacement parts. Includes surgically implanted hearing devices, prior authorization required. Certain medical supplies require TAR.

Base Benchmark Benefit that was Substituted: Source:

" . " Base Benchmark - Orthopedic and Prosthetic Devices

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 7 duplication: Prescribed Prosthetic Devices -- TAR required when cumulative costs of orthotics exceed $250 and prosthetics exceed $500.

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ccms Alternative Benefit Plan

Base Benchmark Benefit that was Substituted: Source:

- Base Benchmark ~ Home Health Services

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 7 duplication: Home Health Services -- Authorization requirements for home health services vary based upon type of service. Services include nursing services which may be provided by a registered nurse ‘when no home health agency exists in area; home health aid services; medical supplies and equipment; and

therapies. Base Benchmark Benefit that was Substituted: Source: Base Benchmark ae Lab, X-Ray, and Other Diagnostic Tests ase enema Remove |

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 8 duplication: Other Laboratory and X-Ray Services -- Laboratory services are subject to frequency limits. These limits are set per recipient, per service, per month by the Laboratory Services Reservation System (LSRS). Up to four of the following radiological ultrasound procedure codes for each beneficiary per year based on medical necessity: ultrasound, chest ultrasound, abdominal, and retroperitoneal. More than four requires documentation of medical necessity or by report. Prior authorization required for portable X-ray unless performed in SNF or ICF, Various advanced imaging procedures are covered, based on medical necessity. Many of the procedures require a TAR and are subject to frequency limitations.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Family Planning

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 9 duplication: Family Planning Services -- Includes family planning visits and counseling, invasive contraceptive procedures/devices, tubal ligations, vasectomies, contraceptive drugs or devices, and laboratory procedures, radiology and drugs associated with family planning procedures. TAR required for inpatient sterilization. Frequency limits on certain contraceptives and other services. Informed consent required for sterilizations.

Base Benchmark Benefit that was Substituted: Source: a " , Te ae Base Benchmark — Treatment Therapies: Dialysis/Hemodialysis Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB | duplication: Outpatient Hospital, Dialysis/Hemodialysis -- Chronic dialysis covered as an outpatient service when provided by renal dialysis centers or community hemodialysis units. Includes physician services, medical supplies, equipment, drugs and laboratory tests. Hemodialysis routine test can be conducted per treatment, weekly or monthly.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Educational Classes & Programs: Smoking Cessation

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CCMS Alternative Benefit Plan

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 9 duplication: Physician Services, Smoking Cessation -- Includes diagnosis, treatment, smoking cessation products when used in conjunction with behavior modification support, referral to 1-800 helpline and one face-to-face counseling session per quit attempt for specific populations.

Remove

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Skilled Nursing Care Facility

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB 7 duplication: Skilled Nursing Facility and Other -- Nursing care, bed and boarding care, physical therapy, occupational therapy, speech-language pathology services, medical social services, drugs, biologicals, supplies, appliances and equipment. Patient must need daily care.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Medical Services Provided by Physician

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHBI duplication: Physician Services -- physician services within license.

Base Benchmark Benefit that was Substituted: Source: Base Benchmark

Ambulance Transport Service

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

EHB | duplication: Medical Transportation, Non-Emergency Ambulance Service -- Air transportation only covered when ground transportation is not feasible; transportation covered from non-contract hospital to nearest contract hospital when patient is stable.

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cms

ON MEAMOARE A MRCS

Alternative Benefit Plan

Scope Limit:

Orthoptics, pleoptics and glasses are not covered.

| Remove

Other:

Glasses and contact lenses are covered for EPSDT and pregnant women.

Other 1937 Benefit Provided:

Local Education Agency Services

Authorization:

Source: Section 1937 Coverage Option Benchmark Benefit Package

Provider Qualifications:

Authorization required in excess of limitation

Medicaid State Plan

Amount Limit:

Duration Limit:

24 services within 12 months

None

Scope Limit:

Medi-Cal eligible public school children up to age 22 or end of school year beneficiary turns 22.

Other:

May exceed 24 services within 12 months with TAR or authorization provided by Individualized Education Plan, Individualized Family Service Plan, California Children Services, Short-Doyle, or prepaid health plan. Services include health and mental health evaluation and education, individualized education plan, individualized family service plan, physician services, physical therapy, occupational therapy. speech therapy, audiology services, psychology and counseling, nursing services, school health aid services, medical transportation/mileage and targeted care management services.

| Remove

Other 1937 Benefit Provided:

TCM: Children at Risk of Medical Compromise

Authorization:

Source: Section 1937 Coverage Option Benchmark Benefit Package

Provider Qualifications:

Other

Medicaid State Plan

Amount Limit:

Duration Limit:

None

Scope Limit:

Children up to age 21.

Other:

authorization is not required.

1915(g) State Plan. Services to assist eligible individuals access medical, social and educational services. Includes children who need assistance to access medical, social and education services when comprehensive case management is not provided elsewhere. Only available in specific areas Prior

Other 1937 Benefit Provided:

TCM: Medically Fragile with Multiple Diagnoses

Source: Section 1937 Coverage Option Benchmark Benefit Package

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Alternative Benefit Plan

Scope Limit: Children up to age 21 with laboratory test results showing elevated lead blood levels. Remove |

Other: 1915(g) State Pian. Services to assist eligible individual access medical, social and educational services. Prior authorization is not required.

Other 1937 Benefit Provided: Source: ; TCM: Individuals with Developmental Disability Peckawe 937 Coverage Option Benchmark Benefit Authorization: Provider Qualifications: Other Medicaid State Plan Amount Limit: Duration Limit: None None

Scope Limit:

Individuals diagnosed with a developmental disability.

Other:

1915(g) State Plan. Services to assist eligible individuals access medical, social and educational services. Includes individuals transitioning to a community setting. Services available for up to 180 consecutive days of a covered stay in a medical institution. Prior authorization is not required.

Other 1937 Benefit Provided: Source: ” ve Section 1937 Coverage Option Benchmark Benefit : Skilled Nursing Facility Package

Provider Qualifications:

Authorization:

Prior Authorization Medicaid State Plan Amount Limit: Duration Limit: None None

Scope Limit:

Medical necessity as described in “other.”

Other:

The individual is unable to perform some activity of daily living independently and patient must need daily care. Services include nursing care, bed and boarding care, physical therapy, occupational therapy, speech- language pathology services, medical social services, drugs, biological, supplies, appliances and equipment. An initial authorization may be granted for periods up to one year from date of admission and shall be required prior to the transfer of a beneficiary between skilled nursing facilities. The attending physician must re-certify at least every 60 days.

Other 1937 Benefit Provided: Source: P 1 Care Servi Section 1937 Coverage Option Benchmark Benefit ersonai Care services Package TN No: 13-035 Approval Date: 3/28/2014

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Crs

CRUE ASHE ANETAE NE AAEM RATED

Alternative Benefit Plan

Authorization:

Provider Qualifications:

Other

Medicaid State Plan

Remove

Amount Limit:

Duration Limit:

283 hours per month

None

Scope Limit:

Medical necessity as described in "other."

Other:

of a hospital, NF, ICF-DD, or ICF-MD.

Beneficiary has chronic. disabling disease expected to last at least 12 months and requires assistance in performing some activities of daily living, is unable to obtain, retain or return to work, and is at risk of institutional placement. Authorized by county based upon assessment in accordance with plan of treatment prepared by physician. Services may include activities such as assistance with administration of medication, basic personal hygiene, eating, grooming, etc. Beneficiary must not be an inpatient or resident

Other 1937 Benefit Provided:

Self-Directed Personal Assistance Services

Authorization:

Source: Section 1937 Coverage Option Benchmark Benefit Package

Provider Qualifications:

Other

Medicaid State Plan

Amount Limit:

Duration Limit:

283 hours per month

None

Scope Limit:

Medical necessity as described in "other."

Other:

1915(j) State Plan. Beneficiary has chronic, disabling disease expected to last at least 12 months and requires assistance in performing some activities of daily living, is unable to obtain. retain or return to work, and is at risk of institutional placement. Authorized by county based upon assessment in accordance with plan of treatment prepared by physician. Services include personal care and related services, to be self- directed by the beneficiary. Beneficiary may not be an inpatient or resident of a hospital, NF, ICF-DD, or ICF-MD.

Other 1937 Benefit Provided: Source: Section 1937 C Option Benchmark Benefit Community First Choice Option Packone of Coverage Option benenmar ' ig

Authorization: Provider Qualifications:

Other Medicaid State Plan

Amount Limit: Duration Limit:

None None

Scope Limit:

Medical necessity as described in "other."

TN No: 13-035 California

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CcmMs. Alternative Benefit Plan

Other:

1915(k) State Plan. Effective on July 1, 2013, an individual is eligible for CFCO services when, (1) he or

she is in an eligibility group under the State Plan that includes nursing facility services or has an income that is at or below 150 percent of the Federal Poverty Level, and in addition, (2) it is determined that in the absence of home and community-based attendant services and supports, he or she would otherwise require a Medicaid-covered level of care furnished in a hospital, a nursing facility, an intermediate care facility for the mentally retarded, an institution providing psychiatric services (for individuals under age 21), or an institution for mental diseases (for individuals age 65 and over). The individual is unable to perform some activity of daily living independently and without access to this service would be at risk of placement in out-of-home care. Services include assistance with Activities of Daily Living; and acquisition, maintenance and enhancement of skills necessary for the individual to accomplish activities of daily living and health related tasks. The California Department of Social Services will complete authorization by annual review or as needed when the individual's support needs or circumstances change, or at the request of the individual or the individual's representative. EPSDT beneficiaries may receive additional services for medical necessity.

Other 1937 Benefit Provided: Source: " " Section 1937 Coverage Option Benchmark Benefit Home and Community Based Services acles Package

Authorization: Provider Qualifications:

Prior Authorization Medicaid State Plan

Amount Limit: Duration Limit:

None None

Scope Limit:

Medical necessity as described in "other."

Other:

1915(i) State Plan. Must have developmental disability and need habilitation services. Individual must have a condition that results in major impairment of cognitive and/or social functioning and is likely to retain new skills through habilitation. Services include habilitation — community living arrangement services, supported living services, day services, behavioral intervention services, respite care, supported employment, prevocational services, homemaker services, home health aide services, community based adult services; personal emergency response systems: and vehicle modification and adaptation services. A developmental disability is a condition that originated before the age of 18, expected to continue indefinitely and constitute a substantial disability for the individual. It includes mental retardation, cerebral palsy, autism and any other disabling conditions similar to mental retardation, but not handicapping conditions solely physical in nature.

Add

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Alternative Benefit Plan

OMB Control Number: 0938-1148

Attachment 3

EP:

Assurances

If the target population includes persons under 21, please complete the following assurances regarding EPSDT. Otherwise, skip to the Prescription Drug Coverage Assurances below.

The alternative benefit plan includes beneficiaries under 21 years of age. y

The state/territory assures that the notice to an individual includes a description of the method for ensuring access to EPSDT services (42 CFR 440,345).

The state/territory assures EPSDT services will be provided to individuals under 21 years of age who are covered under the state/ territory plan under section 1902(a)(10)(A) of the Act.

Indicate whether EPSDT services will be provided only through an Alternative Benefit Plan or whether the state/territory will provide additional benefits to ensure EPSDT services:

@ Through an Alternative Benefit Plan. C Through an Alternative Benefit Plan with additional benefits to ensure EPSDT services as defined in 1905(r).

Other Information regarding how ESPDT benefits will be provided to participants under 21 years of age (optional):

Prescription Drug Coverage Assurances

The state/territory assures that it meets the minimum requirements for prescription drug coverage in section 1937 of the Act and implementing regulations at 42 CFR 440.347. Coverage is at least the greater of one drug in each United States Pharmacopeia (USP) category and class or the same number of prescription drugs in each category and class as the base benchmark.

The state/territory assures that procedures are in place to allow a beneficiary to request and gain access to clinically appropriate prescription drugs when not covered.

The state/territory assures that when it pays for outpatient prescription drugs covered under an Alternative Benefit Plan, it meets the requirements of section 1927 of the Act and implementing regulations at 42 CFR 440.345, except for those requirements that are directly contrary to amount, duration and scope of coverage permitted under section 1937 of the Act.

The state/territory assures that when conducting prior authorization of prescription drugs under an Alternative Benefit Plan, it complies with prior authorization program requirements in section 1927(d)(5) of the Act.

Other Benefit Assurances

The state/territory assures that substituted benefits are actuarially equivalent to the benefits they replaced from the base benchmark plan, and that the state/territory has actuarial certification for substituted benefits available for CMS inspection if requested by CMS.

The state/territory assures that individuals will have access to services in Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC) as defined in subparagraphs (B) and (C) of section 1905(a)(2) of the Social Security Act.

The state/territory assures that payment for RHC and FQHC services is made in accordance with the requirements of section 1902(bb) of the Social Security Act.

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Alternative Benefit Plan

[¥] The state/territory assures that it will comply with the requirement of section 1937(b)(5) of the Act by providing, effective January 1. 2014, to all Alternative Benefit Plan participants at least Essential Health Benefits as described in section 1302(b) of the Patient Protection and Affordable Care Act.

[¥] The state/territory assures that it will comply with the mental health and substance use disorder parity requirements of section 1937(b)(6) of the Act by ensuring that the financial requirements and treatment limitations applicable to mental health or substance use disorder benefits comply with the requirements of section 2705(a) of the Public Health Service Act in the same manner as such requirements apply to a group health plan.

[¥] The state/territory assures that it will comply with section 1937(b)(7) of the Act by ensuring that,benefits provided to Alternative Benefit Plan participants include, for any individual described in section 1905(a)(4)(C), medical assistance for family planning services and supplies in accordance with such section.

The state/territory assures transportation (emergency and non-emergency) for individuals enrolled in an Alternative Benefit Plan in accordance with 42 CFR 431,53.

The state/territory assures, in accordance with 45 CFR 156.115(a)(4) and 45 CFR 147.130, that it will provide as Essential Health Benefits a broad range of preventive services including: “A” and “B” services recommended by the United States Preventive Services Task Force; Advisory Committee for Immunization Practices (ACIP) recommended vaccines: preventive care and screening for infants, children and adults recommended by HRSA's Bright Futures program/project; and additional preventive services for women recommended by the Institute of Medicine (IOM).

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 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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c cms Alternative Benefit Plan

CMT MEINE & RE RI REET

OMB Control Number: 0938-1148 Attachment 3 -L-[ | OMB Expiration date: 10/31/2014

Provide detail on the type of delivery system(s) the state/territory will use for the Alternative Benefit Plan's benchmark benefit package or benchmark-equivalent benefit package, including arly variation by the participants’ geographic area.

Type of service delivery system(s) the state/territory will use for this Alternative Benefit Plan(s).

Select one or more service delivery systems: [X] Managed care. X] Managed Care Organizations (MCO). [X] Prepaid Inpatient Health Plans (PTHP). (] Prepaid Ambulatory Health Plans (PAHP). (-] Primary Care Case Management (PCCM). Fee-for-service. (C] Other service delivery system. Managed Care Options Managed Care Assurance

The state/territory certifies that it will comply with all applicable Medicaid laws and regulations, including but not limited to sections 1903(m), 1905(t), and 1932 of the Act and 42 CFR Part 438, in providing managed care services through this Alternative Benetit Plan. This includes the requirement for CMS approval of contracts and rates pursuant to 42 CFR 438.6.

Managed Care Implementation

Please describe the implementation plan for the Alternative Benefit Plan under managed care including member, stakeholder, and provider outreach efforts.

CA has actively engaged in numerous activities to ensure successful expansion of Medicaid coverage to newly eligible adults. CA is expecting that approximately 600,000 eligible beneficiaries will be covered on January |, 2014 with a projected take up between 30,000-45.000 a month over the course of the first year. CA has 35 health plan contract amendments and has worked closely with the Region 9 team to ensure all 35 contracts are executed prior to January |, 2014. To ensure network adequacy, CA assessed health plan capacity based on the provider ratios, such as PCPs (1:2000) and Physicians (1:1200) as well as measures of time and distance to Hospitals and PCPs (10 miles or 30 minutes), Additionally, CA took into account the Primary Care Physicians who are accepting new patients.

The majority of the newly eligible adults will be enrolled in Medi-Cal managed care through the administrative eligibility transition of the current Low Income Health Program (LTHP) population. LIHP is a county-based, optional health care services program under the California “Bridge to Reform” §1115 Medicaid Demonstration. To meet expansion goals, DHCS in collaboration with stakeholders implemented a LIHP Transition Plan to ensure a seamless transition of LIHP enrollees to the Medi-Cal Program. CA monitors network capacity and access issues on a quarterly basis. Additionally, CA monitors access to care through an Ombudsman’s office for Managed Care enrollees and a compliance call center through its Licensing department. CA will determine trends or daily activities to work with health plans to address issues or concerns of access to care. As a result of extensive preparation, CA remains in good standing to implement effective January 1, 2014.

MCO: Managed Care Organization

The managed care delivery system is the same as an already approved managed care program. Yes

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CCmMSs Alternative Benefit Plan

The managed care program is operating under (select one):

C Section 1915(a) voluntary managed care program.

C Section 1915(b) managed care waiver.

C Section 1932(a) mandatory managed care state plan amendment.

@ Section 1115 demonstration.

C Section 1937 Alternative (Benchmark) Benefit Plan state plan amendment.

Identify the date the managed care program was approved by CMS: Jun 28, 2013

Describe program below:

The State submitted a section 1115 Demonstration proposal as a bridge toward full health care reform implementation in 2014. This proposal allows CA to phase in coverage in individual counties for adults aged 19-64 with incomes at or below 133 percent of the federal poverty level (FPL), who are eligible under the new Affordable Care Act State option and adults between 133 percent - 200 percent of the FPL who are not otherwise eligible for Medicaid: expand the existing Safety Net Care Pool (SNCP) that was established to ensure continued government support for the provision of health care to the uninsured by hospitals, clinics, and other providers; implement a series of infrastructure improvements through a new funding sub-pool, that would be used to strengthen care coordination, enhance primary care and improve the quality of patient care; create coordinated systems of care for Seniors and Persons with Disabilities (SPDs) in counties with new or existing Medi-Cal managed care organizations through the mandatory enrollment of the population into Medicaid managed care plans.

Additional Information: MCO (Optional)

Provide any additional details regarding this service delivery system (optional):

PIHP: Prepaid Inpatient Health Plan

The managed care delivery system is the same as an already approved managed care program. ‘Yes

The managed care program is operating under (select one): C Section 1915(a) voluntary managed care program. @ Section 1915(b) managed care waiver.

C Section 1115 demonstration.

C Section 1937 Alternative (Benchmark) Benefit Plan state plan amendment.

Identify the date the managed care program was approved by CMS: December 26, 2013

Describe program below:

1915 (b) Medi-Cal Specialty Mental Health Services (SMHS) Consolidation. Section 1915 (b) waivers relevant to Specialty Mental Health Services (SMHS) have been in effect in California since 1995. An eighth renewal of the SMHS waiver has been granted for a two year period effective July 1, 2013-June 30, 2015. For the purposes of the SMHS waiver program, persons with special health care needs are adults who have a serious mental disorder and children with a serious emotional disturbance. These beneficiaries are identified through the assessment process by the county Mental Health Plan (MHP) as meeting the SMHS medical necessity criteria. The design of managed care for California’s Medi-Cal mental health program was phased in

over several years. The State’s enabling legislation for this waiver is set forth at Welfare and Institutions (W&I) Code, Sections 14680-14685.1 and 14700-14726.

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CcCmMs. Alternative Benefit Plan

All Medi-Cal beneficiaries are enrolled in the SMHS waiver and have access to the services provided through the waiver If they meet the medical necessity criteria. During the eighth waiver renewal SMHS will be provided to the newly eligible adult beneficiaries by the county MHPs. CMS approved a waiver amendment request to include this population on December 26, 2013.

The PIHPs are not at risk for FFP for the cost of services. The SMHS Consolidation waiver program is administered locally by each county’s MHP and each county’s MHP provides, or arranges for, specialty mental health services for Medi-Cal beneficiaries. MHPs are not paid on a capitated basis; instead, MHPs are paid on a fee-for-service basis.

Beneficiaries are automatically enrolled in the single MHP in their county. The State continues to contractually require MHPs to ensure the availability and accessibility of adequate numbers of institutional facilities, service locations, service sites, and professional, allied and supportive personnel to provide medically necessary services, and ensure the authorization of services for urgent conditions on a one-hour basis.

Beneficiaries are provided with a choice of providers within the MHP and an opportunity to change providers whenever feasible. Although the regulation allows MHPs to limit the beneficiary's choice to two (2) providers, the beneficiary may request an additional change if not satisfied: the opportunity for choice may be limited by feasibility. In most cases, feasibility is linked to the number of providers in the MHP's network.

Access continues to be assured and monitored through state regulations, and the MHP contract, the State’s review and approval of any amendments to the MHPs implementation plans for the program on-going contract management by the State; and formal triennial reviews of the MHPs conducted by State staff, and annual External Quality Reviews conducted by the contracted External Quality Review Organization.

Additional Information: PIHP (Optional)

Provide any additional details regarding this service delivery system (optional):

Fee-For-Service Options

Indicate whether the state/territory offers traditional fee-for-service and/or services managed under an administrative services organization:

@ Traditional state-managed fee-for-service

C Services managed under an administrative services organization (ASO) arrangement

Please describe this fee-for-service delivery system, including any bundled payment arrangements, pay for performance, fee-for- service care management models/non-risk, contractual incentives as well as the population served via this delivery system.

A significant proportion of total Medi-Cal expenditures are generated through the FFS health care delivery system. FFS providers render services and then submit claims for payment that are adjudicated, processed and paid (or denied) by the Medi-Cal program’s fiscal intermediary. Generally, Medi-Cal outpatient FFS rates are set at no more than 80% of the California Specific Medicare Rate. The CA-MMIS system reimburses at no more than the maximum allowable rate that is on file in the system. Further, as a result of the Managed Care expansion in California, all 58 counties now participate in a Managed Care system, which prior to the expansion served approximately 74% of the total Medi-Cal population or about 6.0M Medi-Cal beneficiaries in 30 counties.

Specified services are carved out of the Managed Care Plans and only reimbursed via FFS, such as county based Specialty Mental Health Services (1915 (b) waiver) and Substance Use Disorder Services, which are reimbursed on a cost-based fee-for-service basis, based on certified public expenditures.

Additional Information: Fee-For-Service (Optional)

Provide any additional details regarding this service delivery system (optional):

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Alternative Benefit Plan

OMB Control Number: 0938-1148 Attachment 3.1 OMB Expiration date: 10/31/2014

The state/territory provides the Alternative Benefit Plan through the payment of employer sponsored insurance for participants

with such coverage, with additional benefits and services provided through a Benchmark or Benchmark-Equivalent Benefit No Package.

The state/territory otherwise provides for payment of premiums. Yes

Provide a description including the population covered, the amount of premium assistance by population, required contributions, cost-effectiveness test requirements, and benefits information.

The Medicaid agency pays insurance premiums for medical or any other type of remedial care to maintain a third party resource for Medicaid covered services provided to eligible individuals. The requirements for Requirements for Health Insurance Premium Payment (HIPP) Program / Cost Avoidance: Full scope or fee-for-service Medi-Cal: a high cost medical condition that requires on- going treatment from a medical provider; current health insurance coverage (or access to health coverage through an employer at the time of application) — policy must cover the health condition.

Other Information Regarding Employer Sponsored Insurance or Payment of Premiums:

The state assures that ESI coverage is established in sections 3.2 and 4.22(c) of the state’s approved Medicaid state plan. The beneficiary will receive a benefit package that includes a wrap of benefits around the employer sponsored insurance plan that equals the benefit package to which the beneficiary is entitled. The beneficiary will not be responsible for payment of premiums or other cost sharing that exceeds nominal levels as established at 42 CFR part 447 subpart A.”

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 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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CCMS Alternative Benefit Plan

OMB Control Number: 0938-1148 Attachment 3.1-L [] OMB Expiration date: 10/31/2014

Economy and Efficiency of Plans

The state/territory assures that Alternative Benefit Plan coverage is provided in accordance with Federal upper payment limit requirements and other economy and efficiency principles that would otherwise be applicable to the services or delivery system through which the coverage and benefits are obtained.

Economy and efficiency will be achieved using the same approach as used for Medicaid state plan services. Yes

Compliance with the Law

The state/territory will continue to comply with all other provisions of the Social Security Act in the administration of the state/ territory plan under this title.

The state/territory assures that Alternative Benefit Plan benefits designs shall conform to the non-discrimination requirements at 42 CFR 430.2 and 42 CFR 440.347(e).

[Y] The state/territory assures that all providers of Alternative Benefit Plan benefits shall meet the provider qualification requirements of the Base Benchmark Plan and/or the Medicaid state plan.

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 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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4VQQMFNFOUUP"UUBDINFOU# QBHFT -JNJUBUJPOTPO"UUBDINFOU" QBHFTC Q -JNJUBUJPOTPO"UUBDINFOU# QBHFTC Q -JNJUBUJPOTPO"UUBDINFOU" QBHFT N -JNJUBUJPOTPO"UUBDINFOU# QBHFT N 4VQQMFNFOUUP"UUBDINFOU# QBHFT -JNJUBUJPOTPO"UUBDINFOU" QBHFTC Q 4FFCPYCFMPXGPSBEEJUJPOBMQBHFT .BSDI %JSFDUPS %JWJTJPOPG1SPHSBN0QFSBUJPOT @@@@@@@@@ @@@@@@@@@ 5IFTFDIBOHFTXFSFTVCNJUUFEPOJOSFTQPOTFUP$.4h3FRVFTU +BOVBSZ +BNFT(4DPUU 5IFTUBUFVQEBUFEUIFJNQBDUFE4UBUF1MBOQBHFTGPSCPYFT GPS"EEJUJPOBM*OGPSNBUJPO 3"* RVFTUJPOT "EEJUJPOBMQBHFTGPSCPY -JNJUBUJPOTPO"UUBDINFOU# QBHFTC Q -JNJUBUJPOTPO"UUBDINFOU" QBHFT N -JNJUBUJPOTPO"UUBDINFOU# QBHFT N @@@@@@@@@@@@@@+BOVBSZ #PY$.4SFWJTFECVEHFUJNQBDUOVNCFSTCBTFEPO%)$4SFTQPOTFUP$.43"*RVFTUJPOTEBUFE5IFTFQFOJOLSFWJTJPOTBSFNBEF JOUIPVTBOETVOJUT #PY$.4QFOJOLSFWJTJPOUP41"FGGFDUJWFEBUFQFS$"hTQFSNJTTJPOJOFNBJMEBUFE 0DUPCFS DEPARTMENT OF HEALTH AND HUMAN SERVICES IIEALTII CARE FINANCING ADMINISTRATION FORM APPROVED 0MB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF L TRANSMITTAL NUMBER: 2. STATE California STATE PLAN MATERIAL 16-00 I 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 January 1, 2016 ---- 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN [gjAMENDMENT 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: Social Sccurit Act 1915 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Supplement le lo Allachment 3.1-A, pages 1-5 10. SUBJECT OF AMENDMENT: Targeted Case Management Services-All Medicaid Eligible 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 WITHIN 45 DAYS OF SUBMITTAL 12.S FFICIAL: E: State Medicaid Director R 2 9 016 15. DATE SUBMITTED: a. FFY 2015 $ unknown b. FFY 2016 $ unknown 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Supplement le to Allachment 3.1-A, pages 1-4 [gj 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 71.326 P.O. Box 997417 Sacramento, CA 95899-74L7 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 118. DATE APPROVED: PLAN APPROVED - ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: ----=-:=---:-:-:--=-=-=------ ------- --t-::-=-=:=::-::: 21. TYPED NAME: 22. TITLE: 23. REMARKS: FORM HCFA-179 (07-92)

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Limitations on Attachment 3.1-A Page 9p STATE PLAN CHART TN No.16-001 Supersedes TN No. 15-021 Approval Date Effective Date January 2, 2016 Type of Services Program Coverage** Prior Authorization or Other Requirements* 4b EPSDT (cont.) Services provided by LEA providers (cont.) *Prior authorization is not required for emergency services. **Coverage is limited to medically necessary services. Targeted Case Management (TCM) Services Definition: As defined in Supplement 1c to Attachment 3.1-A. Qualified Practitioner Type: x Associate Marriage and Family Therapists x Certified Nurse Practitioners x Certified Public Health Nurses x Credentialed School Counselors x Credentialed School Psychologists x Credentialed School Social Workers x Credentialed Speech-Language Pathologists x Licensed Clinical Social Workers x Licensed Educational Psychologists x Licensed Marriage and Family Therapists x Licensed Occupational Therapists x Licensed Physical Therapists x Licensed Psychologists x Licensed Registered Nurses x Licensed Speech-Language Pathologist x Licensed Vocational Nurses x Program Specialists x Registered Associate Clinical Social Workers x Registered Credentialed School Nurses Practitioner qualifications, limits and supervision requirements: x 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 x An individual with at least a Bachelor’s degree from an accredited college or university, who has completed a LEA agency- approved case management training course, or x An individual with at least an Associate of Arts degree from an accredited college, who has completed a LEA agency-approved case management training course and has two years of experience performing case management duties in the health or human services field, or x An individual who has completed a LEA agency-approved case management training course and has four years of experience performing case management duties in a health or human services field. 2FWREHU

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Limitations on Attachment 3.1-A Page 29m STATE PLAN CHART TN No. 16-001 Supersedes TN No.15-021 Approval Date Effective Date January 2, 2016 Type of Services Program Coverage** Prior Authorization or Other Requirements* 24g Local Educational Agency (LEA) Services (cont.) *Prior authorization is not required for emergency services. **Coverage is limited to medically necessary services. Targeted Case Management (TCM) Services Definition: As defined in Supplement 1c to Attachment 3.1-A. Qualified Practitioner Type: x Associate Marriage and Family Therapists x Certified Nurse Practitioners x Certified Public Health Nurses x Credentialed School Counselors x Credentialed School Psychologists x Credentialed School Social Workers x Credentialed Speech-Language Pathologists x Licensed Clinical Social Workers x Licensed Educational Psychologists x Licensed Marriage and Family Therapists x Licensed Occupational Therapists x Licensed Physical Therapists x Licensed Psychologists x Licensed Registered Nurses x Licensed Speech-Language Pathologist x Licensed Vocational Nurses x Program Specialists x Registered Associate Clinical Social Workers x Registered Credentialed School Nurses Practitioner qualifications, limits and supervision requirements: x 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 x An individual with at least a Bachelor’s degree from an accredited college or university, who has completed a LEA agency- approved case management training course, or x An individual with at least an Associate of Arts degree from an accredited college, who has completed a LEA agency-approved case management training course and has two years of experience performing case management duties in the health or human services field, or x An individual who has completed a LEA agency-approved case management training course and has four years of experience performing case management duties in a health or human services field. 2FWREHU

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Limitations on Attachment 3.1-B Page 9p STATE PLAN CHART TN No. 16-001 Supersedes TN No. 15-021 Approval Date Effective Date January 2, 2016 Type of Services Program Coverage** Prior Authorization or Other Requirements* 4b EPSDT (cont.) Services provided by LEA providers (cont.) *Prior authorization is not required for emergency services. **Coverage is limited to medically necessary services. Targeted Case Management (TCM) Services Definition: As defined in Supplement 1c to Attachment 3.1-A. Qualified Practitioner Type: x Associate Marriage and Family Therapists x Certified Nurse Practitioners x Certified Public Health Nurses x Credentialed School Counselors x Credentialed School Psychologists x Credentialed School Social Workers x Credentialed Speech-Language Pathologists x Licensed Clinical Social Workers x Licensed Educational Psychologists x Licensed Marriage and Family Therapists x Licensed Occupational Therapists x Licensed Physical Therapists x Licensed Psychologists x Licensed Registered Nurses x Licensed Speech-Language Pathologist x Licensed Vocational Nurses x Program Specialists x Registered Associate Clinical Social Workers x Registered Credentialed School Nurses Practitioner qualifications, limits and supervision requirements: x 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 x An individual with at least a Bachelor’s degree from an accredited college or university, who has completed a LEA agency- approved case management training course, or x An individual with at least an Associate of Arts degree from an accredited college, who has completed a LEA agency-approved case management training course and has two years of experience performing case management duties in the health or human services field, or x An individual who has completed a LEA agency-approved case management training course and has four years of experience performing case management duties in a health or human services field. 2FWREHU

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Limitations on Attachment 3.1-B Page 28m STATE PLAN CHART TN No. 16-001 Supersedes TN No. 15-021 Approval Date Effective Date January 2, 2016 Type of Services Program Coverage** Prior Authorization or Other Requirements* 23g Local Educational Agency (LEA) Services (cont.) *Prior authorization is not required for emergency services. **Coverage is limited to medically necessary services. Targeted Case Management (TCM) Services Definition: As defined in Supplement 1c to Attachment 3.1-A. Qualified Practitioner Type: x Associate Marriage and Family Therapists x Certified Nurse Practitioners x Certified Public Health Nurses x Credentialed School Counselors x Credentialed School Psychologists x Credentialed School Social Workers x Credentialed Speech-Language Pathologists x Licensed Clinical Social Workers x Licensed Educational Psychologists x Licensed Marriage and Family Therapists x Licensed Occupational Therapists x Licensed Physical Therapists x Licensed Psychologists x Licensed Registered Nurses x Licensed Speech-Language Pathologist x Licensed Vocational Nurses x Program Specialists x Registered Associate Clinical Social Workers x Registered Credentialed School Nurses Practitioner qualifications, limits and supervision requirements: x 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 x An individual with at least a Bachelor’s degree from an accredited college or university, who has completed a LEA agency- approved case management training course, or x An individual with at least an Associate of Arts degree from an accredited college, who has completed a LEA agency-approved case management training course and has two years of experience performing case management duties in the health or human services field, or x An individual who has completed a LEA agency-approved case management training course and has four years of experience performing case management duties in a health or human services field. 2FWREHU

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Supplement 1c to Attachment 3.1-A Page 1 State Plan under Title XIX of the Social Security Act State/Territory: CALIFORNIA TARGETED CASE MANAGEMENT SERVICES MEDICAID ELIGIBLE STUDENTS UNDER AGE 22 TN No. 16-001 Supersedes: TN No. 12-009 Effective Date: January 2, 2016 Approval Date ______ Target Group (42 Code of Federal Regulations 441.18(a)(8)(i) and 441.18(a)(9) Local Educational Agency (LEA) eligible beneficiaries include students under age 22 who are Medicaid eligible beneficiaries and have an Individualized Education Plan (IEP) or Individualized Family Service Plan (IFSP) under the Individuals with Disabilities Education Act (IDEA) or an Individualized Health and Support Plan (IHSP). An IHSP, also known as a “Care Plan”, is a medical management tool for providing medically necessary direct healthcare services to a student in a school setting. Other common names for an IHSP can include, but are not limited to: Individualized School Healthcare Plan, Individualized Healthcare Plan, Treatment Plan, Plan of Care, Nursing Plan and Section 504 Plan. Areas of state in which services will be provided (§1915(g)(1) of the Act): X_ Entire State ___ Only in the following geographic areas: Comparability of services (§§1902(a)(10)(B) and 1915(g)(1)) ___ Services are provided in accordance with §1902(a)(10)(B) of the Act. X_ Services are not comparable in amount duration and scope (§1915(g)(1)). Definition of services (42 CFR 440.169): TCM services are defined as services furnished to assist students, eligible under the State Plan, in gaining access to needed medical, social, educational, and other services. TCM includes the following assistance: 1. Comprehensive assessment and periodic reassessment of students needs, to determine the need for any medical, educational, social or other services. These assessment activities include: x Reviewing individual’s records, such as cumulative files, health history, and/or medical records; x Interviewing the students and/or parent/guardian; x Observing the students in the classroom and other appropriate settings; and x Writing a report to summarize assessment results and recommendations for additional LEA services; Assessment and/or periodic reassessment to be conducted on an annual, triennial and as needed basis (one amended assessment allowed to be reimbursed for each service type every 30 days) to determine if a student’s needs, conditions, and/or preferences have changed. 2FWREHU

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Supplement 1c to Attachment 3.1-A Page 2 State Plan under Title XIX of the Social Security Act State/Territory: CALIFORNIA TARGETED CASE MANAGEMENT SERVICES MEDICAID ELIGIBLE STUDENTS UNDER AGE 22 TN No. 16-001 Supersedes: TN No. 12-009 Effective Date: January 2, 2016 Approval Date ______ 2. Development (and periodic revision) of a student’s Care Plan that is based on the information collected through the assessment that: x Specifies the goals and actions to address the medical, social, educational, and other services needed by the student; x Includes meeting with the student and parent(s) or guardian(s) to establish needs; x Includes activities such as ensuring the active participation of the eligible student, and working with the individual (or the student’ authorized health care decision maker) and others to develop those goals; and x Identifies a course of action to respond to the assessed needs of the eligible student; 3. Referral and related activities (such as scheduling appointments for the student to help the eligible student obtain needed services including: x Activities that help link the student 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: x Activities and contacts that are necessary to ensure the Care Plan is implemented and adequately addresses the eligible student’s needs, and which may be with the individual, family members, service providers, or other entities or students 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 student’s Care Plan; o Services in the Care Plan are adequate; and o Changes in the needs or status of the student 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. X_ Case management includes contacts with non-eligible students that are directly related to identifying the eligible student’s needs and care, for the purposes of: helping the eligible student access services; identifying needs and supports to assist the eligible 2FWREHU

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Supplement 1c to Attachment 3.1-A Page 3 State Plan under Title XIX of the Social Security Act State/Territory: CALIFORNIA TARGETED CASE MANAGEMENT SERVICES MEDICAID ELIGIBLE STUDENTS UNDER AGE 22 TN No. 16-001 Supersedes: TN No. 12-009 Effective Date: January 2, 2016 Approval Date ______ student in obtaining services; providing case managers with useful feedback, and alerting case managers to changes in the eligible student’s needs. (42 CFR 440.169(e)) Qualifications of providers (42 CFR 441.18(a)(8)(v) and 42 CFR 441.18(b)): TCM Provider Agency Qualifications: x Must be an agency employing staff or contracting with qualified practitioners with case management qualifications; and x Have demonstrated the ability to collaborate with public and private service providers; and x Have demonstrated direct experience in the coordination of educational support services (e.g. Early Periodic Screening, Diagnosis, and Treatment, Social Services; Counseling Services; Psychological Services; Student Assistance; Special Education; and Nutritional Services); and x Have an administrative capacity to ensure quality of services in accordance with state and federal requirements; and x Have a financial management capacity and system that provides documentation of services and costs. For entities that also furnish services by another federally funded program, costs must be in accordance with OMB A- 87 principles; and x Have a capacity to document and maintain individual case records in accordance with state and federal requirements; and x Have demonstrated ability to meet all state and federal laws governing the participation of providers in the state Medicaid program, including, but not limited to, the ability to meet federal and state requirements for documentation, billing and audits. TCM Case Manager Qualifications: Case managers employed by the TCM Provider Agency must meet the requirements for education and/or experience as defined below: x 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 x 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 x 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 2FWREHU

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Supplement 1c to Attachment 3.1-A Page 4 State Plan under Title XIX of the Social Security Act State/Territory: CALIFORNIA TARGETED CASE MANAGEMENT SERVICES MEDICAID ELIGIBLE STUDENTS UNDER AGE 22 TN No. 16-001 Supersedes: TN No. 12-009 Effective Date: January 2, 2016 Approval Date ______ x 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 will ensure the provision of TCM services will not restrict a student’s free choice of providers in violation of section 1902(a)(23) of the Act. x Eligible students will have free choice of any qualified Medicaid provider. x Eligible students will have free choice of any qualified Medicaid providers of other medical care under the Care Plan . Access to Services (42 CFR 441.18(a)(2), 42 CFR 441.18(a)(3), 42 CFR 441.18(a)(6)): The state will ensure the following: x TCM services will not be used to restrict a student’s access to other services under the Care Plan; x Students will not be compelled to receive TCM services, condition receipt of TCM services on the receipt of other Medicaid services, or condition receipt of other Medicaid services on receipt of TCM services; and x Providers of TCM services do not exercise the agency’s authority to authorize or deny the provision of other services under the Care Plan . Payment (42 CFR 441.18(a)(4)): Payment for TCM services under the Care 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 will maintain case records that document the following information: name of the student; the dates of the case management services; name of the agency and the person providing the case management service; the nature, content, and units of case management services received and whether goals specified in the Care Plan have been achieved; whether the student has declined any services in the Care Plan, the need for, and occurrences of, coordination with other case managers; and a timeline for obtaining needed services; and a timeline for revaluation of the Care Plan . Students may receive TCM services from more than one agency or provider. To avoid duplication of services and billing, LEAs must clearly document the LEA and TCM services rendered by each TCM agency or provider, and where necessary, develop written agreements or protocols to define the TCM service(s) each agency or provider will be responsible for rendering. 2FWREHU

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Supplement 1c to Attachment 3.1-A Page 5 State Plan under Title XIX of the Social Security Act State/Territory: CALIFORNIA TARGETED CASE MANAGEMENT SERVICES MEDICAID ELIGIBLE STUDENTS UNDER AGE 22 TN No. 16-001 Supersedes 97-015 Effective Date: January 2, 2016 Approval Date ______ 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 student 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)) TCM services identified in the student’s IEP, IFSP or IHSP may be billed up to 32 units per individual per day. A unit is defined as 15 minutes of continuous treatment (any time over seven continuous treatment minutes can be billed as a 15-minute increment). TCM Services Do Not Include: x Provision of medical treatment or services, x Discharge planning from an institution, x Administrative activities of eligibility determination, screening, intake, outreach, and utilization review, or program activities that do not meet the definition of TCM, x Formal advocacy and development of new provider resources, x Payment for administration costs of other services or programs to which the child is referred, x General Medicaid administrative expenses, and prior authorization of services. x Diagnostic or treatment services, educational activities that may be reasonably expected in the school system, and x Services that are an integral part of another service already reimbursed by Medicaid.) and 1905(c)). 2FWREHU

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Attachment 4.19-B Supplement 8 Page | 3 OMB No.: TN No. 16-001 Supersedes TN No. 15-021 Approval Date ____________ Effective Date January 2, 2016 4. In rebasing periods, the Department will collect health care-related costs by type of practitioner from the cost report, including salary, benefits and other personnel expenses. Indirect costs will be calculated by applying the LEA’s approved indirect cost rate to the health-care related costs. Education-related costs will be excluded. The hourly basis for the costs will be based on total annual hours worked by practitioner type. C. Assessments 1. Median assessment times for IEP/IFSP assessments were developed using time reported in the IEP Time Survey and validated in interviews with health service practitioners. 2. Service Categories Assessment time from the IEP Time Survey was evaluated by service type (psychology, health, speech therapy, audiology, occupational therapy, and physical therapy) and IEP/IFSP type of review (initial, annual, triennial and amended). Two versions of IEP/IFSP assessment rates for each service type were developed: (a) Assessment conducted for an initial or triennial IEP/IFSP review The initial review is conducted for a student that has not yet been determined to be eligible for services under the Individuals with Disabilities Education Act (IDEA). The triennial review occurs every 36 months. (b) Assessment conducted for an annual or amended IEP/IFSP review The annual review occurs every year to determine whether the existing IEP/IFSP is appropriately meeting the needs of the student. The amended review occurs periodically when requested by a parent, guardian or professional working with the student or when a student transfers from one LEA to another. 3. Interim Rates for Assessment Services (a) Rates for assessments provided by social workers and counselors will be based on the time incremental cost of these practitioners and billed in service units representing 15-minute increments. (b) Rates for assessments provided by physicians will be based on the time incremental cost of school nurses (used as a proxy) and billed in service units representing 15-minute increments. The use of the school nurse cost as a proxy for physician cost is described in paragraph 3.(e). (c) Rates for assessments provided by optometrists will be based on the time incremental cost of school nurses (used as a proxy) and billed in service units 2FWREHU

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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 FORM HCFA-179 (07-92) TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION 1. TRANSMITTAL NUMBER: 17-021 2. STATE California 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, 2017 5. TYPE OF PLAN MATERIAL (Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: Affordable Care Act, Section 2301; W&I Code, Section 1405.28; and W&I Code, Section 14148.8 7. FEDERAL BUDGET IMPACT: a. FFY 2017 $6,250 b. FFY 2018 $18,750 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Attachment 4.19-B, page 65 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Attachment 4.19-B, page 65 10. SUBJECT OF AMENDMENT: Reimbursement for Alternative Birth Centers 11. GOVERNOR’S REVIEW (Check One): GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR’S OFFICE ENCLOSED The Governor’s Office does not NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL wish to review the State Plan Amendment. 12. SIGNATURE OF STATE AGENCY OFFICIAL: 13. TYPED NAME: Mari Cantwell 14. TITLE: State Medicaid Director 15. DATE SUBMITTED: FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: PLAN APPROVED – ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: 21. TYPED NAME: 22. TITLE: ------039 ________________________________________________________ _______________________ 42 CFR 447, Subpart F --------- $25,000 August 29, 2017 23. REMARKS: Boxes 1, 6 and 7: Pen and ink changes made per CA response to CMS informal questions made via email dated 10/16/17. Box 15: Pen and ink change made by CMS via CA email dated 11/14/17. August 29, 2017 July 1, 2017 Henrietta Sam-Louie Associate Regional Administrator, Division of Medicaid & Children's Health Operations November 22, 2017 /s/

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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 FORM HCFA-179 (07-92) TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION 1. TRANSMITTAL NUMBER: 18-0040 2. STATE CA 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, 2019 5. TYPE OF PLAN MATERIAL (Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: Social Security Act 1905(a)(13) 42 CFR 440.130 7. FEDERAL BUDGET IMPACT: a. FFY 2018 $116,000 b. FFY 2019 $252,000 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Limitations on Attachment 3.1-A, page 18c and 18d Limitations on Attachment 3.1-B, page 18c and 18d Supplement 33 to Attachment 4.19B, page 1 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Limitations on Attachment 3.1-A, page 18c Limitations on Attachment 3.1-B, page 18c Supplement 29 to Attachment 4.19B, page 1 10. SUBJECT OF AMENDMENT: Diabetes Prevention Program 11. GOVERNOR’S REVIEW (Check One): GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR’S OFFICE ENCLOSED The Governor’s Office does not NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL wish to review the State Plan Amendment. 1 OFFICIAL: 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 1 Mari Cantwell 14. TITLE: Chief Deputy Director Health Care Programs State Medicaid Director 15. DATE SUBMITTED: December 26, 2018 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: PLAN APPROVED – ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: 21. TYPED NAME: 22. TITLE: 23. REMARKS: Box 8: DHCS pen and ink change to add the new page 18d and the new Supplement 33 to Attachment 4.19B from Box 9 on 8/22/19. Director, Center for Medicaid & CHIP Services, Western Regional Operations Group Richard C. Allen December 26, 2018 January 1, 2019 October 24, 2019

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Limitations on Attachment 3.1-A

Page 18c STATE PLAN CHART

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

TN No. 18-0040 Supersedes

Approval Date: October 24, 2019

Effective Date: 1/1/2019 TN No. 18-011

TYPE OF SERVICE PROGRAM DESCRIPTION** PRIOR AUTHORIZATION OR OTHER REQUIREMENTS* 13c

13c

Preventive services (cont.) BHT Services (cont.)

Diabetes Prevention Program (DPP) Services

DPP services are a set of medically necessary services recommended by a physician or other licensed practitioner of the healing arts to prevent or delay the onset of type 2 diabetes for beneficiaries with indications of prediabetes, in accordance with 42 CFR 440.130(c).

DPP services provide a variety of behavioral and nutritional interventions identified as evidence- based by clinical research or studies and/or nationally recognized organizations specializing in disease control and prevention.

Medically necessary DPP services are provided during sessions that occur at regular, periodic intervals over the course of one year, and, if eligible based upon individual measurable health- outcomes, additional ongoing maintenance sessions at regular, periodic intervals for another year. At these sessions, DPP services include: Qualified Autism Service Professional (see BHT Services Chart in Supplement 6 to Attachment 3.1-A Page 1)

Qualified Autism Service Paraprofessional (see BHT Services Chart in Supplement 6 to Attachment 3.1-A Page 1)

A DPP services provider must be an organization enrolled in Medi-Cal and must have either pending, preliminary, or full recognition by the Centers for Disease Control and Prevention (CDC) for DPP. DPP services providers use lifestyle coaches for delivery of DPP services.

DPP services are delivered by lifestyle coaches and must have completed nationally recognized training for delivery of DPP services. Lifestyle coaches may be: • Physicians • Licensed nonphysician practitioners, such as nurses, and physical therapists. • Unlicensed practitioners under the supervision of a DPP services provider or a licensed Medi-Cal practitioner.

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Limitations on Attachment 3.1-B

Page 18c STATE PLAN CHART

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

TN No. 18-0040 Supersedes

Approval Date: October 24, 2019

Effective Date: 1/1/2019 TN No. 18-011

TYPE OF SERVICE PROGRAM DESCRIPTION** PRIOR AUTHORIZATION OR OTHER REQUIREMENTS* 13c

13c

Preventive services (cont.) BHT Services (cont.)

Diabetes Prevention Program (DPP) Services

Qualified Autism Service Paraprofessional (see BHT Services Chart in Supplement 6 to Attachment 3.1-A Page 1)

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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL 1. TRANSMITTAL NUMBER 2. STATE FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 3.PROGRAM IDENTIFICATION: TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE 5. TYPE OF PLAN MATERIAL (Check One) NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT a. FFY__________________ $ __________________ b. FFY__________________ $ __________________ 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) 10. SUBJECT OF AMENDMENT 11. GOVERNOR’S REVIEW (Check One) GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED COMMENTS OF GOVERNOR’S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL CY OFFICIAL 16. RETURN TO 13. TYPED NAME 14. TITLE 15. DATE SUBMITTED FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED 18. DATE APPROVED PLAN APPROVED - ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL 20. CIAL 21. TYPED NAME 22. TITLE 23. REMARKS FORM CMS-179 (07/92) Instructions on Back 1 9 0 0 15 California Title XIX of the Social Security Act (Medicaid) 07/01/2020 ■ 42 CRF Part 447 Subpart I - Payment for Drugs 2020 (1.25 million) 2021 (5 million) Supplement 2 to Attachment 4.19-B, page 9 Supplement 2 to Attachment 4.19-B, page 9 Proposed Changes to Blood Factors Reimbursement ■ Department of Health Care Services Attn: Director's Office P.O. Box 997413, MS 0000 Sacramento, CA 95899-7413 Mari Cantwell State Medicaid Director November 15, 2019 For Box 11 "Other, As Specified," Please note: The Governor’s Office does not wish to review the State Plan Amendment. November 15, 2019 January 24, 2020 July 1, 2020 James G. Scott Director, Division of Program Operations Medicaid & CHIP Operations Group

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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES FOFM APPROVED OMB No. 0938-0193 2 California 3. PROGRAM IDENTIFICATION: Title XIX of the Social Security Act (Medicaid) 4. PROPOSED EFFECTIVE DATE August 1,2019 Inueruouerur 5. TYPE OF PLAN MATERIAL (Check One) ! ruew srATE eLAN ! nuexoueNTTo BE coNStDERED AS NEW eLAN 1. TRANSMITTAL NUMBER 1 I -0 0 22 COMPLETE BLOCKS 6 THRU 10 lF THIS lS AN AMENDMENT (Separate transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION Title 42 S CFR 447 Subpart C 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT Attachment 4.19-D, Pages 35-35a 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (ff Appticabte) Attachment 4.19-D, Pages 35 7. FEDERAL BUDGET IMPACT a. FFY 18/19 b. FFY 19t20 1.767.483 10.604.900 $ $ 10. SUBJECT OF AMENDMENT Extension of the time-limited supplemental payment for lntermediate Care Facilities for the Developmentally Disabled, including Habilitative and Nursing facilities, using California Healthcare, Research and Prevention Tobacco Tax Act (Commonly known as Proposition 56). The supplemental payment extension would be for services rendered on or after August 1,2019 through December 31 ,2021. 11. GOVERNOR'S REVIEW (Check One) n covenruon's oFFrcE REeoRTED No coMMENT ! conaueruTs oF GovERNoB's oFFrcE ENCLoSED IorHrn, AS sPEcrFIED ¡ NO FEPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12 6. 13. Department of Health Care Services Attn: Director's Office P.O. Box 997413, MS 0000 Sacramento, CA 95899-741 3 Mari State dicaid Director 15. DATE SUBMITTED ust22 2019 OFFICE USE ONLY 14. FICIAL 17. DATE RECEIVED 18. DATEAPPROVED sEP 2 6 20t9 PLAN APPROVED . ONE COPY ATTACHED 19. EFFECTIVE DATE OFAPPROVED AUG (} 21. TYPED NAME MATERIAL 1 2019 22.-nTLE [ri¡ h "' (u^ þrruczlvt, lU6 23. REMARKS For Box 7 "Federal Budget lmpact", please note the additional information: c. FFy 20121= 910,604,900 d. FFy 2j122 = 92,651,225 For Box 11 "Other, As Specified," Please note: The Governor's Office does not wish to review the State Plan Amendment. 20. s FORM CMS-179 (07192) lnstructions on Back

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Attachment 4.19-D Page 35 Time Limited Supplemental Payment Program for Intermediate Care Facilities For The Developmentally Disabled, Including Habilitative And Nursing Facilities A. Scope and Authority This program provides supplementalpayments to Intemediate Care Facilities folthe Developmentally Disabled QCF/DD), Intennediate Care Facilities for the Developmentally Disabled-Habilitative 0CF/DD-H), and Intermediate Care Facilities for the Developmentally Disabled-Nursing (lCF/DD- N). The supplemental payments will be plovided for dates of service beginning August 1, 2017 through December 31,2021. State-owned ICF/DD facilities aré excluded from the supplemental payment. B. Supplemental PaymentMethodology The supplemental payment program for ICF/DD,ICF/DD-H, and ICF/DD-N facilities will consist of the following: Supplemental payments calculated based on the difference between the rate rnethodology applied to the 201 7- 1 8 rate year as desclibed in Attachment 4.19-D, Section IV, paragraph M, which is frozen at the 2008-09 65tr' percentile increased by 3.7%, and the unfrozen 2017-18 65n' percentile rate. The unfrozen 201 7- I 8 65rl' percentile rate is the rate that would have been calculated in Attachrnent 4.19-D, Section IV, without the application of paragraphs K through M. 2. The total fee-for-selvice supplenental payment amount for each facility will be calculated based on the supplemental payment peer group 2017-18 peldiem differential, as described in B 1., multiplied by the facility's total Medi-Cal fee-for-seruice days claimed for dates of service during each respective rate year ending July 31, 2018; July 31,2019; Iuly 31,2020; Iuly 31, 2021; and in the 2021-22 rate year for each patient day on or before December'31, 2021. Facilities in peer groups in which the unfroze¡2017-18 65t¡'percentile rate is lower than the 2017-18 reimbursement rate will not receive the supplemental payment. The supplemental payments will be paid concurently with the reimbursement rates the facilities receive under the current reimbursement methodology, as described in State PIan Amendment 4.l9-D. Thus, the total reimbursement amount that an eligible facility will receive for services rendered during each respective rate year ending July 31,2018; July 31,2019; July 31,2020; July 31,2021; and in the 2021-22 rate year for each patient day on or before December 31, 2021, is the sum ofthe facilif's reimbursement rate under the current reimbursement methodology and the supplemental payment. 4. The total Medi-Cal reimbursement shall not exceed any applicable federal upper payment limit. If the supplemental payments for eligible ICF/DD; ICF/DD-H; and ICF/DD-N facilities, as computed above, rcsult in total Medi-Cal payments that exceed the federal upper payment limit for each respective rate year ending July 31,2018; July 31,2019; Iuly 31,2020; Iuly 31,2021; and in the 2021-22 rate year for each palient day on or before December 3 l, 2021, each TN 19-0022 Supersedes TN l8-0029 Approval oate: SEP 2 6 2019 Effective Date:8l1l2o1g

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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: REGIONALADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES FOFM APPBOVED OMB No.0938-0193 2. STATE California 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT 4. PROPOSED EFFECTIVE DATE July 1 ,2019 []nueruouerur 5. TYPE OF PLAN MATERIAL (Check One) ! ¡lew srATE eLAN I nueruoueNT To BE coNStDERED AS NEW eLAN 1. TRANSMITTAL NUMBER 1 I -0 0 23 COMPLETE BLOCKS 6 THRU 10 lF THIS lS AN AMENDMENT lSeparate transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION 42 CFR 447 Subpart C 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT Supplement 4 to Attachment 4.19-4, Pages 1, 3, 4, 5, 8, 9, and 10 b. FFy2020 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMEN'I (lf Applicable) Supplement 4 to Attachment 4.'19-4, pages 1,3,4,5,8,9, and 10 7. FEDERAL BUDGET IMPACT a. FFY2019 $ $ 1 O. SUBJECT OF AMENDMENT SUPPLEMENTAL REIMBURSEMENT FOR QUALIFIED PRIVATE HOSPITALS 1 11. GOVERNOB'S REVIEW (Check One) I covenruon's oFFtcE REpoRTED No coMMENT I cotuurruTs oF covERNoR's oFFrcE ENcLoSED n NO REPLY RECETVED WtTHtN 45 DAYS OF SUBMTTTAL 13. Mari 14. TITLE State Medicaid Director 15. DATE SUBMITTED 2 @orHen, AS sPEcrFrED Department of Health Care Services Attn: State Plan Coordinator 1501 Capitol Avenue, Suite 71 .326 P.O. Box 997417 Sacramento, CA 95899-7 417 NAME 17. DATE RECEIVED 18. DATEAPPROVED JUL 1? 2019 19. EFFECTIVE DATE OFAPPROVED MATERIAL JUL 01 2019 21. TYPED NAME PLAN APPROVED. ONE COPY ATTACHED 20. src E OF REGIONALOFFICIAL 22 Ktish " Ç0., ir¿ chs-v- d 23. REMARKS For Box 11 "Other, As Specified," Please note: The Governor's Office does not wish to review the State Plan Amendment. Box 7: Pen and ink change submitted by state on0711612019. FORM CMS-179 (07192) lnstructions on Back

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Supplement 4 to Attachment4.l9 A Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: CALIFORNIA SUPPLEMENTAL REIMBURSEMENT FOR QUALIFIED PRIVATE HOSPITALS This segment of the State Plan describes an enhanced Medi-Cal payment for private hospitals that have a need for assistance in ensuring the availability of essential services for Medi-Cal beneficiaries, and that meet the requirements in Sections A and B below. The Private Hospital Supplemental Fund Program (PHSF) was established under Social Security Act (SSA) section 1915(b) wa¡ver (and starting in 2005 under a SSA section 1 I 15(a) Medicaid Demonstration) granting the Department of Health Care Services (DHCS) its authority to make PHSF supplemental payments to hospitals participating in the Medi-Cal Selective Provider Contracting Program (SPCP). The SPCP ended on June 30, 2013. This section of Attachment 4.19-A is written to continue the Department's federal authority for State Fiscal Years (SFYs) 2015-16 , 2016-17 , 2017-18, and 2018-19, and to extend the authority through SFY 2019-20, to provide supplemental reimbursement payments to private hospitals participating in the PHSF. The SPA effective date is July 1,2019. A. DEFINITION OF A PRIVATEHOSPITAL A private hospital is defined as a hospital that is Medi-Cal Certified and meets all of the following conditions: L ls licensed pursuant to subdivision (a) of section 1250 of the Health and Safety Code, as the law was in effect on July 1 ,2015. 2. ls in the Charitable Research Hospital peer group, as set forth in the 1991 Hospital Peer Grouping Report published þy the Department, or is not designated as a specialty hospital in the hospital's Office of Statewide Health Planning and Development Annual Financial Disclosure Report for the hospital's latest fiscalyear. 3. Does not satisfy the Medicare criteria to be classified as a long-term care hospital. 4. ls a nonpublic hospital, nonpublic converted hospital, or converted hospital as those terms are defined in paragraphs (26) to (28), inclusive, respectively, of subdivision (a) of section 14105.98 of the Welfare & lnstitutions Code, as the law was in effect on July 'l ,2015. TN No. 19-0023 Supersedes: TN No. l8-010 Approvat Date Jl'li I 7 20lgrtrect¡ve Date: Jutv 1,2019

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Supplement 4 to Attachment 4.19 A Page 4 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: CALIFORNIA SUPPLEMENTAL REIMBURSEMENT FOR QUALIFIED PRIVATE HOSPITALS Except for hospitals eligible under 8.2, DHCS shall identify DSH eligible hospitals for the applicable fiscal year from the Final DSH Eligibility List adopted by DHCS. lf the Final DSH Eligibility List is not available by November 1 of the SFY, then DHCS will utilizethe Tentative DSH Eligibility List. DHCS will then identifu any private DSH hospitals that meet other criteria for supplemental payment eligibility. b. The aggregate supplemental payment amount of 9237 ,144,384 for SFY 2015-'16 and $236,800,000 for SFYs 2016-17 ,2017-18, 2018-19 and 2019-20 will be paid to hospitals asfollows: lf the hospital is eligible to part¡cipate in the applicable SFY supplemental program and also participated in the SFY 2014-15 supplemental program, 85 percent of the funding received for SFY 2014-15 will be its amount for the applicable SFY. a. For a hospital eligible in the applicable SFY that did not participate in SFY 2014-15 supplemental program, but had participated ¡n a prior supplemental program year, its amount for the applicable SFY will be 85 percent of the funding it received in its most recent year in which it participated. lf the individual hospital's amount determined above in b.i. when divided by the sum of General Acute Care-Electronic Data System Fee For Service (GAC-EDS FFS), Administrative-Electronic Data System Fee For Service (Admin-EDS FFS), and the Well Baby-Electronic Data System Fee For Service (Well Baby-EDS FFS) inpatient days identified in the Final Medi-Cal Utilization Statistics for the current payment year (as specified on page 30, paragraph B of this Attachment), or the Tentative Medi-Cal Utilization Statistics for the current payment year if the Final is not available, as calculated by DHCS, is less than one hundred dollars ($100) per diem, then the hospital will receive a payment increase to get them up to the $100 per diem for its base supplemental paymentamount. TN No. l9-0023 Supersedes: TN No. 18-010 a. . Approval Date JUt I 7 2019 Effective Date: Julv 1. 2019

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Supplement 4 to Attachment 4.19 A Page 5 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: CALIFORNIA SUPPLEMENTAL REIMBURSEMENT FOR QUALIFIED PRIVATE HOSPITALS For any hospital eligible in the applicable SFY that has not previously been eligible to participate in PHSF dishibutions, a base supplemental payment amount for the applicable SFY will be calculated by multiplying a per diem payment of one hundred dollars ($100) times the sum of the 'GAC-EDS FFS', "Admin-EDS FFS" and the "Well Baby-EDS FFS" inpatient days identified in the Final Medi-Cal Utilization Statistics for the current payment year (as specified on page 30, paragraph B of this Attachment) as calculated byDHCS. lf a hospital eligible to participate in the SFY 2014-15 supplemental program divides into two or more separately licensed hospitals (i.e., the original licensed hospital and one or more newly licensed hospitals), and where one or more of those separately licensed hospitals continues after the separation to meet the eligibility criteria in Section B. for SFYs 201 5-1 6, 201 6-1 7, 201 7 -1 8, 20 1 8-1 I or 201 9-20, the original licensed hospital's payment amount for the applicable SFY will be calculated in accordance with steps C.1.b.i. and ii, and the newly licensed hosp¡tal's payment amount for the applicable SFY will be calculated in accordance with step C.1.b.iii. The sum of the amounts calculated for the eligible separately licensed (original and new) hospitals for any of those SFYs shall not exceed the amount calculated for the original licensed hospital and the payment amount for the original licensed hospital will be adjusted by the amount calculated for the eligible newly licensed hospital. lf prior to separation, the hospital participated during the previous five state fiscal years in the PHSF payment program, then the surviving, separated PHSF-eligible hospital will be considered to continue to meet the previous five-year participat¡on requirement for payment eligibility. Conversely, if two or more hospitals eligible to participate in the SFY 2014-15, or are newly eligible to participate in SFY's 2015- 16 or 2016-17 supplemental programs, consolidate and are eligible for SFYs 2015-16, 2016-17 , 2017-18, 2018-19 or 2019- 20, then the amount calculated for step C.1.b.i for the consolidated hospital is equal to the sum of 85 percent of the pre- TN No. 19-0023 .t¡t 1? Z0lg Supersedes: Approval Date___ Effective Date: Julv 1. 2019 TN No. 18-010 iii.

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Supplement 4 to Attachment 4.19 A Page I STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: CALIFORNIA SUPPLEMENTAL REIMBURSEMENT FOR QUALIFIED PRIVATE HOSPITALS those hospitals that are identified on the Final DSH Eligibility List adopted by DHCS or the Tentative DSH Eligibility List if the Final List is not available by November 1, and have been continuously eligible for PHSF payments during the previous five (5) State Fiscal Year PHSF payment programs and are eligible for the current year. Round C installment payment shall be for services rendered up to and including the fourth quafter of the applicable SFY and shall be distributed as determined under Section C.1.b.i through v. Round A and B installment payments shall be subtracted from the final adjusted payment amount to determine the Round C payment for each hospital. All hospitals shall be eligible to receive Round C payments if they are eligible under 8.2 or arc identified as being a DSH Eligible Hospital on the Final DSH Eligibility List for the applicable SFY and meet the eligibilitycriteria. i. For the applicable SFY, if a hospital is eligible under 8.1 through 8.4 and is paid a Round A and/or B installment payment based on the Tentative Medi-Cal Utilization Statistics for the applicable payment year, the Round A and/or B installment payments will be recalculated based on the Final Medi-Cal Utilization Statistics. The hospital's Round C payment will be adjusted to reflect the under or overpayment it received. ii. For the applicable SFY, if a hospital is eligible under 8.1 through 8.4 and is paid Round A and/or Round B installment payments based on being identified on the Tentative DSH Eligibility List, but is not identified on the Final DSH Eligibility List, then Round A and B payments will be recovered from the hospital and the hospital will not be eligible for Round C installment payment. iii. Payment(s) received by hospitals from the PHSF for SFYs 201 5-1 6, 201 6-1 7, 2017 -1 8, 201 8-1 I and 20 1 9-20 will be subject to recovery by the Department, if the Department determines that the hospital fails at any time during the respective fiscal years to meet eligibility criteria for PHSF distributions. lf the hospital fails to return the funds within 30 calendar daysfrom time of the Department's notification, the Department may TN No. 19-0023 Supersedes: TN No. 18-010 Approval DateJUL I 7 Z0l9 Effective Date: Julv 1.2019

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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL 1. TRANSMITTAL NUMBER 2. STATE FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 3. PROGRAM IDENTIFICATION: TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE 5. TYPE OF PLAN MATERIAL (Check One) NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT a. FFY__________________ $ __________________ b. FFY__________________ $ __________________ 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) 10. SUBJECT OF AMENDMENT 11. GOVERNOR’S REVIEW (Check One) GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED COMMENTS OF GOVERNOR’S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL CY OFFICIAL 16. RETURN TO 13. TYPED NAME 14. TITLE 15. DATE SUBMITTED FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED 18. DATE APPROVED PLAN APPROVED - ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL 20. SIGNATURE OF REGIONAL OFFICIAL 21. TYPED NAME 22. TITLE 23. REMARKS FORM CMS-179 (07/92) Instructions on Back __ F July 1, 2019 Richard C. Allen Director, Centers for Medicaid & CHIP Services, Regional Operations Group Box 6: CMS pen and ink correction made on 8/01/19 . July 3, 2019 August 14, 2019 1 9 0 0 38 California Title XIX of the Social Security Act (Medicaid) July 1, 2019 I 42 C.F.R. Part 447, Subpart B 2019 87,731,968 2020 350,927,872 Supplement 25 to Attachment 4.19-B page 1 Supplement 25 to Attachment 4.19-B page 1 Extension of the FY 2018-19 one-year supplemental payment for certain dental services using California Healthcare, Research and Prevention Tobacco Tax Act (Proposition 56 Tobacco Tax). The supplemental payment extension would be for services rendered on or after July 1, 2019 through December 31, 2021. I Department of Health Care Services Attn: Director's Office P.O. Box 997413, MS 0000 Sacramento, CA 95899-7413 Mari Cantwell State Medicaid Director July 3, 2019 For Box 11. "Other, As Specified," Please note: The Governor’s Office does not wish to review the State Plan Amendment. For Box 7. FFY 2021: October 2020 – September 2021 (approx. $350,927,872 mill) FFY 2022: October 2021 – December 2021 ((approx. $87,731,968 mill)

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Supplement 25 to Attachment 4.19-B

Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

STATE: California TN 19-0038 Supersedes Approval Date: August 14, 2019 Effective Date: July 1, 2019 TN 18-0024

Extend the Time Limited Proposition 56 Supplemental Payments for Certain Dental Services The Medi-Cal Dental Program will continue to provide time-limited supplemental payments, applied to certain dental services in the following dental categories: restorative, endodontic, prosthodontic, oral and maxillofacial, adjunctive, visits and diagnostic services for dates of service for the period of July 1, 2019 through December 31, 2021. These supplemental payment rates for the existing categories stated above will be between 20- 60 percent of the Dental Schedule of Maximum Allowances (SMA), unless a proposed change to the procedure code is identified in the table referenced below. For the previously identified top 26 utilized dental services, including general anesthesia, periodontal and orthodontia, the supplemental payments will continue to either reflect a specific dollar increase per the identified code or will be a percentage increase above the existing Medi- Cal SMA rate. The table reflecting the rates in effect on July 1, 2019 for the procedure codes that are eligible for the dental supplement payments can be found at this website: https://www.dhcs.ca.gov/services/Documents/MDSD/Prop%2056/Prop56DentalFY19- 21Codes.pdf

The supplemental payment for services in these categories will be reimbursed to providers who have the ability to bill for these services through the Dental Fiscal Intermediary, or Medi-Cal Dental providers who bill through the Dental Managed Care delivery system. The SMA and supplemental payment will be issued together on a claim line basis. The supplemental payments will be issued for the specified codes for dates of service during the period of July 1, 2019 through December 31, 2021. The SMA website link can be found here: https://www.denti- cal.ca.gov/DC_documents/providers/provider_handbook/handbook.pdf#page=240 For reference, the SMA is published in the Provider Services Handbook, Section 5, pages 5-106 through 5-126.

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1. TRANSMITTAL NUMBER 1 I -0 0 42 DEPABTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPBOVED OMB No.0938-0193 2. California 3. PROGRAM IDENTIFICATION : Title XIX of the Social Security Act (Medicaid) 4. PROPOSED EFFECTIVE DATE August 1,2019 Iaueruol,rerur 5. TYPE OF PLAN MATERIAL (Check One) ! ruew srATE eLAN I nueruourNTTo BE coNSTDERED AS NEW eLAN COMPLETE BLOCKS 6 THRU 10 lF THIS lS AN AMENDMENT (Separate transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION Title 42 S CFR 447 Subpart B & C 8. PAGE NUMBER OF THE PLAN SECTION OR ATÏACHMENT Attachment 4.19-D page 37 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (lf Applicabte) Attachment 4.19-D page 37 7. FEDERAL BUDGET IMPACT a. FFY 18/19 b. FFy 19/20 $ Zl3;12.8 666,667 g 4JZ8J66 a,ooo,ooo 1 O. SUBJECT OF AMENDMENT Extension of the time-limited supplemental payment for Freestanding Pediatric Subacute Facilities under the Medi-Cal program using California Healthcare, Research and Prevention Tobacco Tax Act (Coinmonly known as Proposition 56). The supplemental payment allocation would be for services rendered for the period of August 1 ,2019 through December 31, 2021 . 11. GOVERNOR'S REVIEW (Check One) n coven¡¡on's oFFrcE REpoRTED No ooMMENT I coulaeruTs oF GovERNoR's oFFrcE ENcLoSED ! NO REPLY RECETVED WtrHrN 45 DAYS OF SUBMTTTAL IorHen, AS sPEcrFrED 1 13. Depaftment of Health Care Services Attn: Director's Office P.O. Box 997413, MS 0000 Sacramento, CA 95899-741 3 15. DATE SUBMITTED ust22 2019 Mari Ca 14. TITLE State Medicaid Director 17. DATE RECEIVED 18. DATEAPPROVED sEP 2 ß zntr¡ 19. EFFECTIVE DATE OFAPPROVED MATERIAL 2.I. TYPED NAME PLAN APPROVED. ONE COPY ATTACHED 20. OF REGIONAL OFFICIAL (ri sfir"r (¡i.¡v, 22.TITLE }vec*vt, FUIA 23. REMARKS On 9125119, the State made pen-and-ink changes to update the federal budget ¡mpact amounts. For Box 7 "Federal Budget lmpact", please note the additional information: c. FFY 2O121 = $f€7ôç766 $4,ooo,ooo d.FFY 21122 =$,ffi69€92 $1,000,000 For Box 11 "Other, As Specified," please note: The Governor's Office does not wish to review the State Plan Amendment. FoRM€MA-179 (07192) lnstructions on Back

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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 and Children's Health Operations Richard Figueroa Acting Director California Department of Health Care Services 1501 Capitol Avenue Sacramento, CA 95814 Re: Approval of State Plan Amendment CA-19-0050 Dear Richard Figueroa: On September 30, 2019, the Centers for Medicare and Medicaid Services (CMS) received California State Plan Amendment (SPA) CA-19-0050 to elect authority under section 1902(r)(2) of the Social Security Act (the Act) to apply an income methodology less restrictive than the supplemental security income (SSI) program’s for certain Medicaid applicants and beneficiaries. Specifically, California proposed to disregard income up to 138 percent of the federal poverty level (FPL) for individuals seeking eligibility on the basis of having blindness for the eligibility group described in section 1902(a)(10)(A)(ii)(I) of the Act, and individuals seeking eligibility in the eligibility group described in section 1902(a)(10)(A)(ii)(X) of the Act. This income disregard is permissible under the authority of section 1902(r)(2) of the Act. . We approve California State Plan Amendment (SPA) CA-19-0050 with an effective date(s) of August 01, 2020. Name Date Created No items available If you have any questions regarding this amendment, please contact Cheryl Young at cheryl.young@cms.hhs.gov. Sincerely, Richard C. Allen Director, Western Regional Operations Group Center for Medicaid and CHIP Services Division of Medicaid and Children's Health Operations Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | CA2019MS0008O | CA-19-0050 Package Header Package ID CA2019MS0008O Submission Type Official Approval Date N/A Superseded SPA ID N/A SPA ID CA-19-0050 Initial Submission Date 9/30/2019 Effective Date N/A State Information State/Territory Name: California Medicaid Agency Name: California Department of Health Care Services Page 2 of 66 Medicaid State Plan Print View 12/20/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

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Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | CA2019MS0008O | CA-19-0050 Package Header Package ID CA2019MS0008O Submission Type Official Approval Date N/A Superseded SPA ID New User-Entered SPA ID CA-19-0050 Initial Submission Date 9/30/2019 Effective Date 8/1/2020 D. Family Size 1. The family size of an individual for whom the SSI income and resource methodologies are used (as described in section A) includes the persons identified below: a. The individual applying, or b. If the individual lives together with his or her spouse, the individual applying and the spouse, or c. If the individual lives together with his or her parent(s) and the individual is under 21 or has blindness or a disability, the individual applying and the parent(s). 2. The family size of an individual for whom the AFDC income and resource methodologies are used (as described in section A.), includes the persons who would have been included in the family under the state's July 16, 1996 AFDC state plan, except where the state has elected to use the MAGI-like methodologies (as described in section E). 3. The state defines family size for one or more of the following FPL eligibility groups to include others beyond those identified in D.1. and D.2. Yes No  a. Qualified Medicare Beneficiaries (described in section 1902(a)(10)(E)(i) of the Act)  b. Specified Low Income Medicare Beneficiaries (described in section 1902(a)(10)(E)(iii) of the Act)  c. Qualifying Individuals (described in section 1902(a)(10)(E)(iv) of the Act) d. Qualified Disabled and Working Individuals (described in section 1902(a)(10)(E)(ii) of the Act) e. Age and Disability-Related Poverty Level (described in section 1902(a)(10)(A)(ii)(X) of the Act) f. Work Incentives (described in section 1902(a)(10)(A)(ii)(XIII) of the Act) g. Family Opportunity Act Children with a Disability (described in section 1902(a)(10)(A)(ii)(XIX) of the Act) h. Individuals Receiving State Plan Home and Community-Based Services (described in 42 CFR 435.219) 4. The state uses the same definition of family size for the selected FPL eligibility groups. Yes No 5. For the selected FPL eligibility groups, family size is defined as follows: a. Family is defined as the individual, the individual's spouse and the individual's children under age 18 living together in the same household. If the individual is a child, the child's parents and siblings under age 18 are also included in the household if living together. b. The state uses another definition of family. Name of other definition: Description: Alternative definition of family for QMB, SLMB, and QI 1 Family members include spouse, parents, and children under age 21, if living together, and children 18 years of age or older but under 21, whether living in the home or away from home, being claimed as a dependent by the parent(s) in order to receive a tax credit or deduction for state or federal income tax purposes. However, if the person is 18 to 21 years of age, blind, or disabled, living in the home with the parents, not claimed as a dependent by the parent in order to receive a tax credit or deduction for state or federal income tax purposes, and not currently enrolled in school, college, university, or Page 12 of 66 Medicaid State Plan Print View 12/20/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

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Individuals Eligible for but Not Receiving Cash Assistance MEDICAID | Medicaid State Plan | Eligibility | CA2019MS0008O | CA-19-0050 Package Header Package ID CA2019MS0008O Submission Type Official Approval Date N/A Superseded SPA ID CA-09-009 User-Entered SPA ID CA-19-0050 Initial Submission Date 9/30/2019 Effective Date 8/1/2020 C. Financial Methodologies 1. In calculating household income and resources for individuals who are seeking eligibility on the basis of being age 65 or older or having blindness or disability, SSI methodologies are used. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 3. Less restrictive methodologies are used in calculating countable income. Yes No The less restrictive income methodologies are:  General income disregard: Name of disregard: Description: Blind FPL Expansion Disregard the amount of countable income over 100% FPL up to 138% FPL. If such disregards are not sufficient to result in an effective income level equal to the SSI/SSP payment level for a disabled individual or, in the case of a couple, the SSI/SSP payment level for a disabled couple, then an income disregard sufficient to achieve that result [shall be applied].  A specified type of income is disregarded: Name of income type: Description: In-home caregiver wages As referenced in Supplement 8a of Attachment 2.6-A page 8: In-home caregiver wages paid to a household member shall be exempt when both of the following conditions are met: 1) The caregiver is being paid for providing the in-home care to his/her spouse or minor child living in the home, and 2) The spouse or minor child is receiving those in-home services through any federal, state or local government program. Payments made by the California Department of Social Services to an in-home care recipient for the purpose of purchasing in-home care Page 27 of 66 Medicaid State Plan Print View 12/20/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

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Name of resource type: Description: the United States or Canadian governments shall be exempt if received by the spouse or inherited from the spouse who was the original recipient, or both. Where Japanese Reparation payments, whether made by the United States or Canadian governments, are converted to another form, amounts of otherwise excess, nonexempt resources sufficient to ensure that the amount of the exemption equals the amount of the reparation payments received by the individual or inherited by the spouse of the individual, or both, shall not be considered as resources in determining eligibility for Medi- Cal. These exemptions shall apply to the following coverage groups referenced in the Social Security Act at Section 1902(r) (2): • (a)(10)(A)(ii)(I) • (a)(10)(A)(ii) (VI) •(a)(10)(A)(ii)(VIII) • (a)(10)(A) (ii)(IX) • (a)(10)(A)(ii)(X) • (a)(10) (A)(ii)(XII) • (a)(10)(A)(ii)(XIII) • (a) (10)(A)(ii)(XVII) • (a)(10)(A)(ii) (XVIII) • (a)(10)(A)(ii)(XXI) • (a)(10) (C)(i)(III) • 1905(p) SSI and AFDC differing methodologies As referenced in SUPPLEMENT 8b TO ATTACHMENT 2.6-A Page 8: In considering all of the various items of resources where the SSI program and the AFDC program have differing methodologies, the State shall follow the methodology of the least restrictive of either the SSI program or the AFDC program. • The general rules contained in the paragraph above shall apply to determine the resource methodologies employed in consideration of all resource items unless a more specific methodology for a specific resource item is otherwise set forth and included in the State plan. The above paragraphs apply to the resources of all applicants and recipients who are otherwise eligible under California's State Plan and who are also a member of one of the following coverage groups Page 32 of 66 Medicaid State Plan Print View 12/20/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

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Name of resource type: Description: referenced in the Social Security Act at Section 1902(r) (2): • (a)(10)(A)(ii) • (a)(10)(C)(i)(III) • 1905(p) Principal residence disregard As referenced in SUPPLEMENT 8b TO ATTACHMENT 2.6-A Page 9: The principal residence shall not be considered as a resource if any of the following circumstances exist (this is in addition to the reasons specified by the SSI program and the AFDC program): • if a child under the age of 21 lives on the property, or • if a dependent relative lives on the property, (for this purpose only, a disabled child age 21 or over shall be considered a dependent relative), • if a sibling or child age 21 or over of the applicant or beneficiary has continuously resided on the property for at least one year immediately prior to the date the applicant or beneficiary entered a skilled nursing facility or intermediate care facility and continues to reside there, or • if the property cannot be readily converted to cash but a bona fide effort is being made to sell the property. A bona fide effort to sell means that the property is listed for sale with a licensed real estate broker for its fair market value established by a qualified real estate appraiser, a good faith effort is being made to sell the property, offers at fair market value are accepted, and the applicant or beneficiary has supplied proof of compliance with these conditions to the county. The above paragraphs apply to all applicants and recipients who are otherwise eligible under California's State Plan and who are also a member of one of the following coverage groups referenced in the Social Security Act at Section 1902(r) (2): • (a)(10)(A)(ii) • (a)(10)(C)(i)(III) • 1905(p) Bona fide, good faith effort to sell or liquidate resource As referenced in SUPPLEMENT 8b TO ATTACHMENT 2.6-A Page Page 33 of 66 Medicaid State Plan Print View 12/20/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

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Name of resource type: Description: • 1902(a)(10)(A)(ii)(I) • 1902(a) (10)(A)(ii)(X) • 1902(a)(10)(C)(i) Precertified long-term care insurance policy or health care service plan contract As referenced in SUPPLEMENT 8b TO ATTACHMENT 2.6-A Page 1: A resource disregard is given to an individual who has purchased a precertified long- term care insurance policy or health care service plan contract which covers long- term care and has used such policy or plan to pay for services. Services which the individual receives and are paid for by the precertified long-term care insurance policy or health care service plan contract, which covers long-term care, must not be delivered by a member of the individual's family, unless: • The family member is a regular employee of an organization which is providing the services; and • The organization receives the payment for the services: and • The family member receives no compensation other than the normal compensation for employees in his or her job category. The amount of the disregard is equal to the lesser of the following amounts: • the amount of payments made for services by the insurance policy; or • the actual charge for the services. Such disregard is in effect for the lifetime of the individual. The disregard is also allowed if a Medicaid application is filed on behalf of a deceased individual for payment of costs for care and services received by the individual during his or her lifetime. The disregard of resources is allowed for aged. blind and disabled individuals who are otherwise eligible and: A. Medically Needy [1902(a)(10) (C)(i)(III)], or B. Optional Categorically Needy [1902(a)(10)(A)(ii)]. except those who are included in Section 1902 (a)(10)(A)(ii)(VIII), 1902(a) (10)(A)(ii)(XI) and 1902(a)(10) (A) (ii)(IV) who are receiving Supplemental Security Income Page 35 of 66 Medicaid State Plan Print View 12/20/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

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Name of resource type: Description: Payments under Title XVI or a State Supplemental Payment. or C. Who are Qualified Medicare Beneficiaries [1905(p)]. Restitution payments made to Holocaust victims As referenced in SUPPLEMENT 8b TO ATTACHMENT 2.6-A Page 12 and 13: Excludable restitution payments made to a holocaust victim or his or her heirs or beneficiaries shall be considered an exempt resource for the purpose of determining eligibility to receive Medi-Cal benefits or the amounts of those benefits. A "holocaust victim" is a person who was persecuted by Nazi Germany, any other Axis regime, or any other Nazi controlled or Nazi-allied country: (1) on the basis of race, religion, physical or mental disability, or sexual orientation; (2) during any period before, during or after. An "excludable restitution payment" is any payment or distribution, recovered or returned asset or property, received directly by a holocaust victim or heirs or beneficiaries of a holocaust victim: (1) as compensation pursuant to the German Act Regulating Unresolved Property Claims, as amended (Gesetz zur Regelung offener Vermogensfragen); (2) as a result of a settlement of claims against any entity or individual for any recovered asset. A "recovered asset" is any asset of any type, including any bank deposits, insurance proceeds, artwork, or interest earned on any of these assets, owned by a holocaust victim, withheld from that holocaust victim or his or her heirs or beneficiaries and recovered, returned or otherwise compensated to the holocaust victim or his or her heirs or beneficiaries; (3) as a payment or restitution provided by law, or by a fund, established by any foreign country, the United States of America, or any other foreign or domestic entity, or as a result of a final resolution of a legal action; Page 36 of 66 Medicaid State Plan Print View 12/20/2019 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

(ca-09-006)(approval-document)California Medicaid SPA CA-09-006: Approval Document (approved September 29, 2009, effective October 1, 2009)#

(ca-09-006)(approval-document)California Medicaid SPA CA-09-006: Approval Document (approved September 29, 2009, effective October 1, 2009)#

(ca-09-006)(attachment)California Medicaid SPA CA-09-006: Attachment (approved September 29, 2009, effective October 1, 2009)#

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(ca-09-006)(form-cms-179)California Medicaid SPA CA-09-006: Form CMS-179 (approved September 29, 2009, effective October 1, 2009)#

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(ca-09-010)(approval-document)California Medicaid SPA CA-09-010: Approval Document (approved September 24, 2009, effective July 1, 2009)#